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Nursing 251 > Exam 3--Client safety, mobility, restraints, pressure injuries, pain > Flashcards

Exam 3--Client safety, mobility, restraints, pressure injuries, pain Flashcards

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1
Q

When to do the fall risk assessment?

A

Older patients, history of falls, has fallen

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2
Q

what to have prepared and what to do for a patient having a seizure?

A

–Make sure rescue equipment is at bedside
–stay with client, call for help
measure vitals after
–document precipitating behavior and description
–O2, oral airway, suction, padding for side rails
Ensure rapid intervention with O2, airway, suction
–Saline lock in place for IV access for generalized seizure patients
–Advise caregivers not to put anything in clients mouth, and not to restrain during seizure
–Just lower client to floor or bed, protect head, move nearby furniture, privacy, turn head to side but flexed forward, loosen clothing

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3
Q

what is the most important rule when restraining a patient?

A
  • -use least restrictive possible, shortest duration possible, use as last resort
  • -make sure to have a provider order
  • -check vitals after, assess
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4
Q

when is it inappropriate to use restraints?

A
  • -Convenience of staff
  • -Punishment
  • -Clients who are extremely physically/mentally unstable
  • -Clients who cannot tolerate the decreased stimulation of a seclusion room
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5
Q

what 4 things should restraints do to not harm patient?

A
  • -Never interfere with treatment
  • -Restrict movement as little as is necessary
  • -Fit properly and to be discreet as possible
  • -Be easy to remove or change
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6
Q

how often to take off restraints and perform mobility?

A

every 2 hours

  • -assess for skin integrity
  • -perform hygiene
  • -monitor vitals
  • -ROM exercises
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7
Q

what does the prescription for restraints include? how does the time differ for adult–kid–less than 9 yr old?

A

–reason, type of restraints, location paled, how long to use, and type of behavior that warrants

– only 4 hours of restraint for adult, 2 hours for kids 9-17, 1 hour for less than 9

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8
Q

what 9 things do you need to document about restraints?

A
  • -precipitating events/behavior
  • -Alternative actions to avoids seclusion or restraints
  • -Time of application and removal
  • -Type of restraints and location
  • -Clients behavior w restraints
  • -Type and frequency of care (range of motion, neurologic checks, removal, skin checks)
  • -Condition of body part in restraints
  • -Clients response at removal of restraints
  • -Med administration
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9
Q

What is RACE with fire safety?

A

rescue
alarm
contain
extinguish

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10
Q

what is PASS with fire safety?

A

Pull pin
aim
squeeze
sweep

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11
Q

what is body mechanics? what are 2 things that good mechanics do?

A

–Body mechanics–use of muscles to maintain balance, posture and body alignment

  1. Body alignment keeps center of gravity stable
  2. Good mechanics reduces risk of injury
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12
Q

should you avoid repetitive movements when lifting/moving?

A

yes, avoid

could lead to injury

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13
Q

what is semi fowlers? what is it used for?

A

Supine, head of bed 15-45 degrees
Prevents regurgitation and aspiration
Good for ppl that can’t swallow well
Promotes lung expansion

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14
Q

what is fowlers? what is it used for?

A

Supine, head of bed 45-60
During procedures (nasogastric tube insertion/suctioning)
Better chest expansion and ventilation
Better dependent drainage after abd surgery

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15
Q

what is high fowlers? what is it used for?

A

Supine, bed 60-90
Promotes lung expansion by lowering diaphragm, relieve dyspnea
Helps prevent aspiration during meals

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16
Q

what is supine (dorsal recumbent) and what is it used for?

A

Lie on back w head and shoulders elevated on pillow, forearms on pillow or at sides
Food support prevents food drop, maintains proper alignment
Ensure vertebrae are straight

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17
Q

what is prone? what is it used for?

A

Lies flat on abd and chest, head to one side and back in correct alignment
Pillow can be placed under lef, promotes relaxation with knee flexion and dorsiflexion of ankles
Promotes drainage from mouth after throat or oral surgery, inhibits chest expansion
Short term only

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18
Q

what is lateral/side lying position?

A

Client lies on side with most weight on dependent hip and shoulder and the arms in flexion in front of body
Pillow under head and neck, upper arms, legs and thighs

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19
Q

what is sims’ or semi-prone? what is it used for?

A

Client on side halfway between lateral and prone
Weight is on anterior ileum, humerus, clavicle; lower arm behind them while upper in front; legs are in flexion but upper leg is flexed at greater angle
Differs from side lying in distribution of weight
Comfortable sleeping position
Promotes oral drainage

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20
Q

what is orthopneic positioning? what is it beneficial for?

A

Sits at bedside with pillow on overbed table, across lap
Rest arms on overbed table
Allows for chest expansion
Beneficial for COPD

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21
Q

what is trendelenburg? what is it good for?

A

Entire bed tilted w head of bed lower than foot

For postural drainage and venous return

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22
Q

what is reverse trendelenburg? what is it good for?

A

Entire bed tilted w foot of bed lower than head

Promotes gastric emptying and prevents esophageal reflux

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23
Q

what is modified trendelenburg? what is it good for?

A

Lying flat w legs above level of head of bed

Helps prevent and treat hypovolemia and facilitate venous return

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24
Q

what factors affect mobility?

A
  • -Alterations in muscles
  • -Posture
  • -Injury
  • -Impaired CNS
  • -Health status and age
  • can be temporary, permanent, sudden onset, slow onset
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25
Q

what are the effects of immobility on the integumentary system?

A
  • -Increased pressure on skin, aggravated by metabolic changes
  • -Decreased circulation to tissue causing ischemia
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26
Q

what are the effects of immobility on the respiratory system?

A
  • -Decreased oxygenation and CO2 exchange
  • -Stasis of secretions
  • -Decreased cough response

–nurse should encourage turn and cough every 2 hours

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27
Q

what are the effects of immobility on the cardiovascular system?

A

–Orthostatic hypotension
–Less fluid volume in circ system
–Diminished autonomic response
–Decreased cardiac output, effectiveness and leads to increased cardiac load
Increased O2 requirement
–Risk of thrombus development

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28
Q

what are the effects of immobility on the metabolic system?

A
  • -Changes in protein, carb, and fat metabolism
  • -Decreased appetite
  • -Loss of weight
  • -Alterations in Ca, fluid and electrolytes
  • -Reabsorption of Ca from bones
  • -Decreased urinary elimination of Ca, results in hypercalcemia
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29
Q

what are the effects of immobility on the elimination (genitourinary) system?

A
  • -Urinary stasis
  • -Change in Ca metabolism with hypercalcemia, leads to renal calculi
  • -Decreased fluid intake and increased use of indwelling urinary catheters, resulting in urinary tract infections
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30
Q

what are the effects of immobility on the GI system?

A
  • -Decreased peristalsis
  • -Decreased fluid intake
  • -Constipation, increasing risk for fecal impaction
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31
Q

what are the effects of immobility on the musculoskeletal system?

A
  • -Decreased endurance, strength, mass
  • -Impaired balance
  • -Atrophy of muscles
  • -Decreased stability
  • -Altered calcium metabolism
  • -Osteoporosis
  • -Pathological fractures
  • -Contractures
  • -Foot drop
  • -Altered joint mobility

–nurse should reposition every 2 hours, perform ROM exercises

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32
Q

what are the effects of immobility on the neurological/psychological system?

A
  • -Altered sensory perception
  • -Ineffective coping
  • -Emotional status changes–depression
  • -Behavioral changes
33
Q

what does heat vs cold treatment do?

A

heat: Increases blood flow
Increases tissue metabolism
Relaxes muscles
Eases joint stiffness and pain

cold: Decreases inflammation
Prevents swelling
Reduces bleeding
Reduces fever
Diminishes muscle spasms
Decreases pain by decreasing the velocity of nerve conduction
34
Q

what to look for when applying heat/cold treatment?

A 
Redness or pallor
pain/burning
Numbness
Shivering
Blisters
Decreased sensation
Mottling of skin
Cyanosis (cold)

–nurse should assess every 5-10 min

35
Q

what do antiembolic stockings do? how do ROM exercises promote blood flow?

A

–cause external pressure on muscles of lower extremities to promote blood return to heart

  • -ROM cause skeletal muscle contractions, which promote blood return
  • -Exercises: (Ankle pumps, Foot circles, Knee flexion)
36
Q

what is thrombophlebitis (deep vein thrombosis)?

A
  • -Inflammation of vein that results in clot formation
  • -Pain edema, warmth, erythema at site
  • -Assess bilateral calf and thigh circ
  • -Notify provider immediately
  • -Position leg elevated
  • -Avoid pressure on site of inflamm
  • -Anticipate giving anticoagulants
37
Q

what is a pulmonary embolism?

A
  • -Occlusion of blood flow to one or more of pulm arteries by a clot (usually comes from lower extremities)
  • -Shortness of breath, chest pain, hemoptysis (coughing blood), decreased BP, rapid pulse
  • -Prepare to give thrombolytics or anticoags
  • -Position client in semi fowlers
  • -Obtain pulse ox
  • -Admin O2
  • -Prepare to obtain blood gas analysis
  • -Monitor vital signs frequently
38
Q

what are the 3 stages of wound healing?

A
  • -inflammatory (3-6 days, vasoconstriction, WBCs, Macrophages, fibrin accumulation, clot formation_
  • -proliferative (3-24 days, connective tissue/granulation tissue and collagen, wound edges contract, new epi cells)
  • -maturation/remodeling stage (day 21, collagen and scar, normal appearance, can take more than 1 year)
39
Q

what is primary, secondary and tertiary wound healing?

A

primary intention–edges approximated, surgical incision, low risk for infection
secondary–wound edges widely separated, heal by granulation
tertiary–widely separated, deep, spontaneous opening of previously closed wound (dehiscence), closed later once infection is resolved

40
Q

what factors affect wound healing?

A

age, wellness, decreased leukocyte count, infection, anti-inflamm and antineoplastic meds; malnourishment, bad tissue perfusion, low HgB levels, obesity, chronic disease, smoking, wound stress

41
Q

what are the 5 principles of wound management?

A
  • -Wounds impair skin integrity
  • -Inflammation is a localized protective response to injury or destruction of tissue
  • -Wounds heal by various processes and in stages
  • -Wound infections result from the invasion of pathogenic microorgs
  • -Principles of wound care include assessment, cleaning and protection
42
Q

what does red, yellow, or black wound mean? What should you do for each?

A 
Red = healthy regeneration
Yellow = presence of purulent drainage
Black = presence of eschar that hinders healing and requires removal

Red–cover
Yellow–clean
Black–debride, remove necrotic tissue

43
Q

for drainage from a wound, what should you document and look for?

A
  • -Result of healing via inflammatory process
  • -Note amount, odor, color, consistency
  • -Note integrity of surrounding skin
  • -With each cleansing, observe the skin around a drain for irritation and breakdown
  • -For accurate measurement of drainage, weigh the dressing
  • -Remove sutures and staples
  • -Administer analgesics and monitor for effective pain management
  • -Admin antimicrobials (topical, systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count)
  • -Document location and type of wound and incision, status of wound, type of drainage, type of dressing and materials, client teaching, how the client tolerated the procedure
44
Q

what are different kinds of wound dressings?

A

–Woven gauze
Absorbs exudate
–Non Adherent material
Does not stick to the wound bed
–Damp to damp 4-inch by 4-inch dressing
Used to mechanically debride a wound until granulation tissue starts to form in the wound bed
Must keep moist at all times to prevent pain and disruption of wound healing
–Self-adhesive, transparent film
Temporary second skin for small superficial wounds
–Hydrocolloid
Occlusive dressing that swells in presence of exudate, composed of gelatin and pectin, forms seal
Maintains granulating wound bed
Leave for 3-5 days
–Hydrogel
Composition is mostly water, gels after contact with exudate, promoting autolytic debridement and cooling
Rehydrates and fills dead space
Might require secondary occlusive dressing
For infected, deep wounds or necrotic tissue
Provides moist wound bed
Not for moderate to heavy draining wounds
Soothing and can reduce wound pain
Prevents skin breakdown (sacrum)
–Alginates
Non adherent dressings that conform to the wounds shape and absorb exudate
Provides a moist wound bed
Packs wounds
Supports debridement
–Collagen
Powders, pastes, granules, sheets, gels
Helps stop bleeding
Promotes healing

45
Q

what is a wound vac good for?

A
  • -Use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing placed for negative pressure (suction) to occur one tubing is connected to unit
  • -Speeds up tissue generation
  • -Decreases swelling
  • -Enhances healing in a moist, protected environment
46
Q

what are 2 complications of wound healing?

A

–Dehiscence: Partial or total rupture/separation of a sutured wound, usually with separation of underlying skin layers

–Evisceration: A dehiscence that involves the protrusion of visceral organs through a wound opening
Manifestations
Significant increase in flow of serosanguineous fluid on the wound dressing
Immediate history of sudden straining (coughing, sneezing, vomiting)
Client report of a change or popping, giving way in wound area
Visualization of viscera

47
Q

when is hemorrhage most probable after injury/surgery?

A

24-48 hours

48
Q

what are signs of infection?

A 
Purulent drainage
Pain
Redness, edema
Fever, chills
Odor 
Increased pulse, RR
Increased WBC count
49
Q

what is a pressure injury? What are some manifestations/observations?

A

pressure injury: Deep tissue pressure injury, persistent nonblanchable deep red, maroon or purple discoloration

  • -Discoloration of non intact or intact skin from damage following prolonged or intense pressure or shear
  • -Intact skin is nonblanchable with deep red, maroon, purple discolor
  • -Open wounds have dark wound bed or blood blister
  • -Pain and temp changes can be detected earlier than color changes
  • -If subcut or granulation tissue or bone etc is showing, wound should be restaged
50
Q

what are the 4 (5) stages of a pressure injury?

A

–Stage 1: Non blanchable erythema of intact skin
Feels warmer or cooler than adjacent tissue
Swollen, can have diff texture than surrounding skin
Treatment
Relieve pressure, turn/reposition freq, use pressure-relieving devices
Keep dry, clean, well nourished, hydrated
–Stage 2: Partial thickness with exposed dermis
Involves epi and dermis
Wound bed is viable with reddish-pink bed without slough, eschar, granulation tissue, adipose tissue
Can appear as intact or ruptured blister
Treatment
Maintain moist healing environment (saline or occlusive dressing)
Hydrocolloid dressing
Nutritional supps
Admin analgesics
–Stage 3: Full thickness skin loss
Visible adipose tissue with poss granulation tissue and epibole (wound edges appear rolled under), some slough and eschar
No exposed underlying tissue
Some undermining or tunnel possible
Treatment
clean/debride wound
Use Prescribed dressing, surgical intervention, proteolytic enzymes
Nutrition supps
Admin analgesics
Admin antimicrobials (topical or systemic)
–Stage 4: Full thickness skin and tissue loss
Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments or tendon exposed in the wound
Epibole, tunneling and undermining common
Treatment
Clean, debride
Use prescribed dressing, surgical intervention, proteolytic enzymes
Perform non adherent dressing changes every 12 hours
Treatment can include skin grafts or specialized therapy (hyperbaric o2)
Nutrition supps
Analgesics
antimicrobials
–unstageable: obscured, full thickness skin and tissue loss
No determination of stage bc eschar or slough obscures the wound bed
Actual depth of injury is unknown unless slough and eschar removed, at which time the wound is restaged
Treatment
Debride until stageable
Do not use alcohol, dakin’s solution, acetic acid, povidone iodine, hydrogen peroxide, or other cytotoxic cleansers on pressure injury wound

51
Q

what is epibole of a wound? (pressure wounds)

A

wound edges appear rolled under

52
Q

what should you do to help wound healing?

A

–raise heels of bed, monitor for sepsis (LOC, fever, tachycarida, tachypnea, hypotension, increase in WBC, oliguria); reposition every 2 hours, keep head of bed at or below 30 degrees, no wrinkles in sheets, skin hygiene, do not massage bony prominences

53
Q

what are the 2 types of pain? which is protective, which is not?

A

acute–protective, temporary, self limiting

chronic–non protective, lasts longer than 6 months

54
Q

what is idiopathic pain?

A

pain without a known cause

55
Q

what is nociceptive pain? what are the 3 kinds?

A

–Arises from damage or inflammation of tissue
–Triggers pain receptors (nociceptors)
–Throbbing, aching, localized
–Responds to opioids and non-opiods
–Types of noci pain
(Somatic)
Bones, joints, muscles, skin, connective tissues
(Visceral)
Internal organs
Can cause referred pain in other body locations
(Cutaneous)
Skin, subq tissue

56
Q

what is neuropathic pain? what is allodynia?

A
  • -Arises from abnormal or damaged pain nerves
  • -Phantom limb pain, pain below level of spinal cord injury, diabetic neuropathy
  • -Intense, shooting, burning, pins and needles
  • -Responds to adjuvant meds (antidepressants, antispasmodic agents, skeletal muscle relaxants)
  • -Topical meds for peripheral neuropathic pain
  • -Allodynia – characteristic feature (stimulus that creates pain that usually wound not be painful)
57
Q

what is psychogenic pain?

A
  • -More psychological in nature

- -Unable to determine a physical cause for the pain

58
Q

what are the 4 processess of nociceptive pain?

A

transduction–conversion of painful stimuli to electrical impulse through peripheral nerve fibers (nociceptors)
transmission– electrical impulse travels along nerve fibers, neurotransmitters regulate it
perception–pain tolerance, pain threshold, physical dependence, addiction
modulation–Occurs in spinal cord, causing muscles to contract reflexively, moving body away from painful stimuli (neuromodulators: endorphins, dynorphin–enkephalins)

59
Q

what is the gate control theory of pain?

A
  • -Describes the transmission of painful stimuli
  • -Recognizes a relation between pain and emotions
  • -“Rubbing head after hitting it” makes it feel better
  • -Perception of Pain: Pain Threshold
60
Q

what are 4 substances that cause an inflammatory response, and what are 2 substances that decrease pain transmission and produce analgesia?

A

inflammation:
- -Substance P
- -Prostaglandins
- -Bradykinin
- -Histamine

analgesia:
- -serotonin
- -endorphins

61
Q

what are neuromodulators?

A
  • -have an analgesic activity and alter the perception of pain
  • -Are endogenous opioid compounds
  • -Morphine-like regulators in the spinal cord and brain
  • -Produce their analgesic effect by binding to specific opioid receptor sites, blocking the release or production of pain transmitting substances
  • -Response can be: Physiologic, Behavioral, Affective
62
Q

what 7 things should you ask when evaluating pain?

A

Ask about location
Ask about how it feels
Ask about intensity, strength and severity
Ask about setting (how it affected ADL)
Ask about the timing (onset, duration, frequency)
Ask about associated findings (anxiety, fatigue, nausea, depression etc)
Ask about aggravating and relieving factors

63
Q

what populations are at risk for under-treatment of pain?

A

Infants
Children
Older adults
Clients who have substance use disorder

64
Q

what are some causes of acute and chronic pain?

A 
Trauma
Surgery
Cancer
Arthritis
Fibromyalgia
Neuropathy
Diagnostic or treatment procedures (injection, intubation, radiation)
65
Q

what factors affect a person’s pain experience?

A 
Age
Fatigue
Genetic sensitivity
Cognitive function
Prior experiences
Anxiety and fear--increases sensitivity to pain
Support systems and coping styles
Culture
66
Q

what are some observations and measurements to make during a pain assessment?

A

–Facial expressions
–BP, pulse, RR increase with acute pain (vitals will stabilize eventually)
–Hyperalgesia (heightened sense of pain)
–Allodynia
Condition in which client experiences pain during things that are not usually painful (wearing clothes, wind blowing etc)

67
Q

what are the 3 types of analgesics?

A

non-opioids: Acetaminophen, NSAIDs, salicylates

opioids: morphine, fentanyl, codeine
adjuvants: Anticonvulsants, Antianxiety agents, Tricyclic antidepressants, Antihistamine, Glucocorticoids, Antiemetics, Bisphosphonates and calcitonin

68
Q

what should you assess for with a patient on opioids?

A

–Essential to monitor use and intervene for adverse effects
–Sedation
–Measure LOC and take precaution for resp depression
–Respiratory depression
–Orthostatic hypotension
–Urinary retention
–Monitor for I&O, assess for distension, admin bethanechol, catheterize
nausea/vomiting
–Constipation
–Monitor BMs, fluids, fiber intake, exercise, stool softeners, stimulant laxatives, enemas

69
Q

what should you be aware of when using a non-opioid and an opioid together?

A

–opioids have acetaminophen too

beware of hepatotoxic affects of acetaminophen

70
Q

what are non-pharmacological pain interventions?

A
  • -Cognitive behavioral measures
  • -Skin stimulation: Interruption of pain pathways, Cold for inflamm, Heat to increase blood flow
  • -Distraction
  • -Relaxation
  • -Imagery
  • -Divert focus
  • -Acupuncture, acupressure
  • -Reduction to pain stimuli
  • -Elevation of edematous extremities (promote venous return, decrease swelling)
71
Q

what are 3 other pain interventions?

A

topical, local, and regional anesthesia

72
Q

what happens if someone has too much of an opioid?

A

–Sedation, respiratory depression, coma can occur
Identify high risk clients (older, opioid naive)
–Stop opioid and five antagonist naloxone if RR is below 8/min and shallow, or client is difficult to arouse
–Titrate client dose closely while monitoring RR
–Identify cause of sedation

73
Q

what is breakthrough pain?

A
  • -Pain that breaks through a treatment regimen

- -Another method/drug needs to be used then in addition to current treatment to help

74
Q

what is ADPIE for pain management?

A

Assessment
Planning
Diagnosis
Planning/outcome identification
Implementation–understand use of medications, using combination of pain meds and adjuvant therapy
Evaluation, reassess pt to see if intervention was effective

75
Q

what causes a pressure ulcer?

A
  • -Prolonged tissue ischemia from pressure on capillaries
  • -Occur over bony prominences
  • -Characterized by inflammation
  • -Increased risk for elderly and in paralysis
  • -Can happen in 1-2 hours
76
Q

what are risk factors for decubitus ulcers?

A 
Collagen Loss
Decreased subcutaneous tissue
Low serum albumin
Incontinence
Use of cooling blankets
Wrinkled linen
Altered circulation
77
Q

what are the 4 sleep cycle stages?

A 
--Stage 1 NREM
(Very light sleep
Only few minutes
Muscle relaxation
Loss of awareness and surroundings
Vital signs and metabolism decrease
Awakens easily
Feels relaxed and drowsy)
--Stage 2 NREM
(Deeper sleep
20 min
Vital signs and metabolism continuing to slow
Requires slightly more stimulation to awaken
Increased relaxation)
--Stage 3 NREM
(Slow wave sleep or delta sleep
Vital signs decreasing
More difficult to awaken
Psychological rest and restoration
Reduced sympathetic activity)
--REM
(Vivid dreaming
90 min after falling asleep, recurring every 90 min
Longer with each sleep cycle
20 min long average
Varying vital signs
Very difficult to awaken
Cognitive restoration)
78
Q

what are 4 sleep disorders?

A

Insomnia–acute or chronic
Sleep apnea–central or obstructive
Narcolepsy–sudden attacks
Hypersomnolence disorder–excessive daytime sleepiness

Nursing 251 (5 decks)

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