Galen college of nursing NUR 155 exam
3 study set
What do fistulas cause?
Fluid and electrolyte loss, nutritional deficits, and alterations in the skin integrity
Why is fistula drainage dangerous ?
Exposure to digestive enzymes can cause extensive damage to skin rapidly
capillary closing pressure and critical closing pressure
the minimum pressure required to collapse a capillary
capillary closing pressure
12-32 mm hg
What tissues are more susceptible to the effects of pressure then other tissues ?
Subcutaneous and muscle tissues
The nervous system controls posture and gait through what ?
Prorioception
What depends on the cerebellum and the inner ear ?
Equilibrium and it happens by inner ear fluid that remains stationary
What does the cardiopulmonary system do ?
Provides oxygen and circulates nutrients to body tissues.
What has the greatest risk for osteoporosis
White women
,Children with developmental disorders such as cerebral palsy and spina bifda may
reveal what during an assessment
Spasticity and hypertonicity ( increased muscle tone)
What are bony prominences?
They are the end or a protrusion of bone where skin , muscle, and tissue is thin. They are
the highest risk areas of the body for developing pressure sores.
Full thickness injury
An injury extending through the subcutaneous skin layers, muscles, and down to the
bone
What is blanching?
It's whitening of the skin when pressure is applied. The result is brief temporary loss of
blood flow.
Note} pressure injuries and ulcers are non-blanchable.
What is a Partial thickness injury ?
It's an injury to layers of the skin including the subcutaneous, dermis, and , epidermis.
Note Partial thickness wounds are associated with stage 2 pressure injuries/ ulcers
What is debridement?
Within woundcare, debridement refers to the removal of adherent, dead or
contaminated tissue from the wound.
serous drainage
clear, watery
Made from plasma
Healing wounds
, purulent drainage
Thick, yellow, green, tan, or brown drainage
In infected wounds
sanguineous drainage
Pink or pale red
Mix of serous and red blood fluid
Occurs in fresh wounds
serosanguineous drainage
Bright red mostly blood
Sign of healing
Indicates bleeding
R.E.E.D.A.N
Redness
Ecchymosis / bruise
Edema
Drainage
Approximation
Number of staples or sutures
Inflammatory stage of wound healing
lasts for about 3 days. phagocytosis of body works to clean the wound
Bleeding occurs which triggers coagulation cascade and the formation of a clot to stop
bleeding
Cytokines are released in this stage
Increase of pain, redness, warmth, and swelling in the injured area as the blood vessels
dilate and leak fluid to the tissue surrounding a injury .
Macrophages and neutrophils are drawn to the site of the injury and begin to process of
cleaning the wound of bacteria and debris.
3 study set
What do fistulas cause?
Fluid and electrolyte loss, nutritional deficits, and alterations in the skin integrity
Why is fistula drainage dangerous ?
Exposure to digestive enzymes can cause extensive damage to skin rapidly
capillary closing pressure and critical closing pressure
the minimum pressure required to collapse a capillary
capillary closing pressure
12-32 mm hg
What tissues are more susceptible to the effects of pressure then other tissues ?
Subcutaneous and muscle tissues
The nervous system controls posture and gait through what ?
Prorioception
What depends on the cerebellum and the inner ear ?
Equilibrium and it happens by inner ear fluid that remains stationary
What does the cardiopulmonary system do ?
Provides oxygen and circulates nutrients to body tissues.
What has the greatest risk for osteoporosis
White women
,Children with developmental disorders such as cerebral palsy and spina bifda may
reveal what during an assessment
Spasticity and hypertonicity ( increased muscle tone)
What are bony prominences?
They are the end or a protrusion of bone where skin , muscle, and tissue is thin. They are
the highest risk areas of the body for developing pressure sores.
Full thickness injury
An injury extending through the subcutaneous skin layers, muscles, and down to the
bone
What is blanching?
It's whitening of the skin when pressure is applied. The result is brief temporary loss of
blood flow.
Note} pressure injuries and ulcers are non-blanchable.
What is a Partial thickness injury ?
It's an injury to layers of the skin including the subcutaneous, dermis, and , epidermis.
Note Partial thickness wounds are associated with stage 2 pressure injuries/ ulcers
What is debridement?
Within woundcare, debridement refers to the removal of adherent, dead or
contaminated tissue from the wound.
serous drainage
clear, watery
Made from plasma
Healing wounds
, purulent drainage
Thick, yellow, green, tan, or brown drainage
In infected wounds
sanguineous drainage
Pink or pale red
Mix of serous and red blood fluid
Occurs in fresh wounds
serosanguineous drainage
Bright red mostly blood
Sign of healing
Indicates bleeding
R.E.E.D.A.N
Redness
Ecchymosis / bruise
Edema
Drainage
Approximation
Number of staples or sutures
Inflammatory stage of wound healing
lasts for about 3 days. phagocytosis of body works to clean the wound
Bleeding occurs which triggers coagulation cascade and the formation of a clot to stop
bleeding
Cytokines are released in this stage
Increase of pain, redness, warmth, and swelling in the injured area as the blood vessels
dilate and leak fluid to the tissue surrounding a injury .
Macrophages and neutrophils are drawn to the site of the injury and begin to process of
cleaning the wound of bacteria and debris.
