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Nursing > Nursing Procedures - sem 1 2nd Half > Flashcards

Nursing Procedures - sem 1 2nd Half Flashcards

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1
Q

Skin function - protection

A

Protects from microorganisms, dehydration, UV radiation, medical trauma and chemical hazards

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2
Q

Skin function - sensation

A

Hot cold pain touch pressure are all sensory receptors of sensation

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3
Q

Skin manufactures what vitamin

A

Vit D
Which ensures calcium absorption

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4
Q

Skin function - flexibility

A

For movement of the body to occur without injury, the skin must be supple and elastic. It grows as we grow an exhibit stretch and recoil characteristics that permit changes in body contours to occur without tearing or laceration.

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5
Q

Hormone (vit d) production

A

First step of the production in the body occurs when the skin is exposed to ultraviolet light

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6
Q

Skin function - exertion

A

By regulating volume and chemical content of sweat, the body through function of the skin can influence both its total fluid volume in the amounts of certain waste products such as uric acid and urea that are excreted

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7
Q

Epidermis is made of…

A

Epithelial tissue

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8
Q

Structure of the epidermis

A

Covered in normal flora
Avascular
Contains no nerves or glands
The cells of the epidermis are found in up to 5 distinct layers

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9
Q

Dermoepidermal junction

A

Glues the epidermis and dermis together
Stops things from the environment making way to the dermis into the blood

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10
Q

The 2 layers of the dermis are…

A

Papillary and reticular

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11
Q

Structure of the dermis

A

Tough leathery layer that sits between the derma and the hypodermis
Made of fibrous connective tissue
Provides a storage area for water and electrolytes
Vascular
Contains muscle fibres, sweat and sebaceous glands, hair follicles macrophages and dendritic cells
Contains a wide network of nerves and nerve endings or sensory receptors

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12
Q
A
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13
Q

Fibroblasts

A

Are important during wound
Produces collagen and elastin
As we age, we begin to produce less fibroblasts

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14
Q

Structure of the hypodermis

A

Located between the dermis and underlying structures of the body
Made of fibrous and adipose tissue
Carries a major blood vessels and nerves to the skin

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15
Q

Melanin is dependant on

A

Genetics
Sun exposure

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16
Q

The 2 types of glands

A

Sweat and sebaceous

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17
Q

Hair follicles

A

Follicle is connected to arrector pili muscles
Follicles contain a large number of sensory fibres

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18
Q

Structure of nails include the…

A

Nail body, lunula, cuticle and nail root

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19
Q

Nails are made from

A

Keratin
Which contributes to their protective function?

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20
Q

Sweat gland contain 2 glands

A

Eccrine glands - found all over the body produced sweat/perspiration, which removes waste, maintains body temp

Apocrine glands - located in the axilla, breast and anal region. Not until puberty that they become active.

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21
Q

Sebaceous gland

A

Located wherever hair grows
Secret sebum for the skin and hair

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22
Q

Clinical judgment model

A

Noticing -gathering info (subjective and objective)
Interpreting - what is the most likely explanation?
Responding - what needs to happen now?
Reflecting - evaluate outcome and decide what next

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23
Q

Older adults skin changes

A

Thinning skin, reduced ability for healing due to poor circulation issues, poor nutrition - needs a lot of protein

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24
Q

SCOTTT skin observation

A

Skin changes
Colour
Oedema
Temp
Texture
Turgor

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25
Nails clubbing
The nail plate shape and angle is >180 degrees maybe caused by long-term lack of oxygen
26
Skin oedema
Presence of excess fluid in the interstitial compartment Usually appears swollen, stretched and shiny Typical sites are feet, ankles and sacrum Graded with a + system
27
The 2 assessments for prevention for pressure injuries
SSKIN assesment (nursing assessment skills) Braden scale (risk assessment tools)
28
Lesion characteristics
Location and distribution Colour Pattern Elevation Size and shape Edges Characteristics
29
Braden scale covers:
Sensory perception Moisture Activity Mobility Nutrition Friction and shear
30
ABCDE’s of melanoma
Asymmetry Border Colour Different Evolving
31
Acute wound healing timeline
Often within 2 weeks
32
Chronic wound healing timeline
Longer than 3 weeks Some may never heal
33
In the wound healing process phagocytes cells remove what?
Necrotic/dead and damaged tissues
34
The 4 processes of healing
Haemostasis Inflammation Proliferation Maturation
35
Vasoconstriction
Stops bleeding
36
Vasodilation
Causes inflammation - stops infection
37
Haemostasis phase 1
Vasoconstriction Blood vessels constrict this causes the wound to close as a result there is less or no bleeding from the injury/wound
38
Haemostasis phase 2
Formation of platelet plug Collagen fibres are seen where the epithelium has been damaged Platelet stick to the collagen fibres within in the blood vessel of walls This causes a plug to form
39
Haemostasis phase 3
The bio chemical response Involves a complex chemical cascade whereby once the clot has developed it begins to breakdown and is replaced by wound edge joining the wound back together Fibro restores the tissue and add strength to the wound by attracting to the platelets holding the clot in place
40
Inflammation stage 2
Involves both cellular vascular response Involves vasodilation, activation of compliment, movement of leucocytes
41
Inflammation approx 2-3 days for wounds healing
Phagocytic leukocytes - neutrophils and macrophages clean up foreign cells and foreign debris and dead tissue The presence of phagocytic cells brings an increase in fibroblasts and epithelial cells Fibroblast manufacture new collagen and extra cellular matrix Newly formed granulation tissue joints of vessels beginning to close the wound
42
Proliferation stage 3
Extensive growth of epithelial cells The laying down of collagen by fibroblasts the extra cellular matrix makes women strong stronger A gel light substance is laid down in the wound bed The substance allows collagen and ground substance to contribute to decrease in the size of the wound and gives the wound renewed strength and flexibility
43
During proliferation
New capillary development is seen as bumpy granulation tissue at the base of the wound. Epithelial cell migration occurs over the granulated wound bed and epithelial has migrate from surrounding wound edges or from hair follicles, sweat or sebaceous glands in the wound and appear as a thin translucent form across the wound bed.
44
Proliferation approx 2-24 days
The wound continues, tore it back together New capillaries are formed bringing improved blood flow oxygen and nutrients to the injured area During this phase, the body fills the wound with connect tissue (granulation) Contracts the wound edges The proliferation phase involves regeneration of blood vessels and formation of connective tissue which is fragile and can bleed easy
45
Maturation stage 4
Granulation tissue fills the Increased blood flow The arrangement of collagen become stronger 80% of normal strength Formation of a scar from collagen This phase is also also known as remodelling During this stage fibroblast leave the side of the wound vascular restrictions reduced
46
Is a healed wound as strong as normal skin
No 80% of normal strength
47
Factors affecting wound healing
Co- morbidities Nutrition and hydration Age Medications Infection Smoking
48
Effects of ageing on wound healing
Decrease sensory perception Increased dryness of the skin Skin becomes thinner and less elastic reduce collagen and elastin and adipose tissue Decreased vit D synthesis Reduced immune response Decreased thermoregulation Decrease blood supply to skin
49
Generic vs brand names of drugs
Generic - chemical name of drug - people who manufacture social make the drug Trade/brand - trade/advertise/product name- by people who sell the drug
50
Paracetamol is not a
Anti inflammatory or antiplatelet agent
51
4 signs of inflammation
Redness Swelling Heat Pain
52
Pharmokinetics 4 stages
Absorption - blood stream and small intestines Distribution - through the blood stream Metabolism - by the liver Excretion - by the kidneys
53
Forms of paracetamol
Tablet Capsule Caplet Soluble tablet Oral liquid Liquid for injection Oral powder Suppository
54
Dosage or paracetamol
Adults - 0.5-1g (1-2 tablets) every 4-6 hrs MAXIMUM-4g (8 tablets) in 24hrs Children - depends of age, weight and strength of paracetamol
55
Thrombopoietin is produced where ?
Liver
56
Leukocytes are regulated by the…
Liver
57
Liver impairment
If the liver is not functioning, the body will not be able to break drugs down in this can cause toxicity
58
Renal impairment
Paracetamol should be administered with caution to patients with the renal impairment. Elimination of paracetamol can be delayed for those with severe renal impairment. Administration of paracetamol should be at an interval of at-least 6hrs
59
Lymphatic system functions are
To house the immune cells Clean fluid in the body Absorb fat and fat soluble vits Keep blood volume constant Cleans interstitial fluid
60
During circulation of the lymphatic system what leaks into tissues extracellular or interstitial fluid
Plasma
61
What is the primary function of the lymphatic system?
To clean interstitial fluid and return it to the bloodstream ## Footnote The lymphatic system plays a crucial role in maintaining fluid balance in the body.
62
What are lacteals?
Lymphatic capillaries in the villi of the small intestine that absorb fats and fat-soluble vitamins ## Footnote Lacteals are essential for the absorption of dietary lipids.
63
How does the lymphatic system function as a drainage system?
It collects extracellular or interstitial fluid and returns it to the bloodstream after cleaning ## Footnote This process helps maintain the appropriate volume and composition of fluids in the body's tissues.
64
What do arteries and veins represent in the circulatory system?
Arteries = A-Away (carry blood away from the heart); Veins = V-Visits (carry blood back to the heart) ## Footnote This mnemonic helps remember the direction of blood flow in the circulatory system.
65
What is the role of lymphatic capillaries?
They gather fluid and proteins from tissues ## Footnote Lymphatic capillaries are essential for collecting excess interstitial fluid.
66
Where do lymphatic vessels lead?
To lymphatic trunks (main vessels) ## Footnote Lymphatic trunks are larger vessels that collect lymph from different regions of the body.
67
What is the function of the right lymphatic duct?
It drains lymph from the upper right part of the body into the right subclavian vein ## Footnote This duct is crucial for returning lymph to the bloodstream.
68
What assists lymphatic circulation in the body?
Muscle contractions ## Footnote The movement of muscles helps propel lymph through the lymphatic vessels.
69
What is the role of lymph nodes?
To remove foreign materials from lymph ## Footnote Lymph nodes are key components of the immune system, filtering lymph and housing immune cells.
70
What happens to plasma that leaks from capillaries?
It enters lymphatic vessels, gets cleaned, and then returns to the blood ## Footnote This process is vital for maintaining fluid balance and filtering out pathogens.
71
True or False: Red blood is fully oxygenated blood.
True ## Footnote Oxygenated blood is crucial for delivering oxygen to tissues and organs.
72
Fill in the blank: The lymphatic system helps absorb _______ and fat-soluble vitamins.
fats ## Footnote This absorption occurs primarily in the small intestine through lacteals.
73
What is the function of pressure in the lymphatic system?
Pressure pushes lymph into the lymphatic capillaries. ## Footnote This mechanism is crucial for the movement of lymph throughout the body.
74
How is lymph moved through the lymphatic system?
Lymph is moved via muscle contraction and pressure changes occurring during breathing. ## Footnote This movement relies on physical activity to enhance circulation.
75
What are the smallest vessels in the lymphatic system?
Capillaries. ## Footnote Lymphatic capillaries are the starting point for lymph flow.
76
What does the right lymphatic duct do?
It pushes lymph from the right side of the chest, head, and neck into the right subclavian vein. ## Footnote This duct collects lymph from specific regions of the body.
77
What is the role of the thoracic duct?
It pushes lymph from the remainder of the body into the left subclavian vein. ## Footnote This duct is essential for draining lymph from most of the body.
78
What are the primary lymphoid organs?
Thymus and bone marrow. ## Footnote These organs are vital for the production and maturation of lymphocytes.
79
Where do T-lymphocytes mature?
In the thymus. ## Footnote T-cells are critical for adaptive immunity.
80
Where do B-lymphocytes mature?
In the bone marrow. ## Footnote B-cells are important for antibody production.
81
What activates T-lymphocytes?
Contact with foreign material. ## Footnote This activation is a key step in the immune response.
82
Fill in the blank: The blood volume in the body is _______.
Constant. ## Footnote This indicates a balance between blood and lymphatic systems.
83
Where is the thymus located
Behind the sternum at the base of the neck where the clavicles meet
84
Where do T cells mature
In the thymus
85
Does the thymus demishish with age
Yes just like age impacts immune system
86
Thymus allowed the ability to distinguish self and non self ?
True
87
Positive selective in the thymus is
Where cells learn to differentiate self
88
Negative selection in the thymus is
Thymus destroying those that cannot distinguish self and non self
89
Where are B cells maturing
In bone marrow
90
Primary lymphoid organs
Thymus and bone marrow
91
Secondary lymphoid organs
Lymph nodes, spleen, Peter’s patches, appendix, mucosal surfaces, tonsils
92
Prominate Lymph node area
Armpits, groins, neck, behind knees, abdominal
93
What context are the T and B cells
T - cells = inter cortex B - cells = outer cortex
94
Where is the spleen located
Behind the stomach
95
What does the spleen do
Cleans dead blood cells - red pulp and white pulp Connects blood and lymphocytes
96
Mucosa associated lymphoid tissue (MALT) is
Half of the lymphoid system Anywhere that mucus is produced (digestive, genitourinary, respiratory tract) Has its own system

Nursing (7 decks)

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