tissue integrity 1

Question 1

activated form of vitamin D

Answer 1

calcitriol

Question 2

what is the purpose of the skin?

Answer 2

protection, sensory, vitamin D synthesis, fluid balance, and natural flora

Question 3

what two sweat glands are found in the dermis layer of the skin?

Answer 3

eccrine sweat gland and apocrine sweat gland

Question 4

layers of the skin from outer to inner

Answer 4

epidermis, dermis, and subcutaneous tissue

Question 5

assessment of the skin:

Answer 5

inspect entire body, especially bony prominences, visual and tactile, assess any rashes or lesions, note hair distribution, skin color, and blanch test

Question 6

skin assessment focus on

Answer 6

level of sensation, movement, and continence

Question 7

skin dragging against surface is ____, can cause skin tears and blisters

Answer 7

friction

Question 8

sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary is ___

Answer 8

shear

Question 9

shear causes stretching and tearing of blood vessels which ____ blood flow, ____ blood pooling and lead to cell damage

Answer 9

reduce, increase

Question 10

braden scale: low risk points are ____

Answer 10

15-18

Question 11

braden scale moderate risk is how many points ____

Answer 11

13-14

Question 12

high risk on braden scale points are ____

Answer 12

12 or less

Question 13

tissue integrity interventions:

Answer 13

frequent repositioning, sitting in chair for only 2-hour intervals, anything longer may increase pressure to sacral tissue, keeping HOB at 30 degrees (NO HIGHER, unless respiratory issues), keep a written schedule of turning and positioning

Question 14

stage I of wound staging:

Answer 14

intact skin with a localized are of nonblanchable redness

Question 15

stage II wound staging

Answer 15

partial-thickness, skin loss with exposed epidermis, presents as an intact or ruptured serum-filmed blister

Question 16

stage III wound staging:

Answer 16

full-thickness, skin loss, adipose tissue is visible, possible slough or eschar. may have undermining tunnel

Question 17

stage IV wound staging:

Answer 17

full-thickness, tissue loss with exposed tendon, muscle, fascia, ligament, cartilage or bone in the ulcer

Question 18

unstageable/unclassified wound staging:

Answer 18

full-thickness, skin or tissue loss, depth unknown because it is obscured by eschar or slough

Question 19

suspected deep-tissue injury wound staging:

Answer 19

depth unknown

Question 20

early intervention protocol- CHANT

Answer 20

cleanse, hydrate (& protect) skin, alleviate pressure, nourish, treat

Question 21

intervention for redness/excoriation between skin folds

Answer 21

cleanse, dry thoroughly, place inter dry or dry AG textile in skin folds

Question 22

intervention for red heels

Answer 22

position pressure off of heels, elevate on pillows, sage boot, and reduce friction

Question 23

intervention protocol for red sacral/coccyx area

Answer 23

change position every 1-2 hours, HOB 30 degrees, avoid excess moisture, frequent peri care, and wrinkle free linen

Question 24

inflammation and infection:

Answer 24

inflammation is always present with infection, but infection is not always present with inflammation

Question 25

any disruption of the integrity and function of tissues in the body is called a _____

Answer 25

wound

Question 26

______ causes an inflammatory response in the first ___ hours

Answer 26

tissue trauma, 24 hours

Question 27

neutrophils are ___

Answer 27

new white blood cells

Question 28

neutrophils and macrophages remove pathogens by ____

Answer 28

phagocytosis

Question 29

vascular response is ___

Answer 29

increased capillary permeability, fluid moves into tissue spaces

Question 30

result of vascular response:

Answer 30

redness, heat, and swelling at site of injury and surrounding area

Question 31

_____ is activated to fibrin, which strengthens the blood clot, prevents spread of bacteria

Answer 31

fibrinogen

Question 32

cellular response is ____

Answer 32

neutrophils and monocytes move through capillary wall and accumulate at site of injury

Question 33

local response to inflammation

Answer 33

redness, heat, pain, swelling, loss of function

Question 34

serous is

Answer 34

clear, watery plasma

Question 35

purulent

Answer 35

is thick, yellow, green, tan, or brown- concerning**

Question 36

serosanguineous

Answer 36

pale, red, watery: mixture of serous and sanguineous

Question 37

sanguineous

Answer 37

bright red; indicates active bleeding

Question 38

clinical manifestations for systemic response to inflammation:

Answer 38

increased WBC count, malaise (lethargic), N/V, increased pulse and respiratory rate, fever

Question 39

types of inflammation: acute

Answer 39

healing in 2-3 weeks, no residual damage; neutrophils predominant cell type at site

Question 40

types of inflammation: subacute

Answer 40

same features, but lasts longer

Question 41

types of inflammation: chronic

Answer 41

may last for years, injurious agent persists or repeats injury to site, predominant cell types are lymphocytes and macrophages, may result from changes in immune system

Question 42

wound healing: regeneration

Answer 42

replacement of lost cells and tissues with cells of the same type

Question 43

wound healing: repair

Answer 43

healing as a result of lost cells being replaced by connective tissue, results in scar formation - more common, more complex, occurs by primary, secondary, or tertiary intention

Question 44

healing by primary intention: 3 phases

Answer 44

initial phase (3-5 days), granulation phase, maturation phase and scar is formed (7 days after)

Question 45

healing by secondary intention:

Answer 45

wounds from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss; edges can be approximated, same healing process but may need debriding

Question 46

healing by tertiary intention:

Answer 46

delayed primary intention due to delayed suturing of wound, occurs when a contaminated wound is left open and sutured closed after infection is controlled.

Question 47

factors that would influence wound healing:

Answer 47

protein, vitamins (esp. A & C), trace minerals of zinc & copper, adequate calories, tissue perfusion

Question 48

hemorrhage

Answer 48

bleeding

Question 49

hematoma

Answer 49

bleeding under skin

Question 50

dehiscence

Answer 50

separation or splitting open of layers of a surgical wound

Question 51

evisceration

Answer 51

extrusion of viscera or intestine through surgical wound

Question 52

skin tear is usually common in what type of patients?

Answer 52

older adults and those critically/chronically ill

Question 53

what is the most common drain to help remove excess fluid?

Answer 53

jackson-pratt drain

Question 54

purposes of dressings:

Answer 54

protect from microorganisms, aids in hemostasis, promotes healing by absorbing drainage, supports wound site, promotes thermal insulation, provides a moist environment

Question 55

types of dressings:

Answer 55

gauze, transparent film, hydrocolloid, hydrogel, foam, composite

Question 56

_____ antibiotics can decrease the incidence of infection in certain kinds of surgery

Answer 56

prophylactic

Question 57

most effective against cells undergoing active growth and division, one of the most widely used antibacterial drugs

Answer 57

cephalosporins

Question 58

this person said "if patient has a bedsore, it is not the patients fault it is the nurse's fault"

Answer 58

Florence Nightingale

Question 59

when do you asses skin of a patient?

Answer 59

initiation of care (beginning of shift), then at least once a shift

Question 60

what light is the best to assess patient skin

Answer 60

natural light not flourescent

Question 61

wound approximation:

Answer 61

two edges come together

Question 62

eschar is

Answer 62

dead tissue

Question 63

factors that influence wound healing

Answer 63

nutrition, tissue perfusion, infection and age

Question 64

nutrition for wound healing

Answer 64

protein, vitamins (especially A & C), trace minerals of zinc and cooper, and adequate calories

Question 65

tissue perfusion:

Answer 65

oxygen fuels cellular functions

Question 66

how do you clean a wound?

Answer 66

from least contaminated to the surrounding skin