which types of leukocytes are especially involved with fighting infection?
Neutrophils and monocytes
100
The elimination of microorganisms from any object that comes in contact with the patient is called:
Surgical asepsis
100
While walking in the woods. and 8 year old boy trips and stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record?
unintentional, partial- thickness wound
An unintentional wound is an accidental wound. a partial thickness wound is characterized by all or a portion of the dermis remaining intact
100
A 77 year old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the patient's chance of skin breakdown?
Reposition the patient on a regular basis
100
Pressure ulcer is
ischemic lesions of skin, underlying tissue caused by external pressure that impairs blood flow
caused by forces that tear and injure vessels
Shearing forces- pulling people up rather than lift it
Pressure- occur when 2 surfaces rub against each other
200
The best way to fight viral illness is:
prevention
200
a diet recommended for patients with infection is:
high protein
200
what does the wound assessment involve?
inspection- sight and smell
palpation - appearance, drainage, odor and pain
200
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child:
An infant's skin and mucous membranes are easily injured and at risk for infection
200
During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when she notices the skin is which color:
White
The first indication that a pressure ulcer may be developing is blanching ( becoming pale and white)
300
The route by which the infectious agent leaves one host and travels to another is called:
portal of exit
300
Transient and resident bacterial flora can reside on the hands, so strict handwashing techniques are important. Where are resident bacteria most likely to reside?
In creases of the skin
Resident bacterial flora is most likely to exit in the creases of the skin
Transient bacteria are found in greatest number under the fingernails
300
Phase of wound healing:
homeostasis: occur immediately after the initial injury
inflammation: last about 4 to 6 days. White blood cells, predominantly leukocytes and macrophages move to the wound
proliferation: know as fibroblastic, regenerative, or connective tissue phase
Maturation: final stage, begin about 3 weeks after injury, possibly continues a month or a year
300
functions of the skin and mucous membranes:
protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, elimination
300
The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a patient with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound?
Stage III pressure ulcer
Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full thickness skin loss is categorized as stage IV
400
The most basic and most effective method of preventing cross- contamination is:
handwashing
400
a patient has sought care because of a knee wound that appears to have become infected. Which of the following processes is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?
Migration of leukocytes to the area of the wound
During the cellular stage of inflammation, white blood cells move quickly into the area
400
examples of NANDA Nursing Diagnoses
impaired skin integrity
risk for infection
Acute pain
Disturbed body image
Impaired tissue integrity
Chronic pain
400
age related skin alteration:
subcutaneous and dermal tissue become thin
Skin is more easily injured
skin has less capacity to insulate
skin wrinkles more easily
sensation of pressure and pain is reduced
400
Risk factors of pressure ulcers
immobility
inadequate nutrition
Fecal and urinary incontinence
Decreased mental status
Diminished sensation
excessive body heat
500
The primary cause of nosocomial infection is :
soiled hands
500
what are the cardinal sign of acute infection
redness
swelling
heat
pain
loss of function
appear at the site of injury or inflammation
500
another word for wound drainage is
exudate, exudate is describe as Serous- composed primarily of clear and watery; Sanguineous-consist of large number of blood red cells and looks like blood; Serosanguineous- mixture of serum and red blood cells, it like pink to blood tinged; Purulent -mean infected, musty or thick or foul order and varies in color such as dark yelow and green
500
focus assessment for skin integrity
appearance of skin
recent changes in skin
activity/ mobility
nutrition
pain
elimination
500
ways to prevent pressure ulcers
Provide nutrition (protein and calories)
Maintain hygiene (clean, avoid hot water)
Avoid skin trauma
Provide supportive devices
Turning every 2 hours
improve mobility and activity