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NRSG 126 > Week # 6 tissue integrity and nutrition > Flashcards

Week # 6 tissue integrity and nutrition Flashcards

1
Q

What kind of fats should be avoided the most

A

Trans and saturated fats

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2
Q

What which type of Lipoprotein is bad high density or low density

A

Low Density Lipoprotein are the bad ones

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3
Q

what are two important function of water in the body

A

Helps regulate body temperature and acts as a solvent for nutrients and waste products

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4
Q

What are two types of vitamins

A

Fat soluble and water soluble

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5
Q

What is a vitamin

A

Organic substance that the body is unable to synthesize that is essential for normal metabolism and body function

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6
Q

What is a dietary mineral

A

Inorganic elements that are essential to the body as biochemical catalysts

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7
Q

what is a macro mineral

A

Mineral where the daily requirement is 100 mg or more

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8
Q

what is a micromineral and what is another name for it

A

Mineral where the daily requirement is less than 100 mg
another name is trace elements

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9
Q

What is the top layer of the skin

A

Epidermis

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10
Q

what is the second layer of skin

A

Dermis

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11
Q

What is the third layer of skin

A

Hypodermis

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12
Q

What is under the hypodermis

A

Muscle

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13
Q

What is the main function of the epidermis

A

Provides a physical barrier against injury and hazardous substances

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14
Q

What is the function of the dermis

A

provides tensile strength mechanical support and protection of the underlying muscle bone and organs

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15
Q

What are the three components of pressure that contribute to a PI

A

Pressure intensity
Pressure duration
Tissue Tolerance

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16
Q

how does pressure intensity affect a PI

A

for a PI to occur the pressure applied to the person must be more than pressure in the capillaries

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17
Q

How does pressure duration affect a PI

A

Duration could be low pressure over a prolonged period or high pressure over a short period

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18
Q

How does tissue tolerance affect a PI

A

Different people can tolerate different levels of pressure depending of integrity of skin

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19
Q

What three factors could affect the skin’s ability to tolerate pressure

A

friction moisture and the ability of the skin to redistribute pressure

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20
Q

Is a low score good or bad on the braden scale

A

The lower the score on the braden scale the more likely the PT is to get a PI

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21
Q

What is a deep tissue injury

A

Persistent non blanchable areas that are deep red or purple and result from pressure or shear force at bone muscle interface

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22
Q

What is a stage 1 pressure injury

A

Intact skin with a localized area of non blanchable skin; a change in temperature sensation or firmness may proceed visual changes

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23
Q

What is a stage 2 pressure injury

A

Partial thickness loss of skin with exposed dermis but you can not see the hypodermis

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24
Q

Is granulation tissue present in a stage 2 pressure injury

A

No granulation tissue usually only in a stage 3 PI

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25
What is a stage 3 PI
Full thickness loss of skin where hypodermis will be visible but bone or muscle will not be showing
26
What is a stage 4 PI
Full thickness skin loss with exposed muscle or bone
27
What is an unstageable PI
Full thickness skin loss but extent of skin loss can not be confirmed because it is obscured by slough or eschar
28
what does it mean when a wound heals by primary intention
the wound edges are approximated (intact) so the wound can be closed by staples or stitches
29
what does it mean when a wound heals by secondary intention
edges of the skin can not be brought together so it has to fill from the bottom up with scar tissue
30
what does it mean when a wound heals by tertiary intention
A wound that has contracted an infection and needs delayed closure to give time for the infection to clear and require surgery to close/cover the wound
31
What are the 4 stages of partial thickness wound healing
Hemostasis inflammation Epithelial proliferation migration
32
What are the four stages of full thickness wound healing
Hemostasis (bleeding) Inflammation Proliferation Remodeling
33
What is involved in the Hemostasis phase
This is the body's immediate response to injury where it tries to control the bleeding by vasoconstriction and formation of a clot
34
what is involved in the inflammatory phase
goal of this phase is to establish a clean wound bed so WBC enter wound bed and begin phagocytosis
35
In a healthy wound how long will the inflammatory phase last
3-6 days
36
What is involved in the Proliferation phase of wound healing
Main activity of this phase is filling in the wound with granulation tissue, contracting the edges of the wound and resurfacing the wound for epithelization
37
In a healthy wound how long will proliferation last
3-24 days
38
in which phase of healing is protein key
Protein is especially important in the proliferation phase of wound healing
39
What is involved in the remodeling phase of wound healing
Additional collage is laid for wound strength and the edges of the wound are brought closer together
40
How long does the remodeling phase of wound healing last
21 days-2 years
41
What are the 3 different types of ulcers
Venous ulcer Arterial Ulcer Diabetic ulcer
42
What causes a venous ulcer
Weak vein walls or improper functioning valves impair the return of blood and impair perfusion of blood to the extremities resulting in tissue death
43
What causes an arterial ulcer and what do they usually look like
Caused by inadequate blood perfusion to the lower extremities and usually have a punched out look and are smaller than venous ulcers
44
What causes diabetic ulcers
Occur due to neuropathic changes related to diabetes like loss of sensation dry cracking skin and deformed extremities which leads to pressure points
45
What are the two key methods of preventing IAD
Manage incontinence Implement a structured skin care regime (cleanse protect restore)
46
What is orthopnea
Sensation of breathlessness when lying down usually relieved by sitting or standing
47
What intention do skin tears heal by
They always heal by secondary intention
48
what are the three ways that secondary intention is different from primary intention
1. Longer repair and healing time 2. Greater chance of scarring and with severe scarring tissue function is impacted permanently 3. increased chance of infection
49
To increase wound healing what nutrients are very important
Protein and carbs
50
How much water does the average adult need per day
3L
51
what are the fat soluble vitamins
A D E K
52
What are the water soluble vitamins
B C
53
What is a major role of dietary minerals
Help with digestion of the three major macronutrients (carbs Protein and Fat)
54
What does Vit A do
Helps with immune system and cell regrowth also can help prevent effects of steroids
55
What does Vit D do
Helps with calcium absorption (think D for Bone DENSITY)
56
What does Vit E do
Antioxidant
57
What does Vit K do
Helps with clotting
58
What does Vit B do
Helps with bone marrow and RBC production
59
What does Vit C do
Antioxidant helps us use Fe and synthesize collagen
60
What is Mg used for in the body
DNA repair and energy
61
What the definition of an acute wound
One where the wound happens suddenly heals rapidly and the original source of the wound can be removed
62
What's the definition of a chronic wound
One that takes longer than 6 weeks to heal and the original cause of the wound can not be removed ie if someone has a diabetic ulcer can't stop them having diabetes
63
when does hemostasis begin and how long does it last
Begins at the moment of injury and should only last for about 15 minutes
64
What are 5 things that could prolong hemostasis
clotting disorders anticoagulants NSAID's liver damage low vitamin K
65
4 things that could delay inflammatory response
Advanced age medications steroids cancer
66
what is worse for the skin feces or urine
Feces because it contains enzymes that are better at breaking down the skin
67
How does feces and urine effect the pH and why does that make you more at risk for an infection
They both increase the pH of the skin which allows microorganisms to thrive
68
How does feces and urine effect the pH and why does that make you more at risk for an infection
They both increase the pH of the skin which allows microorganisms to thrive
69
Does IAD increase risk for Pressure injury
Yes
70
How do IDA and PIs look different
IDA wound will be diffuse with no clearly defined edges while PI will have distinct edges or margins
71
What medication puts the client at an increased risk for bleeding
Aspirin (acetylsalicylic Acid)
72
What is a cerebrovascular accident
Another name for a stroke where part of the brain loses blood resulting in tissue death
73
A nurse is assessing a client with an open area that extends through the epidermis, dermis and into the fat tissue. The client reports they have had this wound for 2 months and "it just won't heal". Select the best answer that describes this wound.
Chronic stage 3 pressure wound (remember a wound that has been there longer than 6 weeks is chronic)
74
what is the normal turning schedule for someone who is at risk for a PI
Q2H
75
What is the first intervention a nurse should implement for a client with a pressure injury
Offload the pressure site

NRSG 126 (11 decks)

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