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Nursing 2160
Exam 1
| Question | Answer |
|---|---|
| the absence of disease | health, wellness |
| a state of complete physical, mental, and social well being | holistic approach |
| a systematic method of collecting data (subjective, objective) about a client | health assessment |
| An interview collects _____ data | subjective |
| Physical assessment or exam collects ____ data | objective |
| What data is the information experience and verbalized by the client to the nurse? | subjective data |
| What data is observed or measured by the nurse? | objective data |
| What type of documentation is like writing a story on the client? | narrative notes |
| What type of documentation is similar to narrative notes but organized into sections? | problem oriented charting |
| What type of documentation is used to describe pain- can be numeric from 0 to 10 or the faces scale? | scales |
| What type of documentation is hourly, shift, day week- used for vital signs, intake/output, usually to chart a lot of numeric data? | flow sheets |
| What type of documentation is specific- such as an abdominal assessment form? | focus documentation |
| What type of documentation is where you can check off on the form only abnormals noted? | charting by exception |
| The charts should always be kept behind the _____. | counter |
| The charts should NEVER be left in the _____. | clients room |
| If documenting use ____ _____ ink ONLY. | black, non erasable |
| The documentation should be _______- appropriate to clients problem. | non judgmental |
| When documenting, be complete and concise and eliminate ____ and _____ | prepositions, 1st person pronouns |
| When documenting, if you make a mistake, strike through with ______, write ____, and write your initials, data, time. | one straight line, error |
| Compare your client to ____ and ____ range of findings for their age, gender, race, clients own baseline, disease process, the clients status at the time. | normal and expected ranges of findings |
| What 3 developmental factors do you consider when assessing patient? | age, intellect, developmental handicaps |
| What 4 emotional factors do you consider when assessing patient? | anxiety, self esteem issues, depression, grieving state |
| What 3 family factors do you consider when assessing patients? | family history of first degree relatives, risk for inheriting disease, decision making process |
| What 3 cultural factors do you consider when assessing patients? | clients primary language, expression of emotions, special health practices and beliefs |
| Response to medication and treatment is an ____ environmental factor | internal |
| Irritants that are inhaled,ingested, or come in contact with the body are ____ environmental factors | external |
| Clients emotional state is _____ environmental factor | internal |
| A rational and dynamic process used by the nurse to plan and provide client care | nursing process |
| What are the 5 steps of the nursing process? | assessment, diagnosis, planning, implementation, evaluation |
| _____- step where the nurse puts the nursing interventions into action | implementation |
| _____- the collection, organization, and validation of subjective/objective data | assessment |
| _______- comparing the client status to the stated goals or outcomes | evaluation |
| ______- use of critical thinking and application of knowledge from the sciences and other disciplines to analyze and synthesize data | diagnosis |
| ______- priority setting, stating client goals or outcomes, and selecting nursing interventions | planning |
| Vital signs reflect _____ status | physiologic |
| Vital signs are regulated through _____ | homeostasis |
| Assess vital signs upon ____ and usually every ___ hours. | admission, four |
| Assess vital signs more frequently in ____ | severely ill |
| Changes in clients condition require more ____ assessment of vital signs | frequent |
| Assess vital signs before administering ______ that affect cardiovascular and respiratory functioning. | medications |
| Body temperature regulation is by the _____ | hypothalamus |
| Whats normal body temp? | 97-99.5 |
| Your lowest temperature is in the _____ and highest in _______ | morning, late afternoon |
| What 5 factors affect body temperature? | circadian rhythms, age, gender, stress, environmental temperature |
| Primary source of heat in body is _____ | metabolism |
| Whats the primary site of heat loss? | skin |
| Normal body temp is called ____ | afebrile |
| Increased body temp is called _____ | febrile |
| Fever is also called ____ | pyrexia |
| Death can occur below what body temp? | 93.2 F |
| Whats the danger of glass thermometers? | mercury poisoning |
| Disposable single use thermometers are swiped across what 2 areas? | abdomen, forehead |
| What 4 factors affect what site the temperature should be taken at? | age, state of consciousness, amount of pain, other care being provided |
| Tympanic thermometer goes in the _____ | ear |
| Where is considered the core body temp? | ear |
| What are some contraindications for giving oral thermometer? | infants/young children, unconscious, seizure prone, oral cavity/nasal surgery/disease, recent oral intake, O2 per face mask |
| What temperature site is considered most accurate? | anal |
| Taking rectal temperature may stimulate ____ nerve which could ___ the heart rate. | vagus, slow |
| What are some contraindications of taking rectal temp? | newborns, diarrhea, rectal disease/surgery, some cardiac conditions |
| What site is used in newborns to get temperature? | axillary |
| Pulse are perceptible throbbing sensations as a wave of blood is pumped into the arteries by contraction of the _______ | left ventricle |
| Pulse is regulated by the _____ | autonomic nervous system |
| Whats normal pulse rate for adult? | 60-100 |
| When assessing pulse, you palpate sites with _____ ____ fingers | three middle |
| You use a stethoscope for the ___ pulse | apical |
| Tachycardia is how many beats per minute? | 100-180 |
| Tachycardia can be from pain, ____, ___. prolonged application of ___, ____ in BP, elevated ____, poor oxygenation, medications. | strong emotions, exercise, heat, decrease, temperature |
| Bradycardia is how many beats per minute? | below 60 |
| A person might have bradycardia at rest an on ______. | awakening |
| Are males or females more likely to have bradycardia? | males |
| Does hypothermia cause tachycardia or bradycardia? | bradycardia |
| _____- the pattern of pulsations and the pauses between them | pulse rhythm |
| _____- an irregular pattern of beats | dysrhythmia |
| _____- the quality of the pulse in terms of its fullness | pulse amplitude |
| Pulse amplitude reflects ___ ventricular function | left |
| Whats the most common spot for assessing peripheral pulse? | radial artery |
| Whats the artery to get pulse in the foot? | dorsalis pedis |
| Apical pulse- you count for ____ full minute with stethoscope over apex | 1 |
| Use apical pulse when giving cardiac ____ and when peripheral pulse is ____ | medications, abnormal |
| Use _____ artery for emergencies | carotid |
| Use ____ artery in infants in cardiac arrest | brachial |
| ______- counting at the apex of the heart and at the radial artery at the same time | apical radial |
| Apical radial pulse is taken when radial pulse is _______ | irregular |
| _____- difference between the apical and the radial pulse rates | pulse deficit |
| _____ is called breathing | pulmonary ventilation |
| One respiration is considered the ______ of a breath | in and out |
| An increase in ___ is the most powerful respiratory stimulant | carbon dioxide |
| Rate and depth of breathing is controlled by the respiratory center in the ___ and ___ | medulla, pons |
| Rate and depth of breathing are activated by impulses from ____ | chemoreceptors |
| Brain damage and death occurs ____ minutes after no longer breathing | 4-6 |
| Normal respiratory is called | eupnea |
| Increased respiratory rate is called ____ | tachypnea |
| Decreased respiratory rate is called ____ | bradypnea |
| A fever causes ___ in respiratory rate | increase |
| Respiratory depth is considered from ___ to __ | shallow, deep |
| No breathing is called ___ | apnea |
| difficulty breathing is called ____ | dyspnea |
| Breathing in upright position is called ___ | orthopnea |
| Normal respiratory is ____ times a minute | 12-20 |
| Infants breathe more ___ | rapidly |
| When assessing respiration, assess the __, __, and ___ | rate, depth, rhythm |
| When assessing respirations, you are assessing the _____ results | arterial blood gas |
| You can assess respirations using a _____ | pulse oximeter |
| The diaphragm of a stethoscope is used for the _____ sounds such as respiratory sounds | high frequency |
| The bell of a stethoscope is used for ____ sounds such as for heart and blood in vessels. | low frequency |
| Width of a blood pressure cuff should be ___% circumference of a limb. | 40 |
| ____- round calibrated dial that indicates pressure | aneroid |
| _____- force of the blood against the arterial walls | blood pressure |
| _______- maximum blood pressure- left ventricle contracts | systolic pressure |
| _____- lowest pressure- heart at rest between beats | diastolic pressure |
| ______- difference between the two pressures | pulse pressure |
| Blood pressure is measured in _____ | millimeters of mercury (mm Hg) |
| Regulation of BP is determined by ___, pumping action of the heart, blood volume, ____ of the blood, ____ of vessel walls. | peripheral resistance, viscosity, elasticity |
| _______- low blood pressure associated with weakness or fainting when rising to an erect position | postural (orthostatic) hypotension |
| Orthostatic hypotension occurs because of peripheral _____ without compensatory increase in cardiac output | vasodilation |
| At the popliteal artery, the systolic is usually ___ mm Hg higher | 10-40 |
| Leading cause of injury fatalities in adults 65 and older is ___ | falls |
| R in Restraint stands for | respond to the present, not the past |
| E stands for | evaluation potential for injury |
| S stands for | speak with family members or caregivers |
| T stands for | try alternative measures first |
| R stands for | reassess the patient to determine whether alternatives are successful |
| A stands for | alert the physician and family if restraints are indicated |
| I stands for | individualize restraint use |
| N stands for | note important info on patients chart |
| T stands for | time- limit use of restraints |
| Restraints can cause impaired ____ and altered ____ | circulation, skin integrity |
| Restraints can cause diminished ______ | muscle, bone mass |
| Assign confused or disoriented clients to rooms near the ____ | nurses' station |
| What are the 2 peak fall times for providing scheduled toileting? | 6-8 am 4-6 pm |
| Incident reports are NOT part of the ___ and should not be mentioned in the documentation | medical record |
| R in RACE for fire emergency stands for | rescue anyone in immediate danger |
| A stands for | activate fire code, notify appropriate person |
| C stands for | confine fire by closing doors and windows |
| E stands for | evacuate patients and other people to safe area |
| Whats the most effective agent for preventing absorption of ingested toxin? | activated charcoal |
| If need emergency restraint, get physicians order within ____ hour. | 1 |
| When maintaining emergency preparedness, address ___, ___, ___ threats | biological, chemical, nuclear |
| ____- deliberate spread of pathogenic organisms into a community | bioterrorism |
| ____- deliberate release of a chemical compound for purpose of causing mass destruction | chemical terrorism |
| ____- intentional disposal of radioactive materials into environment for purpose of causing injury/death | nuclear terrorism |
| What are the 5 chemicals used for mass destruction? | pulmonary agents, cyanide, vesicants, nerve agents, incapacitating agents |
| ______- contracted skeletal muscles that keep body upright against gravity | postural tonus |
| Sensory organs in ____ provide for sense of position and movement | inner ear |
| Use longest and strongest muscles of _____ and ____ to provide power needed in strenuous activities | arms, legs |
| Use the ___ and ___ to stabilize the pelvis and protect the abdominal viscera when stooping, lifting, and pulling. | internal girdle, long midriff |
| use the weight of the body to push an object by _____ or ___ forward | falling, rocking |
| What position is the bed in if entire bed tilted downward with head of bed down? | trendleburg |
| What position is bed in if head of bed is raise to angle of 45 degrees or more; semisitting position | fowlers |
| What position is bed in if the head of bed is raised approx 30 degrees | semi fowlers |
| What position is bed in if entire bed grame tilted downward with foot of bed down | reverse trendleburg |
| ____ rolls prevent external rotation of hips of bedridding patients | trochanter |
| Fowlers position promotes ___ and ___ functioning | cardiac, respiratory |
| Supine or dorsal recumbent position allows for _____ | correct alignment |
| Prone position helps to prevent flexion contractures of ___ and ___ | hips, knees |
| ROM exercises improve ____ and ____ | mobility, circulation |
| Only ___ ROM increases muscle tone, mass, and strength and improves cardio respiratory function | active |
| When doing ROM, support the joint by holding the __ and ___ areas adjacent to the joint. | distal, proximal |
| What are 3 support measures to do when doing ROM exercises? | cupping, supporting, cradling |
| What are the four basic techniques used by the professional nurse when performing physical assessment? | inspection, palpation, percussion, auscultation |
| _____- assessing client through observation; always proceeds any other assessment skill | inspection |
| _____- assessing the client through the sense of touch to determine characteristics | palpation |
| What 5 things do you palpate for? | size, shape, location, mobility, position |
| What are 6 other things you palpate for? | vibrations, temp, texture, moisture, tenderness, edema |
| Light palpation means you palpate of __ cm in depth of less | 1 |
| ____ are used for palpation in general | fingerpads |
| When palpating for temperature, use ___ aspect of hand | dorsal |
| When feeling for vibration or fremitus, use the ___ or __side of hand | palmar, ulnar |
| Moderate palpation requires you to palpate ___ to __cm in depth | 1-2 |
| Use moderate palpation to assess some ___, size of lesion, shape, consistency, mobility, pain, tenderness | pulses (brachial, popliteral, aortic) |
| Deep palpation requires you to palpate __ to ___ cm in depth | 2-4 |
| You can do deep palpation by doing what with you hands? | one over the other |
| CAREFUL with deep palpation because if organs are ___, you can cause damage. | enlarged |
| Palpate known painful areas ____. | Last |
| _____- to strike through- tapping with fingers or object to produce sound (also to induce tenderness in some methods) | percussion |
| _____ percussion- use three to four fingerpads to directly tap. mostly used in illict tenderness of facial sinuses. | direct |
| ____ percussion- assess pain or tenderness of kidneys (most commonly), also can be done over liver/gallbladder area | blunt |
| When doing blunt percussion, place palm of ____ hand flat over organ and pound firmly with dominant first | nondominant |
| ____ percussion- most common type- tapping done of one finger on top of another finger on the body surface to elicit a sound | indirect percussion |
| To do indirect percussion, what fingers can you use? | middle finger to middle or index and middle finger |
| Indirect percussion- this sound produced tells you how ___ the tissue or underlying organ is | dense |
| Indirect percussion- you can detect abnormalities up to ___ cm deep | 5 |
| What are 4 characteristics of percussion sounds? | intensity, pitch/frequency, duration, quality |
| ____ sound- loud, high pitched, drum like, medium duration (over air filled intestines) | tympany |
| ____ sound- loud, lower pitched than tympany; hollow; medium duration- over normal lung fields | resonance |
| ______ sound- very loud; low pitch; booming sounds; long duration (over abnormal hyperinflated lungs) | hyperresonance |
| _____ sound- soft, high pitch, dull, short duration (over major thoracic, and abdominal organs, over feces filled intestines) | dullness |
| _____ sound- soft, high pitch, flat, very short duration (over muscle mass, over bone) | flatness |
| _______- use of stethoscope to amplify internal body sounds | auscultation |
| What are 4 sounds you can detect by auscultation? | intensity, pitch, duration, quality |
| ____- natural habitat of the organism | reservoir |
| _____- point of escape for the organism | portal of exit |
| What are 3 routes of transmission? | direct contact, indirect contact, airborne route |
| _____- point at which organisms enter a new host | portal of entry |
| What infectious agent is most significant and most prevalent in hospital settings? | bacteria |
| Whats the smallest of all microorganisms? | virus |
| What are plantlike organisms that are present in air,soil, water? | fungi |
| spherical bacteria are called ___ | cocci |
| Rod shaped bacteria are called ____ | bacilli |
| corkscrew shaped bacteria are called ___ | spirochetes |
| What are the 4 factors affecting an organisms potential to produce disease? | number of organisms, virulence, competence of persons immune system, length and intimacy of contact between person and microorganism |
| What are 5 possible reservoirs for microorganisms? | other humans, animals, soil, food/water/milk, inanimate objects |
| What are 5 common portals of exit? | respiratory, GI, genitourinary tracts, breaks in skin, blood and tissue |
| Medical asepsis is called ____ technique | clean |
| Surgical asepsis is called ____ technique | sterile |
| Antibiotic resistant organisms developed in hospitals such as MRSA, VRE, C-diff, and Thrush predispose patient to ____ infections | nosocomial |
| _____ bacterial flora- attacked loosely on skin, removed with relative ease | transiet |
| _____ bacterial flora- found in creases in skin, requires friction with brush to remove | resident |
| What are the 4 stages of infection? | incubation period, prodromal stage, full stage of illness, convalescent period |
| _____ stage- person is most infectious; vague, and nonspecific signs of disease | prodromal |
| ______ stage- recovery from the infection | convalescent |
| ______ stage- organisms growing and multiplying | incubation period |
| ______ stage- presence of specific signs and symptoms of disease | full stage of illness |
| What are 3 of the bodys defense against infection? | bodys normal flora, inflammatory response, and immune response |
| What is a normal white blood cell count | 5000-10,000/mm3 |
| ____ in specific types of white blood cells indicates infection | increase |
| elevated __ ___ ___ indicates infection | erythrocyte sedimentation rate |
| In what order to you remove PPE? | gloves, gown, goggles, mask |
| What precautions are used in care of all hospitalized patients-apply to blood, bodily fluids, secretions, excretions, non intact skin and mucous membranes? | standard precaution |
| What precautions are used in addition to standard precautions for patients with suspected infection- apply to include airborne, droplet, or contact precautions? | transmission based precautions |
| What precautions do you use for patients with infections such as TB, chicken pox, measles? | airborne precautions |
| In airborne precations, place patient in private room with ______ _____ | negative pressure |
| You must use a ____ when entering a negative pressure room. | respiratory protection |
| What precautions do you use with patients with diseases spread in large droplets such as rubella, measles, mumps, and diphtheria? | droplet precautions |
| When using droplet precautions, wear a mask when working within ___ feet of the patient and keep visitors ___ feet away from patient | 3,3 |
| Use ____ precautions when working with patients that have diseases such as VRE, MRSA, C-diff? | contact precautions |
| When washing hands, wash at least ___ above area of contamination. | 1 inch |
| Keep hands below ___ to keep flow going from cleaner toward more contaminated. | elbows |
| Continue friction for at least ___ seconds. | 15 |
| Surgical- arms ____ | up |
| Medical- arms ___ | down |
| In operating rooms and labor and delivery rooms, you use ____ asepsis. | surgical |
| After a bottle is opened, it should be ____ | labeled |
| Most solutions are considered sterile for ___ hours | 24 |
| When pouring solution, grasp the bottle with _____ to ____ | label, hand |
| ___ the bottle if it has been previously used | lip |
| What are 6 functions of the skin? | protection, body temperature regulation, sensation, excretion, maintenance of water and electrolyte balance, vitamin D production and absorption |
| Adequate ___ is necessary to maintain cell life. | circulation |
| Adolescent has enlarged ____ glands and increased secretions. | sebaceous |
| Adults tissue becomes ___ and wrinkles appear and ___ spots appear. | thinner, liver |
| Very ___ and very ___ people are more susceptible to skin injury | thin, obese |
| Excessive perspiration during illness ____ skin to breakdown | predisposes |
| Jaundice causes ___, ___ skin | yellowish, itchy |
| What 8 factors do you look at when examining skin? | cleanliness, color, temp, turgor, moisture, sensation, vascularity, evidence of lesions |
| Bathing serves as ____ exercise and stimulates the rate and depth of ____ | musculoskeletal, respirations |
| Remove antiembolism stockings daily, usually during ___ care | AM |
| What are prescribed for high risk surgical patients and patients with chronic venous disease or at risk for deep vein disorders? | intermittent pneumatic compression stockings |
| Intermittent pneumatic compression stockings stimulate normal _____ action in the legs. | muscle pumping action |
| What are the 3 layers of skin in order from outside to inside? | epidermis, dermis, subcutaneous |
| Name 4 functions of skin? | synthesis of vitamin D, repair wounds, regulate temp, prevent fluid/electrolyte loss |
| Name three types of glands. | eccrine, apocrine, sebaceous |
| What layer are the glands located in? | subcutaneous layer |
| Which of the glands is located throughout the skin? | eccrine |
| What senses do you need to assess someones hair, skin, nails? | sight, hearing, smell, touch |
| What are 5 abnormalities of hair? | pediculosis, folliculitis, hirsutism, alopecia, trichotillomania |
| What do sebaceous glands release and where is this released? | oil, released into hair follicles |
| What is hair made out of? | dead keratinzed cells |
| Name two types of hair? | vellus, terminal |
| What makes hair different from nails? | hair is fiber compound; nails are thin plates of cells |
| What abnormal skin discoloration is from anemia, vasoconstriction, stress? | pallor |
| What abnormal skin discoloration is from anemia, CV or pulmonary disease, stress, cold temperature? | cyanosis |
| What abnormal skin discoloration is from autoimmune disorder? | vitiligo |
| What abnormal skin coloration is from a fungal infection? | tinea versicolor |
| What abnormal skin coloration is floor blood trapped in tissue? | hemosidirin stains |
| What abnormal skin coloration is from long term arterial vascular disease from loss of vasoconstrictive ability of artery? | ruddy |
| Rubor is the same as ___ | ruddy |
| What abnormal skin coloration comes from liver disease, hemolytic diseases, newborn physiological? | jaundice |
| Uremia is from ___ disease | kidney |
| ____ is from vasodilation of superficial vessels, inflammation. | erythema |
| ____- absence of color due to absence of oxygenated hemoglobin | pallo |
| ____- mottled blue hue due to inadequate perfusion with oxygenated blood | cyanosis |
| ____- loss of malanin pigment | vitiligo |
| ____- deep reddish purple hue due to increased hemoglobin levels or stasis in capillaries | ruddy |
| _____- increased yellow undertones of skin and sclera of eyes, palms, soles? | jaundice |
| ____- pale yellow undertones generally lighter than jaundice due to urinary and nitrous wastes retained in blood? | uremia |
| ____- redness of skin due to increased visibility of normally oxygenated hemoglobin? | erythema |
| The gray line around tissue is ____ and the tissue inside wound that looks like hamburger meat is ____ tissue | reepithelization, granulation |
| ____- swelling of tissues or organs with fluid, graded 1+ to 4+ | edema |
| Measuring pitting edema, for each +, its worth _____ of depth that you can push into the skin | 2 mm |
| What do ABCDE stand for relating to melanoma? | asymmetry, border irregularity, color, diameter, evolving |
| Stage 1 pressure ulcer is _____ erythema and is NOT an open area | non blanchable |
| Stage 2 pressure ulcer is a partial thickness lesion, opens into ___ only and heals by ____________ | dermis, reepethelization |
| Stage 3 pressure ulcer is full thickness and goes through layers __,___,___. However, it does NOT go into ___ tissue and it heals by? | epidermis, dermis, subcutaneous muscle scar tissue formation |
| Stage 4 pressure ulcer is a full thickness lesion, it goes through ___ tissue and often exposes underlying structures. It heals by? | muscle, scarring |
| _____- area of deep purple hue indicating possible injury to deep tissue | deep tissue injury |
| What does blanchable mean? | when you press on something, if it turns white |
| In stage 1 pressure ulcer and in a DTI, the skin is still _____ | closed |
| It takes ___ minutes for tissue death to occur | 15 |
| How do you measure wounds? | length by width by depth |
| DTI are ____ than stage 1 ulcers. | darker |
| Yellow drainage is called ____ | serum |
| ____ is when you take a cotton tip and sweep underneath the intact skin, bigger at bottom than it is at top? | undermining |
| ____- when a surgical wound opens at the incision line | dehiscence |
| _____- when the internal organs come out through an opening-surgical emergency | evisceration |
| Green stuff on a wound is called ____ | chlorophyll |
| avascular tissue is ____ | dead |
| ____- hardness around wound, usually associated with infection | induration |
| ____- open space extending beyond wound edges | undermining |
| ____- collection of blood in the subcutaneous tissue, causing purplish discoloration | ecchymosis |
| ____ is from scratching; linear lesions, often with petechiae | excoriation |
| ____- small hemorrhagic spots caused by capillary bleeding | petechiae |
| ____- epidermal stripping/ peeling, tape often causes this, often due to chemical exposure | denudation |
| _____- disruption in the normal integrity of the skin | wound |
| ____ wound- result of planned therapy or treatment that requires invasive measures such as surgery, IV therapy. | intentional wound |
| In an intentional wound, the edges are ___, bleeding controlled, sterile procedure, less risk for infection, and healing facilitated. | clean |
| _____ wound- unexpected trauma such as accidents, forcible injury, and burns. | unintentional |
| In unintentional wounds, the edges are usually ____, bleeding uncontrolled, unsterile, high risk for infection, longer healing time. | jagged |
| ____ wound- skin surface open, may have bleeding, tissue damage, increase risk of infection | open |
| ____ wound- results from a blow, force, or strain caused by trauma such as a fall, assault, or motor vehicle accident | closed |
| In a closed wound, the skin surface not broke but ______ damage may occur; internal injury and hemorrhage may occur | soft tissue |
| Acute wound usually heals within ___ to ___ | days- 2 weeks |
| In acute wounds, the edges are well ___ and low risk of infection, uneventful healing process. | approximated |
| Chronic wounds take longer than ___ to heal and the edges are often not well approximated. There is a higher risk of infection and delayed healing time. | 2 weeks |
| Chronic wounds often remain longer in ___ phase | inflammatory |
| What are the 4 phases of wound healing? | hemostasis, inflammatory (reaction), proliferative (regenerative), maturation (remodeling) |
| In inflammatory phase, ____ enter immediately to being clean up. | neutrophils |
| In inflammatory phase, ____ become macrophages and they eat up dead tissue/cells/bacteria. | monocytes |
| Exudate is highest in ____ phase | inflammatory |
| Chronic wounds get suck in ____ phase | inflammatory |
| Formation of granulation tissue occurs in the ___ phase | proliferative |
| What else happens in proliferative phase? | re-epithelialization |
| Vascularity ____ in the maturation phase | decreases |
| There is ____ tensile strength in the maturation phase | increased |
| Pigmentation occurs in _____ phase | maturation |
| After wound closure, wounds regain ____% of original tensile strength. It's always a tender area because it has a loss of ____. | 70-75%, elasticity |
| Adequate ____ is essential for normal response to any injury. | blood supply |
| Intact skin and _____ are first line of defense against microogranisms. | mucous membranes |
| Healing is promoted when wound is free of ____ | foreign material |
| In a primary intention wound, the wound is ____, ___ line, and little loss of tissue. | clean, straight |
| In a secondary intention, edges cannot be ____, formation of ____ tissue, wound is open, longer healing time, greater risk for infection, more scarring. | approximated, granulation |
| In tertiary intention, there is a time delay before wound is sutured, greater ____, greater risk for infection, greater ___ reaction, larger amount of scarring. | granulation, inflammatory |
| _____- too much moisture that impairs skin integrity | maceration |
| ____ dry, dead cells that delay healing | desiccation |
| Local symptoms are usually within __ to ___ days; purulent drainage, pain, redness, swelling | 2-7 |
| Systemic symptoms include increased ___ and ___ | body temp, WBCs |
| ______- partial or total disruption of wound layers | dehiscence |
| ____- complication of dehiscence, protrusion of viscera through wound layers | evisceration |
| ____- abnormal passage from or between internal organs | fistula |
| Drainage that is clear and watery is usually ____ | serous |
| Drainage that looks like blood and has a large number of RBCs is called ____ | sanguineous |
| Drainage that is a mixture of serum and RBCs and is most common is? | serosanguineous |
| Drainage that has WBCs, liquefied dead tissue debris, and both dead and live bacteria; thick; musty odor is called ____ | purulent |
| Color of purulent drainage depends on ______ | causative organism |
| Wound pain is usually most severe in first ____ days | 2-3 |
| Sutures and staples are usually in for ____ days | 6-8 |
| _____- strips of adhesive applied directly to wound to continue suture support | steri strips |
| ____ drain- open system- placed directly through wound, large safety pin placed on outside end to prevent slipping back into incised area; not sutured in place | penrose |
| What are two closed drainage systems? | jackson pratt and hemovacs |
| Closed drainage systems are usually ____ to skin. | sutured |
| _____- uniform negative pressure on wound bed, removal of excess wound fluid and bacteria | wound VAC |
| Oxygen therapy for wounds is called a ____ | hyperbaric chamber |
| Hemorrhage causes a drop in ____ systolic BP and a ___ in heart rate and resp rate. | drop, increase |
| When a patient has a hemorrhage, they have a ____ H & H | decreased |
| Whats the best wound cleanser? | normal saline |
| Normal saline is ___tonic. | isotonic |
| What wound cleanser kills healthy tissue? | hydrogen peroxide |
| What wound cleanser is caustic to healthy tissue but great for odor control? | dakins solution |
| Length is longest point from __ to __ o clock | 12-6 |
| Width is longest point from ___ to ___ o clock | 9-3 |
| _____- due to blood vessel collapse caused by unrelieved pressure between two hard sufaces | pressure ulcers |
| _____- thick, leathery necrotic tissue | eschar |
| ____- warm, red area after ischemic | hyperemia |
| ______- blanchable reddening of skin that usually fades within 90 minutes of pressure removed | reactive hyperemia |
| Yellow tissue is ___ or ___ | avascular, necrotis |
| Red tissue is _____ | granulation |
| Black tissue is ____ tissue | eschar |
| Retention sutures can cause ____ | pressure ulcers |
| Drain that looks like a hand grenade is called a ____ | jackson pratt |
| Drain that looks like a giant rubber band is called a ____ | penrose drain |
| Drain that looks like a giant spring trapped in a plastic sheath is called a _____ | hemovac |
| Does cartilage have bloody supply? | NO |
| ______- circumscribed elevation that contains pus, usually less than 0.5 cm in diameter | pustule |
| ______- discrete, solid, elevated body usually less than 0.5 cm in diameter; further classified by shape, size, color, surface change | papule |
| _______- fluid filled blister greater than 0.5 cm in diameter; fluid can be clear, serious, hemorrhagic, or purulent | bulla |
| _______- fluid filled cavity or elevation less than 0.5 cm in diameter, fluid may be clear, serous, hemorrhagic, or pus filled | vesicle |
| ______- flat, generally less than 0.5 cm; area of skin or mucous membrane with different color from surrounding tissue | macule |
| _____- discrete, solid elevated body usually broader than it is thick; measuring greater than 0.5 cm in diamter | plaque |
| _____- thickened skin with accentuated markings usually due to repeated rubbing and scratching of skin | lichenification |
| _____- hardened layer that results when serum, blood, or purulent exudate dries | crust |
| ______- fluid filled cavity or elevation less than 0.5 cm in diameter; fluid may be clear, serous, hemorrhagic, or pus filled | vesicle |
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theresa9133
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