Nursing Level I

  1. Infection
    invasion of body tissue by microorganisms and their growth there
  2. Disease
    detectable alteration in normal tissue function
  3. Communicable disease
    if the infectious agent can be transmitted to an individual by direct or indirect contact or as an airborne infection
  4. Pathogenicity
    ability to produce disease
  5. Asepsis
    freedom from disease-causing microorgansims
  6. Sepsis
    state of infection and can take many forms, including septic shock
  7. Local Infection
    limited to the specific part of the body where the microorganisms remain
  8. Systemic Infection
    if the microorganisms spread and damage different parts of the body
  9. Bacteremia
    bacteria in the blood
  10. Septicemia
    bacteremia spreads throughout systems
  11. Nosocomial Infections
    classified as infections that originate in the hospital
  12. Iatrogenic Infections
    direct result of diagnostic or therapeutic procedures
  13. Chain of Infection x6
    • 1. etiologic agent/microorganism
    • 2. reservoir/place where organism naturally resides
    • 3. portal of exit from the reservoir
    • 4. mode/method of transmission
    • 5. portal of intry into host
    • 6. susceptibility of host
  14. Direct Transmission
    immediate and direct transfer of microorganisms from person to person
  15. Indirect Transmission
    • vehicle-borne
    • vector-borne
  16. Airborne Transmission
    involves droplets or dust
  17. Inflammation
    • local/nonspecific defensive response to the tissues to an injurious or infectious agent
    • pain
    • swelling
    • redness
    • heat
    • impaired function of part
  18. Granulation Tissue
    fragile, gelatinous tissue, appearing pink or red because of the new capillaries
  19. Pressure Ulcers
    consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement
  20. Reactive Hyperemia
    when pressure ir relieved the skin takes on a bright red flush
  21. Vasodilation
    The enlarging of vessels to allow more blood flow more quickly
  22. Friction
    force acting parallel to the skin surface
  23. Shearing force
    combination of friction and pressure
  24. Immobility
    reduction in the amount and control of movement a person has
  25. Maceration
    tissue softened by prolonged wetting or soaking
  26. Excoriation
    area of loss of the superficial layers of the skin
  27. Primary Intention Healing
    occurs where the tissue surfaces have been approximated and there is minimal or no tissue loss
  28. Secondary Intention Healing
    extensive and involves considerable tissue, and in which the edges cannot or should not be approximated
  29. Tertiary Intention
    wounds that are left open for 3-5 days to allow edema or infection to resolve or exudate to drain and then closed with sutures, staples, or adhesive skin closures
  30. Proliferative Phase
    second phase in healing, extends from days 3/4 to day 21 post injury, fibroblasts begin collagen formation
  31. Eschar
    dried plasma proteins and dead cells - usually black
  32. Maturation Phase
    21days-few years fibroblasts continue to synthesize collagen, more orderly matrix, remodeled wound
  33. Keloid
    hypertrophic scar, abnormal amount of collagen laid down to form healing scar
  34. Serous exudate
    chiefly of serum, watery
  35. Purulent exudate
    thicker including pus, leukocytes, liquified dead tissue debris,  dead and living bacteria
  36. Sanguineous exudate
    large amounts of red blood cells indicating damage to capillaries, bleeding is a bad sign
  37. Dehiscence
    partial or total rupturing of a sutured wound
  38. Evisceration
    protrusion of internal viscera through an incision
  39. Debridement
    removal of the necrotic tissue
  40. Mobility
    ability to moove freely, easily, rhythmically, and purposefully in the environment
  41. Range of Motion
    of a joint is maximum movement that is possible
  42. Proprioception
    awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance fo objects in relation to the body
  43. Osteoporosis
    condition in which the bones become brittle and fragile due to calcium depletion
  44. Atrophy
    decrease in muscle size
  45. Contracture
    permanent shortening of the muscle
  46. Foot Drop
    stronger muscle dominates weaker muscle repetitively
  47. Orthostatic hypotension
    immobility causes dilation of vessels which leads to serous fluid seeping into interstitial tissues
  48. Thrombus
  49. Embolus
    when a thrombus comes loose and obstructs circulation elsewhere
  50. Mobility
    ability to move freely, easily, rhythmically, and purposely in the environment, is an essential part of living
  51. Proprioception
    your awareness of position, posture, movement of body, each affecting the other
  52. Joint movements
    • Synostatic
    • Cartilaginous
    • Fibrous
    • Synovial
  53. Immobility
    • inability to move about freely
    • Causes
    • - pain
    • - bed rest
    • - immobiliation of limbs
    • - LOC: Head injury/CVA
    • - Chronic Illness
    • - Psychological
    • - Medications
  54. Immobility Immediate Outcomes
    • muscular deconditioning after 24 hours
    • decreased cardiac output
    • decreased size of muscle fibers
    • nerve damage
    • psychological
    • death
    • blood clot
  55. Cardiovascular Effects of Immobility
    • venous stasis-blood clotting, pooling in legs
    • increased cardiac workload
    • decreased fluid volume (dehydration & edema)
    • Thrombus/Embolus formation
    • orthostatic hypotension
    • decreased autonomic response
  56. DVT sign and symptom
    • sudden swelling of leg
    • redness or discoloration
    • warmth
    • pain w/ activity and constant
    • low-grade fever
    • increased heart rate
    • Homan's sign
  57. Pulmonary Embolism (PE)
    • SOB
    • chest pain
    • coughing w/ bloody mucus/sputum
    • lack of circulation in hands and feet
  58. DVT Risk Factors
    • +40
    • immobility, paralysis
    • stroke, previous DVT
    • Cancer and treatment
    • cardiac disease
    • surgery
    • trauma
    • obesity
    • indwelling IV catheter
    • infection
    • hypercoagulable states (INR lab)
  59. DVT prophylaxis
    • early mobilization
    • careful monitoring
    • compression stockings
  60. Metabolic Effects of Immobility
    • decreased metabolic rate
    • hypercalcemia
    • negative nitrogen balance-d/tbreakdown of tissue
    • inactivity-leading to weight loss, weakness, muscle loss
  61. Cachexia
    wasting syndrome, loss of weight, d/t muscle atrophy, fatigue, weakness, loss of appetite
  62. Gastrointestinal Effects of Immobility
    • malnutrition -cachexia, disturbance in appetite
    • constipation/impaction
    • diarrhea
  63. Urinary Effects of Immobility
    • urinary stasis- positioning, lack of gravity to empty bladder, decrease intake, hypercalcemia, dehydration
    • renal calculi
    • catheter
  64. Atelectasis
    collapse or closure of lung d/t extremely low gas exchange
  65. Respiratory Effects of Immobility
    • hypostatic pneumonia- increased temp, thick copious secretions, cough, increased pulse, confusion, irritability, disorienttaion, sharp chest pain, dyspnea
    • Atelectasis- cough, chest pain, SOB, low O2, increased HR, fever, no breath sounds over area, decreased chest expansion
    • impaired cough
    • pulmonary inflammation
  66. Musculoskeletal Effects of immobility
    • muscle atrophy
    • contractures
    • osteoporosis
    • impaired gait
    • pathological fractures
    • risk for falls
    • risk for injury
  67. Psychosocial Effects of Immobility
    • behavioral changes- delirium, disorientation, agitation, altered sleep/wake pattern, depression (loss of control)
    • decreased coping ability - fear and anxiety, decreased self concept (distorted), innefective individual coping
  68. Skin Effects of Immobility
    • Impaired skin integrity-immobility, incontinence, emaciation, obesity, age-related skin changes, decreased tissue circulation
    • Turn every 2 hours
  69. Pressure Sores
    • bony prominence with pressure against it for long periods of time
    • decreased circulation-impaired o2 to tissue
    • first sign is redness that will not blanch
    • bed confinement
    • Friction-superficial epidermal layer
    • Pressure Ulcers-pressure point sites
    • Shear Injury-mechanical force
    • Excoriation-scratching, burns, chemicals
    • Maceration-prolonged moisture
  71. Friction injury
    superficial epidermal layer
  72. Pressure Ulcers
    pressure point sites
  73. Shear injury
    mechanical force
  74. Excoriation
  75. Maceration
    prolonged moisture
  76. Stroke
    • Ischemic-artery that supplies blood blocked by a thrombi, 80% of all strokes
    • Hemorrhagic-weakened artery ruptures and causes blood to leak into the brain
  77. Stroke Signs and Symptoms
    • 3 hour window
    • Numbness or weakness in face, arm, leg especially one side of the body
    • First sign=confusion/trouble speaking or understanding
    • Vision impairment
    • Dizziness, difficulty walking, loss of balance or coordination, limb spasticity
    • Severe HA with no known cause
Card Set
Nursing Level I
Skin, Mobility