Exam 2 Material Flashcards
(122 cards)
1
Q
What is a primary intention wound?
A
A wound with edges approximated and little to no tissue loss or scaring.
Could be stapled or sutured depending on wound
2
Q
What is a secondary intention wound?
A
Edges not approximated
Tissue loss
Heals by granulation formation
Very rough injury
3
Q
What is a tertiary intention wound?
A
Delayed closure-left open before closing
Contaminated or s/s of infection
Will close when risk of infection is resolved
4
Q
A tertiary intention wound would normally requires the use of what medical device?
A
A wound vac
5
Q
Wound classification:
Partial Thickness Wounds
A
Shallow, moist, painful
Loss of epidermis and dermis
6
Q
What is an example of a partial thickness wound?
A
Scrape or abrasion
7
Q
Wound classification:
Full thickness wounds
A
Extend into dermis
Dermis does not regenerate=scar tissue formation
8
Q
What are two examples of full thickness wounds?
A
Stage 3 and 4 pressure injuries
9
Q
What determines where scar tissue is formed in a full thickness wound?
A
Depth varies due to where the tissue is located
10
Q
An acute or traumatic wound will heal in a?
A
timely manner with restoration in an organized way
11
Q
An injury that does not heal in an organized way would be most likely classified as a ?
A
Chronic injury
12
Q
A stage 1 pressure injury would present as?
A
Intact skin with nonblanchable edema
13
Q
A stage 2 pressure injury would present as?
A
Partial thickness with skin loss and exposed dermis
14
Q
What are the causes of a venus stasis ucler?
A
Venus hypertension (edema, skin changes) and poor perfusion
15
Q
What are the causes of a Diabetic foot ucler?
A
Peripheral neurophathy and atherosclerosis=poor perfusion=ucler
16
Q
A stage 3 pressure injury would present as?
A
A full thickness skin loss with visible adipose tissue
17
Q
What are the 6 cateogories of the Brayden scale?
A
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
18
Q
The ________ the Brayden score equals the _____________ chance of skin breakdown
A
The lower the score, the higher the chance of skin breakdown
19
Q
SAFETY FRAMEWORK WOUNDS:
What would be included in your system specific assessments?
A
Brayden Scale
Nutritional Status
Bony Prominences
Skin Color
Location
Apperance
Drainage
Bring Big Nachos after Latin Salsa Dance.
20
Q
What would you be looking for when assessing a wound appearance?
A
Wound bed color, edges, exuhdate, slough, eshar, tunneling
21
Q
What is the normal range of Albumin?
A
3.5-5
22
Q
What is the normal range of Prealbumin?
A
16-30
23
Q
What is the normal range of Serum Iron?
A
60-150
24
Q
What is the normal range of Transferrin?
A
200-400
25
A healthy HbAIC would be?
<6%
26
SAFETY FRAMEWORK WOUNDS:
Analysis of Concept for Wound care would include?
What is the skin integrity?
What other concepts might apply for skin integrity problems?
27
How long do nurses have to do a full skin assessment after the patient arrives?
24 hours or else any issues become a HAC
28
SAFETY FRAMEWORK WOUNDS:
What would be 3 First do priorities for acute skin injuries?
Hemorrhage
Dehiscense
Evisceration
29
What would be the steps if a Dehiscense occurs?
Call for assistance and notify provider
Reposition to intra-abdominal pressure
Splint with pillow when coughing/sneezing
30
What would be the steps if an evisceration occurs?
-Call for assistance and notify provider
-Cover wound with sterile towels or sterile dressing soaked in saline
-do NOT try to reinsert organs
-Position supine with hips and knees bent
-Observe for shock
-Prep for surgery
31
What is the purpose of a Dry Dressing change?
maintain enviroment to promote wound healing and to protect and absorb drainage
32
What is the purpose of a Damp to dry dressing change?
mechanical debridment
33
What is the purpose of guaze?
It is absorbent and wicks away would exhudate
34
What is the purpose of transparent film?
traps moisture while allowing wound to breathe
35
What is the purpose of a hydrocolloid?
To pull discharge from wound into dressing
Absorbend and occlusive; forms a gel when in contact with mild amount of exudate from wound
36
What is the purpose of a hydrogel?
Hydrates, infused with gel; does not adhere to wound
37
What is the purpose of foam or alginates?
Highly absorbent; designed for wounds with large amount of exudate but must cover with a secondary dressing
38
A hemovac is just a better version of a ?
Jackson pratt drain
39
What should you consider when addressing abdominal wounds?
An abdominal binder for extra support
40
SAFETY FRAMEWORK WOUNDS:
Evaluation of expected outcomes would be?
Intact skin, no erythema or non-blanchable areas, able to turn and reposition one's self...
41
SAFETY FRAMEWORK WOUNDS:
Trend for Potiential complications-What would be some complications of wound healing?
Hemorrage
Hematoma
Infection
Dehiscense
Eviseration
Delayed Healing
42
What is a dihiscence?
A partial or total seperation of wound layers
43
What should you never delegate to UAP?
wound assessment
44
SAFETY FRAMEWORK PAIN:
What could you use to assess pain?
PQRST
OLD CART
Pain scales
Type of pain
Impact of quality of life and function
SNS response
Behavior Change
45
What are the types of pain?
Somatic
Visceral
Cutaneous
Neuropathic
Referred
46
SAFETY FRAMEWORK PAIN:
First do priorites for pain would include?
Staying ahead of the pain (Continous/preventive rather than 'as needed')
Individualize pain control for needs
Pharmacological/Non-pharm interventions
47
Where do you not use hot/cold therapy for pain?
if pain increases
Heat-On areas that are bleeding/sustained a recent injury or have oil or menthol on them
Cold-Areas with poor perfusion
48
How long should you use hot/cold therapy?
10-20 min
49
SAFETY FRAMEWORK Pain:
Evaluation of Expected outcomes would be?
Re-assess pain w/vital signs
See if vital signs have gone back to baseline
Determine if relief was achieved
Explore improvement in functioning
Asses extent to which patient can participate
Vital signs->back to normal->relief acheived->improved functioning->patient participation
50
SAFETY FRAMEWORK PAIN:
What are some things to consider in trending for potiential complications in pain relief?
Over Sedation
Respiratory Depression
Constipation
Orthostatic Hypotension
Urinary Retention
Allergy
N/V
Toxcity
Interactions
Tolerances
Orange Rats Constantly On Unique Ants NeVer Take In Totes
51
SAFETY FRAMEWORK Pain:
What are some of the risks to your patient and you?
Conversions between oral and IV meds
Understand pain presents differently
Untreated pain has impacts on many other areas
Chain of custody & wasting of controlled substances
52
What does SALAD stand for?
Sound Alike Look Alike
53
What are 3 cardinal rules of medication administration?
Always use barcode scanner for meds and patient
Never use med dispensing overrides
Always follow 5 rights and 3 checks
54
What are the Special population red flag alerts in regards to medication administration?
Ends of age spectrum
Pregnancy and breastfeeding
Polypharm
55
For medication order types, what are some of the Entry type orders?
Written (CPOE, hand)
Verbal (not always allowed)
Telephone
56
For medication order types, what are some of the circumstance/need orders?
Standing orders/routine orders
PRN
Single/one time
STAT
Now
Prescriptions
57
What are the components of a medication order?
Full Name
Date/Time
Name of Med
Dose
Frequency
Route
Indication of use
Signature of prescriber
58
What are the 3 checks prior to med administration?
Before you pour: Check med against MAR
After you pour: Check med against MAR
At beside with patient: Verify medication with MAR with the patient armband
59
What are the 6 special factors affecting medication response?
Age
Gender/body habitus
Chronic Disease
First Pass Effect
Nutritional Status
Pregnancy
Concurrent Medication
60
How does age effect medication?
Immature liver in infants/children
Old age affects liver/kidney function/GI motility/circulation
61
How does Gender effect medication?
Distribution of fat
Lean mass
62
How long must you wait before drinking after taking a sublingual drug?
15 min
63
How do oral medications and cognitive status interact?
Impaired cognitive status can increase aspiration risk in pt
64
Which PO med must be swallowed whole and not be crushed?
Enteric Coated, ER, SR and CR
65
What type of med administration almost always has local effects, but many have systemic effects?
Topical
66
What should you do after applying a topical medication?
Cover with labeled plastic film or a transparent dressing
67
What are the steps to administering an eye medication?
-Head up, looking up
-Gently pull down lower lid with thumb
-Position dropper approx 1/2 inch to 3/4 inch above lower lid
-Instill drops in conjunctival sac
-Do not touch cornea
-Gentle pressure over inner canthus to avoid systemic effects
68
What are the steps to administering an ear medication?
-Position on uneffected side with ear receiving med up
-Pinna back
-Children <3: pinna back and up
-Keep dropper out of auditory canal
-instill drops along canal at room temp
-Verify appropriateness if ear drum is ruptured
-remain lying for several min
69
What is a large factor to consider with inhalant medication?
Does the patient have enough strength to use inhaler
70
What are the factors to consider in Metered-Dose inhalers?
Hand-breath coordination and strength
Spacers=increased delivery to lower airways
For corticosteriods, follow with oral rinse to reduce chance of thrush
71
How do you use a MDI?
Shake 5-6 times
Inhale for 3-5 seconds
Hold for 10 seconds
Wait one minute inbetween
72
If you were administering rapid acting insulin, what would you want to wait for?
Wait until the meal tray has arrived
73
What kinds of medications and products would you administer through an IV line?
Non-caustic medications
Administration of fluids including blood products
74
What kind of medications and products would you adminster through a central line?
Infusion of caustic medications
Large fluid volume resuscitation
Emergency venous access
Central venous pressure monitor
75
What can you administer through BOTH a PIV and a Central line?
Continous fluids
Fluid bolus
Medication admin (infusion and push)
IV piggyback
Volume controlled medication admin with a syringe pump
76
What are continuous fluids?
Fluids pre-prepared commercially or via pharmacy with or without additives
77
What is an example of a Hypotonic Fluid?
0.45% NaCL
78
What are 3 examples of isotonic fluids?
0.9% NaCL
Lactated Ringers
D5W
79
What are two examples of Hypertonic fluids?
3% NaCL
D10W
80
What are 3 things to consider for an IV Push?
Not performed as a student
Most dangerous with high risk (especially with Lasik or Dioxin)
Verify rate as the amount per min
81
An IVPB is?
A secondary bag or bottle that is hung higher
82
PCA stands for?
Patient controlled Analgesia
83
What 3 things are only adminstered through a central line?
Total Parenteral Nutrition (TPN)
Lipids
Caustic medications/vesicants
84
What are 4 reasons why one would want to use an IV pump?
To get a low hourly flow rate
Pts that are high risk for fluid volume overload
Pts that have impaired renal volume
Pts who require an hourly volume
85
What are 6 things you want to assess at the IV sight?
Assess for:
Size and Location
phlebitis
Infilration
Patency
Transparent dressing clean and dry
Insertion date
86
What are the time restrictions for IVs?
IVF Bag changed every 24 hours
IV tubing changes every 72-96 hours
87
What do you want to assess for a central line?
Type and Location
Insertion site
Sterile Dressing change
+Biopatch or antimicrobial dressing
Tubing Date
88
What are the time restrictions for central line tubing?
Tubing change every 24 hours
89
What do you want to assess for BOTH Iv and central line?
Renal Function: GFR, BUN, CR
Lung sounds
Assessments and Labs related to fluids/medications
Compatibility
90
For a PIV catheter, how are gauge and diameter related?
Inversely, the larger the gauge, the smaller the diameter and vice versa
91
What situation would you use a 16g needle?
Trauma patient
Rapid and Large fluid volume resucitation
92
What situation would you use a 18g needle?
Surgical Patient
Blood Infusions
93
What situation would you use a 20g needle?
Most common needle used
Minimum gauge for blood products
94
What situation would you use a 22-24g needle?
Pediatrics/Elderly
Small veins
95
What should always be labeled at the IV site?
Date and Time
96
IV catheter sizes and flow rates are related how?
The larger the size of the gauge the faster the flow rate
97
Nursing interventions for IV Therapy:
What are the interventions for an PIV?
Clean dressing change
Remove and insert in a new location per policy
98
Nursing interventions for IV Therapy:
What are the interventions for a Central line?
Sterile Dressing change
Dedicated infusion ports
Central line bundles
Work towards discontinuing the central line ASAP
99
Nursing interventions for IV Therapy:
What are the nursing interventions for both PIV and Central lines?
Change tubing per time restrictions
Swab ports before access
Cap with green caps
Prime tubing before attaching
Date/Time all bags, tubing, dressings
Correct set up and programing of pump
100
What are the potential complications and risks with intravenous therapy:
PIV
Phlebitis
Infiltration
Extravasation (fluid flows out of a vessel to surrounding area)
Hematoma
101
What are the potential complications and risks with intravenous therapy:
Central Line
Infection
Sepsis
Pneumothorax (air causing lung to collapse)
Thrombulus/Embolus
Dislodgement
102
What are the potential complications and risks with intravenous therapy:
Both PIV and Central lines
Air Emboli
Fluid Overload-CV and Respiratory
incompatibility and precipitate in fluids
Electrolyte imbalances
Medication-Specific Adverse Reactions
Fall risk
103
What are the symptoms of Phelbitis?
Pain
Edema
Erythema
Red Streak up arm 'cord'
Skin Temp elevation over IV site
Slowed infusion
Sunday Evan ran pass even Sally.
104
What are the treatments for Phlebitis?
Remove, Elevate, warm moist heat for 3-4 times a day
Insertion of new IV if needed
105
What are the symptoms for Infiltration at an IV site?
Swelling
Pallor
Coolness at site
Pain proportionate to edema
Possible lowering of flow rate
106
What are the symtoms of a hematoma?
Ecchymosis (discoloration of skin) at sight
107
What are the treatments for a hematoma at an IV site?
Apply Pressure after removal, compress, elevate
108
What are the symptoms of Fluid volume overload in regards to IVs?
Shortness of breath
Crackles
Tachypnea
Tachycardia
JVD
Increased Blood Pressure
109
What are the treatments for Fluid volume overload at an IV site?
Slow IV Rate
Raise HOB
Apply O2
Administer diuretics as ordered
Notify Provider
110
Hypovolemic fluid shifts are caused by?
Burns
Third Spacing
Ascities
Liver Failure
111
Hypervolemic fluid shifts are caused by?
Hypertonic Fluids
Sodium Retention
112
Hypervolemia (Fluid volume Excess) is caused by?
Excess salt intake
Decreased Fluid Losses
113
Hypovolemia is caused by?
Insufficent fluid intake (anything that would cause you to loose water) since it's a fluid volume deficit
114
What condition is causing these symptoms?
Increased thirst, Dry mucous membranes, hypotension, Tachycardia, Syncope, Decreased urine output, decreased weight, decreased mental status, increased HCT, BUN & urine specific gravity
Fluid Volume Deficit
115
What condition is causing these symptoms?
Bounding pulse, JVD, hypertension, edema, acute weight gain, crackles, tachypnea, dyspnea, orthopnea, confusion
Fluid Volume Excess
116
Analysis of Priority Concept:
Aside from fluid balance, what other concepts might apply to patients experiencing fluid volume deficit or fluid volume excess?
Oxygenation
Sodium Imbalance
Potassium Imbalance
Acid-Base Imbalance
Peripheral Perfusion
Pitutary/Adrenal Metabolism
Elimination
Renal Perfusion
Tissue/Skin integrity
117
First-Do Priority Interventions:
What are some priorities when dealing with Fluid volume deficit?
Isotonic IVF
Blood (if needed)
Evaluate urine
Measure orthostatics
Evaluate for shock
Take weight to see if changes occur
118
If a patient is experiencing shock from a fluid volume deficit, what position should you put them in?
Supine position with legs elevated
119
First-Do Priority Interventions:
What are some priorities when dealing with fluid volume overload?
Fluid Restriction
Evaluate breathing (to check for pulmonary edema)
Place in semi-fowlers position
Treat with O2
Daily weight
Chest xray
Turn, cough and reposition every 2 hrs
120
If a patient is experiencing Fluid Volume Excess what position should you place them in?
Semi-fowlers position
121
Trend for Potential Complications:
What are some complications from Fluid Volume deficit?
Decreased Cardiac Output
Shock
End Organ Damage (renal, heart)
Organ failure from poor perfusion
Falls
Iatriogenic-flash pulmonary edema from excessive fluid resuscitation (Pulmonary edema when trying to adminster fluids to fix the hypovolemia)
122
Trend for Potential Complications:
What are some complications from Fluid Volume Excess
Pulmonary Edema
Respiratory Failure
Heart Failure
Skin Breakdown
Impaired bowel function
