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Fundamentals SEM2 > WEEK 2-ATI > Flashcards

WEEK 2-ATI Flashcards

alterations in tissue integrity

1
Q

layers in the skin

A

epidermis
dermis
hypodermis

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2
Q

epidermis layers

A

made of up of four or five layers depending on the area of your body (soles of the feet require 5 since it’s thicker skin in that area)

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3
Q

what does the epidermis serve as

A

the outermost layer of the skin and provides the waterproof nature of the skin and influences skin color

contains natural flora, which is not pathogenic in the body’s normal state

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4
Q

common skin bacteria

A

Staphylococcus epidermitis, aureus, and cutibacterium acnes

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5
Q

dermis

A

directly beneath the epidermis

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6
Q

dermis layer

A

contains 2 layers

The sweat glands, hair, hair follicles, muscle, sensory neurons, and blood and lymphatic vessels are in the dermis.

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7
Q

hypodermis

A

deepest layer and is also referred to as the subcutaneous fascia

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8
Q

what does the hypodermis contain

A

This layer contains adipose lobules and connective tissue, as well as hair follicles, sensory neurons, and blood vessels.

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9
Q

who has thinner skin

A

children and people after the fifth decade

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10
Q

causes of skin pathologies

A

Allergens, injury, irritants, diseases, immune responses, and genetics

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11
Q

define skin wound

A

disruption in the epidermal layer that can go deeper into the dermis or subcutaneous tissue.

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12
Q

what happens during the first stage of wound healing

A

clotting is initiated
vasoconstriction occurs
fibrin mesh is established
vasodilation occurs
causing hyperemia and edema
neutrophils are recruited to kill bacteria and debride necrotic tissue

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13
Q

proliferation

A

starts from day 3-day 10 and takes weeks to complete

It is characterized by granulation tissue and repair of vascular structures. The new vascular network brings nutrients to help heal the wound. Epithelialization begins. Fibroblasts proliferate to the wound, and granulation tissue develops.

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14
Q

tissue remodeling

A

occurs from day 21 up to a year

During the remodeling phase, the balance of synthesis of new cells and degradation of tissue is no longer needed. Collagen strengthens the wound.

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15
Q

clients at risk for skin injuries

A

advanced in age, multiple health problems, physical limitations, poor nutrition, incontinence, poor circulation and oxygenation, decreased sensation, altered cognition, and taking multiple medications.

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16
Q

alterations in skin integrity can occur for a variety of reasons, including…?

A

moisture, friction, shearing, pressure, burns, and trauma.

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17
Q

friction

A

Mechanical force of dragging skin across surface.

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18
Q

shearing

A

The force of body structures upon the skin, moving in opposite direction.

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19
Q

a common cause of moisture-related skin conditions

A

incontinence

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20
Q

incontinence-associated dermatitis (IAD)

A

caused by prolonged exposure to moisture from urine and stool.

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21
Q

intertrigo

A

inflammation of the skin on surfaces that have folds, such as between the fingers, axilla, and under breasts.

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22
Q

example of shearing

A

An example is the shearing force of the coccyx on the subcutaneous tissues and the friction of the skin surface as the body slides down or is pulled up in bed

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23
Q

friction vs. shearing

A

Friction affects the superficial layers, whereas shearing affects the deeper tissues.

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24
Q

who is at the highest risk for skin tears

A

clients older than 65 because aging and fragile skin is more susceptible to separating and tearing

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25
Q

nutrients needed for healing

A

proteins
carbs
fats
vitamins and growth factors

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26
Q

perfusion

A

Blood supply to the area.

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27
Q

vitamin A

A

supports fibroplasia and epithelialization, which are keys to wound healing.

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28
Q

vitamin B

A

important for enzymatic functions to support wound healing

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29
Q

vitamin C

A

collagen synthesis, antioxidant response, and angiogenesis.

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30
Q

vitamin D

A

key for structural integrity and movement across epithelial layers

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31
Q

vitamin E

A

may have a negative effect on wound healing by negatively affecting collagen synthesis and the inflammatory process.

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32
Q

zinc

A

. Zinc supports the immune response and decreases the likelihood of infection.

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33
Q

proteins are?

A

often lost in excretion of wound exudate

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34
Q

amino acids help?

A

stimulate growth hormone and facilitate inflammation process to help with immunity

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35
Q

vitamins are?

A

important micronutrients for the healing process

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36
Q

carbohydrates help?

A

fuel the body and increase hormone growth factor secretion

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37
Q

fats are?

A

important for normal cell function and are precursors to prostaglandins

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38
Q

conditions that can affect wound healing

A

vasoconstriction
medications like corticosteroids
taking anti-inflammatory medication the first few days of injury
receiving chemo
diabetes
stress

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39
Q

what medications could impact wound healing

A

immunosuppressors

like corticosteroids

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40
Q

chronic wounds

A

open for more than one month or do not progress through the stages of normal wound healing.

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41
Q

chronic nonhealing wounds can be caused by

A

metabolic disorders, such as diabetes; vascular deficits, such as arterial or venous insufficiency; or mechanical reasons, such as pressure on the skin

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42
Q

who is higher risk for chronic wounds

A

obese or diabetic clients

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43
Q

who is most prevalent with chronic wounds

A

clients older than 65

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44
Q

common chronic wound

A

diabetic foot ulcers

because diabetes impacts blood flow to the wound as well as the body’s ability to fight off infection, so wounds will heal more slowly or fail to heal.

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45
Q

what can poorly treated chronic wounds lead to

A

necrotic tissue, infection, amputation, sepsis, or death

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46
Q

physical findings in client with chronic wounds

A

pain, difficulty sleeping, and a reduction in functional status, including completing activities of daily living.

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47
Q

acute wounds

A

Heals within four weeks.

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48
Q

any break in the skin may have manifestations of what?

A

pain, warmth, redness, bleeding, or oozing.

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49
Q

examples of common acute wounds

A

Skin incisions
Skin tears
Abrasions
Moisture-associated skin damage

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50
Q

chronic wounds

A

Does not heal within four weeks.

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51
Q

examine for chronic wound

A

wound for…

size
location
depth
drainage

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52
Q

systemic causes of chronic wounds

A

diabetes, malnutrition, and connective tissue diseases, such as rheumatoid arthritis.

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53
Q

regional causes of chronic wounds

A

neuropathy, arterial or venous insufficiency, or lymphatic problems.

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54
Q

local causes of chronic wounds

A

continued pressure, such as from immobility, infection, and autoimmune conditions.

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55
Q

venous ulcer

A

Located on the medial area of lower extremity. Shallow depth.

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56
Q

arterial ulcer

A

Punched out appearance with smooth, well-demarcated wound edges

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57
Q

diabetic ulcer

A

Located on the weight-bearing areas of the feet. Range from superficial to deep

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58
Q

ABI (ankle-brachial index)

A

An ABI of less than 0.8 may indicate an arterial perfusion problem.

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59
Q

Doppler ultrasound

A

may be helpful in diagnosing venous problems.

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60
Q

what may not be present in chronic wounds

A

Acute infection manifestations such as erythema, pain, edema, and fever may not be present in chronic wounds.

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61
Q

biopsy with culture

A

may be needed, and the presence of greater than 100,000 colony-forming units is indicative of infection

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62
Q

Levine technique for wound culture

A

swabbing area of 1cm on the wound

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63
Q

laboratory tests that may be helpful in diagnosing chronic wounds

A

complete blood count (CBC) to assess white blood cells, identify anemia, and count platelets.

BMP can be helpful in evaluating electrolytes and renal status.

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64
Q

infection can be evaluated with what?

A

STONEES

Size becoming larger
Temperature increasing
Os (bone exposed)
New breakdown
Erythema
Exudate
Smell

65
Q

Which of the following is an example of a regional cause for chronic wound development?

Malnutrition
Neuropathy
Immobility
Diabetes

A

Neuropathy

66
Q

common locations for pressure injuries

A

the sacrum, hip, buttock, heel, back of the head, shoulder, and elbow.

67
Q

stages of pressure injuries

A

4 stages
unstageable
deep tissue injuryy

68
Q

stage 1 PI

A

nonblanchable erythema, skin intact

69
Q

stage 2 PI

A

Partial thickness loss of skin and may have blisters, wound bed pink and moist

70
Q

stage 3 PI

A

Full thickness loss of skin exposed adipose tissue, undermining or tunneling may occur

71
Q

stage 4 PI

A

Full thickness loss of skin; fascia, muscle, tendon, ligament, or bone will be exposed. Undermining or tunneling often occur.

72
Q

unstageable stage of PI

A

Full thickness loss of skin and tissue but the extent of the wound is obscured by slough or eschar

73
Q

deep tissue injury stage of PI

A

Intact or nonintact skin where the area below is persistent nonblanchable deep red, maroon, or purple. A blood-filled blister may be present. Discoloration may appear different on dark skin.

74
Q

medications helpful for pressure injuries

A

non-opiate (Tylenol)
NSAIDs (ibuprofen or Motrin)
more severe pain can be treated with morphine or oxycodone (Vicodin)

75
Q

infections and PIs

A

PIs do not typically require antibiotics but watch for manifestations of infection.

Superficial skin infections may be treated with topical antibiotics, and deeper infected wounds may require oral or IV antibiotics

76
Q

A nurse is admitting a client who has a stage 4 sacral pressure injury that is draining yellow exudate. The client has a history of COPD, diabetes, and cerebrovascular accident and a temperature of 38.9° C (102° F). Which of the following diagnostic tests should the nurse plan to request?

Select all that apply.

A

White blood cell (WBC) count

b
Hemoglobin A1c

c
Wound culture

d
MRI of sacrum

e
Total protein, albumin and prealbumin

77
Q

how do cells respond to inflammation

A

increasing white blood cells and inflammatory mediators, such as bradykinin and histamine.

78
Q

what is a vascular reaction in regards to inflammtion

A

vasodilation causing redness and warmth.

79
Q

define infection colonization

A

If the micro-organism is present and multiplying but not overwhelming the immune system

80
Q

local infection

A

occurs once the micro-organisms are sufficient in quantity to challenge the immune system.

81
Q

unmanaged local infection

A

the infection can spread to surrounding tissues. If the infection continues, systemic infection can occur.

82
Q

A nurse is caring for a client with a wound. The infectious disease health care provider has indicated that the wound has colonization. Which of the following does this mean?

A

Micro-organisms are present but are not causing infection.

83
Q

who is at increased risk for skin infection

A

Clients who are over age 65, who smoke, who are immunocompromised, who use steroids, who are obese, or who have malnutrition are at increased risk for wound infection.

84
Q

comorbities and skin inflammation

A

Celiac disease may be a comorbidity of inflammatory skin conditions because of the link between gluten and inflammation

84
Q

phases of infection: contamination

A

number one
Micro-organisms are present, and the host has the opportunity to protect the wound from infection.

84
Q

phases of infection

A

contamination
colonization
local infection
spreading infection
systematic infection

85
Q

phases of infection: colonization

A

Microbes multiply but do not yet form an infection.
number 2

86
Q

phases of infection: local infection

A

There is warm, red swelling and pain in and around the wound.
number 3

87
Q

phases of infection: spreading infection

A

There is an extended area of erythema, swelling of lymph nodes, and general findings such as malaise and anorexia.
number 4

88
Q

phases of infection: systematic infection

A

number 5
The infection spreads into the bloodstream and affects the organs of the body.

89
Q

Which of the following best describes biofilm on a wound?

A

Layer of microbes that cover the wound bed

90
Q

signs of anaphylaxis

A

Hives, gastrointestinal upset, feeling faint or dizzy, tightness in the throat, trouble breathing, wheezing, low blood pressure, elevated heart rate, a feeling of impending doom, and cardiac arrest.

91
Q

medications that can cause anaphylaxis

A

Penicillin, aspirin, nonsteroidal anti-inflammatory drugs, and anesthesia

92
Q

A school nurse is responding to a call from a teacher about a child who is experiencing sudden difficulty breathing, tightness in throat, wheezing, hives, and feeling dizzy. Which of the following should be the nurse’s priority action?

A

Administer epinephrine intramuscularly.

93
Q

Be S.A.F.E for managing anaphylaxis

A

S- Seek treatment, call 911
A- Identify allergen
F- Follow up with an allergy specialist
E- Carry an Epinephrine kit

94
Q

parkland formula to calculate fluid replacement

A

2 to 4 ml x kg x % TBSA burned

95
Q

what can happen from severe burns

A

fluid loss (dehydration)
important to know the rule of 9s to know how much fluid to replace

96
Q

rule of 9s

A

rule of how to calculate how much of the body is burned

front of face- 4.5%
back of face-4.5%
front of chest: 18%
back/trunk: 19%
front of one arm: 4.5%
back of one arm: 4.5%
(obviously applies to both left and right arms)
front of one leg: 9%
back of one leg: 9%
(obviously applies to both left and right legs)
perineal area: 1%
palm of hand: 1%
(obviously applies to both left and right palms)

97
Q

burn depth

A

1st degree to 6th degree

98
Q

1st degree burn

A

damage to epidermis

such as a sunburn

99
Q

2nd degree burn

A

damage to both epidermis and dermis

100
Q

3rd degree burn

A

damage to epidermis and dermis
requires skin grafting

101
Q

4th degree burn

A

same as third degree-but extending to fat layer

102
Q

5th degree burn

A

same as third degree-but extending muscle layer

103
Q

6th degree burn

A

same as third degree-but extending to the bone

104
Q

what can deep burns result in

A

release of myoglobin, which can lead to rhabdomyolysis and kidney damage

105
Q

primary survey

A

ABC
D disability
E exposure

106
Q

secondary survey

A

history of events
health history
head to toe assessment
determine depth, size, and severity of burn

107
Q

diet recs with burns

A

meet protein, carbs, fats goals
as well as micronutrients (glutamate, vitamin C, zine, selenium)

108
Q

burn center referral criteria (8 things)

A

-partial thickness burns greater than 10% OF YOUR BODY
-burns to the FACE, HANDS, GENITALIA, PERINEUM, MAJOR JOINTS
-THIRD degree of FULL thickness burns
-electrical burns, including lightening burns
-chemical burns
-inhalation injury
-clients with preexisting issues that could affect mortality
-clients who have burns PLUS other traumatic injuries

109
Q

connections to burns

A

nutrition
mobility
perfusion

110
Q

who grows more yeast infections

A

diabetic patients because yeast grows with sugar

111
Q

what does Group A cause

A

flesh-eating bacteria

112
Q

parasites on the skin

A

scabies
lice
ringworm

113
Q

what happens to scabies patient

A

put in isolation

114
Q

what should you always do before and after each care?

A

GOOD HAND HYGIENE

115
Q

what makes an older person not have enough body temperature

A

skin becomes thinner and loses collagen/elasticity
or (sun damaged or chemical damaged skin)

116
Q

skin cut reaction

A

platelets and fribrions clot in
vessels with vasoconstriction
pressure to stop bleeding and things form coming to cut the body

117
Q

wound healing

A

hemostatis and inflammation
proliferation
tissue remodeling

118
Q

does running water could as washing

A

NO
need soap and water and scrub

119
Q

virus: shingles

A

one side of body (follows the nerve path)
isolation (until crusted over)
NO PREG PEOPLE CARING FOR PEOPLE WITH SHINGLES

120
Q

virus: herpes

A

blisters, tingling, itchy, painful
around the MOUTH, GENITALS, HANDS
(dentists get this on their hands)

121
Q

WART (test Q)

A

raised or flat spot
not painful or draining

122
Q

scabies

A

Pimple-like, itchy
Treatment: ointment (all over body and wait before you shower)
Everyone should be treated

123
Q

eczema/psoriasis

A

-red and flaky
-itchy
-plaque
-painful

124
Q

acne

A

Occurs when oil from the skin blocks the hair follicles, producing lesions commonly referred to as pimples.

125
Q

contact dermatitis (rash)

A

Itchy, red, inflamed skin is caused by contact with an irritant or allergen.

126
Q

rosacea

A

Dry, thick raised patches. May have a scaly or plaque-like appearance. Often occurs on the scalp, elbows, and knees and may occur in flare-ups. It is caused by an overactive immune response.

127
Q

urticaria

A

hives
Patches of red bumps that vary in size. Caused by an allergic response, stress, cold, or other unknown reasons.

128
Q

phases of infection

A

contamination
colonization
local infection
spreading infection
systematic infection

129
Q

contamination

A

Micro-organisms are present, and the host has the opportunity to protect the wound from infection.

130
Q

colonization

A

Microbes multiply but do not yet form an infection.

131
Q

local infection

A

There is warm, red swelling and pain in and around the wound.

132
Q

spreading infection

A

There is an extended area of erythema, swelling of lymph nodes, and general findings such as malaise and anorexia.

133
Q

systematic infection

A

The infection spreads into the bloodstream and affects the organs of the body.

134
Q

Which of the following best describes biofilm on a wound?

A

Layer of microbes that cover the wound bed

135
Q

A school nurse is responding to a call from a teacher about a child who is experiencing sudden difficulty breathing, tightness in throat, wheezing, hives, and feeling dizzy. Which of the following should be the nurse’s priority action?

A

Administer epinephrine intramuscularly.

136
Q

serous exudate

A

thin, watery wound drainage

137
Q

sanguineous exudate

A

bloody wound drainage

138
Q

serosanguineous exudate

A

thin, watery wound drainage mixed with blood

139
Q

purulent drainage

A

INFECTION
green/yellow wound drainage

140
Q

risk factors for alterations in tissue integrity

A

mobility, age, chronic illness, accidents, diet, hygiene

141
Q

wound healing: medications that can impact it

A

blood thinners
anti-inflammatory
steriods
immunosuppressors (chemo, radiation)
beta-blockers (decrease perfusion)
diabetic medications

142
Q

test Q: cheeseburger or salmon soup for diet intake for someone would altered skin integrity?

A

salmon
LEAN piece of meat, healthy carbs

143
Q

healthy carbs

A

sweet potato over normal potato

144
Q

keloids

A

scarring
can burn off for treatment but doesn’t always work

145
Q

delayed healing

A

age and medically ill

146
Q

chronic wounds: excessive healing

A

hypertrophic
keloids

147
Q

chronic wound healing

A

open for more than a month
doesn’t progress through normal wound healing stages

148
Q

pain management for chronic wounds

A

NSAIDs
pain levels

149
Q

LABS for wounds

A

CBC (platelets, WBCs, hemoglobin, hematocrit, anemia)
BMP ( heart failure (perfusion can be lowered)
albumin ( pulls the fluid back into the vascular system, like with swelling)

150
Q

diagnostic tests for wounds

A

Biopsy, ultrasound, culture (swabbing) (find what it is resistant to)

151
Q

acute vs chronic wounds

A

Acute: incision, skin tear, abrasions, moisture-associated damage
Heals within 4 weeks
Chronic: arterial ulcer, venous ulcer, diabetic ulcer
Does not heal within 4 weeks

152
Q

minor burns

A

1st and 2nd degree don’t usually need medical attention but 3rd and 4th do

153
Q

CARE FOR BURNS

A

3 C’s

cool water (NO ICE/creams)
cover the area (clean dry cloth to prevent infection)
clothing removal (not adhered, first thing to do with chemical burns)

154
Q

first thing to do with chemical burns

A

uncover the area, remove clothing!

155
Q

lactated ringers

A

treat fluids lost for severe burns
ISOTONIC (goes were you put it)
put it in a IV bag warmer so you dont cause patient to get hypothermic

156
Q

BURN patient

A

AIRWAY
BREATHING
CIRULATION (fluid loss, electrolytes, POTASSIUM LEVELS)

Fundamentals SEM2 (7 decks)

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