NSE 211 Final Exam Review Questions
and Answers
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.
infection nsg dx manifested by - answer fever, tenderness, pain @ wound site,
erythema, edema, induration, warmth, elevated WBC, inflamed edges, foul odor,
purulent drainage, delayed healing
life threatening infection S&S - answer - pain
- swelling, induration
- erythema
- wound breakdown
- increased size
- undermining or tunneling
- probing to bone
- anorexia
- flu-like symptoms
- erratic glucose control
- fever
- rigour
- chills
- hypotension
- multi-organ failure
non-limb threatening infection - answer - non-healing
- bright red granulation tissue
- new areas of breakdown/necrosis
- increased exudates
- bridging of soft tissue & epithelium
- foul odor
dehiscence - answer partial or total separation of (skin & tissue) wound layers: when
a wound fails to heal properly.
evisceration - answer *total separation of wound layers*, protrusion of visceral
organs through opening
fistula - answer abnormal passage b/w 2 organs, or an organ & external part of body.
