Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

IM 1 > Tissue Integrity - Exam 4 > Flashcards

Tissue Integrity - Exam 4 Flashcards

1
Q
  • largest organ
  • protective barrier
  • nursing responsibility to assess and monitor skin integrity
A

Skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the purpose of the skin?

A
  • protection
  • sensory
  • vitamin D synthesis
  • Fluid balance
  • natural flora
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What to assess on the skin?

A
  • bony prominences **
  • visual and tactile
  • assess any rashes or lesions
  • note hair distribution
  • skin color
  • blanch test
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How often do you assess high risk patients ?

A

Assess every 4 hours or more often

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

During the skin assessment identify signs and symptoms of?

A

Impaired skin integrity
Poor wound healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Assess skin when

A
  • on admission
  • at least once/shift
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

We palpate areas of redness to determine if skin in

A

Blanchable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Sensory perception

A

Ability to respond meaningfully to pressure related discomfort

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Moisture

A

Degree to which skin is exposed to moisture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Activity

A

Degree of physical activity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Mobility

A

Ability to change and control body position

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Nutrition

A

Usual food intake pattern

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Sensory Perception:
completely limited

A

-unresponsive
- limited ability to feel pain over most of the body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Sensory Perception:
- Very limited

A
  • painful stimuli
  • cannot communicate discomfort
  • sensory impairment over half the body
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Sensory Perception:
- slightly limited

A
  • verbal commands
  • cannot always communicate discomfort
  • sensory impairment 1-2 extremities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Sensory Perception
- no impairment

A
  • verbal commands
  • no sensory deficit
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Sensory Perception

A
  • completely limited
  • very limited
  • slightly limited
  • no impairment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Moisture
- constantly moist

A
  • perspiration, urine, ect
  • always
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Moisture
- very moist

A
  • often but not always
  • linen changed at least once per shift
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Moisture
- occasionally Moist

A
  • extra linen changed qday
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Moisture
- rarely moist

A
  • usually dry
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Moisture

A
  • constantly moist
  • very moist
  • occasionally moist
  • rarely moist
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Activity
- bedfast

A

Never out of bed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Activity
- chairfast

A
  • ambulation severely limited to non-existent
  • cannot bear own weight (assisted to chair)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Activity
- walks occasionally

A
  • short distances daily with or without assistance
  • majority of time in bed or chair
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Activity
- walks frequently

A
  • outside room 2x per day
  • inside room q2 hours during walking hours
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Mobility
- completely immobile

A

makes no change in body or extremity position

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Mobility
- very limited

A
  • occasional slight changes in position
  • unable to make frequent/significant changes independently
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Mobility
- slightly limited

A

frequent slight changes independently

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Mobility
- no limitation

A
  • major and frequent changes without assistance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Nutrition
- very poor

A
  • never ears complete meal, very little protein
  • NPO, clear liquids, IV > 5 days
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Nutrition
- probably inadequate

A
  • barely eats complete meal, some protein
  • occasionally takes dietary supplement
  • Receives less than optimum liquid diet or two feeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Nutrition
- adequate

A
  • eats over half of most meals, adequate protein
  • usually takes a supplement
  • Tube feeding or TPN probably meets nutritional need 
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Nutrition
- excellent

A
  • eats most of meal, never refuses, plenty of proteins
  • occasionally eat between meals
  • Does not require supplements 
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Friction and Sheer
- problem

A
  • moderate to maximum assistance in moving
  • frequently slides down in bed or chair
  • Spasticity, contractures or agitation leads to almost constant friction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Friction and sheer
- potential problem

A
  • moves feebly, requires minimum assistance
  • skin probably slides against sheets
  • relatively good position in chair or bed with occasional sliding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Friction and sheer
- no apparent problem

A
  • moves in bed and chair independently
  • Sufficient muscle strength to lift up completely during move
  • Good position in bed or chair
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Low risk (Braden scale)

A

15-18

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q
  • regular turning schedule
  • enable as much activity as possible
  • protect heels
  • manage moisture, friction and sheer
A

Low risk 15-18

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Moderate risk (Braden scale)

A

13-14

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q
  • regular turning schedule
  • enable as much activity as possible
  • protect heels
  • manage moisture, friction and sheer
  • position patient at 30 degree lateral incline using wedges or pillows
A

Moderate risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

High risk (Braden scale)

A

12 or less

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q
  • regular turning schedule
  • enable as much activity as possible
  • protects heels
  • manage moisture, friction, and sheer
  • position patient at 30 degree lateral incline using wedges or pillows
  • make small shrifts in position frequently
  • pressure redistribution surface
A

High risk 12 or less

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Stage 1 (wound staging)

A

Nonblanchable redness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Stage II (wound staging)

A

Partial- thickness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Stage III

A

Full thickness skin loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Stage IV - wound staging

A

Full-thickness tissue loss

48
Q

Unstageable/unclassified

A

Full thickness skin or tissue loss-depth unknown

49
Q

Suspected deep

A

Tissue injury depth unknown

50
Q

What does the C in “chant” mean

A

Cleanse

51
Q

What does the H mean in Chant

A

Hydrate and protect the skin

52
Q

What does the “A” mean in CHANT

A

Alleviate pressure

53
Q

What does the “N” in CHANT mean?

A

Nourish

54
Q

What does the “T” in CHANT mean?

A

Treat

55
Q

What are the 4 nursing priorities for skin?

A

-Assessing and monitoring skin integrity
-Identifying risks
-Identifying present skin problems
-Planning, implementing, and evaluating interventions to maintain skin integrity

56
Q

Sequential response to cell injury

A

-Neutralizes and dilutes inflammatory agent
- removes necrotic materials
- establishes an environment suitable for healing and repair

57
Q

Inflammation is always present with ______, but infection is not always present with ______.

A

Infection; inflammation

58
Q

Tissue trauma causes an ___ ____ in the first 24hours

A

Inflammatory response

59
Q

Vascular response result

A

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

60
Q

—— and —— move through capillary wall and accumulate at site if injury

A

Neutrophils / monocytes

61
Q

Bone Morrow releases more —- in response to infection, WBC elevated

A

Neutrophils

62
Q

Local response to inflammation

A

Redness
Heat
Pain
Swelling
Loss of function

63
Q

Systemic response to inflammation

A

Increased WBC count
Malaise
Nausea
Anorexia
Increased pulse and RR
Fever

64
Q

Acute inflammation

A
  • healing in 2-3 weeks, no residual damage
  • neutrophils predominant cell type at site
65
Q

Subacute

A

Last longer then acute

66
Q

Chronic inflammation

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
67
Q

Health promotion

A
  • prevention of injury
  • adequate nutrition
  • early recognition of injury/inflammation
  • immediate treatment
68
Q

Classic manifestations of inflammation may be masked for _____ patient, early symptom may be general malaise

A

Immunosuppressed

69
Q

Vitals signs change how when infection is present?

A

Temperature
Pulse
Respiratory rate may increase

70
Q

Fever greater than ___ can be damaging to body cells

A

104

71
Q

Finale phase of inflammatory process is ?

A

Healing

72
Q

What are the two major components of healing?

A

Regeneration & repair

73
Q

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

A

Regeneration

74
Q

Healing as a result of lost cells being replaced by connective tissue, results in scar formation

A

Repair

75
Q

What are the three phases of healing by primary intention

A
  1. Initial phase
  2. Granulation
  3. Maturation phase
76
Q

Initial phase

A

3-5 days
Acute inflammatory response

77
Q

Granulation phase

A
  • fibroblast secrete collagen
  • wound pink & vascular
  • risk for dehiscence
  • resistant to infection
78
Q

Maturation phase

A
  • scar formation
  • begins 7 days after injury
  • fibroblast disappear
  • wound becomes stronger
  • mature scar forms
79
Q

Healing by ——- intention, where the wound may need to be debriefed before healing can take place

A

Secondary

80
Q
  • irregular, large wound with blood clot
  • granulation tissue filled in wound
  • large scar
A

Healing by secondary intention

81
Q

Occurs when a contaminated wound is left open and sutured closed after infection is controlled

A

Healing by tertiary intention

82
Q
  • contaminated wound
  • granulation tissue
  • delayed closure with suture
A

Healing by tertiary intention

83
Q

What are the three components of wound healing for partial- thickness wounds?

A
  • inflammatory response
  • epithelial proliferation and migration
  • reestablishment of epidermal layers
84
Q

What are the four phases in full thickness wound healing?

A
  • Hemostasis
  • inflammatory phase
  • proliferative phase
  • maturation phase
  • full thickness wounds extend into dermis, they heal by scar formation
85
Q

Factors that influence wound healing

A

Nutrition, tissue perfusion, infection, and age

86
Q

Nutrition- wound healing

A

-Protein, vitamins, and trace minerals of zinc & copper
- adequate calories

87
Q

Tissue perfusion - wound healing

A

Oxygen fuels cellular functions

88
Q

Age - wound healing

A

Decreased function of macrophages leads to delayed inflammatory response in older adults

89
Q

Hemorrhage

A

Bleeding

90
Q

Hematoma

A

Bleeding under skin

91
Q

Infection

A

Bacteria, virus

92
Q

Dehiscence

A

Wound opens up

93
Q

Evisceration

A

Wound falling out

94
Q

Wounds are classified by

A

Cause and depth
- surgical/ non surgical
- acute or chronic
Superficial, partial thickness , full thickness

95
Q

Wound cause by shear, friction, and blunt force

A

Skin tear
- can be partial thickness or full thickness

96
Q

Wound assessment should happen when?

A

On admission and every shift

97
Q

Wound assessments include

A

Location, size, condition of surrounding tissue, and wound base

98
Q

Tunneling

A

Looking at a wound and goes deeper than what we can see

99
Q

Undermining

A

Wound expanding under skin

100
Q

Management of wounds includes

A
  • types of dressings
  • depends on type
  • extent
  • character of wound
  • phase of healing
101
Q

What can we use on wounds for closure ?

A

Adhesive strips
Sutures
Staples

102
Q

What is the enemy of wound healing?

A

Dryness

103
Q

Antimicrobial and antibactericidal solutions can damage new epithelium and delay healing, should not use in a clean ____ ____

A

Granulating wound

104
Q

Surgical wounds may be covered with ____ ___, removed in _____ days

A

Sterile dressing. 2-3 days

105
Q

What is the most conning drain type for wounds

A

Jackson-Pratt

106
Q

Debridement

A

Removal of dead tissue and debris

107
Q

Purposes of dressings

A

Protects
Aids in hemostasis
Promotes healing
Supports wound site
Promotes thermal insulation
Provides a moist environment

108
Q

Types of dressings

A
  • gauze
  • transparent film
  • hydrocolloid
  • hydrogel
  • foam
  • composite
109
Q

Prepare the patient for a dressing change

A
  • review previous wound assessment
  • evaluate pain ~pain meds needed?
  • describe procedure
  • gather all supplies
    Recognize normal signs of healing
  • answer questions about procedure or wound
110
Q

Cleaning skin and drain sites

A
  • clean from least contaminated to the surrounding skin
  • gentle friction
  • when irrigating, allow the solution to flow from the least to most contaminated area
111
Q

Suture removal

A

How many to remove- document
Clip near skin, opposite of knot

112
Q

Steri-strips

A

Don’t pull or create tension
Teach to allow them to fall off naturally
(About 10 days)

113
Q

——- doses of antibiotics can decrease the incidence of infection in certain kinds of surgery

A

Prophylactic

114
Q

Prophylactic antibiotics should be given when

A

Prior to surgery

115
Q

Cephalosporins are widely used, especially —- and —- generations

A

First; seconds

116
Q

Most effective against cells undergoing active growth and division. One of the most widely used antibacterial drugs

A

Cephalosporins

117
Q

Surgical site infection prevention

A

May be given prophylactic antibiotics

IM 1 (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions