Unit 4

Question 1

What are the internal factors that influence tissue integrity?

Answer 1

age, nutrition, hydration, and disease

Question 2

What are the external factors that influence tissue integrity?

Answer 2

activity, moisture

Question 3

What are the layers of the skin?

Answer 3

epidermis, dermis, subcutaneous tissue

Question 4

What factors affect skin integrity?

Answer 4

age, mobility status, nutrition, hydration, sensation level, impaired circulation, medications, fever, and infection.

Question 5

What is used to classify wounds?

Answer 5

open/closed, acute/chronic, clean/contaminated/infected, superficial/partial or full thickness, and/or penetrating.

Question 6

What is assessed with wounds?

Answer 6

location, size, drainage, appearance, and odor.

Question 7

What are the types of wound drainage?

Answer 7

serous, sanguineous, serosanguineous, and purulent.

Question 8

What is serous drainage?

Answer 8

clear, watery plasma

Question 9

What is sanguineous drainage?

Answer 9

bright red, current bleeding, bloody drainage.

Question 10

What is serosanguineous drainage?

Answer 10

pale, red, watery mix blood & straw colored.

Question 11

What is purulent drainage?

Answer 11

thick, yellow/green/tan, contains pus

Question 12

What is regeneration?

Answer 12

renewal of tissues

Question 13

What are the three types of wound healing?

Answer 13

primary intention healing, secondary intention healing, and tertiary intention healing.

Question 14

What are characteristics of primary intention healing?

Answer 14

tissue surfaces approximated. minimal or no tissue loss. minimal scarring. less risk for infection. incision wound.

Question 15

What are characteristics of secondary intention healing?

Answer 15

tissue surfaces can not be approximated. considerable tissue loss, scarring, pressure ulcer. heals inside out.

Question 16

What are characteristics of tertiary intention healing?

Answer 16

delayed closure of wound edges. infection. debridement.

Question 17

What are the phases of wound healing?

Answer 17

inflammatory phase, proliferative phase, and maturation or remodeling.

Question 18

What occurs during the inflammatory phase?

Answer 18

hemostasis and phagocytosis. 1-5 days.

Question 19

What occurs during the proliferative phase?

Answer 19

granulation tissue. 3-21 days.

Question 20

What occurs during maturation or remodeling phase?

Answer 20

wound comes together. 14 days - 2 years.

Question 21

What are the complications of wound healing?

Answer 21

hemorrhage, infection, dehiscence, evisceration and fistula formation.

Question 22

What is dehiscence?

Answer 22

the pulling apart of an incision

Question 23

What is evisceration?

Answer 23

the pulling apart of an incision and an organ coming out of the wound.

Question 24

What are the nursing interventions of wound healing?

Answer 24

facilitate wound healing, promote optimal nutrition and hydration, prevent infection, and position to minimize pressure on the wound.

Question 25

What are the key components of wound care?

Answer 25

patient comfort & privacy, infection control, assessment, proper technique, and documentation.

Question 26

What is a pressure ulcer?

Answer 26

skin breakdown caused by unrelieved pressure to an area results in ischemia. affects 15% of hospitalized patients. costs hospitals $5-8.5 billion/year

Question 27

What are intrinsic factors that are risk factors for pressure ulcers?

Answer 27

immobility, impaired sensation, aging, fever, and malnourishment.

Question 28

What are extrinsic factors that are risk factors for pressure ulcers?

Answer 28

friction, shearing, and exposure to moisture.

Question 29

What is in the upper airway?

Answer 29

nasal passages, mouth, pharynx, and larynx.

Question 30

What is in the lower airway?

Answer 30

trachea, bronchi, and bronchioles.

Question 31

What is ventilation?

Answer 31

movement of air into/out of the lungs

Question 32

What is inhalation?

Answer 32

the movement of air into the lungs

Question 33

What is exhalation?

Answer 33

the movement of air out of the lungs

Question 34

Where does the exchange of oxygen and carbon dioxide occur?

Answer 34

between the alveoli & pulmonary capillary membranes in the lungs. between the peripheral capillary and cellular membranes in the body tissues.

Question 35

What controls breathing?

Answer 35

chemoreceptor sites in body detect alterations of O2 and CO2 levels.

Question 36

Why is ventilation increased or decreased?

Answer 36

to maintain normal O2 and CO2 levels

Question 37

What is the primary respiratory drive?

Answer 37

high CO2 levels. (hypercarbia)

Question 38

What is the secondary respiratory drive?

Answer 38

low O2 levels. (hypoxemia)

Question 39

What affects ventilation?

Answer 39

changes in breathing patterns, patency of airway, irritation or inflammation of the respiratory mucosa, damage to supporting thoracic structures, and interference with gas exchange.

Question 40

What is tachypnea?

Answer 40

fast breathing rate

Question 41

What is bradypnea?

Answer 41

slow breathing rate

Question 42

What is apnea?

Answer 42

a suspension of breathing

Question 43

What is dyspnea?

Answer 43

difficulty or labored breathing

Question 44

What is orthopnea?

Answer 44

shortness of breath while laying flat.

Question 45

What causes decreased lung compliance?

Answer 45

pneumothorax, pneumonia

Question 46

What causes decreased lung elasticity?

Answer 46

COPD, emphysema

Question 47

What causes increased airway resistance?

Answer 47

blockage, asthma.

Question 48

How do you assess oxygenation status?

Answer 48

respiratory rate/pattern respiratory effort adventitious breath sounds perfusion

Question 49

What diagnostic testing assesses oxygenation?

Answer 49

arterial blood gases. pulse oximetry. peak expiratory flow rate. chest x-ray.

Question 50

What are interventions to promote respiratory function?

Answer 50

hydration, deep breathing exercises, incentive spirometer. air way patency-suctioning. evaluation of ABGs.

Question 51

What are the signs/symptoms of hypoxemia?

Answer 51

mild to moderate: agitation, confusion, tachycardia, dyspnea. severe: lethargy, increasing dyspnea, tachycardia, cyanosis.

Question 52

Types of oxygen administration?

Answer 52

nasal cannula, simple face mask, partial rebreather, nonrebreather, venturi, and face tent.

Question 53

What are complications of oxygen therapy?

Answer 53

oxygen supports combustion. oxygen tanks are under pressure. Pulmonary oxygen toxicity-100% O2, leads to alveolar collapse and reduced lung elasticity.

Question 54

What are independent nursing interventions for oxygenation?

Answer 54

deep breathing exercises, positioning, promoting secretion clearance. monitoring activity intolerance, assisting with ADLs, and encourage smoking cessation/healthy lifestyle practices.

Question 55

What are collaborative nursing interventions for oxygenation?

Answer 55

improving nutrition, pharmacologic therapy, oxygen administration and safety, and inhale or exhale.