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CPSS: Procedure, Pre-op, Op and Post-Op Notes
Summer II 2011
29
Medical
Graduate
08/08/2011

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Cards

Term
What is a collection of information that is compiled by a provider(s) reflecting the procedure performed on the patient.?
Definition
Clinical Procedure note
Term
What are the purposes of a clinical procedure note?
Definition
legal medical record
communication tool
quality assessment tool
risk reduction aid
reimbursement aid
Term
What does the "red wound" mean?
Definition
"red and ready" to heal
Term
How do you address the "red wound"?
Definition
keep wound moist, clean and protected
Term
If a patient presents with a wound with definite borders, granulation tissue present and revascularization apparent, what type of wound is it?
Definition
Red Wound
Term
What type of wound is described as having pus, debris, fibrin and straw colored exudate present?
Definition
Yellow Wound
Term
How do you address a "yellow wound"?
Definition
Cleansing, minor debridement (usually using application of a preparation that will lift off and separate the pus, topical antimicrobial
Term
What type of wound is described as having necrotic tissue or an dark eschar on it as well as pus or fibrin formation?
Definition
Black Eschar
Term
How should a black wound be addressed?
Definition
mechanical, surgical or chemical debridement to dissolve black, necrotic tissue
Term
If you have a yellow and black wound, how should you treat it?
Definition
Treat as if it were a black wound
Term
If the wound is both red and yellow, how should you treat it?
Definition
As if it were a yellow wound
Term
What is described as being created when the anatomic integrity of the tissue is disrupted?
Definition
Wound
Term
What is described as the process whereby the integrity of the tissue is restored?
Definition
Healing
Term
What is created from ischemia caused when too much pressure is applied to one area for a prolonged period of time?
Definition
Pressure ulcers
Term
Where are pressure ulcers commonly formed?
Definition
Usually over the bony prominences
Term
What are the signs of an arterial ulceration?
Definition
Pulselessness of the extremity
Painful ulceration
Small, Punctate ulcers that are well circumscribed
Cool or cold skin
delayed cap refill
atrophic appearing skin (shiny, thin, dry)
loss of digital and pedal hair
Term
What is the MC type of ulcer affecting the LE?
Definition
venous ulcerations
Term
What stage ulcer is described as erythema not resolving within 30 min of pressure relief, but with epidermis remaining intact?
Definition
Stage 1
Term
What stage ulcer is described as a partial thickness loss of skin layers involving the epidermis and possibly penetrating into but not through the dermis, which may prsent as blistering with erythema and/or induration?
Definition
Stage 2
Term
What stage ulcer is described as full-thickness tissue loss extending through the dermis to involve the subQ tissue that presents as a shallow crater that may be covered by an eschar?
Definition
Stage 3
Term
What stage ulcer is described as deep tissue destruction extending through subQ tissue to fascia and may involve the muscle layers?
Definition
Step 4
Term
In which ulcer stages may undermining and sinus tracts be present?
Definition
Stage 4
Term
In which stage of healing does granulation tissue form?
Definition
regeneration
Term
In which stage does the scar formation occur?
Definition
remodeling phase
Term
What are the four questions you should ask with wound healing?
Definition
Amount of dead tissue
Degree of colonization or infection
Status of the host
Options for closure
Term
What dressing should be used for dry wounds?
Definition
Goal is to hydrate -> Hydrogel, e.g
Term
What dressing should be used for a non-draining wound?
Definition
Goal is to maintain moisture -> Hydrogel, e.g
Term
What dressing should be used for a wound with moderate or heavy drainage?
Definition
Goal is to absorb drainage -> Alginate, e.g
Term
What type of dressing is used for wounds with macerated margins?
Definition
Goal is to protect wound margins -> Zinc oxide, e.g
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