Nur111 Test#2 Infection, Wounds, Pain, Ca, Stress, Sleep

Front 1

Chain of infection includes;

Back 1

Infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host

Front 2

Define infection

Back 2

Invasion of the body by a pathogenic microorganism that reproduce/multiply, causing disease

Front 3

An infectious disease is a communicable disease when;

Back 3

it is transmissible to others

Front 4

Define vector

Back 4

Disease carrier (non-human) from one host to another (i.e. West Nile vector=bird)

Front 5

Factors to susceptibility to infection

Back 5

age, nutritional status, heredity, medical diagnosis, medical therapy

Front 6

Nosocomial infections are;

Back 6

Infections that develop within hospital/LTC setting, after admission

Front 7

Sites of entry for nosocomial infections;

Back 7

Urinary tract, surgical/traumatic wounds, resp tract, bloodstream

Front 8

Diagnostic tests for possible infection(s);

Back 8

CBC, C&S, Ova & Parasite, TB test, chest x-ray

Front 9

Single most important technique in preventing/controlling transmission?

Back 9

hand washing

Front 10

Asepsis is;

Back 10

absence of disease producing pathogens (medical/surgial)

Front 11

medical asepsis

Back 11

used to reduce number of microorganisms and prevent spread (hand washing, ppe)

Front 12

Surgical asepsis

Back 12

procedures to eliminate microorganisms (aka-sterile technique)

Front 13

Inflamatory response is;

Back 13

a local response to injury or infection; localizes and prevents the spread of infection and promotes wound healing

Front 14

vascular phase of the inflammatory response

Back 14

pain, swelling, redness, changes in function

Front 15

Define wound

Back 15

break, disruption in normal skin integrity

Front 16

wound classifications

Back 16

intentional, unintentional, open/closed, acute/chronic

Front 17

intentional wound

Back 17

Closed wound - result of planned invasive threatment or therapy (surgery, IV therapy, etc.)

Front 18

unintentional wound

Back 18

wounds are accidental - unexpected trauma, forcible injury, burns

Front 19

open wound

Back 19

occurs intentional / unintentional - skin surface broken (incisions/abrasions)

Front 20

closed wound

Back 20

blow, force, trauma - skin surface not broken - soft tissue damage - internal injury, hemorrhage

Front 21

accute wound

Back 21

surgial incision - healing in days to weeks - edges well approximated (dec'd risk for infec)

Front 22

chronic wound

Back 22

healing process impaired - edges not approximated (risk for infec) - remain in inflammatory phase of healing - arterial/venous insufficiency related

Front 23

Primary wound healing

Back 23

skin edges are well approximated - min tissue loss - heal from outside in (i.e. surgical incissions)

Front 24

Secondary wound healing

Back 24

Scar tissue formation increases - granulation tissue closes wound from inside out

Front 25

Tertiary healing

Back 25

Wounds left open for several days to allow drainage to occur

Front 26

Factors affecting wound healing

Back 26

Local and systemic

Front 27

local factors

Back 27

pressure, desiccation, maceration, trauma, edema, infection, and necrosis

Front 28

Systemic factors

Back 28

Age, circulation & oxygenation, nutritional status, wound condition, medications, health status

Front 29

Wound complications

Back 29

Infection, hemorrhage, dehiscence, eviseration, fistula

Front 30

Wound complication - infection

Back 30

bacterial invasion at time of surgery, trauma, or after initial wound occurs

Front 31

wound complication - hemorrhage

Back 31

excessive bleeding

Front 32

wound complication - dehiscence

Back 32

partial/total separation of wound layers

Front 33

wound complication - evisceration

Back 33

complication of dehiscence - wound completely seperates with protrusion of viscera through incisional area

Front 34

wound complication - Fistula

Back 34

abnormal passage from an internal organ to outside of body or to another internal organ

Front 35

Phases of wound healing

Back 35

Hemostasis, inflammatory, proliferation, maturation

Front 36

Hemostasis phase

Back 36

platelet activation & clustering occurs; blood vessels constrict & blood clotting (occurs 1st after injury)

Front 37

Inflammatory phase

Back 37

Leukocytes & macrophages present in wound - fibroblasts present to fill in wound - acute inflammaton - (4 to 6 days)

Front 38

Proliferation phase

Back 38

new tissue is built to fill the wound space which forms fibrin - (aka: fibroblastic, regenerative, connective tissue phase) Lasts several weeks

Front 39

Granulation tissue

Back 39

Durring proliferation phase - foundation of scar tissue - highly vascular, red, bleeds easily

Front 40

Maturation phase

Back 40

3 weeks after injury - can continue for months or years - collagen remolding occurs - scar tissue formation occurs

Front 41

Pressure ulcer

Back 41

localized area of tissue necrosis; can be accute or chronic

Front 42

Pressure ulcer causes

Back 42

soft tissue compression between a bony prominence and an external force (insyufficient tissue perfusion, friction & shearing forces)

Front 43

Pressure ulcer locations

Back 43

Sacrum, coccyx, trochanter, calcaneous

Front 44

Pressure ulcer related factors

Back 44

imobility, nutrition/hydration, moisture, mental status, age

Front 45

Pressure ulcer stage 1

Back 45

change in skin temp, tissue consistency, sensation

Front 46

Pressure ulcer stage 2

Back 46

thickening of skin loss (blister, abrasion, shallow crater)

Front 47

Pressure ulcer stage 3

Back 47

full thickness skin loss of subq tissue - may include tendons, etc

Front 48

Pressure ulcer stage 4

Back 48

full thickness skin loss with extensive destruction - involves tendons, bone, possibly organs

Front 49

Wound assessment

Back 49

inspection (sight/smell), palpation, drainage, odor, pain

Front 50

RYB wound classification

Back 50

R=Red-protect with nurse intervention (gentle cleanse, moist dressing)
Y=Yellow-Exudate (drainage)
B=Black-Eschar (necrotic tissue) - debredement of tissue before wound can heal

Front 51

Acute vs chronic pain

Back 51

acute=rapid onset, mild/severe
chronic=limited, intermittent, poorly localized

Front 52

Pain Remission

Back 52

Disease still present, but lacks symptoms

Front 53

Pain exacerbation

Back 53

symptoms reappear

Front 54

Pressure ulcer stage - Cutaneous

Back 54

superficial - skin or subq tissue (ie. paper cut)

Front 55

Description of pain - somatic

Back 55

diffuse of scattered - originates in tendons, ligaments, bones, blood vessels, nerves

Front 56

Description of pain - viscaral

Back 56

poorly localized - associated with organs that stretch, distend, are ischemic, or inflamed (ie. abdomen)

Front 57

Mode of pain transmission

Back 57

referred pain, neuropathic pain, phantom pain, psychogenic pain

Front 58

Referred pain

Back 58

pain manifests where it does not originate (ie. heart attack & arm spasm with jaw pain)

Front 59

Neuropathic pain

Back 59

injury to peripheral nerves of the CNS (burning, stabbing) - short or lingering in duration

Front 60

Phantom pain

Back 60

lacks physiologic or pathologic substance - sensory receptors in brain still exist, but limb does not

Front 61

Psychogenic pain

Back 61

physical cause for pain cannot be identified

Front 62

Responses to pain

Back 62

Behavioral, affective, physiologic

Front 63

Behavioral response

Back 63

protection of injured area, restlessness, moaning, crying (voluntary responses)

Front 64

Affective response

Back 64

withdrawal, depression, anxiety, fear, fatigue (psychological response)

Front 65

Physiologic response

Back 65

(involuntary response)Sympathetic response - (moderate, superficial) - inc'd BP, inc'd PR, inc'd RR, puil dialation, pallor Parasymathetic response (severe, deep), N/V, fainting, dec'd BP & PR, rapid & irregular breathing

Front 66

Pain process involves;

Back 66

transduction, transmission, perception, modulation

Front 67

transduction

Back 67

activation of pain receptors - pain stimuli changes into electrical impulses that travel from periphery to the spinal cord at the dorsal horn

Front 68

transmission

Back 68

pain sensation from site of injury/inflammation

Front 69

perception

Back 69

sensory process that occurs when a stimylas for pain is present

Front 70

modulation

Back 70

sensation of pain is modified/inhibited