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70 Cards in this Set

  • Front
  • Back
Chain of infection includes;
Infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host
Define infection
Invasion of the body by a pathogenic microorganism that reproduce/multiply, causing disease
An infectious disease is a communicable disease when;
it is transmissible to others
Define vector
Disease carrier (non-human) from one host to another (i.e. West Nile vector=bird)
Factors to susceptibility to infection
age, nutritional status, heredity, medical diagnosis, medical therapy
Nosocomial infections are;
Infections that develop within hospital/LTC setting, after admission
Sites of entry for nosocomial infections;
Urinary tract, surgical/traumatic wounds, resp tract, bloodstream
Diagnostic tests for possible infection(s);
CBC, C&S, Ova & Parasite, TB test, chest x-ray
Single most important technique in preventing/controlling transmission?
hand washing
Asepsis is;
absence of disease producing pathogens (medical/surgial)
medical asepsis
used to reduce number of microorganisms and prevent spread (hand washing, ppe)
Surgical asepsis
procedures to eliminate microorganisms (aka-sterile technique)
Inflamatory response is;
a local response to injury or infection; localizes and prevents the spread of infection and promotes wound healing
vascular phase of the inflammatory response
pain, swelling, redness, changes in function
Define wound
break, disruption in normal skin integrity
wound classifications
intentional, unintentional, open/closed, acute/chronic
intentional wound
Closed wound - result of planned invasive threatment or therapy (surgery, IV therapy, etc.)
unintentional wound
wounds are accidental - unexpected trauma, forcible injury, burns
open wound
occurs intentional / unintentional - skin surface broken (incisions/abrasions)
closed wound
blow, force, trauma - skin surface not broken - soft tissue damage - internal injury, hemorrhage
accute wound
surgial incision - healing in days to weeks - edges well approximated (dec'd risk for infec)
chronic wound
healing process impaired - edges not approximated (risk for infec) - remain in inflammatory phase of healing - arterial/venous insufficiency related
Primary wound healing
skin edges are well approximated - min tissue loss - heal from outside in (i.e. surgical incissions)
Secondary wound healing
Scar tissue formation increases - granulation tissue closes wound from inside out
Tertiary healing
Wounds left open for several days to allow drainage to occur
Factors affecting wound healing
Local and systemic
local factors
pressure, desiccation, maceration, trauma, edema, infection, and necrosis
Systemic factors
Age, circulation & oxygenation, nutritional status, wound condition, medications, health status
Wound complications
Infection, hemorrhage, dehiscence, eviseration, fistula
Wound complication - infection
bacterial invasion at time of surgery, trauma, or after initial wound occurs
wound complication - hemorrhage
excessive bleeding
wound complication - dehiscence
partial/total separation of wound layers
wound complication - evisceration
complication of dehiscence - wound completely seperates with protrusion of viscera through incisional area
wound complication - Fistula
abnormal passage from an internal organ to outside of body or to another internal organ
Phases of wound healing
Hemostasis, inflammatory, proliferation, maturation
Hemostasis phase
platelet activation & clustering occurs; blood vessels constrict & blood clotting (occurs 1st after injury)
Inflammatory phase
Leukocytes & macrophages present in wound - fibroblasts present to fill in wound - acute inflammaton - (4 to 6 days)
Proliferation phase
new tissue is built to fill the wound space which forms fibrin - (aka: fibroblastic, regenerative, connective tissue phase) Lasts several weeks
Granulation tissue
Durring proliferation phase - foundation of scar tissue - highly vascular, red, bleeds easily
Maturation phase
3 weeks after injury - can continue for months or years - collagen remolding occurs - scar tissue formation occurs
Pressure ulcer
localized area of tissue necrosis; can be accute or chronic
Pressure ulcer causes
soft tissue compression between a bony prominence and an external force (insyufficient tissue perfusion, friction & shearing forces)
Pressure ulcer locations
Sacrum, coccyx, trochanter, calcaneous
Pressure ulcer related factors
imobility, nutrition/hydration, moisture, mental status, age
Pressure ulcer stage 1
change in skin temp, tissue consistency, sensation
Pressure ulcer stage 2
thickening of skin loss (blister, abrasion, shallow crater)
Pressure ulcer stage 3
full thickness skin loss of subq tissue - may include tendons, etc
Pressure ulcer stage 4
full thickness skin loss with extensive destruction - involves tendons, bone, possibly organs
Wound assessment
inspection (sight/smell), palpation, drainage, odor, pain
RYB wound classification
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
Acute vs chronic pain
acute=rapid onset, mild/severe
chronic=limited, intermittent, poorly localized
Pain Remission
Disease still present, but lacks symptoms
Pain exacerbation
symptoms reappear
Pressure ulcer stage - Cutaneous
superficial - skin or subq tissue (ie. paper cut)
Description of pain - somatic
diffuse of scattered - originates in tendons, ligaments, bones, blood vessels, nerves
Description of pain - viscaral
poorly localized - associated with organs that stretch, distend, are ischemic, or inflamed (ie. abdomen)
Mode of pain transmission
referred pain, neuropathic pain, phantom pain, psychogenic pain
Referred pain
pain manifests where it does not originate (ie. heart attack & arm spasm with jaw pain)
Neuropathic pain
injury to peripheral nerves of the CNS (burning, stabbing) - short or lingering in duration
Phantom pain
lacks physiologic or pathologic substance - sensory receptors in brain still exist, but limb does not
Psychogenic pain
physical cause for pain cannot be identified
Responses to pain
Behavioral, affective, physiologic
Behavioral response
protection of injured area, restlessness, moaning, crying (voluntary responses)
Affective response
withdrawal, depression, anxiety, fear, fatigue (psychological response)
Physiologic response
(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
Pain process involves;
transduction, transmission, perception, modulation
activation of pain receptors - pain stimuli changes into electrical impulses that travel from periphery to the spinal cord at the dorsal horn
pain sensation from site of injury/inflammation
sensory process that occurs when a stimylas for pain is present
sensation of pain is modified/inhibited