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144 Cards in this Set

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involves scraping or rubbing the surface of the skin by friction
Abrasion
involves no break in skin integrity or mucous membrane
Closed wound
involves a blow from a blunt object resulting in swelling, discoloration, bruising, and/or ecchymosis
Contusion
cleaning away of devitalized tissue and foreign matter from a wound; can be accomplished by various methods
Debridement
partial or total rupturing of a wound
Dehiscence
stage of wound healing in which epithelial cells move across the surface of a wound; tissue color ranges from the color of "ground glass" to pink
Epithelialization
a thick, leathery scab or dry crust that is necrotic and must be removed for adequate pressure ulcer staging to occur
Eschar
protrusion of the internal viscera and/or organs through a ruptured wound
Evisceration
fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells
Exudate
abnormal passage between two organs or between an organ and the outside of the body
Fistula
occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin
Friction
involves the epidermal and dermal layers of skin, subcutaneous tissue and, possibly, muscle and bone
Full-thickness wound
new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
Granulation tissue
persistent arterial and/or venous bleeding from a wound
Hemorrhage
constriction of a severed blood vessels to allow clotting of blood to seal a wound
Hemostasis
involves cutting the skin with a sharp instrument
Incision
disease state resulting from pathogens in or on the body
Infection
involves a wound that is the result of planned therapy
Intentional wound
deficiency of blood in a particular area
Ischemia
involves tearing apart of tissues resulting in irregular wound edges
Laceration
death of cells
Necrosis
involves a break in skin integrity or mucous membrane
Open wound
involves only the epidermal and dermal layers of skin
Partial-thickness wound
involves penetration of the epidermal and dermal layers of skin and deeper tissues or organs
Penetrating wound
involves penetration of the skin and, often, the underlying tissues by a sharp instrument
Puncture
consists of serum and pus (leukocytes, liquefied living and dead bacteria, dead tissue debris)
Purulent
any skin lesion caused by unrelieved pressure that results in damage to underlying tissues
Pressure ulcer
the body's flooding of an area with blood after it has suffered from poor circulation for a period; the occurrence of a blanchable reddening of the skin when pressure is removed
Reactive hyperemia
consists chiefly of serum derived from blood and serous membranes of the body
Serous exudate
consists of serum and red blood cells
Sanguineous
force created when layers of tissue move on one another
Shearing force
involves only the epidermal layer of skin
Superficial wound
involves a wound that is the result of unexpected trauma
Unintentional wound
dolor
pain
calor
warmth
tumor
swelling or edema
rubor
hyperemia
functiolaesa
loss of function
Which is the proper sequence of the stages of wound healing?
hemostasis
inflammation
proliferation
maturation
Which of the following causes the clinical sign of inflammation “tumor”?
increased permeability of capillaries, resulting in leakage of large quantities of fluid into the interstitital spaces to cushion the injured tissues and dilution of the concentration of microorganisms or toxic products that may have entered the injured tissues
What is chemotaxis?
attraction of white blood cells to injured tissues
Which of the following causes the clinical sign of inflammation “calor”?
vasodilation of local blood vessels, resulting in excess local blood flow and an increase in nutrients to the injured tissues
What is the proper sequence of hemostasis?
vasoconstriction of severed blood vessels
aggregation of platelets along damaged blood vessel walls
formation of a platelet plug
invasion of fibrin fibers into the platelet plug
formation of a fibrin clot
contraction of the fibrin clot
Which of the following causes the clinical sign of inflammation “functiolaesa”?
encouragement of actions to avoid further injury to or inflammation of the injured tissues
Which of the following causes the clinical sign of inflammation “dolar”?
injury to tissues resulting in secretion of multiple products of inflammation into the blood stream from the injured tissues, e.g.: histamine, bradykinin, serotonin, prostaglandins
1st line of defense
initial macrophage invasion of the injured tissues
2nd line of defense
neutrophil invasion of the injured tissues
4th line of defense
increased proliferation of granulocytes and monocytes by the bone marrow
3rd line of defense
second macrophage invasion of the injured tissues
What is essential for collagen synthesis during wound healing?
Vitamin A
zinc
copper
iron
Which drugs can effect wound healing by influencing the inflammatory response?
adrenocorticoid steroids
hydroactive wafers (usually tan) with an adhesive backing
hydrocolloid wafers
hydroactive compressed foam pads that are nonadhesive and require a secondary dressing
to secure
polyurethane foams
hydrophilic powder, beads, granules, or paste that are nonadhesive and require a
secondary dressing to secure
exudate absorbers
hydroactive polymer sheets, granules, or gels that are nonadhesive and require a
secondary dressing to secure
hydrogels
clear, polyurethane film with an adhesive backing
transparent films
hydrophilic sheets or strips made of seaweed that are nonadhesive and require a
secondary dressing to secure
alginates
white, light, open-meshed fabric of cotton cloth of various thread counts and weights, supplied in various lengths and widths and in different forms (rolls or folds)
gauzes
Alveoli
small air sacs at the end of the terminal bronchioles that are the site of gas exchange
Apnea
breathing pattern evidenced by absence of respirations
Ataxic (Biot's) respirations
breathing pattern evidenced by periods of deep breathing that alternate with periods of apnea in an irregular pattern
Atelectasis
obstruction of airway by secretions and closure of bronchioles because of shallow breathing or failure to periodically hyperventilate the lungs
Barrel chest
chest shape in which the AP = transverse diameter; the costal angle is greater than 90 degrees; the rib slope is 45 degrees or horizontal; and the sternum is positioned even with the ribs
Bradypnea
breathing pattern evidenced by slow (less than 12 per minute) respirations
Bronchial breath sounds
normal breath sounds heard over the trachea that are high in pitch and intensity with expiration being longer than inspiration
Bronchodilator
medication that relaxes contractions of smooth muscles of the bronchioles
Bronchophony
an abnormal increase in tone or clarity in vocal resonance emanating from a bronchus surrounded by consolidated lung tissue
Bronchovesicular breath sounds
normal breath sounds heard over the 1st and 2nd interspaces anteriorly and between the scapulae posteriorly that are medium in pitch and intensity with inspiration being equal to expiration
Chest tube
a tube inserted through the skin and intercostal space into the pleural cavity and connected to a one, two, or three bottle closed system to remove a collection of air or fluid from the pleural cavity and help reexpand the lung
Cheyne-Stokes respirations
breathing pattern evidenced by periods of deep breathing that alternate with periods of apnea in a regular pattern
Crackles (coarse)
low-pitched; "bubbling" or "gurgling" sounds on inspiration that may or may not be cleared by coughing
Crackles (fine)
high-pitched; "crackling" or "popping" sounds on inspiration that are not cleared by coughing
Dullness
a medium, medium-pitched, "thudlike" sound of moderate duration typically heard over the liver, heart
Dyspnea
breathing pattern evidenced by a subjective feeling of difficulty or distressful respirations
Egophony
an abnormal change in tone, somewhat like the bleat of a goat, heart in auscultation of the chest when the subject speaks normally
Endotracheal tube
a guide curved, polyvinylchloride tube that is inserted through either the mouth or nose into the trachea just superior to the bifurcation of the trachea with the guide of a laryngoscope
Expiration
act of breathing out; synonym for exhalation
Friction rub
low-pitched; "grating" sounds on inspiration and expiration that are not cleared by coughing
Hemoptysis
sputum containing blood
High-flow delivery systems for oxygen therapy
deliver oxygen at flow rates that meet or exceed the patient's inspiratory flow rate allowing an accurate delivery of inspired oxygen
Hypercapnia
increased carbon dioxide tension in arterial blood
Hypernea, hyperventilation
respiration that is deeper and more rapid than expected
Hyperresonance
a very loud, very low-pitched, "booming" sound of very long duration typically heard over the emphysematous lung
Hypocapnia
decreased carbon dioxide tension in arterial blood
Hypoventilation
a creased rat or depth of air movement into the lungs
Hypoxemia
reduced oxygen tension in arterial blood
Hypoxia
inadequate amount of cellular oxygen
Inspiration
act of breathing in; synonym for inhalation
Kyphosis
exaggerated convex curvature of the spinal column
Lordosis
exaggerated concave curvature of the spinal column
Low-flow delivery systems for oxygen therapy
deliver oxygen at flow rates that supplement the oxygen contained in ambient (room) air
Nasal cannula
disposable, plastic device that delivers oxygen with two protruding prongs for insertion into the nostrils
Nasopharnygeal tube
a plastic tube that is inserted through a nostril and terminates in the pharynx below the upper edge of the glottis
Obstructive
breathing pattern evidenced by normal inspiration and prolonged expiration
Oropharyngeal tube
a s-shaped, plastic tube that is inserted through the mouth and terminates in the posterior pharynx
Percussion
forceful striking of the skin with cupped hands to mechanically dislodge viscous mucus secretions from congested lung segments in the respiratory tract
Pectus carniatum (pigeon chest)
chest shape in which the AP diameter is greater than transverse diameter; the costal angle is greater than 90 degrees; the rib slope less than 45 degrees; and the sternum is protruding
Pectus excavatum (funnel chest)
chest shape in which the AP diameter is less than transverse diameter; the costal angle is 90 degrees; the rib slope less than 45 degrees; and the sternum depressed
Perfusion
passing of fluid through body tissue
Postural drainage
placement of a patient in a wide variety of positions to drain particular lung segments of secretions by gravity
Pulse oximetry
noninvasive device attached to a finger, toe, nose, or earlobe that uses spectrophotometry to measure the amount of red and infrared light absorbed by oxygenated and unoxygenated hemoglobin in arterial blood to assess hemoglobin saturation
Resonance
a loud, low-pitched, "hollow" sound of long duration typically heard over the lung
Rhonchi
low-pitched; "snoring", monophonic (single notes in a chord) sounds on expiration that may or may not be cleared by coughing
Scoliosis
exaggerated s-shaped curvature of the spinal column
Wheezes
high-pitched; "musical", polyphonic (multiple notes in a chord) sounds on expiration that are not cleared by coughing as air moves through narrowed or partially obstructed airway passages
Spirometer
instrument used to measure lung capacities and volumes; one type is used to encourage deep breathing (incentive spirometry)
Stridor
high-pitched; "crowing", monophonic (single notes in a chord) sounds on inspiration that are not cleared by coughing
Suctioning
aspiration of secretions from the upper or lower respiratory tract through a rubber or polyethylene catheter connected to a suction machine or wall outlet
Tachypnea
breathing pattern evidenced by rapid (greater than 20 per minute), shallow respirations
Tactile (vocal) fremitus
a tremor vibration in any part of the body detectable on palpation
Thoracentesis
aspiration of fluid or air from the pleural space
Tracheostomy tube
a curved, polyvinylchloride tube that is inserted through a tracheotomy (surgical incision into the trachea just below the first or second tracheal cartilage) just superior to the bifurcation of the trachea
Vesicular breath sounds
normal breath sounds heard over the periphery of the lung that low-pitched and soft intensity with inspiration being longer than expiration
Whispered pectoriloquy
a striking transmission of a whisper through the pulmonary structures so that they are clearly audible through the stethoscope that is commonly detected when the lung is consolidated by pneumonia
Post-mortem care
Remove all medical equipment except drains, central lines or chest tubes (follow health care agency policy regarding removal of drains, central lines, and chest tubes; some health care agencies require that they be left in; others allow for removal)
Place the patient’s dentures in his/her mouth and close his/her eyes and mouth before rigor mortis sets in
Wash the body, placing disposable pads under the buttocks and between the legs
Allow the family private time to view the body and ask questions
Identify the body by placing a tag on the ankle and on the shroud; in the hospital the patient’s wrist identification tag is left on, as well
Wrap the patient’s body in a shroud
Formal determination of death (pronouncement) that must be made by a physician or a coroner (and in some instances by a nurse
Cathartic
medication that strongly increases gastrointestinal motility and promotes defecation
Chyme
semifluid state that food is in when it leaves the stomach
Colostomy
an opening into the colon onto the abdominal wall that permits feces from the colon to exit from the stoma
Endoscopy
direct visualization of hollow organs of the body using an endoscope or flexible, lighted tube
Enema
introduction of solution into the lower intestinal tract
Flatus
intestinal gas
Hemorrhoids
abnormally distended rectal veins
Occult blood
blood present in such minute quantities that it cannot be detected with the unassisted eye
Stoma
artificial opening for waste excretion located on the body surface
Suppository
oval- or cone-shaped substance that is inserted into a body cavity and that melts at body temperature
Valsalva maneuver
forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure
Which of the following are functions of the large intestine?
absorb water and from the chyme
secrete mucus into the large intestine
synthesize protein
milliliters of chyme per day pass through the large intestine.
150
Mucus secreted into the large intestine acts as an
adherent for the feces.
Mucus secreted into the large intestine protects the large intestine
from bacterial activity.
Which of the following food sources high in fiber?
celery
apples
prunes
Which of the following foods are gas-forming?
cauliflower
onions
cabbage
Which of the following foods can produce diarrhea?
chocolate
figs
bran
prunes
Which of the following foods can produce constipation?
cheese
eggs
Adequate fluid intake for normal bowel elimination is which of the following?
2,000 – 3000 milliliters per day
A disease of the colon thought to have a significant psychological component is which of the following?
ulcerative colitis
Reflexes that assist in bowel elimination include which of the following?
gastrocolic
duodenocolic
Medications that decrease peristalsis in the large intestine and can result in constipation are which of the following?
Cogentin
morphine sulphate
Which of the following surgical alterations can result in the “dumping syndrome”?
gastrectomy
Some defining characteristics (signs/symptoms) of the nursing diagnosis constipation are which of the following?
abdominal distention
headache
dry, hard stool
Wetting agent, colace
Lowers the surface tension of the feces which helps water and fatty substances to penetrate the feces
Stimulant, bisacodyl
Irritates the intestinal mucosa causing increased peristalsis and rapid expulsion of feces
Bulk-forming, plantago seed
Uses synthetic or natural polysaccharides and cellulose derivatives to absorb water into
the fecal mass to add bulk
Lubricant, mineral oil
Prevents excessive absorption of water from the feces thus delaying drying of the feces