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Fundamentals- NUR 111 > Unit 4 > Flashcards

Unit 4 Flashcards

1
Q

What are the internal factors that influence tissue integrity?

A

age, nutrition, hydration, and disease

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2
Q

What are the external factors that influence tissue integrity?

A

activity, moisture

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3
Q

What are the layers of the skin?

A

epidermis, dermis, subcutaneous tissue

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4
Q

What factors affect skin integrity?

A

age, mobility status, nutrition, hydration, sensation level, impaired circulation, medications, fever, and infection.

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5
Q

What is used to classify wounds?

A

open/closed, acute/chronic, clean/contaminated/infected, superficial/partial or full thickness, and/or penetrating.

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6
Q

What is assessed with wounds?

A

location, size, drainage, appearance, and odor.

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7
Q

What are the types of wound drainage?

A

serous, sanguineous, serosanguineous, and purulent.

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8
Q

What is serous drainage?

A

clear, watery plasma

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9
Q

What is sanguineous drainage?

A

bright red, current bleeding, bloody drainage.

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10
Q

What is serosanguineous drainage?

A

pale, red, watery mix blood & straw colored.

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11
Q

What is purulent drainage?

A

thick, yellow/green/tan, contains pus

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12
Q

What is regeneration?

A

renewal of tissues

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13
Q

What are the three types of wound healing?

A

primary intention healing, secondary intention healing, and tertiary intention healing.

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14
Q

What are characteristics of primary intention healing?

A

tissue surfaces approximated. minimal or no tissue loss. minimal scarring. less risk for infection. incision wound.

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15
Q

What are characteristics of secondary intention healing?

A

tissue surfaces can not be approximated. considerable tissue loss, scarring, pressure ulcer. heals inside out.

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16
Q

What are characteristics of tertiary intention healing?

A

delayed closure of wound edges. infection. debridement.

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17
Q

What are the phases of wound healing?

A

inflammatory phase, proliferative phase, and maturation or remodeling.

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18
Q

What occurs during the inflammatory phase?

A

hemostasis and phagocytosis. 1-5 days.

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19
Q

What occurs during the proliferative phase?

A

granulation tissue. 3-21 days.

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20
Q

What occurs during maturation or remodeling phase?

A

wound comes together. 14 days - 2 years.

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21
Q

What are the complications of wound healing?

A

hemorrhage, infection, dehiscence, evisceration and fistula formation.

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22
Q

What is dehiscence?

A

the pulling apart of an incision

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23
Q

What is evisceration?

A

the pulling apart of an incision and an organ coming out of the wound.

24
Q

What are the nursing interventions of wound healing?

A

facilitate wound healing, promote optimal nutrition and hydration, prevent infection, and position to minimize pressure on the wound.

25
Q

What are the key components of wound care?

A

patient comfort & privacy, infection control, assessment, proper technique, and documentation.

26
Q

What is a pressure ulcer?

A

skin breakdown caused by unrelieved pressure to an area results in ischemia. affects 15% of hospitalized patients. costs hospitals $5-8.5 billion/year

27
Q

What are intrinsic factors that are risk factors for pressure ulcers?

A

immobility, impaired sensation, aging, fever, and malnourishment.

28
Q

What are extrinsic factors that are risk factors for pressure ulcers?

A

friction, shearing, and exposure to moisture.

29
Q

What is in the upper airway?

A

nasal passages, mouth, pharynx, and larynx.

30
Q

What is in the lower airway?

A

trachea, bronchi, and bronchioles.

31
Q

What is ventilation?

A

movement of air into/out of the lungs

32
Q

What is inhalation?

A

the movement of air into the lungs

33
Q

What is exhalation?

A

the movement of air out of the lungs

34
Q

Where does the exchange of oxygen and carbon dioxide occur?

A

between the alveoli & pulmonary capillary membranes in the lungs.
between the peripheral capillary and cellular membranes in the body tissues.

35
Q

What controls breathing?

A

chemoreceptor sites in body detect alterations of O2 and CO2 levels.

36
Q

Why is ventilation increased or decreased?

A

to maintain normal O2 and CO2 levels

37
Q

What is the primary respiratory drive?

A

high CO2 levels. (hypercarbia)

38
Q

What is the secondary respiratory drive?

A

low O2 levels. (hypoxemia)

39
Q

What affects ventilation?

A

changes in breathing patterns, patency of airway, irritation or inflammation of the respiratory mucosa, damage to supporting thoracic structures, and interference with gas exchange.

40
Q

What is tachypnea?

A

fast breathing rate

41
Q

What is bradypnea?

A

slow breathing rate

42
Q

What is apnea?

A

a suspension of breathing

43
Q

What is dyspnea?

A

difficulty or labored breathing

44
Q

What is orthopnea?

A

shortness of breath while laying flat.

45
Q

What causes decreased lung compliance?

A

pneumothorax, pneumonia

46
Q

What causes decreased lung elasticity?

A

COPD, emphysema

47
Q

What causes increased airway resistance?

A

blockage, asthma.

48
Q

How do you assess oxygenation status?

A

respiratory rate/pattern
respiratory effort
adventitious breath sounds
perfusion

49
Q

What diagnostic testing assesses oxygenation?

A

arterial blood gases. pulse oximetry. peak expiratory flow rate. chest x-ray.

50
Q

What are interventions to promote respiratory function?

A

hydration, deep breathing exercises, incentive spirometer. air way patency-suctioning. evaluation of ABGs.

51
Q

What are the signs/symptoms of hypoxemia?

A

mild to moderate: agitation, confusion, tachycardia, dyspnea.
severe: lethargy, increasing dyspnea, tachycardia, cyanosis.

52
Q

Types of oxygen administration?

A

nasal cannula, simple face mask, partial rebreather, nonrebreather, venturi, and face tent.

53
Q

What are complications of oxygen therapy?

A

oxygen supports combustion. oxygen tanks are under pressure. Pulmonary oxygen toxicity-100% O2, leads to alveolar collapse and reduced lung elasticity.

54
Q

What are independent nursing interventions for oxygenation?

A

deep breathing exercises, positioning, promoting secretion clearance. monitoring activity intolerance, assisting with ADLs, and encourage smoking cessation/healthy lifestyle practices.

55
Q

What are collaborative nursing interventions for oxygenation?

A

improving nutrition, pharmacologic therapy, oxygen administration and safety, and inhale or exhale.

Fundamentals- NUR 111 (4 decks)

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