Adult Care Exam 2

Front 1

Frequent & liquid stools
Usually on the right side of abdomen

Sigmoid-

Back 1

Ileum (Ileostomy)

Front 2

An ascending colostomy will show signs of what in the stool

Back 2

frequent and liquid stools

Front 3

When you see more solid formed stool

Back 3

Transverse colostomy

Front 4

When you see near normal stool
Usually on the left side of the abdomen

Back 4

Sigmoid colostomy

Front 5

The organ that neutralizes acidic gastric contents

Back 5

Duodenum

Front 6

Major organ for nutrient absorption

Back 6

Jejunum

Front 7

responsible for nutrient absorption

Back 7

lleum

Front 8

What disease presents with abdominal pain, diarrhea, weight loss, and growth failure, has a slight increse for cancer

Back 8

Chrones disease

Front 9

What disease involves only the colon and the mainfest w/ diarrhea, rectal bleeding, and weight loss, high increase for cancer

Back 9

Ulcerative colitis

Front 10

you should never use an enema for irrigationof what

Back 10

Colostomy

Front 11

Anywhere along GI tract
Abdominal pain, diarrhea weight loss and growth failure
Blood not visible if proximal disease

Back 11

Chrons disease

Front 12

Colon only
Diarrhea, rectal bleeding, weight loss
Blood usually visible

Back 12

Ulcerative colitis

Front 13

Infection

Back 13

Invasion- of tissues or cells by microorganisms such as bacteria, fungi, and viruses

Front 14

Inflamation

Back 14

Reaction- caused by an agent either living or nonliving

Front 15

You have brief vasonconstriction and the release of histomines

Back 15

Vascular response

Front 16

what are the first WBC to respond

Back 16

Neutrophils

Front 17

Second to respond and are there by day three and last up to a week are

Back 17

Monocytes

Front 18

Contamination

Back 18

Presence of non-replicating microorganisms on the wound surface

Front 19

Critical coloinzation

Back 19

Increased bio-burden to overwhelm the host. Poor healing, becomes invasive

Front 20

Replicating bacteria without a host reaction or clinical signs and symptoms of infection

Back 20

colonization

Front 21

Acute Wound that is infected

Back 21

Local inflammation
Pus formation - due to neutrophils
Increased exudate

Front 22

Chronic Wound that is infected

Back 22

Wounds are usually colonized and signs are more subtle
Changes in exudate, Increased pain in wound bed, change in color
Delayed healing,
Unhealthy granulation

Front 23

Healthy granulation tissue looks like?

Back 23

Bright (beefy) red

Front 24

What are the host defences
(protect the pt from infection)

Back 24

Intact skin barrier, good inflammatory responce (healthy)

Front 25

Toxins (endotoxins)

Back 25

Alter normal function of the cells host

Front 26

Environmental factors

Back 26

Some organisms can alter the environment in which they live so that the host’s immune system cannot locate them and/or has difficulty destroying them i.e. capsules, slime and moucus layers.

Front 27

Factors that affect wound healing

Back 27

necrotic tissue, your perfusion status, and the size and duration of the would

Front 28

Obtaining a tissue biospy

Back 28

Time consuming and costly
Risk of trauma and bacteremia
Require special equipment
Not within the scope of practice of RN’s
time consuming, risk of trauma, and introducing bacteria in to the bloos stream

Front 29

needle aspiration

Back 29

Painful
Invasive, painfull, expensive
Not within the scope of practice for RN’s

Front 30

Swab Culture negatives

Back 30

A concern about this is that cultures only reflect the surface colonizing bacteria

Front 31

Swab culture positives

Back 31

It is usefull guide to antibiotic therapy, it is with in the scope of the nurse.

Front 32

Supplies for a cotton swab culture collection

Back 32

cotton swab, sterile gloves, flush with NS or distilled water, debrive wound prior to collection.

Front 33

Stage 1 Ulcer

Back 33

Intact skin with non-blanchable redness of a localized area usually over a bony prominence
Darkly pigmented skin may not have visible blanching, it’s color may differ from surrounding areas

Front 34

Treatment for stage 1 Ulcer

Back 34

No Vigorous massage
Pressure redistribution mattress
Risk assessment on admission and daily
Remove excess moisture
Provide moisture barrier
Turn every 2 hours
Avoid friction and shear

Front 35

Stage II Ulcer

Back 35

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Front 36

NonBlanchable Erythema

Back 36

The ulcer appears as a defined area of redness that does not blanch (become pale) under applied light pressure.

Front 37

Blanchable errythmia

Back 37

Reddened area that turns pale under applied light pressure. NOT a Stage I pressure ulcer

Front 38

What stage ulcer is this?

Back 38

Hint 38

Stage 2

Front 39

What is the treatment for a stage 2 ulcer

Back 39

Pressure relief of site
Wound cleansing

Moist wound healing: decreases pain, reduces infection, decreases cost and hours spent changes dressing

Front 40

What describes a stage three ulcer

Back 40

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Front 41

What is the treatment for a stage three ulcer

Back 41

Pressure relief
Cleanse wound
Provide moisture
Absorb excess exudate
Fill dead space

Front 42

Stage 4 pressure ulcer

Back 42

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Front 43

Moist topical treatment and main goal for what?

Back 43

A stage 2 ulcer healing?

Front 44

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Back 44

Unstageable

Front 45

You will not see muscle, bone, tendon are not ecposed in what stage?

Back 45

Stage 3

Front 46

Undermining and tunneling may or will be included in determining what stage of ulcers

Back 46

Stage 3 and stage 4

Front 47

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Back 47

Suspected deep tissue injury.