Week 4 (tissue integrity & infection)

Question 1

tissue integrity

Answer 1

structurally intact and physiologically functioning tissue

Question 2

epidermis

Answer 2

cells flattened and dead, protects underlying tissues and cells from dehydration, allows evaporation of water from skin, permits absorption of certain topical meds

Question 3

dermis

Answer 3

tensile strength, mechanical support, protection to underlying muscle and bone
-connective tissue and few skin cells

Question 4

pressure ulcer

Answer 4

localized injury to skin or tissue, usually on bony prominences, result of pressure, friction, or shearing

Question 5

pressure intensity

Answer 5

tissue ischemia and blanching

Question 6

prolonged pressure

Answer 6

unable to reposition self

Question 7

shear

Answer 7

sliding mvmt of skin while underlying muscle and bone are stationary

Question 8

frcition

Answer 8

two surfaces moving across one another (bed linens )

Question 9

positioning

Answer 9

using pillows or other devices to life bony prominences off bed or surface

Question 10

stage 1

Answer 10

intact skin, non- blanchable, discoloration, warmth, edema, hardness

Question 11

stage 2

Answer 11

partial thickness skin loss or blister, shallow open ulcer with pink wound w/o slough
*can be serum filled blister

Question 12

stage 3

Answer 12

full thickness skin loss and fat tissue visible, some slough possible, tunneling or undermining

Question 13

undermining

Answer 13

area of tissue injury beneath intact skin around wound

Question 14

tunneling

Answer 14

tract of injury occurring in any direction under skin

Question 15

stage 4 (IV)

Answer 15

full thickness tissue loss, slough or eschar present

-undermining and tunneling

Question 16

usntageable

Answer 16

full thickness skin loss/ depth unknown, black mask, either stage III or IV, should not be removed

Question 17

deep tissue injruy

Answer 17

full thickness skin, depth unknown, stable (dry and intact) can be blood filled blister

Question 18

SKIN

Answer 18

S- surface appropriate
K- keep turning
I- incontinence mngment
N- nutrition

Question 19

granulation tissue

Answer 19

soft, pink, fleshy projections tissue that form during healing process in wound

Question 20

slough

Answer 20

stringy substance attached to wound

Question 21

eschar

Answer 21

thick layer of dead, dry, tissue covering pressure ulcer or thermal burn
either comes off naturally or surgically

Question 22

exudate

Answer 22

fluids and cells that have been discharged from cells or blood vessels slowly through small pores or breaks in membranes

Question 23

primary intention

Answer 23

no loss of tissue, clean cut, sutures and glue or steri strip

Question 24

secondary intention

Answer 24

loos of tissues (pressure ulcers ), infection, foreign material, dead tissue

Question 25

hemorrhage

Answer 25

initial trauma after hemostasis: slipped surgical suture, dislodged clot, infection, erosion of blood vessel internal or external

Question 26

internal hemorrhage

Answer 26

swelling of affected body part, surgical drain (type and amount) , hypovolemic shock could be hematoma: localized collection of blood under tissue

Question 27

what is 2nd most common health care associated infection

Answer 27

wound

Question 28

what determines if wound is infected

Answer 28

purulent material drains

Question 29

what inhibits wound healing

Answer 29

bacterial infection

Question 30

signs and symptoms of wound infection

Answer 30

contaminated or traumatic wound (2-3 days) post op surgical wound (4-5 days) fever, tenderness, and pain @ wound site elevated WBC wound edges inflamed odor filled or color drainage

Question 31

serous drainage

Answer 31

clear and watery plasma

Question 32

purulent

Answer 32

thick, yellow, green, brown

Question 33

serosanguineous

Answer 33

pale, pink, watery, mixture of clear and red fluid

Question 34

sanguineous

Answer 34

bright red and indicates active bleeding

Question 35

dehiscene

Answer 35

partial or total separation of wound layers

Question 36

evisceration

Answer 36

total separation of wound the visceral organ protrudes through opening

Question 37

how to maintain healthy wound environment

Answer 37

prevent and manage infection, clean wound, remove nonviable tissue, manage exudate, moist environment, protect wound

Question 38

how to clean pressure ulcers

Answer 38

use noncytotoxic wound cleaners, normal saline is preferred cleaning agent and doesnt harm tissue

Question 39

what are cytoxic wound cleaners

Answer 39

dakins solution, acetic acid, povidone- iodine, hydrogen peroxide

Question 40

common way to deliver wound solution

Answer 40

irrigation

Question 41

debridement

Answer 41

removable nonviable or necrotic tissue

Question 42

how to protect wound

Answer 42

applying sterile or clean dressing, for primary intention can remove dressing when drainage stops, for secondary intention dressings provide moisture

Question 43

purposes of dressings

Answer 43

protect from microorganism contamination, aid hemostasis, promote healing by absorbing drainage, support or splint wound site, protect from seeing, thermal insulation of wound surface

Question 44

Dressings

Answer 44

dry or moist, film dressing, hyrdocolloid (protects wound from surface contamination) , hydrogel (moist surface to support healing), VAC (negative pressure to suport healing )

Question 45

how to prepare for dressing change

Answer 45

evaluate pain, explain steps, gather supplies, recognize normal signs, answer q's

Question 46

what to do during dressing change

Answer 46

assess skin beneath tape, perform thorough hand hygiene, wear clean gloves, remove or change dressings when wound is wet or showing signs of infections

Question 47

what to do for packing a wound

Answer 47

assess size, depth, and wound

Question 48

how to provide comfort measures during dressing changes

Answer 48

provide analgesics prior, gentle measures, remove tape carefully

Question 49

cleansing skin/ wound steps

Answer 49

clean in direction from least contaminated area, use gentle friction when applying solutions locally *when using irrigation let flow from least to most contaminated

Question 50

what is different about Jackson Pratt drainage device?

Answer 50

Has bulb attached at end of drain and have to manually empty

Question 51

what are natural defenses of the body

Answer 51

skin, mouth (saliva and mucosa), eye (tearing, blinking, eyelashes), respiratory tract (cilia and macrophages), urinary tract (flow of urine), GI tract (acidity and peristalsis)

Question 52

characteristics of localized infection

Answer 52

swelling, redness, heat, pain or tenderness, loss of function in affected part

Question 53

characteristics of systematic infection

Answer 53

fever, leukocytosis, anorexia, nausea, vomiting, lymph node enlargement, organ failure

Question 54

common sites of health care associated infections

Answer 54

urinary tract, blood stream, surgical or trauma wounds, respiratory tract

Question 55

asepsis

Answer 55

absence of pathogenic microorganisms

Question 56

medical asepsis

Answer 56

preventing transmission of pathogens, need to use it all times

Question 57

surgical asepsis

Answer 57

sterile technique, eliminating all microorganism ,

Question 58

important drainage tips

Answer 58

never raise drainage bag above drainage site unless clamped off, empty every shift,

Question 59

principles of surgical asepsis

Answer 59

- sterile object stays sterile only if touched by another sterile subject - only sterile objects on sterile field - held below waist is contaminated - prolonged exposure to air = contamination - sterile surface comes in contact with something that is wet it is then contaminated by capillary action - fluid flows in direction of gravity - edges of sterile field considered contaminated

Question 60

tier one isolation precaution

Answer 60

standard, wear gloves when chance to come in contact with bodily fluids

Question 61

tier two isolation precaution

Answer 61

contact precautions, droplet precautions, airborne, protective environment

Question 62

contact precautions

Answer 62

used for patients who have microorganisms spread by direct contact w/ patient and indirect contact with surfaces or items in room - MRSA & Cdiff - private room, gowns, gloves, masks, equip must be cleaned

Question 63

droplet precautions

Answer 63

patients w/ transmission of large droplets (coughs, sneeze, etc) -mengicoccal meningitis, rubella, influenza, pertussis -private room, masks, gown and gloves -

Question 64

airborne precautions

Answer 64

patients infected with pathogens transmitted airborne route -TB, chicken pox, SARS, measles -private room w/ door closed, mask, gown, glove -