adult/elder quiz one - chapter three

inflammation

the body’s response to cell injury; removes damaged/necrotic tissue, neutralize the cause of injury, create an environment for healing

local signs of inflammation

redness, heat, pain, swelling, loss of function

systemic signs of inflammation

fever, increased WBC count, malaise (discomfort), increased pulse/RR, nausea/anorexia

acute inflammation

short-term; usually resolves within 2-3 weeks; usually no residual damage

subacute inflammation

similar to acute inflammation; lasts longer

chronic inflammation

lasts weeks, months, or years

regeneration

lost cells/tissues are replaced with the same type of cells

repair

damaged tissue is replaced with new tissue and usually results in scar formation

healing - primary intention

wound edges are together (surgical incision)

healing - secondary intention

large tissue loss; edges cannot be brought together (might need to be filled); more exudate and granulation tissue

healing - tertiary intention

wound is closed later after granulation develops

nursing wound care

clean (remove dirt/debris), control infection (use infection-control measures), protect (prevent additional trauma)

pressure injuries

damage to the skin and/or the underlying tissue over a bony prominence, common with bed-ridden clients who are not turned adequately or from a medical device; most common areas: lower back, sacrum/coccyx, hip bones, shoulder area/elbows

braden scale

tool to screen client’s risk of skin breakdown; SCORING: 15-16 = mild risk, 12-14 = moderate risk, <11 = severe risk

pressure injury: stage one

1 layer of damage (epidermis); red skin that is NON blanchable and NOT broken

pressure injury: stage two

2 layers of damage; open wound; affecting both the epidermic and dermis; wound bed is red/pink and shiny/dry

pressure injury: stage three

3 layers of damage (epidermis, dermis, and subcutaneous); full thickness skin loss into the subcutaneous fat; wound may tunnel under the edges of the wound bed

pressure injury: stage four

4 layers of damage; extends all the way down into muscle, bone, or tendon.

pressure injury: unstageable

eschar and slough; necrotic dead tissue that cannot be felt

pressure injury: deep tissue

the fatty tissue is injured below the skin (dark purple and sometimes open wound)

eschar

black/brown; dead necrotic tissue

slough

yellow stringy; skin of a chicken

infection pathogens

bacteria, viruses, fungi, protozoa

localized infection

one area of the body

disseminated

spreads to multiple areas

systematic

affects the body as a whole

incidence

NEW cases occurring during a specific time

prevalence

all existing cases at a given time

epidemic

increase in disease within an area

pandemic

disease spreads across large geographic areas/countries/world

standard precautions

used with all patients

transmission-based precautions

used for patients with specific infections

PPE

gloves, gown, facial protection, safe sharps disposal

nursing priorities

hand hygiene, appropriate PPE, safe handling of sharps, prevent transmission, recognize infection early

healthcare-associated infections (HAIs)

infection acquired through exposure to microorganisms in a healthcare setting

examples of HAIs

hospital care, procedures, devices, healthcare exposure

CAUTI

catheter-associated urinary tract infection: tracks infections linked to urinary catheter insertion and maintenance, reflecting nursing adherence to sterile protocols and timely catheter removal

CLABSI

central line-associated bloodstream infection: measures central venous catheter infections, indicating the quailty of line care, dressing cahnges, and maintenance hygiene

SSI

surgical site infection: evaluates post-operative infections and compliance with surgical prevention bundles

VAP

ventilator-associated pneumonia: monitors respiratory infections in ventilated patients related to oral care and positioning protocols

HIV

an RNA virus that uses its RNA to produce DNA, which becomes integrated into the human genome; damages and destroys CD4+ cells, weakening the immune system; vulneratble to opportunistic infections and cancers

HIV transmission

sexual contact with a person with a detectable viral load is the most common route

HIV infection requires contact with infected:

blood, semen, vaginal secretions, breast milk

blood tests

CD4 count, viral load, screening tests to detect HIV antibodies and/or antigens

acute HIV

2-4 weeks; flu-like signs, such as fever, rash, sore throat, fatigue, and swollen lymph nodes

asymptomatic HIV

usually no signs or feelings; may have generalized symptoms like fever, headache, fatigue

symptomatic HIV

occurs when the immune system is badly damaged; full-blown symptoms; the body cannot fight off basic germs

AIDS

developed after having HIV; CD4 fall below 200 cells

antiretroviral therapy (ART)

decrease viral load, maintain CD4 count, delay disease progression

nursing management

assess, promote, teach, encourage, help, support, address