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NURS 713 Fundamentals of Nursing > Exam 2 Material > Flashcards

Exam 2 Material Flashcards

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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

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2
Q

What is a secondary intention wound?

A

Edges not approximated
Tissue loss
Heals by granulation formation
Very rough injury

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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

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4
Q

A tertiary intention wound would normally requires the use of what medical device?

A

A wound vac

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5
Q

Wound classification:
Partial Thickness Wounds

A

Shallow, moist, painful
Loss of epidermis and dermis

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6
Q

What is an example of a partial thickness wound?

A

Scrape or abrasion

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7
Q

Wound classification:
Full thickness wounds

A

Extend into dermis
Dermis does not regenerate=scar tissue formation

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8
Q

What are two examples of full thickness wounds?

A

Stage 3 and 4 pressure injuries

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9
Q

What determines where scar tissue is formed in a full thickness wound?

A

Depth varies due to where the tissue is located

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10
Q

An acute or traumatic wound will heal in a?

A

timely manner with restoration in an organized way

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11
Q

An injury that does not heal in an organized way would be most likely classified as a ?

A

Chronic injury

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12
Q

A stage 1 pressure injury would present as?

A

Intact skin with nonblanchable edema

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13
Q

A stage 2 pressure injury would present as?

A

Partial thickness with skin loss and exposed dermis

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14
Q

What are the causes of a venus stasis ucler?

A

Venus hypertension (edema, skin changes) and poor perfusion

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15
Q

What are the causes of a Diabetic foot ucler?

A

Peripheral neurophathy and atherosclerosis=poor perfusion=ucler

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16
Q

A stage 3 pressure injury would present as?

A

A full thickness skin loss with visible adipose tissue

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17
Q

What are the 6 cateogories of the Brayden scale?

A

Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear

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18
Q

The ________ the Brayden score equals the _____________ chance of skin breakdown

A

The lower the score, the higher the chance of skin breakdown

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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.

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20
Q

What would you be looking for when assessing a wound appearance?

A

Wound bed color, edges, exuhdate, slough, eshar, tunneling

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21
Q

What is the normal range of Albumin?

A

3.5-5

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22
Q

What is the normal range of Prealbumin?

A

16-30

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23
Q

What is the normal range of Serum Iron?

A

60-150

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24
Q

What is the normal range of Transferrin?

A

200-400

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25
Q

A healthy HbAIC would be?

A

<6%

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26
Q

SAFETY FRAMEWORK WOUNDS:
Analysis of Concept for Wound care would include?

A

What is the skin integrity?
What other concepts might apply for skin integrity problems?

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27
Q

How long do nurses have to do a full skin assessment after the patient arrives?

A

24 hours or else any issues become a HAC

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28
Q

SAFETY FRAMEWORK WOUNDS:
What would be 3 First do priorities for acute skin injuries?

A

Hemorrhage
Dehiscense
Evisceration

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29
Q

What would be the steps if a Dehiscense occurs?

A

Call for assistance and notify provider
Reposition to intra-abdominal pressure
Splint with pillow when coughing/sneezing

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30
Q

What would be the steps if an evisceration occurs?

A

-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

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31
Q

What is the purpose of a Dry Dressing change?

A

maintain enviroment to promote wound healing and to protect and absorb drainage

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32
Q

What is the purpose of a Damp to dry dressing change?

A

mechanical debridment

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33
Q

What is the purpose of guaze?

A

It is absorbent and wicks away would exhudate

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34
Q

What is the purpose of transparent film?

A

traps moisture while allowing wound to breathe

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35
Q

What is the purpose of a hydrocolloid?

A

To pull discharge from wound into dressing
Absorbend and occlusive; forms a gel when in contact with mild amount of exudate from wound

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36
Q

What is the purpose of a hydrogel?

A

Hydrates, infused with gel; does not adhere to wound

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37
Q

What is the purpose of foam or alginates?

A

Highly absorbent; designed for wounds with large amount of exudate but must cover with a secondary dressing

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38
Q

A hemovac is just a better version of a ?

A

Jackson pratt drain

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39
Q

What should you consider when addressing abdominal wounds?

A

An abdominal binder for extra support

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40
Q

SAFETY FRAMEWORK WOUNDS:
Evaluation of expected outcomes would be?

A

Intact skin, no erythema or non-blanchable areas, able to turn and reposition one’s self…

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41
Q

SAFETY FRAMEWORK WOUNDS:
Trend for Potiential complications-What would be some complications of wound healing?

A

Hemorrage
Hematoma
Infection
Dehiscense
Eviseration
Delayed Healing

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42
Q

What is a dihiscence?

A

A partial or total seperation of wound layers

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43
Q

What should you never delegate to UAP?

A

wound assessment

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44
Q

SAFETY FRAMEWORK PAIN:
What could you use to assess pain?

A

PQRST
OLD CART
Pain scales
Type of pain
Impact of quality of life and function
SNS response
Behavior Change

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45
Q

What are the types of pain?

A

Somatic
Visceral
Cutaneous
Neuropathic
Referred

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46
Q

SAFETY FRAMEWORK PAIN:
First do priorites for pain would include?

A

Staying ahead of the pain (Continous/preventive rather than ‘as needed’)
Individualize pain control for needs
Pharmacological/Non-pharm interventions

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47
Q

Where do you not use hot/cold therapy for pain?

A

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

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48
Q

How long should you use hot/cold therapy?

A

10-20 min

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49
Q

SAFETY FRAMEWORK Pain:
Evaluation of Expected outcomes would be?

A

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
Q

SAFETY FRAMEWORK PAIN:
What are some things to consider in trending for potiential complications in pain relief?

A

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
Q

SAFETY FRAMEWORK Pain:
What are some of the risks to your patient and you?

A

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
Q

What does SALAD stand for?

A

Sound Alike Look Alike

53
Q

What are 3 cardinal rules of medication administration?

A

Always use barcode scanner for meds and patient

Never use med dispensing overrides

Always follow 5 rights and 3 checks

54
Q

What are the Special population red flag alerts in regards to medication administration?

A

Ends of age spectrum
Pregnancy and breastfeeding
Polypharm

55
Q

For medication order types, what are some of the Entry type orders?

A

Written (CPOE, hand)
Verbal (not always allowed)
Telephone

56
Q

For medication order types, what are some of the circumstance/need orders?

A

Standing orders/routine orders
PRN
Single/one time
STAT
Now
Prescriptions

57
Q

What are the components of a medication order?

A

Full Name
Date/Time
Name of Med
Dose
Frequency
Route
Indication of use
Signature of prescriber

58
Q

What are the 3 checks prior to med administration?

A

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
Q

What are the 6 special factors affecting medication response?

A

Age
Gender/body habitus
Chronic Disease
First Pass Effect
Nutritional Status
Pregnancy
Concurrent Medication

60
Q

How does age effect medication?

A

Immature liver in infants/children
Old age affects liver/kidney function/GI motility/circulation

61
Q

How does Gender effect medication?

A

Distribution of fat
Lean mass

62
Q

How long must you wait before drinking after taking a sublingual drug?

A

15 min

63
Q

How do oral medications and cognitive status interact?

A

Impaired cognitive status can increase aspiration risk in pt

64
Q

Which PO med must be swallowed whole and not be crushed?

A

Enteric Coated, ER, SR and CR

65
Q

What type of med administration almost always has local effects, but many have systemic effects?

A

Topical

66
Q

What should you do after applying a topical medication?

A

Cover with labeled plastic film or a transparent dressing

67
Q

What are the steps to administering an eye medication?

A

-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
Q

What are the steps to administering an ear medication?

A

-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
Q

What is a large factor to consider with inhalant medication?

A

Does the patient have enough strength to use inhaler

70
Q

What are the factors to consider in Metered-Dose inhalers?

A

Hand-breath coordination and strength
Spacers=increased delivery to lower airways
For corticosteriods, follow with oral rinse to reduce chance of thrush

71
Q

How do you use a MDI?

A

Shake 5-6 times
Inhale for 3-5 seconds
Hold for 10 seconds
Wait one minute inbetween

72
Q

If you were administering rapid acting insulin, what would you want to wait for?

A

Wait until the meal tray has arrived

73
Q

What kinds of medications and products would you administer through an IV line?

A

Non-caustic medications
Administration of fluids including blood products

74
Q

What kind of medications and products would you adminster through a central line?

A

Infusion of caustic medications
Large fluid volume resuscitation
Emergency venous access
Central venous pressure monitor

75
Q

What can you administer through BOTH a PIV and a Central line?

A

Continous fluids
Fluid bolus
Medication admin (infusion and push)
IV piggyback
Volume controlled medication admin with a syringe pump

76
Q

What are continuous fluids?

A

Fluids pre-prepared commercially or via pharmacy with or without additives

77
Q

What is an example of a Hypotonic Fluid?

A

0.45% NaCL

78
Q

What are 3 examples of isotonic fluids?

A

0.9% NaCL
Lactated Ringers
D5W

79
Q

What are two examples of Hypertonic fluids?

A

3% NaCL
D10W

80
Q

What are 3 things to consider for an IV Push?

A

Not performed as a student
Most dangerous with high risk (especially with Lasik or Dioxin)
Verify rate as the amount per min

81
Q

An IVPB is?

A

A secondary bag or bottle that is hung higher

82
Q

PCA stands for?

A

Patient controlled Analgesia

83
Q

What 3 things are only adminstered through a central line?

A

Total Parenteral Nutrition (TPN)
Lipids
Caustic medications/vesicants

84
Q

What are 4 reasons why one would want to use an IV pump?

A

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
Q

What are 6 things you want to assess at the IV sight?

A

Assess for:
Size and Location
phlebitis
Infilration
Patency
Transparent dressing clean and dry
Insertion date

86
Q

What are the time restrictions for IVs?

A

IVF Bag changed every 24 hours
IV tubing changes every 72-96 hours

87
Q

What do you want to assess for a central line?

A

Type and Location
Insertion site
Sterile Dressing change
+Biopatch or antimicrobial dressing
Tubing Date

88
Q

What are the time restrictions for central line tubing?

A

Tubing change every 24 hours

89
Q

What do you want to assess for BOTH Iv and central line?

A

Renal Function: GFR, BUN, CR
Lung sounds
Assessments and Labs related to fluids/medications
Compatibility

90
Q

For a PIV catheter, how are gauge and diameter related?

A

Inversely, the larger the gauge, the smaller the diameter and vice versa

91
Q

What situation would you use a 16g needle?

A

Trauma patient
Rapid and Large fluid volume resucitation

92
Q

What situation would you use a 18g needle?

A

Surgical Patient
Blood Infusions

93
Q

What situation would you use a 20g needle?

A

Most common needle used
Minimum gauge for blood products

94
Q

What situation would you use a 22-24g needle?

A

Pediatrics/Elderly
Small veins

95
Q

What should always be labeled at the IV site?

A

Date and Time

96
Q

IV catheter sizes and flow rates are related how?

A

The larger the size of the gauge the faster the flow rate

97
Q

Nursing interventions for IV Therapy:
What are the interventions for an PIV?

A

Clean dressing change
Remove and insert in a new location per policy

98
Q

Nursing interventions for IV Therapy:
What are the interventions for a Central line?

A

Sterile Dressing change
Dedicated infusion ports
Central line bundles
Work towards discontinuing the central line ASAP

99
Q

Nursing interventions for IV Therapy:
What are the nursing interventions for both PIV and Central lines?

A

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
Q

What are the potential complications and risks with intravenous therapy:

PIV

A

Phlebitis
Infiltration
Extravasation (fluid flows out of a vessel to surrounding area)
Hematoma

101
Q

What are the potential complications and risks with intravenous therapy:

Central Line

A

Infection
Sepsis
Pneumothorax (air causing lung to collapse)
Thrombulus/Embolus
Dislodgement

102
Q

What are the potential complications and risks with intravenous therapy:

Both PIV and Central lines

A

Air Emboli
Fluid Overload-CV and Respiratory
incompatibility and precipitate in fluids
Electrolyte imbalances
Medication-Specific Adverse Reactions
Fall risk

103
Q

What are the symptoms of Phelbitis?

A

Pain
Edema
Erythema
Red Streak up arm ‘cord’
Skin Temp elevation over IV site
Slowed infusion

Sunday Evan ran pass even Sally.

104
Q

What are the treatments for Phlebitis?

A

Remove, Elevate, warm moist heat for 3-4 times a day

Insertion of new IV if needed

105
Q

What are the symptoms for Infiltration at an IV site?

A

Swelling
Pallor
Coolness at site
Pain proportionate to edema
Possible lowering of flow rate

106
Q

What are the symtoms of a hematoma?

A

Ecchymosis (discoloration of skin) at sight

107
Q

What are the treatments for a hematoma at an IV site?

A

Apply Pressure after removal, compress, elevate

108
Q

What are the symptoms of Fluid volume overload in regards to IVs?

A

Shortness of breath
Crackles
Tachypnea
Tachycardia
JVD
Increased Blood Pressure

109
Q

What are the treatments for Fluid volume overload at an IV site?

A

Slow IV Rate
Raise HOB
Apply O2
Administer diuretics as ordered
Notify Provider

110
Q

Hypovolemic fluid shifts are caused by?

A

Burns
Third Spacing
Ascities
Liver Failure

111
Q

Hypervolemic fluid shifts are caused by?

A

Hypertonic Fluids
Sodium Retention

112
Q

Hypervolemia (Fluid volume Excess) is caused by?

A

Excess salt intake
Decreased Fluid Losses

113
Q

Hypovolemia is caused by?

A

Insufficent fluid intake (anything that would cause you to loose water) since it’s a fluid volume deficit

114
Q

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

A

Fluid Volume Deficit

115
Q

What condition is causing these symptoms?
Bounding pulse, JVD, hypertension, edema, acute weight gain, crackles, tachypnea, dyspnea, orthopnea, confusion

A

Fluid Volume Excess

116
Q

Analysis of Priority Concept:
Aside from fluid balance, what other concepts might apply to patients experiencing fluid volume deficit or fluid volume excess?

A

Oxygenation
Sodium Imbalance
Potassium Imbalance
Acid-Base Imbalance
Peripheral Perfusion
Pitutary/Adrenal Metabolism
Elimination
Renal Perfusion
Tissue/Skin integrity

117
Q

First-Do Priority Interventions:
What are some priorities when dealing with Fluid volume deficit?

A

Isotonic IVF
Blood (if needed)
Evaluate urine
Measure orthostatics
Evaluate for shock
Take weight to see if changes occur

118
Q

If a patient is experiencing shock from a fluid volume deficit, what position should you put them in?

A

Supine position with legs elevated

119
Q

First-Do Priority Interventions:
What are some priorities when dealing with fluid volume overload?

A

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
Q

If a patient is experiencing Fluid Volume Excess what position should you place them in?

A

Semi-fowlers position

121
Q

Trend for Potential Complications:
What are some complications from Fluid Volume deficit?

A

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
Q

Trend for Potential Complications:
What are some complications from Fluid Volume Excess

A

Pulmonary Edema
Respiratory Failure
Heart Failure
Skin Breakdown
Impaired bowel function

NURS 713 Fundamentals of Nursing (4 decks)

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