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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
Q

What is a stage 3 PI

A

Full thickness loss of skin where hypodermis will be visible but bone or muscle will not be showing

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26
Q

What is a stage 4 PI

A

Full thickness skin loss with exposed muscle or bone

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27
Q

What is an unstageable PI

A

Full thickness skin loss but extent of skin loss can not be confirmed because it is obscured by slough or eschar

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28
Q

what does it mean when a wound heals by primary intention

A

the wound edges are approximated (intact) so the wound can be closed by staples or stitches

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29
Q

what does it mean when a wound heals by secondary intention

A

edges of the skin can not be brought together so it has to fill from the bottom up with scar tissue

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30
Q

what does it mean when a wound heals by tertiary intention

A

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

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31
Q

What are the 4 stages of partial thickness wound healing

A

Hemostasis
inflammation
Epithelial proliferation
migration

32
Q

What are the four stages of full thickness wound healing

A

Hemostasis (bleeding)
Inflammation
Proliferation
Remodeling

33
Q

What is involved in the Hemostasis phase

A

This is the body’s immediate response to injury where it tries to control the bleeding by vasoconstriction and formation of a clot

34
Q

what is involved in the inflammatory phase

A

goal of this phase is to establish a clean wound bed so WBC enter wound bed and begin phagocytosis

35
Q

In a healthy wound how long will the inflammatory phase last

A

3-6 days

36
Q

What is involved in the Proliferation phase of wound healing

A

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
Q

In a healthy wound how long will proliferation last

A

3-24 days

38
Q

in which phase of healing is protein key

A

Protein is especially important in the proliferation phase of wound healing

39
Q

What is involved in the remodeling phase of wound healing

A

Additional collage is laid for wound strength and the edges of the wound are brought closer together

40
Q

How long does the remodeling phase of wound healing last

A

21 days-2 years

41
Q

What are the 3 different types of ulcers

A

Venous ulcer
Arterial Ulcer
Diabetic ulcer

42
Q

What causes a venous ulcer

A

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
Q

What causes an arterial ulcer and what do they usually look like

A

Caused by inadequate blood perfusion to the lower extremities and usually have a punched out look and are smaller than venous ulcers

44
Q

What causes diabetic ulcers

A

Occur due to neuropathic changes related to diabetes like loss of sensation dry cracking skin and deformed extremities which leads to pressure points

45
Q

What are the two key methods of preventing IAD

A

Manage incontinence
Implement a structured skin care regime (cleanse protect restore)

46
Q

What is orthopnea

A

Sensation of breathlessness when lying down usually relieved by sitting or standing

47
Q

What intention do skin tears heal by

A

They always heal by secondary intention

48
Q

what are the three ways that secondary intention is different from primary intention

A
  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
Q

To increase wound healing what nutrients are very important

A

Protein and carbs

50
Q

How much water does the average adult need per day

A

3L

51
Q

what are the fat soluble vitamins

A

A D E K

52
Q

What are the water soluble vitamins

A

B C

53
Q

What is a major role of dietary minerals

A

Help with digestion of the three major macronutrients (carbs Protein and Fat)

54
Q

What does Vit A do

A

Helps with immune system and cell regrowth also can help prevent effects of steroids

55
Q

What does Vit D do

A

Helps with calcium absorption (think D for Bone DENSITY)

56
Q

What does Vit E do

A

Antioxidant

57
Q

What does Vit K do

A

Helps with clotting

58
Q

What does Vit B do

A

Helps with bone marrow and RBC production

59
Q

What does Vit C do

A

Antioxidant helps us use Fe and synthesize collagen

60
Q

What is Mg used for in the body

A

DNA repair and energy

61
Q

What the definition of an acute wound

A

One where the wound happens suddenly heals rapidly and the original source of the wound can be removed

62
Q

What’s the definition of a chronic wound

A

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
Q

when does hemostasis begin and how long does it last

A

Begins at the moment of injury and should only last for about 15 minutes

64
Q

What are 5 things that could prolong hemostasis

A

clotting disorders
anticoagulants
NSAID’s
liver damage
low vitamin K

65
Q

4 things that could delay inflammatory response

A

Advanced age
medications
steroids
cancer

66
Q

what is worse for the skin feces or urine

A

Feces because it contains enzymes that are better at breaking down the skin

67
Q

How does feces and urine effect the pH and why does that make you more at risk for an infection

A

They both increase the pH of the skin which allows microorganisms to thrive

68
Q

How does feces and urine effect the pH and why does that make you more at risk for an infection

A

They both increase the pH of the skin which allows microorganisms to thrive

69
Q

Does IAD increase risk for Pressure injury

A

Yes

70
Q

How do IDA and PIs look different

A

IDA wound will be diffuse with no clearly defined edges while PI will have distinct edges or margins

71
Q

What medication puts the client at an increased risk for bleeding

A

Aspirin (acetylsalicylic Acid)

72
Q

What is a cerebrovascular accident

A

Another name for a stroke where part of the brain loses blood resulting in tissue death

73
Q

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.

A

Chronic stage 3 pressure wound
(remember a wound that has been there longer than 6 weeks is chronic)

74
Q

what is the normal turning schedule for someone who is at risk for a PI

A

Q2H

75
Q

What is the first intervention a nurse should implement for a client with a pressure injury

A

Offload the pressure site

NRSG 126 (11 decks)

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