Exam 2 Flashcards
for skin, remember (4 descriptors)
pink, warm, dry, intact
risk factors for pressure wounds
impaired sensory perception, impaired mobility, alterations in LOC, shear force (sliding skin, bones and muscles stay put), friction, moisture
stage 1 pressure wound
intact skin, nonblanchable redness
stage 2 pressure wound
partial-thickness skin loss involving epidermis, dermis, or both
stage 3 pressure wound
full-thickness tissue loss with visible fat
stage 4 pressure wound
full-thickness tissue loss with exposed bone, muscle, tendon
unstageable pressure wound
full-thickness tissue loss in which the depth of the ulcer is completely obscured by slough/eschar
deep-tissue injury
purple or maroon localized area of discolored intact skin or a blood filled blister (caused by pressure or shear)
scale used for pressure wounds
Braden
SKIN interventions acronym:
Surface appropriate
Keep turning
Incontinence management
Nutrition assessed
pH body normal range:
7.35-7.45
CO2 normal range:
35-45 mmHg
HCO3 normal range:
22-26 mEq/L
hypoventilation respiratory acidosis causes:
drug overdose, pulmonary edema, chest trauma, neuromuscular disease, airway obstruction, COPD, atelectasis
hyperventilation respiratory alkalosis causes:
fever, anxiety, pregnancy, high altitudes, hypoxia, initial stages of pulmonary emboli
ROME
respiratory opposite, metabolic equal
Metabolic Acidosis causes:
DKA, sepsis, shock, renal failure, severe diarrhea, salicylate OD
Metabolic Alkalosis causes:
loss of gastric juices, overuse of antacids, potassium wasting diuretics, severe vomiting, excessive GI suctioning
The nurse knows that most nutrients are absorbed in which portion of the digestive tract?
duodenum
The nurse would expect the least formed stool to be present in which portion of the digestive tract?
ascending
Fecal impactions occur in which portion of the colon?
rectum
