Anatomy and Physiology: Understanding Body Defenses and Wound Healing, Exams of Nursing

Download Anatomy and Physiology: Understanding Body Defenses and Wound Healing and more Exams Nursing in PDF only on Docsity! NURS208 Infection & Wounds, Mobility /Immobility, Pharmacotherapeutics (350 Questions and Answers) What is an infection? - Correct answer invasion of the body (entry) by microbes and the proliferation (growth in numbers) of these microbes What is Virulence? - Correct answer it is how strong it is - less virulent, less likely to produce an infection What is Normal Flora? - Correct answer resident normal flora - can cause infection of the conditions right and grow abnormally What keeps us from getting infections? - Correct answer body defenses protects us from invasion and profileration What are two types of body defenses? - Correct answer non-specific and specific What is non-specific immunity? - Correct answer protect against any microbe or invader What is specific immunity? - Correct answer protect against certain identifiable bacteria, fungi, etc... What are non-specific defenses? - Correct answer each area and opening into the body has its own defenses What is the primary line of defense with non-specific defenses? - Correct answer it the skin and mucus membranes What adds to non-specific defenses? - Correct answer - dryness of the skin (not dry to the point of the skin cracking or flaking, more the absence of extra moisture) - microbes love and need moisture to grow, severe dryness can cause easy entry What are types of non-specific defenses? - Correct answer - skin - nose - mouth - eyes - GI Tract - Vagina Skin? (Non-Specific Defense) - Correct answer intact, dry Nose? (Non-Specific Defense) - Correct answer cilia, mucus, turbinates Mouth? (Non-Specific Defense) - Correct answer shedding of mucus membranes Eyes? (Non-Specific Defense) - Correct answer tears, lashes, blinking GI Tract? (Non-Specific Defense) - Correct answer hyperacidity Vagina? (Non-Specific Defense) - Correct answer hyperacidity Does non-specific defenses have a inflammatory response? - Correct answer yes What is the inflammatory process also called? - Correct answer inflammation What is the Inflammatory Process? - Correct answer - response to injury or infection - mechanism dilutes invaders and/or destroys them, as well as, promotes repair What are the 5 signs of inflammation? - Correct answer pain, swelling, redness, heat, decrease function of affected part What are the 3 stages of the inflammatory process? - Correct answer 1. Vascular & Cellular Response to Injury 2. Exudate Stage 3. Reparative Stage What is the Vascular & Cellular Response to Injury? - Correct answer - blood vessels initially constrict, then vasodilate What is the Natural Active Immunity? - Correct answer antibodies form in response to an infection a person is exposed to What is artificial active immunity? - Correct answer antibodies form in response to vaccines given What is Passive Immunity? - Correct answer received from another source What is the natural passive immunity? - Correct answer antibodies from a mother are passed in breastmilk or in utero What is the artificial passive immunity? - Correct answer antibodies obtained from another source and injected into a person (can be human or animal) What are the 6 chains of infection? - Correct answer causative agents or pathogens (infectious agent), reservoir, means of exit (portal of exit), mode of transmission, portal of entry, susceptible host What is the causative agent or pathogens (infectious agent)? - Correct answer bacteria, virus, fungus, parasite What is the reservoir? - Correct answer source of the pathogen, where it lives (can be animate or inanimate) What is the means of exit from reservoir (portal of exit)? - Correct answer if human, can be from GI, GU, respiratory, reproductive, blood, lesions What is the 3 types of mode of transmission to a host? - Correct answer - direct contact - indirect transmission - airborne transmission What is indirect transmission? - Correct answer can occur in 2 ways: vectors and vehicles What are vectors? - Correct answer moving source, animal or insects that are a go-between from source to host What are vehicles? - Correct answer any substance that serves as a go- between, such as doorknobs, utensils, toys, IV, needles, food What is airborne transmission? - Correct answer droplet nuclei that remain in the air for long periods or on dust particles - air currents transport the nuclei and/or dust particles to the host What is the portal of entry? - Correct answer similar to the exits, but going in, if human - example: - person coughs pathogen leaves mouth, enter mouth of another - pathogen in lake, water enters mouth of human What is the susceptible host? - Correct answer just because the pathogen enters a host does not mean an infection occurs - it may not proliferate because if host is ill, it has compromised defenses, then can proliferate What does an infection depends on? - Correct answer dose and virulence of the agent What is a compromised host? - Correct answer - age - immune status - therapeutic tx, - burns, invasive lines, or other breaks - decrease nutrition What is age on a compromised Host? - Correct answer very young or very old What is the immune status on a compromised Host? - Correct answer current infections, DM, CA, chronic diseases, decrease WBC What is the therapeutic Tx on a compromised Host? - Correct answer radiation, chemo, meds such as antibiotics, anti-inflammatories, steroids, any surgery What is a nosocomial infection? - Correct answer due to presence of agents and compromised hosts What is iatrogenic infection? - Correct answer caused by medical treatment (inserting an IV, surgery, meds) Is nosocomial and iatrogenic infections preventable? - Correct answer not always, but often preventable How to prevent and control infections? - Correct answer - WASH HANDS!!! - WEAR MASK!!! - support existing defenses - provide adequate rest, nutrition, fluids - monitor carefully What are isolation techniques? - Correct answer prevents spread What is the purpose of precautions and isolation? - Correct answer to break the chain at the transmission link What are the standard precautions of CDC guidelines? - Correct answer - in the care of all hospitalized patients regardless of their diagnosis or possible infection status. - These precautions apply to blood, all body fluids, secretions, excretions except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes. What are the standard precautions for Tier I that will be USED FOR ALL PATIENTS? - Correct answer - wash hands before and after contact - wear gloves for any pt's body fluids - applies to all body fluids, secretions, (except sweat), excretions, broken skin What are Tier II transmission based precautions that are used IN ADDITION to standard precautions? - Correct answer - droplet transmission - airborne transmission - contact transmission What is the Tier II - Droplet transmission-based? - Correct answer infections caused by droplet > 5 microns What is Acinetobacter baumannii? - Correct answer resistance being either intrinsic or acquired by transformation What is a wound? - Correct answer any injury to the body, internal or external, where protective barriers are compromised and the inflammatory process has begun What is the cause of a wound? - Correct answer intentional and unintentional What is the intentional cause of a wound? - Correct answer from therapy, usually under aseptic technique (IV, surgery) What is the unintentional cause of a wound? - Correct answer occurs unexpectedly, traumatic, unsterile conditions (accidents, falls, gunshots, stabbings) What is Acute? - Correct answer recent wound that occurs and heals in a timely way, function restored What is Chronic? - Correct answer fails to heal in a timely/orderly way, difficult, long term process What are the status of the skin? - Correct answer closed and open What is the status of a closed skin? - Correct answer there's no break in the skin What is the status of open skin? - Correct answer involves break in skin or membranes What are the qualities of an closed wound? - Correct answer contusions and closed fractures What is a contusions? - Correct answer bruises, concussions What are closed fractures? - Correct answer broken bones, but skin not broken What are the qualities of an open wound? - Correct answer abrasion, laceration/avulsion, incision, penetrating, punctures, chemical, thermal, irradiation What is an abrasion wound? - Correct answer surface scrape, partial thickness What is a laceration/avulsion wound? - Correct answer torn apart, jagged edges What is an incision wound? - Correct answer slicing open, can involve all layers, full thickness What is an penetrating wound? - Correct answer goes through skin and tissues, even organs What is a puncture wound? - Correct answer round, small usually not deep What is a chemical wound? - Correct answer burns or injury from toxic agents such as acids, drugs, alcohols What is a thermal wound? - Correct answer burns from high or low temps What is a irradiation wound? - Correct answer ultraviolet light or radiation injury What are the cleanliness of wounds? - Correct answer clean, clean- contaminated, contaminated, and infected What is a clean wound? - Correct answer wound contains no pathogens, does not enter GI, GU, respiratory, genital area, or infected areas. (low incidence of infection) What is a clean-contaminated wound? - Correct answer done under aseptic conditions, but involves areas that have microbes (greater risk for infection) What is a contaminated wound? - Correct answer occurs/exists in conditions where microbes are likely, such as a break in asepsis, trauma, gunshots, car wrecks. (high infection risk) What is a infected wound? - Correct answer bacterial organisms are present. Such as non-healing wounds, old traumatic wounds, surgery into an infected area How do wounds heal? - Correct answer when wounds heal, they most of the time form scars What are three types of wound healing? - Correct answer primary intention, secondary intention, tertiary intention, What is the primary intention of wound healing? - Correct answer wound edges are closed, well approximated, and there is little tissue loss, and little scarring What is the secondary intention of wound healing? - Correct answer large wound with considerable tissue loss - can't be closed with suturing - repair time is longer and scarring is greater - susceptibility for infection increased - eschar (dead tissue) is present - debridement is needed to remove eschar - granulation tissue forms and is very fragile - often weep sero-sanquinous fluids - form thick scars What is the tertiary intention of wound healing? - Correct answer wound is left open on purpose to drain exudates - primary closing (suturing) is done later - more scar tissue forms What are the phases of wound healing? - Correct answer inflammatory, proliferative, maturation location (wound assessment)? - Correct answer use landmarks size (wound assessment)? - Correct answer length, width, diameter, depth in cm/mm appearance (wound assessment)? - Correct answer color, wound edges, signs of dehisence, surrounding skin, sutures, staples drainage (wound assessment)? - Correct answer type, from where specifically pain (wound assessment)? - Correct answer where, rating What is a hemovac drain? - Correct answer closed system drain that is portable negative pressure suction device - it drains blood and fluids - used after abdominal, orthopedic surgery What is a Jackson-Pratt drain? - Correct answer a closed bulb suction devices that drains blood and fluid used after breast surgery or mastectomy, abdominal surgery What are the pressure wounds? - Correct answer color classification, Braden Scale, PUSH Tool What is color classification? - Correct answer RYB (red-yellow-black): used for wound assessment and to help direct treatment for open wounds, or healing by secondary intention What is Braden Scale? - Correct answer assesses the risk in numerical scoring based on mental status, continence, activity, mobility, activity, and nutrition What is the PUSH Tool? - Correct answer Pressure Ulcer Scale for Healing: to monitor the change in pressure injury status over time What do staging pressure wounds look like at Stage I? - Correct answer - non-blanchable red area - may be pale at first - reactive hyperemia What is reactive hyperemia? - Correct answer redness that lasts 1/2 - 3/4 as long as the time pressure applied - damage likely if redness persists What do staging pressure wounds look like at Stage II? - Correct answer - top layer of skin missing - blister, abrasion, shallow crater - sometime white or yellow sloughing, or eschar - painful What do staging pressure wounds look like at Stage III? - Correct answer - deep ulcer extending into dermis and subq tissues - painless base - sloughing and white, gray, or yellow eschar - can be purulent What do staging pressure wounds look like at Stage IV? - Correct answer - deep ulcer into muscle, bones, joints - foul smell - brown, black eschar, can be leathery - undermining/tunneling - painless base What are the interventions for prevention? - Correct answer - turning/ROM - constant assessment (Braden, RYB, and PUSH tools) - protection of bony prominences - promoting hydration and nutrition - special beds What are the interventions for dressings? - Correct answer CoursePoint pg. 1073-1074; Table 32-5 What is the Nursing Diagnosis of Infections & Wounds? - Correct answer - HR for Infection - Impaired Tissue Integrity - Impaired Skin Integrity - Risk for Pressure Ulcer - Impaired Oral Mucus Membranes What is mobility essential to? - Correct answer life Mobility serve many purposes in daily lives, such as? - Correct answer independence Mobility keeps us healthy. What does movement effects? - Correct answer every organ What is mobility? - Correct answer a person's ability to move about freely What is immobility? - Correct answer not able to move: paralyzed, coma, extreme weakness, etc... What is impaired physical mobility? - Correct answer decreased/restricted mobility What does BR means? - Correct answer bedrest What does CBR means? - Correct answer complete bedrest What does BR with BRP means? - Correct answer bedrest with bathroom privileges What does BR with BSC means? - Correct answer bedrest with bedside commode What does BR and up for meals means? - Correct answer bedrest and up for meals Why is bedrest ordered or used? - Correct answer - decrease the O2 needs and demands of the body by reducing activity - allow pts. to rest and regain strength - prevent injury and reduce pain How is bedrest beneficial? - Correct answer if the pt. is not resisting it or fighting it Does bedrest mean nurse leave the pt. lying immobile? - Correct answer NO - pooling of secretions, stagnation, secretions become thick - atelectasis - pneumonia What is the effects of mobility on the cardiovascular system? - Correct answer - bedrest deconditioning - heart rate increases and reduces diastolic pressure - coronary blood flow decrease causing angina - activity intolerance What is Valsalva Maneuver in the cardiovascular system? - Correct answer pressure in the chest from bearing down and holding breathe with turning, straining with bowel movements How does deconditioning effects the cardiovascular system? - Correct answer the heart muscle becomes ineffective as a pump causing orthostatic hypotension How does DVT (Deep Vein Thrombosis) effect the cardiovascular system? - Correct answer clots form due to Virchow's Triad What are the S&S of DVT? - Correct answer - pain or tenderness, esp. in calves - swelling - warmth or heat - discoloration to skin What are the three factors of the Virchow's Triad that increase the predisposition for developing clots? - Correct answer 1. impaired venous return to the heart 2. hypercoagulability 3. trauma or injury to a vessel wall What is impaired venous return regarding the Virchow's Triad? - Correct answer lack of muscle contraction to help with pumping blood What is hypercoagulability regarding the Virchow's Triad? - Correct answer decrease hydration makes blood thicker, allows blood to stay in one place, components settle, clots form What is trauma regarding the Virchow's Triad? - Correct answer crossing legs, hitting side rails, pillow under knees, etc. can cause clots to form at injury site How would you prevent Virchow's Triad? - Correct answer - decrease venous return - hypercoagulability - trauma/injury to vessels How would you prevent decreasing venous return? - Correct answer increase mobility as soon as possible so muscles can act as pumps - skeletal muscle pump - TED hose/SCDs How would you prevent hypercoaguability? - Correct answer adequate hydration decreases coagulability (dilutes and increase fluidity) What is anticoagulant? - Correct answer decrease clotting - examples: warfarin (Coumadin), heparin, clopidogrel (Plavix), enoxaparin (Lovenox), ASA How would you prevent trauma/injury to vessels? - Correct answer - position properly to promote venous return - decrease trauma by teach to keep legs uncrossed, no pillows under knees, and pad side rails Should you massage tender calves on anyone on bedrest? - Correct answer No, that's something you should be cautious with. It is possible for mobility to dislodge a clot. True or False? - Correct answer True Can you put a patient on bedrest if they are complaining about leg pain? - Correct answer Yes, until the MD determines there is no clot What are some S&S of Pulmonary Embolus? - Correct answer - sudden sharp, chest pain, cyanosis, respiratory distress, hemoptysis, shock, extreme restlessness, and anxiety - sudden cardio/pulmonary arrest - LOC changes such as confusion, lethargy, extreme restlessness, anxiety What are some interventions for PE (Pulmonary Embolus)? - Correct answer - bedrest - place in semi-fowlers - give anticoagulants (best practice) - O2 How would you prevent DVT and PE? - Correct answer - ROM - Mobility - TED hose - Sequential compression devices (SCD) - Impulse booties How do mobility effect the metabolic/nutritional system? - Correct answer - immobility cause the BMR (basal metabolic rate) to decrease - decrease the need for energy, O2, and food - GI system slows down, including mobility, gastric secretions, appetite decreases - decrease mobility causes a marked imbalance between protein synthesis (anabolism) and protein breakdown (catabolism) What is BMR regarding the prevention of metabolic/nutritional system? - Correct answer minimal amount of energy needed to provide for basic body functions How do catabolism exceeds anabolism regarding the prevention of the metabolic/nutritional system? - Correct answer muscles are being broken down due to lack of protein intake What is nitrogen a product of regarding the prevention of the metabolic/nutritional system? - Correct answer muscle breakdown so negative nitrogen balance results What is the negative nitrogen balance? - Correct answer - indicates decreased nutrition - not enough protein to maintain muscles and heal tissues When more nitrogen is excreted than is taken in what does that show? - Correct answer a decrease in protein and an increase in urine urea Muscle mass decreases causes what? - musculoskeletal system - Correct answer atrophy What does muscle dysfunction causes? - musculoskeletal system - Correct answer joint dysfunction and obvious changes What is ankylosis? - musculoskeletal system - Correct answer fixation of joints What is contractures? - musculoskeletal system - Correct answer limbs that draw up due to shortening of tendons from disuse and loss of strength in counterbalance muscles What causes brittle bones? - musculoskeletal system - Correct answer lack of weight bearing, stress on muscles, and the resultant loss of calcium What is disuse osteoporosis? - musculoskeletal system - Correct answer bony demineralization from decrease mobility When do demineralization starts to occur? - musculoskeletal system (disuse osteoporosis) - Correct answer 2nd and 3rd day of decrease in mobility How can psychological effects effect mobility? - Correct answer - depression - altered sleep-wake cycles - increased isolation - sensory deprivation - behavior changes - decreased coping How can developmental effects effect mobility? - Correct answer - inhibited progress through developmental tasks or possible regression - increased dependence What are some interventions that can help mobility? - Correct answer - repositioning - leg exercises ever 1-2 hours - weight bearing activities - ADLs and IADLs - ROM activities - TED hose and SCDs What is mobility/immobility nursing diagnosis? - Correct answer - Activity Intolerance - Fatigue - Impaired physical mobility: impaired bed mobility and walking - HR Disuse Syndrome - Self-Care Deficit: specify - Self-Care Deficit Syndrome - Constipation - Diarrhea - Impaired Urinary Elimination: functional, continuous urinary, urge, stress, and reflex incontinence How can repositioning help mobility? - Correct answer - frequent and tailored to pt - minimum of every 2 hours - teach pt to shift self, adjust, and change positions if they are able - maintain alignment and protect pressure points How can leg exercises every 1-2 hours help mobility? - Correct answer - teach pt how to do and why - contract and relax large muscles - press on footboard or someone's hand - move feet back and forth at joint - bend and straighten knee How can weight bearing activities help mobility? - Correct answer - ambulate as early as possible - sit pt up and then stand often - tilt tables and special beds How can ADLs and IADLs help mobility? - Correct answer - encourage patients to perform ADLs as much as able (self-care) - sometimes afraid to do for themselves or family intervenes - sometime just want someone to care for them How can ROM activities help mobility? - Correct answer - perform on the pt whenever the opportunity arises (bath) - encourage active ROM - can teach family How can TED hose and SCDs help mobility? - Correct answer - deep breathing and coughing - breathing exercises - maintain fluids and nutrition - discourage Valsalva maneuver - discourage leg crossing What is Pharmacotherapeutics? - Correct answer use of drugs to treat, cure, relieve, prevent, or diagnose diseases What is pharmacokinetics? - Correct answer how the body affects the drugs metabolism and action What are the components of pharmacokinetics? - Correct answer absorption, duration of action and effect, distribution in the body, and method of excretion What is pharmacodynamics? - Correct answer how drugs and their actions affect the body at cellular level Drugs can have 4 different names. What are the name types? - Correct answer chemical, generic, official, brand, trade, or proprietary What are the 4 different names of aspirin? - Correct answer acetylsalicylic acid, aspirin, aspirin, and Bayer, Anacin, Excedrin, BC powder What are the classification of the drugs? - Correct answer - chemical make up of the drug - diseases treated - organs or systems effected - generation of drug What is body weight, water, and fat content? - Correct answer - dosages calculated according to these - lower a pt.'s body weight, greater the concentration in tissues and increase in effect of the drug How are older adults incorporated in body weight, water, and fat? - Correct answer - have decrease amounts of water - have increase in body fat %, less lean body mass What is protein binding? - Correct answer - most drugs bind to the protein albumin - inactivates part of drug - free part of the drug remains active and therapeutic What is biotransformation? (Metabolism) - Correct answer process that occurs to drugs, part of elimination. actions can be increased, decreased, or changed, or may stay the same What may happen with biotransformation? - Correct answer 1. change to a less active form 2. may be changed to another form 3. turn into a toxic substance Biotransformation necessary drugs to detoxify, where does it mostly occur? - Correct answer in the liver Compromised organs decrease ability to do what? - Correct answer metabolize and become toxic Excretion is where drugs can exit through what? - Correct answer kidneys, bowels, lungs, and exocrine glands What is the main excretory organ? - Correct answer kidneys How is deep breathing & coughing important in the Excretion process? - Correct answer we implement exercises where they take a deep breath to open their lungs and then cough it out, a way of excreting medications How is good hygiene important in the Excretion process? - Correct answer because pt.'s are excreting drugs through their skin and it can get irritating so that's where we come in and give them a bath/shower Why is breastfeed important in the Excretion process? - Correct answer because you would want the mothers to be cautious about what drugs their putting in their bodies and now about to feed it to the baby How can the GI Tract influence excretion? - Correct answer laxatives, enemas What do pharmacodynamics do? - Correct answer drug alter the functions of tissues and organs Pharmacodynamics able to show positive actions by? - Correct answer - protecting cells - promoting cell function - accelerating or slowing cell processes - replacing a substance that is missing When pharmacodynamics is in place, how do the patients react? - Correct answer they responses vary and each pt. responds differently What are the types of drug actions? - Correct answer therapeutic effects, side effects, adverse effects, toxic effects, idiosyncratic reactions, and allergic reactions What are the therapeutic effects? - Correct answer intended, know why the drug is given to pt. What are side effects? - Correct answer unintended, secondary effects - example: dry mouth, nausea, dry cough What are adverse effects? - Correct answer severe, unintended responses to the drug - example: circulatory collapse, coma, seizures What are toxic effects? - Correct answer a build up of drug, occurs after taking for a while - example: older adults prone to this What is idiosyncratic reactions? - Correct answer when a pt. overracts or under reacts to a drug - example: benedryl What is allergic reactions? - Correct answer unpredictable, can be sensitized after initial dose, or after repeated exposure What are some mild allergic reactions? - Correct answer - urticaria - rash - pruritus - rhinitis - lacrimal tearing What are some moderate allergic reactions? - Correct answer - nausea/vomiting - diarrhea - wheezing - dyspnea - angioedema What are some severe allergic reactions? - Correct answer anaphylactic shock: an EMERGENCY - edema of larynx - severe wheezing - SOB - hypotension What are drug interactions? - Correct answer one drug changes effects of another, or both What kind of response and effect do drug interaction have? - Correct answer synergistic responses and inhibitive effects What is Iatrogenic effects? - Correct answer drug produces a condition or disease - example: hearing loss (ototoxic), hepatic failure, cancer What are the actions of drugs on the body? - Correct answer - onset of action What should a drug order consists of? - Correct answer must contain drug, dose, route, time, along with date and time ordered - example: 10/5/18 Lanoxin 0.25mg po q day 0820 Dr. Smith What are verbal orders? - Correct answer - nurses writes and signs more - MD must sign within 24 hrs. -- example: v/o S. Randol RN/Dr. W. Smith - make sure order is clear - if in doubt, get it verified by the MD Do student nurses take verbal orders? - Correct answer NO What are the types of orders? - Correct answer - standing or routine orders - PRN orders - single dose orders - STAT orders What is a standing or routine order? - Correct answer - termination date - carry out the order until stopped - routine orders on file for certain types of pt.s What is PRN orders? - Correct answer - "as needed" - lets the nurse use judgements -- example: Ibuprofen 200mg 1-2 tabs q 3-4 hours prn HA What is single dose orders? - Correct answer (one time only) - ordered to be given once - common for pre-op orders or diagnostic tests What are STAT orders? - Correct answer - usually single dose, but for immediate administration - for emergency situations What is the pharmacists role? - Correct answer - prepares and distributes - assesses medication plan - determines if Rx valid and reasonable - fills medications accurately - provide information about medications What are some conditions that can change the status of a pt's orders? - Correct answer surgery, NPO (nothing by mouth), and NG tubes What is the nurses role? What is the nurse accountable for knowing? - Correct answer - what medication ordered - why it is ordered for the pt. - therapeutic/non-therapeutic effects - usual dose ranges - usual route - any nursing considerations - pt's level of knowledge What is the 5 rights of administration? - Correct answer RIGHT patient, drug, dose, route, time, documentation What is the nurse accountable for? - Correct answer - monitoring for effectiveness - adverse, side, toxic, allergic effects - teaching the pt./family about the medications When using these drugs that look and sound alike, you should use caution. What are the drugs? - Correct answer - Accupril - Accutane - Colace - Calan - Minoxidil - Monopril - Nitroderm - Nicoderm - Paxil - Plavix - Kaopectate - Kayexalate What is the nursing diagnosis for pharmacotherapeutics? - Correct answer - High Risk for injury: trauma - (HR) Ineffective Health Management - Noncompliance