NSE 211 FINAL EXAM REVIEW QUESTIONS WITH
COMPLETE SOLUTIONS
wound - ANSWER-break in the continuity of body structure, caused by
violence, trauma, or surgery to tissue bodies
ex; of acute wounds - ANSWER-surgical incisions, traumatic wounds,
lacerations, burns
ex; of chronic wounds - ANSWER-PI, diabetic ulcers, malignant
acute wound - ANSWER-wound that proceeds through an orderly &
timely reparative process --> sustained restoration of anatomical &
functional integrity
phases of wound healing - ANSWER-1) inflammatory phase
2) proliferative phase
3) remodelling phase
what's a part of the proliferative phase? - ANSWER-proliferation,
granulation & contraction
what happens during inflammatory phase? - ANSWER-1) hemostasis.
(vasoconstriction)
,2) platelets + fibrin forms, clot formation
3) histamina, vasodilation, increased capillary permeability, erythema,
swelling & warmth
what happens day 1-3 inflammatory phase? - ANSWER-neutrophils
released to injury site, phagocytosis of debris beings.
what happens during day 3-24 of proliferative phase? - ANSWER-1)
granulation tissue appears in wound
2) contraction of wound edges
3) resurfacing by epithelialization --> dermal regen.
4) vascular bed reestablished
what happens during day 24-2 yrs of remodelling phase? - ANSWER-1)
collagen fibers reorganize & remodel
2) permanent scar
3) attains 80% of original strength
Primary intention healing - ANSWER-wound that is closed by suture or
wound closers & healing occurs by collagen synthesis; lower risk of
infection, and heals quickly w/ minimal scarring.
secondary intention healing - ANSWER-wound edges are not
approximated. heals by granulation tissue formation, wound contraction
& epithelialization.
,has a prolonged phase of inflammation due to increased time needed for
phagocytosis of necrotic tissue.
tertiary intention healing - ANSWER-wound is left open for several days
as it could be contaminated. has an increased risk of infection, so closure
of wound is done later until risk of infection is resolved.
why is the wound kept open for tertiary healing? - ANSWER-to allow
exudate to drain, prevent the spread of deep infection & aiding
granulation.
medical asepsis - ANSWER-aka, *clean technique*.
includes procedures used to reduce & prevent the spread of
microorganisms
ex; of medical asepsis - ANSWER-hand washing, clean gloves, cleaning
environment routinely.
ex; of surgical asepsis - ANSWER-aka *surgical technique*.
requires more stringent techniques, *eliminating all microorganisms*.
when do you use surgical asepsis? - ANSWER-when a patient's kin is
broken, or if the nurse performs an invasive procedure in a body cavity
that is normally free of microorganisms.
ex; of surgical asepsis procedures - ANSWER-- protective clothing
- opening sterile packages
, - sterile field
- pouring sterile solns
- surgical hand scrub
- gowning & gloving
Principles of Surgical Asepsis - ANSWER-- *a sterile object remains
sterile only when touched by another sterile object*
- a sterile object or field out of range of vision or an object held below a
person's waist is contaminated
- a sterile objective or field becomes contaminated by prolonged
exposure to air.
complications of wound healing - ANSWER-hemorrhage, infection,
dehiscence, evisceration, fistula formation
hemorrhage nsg dx d/t - ANSWER-slipped suture, dislodged clot,
infection, or eroded blood vessel
hemorrhage nsg dx manifested by - ANSWER-- external-saturated
sanguinous dressings
- internal-distension of body part
- change in drain output
- signs of hypovolemic shock
infection nsg dx d/t - ANSWER-- exposure to bacteria, contaminated or
trauma wound shows S&S, surgical post-op infection.
COMPLETE SOLUTIONS
wound - ANSWER-break in the continuity of body structure, caused by
violence, trauma, or surgery to tissue bodies
ex; of acute wounds - ANSWER-surgical incisions, traumatic wounds,
lacerations, burns
ex; of chronic wounds - ANSWER-PI, diabetic ulcers, malignant
acute wound - ANSWER-wound that proceeds through an orderly &
timely reparative process --> sustained restoration of anatomical &
functional integrity
phases of wound healing - ANSWER-1) inflammatory phase
2) proliferative phase
3) remodelling phase
what's a part of the proliferative phase? - ANSWER-proliferation,
granulation & contraction
what happens during inflammatory phase? - ANSWER-1) hemostasis.
(vasoconstriction)
,2) platelets + fibrin forms, clot formation
3) histamina, vasodilation, increased capillary permeability, erythema,
swelling & warmth
what happens day 1-3 inflammatory phase? - ANSWER-neutrophils
released to injury site, phagocytosis of debris beings.
what happens during day 3-24 of proliferative phase? - ANSWER-1)
granulation tissue appears in wound
2) contraction of wound edges
3) resurfacing by epithelialization --> dermal regen.
4) vascular bed reestablished
what happens during day 24-2 yrs of remodelling phase? - ANSWER-1)
collagen fibers reorganize & remodel
2) permanent scar
3) attains 80% of original strength
Primary intention healing - ANSWER-wound that is closed by suture or
wound closers & healing occurs by collagen synthesis; lower risk of
infection, and heals quickly w/ minimal scarring.
secondary intention healing - ANSWER-wound edges are not
approximated. heals by granulation tissue formation, wound contraction
& epithelialization.
,has a prolonged phase of inflammation due to increased time needed for
phagocytosis of necrotic tissue.
tertiary intention healing - ANSWER-wound is left open for several days
as it could be contaminated. has an increased risk of infection, so closure
of wound is done later until risk of infection is resolved.
why is the wound kept open for tertiary healing? - ANSWER-to allow
exudate to drain, prevent the spread of deep infection & aiding
granulation.
medical asepsis - ANSWER-aka, *clean technique*.
includes procedures used to reduce & prevent the spread of
microorganisms
ex; of medical asepsis - ANSWER-hand washing, clean gloves, cleaning
environment routinely.
ex; of surgical asepsis - ANSWER-aka *surgical technique*.
requires more stringent techniques, *eliminating all microorganisms*.
when do you use surgical asepsis? - ANSWER-when a patient's kin is
broken, or if the nurse performs an invasive procedure in a body cavity
that is normally free of microorganisms.
ex; of surgical asepsis procedures - ANSWER-- protective clothing
- opening sterile packages
, - sterile field
- pouring sterile solns
- surgical hand scrub
- gowning & gloving
Principles of Surgical Asepsis - ANSWER-- *a sterile object remains
sterile only when touched by another sterile object*
- a sterile object or field out of range of vision or an object held below a
person's waist is contaminated
- a sterile objective or field becomes contaminated by prolonged
exposure to air.
complications of wound healing - ANSWER-hemorrhage, infection,
dehiscence, evisceration, fistula formation
hemorrhage nsg dx d/t - ANSWER-slipped suture, dislodged clot,
infection, or eroded blood vessel
hemorrhage nsg dx manifested by - ANSWER-- external-saturated
sanguinous dressings
- internal-distension of body part
- change in drain output
- signs of hypovolemic shock
infection nsg dx d/t - ANSWER-- exposure to bacteria, contaminated or
trauma wound shows S&S, surgical post-op infection.
