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108 Cards in this Set
- Front
- Back
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A sequential reaction to cell injury
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Inflammatory response
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________is always present with infection
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Inflammation
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_________is not always present with inflammation
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infection
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involves invasion of tissues or cells by microorganisms such as bacteria, fungi, and viruses.
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Infection
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can be caused by nonliving agents such as heat, radiation, trauma, and allergens.
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inflammation
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what are the four phases of the inflammatory response?
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vascular response
cellular response formation of exudate healing |
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what occurs during the vascular response?
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arterioles in the area BRIEFLY vasoconstrict, but vessels dilate after the release of histamine, this increases the blood flow to the ares.
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Hyperemia
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increased blood flow in the area
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how do blood clots help in the inflammation process?
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they function to trap bacteria, to prevent their spread, and to serve as a framework for the healing process.
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chemotaxis
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directional migration of white blood cells along a concentration gradient of chemotactic factors, which are substances that attract leukocytes to the site of inflammation.
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are the first to arrive (usually within 6-12 hours)
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Neutrophils
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What is the purpose of neutrophils?
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they engulf bacteria, other foreign material, and damaged cells.
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what is the lifespan of neutrophils?
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24-48 hours
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what is another name for immature form of neutrophils?
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bands
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what is another name for mature neutrophils?
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segmented neutrophils
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what does "shift to the left" mean?
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the finding of increased numbers of band neutrophils in circulation
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which types of patients will you commonly find "shift to the left" increase of WBC's?
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patients with acute bacterial infections
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what are the second type of phagocytic cells that migrate from circulating blood to the inflammation area?
And within how many days to they arrive to the site of inflammation? |
Monocytes
they arrive 3-7 days after the onset of inflammation |
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what happens to monocytes upon entering the tissue spaces?
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transform into macrophages
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what is the primary role of the monocytes (newly transformed macrophages)?
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assist in phagocytosis of the inflammatory debris
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what is the third leukocyte to arrive at the site of inflammation?
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Lymphocytes
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what is the primary role of the lymphocytes?
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is related to humoral and cell-mediated immunity
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What is released in large quantities during an allergic reaction?
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Eosinophils
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What do Eosinophils do?
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they release chemicals that act to control the effects of histamine and serotonin.
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are involved in phagocytosis of the allergen-antibody complex
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Eosinophils
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have highly caustic chemicals that are capable of destroying a parasite's cells surface?
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Eosinophils
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Histamine and heparin are carried by _______and are released during inflammation
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Basophils
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what are the major functions of the complement system?
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enhanced phagocytosis
increased vascular permeability chemotaxis cellular lysis |
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_____can be synthesized from the phospholipids of cell membranes of most body tissues, including blood cells
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prostaglandins (PGs)
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consists of fluid and leukocytes that move from the circulation to the site of injury.
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exudate
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what is the local response to inflammation?
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redness
heat pain swelling loss of function |
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what are the systemic manifestations of inflammation?
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increased WBC with a shift to the left
malaise nausea and anorexia increased pulse and respiratory rate fever |
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the onset of fever is triggered by the release of
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cytokines
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what are the beneficial aspects of fever?
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increased killing of microorganisms, increased phagocytosis by neutrophils, and increased proliferation of T cells. also enhances the the activity of interferon
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what are the basic types of inflammation?
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acute
subacute chronic |
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in acute inflammation, when does healing occur?
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2-3 weeks
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what is the predominant cell type in acute inflammation?
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Neutrophils
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what happens with subacute inflammation, and what is an example?
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it has the same features of the acute process but lasts longer; ex: infective endocarditis;
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how long does subacute inflammation persist?
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weeks or months
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how long does chronic inflammation last for?
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weeks, months, or even years
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what are the predominant cell types present at the site of inflammation for chronic inflammation?
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lymphocytes and macrophages
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what are examples of chronic inflammation?
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Rheumatoid arthritis and TB
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What are the two components of the healing process?
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regeneration
repair |
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The replacement of lost cells and tissues with cells of the same type
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Regeneration
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healing as a result of lost cells being replaced by connective tissue
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Repair
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which organ injuries are typically followed by rapid regeneration?
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skin, lymphoid organs, bone marrow, and mucous membranes of the GI, urinary and reproductive tracts.
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which organs have stable cells that retain their ability to regenerate but do so only if the organ is injured?
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liver, pancreas, kidney, and bone cells
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What are the three types of healing with Repair?
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primary intention
secondary intention tertiary intention |
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healing takes place when wound margins are neatly approximated, such as in a surgical incision or a paper cut
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Primary intention
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what are the three phases of Primary intention healing?
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Initial
granulation scar contracture |
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what happens in the initial phase of primary intention healing?
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approimation of incision edges; migration of epithelial cells; clot serving as meshwork for starting capillary growth
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what happens in the granulation phase of primary intention healing?
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migration of fibroblasts; secretion of collagen; abundance of capillary buds; fragility of wound
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what happens in the scar contracture phase of primary intention healing?
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remodeling of collagen; strengthening of scar
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How long is the initial phase of primary intention healing?
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3-5 days
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How long is the granulation phase of primary intention healing?
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5 days to 4 weeks
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How long is the scar contracture phase of primary intention healing?
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7 days to several months
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the scar may be more painful at this phase than in the granulation phase of primary intention healing?
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scar contracture
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Secondary intention wounds occur from what type of injury?
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trauma, ulceration, and infection that has large amounts of exudate and wide, irregular wound margins with extensive tissue loss.
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what is the major difference in primary and secondary intention healing?
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the greater defect and the gaping wound edges with the secondary intention wounds.
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how does healing and granulation take place in the secondary intention wound?
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it takes place from the edges inward and from the bottom of the wound upward until the defect is filled.
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Delayed primary intention healing that occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together
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tertiary intention healing
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when does tertiary intention healing occur?
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when a contaminated wound is left open and sutured closed after the infection is controlled. also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured.
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How can wounds be classified?
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by their cause
or by the depth of tissue affected |
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What are example of wound causes?
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surgical or nonsurgical
acute or chronic |
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what are examples of wound depth of tissue affected?
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superficial
partial thickness full thickness |
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superficial wounds involve which layer of the skin?
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epidermis only
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partial-thickness wounds involve which layer(s) of the skin?
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They extend into the dermis
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Full-thickness wounds involve which layers of the skin?
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have the deepest layer of tissue destruction involving the subcutaneous tissue and sometimes extend into the fascia and underlying structures such as muscle, tendon, or bone
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What are the three different wound colors?
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red
yellow black |
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Color classification of wounds can only be applied to which level of healing intention?
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secondary
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what are certain factors that can interfere with wound healing and lead to complications?
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malnutriction, obesity, decreased blood supply, tissue trauma, smoking, drugs(corticosteroids +chemotherapy), wound debris such as necrotic tissue and infection.
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what are some complications that may occur with healing?
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hypertrophic scars and keloids
contracture, dehiscence, excess granulation tissue, adhesions and major organ dysfunction. |
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how do hypertrophic scars and keloid formation occur?
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when the body produces excess collagen tissue
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an inappropriately large, red, raised, and hard scar
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hypertrophic scar
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great protrusion of scar tissue that extends beyond the wound edges and may form tumor-like masses
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Keloid
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is necessary for healing; a shortening of muscle or scar tissue results from excessive fibrous tissue formation, especially if the wound is near a joint
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contracture
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contracture frequently occurs in an area that has what type of injury?
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burn
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separation and disruption of previously joined wound edges
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dehiscence
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Dehiscence usually occurs when?
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a primary healing site bursts open
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What are the three possible contributing causes of dehiscence?
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infection may cause inflammatory process; granulation tissue may not be strong enough to withstand the forces imposed on the wound; obesity due to adipose tissue interfering with healing
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occurs when wound edges separate to the extent that intestines protrude through the wound
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evisceration
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"proud flesh" is another term for what?
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excess granulation tissue
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bands of scar tissue between or around organs
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adhesions
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what is needed to correct the negative nitrogen balance resulting from the increased metabolic rate?
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protein
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what is needed for the increased metabolic energy required in inflammation and healing?
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carbohydrates
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what is a necessary component in the diet to help in the synthesis of fatty acids and triglycerides, which are part of the cellular membrane?
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fats
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what is needed for capillary synthesis and collagen?
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vit C
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what vitamins are necessary as coenzymes for many metabolic reactions?
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B-complex vitamins
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which vitamin is needed in healing because it aids in the process of epithelialization?
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Vit A
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what is the best management of inflammation?
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the prevention of infection, trauma, surgery, and contact with potentially harmful agents
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which individuals are at risk for wound-healing problems?
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malabsorption problems (crohn's, liver disease and GI surgery), deficient intake or high energy demands (malignancy, major trauma or surgery, sepsis, fever) and diabetes patients
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if a wound infection develops in a post-op patient, how soon will the vital signs show a change?
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3-5 days after surgery
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what is the most important aspect of fever management?
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determining its cause
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a localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues
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pressure ulcer
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what is the most common site for pressure ulcers?
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sacrum and heels
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What are factors that influence the development of pressure ulcers?
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amount of pressure (intensity)
length of time pressure is exerted on skin(duration) and the ability of the patient's tissue to tolerate the externally applied pressure |
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pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement
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shearing force
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Which patients are at a higher risk for the development of pressure ulcers?
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elderly, incontinent, bed-or wheelchair-bound, or recovering from spinal cord injuries
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when can the "true" depth and stage of an ulcer be determined?
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when enough slough and/or eschar is removed to expose the base of the wound.
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what is the most common complication of a pressure ulcer?
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recurrence
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what is the score range on the braden scale?
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6-23
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what are the six subscales included in the braden scale?
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sensory perception
moisture, activity, mobility, nutrition and friction + shear |
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what is the primary nursing responsibility
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to identify patients at risk for developing pressure ulcers and implementing pressure ulcer prevention strategies for those identified as being at risk
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what remains the BEST treatment for pressure ulcers?
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prevention
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which solutions should not be used to irrigate or clean a pressure ulcer?
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Dakin's solution, acetic acid, povidone-iodine, hydrogen peroxide--because they are all cytotoxic.
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How much pressure (psi) should be used to adequately clean and irrigate a pressure ulcer?
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4 to 15 psi
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How can a nurse obtain 4 to 15 psi when irrigating or cleaning a pressure ulcer?
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by using a 30 mL syringe and a 19 guage needle
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when should a wet-to-dry dressing be used for pressure ulcers?
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only for mechanical debridement of the wound. Should never be used on a clean, granulating pressure ulcer
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