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fundamentals > Week 4 (tissue integrity & infection) > Flashcards

Week 4 (tissue integrity & infection) Flashcards

1
Q

tissue integrity

A

structurally intact and physiologically functioning tissue

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2
Q

epidermis

A

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

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3
Q

dermis

A

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

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4
Q

pressure ulcer

A

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

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5
Q

pressure intensity

A

tissue ischemia and blanching

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6
Q

prolonged pressure

A

unable to reposition self

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7
Q

shear

A

sliding mvmt of skin while underlying muscle and bone are stationary

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8
Q

frcition

A

two surfaces moving across one another (bed linens )

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9
Q

positioning

A

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

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10
Q

stage 1

A

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

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11
Q

stage 2

A

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

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12
Q

stage 3

A

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

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13
Q

undermining

A

area of tissue injury beneath intact skin around wound

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14
Q

tunneling

A

tract of injury occurring in any direction under skin

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15
Q

stage 4 (IV)

A

full thickness tissue loss, slough or eschar present

-undermining and tunneling

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16
Q

usntageable

A

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

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17
Q

deep tissue injruy

A

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

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18
Q

SKIN

A

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

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19
Q

granulation tissue

A

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

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20
Q

slough

A

stringy substance attached to wound

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21
Q

eschar

A

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

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22
Q

exudate

A

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

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23
Q

primary intention

A

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

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24
Q

secondary intention

A

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

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25
Q

hemorrhage

A

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

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26
Q

internal hemorrhage

A

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

27
Q

what is 2nd most common health care associated infection

A

wound

28
Q

what determines if wound is infected

A

purulent material drains

29
Q

what inhibits wound healing

A

bacterial infection

30
Q

signs and symptoms of wound infection

A

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

31
Q

serous drainage

A

clear and watery plasma

32
Q

purulent

A

thick, yellow, green, brown

33
Q

serosanguineous

A

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

34
Q

sanguineous

A

bright red and indicates active bleeding

35
Q

dehiscene

A

partial or total separation of wound layers

36
Q

evisceration

A

total separation of wound the visceral organ protrudes through opening

37
Q

how to maintain healthy wound environment

A

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

38
Q

how to clean pressure ulcers

A

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

39
Q

what are cytoxic wound cleaners

A

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

40
Q

common way to deliver wound solution

A

irrigation

41
Q

debridement

A

removable nonviable or necrotic tissue

42
Q

how to protect wound

A

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

43
Q

purposes of dressings

A

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

44
Q

Dressings

A

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

45
Q

how to prepare for dressing change

A

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

46
Q

what to do during dressing change

A

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

47
Q

what to do for packing a wound

A

assess size, depth, and wound

48
Q

how to provide comfort measures during dressing changes

A

provide analgesics prior, gentle measures, remove tape carefully

49
Q

cleansing skin/ wound steps

A

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

50
Q

what is different about Jackson Pratt drainage device?

A

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

51
Q

what are natural defenses of the body

A

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

52
Q

characteristics of localized infection

A

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

53
Q

characteristics of systematic infection

A

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

54
Q

common sites of health care associated infections

A

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

55
Q

asepsis

A

absence of pathogenic microorganisms

56
Q

medical asepsis

A

preventing transmission of pathogens, need to use it all times

57
Q

surgical asepsis

A

sterile technique, eliminating all microorganism ,

58
Q

important drainage tips

A

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

59
Q

principles of surgical asepsis

A
  • 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
60
Q

tier one isolation precaution

A

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

61
Q

tier two isolation precaution

A

contact precautions, droplet precautions, airborne, protective environment

62
Q

contact precautions

A

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
63
Q

droplet precautions

A

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

64
Q

airborne precautions

A

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

fundamentals (5 decks)

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