NSE 211 FINAL EXAM REVIEW
wound - ANSWERbreak in the continuity of body structure, caused by
violence, trauma,
or surgery to tissue
bodies
ex; of acute wounds - ANSWERsurgical incisions, traumatic wounds,
lacerations, burns ex; of chronic wounds - ANSWERPI, diabetic ulcers,
malignant
acute wound - ANSWERwound that proceeds through an orderly &
timely reparative
process --> sustained restoration of anatomical &
functional integrity
phases of wound healing - ANSWER1)
inflammatory phase
2) proliferative
phase
3) remodelling
phase
what's a part of the proliferative phase? - ANSWERproliferation,
granulation &
contracti
on
what happens during inflammatory phase? - ANSWER1) hemostasis.
(vasoconstriction)
2) platelets + fibrin forms, clot
formation
3) histamina, vasodilation, increased capillary permeability,
erythema, swelling &
warmt
h
what happens day 1-3 inflammatory phase? - ANSWERneutrophils
released to injury
site, phagocytosis of debris
beings.
what happens during day 3-24 of proliferative phase? - ANSWER1)
granulation tissue appears in wound
2) contraction of wound edges
3) resurfacing by epithelialization --> dermal regen.
4) vascular bed reestablished
what happens during day 24-2 yrs of remodelling phase? - ANSWER1)
collagen fibers
reorganize &
remodel
NSE 211 FINAL EXAM REVIEW
,2) permanent
scar
3) attains 80% of original
strength
Primary intention healing - ANSWERwound that is closed by suture or
wound closers &
healing occurs by collagen synthesis; lower risk of infection, and heals
quickly w/
minimal
scarring.
secondary intention healing - ANSWERwound edges are not
approximated. heals by
granulation tissue formation, wound contraction &
epithelialization.
has a prolonged phase of inflammation due to increased time needed for
phagocytosis
of necrotic
tissue.
tertiary intention healing - ANSWERwound is left open for several days as it
could be contaminated. has an increased risk of infection, so closure of
wound is done later until risk of infection is resolved.
why is the wound kept open for tertiary healing? - ANSWERto allow
exudate to drain,
prevent the spread of deep infection & aiding
granulation.
medical asepsis - ANSWERaka, *clean
technique*.
includes procedures used to reduce & prevent the spread of
microorganisms
ex; of medical asepsis - ANSWERhand washing, clean gloves, cleaning
environment
routinel
y.
ex; of surgical asepsis - ANSWERaka *surgical
technique*.
requires more stringent techniques, *eliminating all
microorganisms*.
when do you use surgical asepsis? - ANSWERwhen a patient's kin is
broken, or if the
nurse performs an invasive procedure in a body cavity that is
normally free of
microorganis
ms.
ex; of surgical asepsis procedures - ANSWER- protective clothing
NSE 211 FINAL EXAM REVIEW
, - opening sterile packages
- sterile field
- pouring sterile solns
- surgical hand scrub
- gowning & gloving
Principles of Surgical Asepsis - ANSWER- *a sterile object remains sterile only
when touched by another sterile object*
- a sterile object or field out of range of vision or an object held below a
person's waist is contaminated
- a sterile objective or field becomes contaminated by prolonged exposure to
air.
complications of wound healing - ANSWERhemorrhage, infection,
dehiscence,
evisceration, fistula
formation
hemorrhage nsg dx d/t - ANSWERslipped suture, dislodged clot,
infection, or eroded
blood
vessel
hemorrhage nsg dx manifested by - ANSWER- external-
saturated sanguinous
dressing
s
- internal-distension of
body part
- change in drain
output
- signs of hypovolemic shock
infection nsg dx d/t - ANSWER- exposure to bacteria, contaminated or
trauma wound
shows S&S, surgical post-op
infection.
infection nsg dx manifested by - ANSWERfever, tenderness, pain @
wound site,
erythema, edema, induration, warmth, elevated WBC, inflamed edges,
foul odor,
purulent drainage, delayed
healing
life threatening infection S&S - ANSWER- pain
- swelling, induration
- erythema
- wound breakdown
NSE 211 FINAL EXAM REVIEW
wound - ANSWERbreak in the continuity of body structure, caused by
violence, trauma,
or surgery to tissue
bodies
ex; of acute wounds - ANSWERsurgical incisions, traumatic wounds,
lacerations, burns ex; of chronic wounds - ANSWERPI, diabetic ulcers,
malignant
acute wound - ANSWERwound that proceeds through an orderly &
timely reparative
process --> sustained restoration of anatomical &
functional integrity
phases of wound healing - ANSWER1)
inflammatory phase
2) proliferative
phase
3) remodelling
phase
what's a part of the proliferative phase? - ANSWERproliferation,
granulation &
contracti
on
what happens during inflammatory phase? - ANSWER1) hemostasis.
(vasoconstriction)
2) platelets + fibrin forms, clot
formation
3) histamina, vasodilation, increased capillary permeability,
erythema, swelling &
warmt
h
what happens day 1-3 inflammatory phase? - ANSWERneutrophils
released to injury
site, phagocytosis of debris
beings.
what happens during day 3-24 of proliferative phase? - ANSWER1)
granulation tissue appears in wound
2) contraction of wound edges
3) resurfacing by epithelialization --> dermal regen.
4) vascular bed reestablished
what happens during day 24-2 yrs of remodelling phase? - ANSWER1)
collagen fibers
reorganize &
remodel
NSE 211 FINAL EXAM REVIEW
,2) permanent
scar
3) attains 80% of original
strength
Primary intention healing - ANSWERwound that is closed by suture or
wound closers &
healing occurs by collagen synthesis; lower risk of infection, and heals
quickly w/
minimal
scarring.
secondary intention healing - ANSWERwound edges are not
approximated. heals by
granulation tissue formation, wound contraction &
epithelialization.
has a prolonged phase of inflammation due to increased time needed for
phagocytosis
of necrotic
tissue.
tertiary intention healing - ANSWERwound is left open for several days as it
could be contaminated. has an increased risk of infection, so closure of
wound is done later until risk of infection is resolved.
why is the wound kept open for tertiary healing? - ANSWERto allow
exudate to drain,
prevent the spread of deep infection & aiding
granulation.
medical asepsis - ANSWERaka, *clean
technique*.
includes procedures used to reduce & prevent the spread of
microorganisms
ex; of medical asepsis - ANSWERhand washing, clean gloves, cleaning
environment
routinel
y.
ex; of surgical asepsis - ANSWERaka *surgical
technique*.
requires more stringent techniques, *eliminating all
microorganisms*.
when do you use surgical asepsis? - ANSWERwhen a patient's kin is
broken, or if the
nurse performs an invasive procedure in a body cavity that is
normally free of
microorganis
ms.
ex; of surgical asepsis procedures - ANSWER- protective clothing
NSE 211 FINAL EXAM REVIEW
, - opening sterile packages
- sterile field
- pouring sterile solns
- surgical hand scrub
- gowning & gloving
Principles of Surgical Asepsis - ANSWER- *a sterile object remains sterile only
when touched by another sterile object*
- a sterile object or field out of range of vision or an object held below a
person's waist is contaminated
- a sterile objective or field becomes contaminated by prolonged exposure to
air.
complications of wound healing - ANSWERhemorrhage, infection,
dehiscence,
evisceration, fistula
formation
hemorrhage nsg dx d/t - ANSWERslipped suture, dislodged clot,
infection, or eroded
blood
vessel
hemorrhage nsg dx manifested by - ANSWER- external-
saturated sanguinous
dressing
s
- internal-distension of
body part
- change in drain
output
- signs of hypovolemic shock
infection nsg dx d/t - ANSWER- exposure to bacteria, contaminated or
trauma wound
shows S&S, surgical post-op
infection.
infection nsg dx manifested by - ANSWERfever, tenderness, pain @
wound site,
erythema, edema, induration, warmth, elevated WBC, inflamed edges,
foul odor,
purulent drainage, delayed
healing
life threatening infection S&S - ANSWER- pain
- swelling, induration
- erythema
- wound breakdown
NSE 211 FINAL EXAM REVIEW
