Exam 2 Flashcards
Preventing alterations in skin integrity? (IINHPA)
Ice is not hot, poop ass
identification inspection nutrition hydration protection assessment
Risk factors for skin integrity are:
IM DD AR M
Im DD, alright mate?
impaired circulation medication dehydration decreased sensation age reduced mobility malnourished
alteration in skin integrity is a ___
wound
how to classify wounds?
CSCS D
classify scrapes, classify scrapes, duh
cause of wound status of skin integrity cleanliness of wound severity of tissue injury descriptive qualities
how to assess the wound?
WWW HTTOP
www. hot topic
what type of dressing what the periwound looks like what the wound bed looks like how much drainage on dressing type/amount of drainage tunneling/undermining pain
types of drainage
SSSP
(sss, pus) (sounds like its leaking, get it from a wound?
serous
serosanguineous
sanguineous
purulent
where is the top of the wound?
towards the head
what unit of measure is used to measure a wound?
centimeters
longest part is ___ to___ and widest part is ____ to the length
top to bottom
perpendicular
steps to first aid of a wound:
stop the bleeding
clean the wound
protect the wound w bandage
function of dressings
absorbs drainage
dressings need frequent ___ and ___
changing and monitoring
dressings must always have a
date, time and initial
pressure ulcers are over ___
bony prominence
pressure ulcers are ____ in health facilities
prevalent
pressure ulcers can cause:
extended stays, sepsis, mortality, cost increase
risk factors for pressure ulcers : AMFS (AMF’s can make you pass out and be immobile)
alteration in LOC
moisture
friction
shearing
Braden scale assesses risk in six categories: MF MANS
moisture friction/shear mobility activity nutrition sensory perception
what are the stages of pressure ulcers
unstageable stage 1 stage 2 stage 3 stage 4
what is an unstageable pressure ulcer
cannot see wound base
full thickness loss
completely obscured by slough or eschar (necrotic tissue)
characteristics of stage 1 pressure ulcer
skin is intact
does not blanch
(goal to prevent breakdown)
characteristic of stage 2 pressure ulcer
shallow, open ulcer
can be a blister filled w serosanguineous fluid
partial thickness loss of epidermis
red pink wound bed
characteristic of stage 3 pressure ulcer
full thickness loss may see subcutaneous fat sloughing could be present eschar could be present (scab) possible undermining or tunneling
stage 4 pressure ulcer characteristics
full thickness loss
exposed bone tendon or muscle
possible slough/eschar
often undermining and tunneling
what is a suspected deep tissue injury?
purple or maroon non blanching area or blood blister
can rapidly evolve into ulcer involving all tissue layers
Wound management steps
PERM, KK?
protect wound/periwound eliminate dead space removed nonviable tissue minimize pain keep moist keep clean, no infection
what must you do when packing a wound?
fill dead space proper material don't over/under moisten don't leave moist dressing outside wound bed fluff material, no tight packing
what is irritant contact dermatitis
can occur with soiling
tender and painful
inflammation/erythema
crusting possibly present
diabetic wounds can range from __ to ___
superficial ulcers to gangrene of whole foot
complications of wound healing
HIDE from healing
hemorrhage
infection
dehiscence (layers of skin and tissue separating)
evisceration (visceral organs through wound opening)
would prevention includes:
PIMO (pima college)
pressure reduction
incontinence care
mobility
optimal nutrition
Triangle of safety, from most basic to self fulfilling
PSBES
psio needs (food, water, rest) safety (security, safety ) belonging/love (relations, friends) esteem (prestige and accomplishment) self actualization (creativeness
basic needs of safety triangle (Maslow)
physiological (food/water) and safety (safety/security)
psychological needs of triangle (Maslow)
belongingness and love (relationships, friends) esteem needs (prestige and accomplishments)
self fulfillment of triangle
self actualization (creativeness, recognizing full potential)
injury deaths per year in US
193k
leading COD for death ages 1-44 is what?
accidental injury
what is the leading type of accidental injury death?
drug overdose
what are the top 5 leading causes of death
heart disease, cancer, COPD, accidents, stroke
what are physical hazards to injury?
MPD FF
motor vehicle accident poison disaster fire falls
what factors influence patient safety?
MK LP
mobility, sensory, cognitive status
knowledge of safety precautions
lifestyle
patient development level
examples of lifestyle risk factors
substance use, dangerous job, risk taker
examples of impaired mobility safety risk factors
muscle weakness, paralysis, poor coordination, lack of balance, emotional hazard
examples of sensory or cognitive impairment safety risk factors
unable to feel injuries, confusion, can’t perceive danger, unable to express need for assistance
examples for “lack of safety awareness” safety risk factors
expiration dates on food or medicine, locking medicines away, firearm safety
common injuries for ages 0-5
poison, choking, fire, fall, drowning, head trauma, MVA
how to prevent injuries for age 0-5
parental education, removal of danger, immunizations
common injuries for a school age child:
home injury, school injury, traveling between
prevention for school age child injury:
stranger danger, sports safety, safety equipment, immunizations.
common adolescent injuries:
MVA, homicide, suicide, substance abuse, risk taking behavior
common adult injuries:
MVA, suicide, homicide, lifestyle, childbirth, bad nutrition, firearms, substance use or abuse
prevention for adult injury:
immunization, lifestyle modification, healthy diet, relax techniques, adequate sleep
common older adult injuries
falls, multiple meds, psychological and cognitive factors, effects of acute and chronic disease
prevention of older adult injury?
immunization, fall education, environment changes, community resources, safe driving
causes of work related musculoskeletal injury:
NON BIT
not using assistance
overexertion
not using lift/transfer device
bending, twisting, lifting, pushing beds
improper lifting/bending
transferring patients
how to prevent work related musculoskeletal injuries:
KKG, KTFB
know capabilities
know patients capabilities
gather right amount of ppl
know facility policy
take advantage of equipment training
follow EBP
body mechanics
what is the definition of workplace violence?
incidents where staff are abused, threatened, or assaulted in circumstances related to work which includes the commute to and from work
What are the types of workplace violence?
criminal intent
client on worker
worker on worker
personal relationship
___ percent of nurses do not feel safe in the workplace
80
___ of ER nurses have been physically assaulted at work in one year
82
___ percent of psychiatric nurses experience disabling injuries from patient assault
25
__ to __ percent of hospital staff have been physically assaulted at least once in their career
35 to 80
what can contribute to worker on worker violence
short people stress over work and fear of a powerful hierarch against them
short staffed overworked stressful patient situation fear of litigation hierarchies floating power (nurses eat their young)
___ of student nurses report being put down by staff
half
___ of nurses report having been threatened or experiencing verbal abuse from coworkers
half
___ percent experience one episode of verbal abuse in the last year
90
what is QSEN
quality and safety education for nurses
what is a fall?
movement downward, typically rapid and without control from a higher to lower level
losing balance and collapsing
intrinsic risk factors for falls in older adults
history, impaired vision, postural hypotension/syncope, conditions affecting mobility or balance and gait, alterations on bladder function, cognitive impairment, adverse reactions to meds, slow reaction times
extrinsic risk factors for falls in older adults
environment hazards, inappropriate footwear, unfamiliar environment, improper use of assistive devices
potential results of fall injury:
hospitalization, rehab/long term care placement, death
how to decrease fall risk in older adults
exercise, tai chi, med review, eye exam, decreasing hazards, relaxing, companions, teaching
what does the nutritional assessment consist of?
PDMSDPG
physical signs, diet history, measurements, self care ability, dietary education, physical environment, general eating patter
what is the physical signs of nutrition assessment
trouble chewin, poor dentition, muscle wasting
what is the diet histroy of nutrition assessment
what they eat, preferences, allergies
what is the measurements of nutrition assessment
height weight, BMI, lab values
what is the self care abilities of nutrition assessment
trouble preparing food, keeping it safe, feeding themself
what is the dietary education of nutrition assessment
do they know about nutrition
what is the physical environment of nutrition assessment
do they have a fridge, are groceries close
what is the general eating patterns of nutrition assessment
do they eat one meal, or snack all day
what are therapeutic diets from most normal to most modified?
regular, diabetic, low cholesterol, low sodium, high fiber, soft/low residue, mechanical soft, pureed, full liquid, clear liquid
what is enteral nutrition (EN)
feeding through a tube directly into GI tract. nasogastric tubes, jejunal tubes, gastric tubes
what is parenteral nutrition (PN)
intravenous nutrition. lipid and fat emulsions. do not connect any other IV lines to the PN IV line
always use infusion line
what does the sleep wake cycle do?
influences and regulates physiologic functions and behavior
what does the circadian rhythm do?
influence pattern biological and behavior functions
what does the biological clock do
synchronizes sleep schedule
stage 1 of sleep:
NREM, lightest level
stage 2 of sleep:
NREM, period of sound sleep where relaxation progresses
stage 3 of sleep:
NREM, initial stages of deep sleep
stage 4 of sleep:
NREM, deepest and most difficult to awake from
stage 5 of sleep:
REM, hard to arouse, dreaming.
how many cycles of sleep per night?
4-5, REM increases each time
what does REM sleep help with?
changes in cerebral blood flow and more O2 consumption
helps w memory storage and learning
what happens to biologic functions in NREM sleep?
HR down
respirations, BP, and muscle tone goes down
basal metabolic rate lowers
functions of sleep:
increase mental performance
repairs and restores body
improves coping ability
strengthens immune system
what can sleep deprivation cause?
OH, CDC?
obesity
heart disease
change in immune function
diabetes
cancer
what is insomnia
difficulty falling and staying asleep
what is sleep apnea
blockage of breathing occurring for 10 sec 5 or more times in one hour
what is narcolepsy
fall asleep uncontrollably
what is parasomnia
undesirable behavior in sleep
what is restless leg syndrome
desire to move legs while laying down
___ percent of workforce is fatigued
38
more than ___ million Americans suffer from sleep disorder
40
what are some interventions to help sleep?
high carb foods, decaf teas, warm milk. medications are last resort
what is the start of “old age”
65 years
what is the biggest fear of the older population?
loss of independence
what is delirium?
acute and confusional state that may be reversible.
what is typically the cause of delirium?
physiologic in some form. medication, electrolyte imbalance, infection, untreated pain
symptoms of delirium
sudden change in LOC, change in speech
what is dementia?
generalized impairment of intellectual functioning , cerebral dysfunction, syndrome of cognitive and functional decline
what percent of older Americans does dementia affect?
15 percent
___ of the patients in long term care have dementia
1/2
what is the most common psychiatric disorder in the general population
depression
what is the number 1 cause of lost quality of life at a global level
depression
