Unit 4 Flashcards
What are the internal factors that influence tissue integrity?
age, nutrition, hydration, and disease
What are the external factors that influence tissue integrity?
activity, moisture
What are the layers of the skin?
epidermis, dermis, subcutaneous tissue
What factors affect skin integrity?
age, mobility status, nutrition, hydration, sensation level, impaired circulation, medications, fever, and infection.
What is used to classify wounds?
open/closed, acute/chronic, clean/contaminated/infected, superficial/partial or full thickness, and/or penetrating.
What is assessed with wounds?
location, size, drainage, appearance, and odor.
What are the types of wound drainage?
serous, sanguineous, serosanguineous, and purulent.
What is serous drainage?
clear, watery plasma
What is sanguineous drainage?
bright red, current bleeding, bloody drainage.
What is serosanguineous drainage?
pale, red, watery mix blood & straw colored.
What is purulent drainage?
thick, yellow/green/tan, contains pus
What is regeneration?
renewal of tissues
What are the three types of wound healing?
primary intention healing, secondary intention healing, and tertiary intention healing.
What are characteristics of primary intention healing?
tissue surfaces approximated. minimal or no tissue loss. minimal scarring. less risk for infection. incision wound.
What are characteristics of secondary intention healing?
tissue surfaces can not be approximated. considerable tissue loss, scarring, pressure ulcer. heals inside out.
What are characteristics of tertiary intention healing?
delayed closure of wound edges. infection. debridement.
What are the phases of wound healing?
inflammatory phase, proliferative phase, and maturation or remodeling.
What occurs during the inflammatory phase?
hemostasis and phagocytosis. 1-5 days.
What occurs during the proliferative phase?
granulation tissue. 3-21 days.
What occurs during maturation or remodeling phase?
wound comes together. 14 days - 2 years.
What are the complications of wound healing?
hemorrhage, infection, dehiscence, evisceration and fistula formation.
What is dehiscence?
the pulling apart of an incision
What is evisceration?
the pulling apart of an incision and an organ coming out of the wound.
What are the nursing interventions of wound healing?
facilitate wound healing, promote optimal nutrition and hydration, prevent infection, and position to minimize pressure on the wound.
What are the key components of wound care?
patient comfort & privacy, infection control, assessment, proper technique, and documentation.
What is a pressure ulcer?
skin breakdown caused by unrelieved pressure to an area results in ischemia. affects 15% of hospitalized patients. costs hospitals $5-8.5 billion/year
What are intrinsic factors that are risk factors for pressure ulcers?
immobility, impaired sensation, aging, fever, and malnourishment.
What are extrinsic factors that are risk factors for pressure ulcers?
friction, shearing, and exposure to moisture.
What is in the upper airway?
nasal passages, mouth, pharynx, and larynx.
What is in the lower airway?
trachea, bronchi, and bronchioles.
What is ventilation?
movement of air into/out of the lungs
What is inhalation?
the movement of air into the lungs
What is exhalation?
the movement of air out of the lungs
Where does the exchange of oxygen and carbon dioxide occur?
between the alveoli & pulmonary capillary membranes in the lungs.
between the peripheral capillary and cellular membranes in the body tissues.
What controls breathing?
chemoreceptor sites in body detect alterations of O2 and CO2 levels.
Why is ventilation increased or decreased?
to maintain normal O2 and CO2 levels
What is the primary respiratory drive?
high CO2 levels. (hypercarbia)
What is the secondary respiratory drive?
low O2 levels. (hypoxemia)
What affects ventilation?
changes in breathing patterns, patency of airway, irritation or inflammation of the respiratory mucosa, damage to supporting thoracic structures, and interference with gas exchange.
What is tachypnea?
fast breathing rate
What is bradypnea?
slow breathing rate
What is apnea?
a suspension of breathing
What is dyspnea?
difficulty or labored breathing
What is orthopnea?
shortness of breath while laying flat.
What causes decreased lung compliance?
pneumothorax, pneumonia
What causes decreased lung elasticity?
COPD, emphysema
What causes increased airway resistance?
blockage, asthma.
How do you assess oxygenation status?
respiratory rate/pattern
respiratory effort
adventitious breath sounds
perfusion
What diagnostic testing assesses oxygenation?
arterial blood gases. pulse oximetry. peak expiratory flow rate. chest x-ray.
What are interventions to promote respiratory function?
hydration, deep breathing exercises, incentive spirometer. air way patency-suctioning. evaluation of ABGs.
What are the signs/symptoms of hypoxemia?
mild to moderate: agitation, confusion, tachycardia, dyspnea.
severe: lethargy, increasing dyspnea, tachycardia, cyanosis.
Types of oxygen administration?
nasal cannula, simple face mask, partial rebreather, nonrebreather, venturi, and face tent.
What are complications of oxygen therapy?
oxygen supports combustion. oxygen tanks are under pressure. Pulmonary oxygen toxicity-100% O2, leads to alveolar collapse and reduced lung elasticity.
What are independent nursing interventions for oxygenation?
deep breathing exercises, positioning, promoting secretion clearance. monitoring activity intolerance, assisting with ADLs, and encourage smoking cessation/healthy lifestyle practices.
What are collaborative nursing interventions for oxygenation?
improving nutrition, pharmacologic therapy, oxygen administration and safety, and inhale or exhale.
