Term
WOUND
the ability of a wound to heal is influenced by: |
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Definition
| increase of blood flow, wall off & remove foreign debris, ability to initiate cellular development |
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Term
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Definition
| A wound without tissue loss; wound edges are approximated & the risk on infection is low. Healing occurs by epithelialization & with minimal scar formation, as long as infection is prevented |
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Term
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Definition
| A wound involving the loss of tissue; The wound is left open until it becomes filled by scar tissue. Wounds heal this way by granulation tissue formation (from bottom upward & then scars), wound contraction, & epithelialization. It takes longer for a wound to heal this way, & the chance of infection is greater. |
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Term
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Definition
| Wound is left open & is closed later after granulation tissue begins to form |
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Term
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Definition
| Body’s reaction to wounding & begins within minutes of injury & lasts approximately 3 days. During homeostasis, injured blood vessels constrict (vasoconstriction), & platelets gather to stop bleeding. This results in localized redness, edema, warmth, & throbbing. In a clean wound, this phase accomplishes control of bleeding & establishes a clean wound bed. |
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Term
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Definition
| With the appearance of new blood vessels as reconstruction progresses, this phase begins & lasts from 3 – 24 days. In a clean wound, this phase accomplishes reestablishing the vascular bed (granulation tissue), filling the area with replacement tissue (collagen, contraction, & granulation tissue), & repair of the surface (epithelialization). This phase usually leaves a pinkish scar. Impairment of healing during this stage usually results from systemic factors (age, anemia, hypoproteinemia, & zinc deficiency) |
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Term
WOUND
maturation/remodeling phase |
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Definition
| The final stage of healing sometimes takes place for more than a year, depending on the depth & extent of the wound. The collagen scar continues to reorganize & gain strength for several months. In some individuals, there is increased collagen & it creates a hypertrophic scar known as a keloid. |
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Term
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Definition
clear, watery;
fluid & cells of blood |
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Term
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Definition
thick yellow, green, tan, or brown; smells foul
WBCs, liquefied dead tissue, live & dead bacteria |
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Term
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Definition
pale red, watery; mixture of clear & red fluid
water mixed w/ blood; indicates bleeding |
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Term
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Definition
bright red
high # of RBCs; should be dark red; if bright red, it indicates frank bleeding |
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Term
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Definition
| Fever, tenderness & pain at wound site, ↑WBCs, edges of wound appear inflamed, odorous & purulent drainage |
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Term
WOUND
infection
what is it? |
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Definition
infective bacteria present.
differs from a contaminated wound by the amount of bacteria present. |
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Term
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Definition
External: obvious; bloody drainage on wound dressings
Internal: distention or swelling of the affected body part; change in type & amount of drainage; or signs of hypovolemic shock |
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Term
WOUND
hemorrhage
what is it? |
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Definition
Bleeding from wound site.
indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object
Risk
is great during first 24 – 48 hours after surgery or injury. |
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Term
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Definition
| Sudden increase in serosanguineous drainage |
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Term
WOUND
dehiscence
what is it? |
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Definition
| Partial or total separation of wound layers |
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Term
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Definition
| Protrusion of visceral organs through a wound opening. |
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Term
WOUND
evisceration
what is it? |
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Definition
| Total separation of wound layers |
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Term
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Definition
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Term
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Definition
| retards collagen production; can affect renal function if absorbed into circulation |
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Term
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Definition
| disturbs new capillaries & granulation tissue; can be toxic to fibroblasts |
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Term
WOUND
apply binder/bandages _____ to _____ |
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Definition
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Term
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Definition
| when one drug counteracts another & cancels it out |
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Term
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Definition
| 2 meds are combined for a greater effect |
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Term
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Definition
| what the drug does to the body |
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Term
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Definition
| what the body does to the drug |
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Term
MEDS
absorption is influenced by: |
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Definition
| route of administration & ability of the med to dissolve |
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Term
MEDS
steps to questioning a med order |
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Definition
| drug book, pharmacist, doctor, nursing supervisor |
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Term
MEDS
what is important when a narcotic is wasted? |
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Definition
| a second nurse needs to witness & sign |
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Term
MEDS
first priority when a med error occurs |
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Definition
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Term
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Definition
| over scapula; middle of forearm; upper outer chest |
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Term
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Definition
length: 3/8-1"
gauge: 25-29
degree: 5-15
max vol: 0.5mL |
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Term
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Definition
| outer posterior upper arm, abdomen, anterior thighs, scapula area, upper ventral/dorsal gluteal areas |
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Term
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Definition
length: 5/8-1/2"
gauge: 25
degree: 45 or 90
max vol: 1mL |
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Term
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Definition
| deltoid, dorsogluteal, ventrogluteal, vastus lateralis |
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Term
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Definition
length: 1/2-3"
gauge: 20-30
degree: 90
max vol: 2mL (deltoid), 5mL all others |
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Term
MEDS
preferred IM site >7 months |
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Definition
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Term
MEDS
IM site of last resort |
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Definition
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Term
IV
tonicity of normal blood plasma |
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Definition
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Term
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Definition
| fluid that is used to expand the vascular compartment |
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Term
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Definition
| draws fluid into the vascular space by osmosis from cells, resulting in increased vascular volume that can lead to pulmonary edema--esp in pts with heart or renal failure |
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Term
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Definition
| causes fluid to shift to the cells |
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Term
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Definition
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Term
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Definition
| indicated for extracellular volume replacement |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| isotonic in the bag; but hypotonic in the body bc the body metabolizes the glucose & leaves the water |
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Term
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Definition
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Term
IV
factors that affect flow rate |
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Definition
solution (viscosity)
position of the container
position of the cannula in vein
position of pt |
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Term
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Definition
| 30-36" above insertion site |
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Term
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Definition
| pooling of blood into subQ space |
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Term
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Definition
| discoloration, swelling, tenderness |
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Term
IV
hematoma
what do you do? |
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Definition
| Remove IV; apply pressure for 2 minutes; apply cold; recheck for bleeding—no more bleeding, apply warm soaks |
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Term
IV
infiltration
what is it? |
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Definition
| IV fluids enter subQ tissue around venipuncture site |
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Term
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Definition
| swelling, pallor & coolness, slowed infusion rate, discomfort |
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Term
IV
infiltration
what do you do? |
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Definition
| Remove IV; apply warm soaks; elevate extremity; use new site if needed; call doc |
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Term
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Definition
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Term
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Definition
| tenderness, redness, heat, edema, cord-like, slowed infusion rate |
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Term
IV
phlebitis
what do you do? |
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Definition
| Remove IV; apply warm soaks; call doc |
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Term
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Definition
| Invasion of pathogens localized in surrounding tissues of IV site |
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Term
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Definition
| tenderness, swelling, erythema, purulent drainage |
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Term
IV
infection
what do you do? |
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Definition
| Remove IV; culture tip of IV; clip off end (w/ suture removal set) & put in sterile container; call doc |
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Term
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Definition
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Term
IV
clotting
what do you do? |
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Definition
| Do not flush IV; remove IV; start new IV at different site; call doc |
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Term
IV
catheter embolism
what is it? |
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Definition
| Fragment of catheter breaks off into vein |
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Term
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Definition
| respiratory distress, cyanosis, thready pulse, ↓BP, discomfort |
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Term
IV
catheter embolism
what do you do? |
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Definition
| Raise head of bed; call doc; give oxygen |
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Term
IV
air embolism
what is it? |
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Definition
| air in the circulatory system; right atrium fills with air |
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Term
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Definition
| respiratory distress, thready pulse, decreased BP, loss of consciousness |
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Term
IV
air embolism
what do you do? |
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Definition
| lay pt on LEFT side; can also lower head of bed lower than the feet (trendelenberg position); call doc; give oxygen |
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Term
IV
circulatory overload
what is it? |
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Definition
| circulatory system has more volume than pt can manage |
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Term
IV
circulatory overload
S&S |
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Definition
| fluid in lungs (pulmonary edema), increased BP, JVD, dyspnea, tachycardia, discomfort |
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Term
IV
circulatory overload
what do you do? |
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Definition
| raise head of bed; slow infusion rate; call doc |
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Term
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Definition
| systemic infection present in the blood |
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Term
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Definition
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Term
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Definition
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Term
IV
septicemia
what do you do? |
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Definition
| remove IV; culture tip; start new IV at different site; call doc |
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Term
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Definition
| supplies oxygen & nutrients for tissue maintenance & repair; transports cellular waste; provides defenses against infection by transporting antibodies; regulates body temp; helps maintain acid-base balance; regulates F&E |
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Term
BLOOD
components of formed cellular elements |
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Definition
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Term
BLOOD
components of plasma |
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Definition
| serum, protein (major: albumin), lipids (fats), electrolytes, vitamins, CHO (carbs), urea (waste product), bilirubin (waste product), gasses (O2 & CO2) |
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Term
BLOOD
autologous transfusion |
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Definition
| collection & reinfusion of pt's own blood |
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Term
BLOOD
hemolytic reaction
what is it? |
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Definition
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Term
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Definition
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Term
BLOOD
mild acute hemolytic reaction
what is it? |
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Definition
| RBCs rupturing & debris is clogging the kidneys |
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Term
BLOOD
volume overload
what is it? |
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Definition
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Term
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Definition
| cough, headache, CHF, JVD, dyspnea, increased BP & pulse |
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Term
BLOOD
volume overload
what do you do? |
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Definition
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Term
BLOOD
febrile reaction
what is it? |
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Definition
| Sensitization to donor WBCs, platelets, or plasma proteins |
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Term
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Definition
| sudden chills & fever (≥1.8° from baseline), headache, flushing, anxiety, muscle pain |
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Term
BLOOD
febrile reaction
what do you do? |
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Definition
| Stop transfusion; call doc; get order for antipyretics |
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Term
BLOOD
hives & rash
what is it? |
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Definition
| Sensitivity to foreign plasma proteins |
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Term
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Definition
| flushing, itching, urticaria (hives) |
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Term
BLOOD
hives & rash
what do you do? |
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Definition
| Call doc; get order for antihistamine & continue transfusion |
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Term
BLOOD
anaphylactic reaction
what is it? |
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Definition
| infusion of IgA proteins to IgA deficient recipient who has developed IgA antibody |
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Term
BLOOD
anaphylactic reaction
S&S |
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Definition
| ↑pulse, ↓BP, wheezing, cyanosis, anxiety, urticarial (hives), progression to shock, cardiac arrest, death |
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Term
BLOOD
anaphylactic reaction
what do you do? |
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Definition
| stop transfusion; have epinephrine ready for injection; call doc |
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Term
BLOOD
delayed hemolytic response
what is it? |
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Definition
| incompatibility of antigens on RBCs |
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Term
BLOOD
delayed hemolytic response
S&S |
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Definition
| ↓hemoglobin levels (for no reason), persistent low grade fever |
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Term
BLOOD
acute hemolytic response
what is it? |
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Definition
| ABO (blood type) or Rh (mother→fetus) incompatibility |
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Term
BLOOD
mild acute hemolytic response
S&S |
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Definition
| fever, chills, back pain, hypotension, nausea, vomiting, flushing, hematuria (blood in urine), oliguria (low urine output) |
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Term
BLOOD
severe acute hemolytic response
S&S |
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Definition
| fever, chills, back pain, hypotension, nausea, vomiting, flushing, hematuria (blood in urine), oliguria (low urine output), dyspnea, chest pain, anuria (<100mL/24hrs), shock, Disseminated Intravascular Coagulopathy (DIC) [little blood clots all over], death |
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Term
PAIN
events of nociceptive (normal) pain |
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Definition
stimulus--transduction
pain is elicited--transmission
suffering--perception
pain behavior--modulation |
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Term
PAIN
stimulus--transduction
what happens? |
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Definition
| the energy of these stimuli is converted to electrical energy; this event begins in the periphery when a pain-producing stimulus sends an impulse across a sensory peripheral pain nerve fiber (nociceptor), initiating an action potential |
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Term
PAIN
pain is elicited--transmission
what happens? |
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Definition
| i. Cellular damage caused by stimuli results in the release of excitatory neurotransmitters—pain-sensitizing substances that spread the pain message & cause an inflammatory response |
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Term
PAIN
the impulse of pain travels via: |
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Definition
| A-Delta fibers & C-Fibers |
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Term
PAIN
A-Delta fibers
what do they do? |
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Definition
| send distinct sensations that localize the source of pain & detect its intensity |
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Term
PAIN
A-Delta fibers
characteristics |
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Definition
mylinated
fast conducting
acute
localized |
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Term
PAIN
C-Fibers
what do they do? |
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Definition
| relay impulses that are poorly localized, burning, & persistent |
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Term
PAIN
C-Fibers
characteristics |
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Definition
unmylinated
slow conducting
chronic
diffuse pain |
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Term
PAIN
suffering--perception
definition |
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Definition
| The sensation of pain is subjective; there are emotional reactions |
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Term
PAIN
Gate Control Theory
what is it? |
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Definition
| mechanisms regulate/block pain impulses |
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Term
PAIN
Gate Control Theory
"gating mechanisms" |
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Definition
| A-Delta fibers, A-Beta fibers, C-fibers |
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Term
PAIN
Gate Control Theory
these regulate/block pain impulses |
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Definition
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Term
PAIN
Gate Control Theory
"close the gate" to block pain impulses from conducting through the.... |
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Definition
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Term
PAIN
characteristics of acute pain |
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Definition
| protective in nature; warns of tissue damage; lasts less than 6 months; when cause is corrected, pain goes away; sympathetic response |
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Term
PAIN
characteristics of chronic pain |
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Definition
| lasts longer than 6 months; associated with progressive disease, & depression; narrowing (pt's focus on living becomes viewed through pain); increasing need for med bc tolerance develops (med tolerance & respiratory tolerance); parasympathetic response |
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Term
PAIN
when do you use the FLACC scale? |
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Definition
| in children or cognitively impaired pts |
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Term
PAIN
independent nursing interventions |
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Definition
| remove the cause; provide distraction; imagery; relaxation |
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Term
PAIN
dependent nursing interventions |
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Definition
|
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Term
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Definition
| non-narcotics, narcotic agonists, narcotic antagonists |
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Term
PAIN
non-narcotics work on..... |
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Definition
| peripheral nervous system |
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Term
PAIN
narcotic agonists work on.... |
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Definition
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Term
PAIN
narcotic agonists
how do they work? |
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Definition
| alter pt's perception of pain; pain still exists, but brain doesnt pick it up |
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Term
PAIN
all analgesics have common side effect |
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Definition
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Term
PAIN
narcotic antagonists are used to.... |
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Definition
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Term
STRESS
homeostasis
what is it? |
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Definition
| relative constancies that the body must maintain to sustain life |
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Term
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Definition
| the perception or appraisal of a stressor |
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Term
STRESS
stressor
what is it? |
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Definition
| disruptive forced operating within or on any system |
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Term
STRESS
responses to stressors occur..... |
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Definition
| in the pituitary hypothalamic adrenal axis |
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Term
STRESS
Local Adaptation Syndrome
purpose |
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Definition
| to localize & prevent the spread of infection & promote wound healing |
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Term
STRESS
response to Local Adaptation Syndrome |
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Definition
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Term
STRESS
phases of inflammatory response in LAS |
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Definition
vascular response (vasoconstriction, then vasodilation)
exudate formation
repair & regeneration |
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Term
STRESS
cardinal signs of inflammation |
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Definition
redness
heat (local)
swelling
pain |
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Term
WOUNDS
cardinal signs of infection |
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Definition
redness
heat (local or systemic--fever)
swelling
pain
exudates (drainage) |
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Term
STRESS
phases of General Adaptation Syndrome |
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Definition
alarm reaction
resistance
recovery/exhaustion |
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Term
STRESS
what happens during the resistance phase of GAS? |
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Definition
stabilization
hormonal levels return to normal
parasympathetic nervous system activity
adaption to stressors |
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Term
STRESS
during the alarm reaction of GAS, what is stimulated? |
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Definition
hypothalamus (increases vitals)
posterior pituitary (increased anti-diuretic hormone)
anterior pituitary (increased ACTH)
sympathetic nervous system & adrenal medulla (increased epinephrine & norepinephrine--adrenaline)
fight or flight response |
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Term
STRESS
what happens during the exhaustion phase of GAS? |
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Definition
increased physiological response as noted in the alarm reaction
decreased energy levels
decreased physiological adaptation
death |
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Term
STRESS
if the body adapts to a stressor, they enter: |
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Definition
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Term
STRESS
if they body does not adapt to a stressor, they enter: |
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Definition
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