exam 2 Flashcards
One-time/ on-call order
given only once at a specified time (usually before OR or special procedures)
risk factors for wound development
o Vascular disease
o Diabetes & malnutrition
o Excessive moisture
o Medication
o External forces & advanced age
eschar tissue description
dead black tissue
slough tissue description
yellow\white tissue
granulation tissue description
regeneration of tissue
measuring a wound
o Size (length x width)
o Depth
o Tunneling
o Undermining
wound drainage (exudate)
o Serous- clear, thin & watery
o Serosanguinous- watery, light pink
o Sanguineous- bright red, bloody
o Purulent – thick, opaque, odorous
inflammatory stage of wound healing
o Time of injury- lasts 3-6 days
o Vasoconstriction, fibrin accumulation, clot formation
o WBCs travel to area & macrophages engulf cellular debris
proliferative stage of wound healing
o Next 3-24 days
o Lost tissue is replaced with connective or granular tissue
o Wound edges are contracted to reduce the size of the wound
o Epithelial cells are resurfaced
maturation/ remodeling stage of wound healing
o Starts at day ~21-24
o Strengthening of collagen fibers to create scar tissue
friction vs shear
shear- sliding movement of skin and subcutaneous layer while muscle and bone are stationary
ex. patient sliding down in bed
friction- the force of two surfaces moving across one another
ex. skin being drug across linens
Risk factors for pressure injury
o Advanced age
o Immobility
o Malnutrition
o Decreased perfusion
o Altered sensation
o Decreased LOC
o Exposure to moisture/ friction/ shear/ pressure
nursing interventions for pressure injuries
o Frequent position changes (q2h)
o Elevate HOB no more than 30°
o 30° side-lying position
o Positioning/ pressure-relieving aids
stage 1 pressure injury
Non-blanchable erythema with intact skin
stage 2 pressure injury
Partial-thickness skin loss with dermis exposed
stage 3 pressure injury
Full-thickness skin loss visible adipose tissue
stage 4 pressure injury
Full-thickness skin and tissue loss - bone or muscle visible
unstageable pressure injury
Obscured full-thickness skin and tissue loss (no determination of stage bc eschar or slough obstructs the wound bed)
Deep Tissue Pressure Injury
persistant nonblachable, deep red, maroon, or purple discoloration
elements of the Braden scale? If a patient has a low scoring is that good or bad?
sensory, moisture, activity, mobility, nutrition, friction and shear
Low score is good, they are at no risk
nursing interventions for decreased sensory preception
-Provide pressure-redistribution surface.
-Be sure to include protection for pressure points from medical devices such as oxygen tubing, feeding tubes, and casts
nursing interventions for moisture
-Following each incontinent episode, clean area with no-rinse perineal cleaner and protect skin with moisture-barrier ointment.
-Keep skin dry and free of maceration.
-Turn patient off at-risk areas often.
nursing interventions for friction and shear
-Reposition patient using drawsheet or a transfer board surface.
-Provide trapeze to facilitate movement in bed.
-Support surfaces
-Position patient at 30-degree lateral turn and limit head elevation to 30 degrees.
nursing interventions for decreased activity/ mobility
-Establish and post individualized turning schedule (bed bound q2h; chair bound q1h)
-Use positioning devices (pillows, foam wedges, or pressure reducing boots) to keep pressure of bony prominences
nursing interventions for poor nutrition
-Provide adequate nutritional and fluid intake; help with intake as necessary.
-Consult dietitian for nutritional assessment and recommended nutrients.
factors that affect wound healing
o Nutrition
o Tissue perfusion
o Presence of infection
o Advanced age
o Impaired oxygenation
o Smoking
healing process: Primary intention
o Edges approximated, little tissue loss
o Heals rapidly, low risk of infection
o Ex. closed surgical incision with sutures, laceration with glue or sutures
healing process: Secondary intention
o Some loss of tissue
o Wound edges widely separated/ not approximated
o Longer healing time, increased risk of infection
o Ex. Pressure injury, burns
Surgical debridement
is the process of surgically removing dead tissue and other debris that can cause infection. During this procedure, dead tissue and accumulated debris (also called biofilm) are removed with a scalpel or scissors.
Biological debridement
Various enzymatic agents (such as collagenase, papain (papaya extract), and bromelain (pineapple extract) can be applied to wounds to clear dead tissue and debris. Larvae therapy can be used for debridement of chronic wounds when surgical debridement is not an option.
Wound Irrigation
removes surface materials and decreases bacterial levels in the wound. Most often, a 0.9% sodium chloride solution is used to irrigate wounds.
allow solution to flow from least contaminated to most contaminated
types of wound drains
Penrose, portable would bulb suction device, large bottle drain, circular portable wound suction
Complications of wound healing
o Local/systemic Infection
o Surgical site infections
o Hemorrhage
o Dehiscence and evisceration
o Fistula formation
Dehiscence
Partial or complete separation of the tissue layers during the healing process (usually a surgical wound)
Evisceration
Total separation of tissue layers with protrusion of visceral organs through the incision, medical emergency!
Management of Dehiscence & Evisceration
o Low Fowler’s position
o Sterile saline-soaked gauze over tissue
o Prep client for OR contact surgical team,
o Keep client NPO, monitor vital signs, 2 IVs, notify supervisor
Sleep cycle: Stage 1 (Non-rapid eye movement)
o Very light sleep
o Lasts 1- 5 minutes
o Loss of awareness of surroundings
o Alpha waves dominate over beta waves
o Normal breathing and skeletal muscle tone
Sleep cycle: Stage 2 (NREM)
o Deeper sleep
o Lasts 10-20 min; progressively lengthens
o More difficult to awaken
o Increased relaxation
Sleep cycle: Stage 3 (NREM)
o Deepest sleep
o delta wave
o Lasts approximately 40 minutes
o Psychological rest and restoration; repair of muscle, tissue and bone; reduced sympathetic activity
Sleep cycle: Stage 4 (Rapid eye movement)
o Includes REM (dreaming stage)
o Loss of muscle tone
o Breathing irregular/ erratic, HR elevated
o Typically begins 90 minutes after falling asleep, lasts 10 minutes, will become longer as night progresses
o Cognitive restoration
Benefits of Sleep
o Repairs muscles, tissue, and bone
o Strengthens immune system
o Weight loss
o Reduces risk of type 2 diabetes
o Improved concentration, mood, memory, and productivity
o Improves reaction time, hand-eye coordination, strength, and power
What are some interventions to promote healthy sleep?
o Avoid caffeine, alcohol, nicotine, and stimulants at least 4-6 hours before bedtime
o Remove unnecessary light and noise
o Establish a bedtime routine; go to bed and wake up at the same time
o Keep room dark, quiet, and at a comfortable, cool temperature
o Go to bed only when tired; If not asleep in 20 minutes, get out of bed (read, listen to music)
o Avoid exercise at least 3 hours before bedo Remove TV and work items from bedroom if possible
o Keep naps short and early in the day (before 3 pm)
Peak level of medication
when a drug is at it highest concentration (not necessarily at its most therapeutic level)
Trough level of medication
lowest level of drug concentration
Therapeutic range of medication
level of drug that is most effective; above the minimally
effective dose and below the toxic dose
Half life of medication
amount of time it takes for half of the medication to be eliminated from
the body
Therapeutic effect of medication
expected and desired effect or response of a drug
Adverse effect of medication
undesired effect of a drug; may be expected or unexpected
Rights of Medication Administration
-Right dose
-Right route
-Right time
-Right individual (patient)
-Right medication
-Right evaluation
-Right client education
-Right assessment
-Right to refuse
-Right documentation
When do you read and verify the medication label?
o Before removing medication from the container
o When removing medication from the container
o In the presence of the client before administering medication
nursing responsibilities- controlled substances
o Documentation:
o Name of client, amount of med given, time, name of dr, name of nurse; if any waste- second RN signs off
o High alert medication- 2 RNs
Parts of a medication order
o Client’s name
o Date and time
o Drug name (generic)
o Dose
o Route
o Frequency
o Indication for use
o Provider’s signature
Routine order
administered until discontinued or the number of doses/ days expires
PRN order
given only as needed; determined by client request or clinical judgment of nurse
stat order
given immediately and only once (single dose); usually emergency situations
now order
similar to stat order but not as urgent; needed quickly, one time dose but not an emergency (ex. antibiotic)
nursing responsibilities when medication errors occur
o Report all errors; patient safety is top priority
o Check patient’s condition immediately; observe for adverse effects
o Notify nurse manager and primary care provider
o Documentation is required; incident report- factual description of what occurred
intradermal injection
small gauge, short needle 15° angle
subcutaneous
45° or 90° angle
Intramuscular
90° angle
injection sites
-vastus lateralis (thigh)
-ventrogluteal (butt) (Locate the greater trochanter with the heel of the hand and spread the fingers along the iliac crest, inject between the first and second fingers)
-deltoid (arm) (Locate using acromion process)
risk factors for injury
o Age & developmental status
o Mobility and balance
o Knowledge about safety hazards
o Sensory perception; cognitive awareness
o Communication skills
o Home/ work environment
o Physical and psychosocial health status
fall risk factors
Lower body weakness, poor vision, balance issues, foot/ shoe issues, psychoactive medications, dizziness, trip hazards in area
fall reduction programs
Screening, hourly rounding, color-coded wristbands and signs for door, non slip footwear
restraints
o Temporary measure only; only used for protection of client or protection of other clients and staff
o Only be used when other, alternative measures have failed
o Should not interfere with treatment; restrict movement as little as necessary; fit properly; and be easy to remove or change
o No verbal or PRN orders for restraints provider must evaluate patient face to face; orders must be renewed every 4 hours for a max of 24 hours (adults)
seizure
Sudden surge of random electrical activity in the brain
Emergency equipment at the bedside for seizures
oxygen, oral airway, suction equipment
o Clients with known seizure disorders should have padded side rails & IV saline lock in place
during a seizure
stay with client, call for help; maintain airway; note onset & duration; for seizures lasting more than 3-5 min, will need medical intervention; expect client to be drowsy, confused after seizure (postictal); explain what happened & be supportive
fire safety
-Know the location of exits, alarms, and extinguishers AND O2 shut- off valves
-Keep fire doors clear
-Know the evacuation routes (unit and facility)
R.A.C.E acronym
o R: rescue (clients in close proximity- move to safe location)
o A: alarm (activate the fire alarm)
o C: contain (close doors/ windows, turn off oxygen & electrical devices)
o E: extinguish (use fire extinguisher if possible)
signs and symptoms of carbon monoxide poisoning
o Nausea & Vomiting
o Headache, weakness
o Unconsciousness… may result in death
health history-cardiopulmonary
o Chest pain, palpitations, dizziness
o Peripheral swelling
o Number of pillows to sleep
o Medications
o Heart problems
o Family history
o Smoking
o Diet, exercise
o History of blood clots
o Color change of extremities
Cardiopulmonary Inspection
o Respiratory effort, shape/ symmetry of chest, skin color
o Altered LOC, restlessness, cyanosis, nasal flaring, use of accessory muscles
Auscultation of cardiopulmonary
o Equal breath sounds?
o listen for any Crackles, rhonchi, wheezes, stridor
cardiopulmonary Interventions
o Sputum collection
o Chest physiotherapy
o Postural drainage
o Cough & deep breathing
o Incentive spirometer
o Pursed lip breathing
o Huff coughing
o Suctioning
Post-op client oxygenation interventions
early ambulation, incentive spirometer, turn/ cough/ deep breathe
Health promotion
process of enhancing people’s influence over and improvement of their health; helping clients seek a healthier life
Disease prevention
primary and secondary preventative measures to reduce disease and associated risk factors; limit the effects of disease
Wellness
positive state of health; actions taken by the client to achieve the fullest potential of health
Factors influencing an individual’s health status
o Genetics
o Age
o Sex
o ethnicity
o family health history
o lifestyle
Primary disease prevention
Focuses on reducing risk
o Vaccines, smoking cessation, education (seat belts, bike helmets, etc)
Secondary disease prevention
Screenings for disease
o BP measurement, routine blood work, Pap test, mammogram
Tertiary disease prevention
Control of chronic disease that has occurred
o Self-care for diabetics, cardiac rehab
adventitious breath sounds
abnormal breath sounds that you cannot definitively describe
hypoxia
low oxygen supply in the body tissues
hypoxemia
low oxygen levels in the blood
early warning signs of hypoxemia
brain: mental status change
-confusion
irritability
-restlessness
HIGH vital signs:
-respiratory rate, tachycardia, hypertension (systolic over 140)
positioning:
-use of accessory muscles, tripod position, paradoxical breathing
late signs of hypoxemia
low vitals, cyanosis, EKG dysthymias
nasal cannula
-1 to 6 L/min
-concentration of 24% to 44%
-humidified oxygen can help prevent drying of the mucous membranes
simple face mask
-6 to 12 L/min
-oxygen concentrations of 35% to 60%
-contraindicated for clients with carbon dioxide retention
partial rebreather mask
-6 to 11 L/min
-oxygen concentrations of 60% to 90%
-** two way valves, allows for the patient to re-breath some exhaled gases**
-Recommended for short-term use with clients having an acute illness and trauma
-risk of oxygen toxicity and atelectasis
nonrebreather mask
-10 to 15 L/min
- Oxygen concentrations of 80% to 95%
-valves on this mask ensure that the exhaled gases are not returned to the bag 100% oxygen no CO2
- not recommended for clients with COPD or respiratory failure for long-term use due to a risk of oxygen toxicity
used during carbon monoxide poisoning
-Recommended for short-term use with clients having an acute illness and trauma
-risk of oxygen toxicity and atelectasis
venturi mask
-4 to 12 L/min
- Oxygen concentrations of 24% to 60%
-** Provides a precise amount of oxygen (Venturi = very accurate O2)**
aerosol mask and face tent
- Used to deliver nebulized solutions (medications that are changed from a liquid form into a mist, which the patient inhales)- also used for face trauma
Positive airway pressure treatment
CPAP & BIPAP
-CPAP is continuous positive air way pressure
-BIPAP is airway pressure that changes when you inhale and exhale
-BIPAP is recommended for patients who have central sleep apnea brain forgets to breathe when they sleep
-CPAP creates a positive pressure to keep the upper airway open recommended for obstructive sleep apnea
safety education for home oxygen use
-Remember oxygen is combustible! Safety is a big priority in the hospital and at the patients home
-NO smoking! Know where the fire extinguishers are, ensure electric devices are operational, no hazardous chemicals, no free- standing oxygen canisters
Common changes in older adulthood
o Each system generally shows some decline- decreased cardiac output, decreased peripheral circulation, slower reaction time, decreased visual acuity, decreased intestinal motility, decreased muscle strength and tone, etc…
Dementia
-refers to various disorders that progressively affect cognitive functioning
-characterized by memory loss, disorientation, and/ or impaired reasoning, language, judgment
-may involve personality changes & behavioral problems (delusions, hallucinations) and affect ability to interact with others, work, perform ADLs
Delirium
-temporary but acute mental confusion
-an acute illness with a specific, underlying cause (surgery, drug interactions, infection, hypoglycemia, fever, pain, distress, change in environment)
aphasia
difficulty with talking or understanding words
apraxia
Inability to perform familiar skilled activities, perform purposeful movements or use objects appropriately
dysgraphia
difficulty writing
visual agnosia
an impairment in recognizing visually presented objects
labile
quick changing
Caring for a client with dementia/ delirium
-Goals:
injury prevention, facilitating communication, reducing agitation, preventing caregiver role strain, fostering/ assisting self- care
Nursing implementations delirium
-Communicate in simple and concrete phrases.
-Use reality-orientation aids (clocks, calendars).
-Encourage family members to be supportive.
-Talk with the patient about familiar things in life.
-Reinforce reality when the patient is delusional.
acute pain
temporary, usually self-limiting, protective, usually has a direct cause and resolves with tissue healing
chronic pain
ongoing or recurs frequently, lasts longer that 6 months- persists beyond tissue healing; may result in depression, fatigue, decreased level of functioning
nociceptive pain
from damage or inflammation of tissue; classified as somatic (bones, tendons, ligaments), visceral (originates in an organ; not localized), or cutaneous (superficial ex. paper cut)
neuropathic pain
nerve pain
pain assessment should include
o Description of pain, Duration, Location, Intensity, Chronology
o Any aggravating or alleviating factors
PQRST pain evaluation
o Precipitating cause
o Quality
o Region
o Severity
o Timing
pain scales
o Numeric scale
o Visual analog scale
o Wong-Baker FACES- children
o CRIES pain scale- neonate
o FLACC scale (face, legs, activity, cry, consolability)
o Nonverbal pain scale (NVPS)
Physiologic responses to pain
o Stimulates sympathetic nervous system
o Eventually stimulates Parasympathetic NS cause of - (pallor, N/V)
Behavioral responses to pain
o Clenching teeth, grimacing, guarding
o Chronic pain affects activity, quality of life
Affective response to pain
Anger, fear, social interactions
Nonopioids
o Acetaminophen, NSAIDs
*Acetaminophen is associated with liver toxicity; NSAIDs are linked to GI bleeding and renal insufficiency
Opioids
o narcotic analgesics
-respiratory depression, N/V, constipation, itching, urinary retention, sedation
*Monitor Vitals! Especially BP and respirations
adjuvants
antidepressants, anticonvulsants
pain med considerations
o Monitor for effectiveness of analgesics
o Monitor vital signs after administration, especially opioids
o Reassess pain scale
patient with PCA pump
client controls administration of medication
-Client should be the only one to press button
-Monitor for oversedation and respiratory depression
tracheostomies
-tube inserted surgically
-used for long term airway assistance
-suctioning- sterile procedure
urticaria
hives
crackles or rales breath sounds
fine to course bubbly sounds as air passes through fluid or re expands collapsed small airways not cleared with coughing
wheezes (breath sounds)
A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways
rhonchi breath sounds
Coarse, loud, low-pitched rumbling sounds during either inspiration or expiration resulting from fluid or mucus, can clear with coughing
exudate
fluid that leaks out of blood vessels into surrounding tissues.
debride
a medical procedure that involves removing dead, damaged, or infected tissue from a wound.
perspiration
sweating
maceration
long term moisture under folds
dermatits
skin inflammation that can cause itchiness, redness, and a rash
cellulitis
large deep bacterial skin infection (needs IV transfusion)
eryhema
redness
purulent drainage
yellow, green, brown
dehiscence
partial or complete separation of the tissue layers during the healing process
evisceration
total separation of tissue layers
wound hemorrhage
internal or external bleeding
hematoma
internal collection of blood underneath the tissue
fistula
abnormal passage from an internal organ/vessel to the outside of the body or from one organ to another
Abscess
collection of infected fluid that has not drained
Pharmacokinetics
study of absorption, metabolism, distribution, and excretion of drugs in the human body
Perfusion
blood flow through the body and organs
First pass Effect
pharmacological phenomenon in which a medication undergoes metabolism at a specific location in the body
hepatic
meaning liver
Peak plasma level
highest level of concentration of a med (they are on too much)
Trough serum levels
lowest level of concentration of a med (they will need a dose)
Therapeutic range
minimum effective concentration - toxic concentration
Half life
amount of time it takes for med to fall to half its strength
Therapeutic effect
expected response
Adverse effect
unintended, unpredictable (serious, sometimes intolerable. Not to be confused with a side effect)
ADR
adverse drug reaction
Drug tolerance
ppl build when taking narcotics/opioids, antidepressants/anti anxiety
Idiosyncratic effect
over or under response (opposite of what is supposed to happen)
Teratogenic
medication that causes fetal defects (thalidomide) - can cause fetal demise/miscarriage causes babies to be born without limbs but gets rid of morning sickness
Accutane
or acne (taken mostly at child bearing age) causes serious fetal demise and miscarriages
Woven gauzes (sponges)
Absorbs exudate from the wound
Nonadherent material
Does not stick to the wound bed
Damp to damp 4-inch x 4-inch dressings
Used to mechanically debride a wound until granulation tissue starts to form in the wound bed. Must keep moist at all times to prevent pain and disruption of wound healing.
Self adhesive, transparent film
A temporary “second skin” ideal for small, superficial wounds
Hydrocolloid
An occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a seal at the wound surface to prevent evaporation of moisture from the skin. Maintains a granulating wound bed, can stay in place for 3 to 5 days.
Hydrogel
Composition is mostly water. Gel after contact with exudate, promoting autolytic debridement and cooling. Rehydrates and fills dead space. Might require a secondary occlusive dressing. For infected, deep wounds, or necrotic tissue. Not for moderately to heavy draining wounds, provides a moist wound bed , soothing and can reduce wound pain, prevent skin breakdown in high-pressure areas (sacrum)
Alginates
Non-adherent dressings that conform to the wound shape and absorbs exudate. Provides a moist wound bed, packs wounds, supports debridement
Collagen
Powders, pastes, granules, sheets, gels. Help stop bleeding, promotes healing.
