Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NURS 220 > 220 Midterm > Flashcards

220 Midterm Flashcards

1
Q

Medical Asepsis

A

“Clean Technique”
Reduce & prevent the spread of microorganisms
Use standard precautions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Surgical Asepsis

A

“Sterile Technique”
Procedures to eliminate all microorganisms
Any sterile object or area is considered contaminated when touched by any object that is not sterile

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Principles of Surgical Asepsis

A
  1. Sterile object remains sterile only when touched by another sterile object
  2. Only sterile objects may be placed on a sterile field
  3. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated
  4. A sterile object or field becomes contaminated by prolonged exposure to air
  5. When a sterile surface comes in contact with a wet contaminated surface, the sterile object or field becomes contaminated by capillary action
  6. Fluid flows in the direction of gravity
  7. The edges of the sterile filed or container are considered to be contaminated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Layers of the Skin

A
  1. Epidermis - dead, 0.5-1.0mm
  2. Dermis - vascular, 1.0-4.0mm
  3. Subcutaneous (hypodermis) - provides insulation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Acute Wound

A

A wound that heals in a timely manner (2-8 weeks)
Causes: trauma, surgical incision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Chronic Wound

A

Wound that fails to heal in a timely manner (over 8 weeks)
Causes: vascular compromise, chronic inflammation, repetitive insults to the tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Simple Wounds

A

Straight and in tact
not swollen, red or bruised
Little to no drainage
To change - clean gloves, sterile instruments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Complex Wounds

A

Not held together, not clean
Puss/drainage
To change - sterile gloves, sterile instruments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Primary Intention

A

VERY minor
very fine scar, about 3-7 days to fully heal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Secondary Intention

A

Longer repair
More scarring
Increased risk of infection
ex. burn, pressure ulcer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Tertiary Intention

A

Delayed closure until the risk of infection is gone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Stages of Wound Healing

A
  1. Hemostasis
  2. Inflammatory
  3. Proliferative
  4. Maturation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Hemostasis

A

Occurs within minutes of initial injury
Body sends platelets to the site of injury to aggregate and vasoconstrict blood vessels
Starts clotting cascade at the same time to stabilize the clot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Inflammatory Phase

A

Body’s protective response to injury
Lasts 2-4 days
Histamine released causing vasodilation and WBCs migration (Swelling)
Leukocytes and macrophages inject bacteria, dead cells and debris

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Proliferative Phase

A

Lasts 3-24 days
New blood vessels form (O2 and nutrients)
Collagen starts to contract, decreasing wound bed size and speeds healing
Epidermal cells migrate over the granulation tissue (epithelialization)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Maturation/Remodelling

A

Up to 2 years
Surface of wound may look healed
Collagen production continues, thickening the epithelium and contracting to form a scar
Scar tensile strength increases to 80% of original tissue, but elasticity is limited.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Factors that Affect Wound Healing

A

Lifespan
Nutrition
Lifestyle
Medications
Contamination, colonization and infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Serous

A

Clear, watery plasma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Purulent

A

Thick, yellow/green, tan or brown

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Serosanguinous

A

Pale, red, watery - mixture of clear and red fluid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Sanguinous

A

Bright red - indicates active bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Amounts of Drainage

A

Scant: <5%
Small: 5-25%
Moderate: 25-50%
Large: 50-75%
Saturated: >75%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Basic Wound Cleansing

A

Clean from least to most contaminated (inside-out)
Use gentle friction
Don’t use gauze to clean across incision twice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

REEDA

A

R: Redness
E: Ecchymosis (bruising)
E: Edema
D: Drainage
A: Approximation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

How to Document Wound care

A
  1. What did you do and why
  2. Pain assessment (pre/intra/post)
  3. What dressing you took off the wound (drainage)
  4. Solution used to cleanse (usually saline)
  5. Wound assessment (REEDA)
  6. What dressing you covered wound with
  7. Patient tolerance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Risk factors for surgery

A

age
nutrition
obesity
immunocompetence
Fluid and electrolyte imbalances

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Pre and Post Op Teaching

A

Deep breathing and coughing
Mobilization
Pain management
Anti-embolic stockings
Pneumatic compression stockings
Leg exercises

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Informed Consent

A

procedure explained
risks/benefits
potential outcomes
recovery process and length
alternative treatment options
outcomes if procedure not performed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Common Types of Fractures

A

Closed
Open
Comminuted (fragments)
Displaced
Oblique
Spiral
Impacted
Green stick

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Stages of Bone Healing

A
  1. Hematoma formation
  2. Granulation tissue
  3. Callus formation
  4. Osteoblastic proliferation
  5. Bone remodeling
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Venous thromboembolism (VTE): Deep Vein Thrombosis (DVT)

A

Blood clot in the vein related to one of the endothelial injury, venous statis or hypercoaguability
Symptoms: asymptomatic, calf/groin tenderness, unilateral swelling with warmth, redness or edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Bone or Soft Tissue Injury

A

Open fractures - more at risk of infection
Symptoms: tenderness or pain, redness, swelling, warmth, increased temp and pulse, purulent drainage, increased WBCs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Compartment Syndrome

A

Swelling in a limited space that compresses the muscles, nerves and blood vessels (internal or external pressure)
S&S: Pain, poikilothermia, pallor, paresthesia, paralysis, pulselessness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Fat Embolism Syndrome

A

Fat globules break away from the bone marrow and float into the bloodstream
S&S: hypoxemia, dyspnea and tachypnea, crackles, chest pain, decreased O2 states, petechiae rash in some patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Chronic Complications from Surgery

A

Avascular necrosis (blood supply to bone disrupted causing decreased perfusion and death of bone tissue)
Delayed Union (fracture not healed after 6 months)
Complex regional pain syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are the majority of fractures caused by?

A

MVA or a fall

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Health promotion/teaching about fractures

A

osteoporosis screening
fall prevention
home safety
dangers of substance use and driving
use of helmets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Fracture Assessment: Hx

A
  • cause of fracture
  • events leading up to injury
  • substance use (opioids)
  • occupational/recreational activities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Fracture Assessment: Physical, S&S

A
  • trauma to other systems
  • maintain adequate CSM, good body position
  • pain management
  • complications for early preventions
  • VS and neuro checks
  • Maintain skin integrity
  • Ins and outs/ IV therapy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Fracture Assessment: Neurovascular

A

Color + Temp + Movement + Sensation + Pulses + Capillary Refill = Circulation, Sensation and Movement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Fracture Assessment: Lab and Imaging Assessment

A

Hemoglobin
Hematocrit
ESR
WBC
Serum calcium, and phosphorus
X-rays
CT
MRI’s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Acute Pain

A

ABC’s secondary survey (head to toe), analgesics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Bone Reduction

A

Realignment of bone ends for proper healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Cast Care

A

Used to immobilize complex fractures
- fiberglass
- plaster
- walking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Traction

A

Skin traction uses a boot to realign joint - prevent bone spasms
Screws can be used to reduce fracture and provide bone realignment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

ORIF

A

Open Reduction with Internal Fixation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Internal Fixation

A

Uses pins and plates to keep fracture immobilized

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

External Fixation

A

Allows swelling to reduce or wounds to heal before having closure completed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Fractures: Care coordination and transition management

A

Can the pt go home right now?
Home care management
Self-management education
Health Care resources

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Fractures: Evaluate Outcomes

A

Pain control
Ambulates independently
Free of physiological consequences
Adequate blood flow
Free from infection

51
Q

Hip Fractures

A

Osteoporosis is the biggest risk factor for hip fractures - 30000 per year in Canada

52
Q

Types of Hip fractures

A

Intertrochanteric
Subtrochanteric
Femoral neck
Subcapital
Capital
Intracapsular (in joint capsule)
Extracapsular (outside joint capsule)

53
Q

Hip Fracture Pre-op care

A

ABC’s and head to toe
VS
Neuro checks
IV with analgesic
NPO for surgery
Nay have traction for comfort

54
Q

Hip Fracture post-op care

A

ORIF preferred
pain control
monitor for delirium, malnutrition, UTI, pneumonia, pressure injuries

55
Q

Common post-op complications: CV system

A

hemorrhage - blood loss
Hypovolemia - low blood volume
Hypovulemic shock - inadequate perfusion of tissues
Thrombus/embolus - clot/dislodged clot

56
Q

Common post-op complications: Resp System

A

Atelectasis - collapsed alveoli
Pneumonia - lung infection
Hypoxemia - low O2 in blood
Pulmonary Embolism - clot in lungs

57
Q

Common post-op complications: GI system

A

Paralytic ileus - diminished or absent peristalsis
- abdominal distension
- nausea and vomiting

58
Q

Common post-op complications: GU system

A

Urinary retention
UTI

59
Q

Common post-op complications: Integumentary system

A

wound infection
wound dehiscence (separation of wound edges)
wound evisceration (protrusion of internal organs at suture line)
skin breakdown (pressure injury)

60
Q

Patient Controlled Analgesia (PCA)

A

Self-administration of opioid analgesic
Push a button to release opioid by bolus via IV route
Orders written by anesthesia
Pump set up and monitored by RN’s
Key assessments: RR, sedation level, comfort level, O2 sats q4h

61
Q

Epidural and Anesthetic post-op

A

Injection of anesthetic and narcotic agents into epidural space
Can be continuous infusion and/or pt controlled boluses
Key assessments: HR, RR, BP, sedation level, comfort level, O2 sats, sensory levels, motor function, epidural site q4h

62
Q

Sedation Scale

A

S - normal sleep, easy to rouse
0 - alert
1 - sometimes drowsy
2 - frequently drowsy
3 - somnolent; difficult to rouse

63
Q

Motor Function Scale

A

2 - no weakness
1 - some weakness of legs/feet
0 - unable to move legs/feet

64
Q

Sensory Level

A

Dermatome levels - describe both sides

65
Q

Wound prevention and management cycle

A
  1. assess/re-assess
  2. set goals
  3. assemble the team
  4. establish and implement a plan of care
  5. evaluate outcomes
66
Q

Wound Management - Key factors

A

Wound cleansing
Debridement of healable wound
Moisture balance
elimination of dead space (packing)
thermal insulation
protection of periwound skin

67
Q

Braden Scale

A

Friction/Shear
Sensory Perception
Moisture
Activity
Mobility
Nutrition

68
Q

Pressure injury stage 1

A

intact skin with non-blanching redness

69
Q

Pressure injury stage 2

A

partial thickness loss of dermis, shallow ulcer
red/pink bed
without slough
could be intact or open

70
Q

Pressure injury stage 3

A

Full thickness tissue loss
subcutaneous fat may be visible
bone, tendon, muscle NOT visible
May have undermining/tunnelling
May have odor/drainage

71
Q

Pressure Injury stage 4

A

Full thickness tissue loss
exposed bone, tendon or muscle
slough or eschar may be present
often undermining/tunnelling
possible odor/drainage

72
Q

Pressure Injury Unstageable

A

Full thickness tissue loss
base of ulcer covered by slough or eschar
extent of tissue damage can’t be confirmed

73
Q

MEASURE

A

M: Measure (length, width, depth)
E: Exudate
A: Appearance of wound base (color)
S: Suffering (pain level)
U: Undermining or tunnelling
R: Re-evaluate
E: Edge

74
Q

Suture Removal Steps

A
  1. Clean incision
  2. Grasp knot with forceps and cut opposite the knotted end
  3. remove alternate sutures and then remaining
  4. clean incision
  5. may use steri-strips
  6. Use REEDA to assess wound
75
Q

Wound Irrigation and Packing

A

Clean out wound and fill space
Fluff, don’t stuff
Use MEASURE to assess wound
Wear face shield

76
Q

Tips for Finding a Vein

A

Begin distally
Use non-dominant arm
Should be easily palpable - soft and full
Avoid areas with injury/procedures that were done
Tourniquet is placed 10-15 cm above desired vein

77
Q

Documenting IV Insertion

A
  1. Size of needle/cathalon gauge
  2. Location of Start
  3. Pt tolerance
  4. Anything abnormal
78
Q

How much of body fluid is plasma?

A

3 L

79
Q

How much of body fluid is interstitial fluid (IF)?

A

10 L

80
Q

How much of body fluid is Intracellular Fluid (ICF)?

A

28 L - 67%

81
Q

How much of body fluid is extracellular fluid (ECF)?

A

32% (intravascular 8%, interstitial 24%)

82
Q

How much of body fluid is transcellular?

A

1%

83
Q

Osmolality

A

Total solute concentration in an aq solution

84
Q

Tonicity

A

Cells affected by osmolality of fluid around them

85
Q

What is Normal Saline Solution?

A

Isotonic

86
Q

Hypotonic Solution

A

Conc is greater inside the cell than the solution - causes cell to grow and lyse

87
Q

Hypertonic Solution

A

Conc is greater in solution than cell - causes cell to shrink

88
Q

D

A

Dextrose

89
Q

LR

A

Lactated Ringers

90
Q

W

A

Water

91
Q

NS

A

Normal Saline

92
Q

IV Gravity Lines

A

Harder to manage (manual)

93
Q

IV Pump Lines

A

Has occlusion monitor (easier to manage)

94
Q

Primary IV Lines

A

“Maintenance IV Lines”

95
Q

Secondary IV Lines

A

Attached to primary line

96
Q

Documenting maintenance of IV fluids

A
  1. Type of solution
  2. rate per hour
  3. How many IV’s pt has
  4. IV fluid changes
  5. What you started in the IV
  6. Location of IV
  7. If pt is difficult/tolerance
97
Q

Infiltration

A

IV fluid enters the surrounding space around the venipuncture site

98
Q

Phlebitis

A

Inflammation of the vein

99
Q

Fluid Volume Excess

A

Pt receives too much fluid

100
Q

TF

A

Tubing drop factor (gtts)

101
Q

Microdrip

A

60 gtt/mL

102
Q

Macrodrip

A

Need to check package
10 gtt/mL
15 gtt/mL
20 gtt/mL

103
Q

Calculating Gravity IV Drip Rates

A

(Number of mL to infuse / number of MINUTES to infuse) x TF = gtts/minute

104
Q

Calculating IV drips for Infusions Pumps

A

Total number of mL ordered/Number of HOURS to run = rate in mL/hour

105
Q

Determining hours an IV will run

A

Number of mL ordered/Number of mL/hour = number of hours to run

106
Q

Cardiac Output equation

A

HR x SV = CO

107
Q

Main Function of the Heart

A

Put out adequate volume of blood effectively enough to perfuse entire body

108
Q

Why is HTN the “silent killer”

A

Because its usually asymptomatic until organ disease occurs

109
Q

Hypertension (HTN)

A

Systolic P > 140mmHg
Diastolic P > 90mmHg

110
Q

Pathophysiology of HTN

A

Genetics
Na and H2O retention
Stress and increased SNS activity
Altered Renin-Angiotensin-Aldosterone Mechanism
Insulin resistance and hyperinsulinemia

111
Q

Primary HTN

A

Without an identified cause (90-95%)

112
Q

Secondary HTN

A

With a specific cause (5-10%)

113
Q

Solutions for HTN

A
  1. Assess risk, monitor BP regularly
  2. Encourage lifestyle changes (physical activity, weight reduction, less alcohol, less sodium, stress mgmt, smoking)
  3. Pt adherence to pain
  4. Drug therapy (decrease vascular resistance OR decrease circulating BV)
114
Q

Overall goal for pt’s with HTN

A

To achieve and maintain target BP

115
Q

Most common cause of CAD

A

Atherosclerosis - fat deposits in the inner lining of artery that obstruct circulation - thrombin generated when vessel is damaged

116
Q

Stages of CAD

A
  1. Chronic endothelial injury: damaged endothelium
  2. Fatty streak: lipids accumulate
  3. Fibrous Plaque
  4. Complicated Lesion: Thrombus formation
117
Q

Modifiable risk factors for CAD

A

Elevated serum levels
HTN
Smoking
Obesity
Inactivity
Metabolic syndrome
Diabetes
Stress

118
Q

Chronic stable angina

A

Occurs intermittently
Same onset, duration and intensity
“pressure” or “ache”
3-5 mins

119
Q

Types of Acute Coronary Syndrome

A

Unstable angina
NSTEMI
STEMI

120
Q

Unstable angina

A

New in onset, unpredictable
No ECG changes
Increase in frequency

121
Q

NSTEMI

A

non-ST segment elevation MI:
chest pain (severe)
diaphoresis, cool clammy skin
BP and HR increased initially
Elevation on ECG
Results in partial occlusion of artery

122
Q

STEMI

A

ST segment elevation MI:
chest pain (severe)
diaphoresis, cool clammy skin
BP and HR increased initially
Elevation on ECG
Results in complete occlusion of artery

123
Q

Virchow’s Triad

A

3 main factors that cause a thrombosis
1. Venous Stasis
2. Vascular injury
3. Hypercoaguability

NURS 220 (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions