AND ANSWERS COMPLETE AND VERIFIED.
Pneumonia, Influenza, Whooping cough, and Bacterial meningitis require
____________ precautions
droplet
Tuberculosis (TB), Varicella, Measles, and COVID-19 require __________
precautions
airborne
the state of structurally intact and physiologically functioning epithelial
tissues such as the integument (including the skin and subcutaneous
tissue) and mucous membranes
tissue integrity
Functions of epithelial cells include ______________
protection, absorption, secretion, excretion
Poor peripheral perfusion, Malnutrition or obesity, Dehydration or edema,
Impaired mobility, and Immunosuppression are health conditions
associated with ______________
impaired tissue integrity
The Braden Scale, Repositioning every 2 hours, and off-loading pressure
are methods used in ______________
dermal ulcer prevention
Adequate nutrition to prevent impaired tissue integrity include
_____________
,protein, vitamin A, and vitamin C
The ____________ phase of wound healing lasts 3 to 5 days, and
homeostasis develops; macrophages remove debris
inflammatory phase
The __________ phase of wound healing lasts 5 to 21 days and new blood
vessels and tissue are formed.
granulation phase
The _________ phase of wound healing lasts for months, collagen fiber is
remodeled; and scar formation and contraction occur.
maturation phase
Wound Bed, Wound Edge, and Periwound Skin are documented for
______________
wound healing
wound tissue that is beefy red or deep pink and is new vascular tissue
granulation
wound that is deep pink to pearly pink, light purple, or lavender in color.
New protective tissue
epithelialization
the yellow/white/or grayish, wet, and soft tissue in the wound
slough
the ooze, puss, or secretions of a wound
exudate
black, hard, or leathery tissue in/on a wound
,necrotic tissue
A wound without tissue loss
Examples: Clean laceration, surgical incision
- Can be closed with sutures, staples, or adhesives
- Approximated: Wound edges are brought together with the skin layers
lined up in the correct anatomic position
- Dead space is eliminated
- Shortens wound healing
Primary (first) intention wound healing
Wounds with a cavity
Examples: Chronic pressure ulcer, venous stasis ulcer
- Requires gradual filling in of the dead space with connective tissue
- Prolongs healing process
Secondary intention healing
Wounds intentionally left open for some time
Examples: Wounds at high risk for infection, surgical incisions into a non-
sterile body cavity, or contaminated traumatic wounds
- Dead tissue and exudate are removed, inflammation subsides, and the
wound will be closed by first intention
- Delayed primary closure
Tertiary (third) intention healing
Normal flora gain entry into the dermis through a break in the skin
- Usually Staphylococcus aureus
- Acute bacterial infection of the dermis
cellulitis
- Warmth, redness, edema, and inflammation at the site
- Increased WBC's
, - Lymphadenopathy
- Fever and chills
Are clinical manifestations of ...
cellulitis
Adequate rest, Elevation of affected area above heart to reduce swelling,
Infection control measures, Administer prescribed antibiotics, Supportive
care, Warm compresses 4x/day, Elevation of affected limb, Bed rest,
Advise client about possible complications, Teach client when to contact
provider
Planning nursing interventions for cellulitis
Inflammation of the skin, red and itchy rash (allergic or irritant)
dermatitis
Inflammation of the skin from irritants, Regular exposure to moist
environment, Burns, Exposure to acids, soaps, detergents, perfumes,
poison plants, metals are causes of _____________
irritant contact dermatitis
- Intact Skin
- Reversible
- Unblanchable
- Harder to tell on darker skin
- May have a slight color difference and warmer temperature
What stage pressure ulcer?
Stage 1 pressure ulcer
- Partial thickness loss of dermis
- May also present as an intact or open/ruptured serum or blood-filled
blister