WEEK 11 Flashcards
tissue integrity and gas exchange
1
Q
what is the largest organ in the body
A
the skin
2
Q
what percentage of body weight does the skin account for?
A
15%
3
Q
what is the main function of the skin
A
is to provide a barrier against injury, infection, ultraviolet radiation (UV), and fluctuations in temperature changes.
4
Q
what does the skin play an important role in
A
perception of touch, pain, pressure, and vibration
5
Q
what are some other functions of the skin
A
elimination of waste, support of underlying structures, and synthesis of vitamin D.
6
Q
what are the three layers of the skin
A
epidermis
dermis
subcutaneous layer of adipose tissue
7
Q
adipose tissue
A
fatty tissue
8
Q
epidermis
A
outermost layer of the skin
9
Q
what kind of cells is the epidermis made of
A
squamous epithelial cells
provide a barrier against the external environment
10
Q
what does the epidermis contain
A
keratinocytes
11
Q
keratinocytes
A
Cells formed in the basal layer of the skin that function to protect the skin from the external environment.
The keratinocytes migrate from the basal layer of the skin to the more superficial layers. With time, these cells die and are removed from the skin through shedding.
12
Q
what are some other cells found in the epidermis
A
melanocytes-produce melanin
Merkel cells-detect light touch, especially in the palms of the hands and soles of the feet
Langerhans cells-ingest and package foreign antigent to be presented to lymphocytes (trigger an immune repsonse in the epidermis)
13
Q
what cells play a role in cutaneous immune system reactions in the epidermis
A
Langerhans cells
14
Q
melanin
A
A pigment that determines the color of the hair and skin.
also absorbs radiant energy from the sun and protects the skin from harmful UV rays
15
Q
dermis
A
The layer under the epidermis that is composed mainly of connective tissue and provides strength and flexibility of the skin.
16
Q
what is the dermis composed of
A
connective tissues
capillaries
blood vessels
lymph vessels
17
Q
subcutaneous tissue
A
composed mainly of adipose tissue is found under the epidermis and dermis
third layer of skin
insulates the body, absorbs shock, and pads the internal organs and structures. This layer also contains blood vessels and nerves that assist in thermoregulation and sensation.
18
Q
A nurse is teaching a group of older adults at a community center about the functions of the skin. Which of the following statements should the nurse include in the teaching? (Select all that apply.)
A
The skin plays an important role in the production of vitamin D.
the skin protects against bacteria and viruses
the skin helps regulate the body temperature
19
Q
clients are at risk during what part of lifespan?
A
early and late in life
20
Q
what is common during infancy and early childhood in regards to skin integrity?
A
maceration (an irritation of the epidermis caused by moisture) and dermatits (a red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound secretions) may occur
21
Q
what is common in later life in relation to skin integrity?
A
as collagen stores decrease, the skin thins and loses elasticity, placing clients at greater risk for the development of skin tears (loss of top layer of the skin caused by mechanical forces) and tissue trauma. Skin exposed to the sun may exhibit premature wrinkling, accelerating the aging process
22
Q
what are some conditions that predispose clients to alterations in tissue integrity?
A
impairments in mobility, such as congenital conditions like spina bifida and cerebral palsy, and chronic diseases, including liver failure, kidney disease, and cancer.
each of these conditions contribute to skin frailty (At-risk vulnerable skin)
23
Q
the most frequently occurring skin problems associated with skin frailty
A
kin tears, pressure injuries (localized damage to the skin and/or underlying tissue, as a result of a pressure or pressure in combination with shear), and infections of the skin such as cellulitis (an infection of the superficial layers of skin).
24
Q
how can nurses decrease risk of clients’ risk of developing skin breakdown?
A
Through their regular skin assessments, observation of environmental factors, and diligent implementation of prevention measures
25
major elements of a comprehensive skin assessment include what?
Gathering the medical history, looking at factors that place clients at risk, and assessing the skin for abrasions, edema, moisture, rashes, and other abnormalities
Skin texture and temperature should also be assessed.
26
pressure injury
Localized damage to the skin and/or the soft underlying tissue, which can be caused from prolonged contact with a firm surface that interferes with circulation to the area.
27
erythema
Redness of the skin due to dilation of blood vessels.
28
blanchable vs nonblanchable
An area of a reddened skin that temporarily turns white or pale when light pressure is applied. the skin then reddens when pressure is relieved.
Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues.
29
where should special attention to when assessing the skin?
obese clients
30
wound
A wound is a disruption in the normal composition and performance of the skin and it s underlying structures.
31
acute wounds
may originate either intentionally or unintentionally. Intentional wounds include those created during a surgical procedure, whereas unintentional wounds develop as the result of a traumatic injury, such as burns, punctures, or gunshot wounds. When caring for clients with acute wounds, the origin of the injury should be considered when developing the plan of care.
32
traumatic wounds
Lacerations are tears in the skin, which are usually caused by blunt or sharp objects. Due to the origin of these wounds, they often have an irregular or jagged shape. Lacerations are classified as simple or complicated.
33
surgical wounds
are acute wounds that are created intentionally during surgery. These wounds are classified as clean, clean-contaminated, contaminated, or dirty, depending on the suspected contamination of the wound.
34
how does an incision develop
appears red on days 1-4
bright pink 5-14
pale pink days 15 to 1 year
35
exudate
Fluid secreted by the body during the inflammatory stage of healing and is made of plasma.
36
Moisture-associated skin damage (MASD)
a form of dermatitis that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates.
Excessive sweating, increased local skin temperature, abnormal skin pH, and deep skin folds all predispose clients to MASD
37
what can wound exudate be?
serous: Thin, watery wound drainage.
serosanguineous: Thin, watery wound drainage mixed with blood.
sanguineous: Bloody wound drainage.
purulent: Green/yellow wound drainage with puss; shows infection
38
shearing
A force parallel to the surface of the skin.
39
Risk Factors Contributing to Pressure Injury Development
The most frequently seen risk factors are immobility, malnutrition (a condition in which there is a nutritional deficit), reduced perfusion, altered sensation, and decreased level of consciousness
40
friction
The force created when two objects rub together.
41
bony prominences
areas most susceptible to pressure injury formation
including the heels, toes, sacrum, hips, elbows, shoulders, and back of the head.
42
A nurse is providing education about pressure injury development to a newly licensed nurse. Which of the following points should the nurse include in the teaching? (Select all that apply.)
Shear forces occur when the skin and muscles are pulled in opposite directions.
Pressure injuries most often develop over bony prominences.
Factors contributing to pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss.
43
hypoperfusion
Inadequate supply of blood circulation, which results in low oxygen levels in tissues.
44
what can chronic hypoperfusion lead to
leads to low oxygen levels in the tissues; this state, coupled with prolonged pressure, can result in tissue breakdown in less than 2 hours.
45
stages of pressure injuries
stage 1: non-blanchable erythema
stage 2: partial-thickness skin loss
stage 3: full-thickness skin loss
stage 4: full-thickness skin and tissue loss
unstagable pressure injury: Obscured Full-Thickness Skin and Tissue Loss
46
surigical debridement
The process of surgically removing dead tissue and other debris that can cause infection.
47
what do you use to irrigate wounds
0.9% sodium chloride
48
hematoma
accumlation of blood in the body
49
seroma
collection of serious fluid in the body
50
what are the two mian components of prevention of poor skin intergrity
identification of clients at risk and implementation of interventions that are designed to reduce risk.
51
define tissue integrity
ability of the human body to regenerate and maintain normal physiologic functioning.
52
what acts as defense mechanisms for the body
The skin, cornea, subcutaneous tissue, and mucous membranes act as defense mechanisms for the body.
53
the skin
The largest organ system of the body accounting for about 15% of the total body weight.
54
what is the main function of the skin
Main function is protection, providing a barrier from injury, infection, ultraviolet radiation (UV), and heat.
55
what crucial role does skin play
Plays a crucial role in sensory perceptions such as touch, pain, pressure, and vibration
56
what does the skin regulate
Regulates temperature and protects the body against temperature changes.
57
what does the skin eliminate
Eliminates waste and supports the underlying structures and synthesis of vitamin D.
58
three layers of the skin: epidermis
Epidermis: outer layer of the skin composed mainly of keratinocytes and other cells, such as melanocytes, Merkel cells and Langerhans cells
59
three layer of the skin: dermis
Dermis: largest portion of the skin; main function is to sustain and support epidermis by providing strength and flexibility; made of connective tissue with capillaries; blood vessels; lymph vessels; nerves; sweat and sebaceous glands; hair roots; elastic fibers; and collagen
60
three layers of the skin: subcutaneous tissue
Subcutaneous tissue: subcutaneous fat (adipose fat) that insulates the body, absorbs shock, and pads the internal organs and structures
61
risk factors for the development of pressure injuries and wounds
age
mobility issues
weight
Conditions such as spina bifida and cerebral palsy, and other chronic conditions such as liver, renal diseases, cancer, and malnutrition
62
skin frailty
Skin frailty refers to at-risk, vulnerable skin.
63
age with skin
As adults age, skin becomes thinner, elasticity is lost, subcutaneous fat becomes thinner, blood supply is more sluggish, and the skin becomes less hydrated.
Therefore, shear, friction, and pressure can cause problems.
64
pressure injury: what is most susceptible areas
The most susceptible areas are over bony prominences, such as the heels, toes, sacrum, hips, elbows, shoulders and back of the head.
65
define pressure injury
A localized damage to the skin and/or underlying tissue as a result of a pressure or pressure in combination with shear.
66
where can pressure injuries also occur?
Most often occur over bony prominences but can also be a result of a pressure caused by a medical device, such as urinary catheters, oxygen tubing, endotracheal tubing, or drains.
67
classifications of pressure injurires
Pressure injuries are classified according to how much tissue loss is observed in the wound. Nurses assess how deep the tissue loss is and stage or ‘classify’ the wounds using a scale of 1-4 based on the level of tissue loss.
68
pressure injury staging
Stage 1: Nonblanchable erythema of intact skin
Stage 2: Partial-thickness skin loss with exposed dermis
Stage 3: Full-thickness skin loss
Stage 4: Full-thickness skin and tissue loss
Unstageable: Obscured full-thickness skin and tissue loss
Deep Tissue Pressure Injury (DTPI): Persistent nonblanchable deep red, maroon or purple discoloration
need to know for exam!
69
TIME mneumonic for how a pressure should be described
T= Tissue Integrity. Describe how the tissue looks, the wound color, and if there is dead necrotized tissue present.
I= Inflammation or infection. Note if there are signs of infection present: redness, warmth, swelling, discharge, and swelling.
M= Moisture. Document if the wound is dry or moist and if the wound is macerated.
E= Edge of wound. Describe the wound edges.
70
factors that influence wound healing
DIDN'T HEAL
D= Diabetes
I= Infection
D= Drugs
N= Nutritional problems
T= Tissue necrosis
H= Hypoxia
E= Extensive tension
A= Another wound
L= Low temperatures
71
three phases in the wound healing process
hemostatic or inflammatory
proliferative
remodeling
72
three phases of wound healing process: hemostatic/inflammatory
The damaged tissue releases cytokines which trigger a process called hemostasis; blood coagulates, and the wound starts to heal. In addition, plasma leaks into surrounding tissue and causes swelling.
73
three phases in the wound healing process: proliferative
New collagen fibers are formed, a new wound bed is created, and capillaries start growing. The wound edges begin pulling closer and new granulation tissue grows
74
three phases in the wound healing process: remodeling
Stronger collagen replaces the soft gelatinous collagen; however, this tissue is much weaker than the original tissue and is susceptible to re-injury.
75
types of wound healing
primary healing/first intention
secondary healing or second intention
delayed primary closure
76
types of wound healing: primary healing/first intention
Occurs in clean lacerations and surgical incisions; closed with skin adhesives or sutures
77
types of wound healing: secondary healing/second intention
wound healing that happens when the wound is left open to heal
78
types of wound healing: delayed primary closure
A combination of primary and secondary healing, where the wound is left open for 5-10 days before it is closed with sutures
79
blanching
Skin redness is usually referred to as blanchable or non-blanchable erythema. Non-blanchable erythema is redness that does not go away when pressure is applied and is a sign that structural damage has occurred to the skin.
80
two methods to measure wound size
Tracing the wound circumference and calculating the wound surface area with a special see-through tape
Measuring the length and width of the wound
81
what should you be when measuring wounds?
consistent
82
acute vs chronic wounds
based on origin and healing process
Acute wounds develop as a result of injury and typically are a result of trauma.
Chronic wounds develop over time from acute wounds that do not progress in healing
83
what are wound dressings
wet or dry
84
what are the major complication of wounds
infections
dihisence
eviscerations
hematoma/seromas
fistulas
85
what is the respiratory system composed of
upper and lower airways
86
what is the upper airway divided into
two areas: the pharynx and the larynx
The pharynx—the cavity posterior to the nose and throat—is subdivided into several regions. The nasopharynx refers to the nasal area, and the oropharynx refers to the throat or mouth. These structures warm, filter, and humidify air taken in through the nose and mouth. The larynx is located at the top of the trachea and is where the vocal cords are found.
87
what does the lower airway include
trachea, bronchi, bronchioles, and alveoli of the lungs.
The trachea divides into the bronchial tubes within the lungs. The lungs are air-filled sacs that are primarily responsible for gas exchange in the body. They consist of right and left lobes that are connected by the bronchial tubes, which give rise first to the bronchioles and then to the alveoli. The alveoli are where the actual gas exchange takes place. The right lung has three lobes and the left lung has two lobes. The lungs are linked to the nervous system by both the parasympathetic and sympathetic nervous systems
88
bronchoconstriction vs bronchodilation
bronchoconstriction- Tightening of the bronchus due to the contraction of the smooth muscle.
bronchodilation-Expansion of the airway in the bronchus.
89
how do the lungs to expand and contract smoothly
pleural fluid is produced in the space known as the pleural cavity.
The pleural cavity is located within a membrane known as the pleura, which surrounds the lungs and is divided into the visceral and parietal pleural layers.
90
surfactant
A lubricant made in the lungs to keep the alveoli from collapsing during exhalation.
91
what happens where this a lack of surfactant in the lungs
the lung tissue collapses so that there is a loss of volume during expansion; this condition is called atelactasis
92
atelactasis
Collapse of airways and small sections of the lung as a result of shallow breathing. The collapsing of the lung during expansion.
93
ventilation
flow of air inside or outside the alveoli
94
perfusion
the flow of blood, driven by the cardiopulmonary system, into the alveolar capillaries
95
brainstem
monitors the body’s oxygen demand and carbon dioxide levels and signals the respiratory system to respond to excesses or under-supply.
For example, the rate and depth of respirations increase when a client is feverish or exercising. This causes more carbon dioxide to be exhaled and more oxygen to be inhaled. In a typical resting adult, respirations are between 12 to 20 breaths per minute.
96
lung compliance
point to which a lung can expand in response to increased pressure within the alveoli (interalveolar pressure).
Diseases such as emphysema, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and atelectasis can either increase or decrease lung compliance.
97
inspiratory reserve volume
Volume of air breathed in after a typical inspiration.
98
tidal volume
Volume of air inspired and expired with each breath.
99
residual volume
Volume of air remaining in the alveoli after expiration.
100
forced vital capacity
Volume of air remaining in the lung after maximal inspiration.
101
vital capacity
Maximum volume of air that is expelled after maximal inspiration.
102
total lung capacity
Volume of air remaining in the lung after maximal inspiration.
103
pulmonary circulation
The movement of blood from the heart to the lungs from the capillaries for gas exchange and back.
104
myocardial blood flow
diastole and systole
diastole-The relaxation phase of the cardiac cycle where the heart muscle is relaxed and the chambers of the heart fill with blood.
systole-The contraction phase of the cardiac cycle when the mitral and tricuspid valves close and blood is ejected into the aorta and pulmonary arteries.
105
cardiac output
The volume of blood ejected by the heart ventricles in one miunute; calculated by multiplying the stroke volume and pulse rate of the heart.
106
cardiac output equation
CO= HR x SV
107
stroke volume
Volume of blood ejected by the LEFT ventricle during one contraction.
108
factors that affect stroke volume
preload-The blood remaining in the left ventricle at the end of diastole causing it to stretch.
afterload-The amount of resistance or force that occurs when the heart ejects blood from the left ventricle.
contractility-The force required to eject blood from the left ventricle.
109
where does the pacemaker go
SA node
located in the wall of the right atrium
110
correct order of electrical conduction in the heart
provides electrical impulse moves from the SA node to the AV node, to the bundle of His, to the right and left bundle branches, and then to the Purkinje fibers
111
what foods are encouraged for good heart health
Diets rich in vegetables, fruits, fiber, whole grains, fish, and omega-3 fatty acids are encouraged.
Foods with high amounts of sodium, added sugars, and processed carbohydrates should be limited, as they are high in calories but nutrient poor.
111
A client reports experiencing stress about their new diagnosis of coronary artery disease (CAD). Which of the following are manifestations of prolonged stress?
increased cortisol level
112
lung sounds: crackles
pneumonia or infection
Caused by fluid filling the air sacs that sound like music or a whistling noise heard on exhalation.
113
lung sounds: wheezing
asthma and COPD
A high-pitched noise creating a whistling sound due to air going through narrowed airways.
114
lung sounds: rhonchi
asthma or COPD
Obstruction of the airway that sounds like rattling.
115
lung sounds: stridor
Narrowing of the airway heard on inhalation that sounds like music or whistling.
it can be caused by an inflammation of the epiglottis (epiglottitis) or by croup, a viral infection.
116
what should the S3 gallop sound like
ken-tuck-y
117
what does S4 gallop sound like
ten-nes-see
118
what can S3 indicate
An S3 gallop in children is often benign, but in adults it can be an indication of heart failure.
119
what can S4 indicate
can be indicative of aortic stenosis, hypertension, or a history of myocardial infarction.
120
hypoxemia vs hypoxia
low oxygen in the blood
below the expected level of oxygen in the body tissue
121
manifestations of hypoxemia
confusion, irritability, and restlessness
122
causes of hyperventilation
Anxiety attacks
Infections such as pneumonia
Lung disease such as COPD and asthma
Diabetic ketoacidosis
Brain injury
123
hypoventilation
Neuromuscular disorders such as muscular dystrophy and Guillain-Barré syndrome
Medications such as barbiturates, narcotics, and benzodiazepines
Neurologic disorders
Trauma
124
what conditions can cause hypoxia
Smoke inhalation
High altitudes
Lung diseases such as COPD, pneumonia, and asthma
Medications that decrease the respiratory rate
Anemia
125
stenosis
Narrowing of a heart valve.
can lead to right or left heart failure
126
A client is experiencing hypoxia. Which of the following manifestation can a nurse expect to find in this client?
bradypnea
127
how many lobes does the right lung have vs the left lung
right- three lobes
left- two lobes
128
lungs
The lungs are responsible for bronchodilation (expansion of the airway in the lungs) and bronchoconstriction (restriction of the airway in the lungs).
The lungs are also linked with the nervous system by both the parasympathetic and sympathetic systems.
129
pulmonary circulation
Deoxygenated blood leaves the right ventricle and is routed to the pulmonary artery, into the tricuspid valve.
Blood is then routed to the pulmonary valve, to the pulmonary trunk within the pulmonary artery.
Blood then flows to the pulmonary semilunar valve into the right and left pulmonary arteries into through the lungs. Carbon dioxide is eliminated.
The alveoli contain capillaries where oxygenation takes place.
Oxygenated blood then flows from the pulmonary venules to the pulmonary veins.
Blood is then returned to the left atrium of the heart by the pulmonary vein.
Blood then moves from the left atrium to the mitral valve into the left ventricle.
Blood then flows to the aorta via the aortic valve into systemic circulation and later returns to the lungs to be circulated.
The pulmonary vein returns oxygenated blood to the left atrium of the heart.
The oxygenated blood then leaves the lungs through pulmonary veins, which return it to the left heart, completing the pulmonary cycle.
This blood then enters the left atrium, which pumps it through the bicuspid valve into the left ventricle.
The blood then passes through the aortic valve to the aorta and is distributed via systemic circulation before again returning to the pulmonary circulation.
