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EXAM 4 Flashcards

PAIN, SKIN INTEGRITY, WOUND, NUTRITION, POST MORTEM, HIPAA, PHYSIOLOGY, OSTOMY, NG, ENTERNAL TUBE FEEDING, CENTRAL VENOUS WEEKS 10-13

1
Q

ACTURE/TRANSIENT PAIN

A

PROTECTIVE MECHANISM THAT HAS AN IDENTIFIABLE CAUSE, IS OF SHORT DURATION, AND LIMITED TISSUE DAMAGE

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2
Q

CHRONIC/PERSISTENT NONCANCER PAIN

A

CONSTANT OR RECURRING PAIN THAT LASTS LONGER THAN 6 MONTHS, SEEMS TO SERVE NO PROTECTIVE PURPOSE AND MAY NOT HAVE AN INDENTIFIABLE CAUSE. IT YIELDS TO GREAT PERSONAL SUFFERING AND CAN BE DEBILITATING THOUGH IT IS NOT LIFE THREATENING

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3
Q

CHRONIC EPISODIC PAIN

A

OCCURS OVER TIME IN UNPREDICTABLE EPISODES SUCH AS HEADACHES

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4
Q

CANCER PAIN

A

OCCURS DUE TO ACUTE AND CHRONIC NOCICEPTIVE OR NEUROPATHIC REASONS. CANCER PAIN HAS BE FOUND TO BE SORELY UNDERTREATED BY HEALTH CARE PROFESSIONALS

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5
Q

INFERRED PATHOLOGICAL PAIN

A

SOMATIC OR VISCERAL PAIN OF NOCICEPTIVE OR NEUROPATHIC NATURE DUE TO INTERNAL ORGAN PATHOLOGY OR DAMAGED NERVES

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6
Q

IDIOPATHIC PAIN

A

CHRONIC PAIN IN THE ABSENCE OF AN IDENTIFIABLE CAUSE. THERE IS NO ABILITY TO SEE OR FEEL TISSUE DAMAGE AT THE SITE OF PAIN

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7
Q

PHANTOM PAIN

A

PERCEPTIONS RELATED TO LIMB OR ORGAN THAT IS NOT PHYSICALLY PART OF THE BODY

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8
Q

WHY PAIN IS BAD

A

CONFUSION
FALLS
IMMOBILITY (PNEUMONIA, SKIN BREAKDOWN, CLOTS)
POOR NUTRITION
DEHYDRATION

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9
Q

WHY TREATING PAIN IS GOOD

A

HAPPIER WITH TREATMENT OUTCOMES
REGAIN MOBILITY
RETURN TO NORMAL ACTIVITIES
SHORTER HOSPITAL STAYS
FEWER DOCTOR VISITS

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10
Q

SOCIOLOGICAL/CULTURAL FACTORS THAT INFLUENCE PAIN

A
  1. KNOWLEDGE, BELIEFS, ATTITUDES
  2. FAMILY/FRIENDS SUPPORT
  3. HOW PAIN SHOULD BE EXPRESSED- QUIET/STOIC
  4. PRIOR EXPERIENCES
  5. PRAYERS/CHAPLAIN/WHY ME- SPIRITUAL
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11
Q

PHYSIOLOGICAL FACTORS INFLUENCING PAIN

A
  1. AGE
  2. PEDS HAVE DIFFICULTY EXPRESSING PAIN
  3. NOT A GENDER RESPONSE
  4. MAY HAVE GENETIC COMPONENT
  5. OLDER ADULTS MAY HAVE AGITATION, CONFUSION, LACK OF SLEEP, FATIGUE MAY WORSEN PAIN
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12
Q

ATTENTION TO VS DISTRATION FROM PAIN

A

ATTENTION TO PAIN MAY HEIGHTEN IT WHILE DISTRACTION MAY EASE IT

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13
Q

PSYCHOLOGICAL FACTORS INFLUENCING PAIN

A

ANXIETY
FEAR
COPING STYLE

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14
Q

NUMERIC SCAL

A

0 = NO PAIN
10 = SEVERE PAIN

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15
Q

FACES PAIN SCALE

A

GOOD FOR PEDS
POINT TO FACE

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16
Q

OUCHER PAIN SCALE FOR CHILDREN

A

SHOW FACES, CHILD SHOULD CHOOSE FACE TO MATCH FEELINGS. EVEN CHILDREN LEARN CULTURAL EXPRESSION OF PAIN

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17
Q

SYMPATHETIC NERVOUS SYSTEM
INITIAL ACUTE PAIN

AUTONOMIC NERVOUS SYSTEM

A
  1. FIGHT OR FLIGHT
  2. INCREASED HR, RR, BP
  3. PALLOR, DISPHORESIS
  4. INCREASED GLUCOSE
  5. PUPILLARY DILATION
  6. DECREASED GASTRIC MOBILITY
  7. MUSCLE TENSION
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18
Q

PARASYMPATHETIC NERVOUS SYSTEM
CONTINUOUS, SEVERE PAIN

AUTONOMIC NERVOUS SYSTEM

A
  1. REST AND DIGEST
  2. DECREASED HR, RR, BP
  3. PALLOR, MUSCLE TENSION
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19
Q

NEUMONIC FOR ASSESSING PAIN

A

PQRSTU

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20
Q

P OF PQRSTU

A

Palliative or Provoking factors- what makes pain better or worse?

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21
Q

Q OF PQRSTU

A

Quality– How do you describe your pain? Sharp, dull, throbbing, aching

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22
Q

R OF PQRSTU

A

Region or Radiation of pain- show where you hurt? Does it spread to other areas?

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23
Q

S OF PQRSTU

A

Severity (0-10)

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24
Q

T OF PQRSTU

A

Timing- is pain intermittent or constant? When did it start & how long does it last?

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25
Q

U OF PQRSTU

A

U-Effect of pain on UR life and activities?

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26
Q

WHAT MUST YOU ALWAYS, ALWAYS DO WITH PAIN

A

*DOCUMENT, DOCUMENT, DOCUMENT- DOCUMENT your reassessment!

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27
Q

DISTRACTION

Non-Pharm measures

A

ACTIVITIES
Guided Imagery, Relaxation, Music, Repositioning

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28
Q

BIOFEEDBACK

Non-Pharm measures

A

person relaxes & decreases RR & HR, Herbals- anti-inflammatory or analgesics

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29
Q

HOLISTIC OPTIONS

NON PHARM MEASURES

A

ACUPUNCTURE
CHIROPRACTOR

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30
Q

Cutaneous Stimulation-

NON PHARM MEASURES

A

interfere w electrical energy in pain-Heat, ice, TENS, Massage

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31
Q

3 OPTIONS FOR ACUTE PAIN MANAGEMENT

A

NONOPIOID
ACETAMINOPHEN
ADJUVANT

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32
Q

Nonopioid:

ACUTE PAIN MANAGEMENT

A

NSAIDs
SE- GI bleeding, renal insufficiency, HTN
Ex. Ibuprofen, ASA

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33
Q

ACETAMINOPHEN

ACUTE PAIN MANAGEMENT

A

SE- Hepatotoxicity
Often in med combos
4 gm Max/Day

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34
Q

ADJUVANT

ACUTE PAIN MANAGEMENT

A

Used to treat other conditions
Pair well w/ pain meds
Ex- antidepress., antianxiety, sedatives, corticosteroids

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35
Q

WHEN ARE OPIOIDS USED

A

FOR MODERATE TO SEVERE PAIN

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36
Q

WHAT SYSTEM DO OPIOIDS WORK ON

A

CNS

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37
Q

SIDE EFFECTS OF OPIOIDS

A

N&V
CONSIPATION- LONG LASTING SIDE EFFECT
ITCHING
URINARY RETENTION
ALTERED MENTAL STATUS

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38
Q

RESPIRATORY DEPRESSION WITH OPIOIDS

A

NAIVE PTS
WATCH FOR SEDATION

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39
Q

PASERO

A

OPIOID INDUCED SEDATION SCALE
AWAKE, ALERT TO SOMNOLENT

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40
Q

NARCAN

A

REVERSES OPIOID EFFECTS
MONITOR VS FREQUENTLY AFTER ADMIN BECAUSE IT HAS A SHORTER 1/2 LIFE

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41
Q

BASIC MEASUREMENT OF ALL NARCOTICS

A

MORPHINE
JUST LIKE GRAMS ARE THE BASIC MEASURE IN THE METRIC SYSTEM

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42
Q

Patient Controlled Analgesia (PCA)

A

Drug delivery system that permits patient to self administer opioids with minimal risk of overdose

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43
Q

HOW MIGHT PCA BE ADMINISTERED

A

SQ OR IV

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44
Q

WHO CONTROLS PCA

A

PATIENT PUSHES BUTTON
NOT NURSE
NOT FAMILY

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45
Q

TEACHING OF PCA

A

Patient must be taught to dose sooner rather than later

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46
Q

NURSE ROLE IN PCA

A

Nurse monitors system & assesses pain, monitors for over-sedation, respiratory depression

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47
Q

Pharmacological Therapies

A

TOPICAL ANALGESICS
LOCAL ANESTHESIA
REGIONAL ANESTHESIA
PERINEAL LOCAL ANESTHETIC
EPIDURAL ANALGESIA

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48
Q

TOPICAL ANALGESICS

PHARMACOLOGICAL THERAPIES

A

CREAMS
OINTMENTS
PATCHES (NSAID PRODUCTS, CAPSAICIN)

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49
Q

LOCAL ANESTHESIA

A

LOCAL INFILTRATION OF AN ANESTHETIC MEDICATION TO INDUCE LOSS OF SENSATION TO A BODY PART
EXAMPLE: LIDODERM PATCH

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50
Q

REGIONAL ANESTHESIA

A

A PARTICULAR REGION OF THE BODY

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51
Q

PARINEURAL LOCAL ANESTHETIC INFUSION

A

BLOCK MOTOR AND SENSORY NERVES

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52
Q

EPIDURAL ANALGESIA

A

REGIONAL
ABDMINISTERED INTO EPIDURAL SPACE

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53
Q

WHY CAN’T WE USE NUMERICAL SCALE FOR YOUNGER PEDS

A

IT IS ABSTRACT FOR THEM. THEY CAN’T UNDERSTAND THE CONCEPT

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54
Q

WHO ARE THE EXPERTS WITH PAIN

TIPS FOR EFFECTIVE PAIN MANAGEMENT

A

PATIENTS

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55
Q

WHO SHOULD YOU ESTABLISH A RELATIONSHIP OF TRUST WITH?

TIPS FOR EFFECTIVE PAIN MANAGEMENT

A

PATIENT AND FAMILY

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56
Q

WHAT SHOULD WE AVOID LABELING PATIENTS AS

TIPS FOR EFFECTIVE PAIN MANAGEMENT

A

DRUG SEEKING

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57
Q

HOW SHOULD DOSING BE SET UP FOR EFFECTIVE MANAGEMENT

A

Around the clock dosing can be more effective than PRN dosing since a steady blood serum is maintained

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58
Q

WHICH PAIN INTERVENTIONS SHOULD YOU DOCUMENT

A

NONPHARM AND PHARM

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59
Q

CONSTIPATION WITH PAIN MANAGEMENT

A

Constipation is a primary symptom that remains in long term opioid administration (Stimulant laxative preferred over stool softener)

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60
Q

PHYSICAL DEPENDENCE

BARRIERS TO USE OF OPIOIDS

A

need for the drug to have pain relief. Withdrawal symptoms if med stopped abruptly- shaking, chills.

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61
Q

ADDICTION

BARRIERS TO USE OF OPIOIDS

A

compulsive use or impaired use of a drug despite harmful effects or cravings. Addiction is rare in appropriate short term addiction use.

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62
Q

TOLERANCE

BARRIERS TO USE OF OPIOIDS

A

need for higher dosage to receive the same pain relief result

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63
Q

PAIN BREAK THROUGH

BARRIERS TO USE OF OPIOIDS

A

occurs when the amount of drug given is not sufficient for the level of pain experienced. It may be due to an increase in pathology or change in activity level.

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64
Q

HOW CAN CARE BE CONTINUED OUTSIDE OF THE HOSPITAL

A

PAIN CLINICS
PALLIATIVE CARE
HOSPICES

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65
Q

HOW DO PAIN CENTERS TREAT PATIENTS

A

ON AN INPATIENT OF OUTPATIENT BASIS

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66
Q

WHAT IS THE GOAL OF PALLIATIVE CARE

A

TO LEARN HOW TO LIVE LIFE FULLY WITH AN INCURABLE CONDITION

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67
Q

WHAT ARE HOSPICE PROGRAMS FOR

A

END OF LIFE CARE
TYPICALLY 6 MONTH PROGNOSIS OR LESS

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68
Q

“I JUST DON’T LIKE TO TAKE MEDS”

A

THINK ITS BAD- MUST EDUCATE
MUST TAKE AS PRESCRIBED
CULTURAL ISSUES
DON’T LIKE THE WAY IT MAKES THEM FEEL

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69
Q

ALLERGY VS ADVERSE REACTION

A

ALLERGY- CODEIN MAKES THROAT CLOSE UP
ADVERSE ACTION- N&V, ADDICTION, DON’T LIKE FEEL

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70
Q

PERCEPTIONS RELATED TO LIMB OF ORGAN THAT IS NOT PHYSICALLY PART OF THE BODY
A. IDIOPATHIC PAIN
B. CANCER PAIN
C. PHANTOM PAIN
D. ACUTE PAIN

A

C

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71
Q

MECHANISM THAT HAS AN IDENTIFIABLE CAUSE, IS OF SHORT DURATION, AND LIMITED TISSUE DAMAGE
A. ACUTE PAIN
B. EPISODIC PAIN
C. CHRONIC PAIN
D. CANCER PAIN

A

A

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72
Q

PAIN CAUSES
A. CONFUSION
B. FALLS
C. IMMOBILITY
D. ALL OF THE ABOVE

A

D

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73
Q

PAIN SCALE USED FOR CHILDREN
A. NUMERICAL
B. ANESTHESIAS SCALE
C. FACES
D. CHILDREN DON’T HAVE PAIN

A

C

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74
Q

WHAT MIGHT A PED PT SAY IF THEY ARE NAUSEATED

A

MY STOMACH HURTS OR DOESN’T FEEL GOOD

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75
Q

NONPHARM MEASURES FOR PAIN
A. MEDITATION
B. MASSAGE
C. ACUPUNCTURE
D. ALL OF THE ABOVE

A

D

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76
Q

HOW TO TIE NUMBERS OF PAIN SCALE TO WHAT THEY CAN UNDERSTAND

A

0 = NO PAIN
5 = MODERATE PAIN- MIGHT NEED MEDS, MIGHT NOT
10 = WORST PAIN EVER, LIKE STICKING HAND IN FIRE

*DOCUMENT WHAT THEY SAY REGARDLESS

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77
Q

WHY DO WE NEED VERBAL DISCRIPTION OF PAIN

A

WE WANT AS MUCH INFO ABOUT PAIN AS WE CAN

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78
Q

FLACC SCALE

A

NONVERBAL
ICU
ANESTHESIA
GRIMACING, MOANING, GRUNTING

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79
Q

MAX DOSE OF ACETAMINOPHEN FOR ADULTS
A. 2 G/D
B. 1 G/D
C. 4 G/D
D. 5 G/D

A

C
BUT REALLY 3 G/D IS SAFER

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80
Q

OPIOIDS ARE FOR MODERATE TO SEVERE PAIN

TRUE OR FALSE

A

TRUE

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81
Q

DIARRHEA IS A SIDE EFFECT OF OPIOID USE

TRUE OR FALSE

A

FALSE

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82
Q

WHO CAN PUSH THE PCA BUTTON
A. NURSE
B. FAMILY
C. DOCTOR
D. PATIENT

A

D

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83
Q

END OF LIFE PROGRAMS ARE REFERRED TO AS
A. HOME HEALTH
B. HOSPICE
C. NURSING HOME
D. ASSISTED LIVING

A

B

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84
Q
A
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85
Q

WHEN SHOULD YOU REEVALUATE AFTER GIVING PAIN MEDS

A

30 MINUTES

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86
Q

WHAT HAPPENS IF IT WASN’T DOCUMENTED

A

IT WASN’T DONE

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87
Q
A
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88
Q

WHO WOULDN’T GET NSAIDS

A

BLEEDING DISORDERS
ON BLOOD THINNERS OR ASPIRIN

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89
Q

CONCERNS WITH TYLENOL

A

COLD MEDS
COMBO MEDS
LIVER ISSUES

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90
Q
A
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91
Q

WHAT PAIRS WELL WITH PAIN MEDS

A

ANTIDEPRESSANTS
ANTIANXIETY

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92
Q

USES FOR ANTIDEPRESSANTS

A

DEPRESSION
PAIN
INSOMNIA
*ASK WHY THEY ARE TAKING THE MED

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93
Q

Pressure injury

A

localized damage to the skin orunderlying tissue resulting from prolonged pressureand/or friction to the skin, predominately occurring overthe bony prominences

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94
Q

NPUAP

A

NATIONAL PRESSURE ULCER ADVISORY PANEL

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95
Q

HOW LONG DOES IT TAKE FOR A PRESSURE INJURY TO BEGIN

A

WITHIN 2 HOURS WHICH IS WHY WE TURN THEM AT LEAST EVERY 2 HOURS

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96
Q

WHAT CAUSES A PRESSURE INJURY

A

BLOOD FLOW IS LOST LIKE PINCHING A STRAW WHEN VASCULAR IS PINCHED

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97
Q

WHAT DOES NPUAP DO

A

NATIONALLY STANDARDIZE PRESSURE WOUND TERMINOLOGY. DOESN’T MATTER FACILITY, IT’S THE SAME. THEY ALSO STANDARDIZE STAGING, DEFINITIONS, REPORTING METHODS.

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98
Q

NOVEMBER 15

A

NATIONAL STOP PRESSURE INJURY DAY

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99
Q

Why do you think it is important to have a committee that standarizes how we assess, document and identify wounds

A

WE NEED TO KNOW WHAT WE ARE LOOKING AT

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4
5
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100
Q

INSURANCE REIMBURSEMENT

PRESSURE INJURY

A

DOESN’T PAY IF THEY DIDN’T COME IN WITH IT. THIS AFFECTS YOUR BOTTOM LINE.

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101
Q

HOW CAN SOMEONE DIE FROM A PI

A

SEPSIS- INFECTION IN BLOOD

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102
Q

MEDICAL STAFF

PI

A

MORE WORK ON YOU

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103
Q

COST TO HEAL

PI

A

9.1 BILL PER YEAR IN THE US ON WOUND HEALING
10.20K-151K /WOUND
11.MORE THAN 17000 LAWSUITS PER YEAR

104
Q

WHAT MEDICATION IS USED MOST ON PI

A

SILVER
Ag

105
Q

WHY SO MANY PI LAWSUITS

A

PREVENTABLE
EVERY WOUND IS TO A DEGREE

106
Q

When looking in the patient’s chart, there was no documentation stating the patient arrived at the hospital with a wound to the left heel.
What ramifications will the hospital have?

A

FINANCIAL RESPONSIBLE
LAWSUIT
INFECTION

107
Q

When looking in the patient’s chart, there was no documentation stating the patient arrived at the hospital with a wound to the left heel.
What will the insurance company pay for?

A

NO

108
Q

ELDERLY

AT RISK FOR PI

A

THIN SKIN
DECREASED HYDRATION, ELASTICITY, CIRCULATION, IMMUNE SYSTEM. MORE SEDENTARY.

109
Q

POOR HEALTH/COMORBIDITIES

RISK FOR PI

A

SENSORY ISSUES, NEUROPATHY (PAIN OR NUMBNESS), ALTERED LOC (MEDICATIONS, TBI, ACCIDENT, DEMENTIA), INCONTINENCE (ELDERLY, CHILDREN, BUT COULD BE YOUNGER ADULT), POOR NUTRITION (TEETH PROBLEMS- ELDERLY)

110
Q

IMMOBILITY AND SPINAL INJURY

RISK FOR PI

A

FRICTION AND SHEAR OF OTHERS MOVING THEM

111
Q

BABIES

RISK FOR PI

A

HEAD- NICU OR NEGLECT

112
Q

BRADEN SCALE

A

TOOL USED TO PREDICT/PREVENT PI

113
Q

CATEGORIES OF BRADEN SCALE

A

MOBILITY, NUTRITION, FRICTION, MOISTURE, ACTIVITY

114
Q

MOBILITY

BRADEN SCALE

A

BEDFAST, CHAIRFAST, WALKS OCCASIONALLY, WALKS FREQUENTLY

115
Q

NUTRITION

BRADEN SCALE

A

POOR, INADEQUATE, ADEQUATE, EXCELLENT
*EAT MORE PROTEIN

116
Q

FRICTION

BRADEN SCALE

A

PROBLEM, POTENTIAL PROBLEM, NO PROBLEM

117
Q

MOISTURE

BRADEN SCALE

A

CONSTANTLY, VERY MOIST, OCCASSIONALLY MOIST, RARELY

118
Q

ACTIVITY

BRADEN SCALE

A

COMPLETELY LIMITED, VERY, SLIGHTLY, NO IMPAIRMENT

118
Q

95-year-old female who eats 20% of each meal, on bed rest and continent of urine

RISK FACTORS

A

MOBILITY
POOR NUTRITION
AGE- SKIN INTEGRITY

119
Q

LOWER BRADEN SCORE EQUALS

A

higher the risk (less than 9 extremely high)

120
Q

24-year-old male who eats 95% of each meal, unable to walk due to paralyzation to left side,on oxygen via nasal cannula, A&O x 1 (self)

A

LOC
MOBILITY
NC- NOSE/EARS

121
Q

2-week-old infant in NICU receiving treatment for gastrointestinal and cardiac congenital disorders

A

NUTRITION- SHOULD BE OKAY WITH NGT
MOBILITY
COMORBIDITIES- PERFUSION/CIRCULATION, SURGICAL SITES

122
Q

54-year-old CHF patient receiving chemotherpy, continent of B&B, inability to transfer self, due to increased weakness from chemo treatment

A

CIRCULATION
WEAKENED IMMUNE SYSTEM
SHEARING/MOBILITY

123
Q

BRADEN SCALE SCORE OVERVIEW

A

6-23 SCALE: Scale of 1-4 in each category, friction 1-3

124
Q

PREVENTION OF PI

A

ASSESSMENT- BEHIND EARS, BETWEEN TOES, SKIN FOLDS ARE OFTEN MISSED
2. POSITION/TURN Q2H
3. SUPPORT PILLOWS/MATTRESSES, SEAT CUSHIONS
4. SKIN CARE- CLEAN, DRY, PERICARE IS CRITICAL
5. EXERCISE- UP AND MOVING FOR CIRCULATION
6. IMPROVED NUTRITION- ENCOURAGE- DON’T SIT TRAY DOWN AND LEAVE
7. PROMPT CARE FOR INCONTINENT PATIENTS- CHECK Q2H

125
Q

Signs of Possible PI

A

Redness that won’t blanch
Darkened areas on skin
Warm skin areas
Purple, blue or shiny skin

126
Q

AT FIRST SIGN OF A PI, WHAT SHOULD YOU DO

A

RELIEVE PRESSURE FOR 30 MINUTES AND REEVALUATE

127
Q

Commonly Missed Assessment Areas

A

Nasal area and behind the ears- especially withpatient is using O2
Back of the head
Heels
Shoulder blades and shoulders
Tips of toes and ankles

CHECK THE ENTIRE BODY

128
Q

Name three ways to prevent pressure injuries.

A
  1. TURNING Q2H OR MORE
  2. ENCOURAGE AMBULATION AND ROM
  3. SKIN CARE- CLEAN, DRY
129
Q

What does non-blanchable mean?

A

DOESN’T TURN WHITE AND BACK RED… NO COLOR CHANGE

130
Q

Name 2 indicators of a possible PI

A

NON BLANCHABLE
ERYTHEMA
SHINY

131
Q

Name 3 commonly missed areaswhen assessingfor PI’s.

A

BETWEEN TOES
ANKLES
EARS

132
Q

WHY IS STANDARDIZATION OF CRITERIA IMPORTANT FOR STAGING WOUNDS

A

THEY VARY IN SIZE AND SHAPE
IT’S IMPORTANT FOR HOLISTIC CARE

133
Q

SKIN INTEGRITY

HOW TO STAGE WOUNDS

A

INTACT OR OPEN

134
Q

SKIN COLOR

HOW TO STAGE WOUND

A

IN COMPARISON TO NORMAL/HEALTHY SKIN

135
Q

DEPTH OF AREA

HOW TO STAGE WOUNDS

A

HOW DEEP IS THE WOUND

136
Q

STAGE 1 WOUND

A

NON- BLANCHING
ERYTHEMA
INTACT SKIN
CHANGES IN SENSATION, TEMP, OR FIRMNESS
NOT PURPLE OR MAROON
*RELIEVE PRESSURE FOR 30 MIN AND REEVALUATE

137
Q

STAGE 2 WOUNDS

A

PARTIAL LOSS OF EPIDERMIS
EXPOSING DERMIS
WOUND BED VIABLE, PINK, OR RED
BLISTER- OPEN OR CLOSED
SHOULD NOT BE BLEEDING UNLESS YOU ARE WIPING THEM HARD

138
Q

WHAT IS NOT INCLUDED AS A STAGE 2 WOUND

A

MEDICAL ADHESIVE RELATED SKIN INJURY (MARSI)
DERMATITIS
TRAUMATIC WOUNDS (BURNS, SKIN TEARS, ABRASIONS)
SURGICAL SITE

139
Q

STAGE 3 WOUND

A

FULL THICKNESS SKIN LOSS
ADIPOSE TISSUE IS PRESENT (WHITE)
EDGES CAN HAVE EPIBOLE
IF SLOUGH AND ESCHAR- ONLY AT SIDES
WATCH FOR UNDERMINING AND TUNNELING

140
Q

IF YOU CAN’T SEE THE BASE OF A WOUND, IS IT STAGE 3

A

NO

141
Q

EPIBOLE EDGES

A

ROLLED EDGES
NOT GOOD FOR HEALING TIME

142
Q

SLOUGH

A

YELLOW AND TAN

143
Q

ESCHAR

A

BLACK OR BROWN

144
Q

WHAT WILL NOT BE SEEN IN A STAGE 3 WOUND

A

MUSCLE, TENDON, AND LIGAMENTS
CARTILAGE AND BONE

145
Q

STAGE 4 WOUND

A

FULL THICKNESS AND TISSUE LOSS
MUSCLE, TENDONS, LIGAMENTS AND OR BONES VISIBLE OR PALPABLE
SLOUGH AND/OR ESCHAR VISIBLE COVERING WOUND
UNDERMINING AND TUNNELING IS COMMON

146
Q

WHAT STAGE IS AN ANKLE PRESSURE WOUND AUTOMATICALLY CLASSIFIED AS

A

STAGE 4

147
Q

UNSTAGEABLE WOUND

A

FULL THICKNESS AND TISSUE LOSS WITH SUCHA GREAT AMOUNT OF SLOUGH THAT A DETERMINATION CANNOT BE ACCURATELY MADE WITHOUT DEBRIDEMENT AS TO THE DEPTH

148
Q

UNDERMINING

A

WOUND CONTINUES UP UNDER THE LIP AROUND THE WOUND

149
Q

Deep Tissue Injury

A

Bone and muscle have had extensive friction
Blood filled blister
Intact skin with darkened area on non-blanching area
Opens–usually goes to a 3-4 (don’tcover it with any kindof dressing- skin prep it)
Can heal, if it opensit willtake lots of money and time toheal

150
Q

SIMPLY PUT-STAGE 1

A

Non-blanching redness with skin intact

151
Q

SIMPLY PUT STAGE 2

A

OPEN AREA, NO FAT SHOWING

152
Q

SIMPLY PUT STAGE 3

A

OPEN AREA WITH FAT SHOWING

153
Q

SIMPLY PUT STAGE 4

A

OPEN AREA WITH MUSCLE, TENDON, OR BONE SHOWING OR PALPABLE

154
Q

SIMPLY PUT UNSTAGEABLE WOUND

A

CANNOT SEE THE BOTTOM OF THE OPEN WOUND TO DETERMINE STAGE

155
Q

SIMPLY PUT DEEP TISSUE INJURY

A

INTACT SKIN WITH DISCOLORATION RELATED TO A BLOOD FILLED BLISTER

156
Q

WHAT IS DRAINAGE

A

LIQUID EXCRETED FROM A WOUND
LIQUID INSIDE OF WOUND
INDICATOR OF WOUND HEALTH

157
Q

WHY DO WE NEED TO LOOK AT WOUND DRAINAGE

A

IT’S THE WOUND VS. IT TELLS US HOW HEALTHY OUR WOUND IS

158
Q

SEROUS

DRAINAGE TYPE

A
  1. CLEAR WATER DRAINAGE
  2. THIS IS A GOOD SIGN
  3. SUGARS, PROTEINS, AND WBC THAT ARE VITAL TO THE HEALING PROCESS
159
Q

SEROSANGUINEOUS

DRAINAGE TYPES

A
  1. PINK, WATERY DRAINAGE WITH RED FLUID
  2. THICK CONSISTENCY- SYRUP
  3. INDICATES GOOD CIRCULATION
  4. INDICATIVE OF RECENT DAMAGE TO VESSELS
160
Q

WET TO DRY DRAINAGE

A
  1. WET DRESSING, PUT IT IN THE WOUND, COVER, PULL IT OUT DRY TO DRIBRIDE
  2. GENERALLY MEDS 30 MIN PRIOR TO DRESSING CHANGES
161
Q

SANGUINEOUS

DRAINAGE TYPE

A

BRIGHT RED
2. GOOD SIGN- BLOOD FLOW
3. WOUND IS ACTIVELY BLEEDING

162
Q

PURULENT

WOUND DRAINAGE

A
  1. THICK YELLOW, GREEN, OR BROWN COLORED
  2. NOT NORMAL HEALING PROCESS
  3. INDICATIVE OF INFECTION
  4. CONTAINS DEAD BACTERIA
163
Q

WHAT COLOR IS SEROUS DRAINAGE

A

CLEAR, WATERY PLASMA

164
Q

WHAT COLOR IS PURULENT DRAINAGE

A

THICK, YELLOW, GREEN, TAN, BROWN

165
Q

WHAT COLOR IS SEROSANGUINEOUS

A

PALE, RED, WATERY, MISCURE OF SEROUS AND SANGUINEOUS

166
Q

WHAT COLOR IS SANGUINEOUS DRAINAGE

A

BRIGHT RED, INDICATES ACTIVE BLEEDING

167
Q

What is green and yellow drainage called?

A

PURULENT

168
Q

What is bright red drainage called?

A

SANGUINEOUS

169
Q

What does clear drainage contain in a wound?

A

SUGARS, PROTEINS, AND WBC

170
Q

S/S THAT ARE INDICATIVE OF INFECTION

A

Feelings of malaise
Low grade fever – or – fever
Fluid drainage
Increased or continual pain
Redness or swelling
Hot incision site
ODOR

171
Q

WHERE SHOULD YOU START WHEN CLEANING A WOUND

A

START AT THE LEAST CONTAMINATED AREA

172
Q

WHAT DIRECTION DO YOU CLEAN A WOUND

A

Clean outwards
NEVER pull contamination into the wound

173
Q

WHAT PRESSURE SHOULD YOU USE WHEN CLEANING A WOUND

A

Don’t Use friction- but be gentle

174
Q

WHAT DIRECTION TO IRRIGATE A WOUND

A

Irrigating-let flow from least contaminated

175
Q

HOW MANY TIMES CAN YOU USE A Q TIP WHEN CLEANING A WOUND

A

1 SWIPE… THEN IT’S CONTAMINATED

176
Q

Cleaning staples/sutures

A

Start at the staple area and move outward- one swipe

177
Q

NURSES AND PROVIDERS ARE RESPONSIBLE FOR

Sterile Dressing Changes

A

REMOVING APPLYING OR CHANGING ALL DRESSINGS

178
Q

WHO CAN DO DRESSING CHANGES

A

NURSE/PROVIDER
CANNOT DELEGATE TO PCT/CNA BECAUSE REQUIRE ASSESSMENT
PCT/CNA CAN ASSIST BUT NOT PERFORM ALONE

179
Q

Aseptic Dressing Changes

A

Also called “clean” technique
Follow all policy procedures for replacing dressings
Tell patient what is happening- step by step
Medicate for pain 30 minutes prior

180
Q

IF A DRESSING IS STUCK, WHAT SHOULD YOU DO

A

moisten with sterile water or normal saline to loosen

181
Q

Steps to Changing a Dressing

FIRST STEPS

A

Hand hygiene
Ensure patient is comfortable
Don gloves
Remove dressing- observe wound, note drainage (amount, color, odor)
Biohazard bag

182
Q

STEPS TO CHANGING A DRESSING

SECOND STEPS

A

Doff gloves and hand hygiene
Prepare aseptic area
Open sterile gauze
Saturate with sterile water

183
Q

STEPS TO CHANGING A DRESSING

LAST STEPS

A

Clean wound
Observe wound- size, depth, odor and color
Apply dressing
Dispose of materials used
Doff gloves
Hand hygiene

184
Q

NEVERS

WOUND MANAGEMENT

A

Clean over the same area twice with the same gauze or pad

Wipe towards the wound

Let irrigation fluid run from contaminated to non-contaminated

185
Q

GAUZE

DRESSING TYPE

A

PACKING OR COVERING

186
Q

TRANSPARENT FILM

DRESSING TYPES

A

Awkward locations
Provide a moist healing environment
Prevent friction
Act as a second skin

187
Q

HYDROCOLLOID

Types of Dressings

A

Acts like gelatin- sucks out fluids and forms a gel
Used in granulating (healing)
Not for highly draining wounds
Impermeable – bacteria cannot get in

188
Q

HYDROGEL

Types of Dressings

A

Provide pain relief
Sometimes used to remove dead skin (Santyl)
Protects from infection

189
Q

FOAM DRESSING

TYPES OF DRESSING

A

Protective barrier
Used on reddened areas to prevent breakdown

190
Q

IMPORTANCE OR READING ORDERS

A

Be sure to read orders completely and follow orders from wound care
YOU ARE LIABLE IF YOU DON’T DO WHAT THE ORDERS SAY OR DO THINGS NOT IN THE ORDERS

191
Q

PREPARING FOR THE DRESSING CHANGE

A

Read notes on previous dressing change
Gather supplies prior
ASK QUESTIONS!!!!
Understand normal healing signs

192
Q

WHY DO WE NEED TO UNDERSTAND NORMAL HEALING SIGNS

A

Will recognize what is abnormal in the healing process
Report abnormal changes immediately

193
Q

DEHISCENCE

A

SURGICAL WOUND REOPENS

194
Q

EVISCERATION

A

ORGANS PROTRUDING- YOUR ORGANS FELL OUT

195
Q

PRESSURE ULCERS

A

Pressure sore, decubitus ulcer, or bed sore.

196
Q

PATHOGENESIS OF PRESSURE ULCERS

A

PRESSURE INTENSITY
PRESSURE DURATION

197
Q

PRESSURE INTENSITY

A

TISSUE ISCHEMIA
BLANCHING

198
Q

TISSUE ISCHEMIA

A

If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, tissue ischemia occurs. If left untreated, tissue death results.

199
Q

BLANCHING

A

occurs when the normal red tones of skin are absent.

200
Q

PRESSURE DURATION

A

Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death.

201
Q

Any patient who is (WHAT) is at risk for pressure ulcer development.

A

experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition

202
Q

IMPAIRED SENSORY PERCEPTION

RISK FACTORS FOR PI

A

cannot feel their body sensations.

203
Q

IMPAIRED MOBILITY

RISK FACTORS FOR PI

A

unable to independently change position are at risk/cannot change or shift off of bony prominences.

204
Q

ALTERATION IN LOC

RISK FACTORS FOR PI

A

UNABLE TO PROTECT THEMSELVES

205
Q

SHEAR

RISK FACTORS FOR PI

A

the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface.

206
Q

FRICTION

RISK FACTORS FOR PI

A

the force of two surfaces moving across one another.

207
Q

MOISTURE

RISK FACTORS FOR PI

A

causes skin breakdown

208
Q

STAGE 1

Classification of Pressure Ulcers

A

Intact skin with nonblanchable redness

209
Q

STAGE 2

Classification of Pressure Ulcers

A

Partial-thickness skin loss involving epidermis, dermis, or both
shallow in depth, moist and painful, and the wound base generally appears red

210
Q

STAGE 3

Classification of Pressure Ulcers

A

Full-thickness tissue loss with visible fat
extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location

211
Q

STAGE 4

Classification of Pressure Ulcers

A

Full-thickness tissue loss with exposed bone, muscle, or tendon
extends into the subcutaneous layer, and the depth and tissue type will vary depending on body location

212
Q

PRIMARY INTENTION

Process of Wound Healing

A

Edges are approximated- “closed” and the risk of infection is lowered. Ex. Surgical incision.

213
Q

SECONDARY INTENTION

Process of Wound Healing

A

wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. If scarring from secondary intention is severe, loss of tissue function is often permanent.

214
Q

Partial-thickness wound repair:

A

inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers

215
Q

FULL THICKNESS WOUND REPAIR

A

HEMOSTASIS, INFLAMMATORY PROLIFERATIVE AND MATURATION

216
Q

Hemostasis-

FULL THICKNESS WOUND REPAIR

A

injured blood vessels constrict, platelets gather to stop bleeding.

217
Q

INFLAMMATORY

FULL THICKNESS WOUND REPAIR

A

THIS RESPONSE IS BENEFICIAL. REDNESS WARMTH AND THROBBING (LOCALIZED)

218
Q

PROLIFERATIVE

FULL THICKNESS WOUND REPAIR

A

filling the wound with granulation tissue (red, moist and composed of new vessels), wound retraction and wound resurfacing

219
Q

MATURATION

FULL THICKNESS WOUND REPAIR

A

can take place for more than a year. Consists of collagen scarring.

220
Q

HEMATOMA

A
  1. HEMORRHAGE
  2. LOCALIZED COLLECTION OF BLOOD UNDERNEATH THE TISSUES
221
Q

second most common health care–associated infection.

A

Infection-

222
Q

S/S OF AN INFECTED WOUND

A

: erythema, increased amount of wound drainage, and change in appearance of the wound drainage (thick, color change, presence of odor), periwound warmth, pain, or edema.

223
Q

Dehiscence- .

A

partial or total separation of wound layers

“tearing/opening”-sensation

224
Q

Evisceration-

A

total separation of wound layers.

225
Q

Medicare and Medicaid:

PI

A

no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization

226
Q

RISK ASSESSMENT- BRADEN SCALE

A

developed based on risk factors in a nursing home population and is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development.

227
Q

Factors Influencing Pressure Ulcer Formation and Wound Healing

A

NUTRITION
TISSUE PERFUSION
INFECTION
AGE
PSYCHOSOCIAL IMPACT OF WOUNDS

228
Q

PREDICTIVE MEASURES

PRESSURE ULCERS

A

BRADEN SCALE

229
Q

NUTRITIONAL STATUS

A

Malnutrition is a risk factor for pressure ulcer development.

230
Q

PAIN

PRESSURE ULCERS

A

maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risk.

231
Q

Drains-

A

emptying. Note frequency of drainage.

232
Q

DOCUMENTATION OF WOUNDS

A

Character of wound drainage- note amount, odor, color and consistency.

233
Q

WOUND APPEARANCE

A

should be assessed on an ongoing basis.

234
Q

WOUNDS IN A STABLE SETTING

A

provider may choose to change the first surgical dressing and provide the 1st dressing change.

235
Q

Wound closures-

A

staples, sutures or wound adhesives for surgical incisions.

236
Q

Palpation of wound-

A

observe for swelling and separation of edges.

237
Q

Wound cultures-

A

must be collected from fresh drainage.
Gram stains
Biopsy

238
Q

HEALTH PROMOTION

A

Prevention of pressure ulcers
Topical skin care and incontinence management
Positioning
Support surfaces

239
Q

Wound management

A

DEBRIDEMENT
EDUCATION
NUTRITIONAL STATUS
PROTEIN STATUS
HEMOGLOBIN

240
Q

DEBRIDEMENT

A

removal of nonviable, necrotic tissue.

241
Q

PROTEIN STATUS

ACUTE CARE WOUND MANAGEMENT

A

A patient can lose as much as 50 g of protein per day from an open, weeping pressure ulcer. Need protein supplementation.

242
Q

HEMOGLOBIN

ACUTE CARE WOUND MANAGEMENT

A

low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia.

243
Q

HEMOSTASIS

FIRST AID FOR WOUNDS

A

Control bleeding.
Allow puncture wounds to bleed. (to remove dirt and contaminants).
Do not remove a penetrating object. (this helps to control bleeding).
Bandage

244
Q

CLEANING

FIRST AID FOR WOUNDS

A
  1. GENTLE
  2. NORMAL SALINE
  3. PROTECTION
245
Q

SECURING DRESSINGS

A

Tape
Ties
Binders
Always date, time & initial!

246
Q

TYPES OF DRESSINGS

A

Gauze
Transparent film
Hydrocolloid
Hydrogel
Foam
Composite

247
Q

BEFORE A DRESSING CHANGE, WHAT SHOULD YOU KNOW

A

Know type of dressing, placement of drains, and equipment needed.

248
Q

PREPARING FOR A DRESSING CHANGE

A

Review previous wound assessment.
Evaluate pain and, if indicated, administer analgesics so peak effects occur during dressing change.
Describe procedure steps to lessen patient anxiety.
Gather all supplies.
Recognize normal signs of healing.
Answer questions about the procedure or wound.

249
Q

Packing a wound

A

Negative-pressure wound therapy- vacuum assisted closure.

250
Q

CLEANING SKIN AND DRAIN SITES

A

Clean from least contaminated to the surrounding skin.
Use gentle friction.
When irrigating, allow the solution to flow from the least to most contaminated area.

251
Q

Suture care-

A

Policies vary within institutions as to who is able to remove sutures.

252
Q

Staples-

A

removed with staple remover

253
Q

A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be:
A. it has no odor.
B. a culture is negative.
C. the edges reveal the presence of fluid.
D. it shows purulent drainage coming from the incision site.

A

D

254
Q

The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges:
A. are approximated.
B. migrate across the incision.
C. appear slightly pink.
D. slightly overlap each other.

A

Answer: A
Rationale: A clean surgical incision is an example of a wound with little tissue loss. The surgical incision heals by primary intention. The skin edges are approximated, or closed, and the risk of infection is low.

255
Q

UNDERSTANDING PRESSURE INJURY

A

https://www.youtube.com/watch?v=xNH8DDvjSME

256
Q
A

201 Intro (9 decks)

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