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Terms in this set (79)
an area where the bone sticks out or projects from the flat surface of the body
the presence of bacteria on the wound surface or in wound tissue; the person does not have signs and symptoms of an infection
removing the epidermis (outer skin layer) as tape is removed from the skin
thick, leathery dead tissue may be loose or adhered to the skin; it is often black or brown
a localized injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from pressure
when layers of the skin rub against each other; when the skin remains in place & underlying tissues move and stretch
dead tissue that is shed from the skin; it is usually light colored, soft, moist; may be stringy at times
What are common causes and risk factors for pressure ulcers?
-pressure, friction, and shearing
-breaks in the skin, poor circulation, moisture, dry skin, and skin irritation by urine or feces
What are the different stages of ulcers?
stage 1- intact skin with redness over a bony prominence
stage 2- partial-thickness skin loss
stage 3- full thickness tissue loss
stage 4- full-thickness tissue loss with muscle, tendon, and bone exposure
unstageable- full-thickness tissue loss with the ulcer covered by slough and eschar
suspected deep tissue injury- a purple or a maroon area of intact skin or a blood-filled blister
How do we prevent pressure ulcers?
- good nursing, cleanliness, skin care
-identifying persons at risk
-prevention measures for those at risk
What do we mean by the 30-degree lateral position (p. 628)? Why is this the best position to prevent pressure ulcers?
this position lifts up the hip to avoid pressure on the hip
Factors effecting oxygen needs
cells do not have enough oxygen
a reduced amount of oxygen in the blood
difficult, labored, or painful breathing
the lack or absense of breathing
any lost, absent, or impaired physical or mental function
care that helps persons regain health, strength, and independence
restorative nursing care
What is the role of CNA with rehab & restorative care?
help promote the person's independence & prevent decline in function
Our goal is to focus on what the person is able to do, not their __________, and help them return to the higest level of _______________ possible
the total or partial loss of the ability to use or understand language; parts of the brain responsible for language are damaged
difficulty expressing or sending out thoughts through speech or writing
difficulty expressing or sending out thoughts and difficulty understanding language
difficulty understanding language
receptive aphasia; Wernicke's aphasia
What are the symptoms of Meneire's disease?
-feeling of fullness or pressure in the ear
a ringing, roaring, hissing, or buzzing sound in the ears or head
clouding of the lens
fluid builds up in the eye causing pressure on the optic nerve
-peripheral vision is lost
blurs central vision
the spread of cancer to other body parts
inflammation of the mouth
a new growth of abnormal cells that is benign or malignant
What are the different types of treatment for cancer?
What are autoimmune diseases?
occurs when the immune system attacks the body's own healthy cells, tissues, or organs
What causes shingles?
caused by the same virus that causes chicken pox
-the virus lies dormant in nerve tissue, and may become active years later
-blood vessel bursts or blood clot blocks blood vessel in brain
transient ischemic attack
-blood supply to the brain is interrupted for a short time
-may occur before a stroke
-rigid stiff msucles
-stooped posture and impaired balance
-mask like expression
Spinal cord injuries
paralysis on one side of the body
paralysis in the legs, lower trunk
paralysis in the arms, legs, trunk, and pelvic organs
-autonomic nervous system over-reacts to a stimulus
-high BP, stroke, seizures, heart attack, and death are risks
-What can it lead to if untreated?
cartilage covering the ends of bones wears away, allowing the bones to rub together
an autoimmune disease, attack the lining of the joint
a vague, uneasy feeling in response to stress
a false belief
an exaggerated belief about one's importance, wealth, power, or talents
delusion of grandeur
a false belief that one is being mistreated, abused, or harassed
delusion of persecution
seeing, hearing, smelling, or feeling things that aren't real
an intense and sudden feeling of fear, anxiety, terror, or dread
a state of severe mental impairment
the response or change in the body caused by any emotional, physical, social, or economic factor
the event or factor that causes stress
How do we care for persons with depression? What to do if a person makes a suicide threat?
notify a nurse at once
involves memory, thinking, reasoning, ability to understand , judgement, and behavior
a mental state of being disoriented to person, time, place, situation, or identity
a state of sudden, severe confusion and rapid changes in brain function
the loss of cognitive function that interferes with routine, personal, social, and occupational activities.
when a person leaves the agency without staff knowledge
a disorder of the mind; false beliefs and suspicion about a person or situation
a way to communicate with person with dementia
-all behavior has meaning
-a person may have unresolved issues and emotions from the past
-a person's mind may return to the past to resolve issues and emotions
-caregivers need to listen and provide empathy
a document stating a person's wishes about health care when that person cannot make his or her own decision
care that involves relieving or reducing the intensity of uncomfortable symptoms without producing a cure
care of the body after death
the stiffness or rigidity of skeletal muscles that occurs after death
an illness or injury from which the person will not likely recover
What are Dr. Kubler-Ross' five stages of grief or dying?
What are comfort measures that are offered to the dying person?
What is a living will?
living will may instruct:
-not to start measures that prolong dying
-to remove measures that prolong dying
tube feedings, ventilators, and resuscitation
What is a DNR order?
Do Not Resuscitate
What are the signs of approaching death?
-restlessness and agitation
-shortness of breath
-constipation or incontinence
-nausea or loss of appetite
What is involved with post-mortem care?
maintaining good appearance after death
-rigor mortis: moving/positioning the body
When can visitors be with the resident/patient?
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