Exam 2 Material Flashcards
What is a primary intention wound?
A wound with edges approximated and little to no tissue loss or scaring.
Could be stapled or sutured depending on wound
What is a secondary intention wound?
Edges not approximated
Tissue loss
Heals by granulation formation
Very rough injury
What is a tertiary intention wound?
Delayed closure-left open before closing
Contaminated or s/s of infection
Will close when risk of infection is resolved
A tertiary intention wound would normally requires the use of what medical device?
A wound vac
Wound classification:
Partial Thickness Wounds
Shallow, moist, painful
Loss of epidermis and dermis
What is an example of a partial thickness wound?
Scrape or abrasion
Wound classification:
Full thickness wounds
Extend into dermis
Dermis does not regenerate=scar tissue formation
What are two examples of full thickness wounds?
Stage 3 and 4 pressure injuries
What determines where scar tissue is formed in a full thickness wound?
Depth varies due to where the tissue is located
An acute or traumatic wound will heal in a?
timely manner with restoration in an organized way
An injury that does not heal in an organized way would be most likely classified as a ?
Chronic injury
A stage 1 pressure injury would present as?
Intact skin with nonblanchable edema
A stage 2 pressure injury would present as?
Partial thickness with skin loss and exposed dermis
What are the causes of a venus stasis ucler?
Venus hypertension (edema, skin changes) and poor perfusion
What are the causes of a Diabetic foot ucler?
Peripheral neurophathy and atherosclerosis=poor perfusion=ucler
A stage 3 pressure injury would present as?
A full thickness skin loss with visible adipose tissue
What are the 6 cateogories of the Brayden scale?
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
The ________ the Brayden score equals the _____________ chance of skin breakdown
The lower the score, the higher the chance of skin breakdown
SAFETY FRAMEWORK WOUNDS:
What would be included in your system specific assessments?
Brayden Scale
Nutritional Status
Bony Prominences
Skin Color
Location
Apperance
Drainage
Bring Big Nachos after Latin Salsa Dance.
What would you be looking for when assessing a wound appearance?
Wound bed color, edges, exuhdate, slough, eshar, tunneling
What is the normal range of Albumin?
3.5-5
What is the normal range of Prealbumin?
16-30
What is the normal range of Serum Iron?
60-150
What is the normal range of Transferrin?
200-400
A healthy HbAIC would be?
<6%
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?
How long do nurses have to do a full skin assessment after the patient arrives?
24 hours or else any issues become a HAC
SAFETY FRAMEWORK WOUNDS:
What would be 3 First do priorities for acute skin injuries?
Hemorrhage
Dehiscense
Evisceration
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
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
What is the purpose of a Dry Dressing change?
maintain enviroment to promote wound healing and to protect and absorb drainage
What is the purpose of a Damp to dry dressing change?
mechanical debridment
What is the purpose of guaze?
It is absorbent and wicks away would exhudate
What is the purpose of transparent film?
traps moisture while allowing wound to breathe
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
What is the purpose of a hydrogel?
Hydrates, infused with gel; does not adhere to wound
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
A hemovac is just a better version of a ?
Jackson pratt drain
What should you consider when addressing abdominal wounds?
An abdominal binder for extra support
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…
SAFETY FRAMEWORK WOUNDS:
Trend for Potiential complications-What would be some complications of wound healing?
Hemorrage
Hematoma
Infection
Dehiscense
Eviseration
Delayed Healing
What is a dihiscence?
A partial or total seperation of wound layers
What should you never delegate to UAP?
wound assessment
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
What are the types of pain?
Somatic
Visceral
Cutaneous
Neuropathic
Referred
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
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
How long should you use hot/cold therapy?
10-20 min
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
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
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
What does SALAD stand for?
Sound Alike Look Alike
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
What are the Special population red flag alerts in regards to medication administration?
Ends of age spectrum
Pregnancy and breastfeeding
Polypharm
For medication order types, what are some of the Entry type orders?
Written (CPOE, hand)
Verbal (not always allowed)
Telephone
For medication order types, what are some of the circumstance/need orders?
Standing orders/routine orders
PRN
Single/one time
STAT
Now
Prescriptions
What are the components of a medication order?
Full Name
Date/Time
Name of Med
Dose
Frequency
Route
Indication of use
Signature of prescriber
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
What are the 6 special factors affecting medication response?
Age
Gender/body habitus
Chronic Disease
First Pass Effect
Nutritional Status
Pregnancy
Concurrent Medication
How does age effect medication?
Immature liver in infants/children
Old age affects liver/kidney function/GI motility/circulation
How does Gender effect medication?
Distribution of fat
Lean mass
How long must you wait before drinking after taking a sublingual drug?
15 min
How do oral medications and cognitive status interact?
Impaired cognitive status can increase aspiration risk in pt
Which PO med must be swallowed whole and not be crushed?
Enteric Coated, ER, SR and CR
What type of med administration almost always has local effects, but many have systemic effects?
Topical
What should you do after applying a topical medication?
Cover with labeled plastic film or a transparent dressing
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
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
What is a large factor to consider with inhalant medication?
Does the patient have enough strength to use inhaler
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
How do you use a MDI?
Shake 5-6 times
Inhale for 3-5 seconds
Hold for 10 seconds
Wait one minute inbetween
If you were administering rapid acting insulin, what would you want to wait for?
Wait until the meal tray has arrived
What kinds of medications and products would you administer through an IV line?
Non-caustic medications
Administration of fluids including blood products
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
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
What are continuous fluids?
Fluids pre-prepared commercially or via pharmacy with or without additives
What is an example of a Hypotonic Fluid?
0.45% NaCL
What are 3 examples of isotonic fluids?
0.9% NaCL
Lactated Ringers
D5W
What are two examples of Hypertonic fluids?
3% NaCL
D10W
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
An IVPB is?
A secondary bag or bottle that is hung higher
PCA stands for?
Patient controlled Analgesia
What 3 things are only adminstered through a central line?
Total Parenteral Nutrition (TPN)
Lipids
Caustic medications/vesicants
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
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
What are the time restrictions for IVs?
IVF Bag changed every 24 hours
IV tubing changes every 72-96 hours
What do you want to assess for a central line?
Type and Location
Insertion site
Sterile Dressing change
+Biopatch or antimicrobial dressing
Tubing Date
What are the time restrictions for central line tubing?
Tubing change every 24 hours
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
For a PIV catheter, how are gauge and diameter related?
Inversely, the larger the gauge, the smaller the diameter and vice versa
What situation would you use a 16g needle?
Trauma patient
Rapid and Large fluid volume resucitation
What situation would you use a 18g needle?
Surgical Patient
Blood Infusions
What situation would you use a 20g needle?
Most common needle used
Minimum gauge for blood products
What situation would you use a 22-24g needle?
Pediatrics/Elderly
Small veins
What should always be labeled at the IV site?
Date and Time
IV catheter sizes and flow rates are related how?
The larger the size of the gauge the faster the flow rate
Nursing interventions for IV Therapy:
What are the interventions for an PIV?
Clean dressing change
Remove and insert in a new location per policy
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
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
What are the potential complications and risks with intravenous therapy:
PIV
Phlebitis
Infiltration
Extravasation (fluid flows out of a vessel to surrounding area)
Hematoma
What are the potential complications and risks with intravenous therapy:
Central Line
Infection
Sepsis
Pneumothorax (air causing lung to collapse)
Thrombulus/Embolus
Dislodgement
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
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.
What are the treatments for Phlebitis?
Remove, Elevate, warm moist heat for 3-4 times a day
Insertion of new IV if needed
What are the symptoms for Infiltration at an IV site?
Swelling
Pallor
Coolness at site
Pain proportionate to edema
Possible lowering of flow rate
What are the symtoms of a hematoma?
Ecchymosis (discoloration of skin) at sight
What are the treatments for a hematoma at an IV site?
Apply Pressure after removal, compress, elevate
What are the symptoms of Fluid volume overload in regards to IVs?
Shortness of breath
Crackles
Tachypnea
Tachycardia
JVD
Increased Blood Pressure
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
Hypovolemic fluid shifts are caused by?
Burns
Third Spacing
Ascities
Liver Failure
Hypervolemic fluid shifts are caused by?
Hypertonic Fluids
Sodium Retention
Hypervolemia (Fluid volume Excess) is caused by?
Excess salt intake
Decreased Fluid Losses
Hypovolemia is caused by?
Insufficent fluid intake (anything that would cause you to loose water) since it’s a fluid volume deficit
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
What condition is causing these symptoms?
Bounding pulse, JVD, hypertension, edema, acute weight gain, crackles, tachypnea, dyspnea, orthopnea, confusion
Fluid Volume Excess
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
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
If a patient is experiencing shock from a fluid volume deficit, what position should you put them in?
Supine position with legs elevated
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
If a patient is experiencing Fluid Volume Excess what position should you place them in?
Semi-fowlers position
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)
Trend for Potential Complications:
What are some complications from Fluid Volume Excess
Pulmonary Edema
Respiratory Failure
Heart Failure
Skin Breakdown
Impaired bowel function
