NUR 125 LECTURE EXAM #1
Questions and Answers
APIE - ANS-Assessment, Nursing Dx, Planning, Implementation, Evaluation.
Step One: Assessment - ANS-Collect and record all the information you need to:
Predict, detect, prevent, and manage actual and potential health problems. Promote
optimum health, independence, and well-being. Clarify expected outcomes (results).
Subjective Data - ANS-What the pt states.
Objective Data - ANS-What you observe.
Step Two: Diagnosis - ANS-Analyze the data you gathered, draw conclusions, and
determine whether there are: Risks for safety or infection transmission (deal with these
immediately). Signs or symptoms that need evaluation by a more qualified professional
(report these immediately). Actual and potential health problems requiring nursing or
medical management. Risk factors requiring nursing or medical management. Issues
that aren't quite clear, but require further investigation. Learning needs that must be
addressed. Patient resources, strengths, and use of healthy behaviors. Health states
that are satisfactory but could be improved.
Components of a Nursing Dx? - ANS-Problem (NANDA Approved Dx), Etiology (Cause)
(Related to factor), and Signs and Symptoms (As evidence by).
Step Three: Planning (Outcomes and Interventions) - ANS-Clarify expected outcomes
(results), set priorities, and determine interventions (nursing actions). The interventions
are designed to: Detect, prevent, and manage health problems and risk factors.
Promote optimum function, independence, and sense of well-being. Achieve the
expected outcomes safely and efficiently.
Priorities: ABC's, Maslows (Human Needs)...
Wound Healing: Homeostasis Phase - ANS-**Occurs in primary intention only.**
Control of bleeding occurs. This does not happen in wounds healing by secondary
intention, compromising repair process.
Wound Healing: Inflammatory Phase - ANS-Goal is to establish a clean wound bed.
White blood cells migrate to area and help clean up site and release growth factors for
tissue regrowth.
, Wound Healing: Proliferative Phase - ANS-Production of new tissue. Epithelialization.
Best occurs in moist environment.
Wound Healing: Remodeling Phase - ANS-Lasts up to one year. Reorganization of
collagen occurs.
Wound Healing: Inflammatory Phase - ANS-The inflammatory phase begins at the time
of injury or cell death. Vessels vasoconstrict and clot formation occurs initially. After
about 10 minutes, vasodilation occurs and increased capillary permeability.
Macrophages move into the wound. Local changes to the area of injury include: local
edema, pain, erythema, and warmth.
Wound Healing: Maturation Phase - ANS-Takes 3 weeks to a year after the injury. Scar
tissue develops and collagen reorganizes and strengthens.
Wound Healing: First Intention - ANS-A wound without tissue loss, such as a clean
laceration or surgical incision. Usually closed with sutures or staples and wound edges
are brought together (approximation). Closing the wound eliminates dead space and
shortens healing time. Results in a thinner appearing scar.
Wound Healing: Second Intention - ANS-Deeper tissue injuries and wounds with tissue
loss results in a cavity-like defect that requires gradual filling of the dead space with
connective tissue. Used for pressure ulcers.
Wound Healing: Third Intention - ANS-Wounds that are left open for several days.
Debridement occurs and then closes by primary closure. Used to leave surgical wounds
open to heal.
Factors affecting wound healing? - ANS-Age, nutrition status, infection, obesity, tissue
perfusion, smoking, diabetes, wound stress.
Factors affecting wound healing: Hemorrhage - ANS-Complication occurring later, can
be internal or external. Symptoms are hypovolemic shock and swelling of the affected
body part. Decrease in hemoglobin and hematocrit. A hematoma is a collection of blood
underneath tissues and often appears as a bluish swelling or mass.
Factors affecting wound healing: Infection - ANS-Impairs the healing process and
increases tissue damage. Assess for color, odor, drainage, vital signs, fever, and white
blood cell count.
Factors affecting wound healing: Dehiscence - ANS-Partial or total separation of wound
edges above the fascia. High risk in the obese because of increased strain on their
wounds. Can occur in abdominal surgical wounds after straining (coughing or vomiting)
so always teach patients to splint their incision. Important to remember that if
serosanguineous drainage increases from a wound, be alert for potential dehiscence.
Questions and Answers
APIE - ANS-Assessment, Nursing Dx, Planning, Implementation, Evaluation.
Step One: Assessment - ANS-Collect and record all the information you need to:
Predict, detect, prevent, and manage actual and potential health problems. Promote
optimum health, independence, and well-being. Clarify expected outcomes (results).
Subjective Data - ANS-What the pt states.
Objective Data - ANS-What you observe.
Step Two: Diagnosis - ANS-Analyze the data you gathered, draw conclusions, and
determine whether there are: Risks for safety or infection transmission (deal with these
immediately). Signs or symptoms that need evaluation by a more qualified professional
(report these immediately). Actual and potential health problems requiring nursing or
medical management. Risk factors requiring nursing or medical management. Issues
that aren't quite clear, but require further investigation. Learning needs that must be
addressed. Patient resources, strengths, and use of healthy behaviors. Health states
that are satisfactory but could be improved.
Components of a Nursing Dx? - ANS-Problem (NANDA Approved Dx), Etiology (Cause)
(Related to factor), and Signs and Symptoms (As evidence by).
Step Three: Planning (Outcomes and Interventions) - ANS-Clarify expected outcomes
(results), set priorities, and determine interventions (nursing actions). The interventions
are designed to: Detect, prevent, and manage health problems and risk factors.
Promote optimum function, independence, and sense of well-being. Achieve the
expected outcomes safely and efficiently.
Priorities: ABC's, Maslows (Human Needs)...
Wound Healing: Homeostasis Phase - ANS-**Occurs in primary intention only.**
Control of bleeding occurs. This does not happen in wounds healing by secondary
intention, compromising repair process.
Wound Healing: Inflammatory Phase - ANS-Goal is to establish a clean wound bed.
White blood cells migrate to area and help clean up site and release growth factors for
tissue regrowth.
, Wound Healing: Proliferative Phase - ANS-Production of new tissue. Epithelialization.
Best occurs in moist environment.
Wound Healing: Remodeling Phase - ANS-Lasts up to one year. Reorganization of
collagen occurs.
Wound Healing: Inflammatory Phase - ANS-The inflammatory phase begins at the time
of injury or cell death. Vessels vasoconstrict and clot formation occurs initially. After
about 10 minutes, vasodilation occurs and increased capillary permeability.
Macrophages move into the wound. Local changes to the area of injury include: local
edema, pain, erythema, and warmth.
Wound Healing: Maturation Phase - ANS-Takes 3 weeks to a year after the injury. Scar
tissue develops and collagen reorganizes and strengthens.
Wound Healing: First Intention - ANS-A wound without tissue loss, such as a clean
laceration or surgical incision. Usually closed with sutures or staples and wound edges
are brought together (approximation). Closing the wound eliminates dead space and
shortens healing time. Results in a thinner appearing scar.
Wound Healing: Second Intention - ANS-Deeper tissue injuries and wounds with tissue
loss results in a cavity-like defect that requires gradual filling of the dead space with
connective tissue. Used for pressure ulcers.
Wound Healing: Third Intention - ANS-Wounds that are left open for several days.
Debridement occurs and then closes by primary closure. Used to leave surgical wounds
open to heal.
Factors affecting wound healing? - ANS-Age, nutrition status, infection, obesity, tissue
perfusion, smoking, diabetes, wound stress.
Factors affecting wound healing: Hemorrhage - ANS-Complication occurring later, can
be internal or external. Symptoms are hypovolemic shock and swelling of the affected
body part. Decrease in hemoglobin and hematocrit. A hematoma is a collection of blood
underneath tissues and often appears as a bluish swelling or mass.
Factors affecting wound healing: Infection - ANS-Impairs the healing process and
increases tissue damage. Assess for color, odor, drainage, vital signs, fever, and white
blood cell count.
Factors affecting wound healing: Dehiscence - ANS-Partial or total separation of wound
edges above the fascia. High risk in the obese because of increased strain on their
wounds. Can occur in abdominal surgical wounds after straining (coughing or vomiting)
so always teach patients to splint their incision. Important to remember that if
serosanguineous drainage increases from a wound, be alert for potential dehiscence.
