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Nursing > Nursing Procedures - sem 1 2nd Half > Flashcards

Nursing Procedures - sem 1 2nd Half Flashcards

1
Q

Skin function - protection

A

Protects from microorganisms, dehydration, UV radiation, medical trauma and chemical hazards

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2
Q

Skin function - sensation

A

Hot cold pain touch pressure are all sensory receptors of sensation

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3
Q

Skin manufactures what vitamin

A

Vit D
Which ensures calcium absorption

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4
Q

Skin function - flexibility

A

For movement of the body to occur without injury, the skin must be supple and elastic. It grows as we grow an exhibit stretch and recoil characteristics that permit changes in body contours to occur without tearing or laceration.

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5
Q

Hormone (vit d) production

A

First step of the production in the body occurs when the skin is exposed to ultraviolet light

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6
Q

Skin function - exertion

A

By regulating volume and chemical content of sweat, the body through function of the skin can influence both its total fluid volume in the amounts of certain waste products such as uric acid and urea that are excreted

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7
Q

Epidermis is made of…

A

Epithelial tissue

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8
Q

Structure of the epidermis

A

Covered in normal flora
Avascular
Contains no nerves or glands
The cells of the epidermis are found in up to 5 distinct layers

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9
Q

Dermoepidermal junction

A

Glues the epidermis and dermis together
Stops things from the environment making way to the dermis into the blood

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10
Q

The 2 layers of the dermis are…

A

Papillary and reticular

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11
Q

Structure of the dermis

A

Tough leathery layer that sits between the derma and the hypodermis
Made of fibrous connective tissue
Provides a storage area for water and electrolytes
Vascular
Contains muscle fibres, sweat and sebaceous glands, hair follicles macrophages and dendritic cells
Contains a wide network of nerves and nerve endings or sensory receptors

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12
Q
A
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13
Q

Fibroblasts

A

Are important during wound
Produces collagen and elastin
As we age, we begin to produce less fibroblasts

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14
Q

Structure of the hypodermis

A

Located between the dermis and underlying structures of the body
Made of fibrous and adipose tissue
Carries a major blood vessels and nerves to the skin

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15
Q

Melanin is dependant on

A

Genetics
Sun exposure

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16
Q

The 2 types of glands

A

Sweat and sebaceous

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17
Q

Hair follicles

A

Follicle is connected to arrector pili muscles
Follicles contain a large number of sensory fibres

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18
Q

Structure of nails include the…

A

Nail body, lunula, cuticle and nail root

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19
Q

Nails are made from

A

Keratin
Which contributes to their protective function?

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20
Q

Sweat gland contain 2 glands

A

Eccrine glands - found all over the body produced sweat/perspiration, which removes waste, maintains body temp

Apocrine glands - located in the axilla, breast and anal region. Not until puberty that they become active.

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21
Q

Sebaceous gland

A

Located wherever hair grows
Secret sebum for the skin and hair

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22
Q

Clinical judgment model

A

Noticing -gathering info (subjective and objective)
Interpreting - what is the most likely explanation?
Responding - what needs to happen now?
Reflecting - evaluate outcome and decide what next

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23
Q

Older adults skin changes

A

Thinning skin, reduced ability for healing due to poor circulation issues, poor nutrition - needs a lot of protein

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24
Q

SCOTTT skin observation

A

Skin changes
Colour
Oedema
Temp
Texture
Turgor

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25
Nails clubbing
The nail plate shape and angle is >180 degrees maybe caused by long-term lack of oxygen
26
Skin oedema
Presence of excess fluid in the interstitial compartment Usually appears swollen, stretched and shiny Typical sites are feet, ankles and sacrum Graded with a + system
27
The 2 assessments for prevention for pressure injuries
SSKIN assesment (nursing assessment skills) Braden scale (risk assessment tools)
28
Lesion characteristics
Location and distribution Colour Pattern Elevation Size and shape Edges Characteristics
29
Braden scale covers:
Sensory perception Moisture Activity Mobility Nutrition Friction and shear
30
31
ABCDE’s of melanoma
Asymmetry Border Colour Different Evolving
32
Acute wound healing timeline
Often within 2 weeks
33
Chronic wound healing timeline
Longer than 3 weeks Some may never heal
34
In the wound healing process phagocytes cells remove what?
Necrotic/dead and damaged tissues
35
The 4 processes of healing
Haemostasis Inflammation Proliferation Maturation
36
Vasoconstriction
Stops bleeding
37
Vasodilation
Causes inflammation - stops infection
38
Haemostasis phase 1
Vasoconstriction Blood vessels constrict this causes the wound to close as a result there is less or no bleeding from the injury/wound
39
Haemostasis phase 2
Formation of platelet plug Collagen fibres are seen where the epithelium has been damaged Platelet stick to the collagen fibres within in the blood vessel of walls This causes a plug to form
40
Haemostasis phase 3
The bio chemical response Involves a complex chemical cascade whereby once the clot has developed it begins to breakdown and is replaced by wound edge joining the wound back together Fibro restores the tissue and add strength to the wound by attracting to the platelets holding the clot in place
41
Inflammation stage 2
Involves both cellular vascular response Involves vasodilation, activation of compliment, movement of leucocytes
42
Inflammation approx 2-3 days for wounds healing
Phagocytic leukocytes - neutrophils and macrophages clean up foreign cells and foreign debris and dead tissue The presence of phagocytic cells brings an increase in fibroblasts and epithelial cells Fibroblast manufacture new collagen and extra cellular matrix Newly formed granulation tissue joints of vessels beginning to close the wound
43
Proliferation stage 3
Extensive growth of epithelial cells The laying down of collagen by fibroblasts the extra cellular matrix makes women strong stronger A gel light substance is laid down in the wound bed The substance allows collagen and ground substance to contribute to decrease in the size of the wound and gives the wound renewed strength and flexibility
44
During proliferation
New capillary development is seen as bumpy granulation tissue at the base of the wound. Epithelial cell migration occurs over the granulated wound bed and epithelial has migrate from surrounding wound edges or from hair follicles, sweat or sebaceous glands in the wound and appear as a thin translucent form across the wound bed.
45
Proliferation approx 2-24 days
The wound continues, tore it back together New capillaries are formed bringing improved blood flow oxygen and nutrients to the injured area During this phase, the body fills the wound with connect tissue (granulation) Contracts the wound edges The proliferation phase involves regeneration of blood vessels and formation of connective tissue which is fragile and can bleed easy
46
Maturation stage 4
Granulation tissue fills the Increased blood flow The arrangement of collagen become stronger 80% of normal strength Formation of a scar from collagen This phase is also also known as remodelling During this stage fibroblast leave the side of the wound vascular restrictions reduced
47
Is a healed wound as strong as normal skin
No 80% of normal strength
48
Factors affecting wound healing
Co- morbidities Nutrition and hydration Age Medications Infection Smoking
49
Effects of ageing on wound healing
Decrease sensory perception Increased dryness of the skin Skin becomes thinner and less elastic reduce collagen and elastin and adipose tissue Decreased vit D synthesis Reduced immune response Decreased thermoregulation Decrease blood supply to skin
50
Generic vs brand names of drugs
Generic - chemical name of drug - people who manufacture social make the drug Trade/brand - trade/advertise/product name- by people who sell the drug
51
Paracetamol is not a
Anti inflammatory or antiplatelet agent
52
4 signs of inflammation
Redness Swelling Heat Pain
53
Pharmokinetics 4 stages
Absorption - blood stream and small intestines Distribution - through the blood stream Metabolism - by the liver Excretion - by the kidneys
54
55
Forms of paracetamol
Tablet Capsule Caplet Soluble tablet Oral liquid Liquid for injection Oral powder Suppository
56
Dosage or paracetamol
Adults - 0.5-1g (1-2 tablets) every 4-6 hrs MAXIMUM-4g (8 tablets) in 24hrs Children - depends of age, weight and strength of paracetamol
57
58
Thrombopoietin is produced where ?
Liver
59
Leukocytes are regulated by the…
Liver
60
Liver impairment
If the liver is not functioning, the body will not be able to break drugs down in this can cause toxicity
61
Renal impairment
Paracetamol should be administered with caution to patients with the renal impairment. Elimination of paracetamol can be delayed for those with severe renal impairment. Administration of paracetamol should be at an interval of at-least 6hrs

Nursing (6 decks)

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