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LCCC Nursing > Chapter 13: Med Surg > Flashcards

Chapter 13: Med Surg Flashcards

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1
Q

regeneration

A

replacement of lost cells and tissues with cells of the same type

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2
Q

repair

A

healing as a result of lost cells being replaced by connective tissue

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3
Q

epithelial regenerative ability

A

skin, blood vessels, mucous membrane; readily regenerate

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4
Q

connective tissue regenerative ability

A

bone active tissue regenerates, cartilage regeneration possible but slow, tendons and ligaments regeneration possible but slow, blood cells actively regenerate

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5
Q

muscle regenerative ability

A

smooth regeneration possible mostly in GI tract, cardiac muscle is replaced by connective tissue, skeletal muscle some regeneration in moderately damaged muscle, but mostly connective tissue replaces severely damaged

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6
Q

nerve regenerative ability

A

neuronal is nonmitotic aka irreversibly damaged, glial the cells regenerate and scar tissue replaces

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7
Q

what type of cells regenerate constantly?

A

labile cells (skin, lymphoid, bone marrow, and mucous membranes)

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8
Q

what type of cells only regenerate if damaged?

A

stable cells (liver, pancreas, kidney, bone cells)

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9
Q

what type of cells do not regenerate?

A

CNS and skeletal and cells muscle

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10
Q

primary intention

A

healing takes place where wound margins are neatly approximated (e.g. surgical incision or paper cut)

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11
Q

initial phase

A

lasts for 3-5 days, incision fills with blood to form clots and begin healing process, macrophages ingest and digest debris and fragments to begin capillary growth

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12
Q

granulation phase

A

5 days-4 weeks, fibroblasts migrate, secrete collagen, the wound is pink, vascular, and red granules are present, wound begins to resemble adjacent skin

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13
Q

maturation phase and scar contraction

A

7 days to several months, overlaps granulation phase, fibroblasts disappear as the wound becomes stronger, myofibroblasts help to cause contraction and close the wound, may be painful

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14
Q

secondary intention

A

wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide irregular wound margins, healing and granulation take place from the edges inward and from the bottom upward and there is more granulation tissue, so the scar is bigger

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15
Q

tertiary intention

A

delayed primary healing, wound may be left open and sutured closed after the infection is controlled, resulting in a larger and deeper scar

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16
Q

what classifies a wound as chronic?

A

does not heal within 3 months

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17
Q

red wound

A

superficial or deep, clean and pink, possible serosanguineous

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18
Q

examples of red wounds

A

skin tears, stage 2 pressure ulcers, partial thickness loss, second degree burns, wounds that heal by secondary intention

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19
Q

red wound dressings

A

transparent dressing, hydrocolloid, gauze, gentle atraumatic cleansing permeable to oxygen

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20
Q

yellow wound

A

prescence of slough or soft necrotic tissue, creamy ivory to yellow-green

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21
Q

examples of yellow wounds

A

wounds with nonviable necrotic tissue

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22
Q

yellow wound dressings

A

absorptive dressing, hydrocolloidal dressing, hydrogel, wound irrigations, moist gauze, wound cleansing to remove nonviable tissue and absorb excess drainage, left in place for up to 7 days

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23
Q

black wound

A

black, gray, or brown, eschar, risk of wound infection high

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24
Q

examples of black wounds

A

full thickness loss, third degree burns, stage 3 and 4 pressure ulcers, gangrenous ulcers

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25
Q

black wound dressings

A

topical debridement, hydrogel, absorptive dressing, debridement of eschar and nonviable tissue

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26
Q

lack of Vitamin C effects the wound by

A

delays collagen production for fiber and capillary development

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27
Q

lack of protein effects the wound by

A

decreases amino acids for tissue repair

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28
Q

lack of zinc effects the wound by

A

impairs epithelialization

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29
Q

inadequate blood supply effects the wound by

A

decreases supply of nutrients to the effected area, decreases removal of nonviable tissue, inhibits inflammatory response necessary in the initial stage

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30
Q

corticosteroid drugs effect the wound by

A

impair phagocytosis of WBCs, inhibit fibroblasts, depress granulation tissue, and inhibit wound contraction necessary for the last stage of healing

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31
Q

infection effects the wound by

A

increases the inflammatory response too much and tissue destruction

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32
Q

smoking effects the wound by

A

impedes blood flow to healing area

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33
Q

obesity effects the wound by

A

decreasing blood supply in fatty tissue

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34
Q

diabetes effects the wound by

A

decreasing collagen synthesis, retards capillary growth, impairs phagocytosis (resulting from hyperglycemia), reduces supply of O2

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35
Q

anemia effects the wound by

A

supplies less oxygen at tissue level

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36
Q

adhesion

A

bands of scar tissue that form between or around organs in the abdominal cavity or between the lungs and pleura

37
Q

contractures

A

normal part of healing, but complications occur when it is excessive; shortening of muscle or scar tissue results from excessive fibrous tissue formation

38
Q

evisceration

A

wound edges separate to the extent that intestines protrude through wound

39
Q

dehiscence

A

separation of previously joined wound edges

40
Q

excess granulation tissue

A

“proud flesh”, if it is cauterized or cut off, normal healing continues

41
Q

fistula formation

A

abnormal passage between organs or a hollow organ and skin

42
Q

hemorrhage

A

abnormal internal or external blood loss

43
Q

hypertrophic scar

A

occur when an overabundance of collagen is produced at healing site, raised red and hard scar that is not life threatening

44
Q

keloid formation

A

great protrusion of scar tissue that extends beyond wound edges and may form tumorlike masses

45
Q

tunneling

A

when a cotton applicator is placed in wound there is movement

46
Q

undermining

A

when a cotton applicator is placed in wound there is a “lip” around the wound

47
Q

fibrin sealant

A

used independently to seal wound sites where sutures cannot control bleedings or would aggravate bleeding

48
Q

when should antimicrobials and antibactericidals not be used?

A

on granulating tissue e.g. types of these solutions: iodine, Dakin’s solution, hydrogen peroxide, chlorhexide

49
Q

wounds that are suitable for negative pressure:

A

acute or traumatic, surgical wounds that have dehisced, pressure ulcers, and chronic ulcers

50
Q

why use negative pressure on wounds?

A

pulls fluid from wound, reduces bacterial load, encourages blood flow to wound

51
Q

what to watch for with negative pressure?

A

monitor serum protein levels and f&e due to losses from the wound, watch coagulation as well (platelets, prothrombin time PT, partial thromboplastin time PTT)

52
Q

gauze

A

provides absorption of exudates and supports debridement

53
Q

nonadherent dressing

A

minimally absorbent, used on minor wounds or as a second dressing e.g. xeroform, Vaseline gauze

54
Q

transparent film

A

semipermeable, permits gaseous exchange between wound and environment, used for dry noninfected wounds e.g. opsite, tegaderm, bioculsive

55
Q

hydrocolloid

A

wafers, powders, or pastes composed of gelatin, pectin, or carboxymethylcellulose, does not allow oxygen, supports debridement and prevents secondary infections, used for superficial or partial thickness loss e,g, duoderm

56
Q

foam

A

polymer solution, moderate to heavy amounts of exudate can be absorbed, nonadhesive, partial or full thickness loss e.g. polyderm, curafoam

57
Q

absorptive dressings

A

large volumes of exudate absorbed, maintains a moist wound surface, partial or full thickness loss e.g. ABD pads

58
Q

hydrogel

A

gives moisture, debrides, partial or full thickness loss, minimal drainage e.g. intrasite, woun’dres

59
Q

alginates

A

nonwoven, nonadhesive, derived from seaweed, forms a moist gel when in contact with exudate, e.g. seasorb, algisite

60
Q

antimicrobials

A

iodine, silver, bacteria are not able to develop resistance, partial or full thickness loss e.g. biopatch, acticoat

61
Q

hyperbaric oxygen therapy

A

delivery of oxygen at increased atmospheric pressures, which allows oxygen to diffuse into the serum rather than RBCs and transported to tissues and move past narrowed arteries and capillaries that RBCs cannot go

62
Q

autolytic debridement

A

semiocclusive or occlusive dressings that soften dry eschar

63
Q

enzymatic debridement

A

drugs applied topically to dissolve necrotic tissue and then covered with moist dressing, process can be slow and dried eschar can be removed with scalpel

64
Q

Regranex

A

platelet derived growth factor gel that accelerates healing and should only be used if wound is free of devitalized tissue and infection; do not use with cancer patients

65
Q

adequate protein needed for

A

correcting the negative nitrogen balance resulting from the increased metabolic rate and synthesis of immune factors

66
Q

adequate carbs needed for

A

increased metabolic energy needed for inflammation and healing

67
Q

adequate vitamin C needed for

A

capillary synthesis and collagen production

68
Q

adequate vitamin A needed for

A

epithelialization

69
Q

Z-technique

A

rotating a culture swan over a cleansed wound bed surface in a 10-point Z track fashion

70
Q

Levine’s technique

A

rotating a culture swab over a cleansed 1 cm area near the center of the wound using sufficient pressure to extract wound fluid from deep tissue layers

71
Q

what to know about swabs

A

do not take the specimen from exudate of eschar and do not use cotton tipped swabs

72
Q

what intention do pressure ulcers fall under?

A

second intention

73
Q

shearing force

A

pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement

74
Q

slough

A

yellow, tan, gray, green, brown

75
Q

eschar

A

tan, brown, black

76
Q

stable eschar

A

on the heels and serves as the bodys natural biologic cover and should not be removed

77
Q

suspected deep tissue injury

A

purple or maroon localized area of discolored intact skin

78
Q

stage 1 pressure ulcer

A

intact skin and nonblanchable redness

79
Q

stage 2 pressure ulcer

A

partial thickness loss of dermis with a shallow open ulcer and red/pink wound bed, shiny; NO SLOUGH OR ESCHAR

80
Q

stage 3 pressure ulcer

A

full thickness loss, subq may be visible, but no bone or muscle, slough may be present but does not obscure the depth of tissue loss; may have undermining and tunneling

81
Q

stage 4 pressure ulcer

A

full thickness loss with exposed bone, tendon, or muscle and often include undermining and tunneling

82
Q

unstageable ulcer

A

full thickness loss in which the base of the ulcer is covered by slough or eschar; REMOVE

83
Q

how often do you reassess an acute care patient for risk of pressure ulcers?

A

every 24 hours

84
Q

how often do you reassess a long term care patient for risk of pressure ulcers?

A

weekly for the first 4 weeks after admission and then at least monthly or quarterly

85
Q

how often do you reassess a home care patient for risk of pressure ulcers?

A

every visit

86
Q

how to assess a dark skin patient for pressure ulcers

A

look for changes of color such as purple or blue skin, use a natural or halogen light, feel the skin for heat and the consistency (boggy or edematous may indicate stage 1 pressure ulcer)

87
Q

what irrigation pressure is used on pressure ulcers?

A

4-15 psi

88
Q

what syringe and gauge are needed for correct irrigation pressure?

A

30 mL, 19 gauge

89
Q

do you want to keep the pressure ulcer moist, wet, or dry?

A

moist to enhance re-epithelialization

LCCC Nursing (15 decks)

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