Nursing 220 Midterm
Chain of infection - answer1. Infectious agent
2. Reservoir
3. Portal of exit
4. Mode of transmission
5. Portal of entry
6. Host
Nosocomial infection - answer Hospital acquired infection. Influenced by therapy
received, length of stay, type and number of procedures, and direct contact. Common
sites inlcude: wounds, urinary tract, respirator tract, or blood stream.
Asepsis - answer Absence of pathogenic disease producing microorganisms (medical
or surgical).
Medical asepsis - answer Reduce and prevent spread of microorganisms (clean).
Surgical asepsis - answer Eliminate all microorganisms. Contaminated when touched
with anything non-sterile (sterile).
Tool for assessing simple wounds - answerRedness, Ecchymosis, Edema, Drainage,
Approximation (REEDA).
Types of drainage - answerSerous: clear, watery plasma.
Purulent: thick, green, yellow, brown, often odorous and indicates infection.
Serosanguineous: pale, red, watery, mixed fluid.
Sanguineous: bright red, indicates active bleeding.
Wound cleansing - answerLeast to most contaminated (incision outwards), gentle
friction, one swipe per gauze.
Factors affecting wound healing - answer-Nutrition
-Lifespan
-Lifestyle
-Medications
-Infection
Documentation for dressing change - answer-What you took off
-REEDA
-What you put on
-Pain assessment pre, intra, post
, Analgesics - answer1. non-steroidal anti-inflammatory drugs
2. opioids
3. co-analgesics (adjuvants)
Patient controlled analgesic - answer-Local anaesthetic infusion pump.
-Topical analgesic and anaesthetic
-Sucrose (infants)
Local anaesthesia - answerCreates loss and sensation to a localized body part.
Regional anaesthesia - answerUsed for deeper structures of the body as it blocks a
group of sensory nerve fibers.
Epidural anesthesia - answerControls pain without the serious side effects of narcotics.
Stages of pressure ulcers - answerStage 1: only the epidermis affected.
Stage 2: invades the dermis.
Stage 3: invades the subcutaneous tissue layer.
Stage 4: invades the connective tissue.
Unstageable: cannot stage because of lack of visibility.
Risk factors for pressure ulcers - answer-Impaired senses
-Impaired mobility
-Alteration in LOC
-Shear
-Friction
-Moisture
-Nutrition
-Tissue perfusion
-Infection
-Pain
-Age
Braden Scale - answerScale used to indicate risk for pressure ulcers. Scored from 6-23,
lower score is higher risk. Categories include senses, moisture, activity, mobility,
nutrition, and friction/shear.
Wound - answerDisruption in integrity and function of tissues.
Acute wound - answerWound with sustained restoration.
Chronic wound - answerWound where healing is impeded.
Healing process - answerPrimary: wound closed with sutures.
Seconday: wound closes naturally.
Tertiary: wound is left open; patient returns in 3-4 days for cleaning and closure.
Chain of infection - answer1. Infectious agent
2. Reservoir
3. Portal of exit
4. Mode of transmission
5. Portal of entry
6. Host
Nosocomial infection - answer Hospital acquired infection. Influenced by therapy
received, length of stay, type and number of procedures, and direct contact. Common
sites inlcude: wounds, urinary tract, respirator tract, or blood stream.
Asepsis - answer Absence of pathogenic disease producing microorganisms (medical
or surgical).
Medical asepsis - answer Reduce and prevent spread of microorganisms (clean).
Surgical asepsis - answer Eliminate all microorganisms. Contaminated when touched
with anything non-sterile (sterile).
Tool for assessing simple wounds - answerRedness, Ecchymosis, Edema, Drainage,
Approximation (REEDA).
Types of drainage - answerSerous: clear, watery plasma.
Purulent: thick, green, yellow, brown, often odorous and indicates infection.
Serosanguineous: pale, red, watery, mixed fluid.
Sanguineous: bright red, indicates active bleeding.
Wound cleansing - answerLeast to most contaminated (incision outwards), gentle
friction, one swipe per gauze.
Factors affecting wound healing - answer-Nutrition
-Lifespan
-Lifestyle
-Medications
-Infection
Documentation for dressing change - answer-What you took off
-REEDA
-What you put on
-Pain assessment pre, intra, post
, Analgesics - answer1. non-steroidal anti-inflammatory drugs
2. opioids
3. co-analgesics (adjuvants)
Patient controlled analgesic - answer-Local anaesthetic infusion pump.
-Topical analgesic and anaesthetic
-Sucrose (infants)
Local anaesthesia - answerCreates loss and sensation to a localized body part.
Regional anaesthesia - answerUsed for deeper structures of the body as it blocks a
group of sensory nerve fibers.
Epidural anesthesia - answerControls pain without the serious side effects of narcotics.
Stages of pressure ulcers - answerStage 1: only the epidermis affected.
Stage 2: invades the dermis.
Stage 3: invades the subcutaneous tissue layer.
Stage 4: invades the connective tissue.
Unstageable: cannot stage because of lack of visibility.
Risk factors for pressure ulcers - answer-Impaired senses
-Impaired mobility
-Alteration in LOC
-Shear
-Friction
-Moisture
-Nutrition
-Tissue perfusion
-Infection
-Pain
-Age
Braden Scale - answerScale used to indicate risk for pressure ulcers. Scored from 6-23,
lower score is higher risk. Categories include senses, moisture, activity, mobility,
nutrition, and friction/shear.
Wound - answerDisruption in integrity and function of tissues.
Acute wound - answerWound with sustained restoration.
Chronic wound - answerWound where healing is impeded.
Healing process - answerPrimary: wound closed with sutures.
Seconday: wound closes naturally.
Tertiary: wound is left open; patient returns in 3-4 days for cleaning and closure.
