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1. infection: invasion of body tissue by microorganisms with potential to cause disease or illness
2. inflammation: the physiologic response to reduce the effects of what the body perceives as harmful
3. hyperthermia related to infection: the ability to maintain normal body temperature. the invasion of
body tissue by microorganisms with potential to cause disease or illness
4. Classic signs of infection: heat, redness, inflammation, increased exudate
5. pyrexia: raised body temperature; fever
6. inflammation: 1st phase of healing process, bodys protective response to injury/infection/harmful stimuli,
brings fluid (plasma) dissolved substances and blood cells to the interstitial tissue
7. vascular and cellular response: vasodilation
increased permeability
chemical mediators: histamines/prostaglandins/bradykinin
8. serous: clear, watery plasma drainage
9. serosanguinous: pale pink drainage
10. sanguinous: bright red drainage
11. purulent: thick, yellow, green, tan, or brown drainage
12. exudate production: serous, serosanguinous, sanguinous, purulent
13. reparative phase: 1.phagocytosis
2.angiogenesis
3.fibroblast activation
4.granulation tissue forms
5.regeneration
14. Cardinal signs of inflammation: pain, warmth, redness, swelling, loss of function
15. cellulitis: inflammation of subcutaneous tissue
16. priority assessment: cellulitis: vital signs and medical history
laboratory and diagnostic tests
monitor for signs of sepsis
inspect affected area and lymphatic involvement
assess functional status
17. recognize cues: cellulitis: erythema, edema, pain/tenderness, warm to touch
hyperthermia, chills, fatigue/malaise
lymphadenopathy, lymphangitis
elevated WBC, (+) blood culture
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18. Wound Care instructions: 1. wash hands before touching the wound
2. clean the wound gently as instructed
3. watch for infection
4. elevate the area
5. avoid scratching or picking at the wound
6. attend follow up appointments
19. mechanism of fever: pathogens activate leukocytes release cytokines stimulate hypothalamus produce
prostaglandins trigger fever
20. wound healing: final phase of the inflammatory response
normal body response to injury to restore the normal structure and function
two major components: regeneration and repair
21. primary intention: wound is closed with surgical intervention. edges are brought together
best choice for clean, fresh wounds in sufficiently vascularized areas
22. secondary intention: wound is left open and allowed to heal spontaneously
increased scarring
good for contaminated/infected wounds
23. tertiary intention: delayed primary closure
good for wounds which are contaminated/infected initially
24. wound classification by color: red: protect the wound
gentle cleaning if needed
25. wound classification by color: yellow: dressing that absorbs exudate and cleanses the wound
surface
26. wound classification by color: black: debridement of non-viable eschar tissue
27. dehiscence: separation of previously closed wound
28. post op infection: red, painful, hot, fever
29. hypertrophic scar: thick raised scar
30. keloid scar: protrusion of scar tissue
31. wound assessment: coca
length: head to toe
width: side to side
depth: if applicable
32. tunneling: deeper than the visual wound