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Module 1 Exam 4 > Tissue Integrity Part 2 > Flashcards

Tissue Integrity Part 2 Flashcards

1
Q

What is at fault when a pt gets a bedsore?

A

The Nurse

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2
Q

What are some natural flora on the skin?

A

Staph.
Strep.
E. Coli

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3
Q

What is the activated form of Vitamin D?

A

Calcatriol

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4
Q

What layer of skin are most structures located in?

A

the dermis

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5
Q

What does the subcutaneous layer of skin hold?

A

Maybe some of the apocrine glands
blood vessels
fat

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6
Q

What can a lack of hair indicate?

A

Low/Bad Circulation

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7
Q

What is the best light source to assess skin?

A

Natural light

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8
Q

When should you assess HIGH RISK pt’s?

A

even 4 hours

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9
Q

What should you watch for on pt’s when a pt has medical devices? (Like IV’s or Call Lights)

A

They can rub against and damage skin

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10
Q

On the Braden scale, what is the difference between Mobility and Activity?

A

Activity = Ability to move out of bed/Walking around
Mobility = Moving around in bed

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11
Q

What can cause a 1 on the Braden Scale for moisture?

A

Inflammation

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12
Q

How does Nutrition play a role in skin health?

A

Protein and fats are very important to help skin

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13
Q

Signs of No, Potential or obvious problems for friction/shear?

A

No = Can move independently
Potential = Moves feebly w/ lil assist.
Obv = Moderate to max assistance

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14
Q

Braden scale ranges.

A

15-18 = Low Risk
13-14 = Moderate risk
12 or less = High risk

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15
Q

What devices are used on high risk pt’s?

A

Pressure redistribution devices

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16
Q

What’s a good method of frequent repositioning?

A

Sitting in chair for 2-hour intervals

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17
Q

What is the early intervention protocol for skin integrity?

A

C.H.A.N.T
Cleanse
Hydrate skin
Alleviate pressure
Nourish
Treat

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18
Q

Excoriated

A

Diaper Rash

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19
Q

On heavier pt’s, where can you see skin breakdown?

A

In between skin folds

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20
Q

What can you place in skin folds to help?

A

Dry tactile to reduce rough friction

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21
Q

What should you make sure linens are free of on pt beds?

A

Wrinkles

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22
Q

Wound

A

Any disruption of the integrity and function of tissue

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23
Q

How fast can trauma cause inflammatory responses?

A

24hr

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24
Q

What are Mast Cells?

A

Ball of Chemical Mediators. Helps w/ vasodilation/constriction to stop bleeding

25
Q

Whatre neutrophils?

A

New White Blood Cells

26
Q

Inflammatory Process?

A
  1. Bacteria enters wound
  2. Platlests stop blood
  3. Mast cells activate
  4. Neutrophils secrete factors
    5 Neu. and Macrophages removes pathogens
  5. Macrophages secrete cytokines to attract tissue repair
27
Q

5 signs of inflammations

A

Redness
Heat
Pain
Swelling
Loss of Function (Rare)

28
Q

What is exudate made of?

A

Fluid and leukocytes

29
Q

What is the vascular response to inflammation?

A

More cap. permiability
Serous fluid
Causes the signs of inflammation
Activates fibrin to strengthen blood clots

30
Q

Types of exudate?

A

Serous
Purulent
Serosanguineous
Sanguineous

31
Q

What to do when there’s lots of sero/sanguineous fluid

A

Apply pressure

32
Q

Systemic Responses to inflammation?

A

More WBC
Malaise/Lethargy
N&V
^ Pulse and resp.
FEVER

33
Q

3 types of inflammation?

A

Acute (2-3 weeks w/ no damage)
Subacute (Just lasts a bit longer)
Chronic: Years2

34
Q

2 major types of would healing?

A

Regeneration: Replacing lost cells w/ cells of same type
Repair: Lost cells replaces w/ conn. tissue, causes scars, more common and complex, caused by primary, secondary,, or tertiary intention

35
Q

3 phases of primary intention healing?

What is it also called?

A

Initial Phase: Acute Inflammation
Granulation: Collagen secreted,
Maturation & Scarring: 7 days after injury, lasts months/years, fibroblasts leave,

Edge-Edge or Wound Approximation

36
Q

What causes secondary intention healing?

A

Trauma, ulcers, Infection

37
Q

What can wounds healed by sec. intention not do? How do they heal?

A

Cannot approximate.
They heal from the inside out

38
Q

What causes tert. intention healing?

A

Delaying primary intention by SUTURING WOUNDS due to INFECTED WOUNDS

39
Q

How to use tert. healing

A

Clean infected wound
Suture wound
Let heal

40
Q

Factors affecting wound healing?

A

Nutrition
Perfusion
Infection
Age

41
Q

Dehiscence

A

Opening of surgical wounds

42
Q

Evisceration

A

Intestines dropping from surgical wounds

43
Q

5 complications of wound healing?

A

Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration

44
Q

How are wounds classified?

A

Cause and Depth
Surgical or non
Acute/Chronic

45
Q

What’s a skin tear?

A

Caused by shear friction or blunt force
Has the skin flap

46
Q

How to assess and doc wounds?

A

Include:
Location
Size
Surrounding tissue condition
Wound Base
Any Drainage

47
Q

What is the enemy of wound healing?

A

Dryness, but it can’t be too moist either, theres a fine line

48
Q

Debridement

A

Cleaning of a wound

49
Q

What are the purposes of dressings?

A

Protects from microorganisms
Helps Hemostasis
Absorbs drainage and cleanse
Supports wound site
Thermal insulation
Gives moist environment

50
Q

Types of dressings

A

Gauze
Transparent Film
Hydrocolloid
Hydrogel
Foam
Composite

51
Q

When changing dressings, what must you know?

A

Type, drains placement, needed equipment

52
Q

How to prep a pt to change dressing?

A

Review wound assessment
Evaluate pain give analgesics if needed
Describe procedure
Gather supplies
Check for normal healing signs
Answer questions

53
Q

How to change dressings?

A

give analgesic meds 30-60 mins before
Remove tape
Clean wound edges
place dressings and drains carefully
Reposition pt
Date, time, document

54
Q

How to properly clean skin and drain sites

A

Clean from left to most contaminated sites
Use gentle friction

55
Q

How to cute sutures before you remove them?

A

Cut as close to the skin as possible without harming pt

56
Q

How long do steri-strips last

A

10 days

57
Q

Most common drug for skin infection?

A

Cephalosporins

58
Q

When about to do surgery, when should antibiotics be given?

A

Before surgery and MAYBE one after but very rarely

59
Q

For what type of surgeries can you give antibiotics before?

A

Surgical Site Infection

Module 1 Exam 4 (5 decks)

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