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MODULE 1 > tissue integrity 1 > Flashcards

tissue integrity 1 Flashcards

1
Q

activated form of vitamin D

A

calcitriol

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2
Q

what is the purpose of the skin?

A

protection, sensory, vitamin D synthesis, fluid balance, and natural flora

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3
Q

what two sweat glands are found in the dermis layer of the skin?

A

eccrine sweat gland and apocrine sweat gland

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4
Q

layers of the skin from outer to inner

A

epidermis, dermis, and subcutaneous tissue

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5
Q

assessment of the skin:

A

inspect entire body, especially bony prominences, visual and tactile, assess any rashes or lesions, note hair distribution, skin color, and blanch test

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6
Q

skin assessment focus on

A

level of sensation, movement, and continence

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7
Q

skin dragging against surface is ____, can cause skin tears and blisters

A

friction

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8
Q

sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary is ___

A

shear

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9
Q

shear causes stretching and tearing of blood vessels which ____ blood flow, ____ blood pooling and lead to cell damage

A

reduce, increase

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10
Q

braden scale: low risk points are ____

A

15-18

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11
Q

braden scale moderate risk is how many points ____

A

13-14

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12
Q

high risk on braden scale points are ____

A

12 or less

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13
Q

tissue integrity interventions:

A

frequent repositioning, sitting in chair for only 2-hour intervals, anything longer may increase pressure to sacral tissue, keeping HOB at 30 degrees (NO HIGHER, unless respiratory issues), keep a written schedule of turning and positioning

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14
Q

stage I of wound staging:

A

intact skin with a localized are of nonblanchable redness

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15
Q

stage II wound staging

A

partial-thickness, skin loss with exposed epidermis, presents as an intact or ruptured serum-filmed blister

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16
Q

stage III wound staging:

A

full-thickness, skin loss, adipose tissue is visible, possible slough or eschar. may have undermining tunnel

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17
Q

stage IV wound staging:

A

full-thickness, tissue loss with exposed tendon, muscle, fascia, ligament, cartilage or bone in the ulcer

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18
Q

unstageable/unclassified wound staging:

A

full-thickness, skin or tissue loss, depth unknown because it is obscured by eschar or slough

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19
Q

suspected deep-tissue injury wound staging:

A

depth unknown

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20
Q

early intervention protocol- CHANT

A

cleanse, hydrate (& protect) skin, alleviate pressure, nourish, treat

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21
Q

intervention for redness/excoriation between skin folds

A

cleanse, dry thoroughly, place inter dry or dry AG textile in skin folds

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22
Q

intervention for red heels

A

position pressure off of heels, elevate on pillows, sage boot, and reduce friction

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23
Q

intervention protocol for red sacral/coccyx area

A

change position every 1-2 hours, HOB 30 degrees, avoid excess moisture, frequent peri care, and wrinkle free linen

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24
Q

inflammation and infection:

A

inflammation is always present with infection, but infection is not always present with inflammation

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25
Q

any disruption of the integrity and function of tissues in the body is called a _____

A

wound

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26
Q

______ causes an inflammatory response in the first ___ hours

A

tissue trauma, 24 hours

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27
Q

neutrophils are ___

A

new white blood cells

28
Q

neutrophils and macrophages remove pathogens by ____

A

phagocytosis

29
Q

vascular response is ___

A

increased capillary permeability, fluid moves into tissue spaces

30
Q

result of vascular response:

A

redness, heat, and swelling at site of injury and surrounding area

31
Q

_____ is activated to fibrin, which strengthens the blood clot, prevents spread of bacteria

A

fibrinogen

32
Q

cellular response is ____

A

neutrophils and monocytes move through capillary wall and accumulate at site of injury

33
Q

local response to inflammation

A

redness, heat, pain, swelling, loss of function

34
Q

serous is

A

clear, watery plasma

35
Q

purulent

A

is thick, yellow, green, tan, or brown- concerning**

36
Q

serosanguineous

A

pale, red, watery: mixture of serous and sanguineous

37
Q

sanguineous

A

bright red; indicates active bleeding

38
Q

clinical manifestations for systemic response to inflammation:

A

increased WBC count, malaise (lethargic), N/V, increased pulse and respiratory rate, fever

39
Q

types of inflammation: acute

A

healing in 2-3 weeks, no residual damage; neutrophils predominant cell type at site

40
Q

types of inflammation: subacute

A

same features, but lasts longer

41
Q

types of inflammation: chronic

A

may last for years, injurious agent persists or repeats injury to site, predominant cell types are lymphocytes and macrophages, may result from changes in immune system

42
Q

wound healing: regeneration

A

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

43
Q

wound healing: repair

A

healing as a result of lost cells being replaced by connective tissue, results in scar formation - more common, more complex, occurs by primary, secondary, or tertiary intention

44
Q

healing by primary intention: 3 phases

A

initial phase (3-5 days), granulation phase, maturation phase and scar is formed (7 days after)

45
Q

healing by secondary intention:

A

wounds from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss; edges can be approximated, same healing process but may need debriding

46
Q

healing by tertiary intention:

A

delayed primary intention due to delayed suturing of wound, occurs when a contaminated wound is left open and sutured closed after infection is controlled.

47
Q

factors that would influence wound healing:

A

protein, vitamins (esp. A & C), trace minerals of zinc & copper, adequate calories, tissue perfusion

48
Q

hemorrhage

A

bleeding

49
Q

hematoma

A

bleeding under skin

50
Q

dehiscence

A

separation or splitting open of layers of a surgical wound

51
Q

evisceration

A

extrusion of viscera or intestine through surgical wound

52
Q

skin tear is usually common in what type of patients?

A

older adults and those critically/chronically ill

53
Q

what is the most common drain to help remove excess fluid?

A

jackson-pratt drain

54
Q

purposes of dressings:

A

protect from microorganisms, aids in hemostasis, promotes healing by absorbing drainage, supports wound site, promotes thermal insulation, provides a moist environment

55
Q

types of dressings:

A

gauze, transparent film, hydrocolloid, hydrogel, foam, composite

56
Q

_____ antibiotics can decrease the incidence of infection in certain kinds of surgery

A

prophylactic

57
Q

most effective against cells undergoing active growth and division, one of the most widely used antibacterial drugs

A

cephalosporins

58
Q

this person said “if patient has a bedsore, it is not the patients fault it is the nurse’s fault”

A

Florence Nightingale

59
Q

when do you asses skin of a patient?

A

initiation of care (beginning of shift), then at least once a shift

60
Q

what light is the best to assess patient skin

A

natural light not flourescent

61
Q

wound approximation:

A

two edges come together

62
Q

eschar is

A

dead tissue

63
Q

factors that influence wound healing

A

nutrition, tissue perfusion, infection and age

64
Q

nutrition for wound healing

A

protein, vitamins (especially A & C), trace minerals of zinc and cooper, and adequate calories

65
Q

tissue perfusion:

A

oxygen fuels cellular functions

66
Q

how do you clean a wound?

A

from least contaminated to the surrounding skin

MODULE 1 (27 decks)

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