NURS 6011 Study Guide for Exam 3
With complete solution New!!
normal BP - 120/80
normal respiratory rate - 12-20
normal pulse rate - 60-100
Normal temperature - 97.8-99.1
debridement - cleaning away devitalized tissue and foreign matter from a wound
dehiscence - separation of layers of a surgical wound; may be partial, superficial or a
complete disruption of the surgical wound
desiccation - dehydration
the process of being rendered free from moisture
epithelialization - stage of wound healing in which epithelial cells form across the
surface of a wound; tissue color ranges from the color of ground glass to pink
eschar - thick, leathery, scar or dry crust that is necrotic and must be removed for
adequate healing to occur
evisceration - protrusion of viscera through an incision
purulent drainage - compromised of WBCs, liquefied dead tissue debris, and both dead
and live bacteria
an intentional wound is the result of? - planned invasive therapy or treatment
examples are wound resulting from surgery, IV therapy, and lumbar puncture
in older adults what are age related changes that occur that could affect wound healing
- skin loses turgor and is more fragile
decreased secretion of enzymes and absorption of nutrients and minerals may increase
risk for delayed wound healing
risk of infection increases because:
-slower inflammatory response
-reduced antibody production and endocrine system function
-increased incidence of chronic illnesses, such as diabetes and CV disease, that
compromise circulation and tissue oxygenation
, You have a 6th grader who has been getting bad grades lately, rubs their eyes
frequently, visual acuity is poor what is the nursing diagnosis? - ineffective role
performance related to visual impairment
in an older adult the skin loses turgor and is more fragile what are some nursing
interventions to help with that? - maintain hydration and IV fluids as prescribed
maintain record of intake and output
use caution when removing tape
in older adults they experience decreased secretion of enzymes and absorption of
nutrients that increase their risk for delayed wound healing what are some nursing
interventions to combat this? - maintain intake of adequate calories
ensure that the diet is high in protein, vitamin A, vitamin C and trace elements
monitor lab results such as serum albumin, total protein
in older adults if they have a wound the risk for infections increases what are some
nursing interventions to combat this? - -hand hygiene
-take and record vital signs noting and reporting increased temp
-monitor wound for signs of infection
-administer meds as prescribed
symptoms of infection of a wound include? - purulent drainage
increased drainage
pain
redness
swelling in and around the wound
increased body temperature
increased WBC
a pressure injury or ulcer - defined as localized damage to the skin and underlying
tissue that usually covers over a bony prominence or is related to the use of a medical
or other device
risk factors for pressure ulcers
AVOID PRESS - aging skin
vascular disorders
obesity
immobility and incontinence
diabetes
With complete solution New!!
normal BP - 120/80
normal respiratory rate - 12-20
normal pulse rate - 60-100
Normal temperature - 97.8-99.1
debridement - cleaning away devitalized tissue and foreign matter from a wound
dehiscence - separation of layers of a surgical wound; may be partial, superficial or a
complete disruption of the surgical wound
desiccation - dehydration
the process of being rendered free from moisture
epithelialization - stage of wound healing in which epithelial cells form across the
surface of a wound; tissue color ranges from the color of ground glass to pink
eschar - thick, leathery, scar or dry crust that is necrotic and must be removed for
adequate healing to occur
evisceration - protrusion of viscera through an incision
purulent drainage - compromised of WBCs, liquefied dead tissue debris, and both dead
and live bacteria
an intentional wound is the result of? - planned invasive therapy or treatment
examples are wound resulting from surgery, IV therapy, and lumbar puncture
in older adults what are age related changes that occur that could affect wound healing
- skin loses turgor and is more fragile
decreased secretion of enzymes and absorption of nutrients and minerals may increase
risk for delayed wound healing
risk of infection increases because:
-slower inflammatory response
-reduced antibody production and endocrine system function
-increased incidence of chronic illnesses, such as diabetes and CV disease, that
compromise circulation and tissue oxygenation
, You have a 6th grader who has been getting bad grades lately, rubs their eyes
frequently, visual acuity is poor what is the nursing diagnosis? - ineffective role
performance related to visual impairment
in an older adult the skin loses turgor and is more fragile what are some nursing
interventions to help with that? - maintain hydration and IV fluids as prescribed
maintain record of intake and output
use caution when removing tape
in older adults they experience decreased secretion of enzymes and absorption of
nutrients that increase their risk for delayed wound healing what are some nursing
interventions to combat this? - maintain intake of adequate calories
ensure that the diet is high in protein, vitamin A, vitamin C and trace elements
monitor lab results such as serum albumin, total protein
in older adults if they have a wound the risk for infections increases what are some
nursing interventions to combat this? - -hand hygiene
-take and record vital signs noting and reporting increased temp
-monitor wound for signs of infection
-administer meds as prescribed
symptoms of infection of a wound include? - purulent drainage
increased drainage
pain
redness
swelling in and around the wound
increased body temperature
increased WBC
a pressure injury or ulcer - defined as localized damage to the skin and underlying
tissue that usually covers over a bony prominence or is related to the use of a medical
or other device
risk factors for pressure ulcers
AVOID PRESS - aging skin
vascular disorders
obesity
immobility and incontinence
diabetes
