6/11/2021 NS1881 EXAM PREP Flashcards | Quizlet

NS1881 EXAM PREP

Terms in this set (124)

what can affect oxygen saturation Activity

readings?

Nursing intervention to break a link cover ones mouth and nose when sneezing
in the chain of infection (mode of
transmission)

infectious agent, reservoir, portal of exit, mode of transmission, portal of

chain of infection
entry, susceptible host

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●Stage I - persistent redness; skin is intact with visible, non blanchable

redness over a localized area, typically over bony prominence; changes
in skin temperature, tissue consistency and sensation (pain, itching)

●Stage II - involves the dermis with partial thickness loss which presents
as shallow open ulcer that can be shiny or dry; can also present as a
Stages of pressure ulcers
blister that is intact or open/ruptured; wound bed is red pink color
without slough or bruising

●Stage III - full thickness tissue loss with subcutaneous fat possibly
visible; bone, tendon or muscle are not exposed or directly palpable

●Stage IV - full thickness tissue loss with bone, tendon, or muscle visible

used when caring for people infected with pathogens that can be
contact isolation
transmitted directly or indirectly

Obtaining a clean voided urine collect the first voided specimen in the morning
specimen

stimulate circulation

Reasons for daily bath

assess skin integrity

SKIN INTEGRITY, IMPAIRED ...A state in which an individual has altered epidermis and/or dermis.

when oxygenated blood does not flow freely through the vessels to the
Altered tissue perfusion
tissue

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Correct procedure for shaving a Hold the skin taut around creases
client

Wound healing phases inflammatory, proliferative, maturation

the initial phase of wound healing in which bleeding is reduced as

inflammatory phase
blood vessels in the affected area constrict

Granulation

Proliferative phase of wound Epithelialization

healing Requires fibroblast proliferation, collagen formation, wound contraction

Tender fragile tissue

-final phase begins about 3 weeks from injury

-may take up to 2 years

-collagen is lysed and resynthesized by macrophages, producing

storng scar tissue

maturation phase of wound healing

-scar maturation, or remodeling

-scar tissue slowly thins and becomes paler

Keloid decelopment

keloid overgrowth of scar tissue

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