Exam 4; fundamentals of nursing Flashcards
What are some factors that affect skin integrity
impaired mobility, nutrition and hydration, impaired circulation, medications, fever, contamination or infection, lifestyle
Of the following factors, which would put a client at greatest risk for impaired skin integrity?
A. medication
B. moisture
C. Decreased sensation
D. dehydration
C
What is an open/ closed wound
open: a break in the skin or mucous membranes
closed: no breaks in the skin, tissue swelling
What is acute/ chronic wound
Acute: new fresh wound
Chronic: ongoing
What is clean/ contaminated/ infected wound
Clean: minimal infection, low risk for infection
Contaminated: increased risk for infection (surgical wounds)
Infected: open traumatic wounds, aspepsis, high risk of infection/ already occurring
What is superficial/ partial or full thickness wounds
superficial: epidermal layer caused by friction and shear
Partial: epidermis layer but not dermal layer
Full thickness: subq layer and beyond
What is penetrating wounds
penetrating: indicated that wound involves internal layers
What are some complications of wound healing
hemorrhage (24-48 hours, swelling and pain. internal bleeding), infection, dehiscence (rapture of separation of one or more layer), evisceration (total separation of the wound were internal viscera), fistula formation (abnormal passage -> through 2 body cavities. abscess usually forms, breaks down tissue)
What is the difference between dehiscence and evisveration
Dehiscence: bursting open of a wound
Evisceration: removal of the contents of a cavity or protrusion of the viscera.
What are some nursing interventions related to wound care?
cleaning/ irrigating
caring for a drainage device (jackson- pratt & hemovac)
debriding a wound (mechanical, enzymatic, autolysis, biotherapy, sharp)
applying negative pressure wound therapy
dressing a wound
supporting/ immobilizing a wound
applying heat and cold
What are some intrinsic risk factors of pressure injury developing
immobility
impaired sensation
aging
fever
infection
edema
dehydration
What are some extrinsic risk factors of pressure injury developing
friction
pressure
shearing
moisture
What are some nursing assessments of pressure injuries
determine the state: stages 1-4 (classified by tissue involvement) stages 3-4 (involve tissue necrosis, tissue death)
suspected deep tissue injury
unstageable pressure injury
What are some defining characteristics of stage one pressure injuries
area may be painful, firm, soft, or warmer or cooler than adjacent tissue.
discoloration will remain for 30 minutes after pressure is released.
redness discoloration
What are some defining characteristics of stage two pressure injuries
pressure injury is open and shallow and with a red pink wound bed.
no slough
may be intact or shallow opening
What are some defining characteristics of stage three pressure injuries
full thickness skin loss with damage or necrosis of subq tissue.
adipose visible
bone tendon is not visible
What are some defining characteristics of stage four pressure injuries
full thickness skin loss with extensive destruction of tissue
exposed bone and tendon
eschor and slough visible
ebole (rolled edges)
What are some defining characteristics of stage deep tissue injury pressure injuries
intact or non intact skin
pain and temperature change and color changes
What are some defining characteristics of stage unstageable pressure injuries
full thickness skin loss. base of wound is obscured by slough or eschar
when do risk assessments start for patients? What patients do you do risk assessments on?
ALL patients require a risk assessment at time of admission
When are reassessments done for risk assessments?
Every 24 hours= minimum
Every 12 hours= best practice
pressure ulcers can develop within 24 hours of insult or take as longa s 5 days to be present
Change in condition: surgery, nutrition, level of mobility, ect.)
when do skin inspections assessments start for patients? What patients do you do skin assessments on?
All patients require full skin inspection upon admission: inspect and palpate skin from head to toe
What are some ways to integrate skin inspection with your assessment of the patient?
when applying O2: look behind hears
for immobile patients: coccyx, back of head, bony prominent areas
when listening to lung sounds or repositioning: check the back/ sacrum
when checking bowel sounds: between skin folds and hips
when placing pillows under calves: heels and feet
when checking iv sites: elbows and arms
if patient is here for surgery: know areas prone to breakdown
when getting patient up or doing cares: back, sacrum, genital, heels, full body
What is the braden scale
a test to measure risk for skin breakdown
how is the braden scale scored
the lower the number, the more you’re at risk
6-23 is range
what are some interventions for friction and shear
use transfer devices
use minimum of 2 people
don’t drag the patient
keep HOB at or below 30 degrees
use trapeze
pad skin surfaces as needed
apply moisturizer to skin at least daily and prn
The nurse is caring for a patient on the medical- surgical unit with a wound that has a drain and a dressing that needs changing. which of these actions should the nurse take first?
A. don sterile gloves
B. provide analgesic medications as ordered
C. avoid accidentally removing the drain
D. gather supplies
B
A client has been lying on her back for two hours. When the nurse turns her, the nurse notices the skin over her sacrum is very white. By the time the nurse finishes repositioning her, the spot has turned bright red. The nurse should:
A. massage the spot with lotion
B. apply a warm compress for 30 minutes
C. return in 30-45 minutes to see if the redness has disappeared
D. wash the area with soap and water and notify the physician
C
During evening cares, the student nurse assesses the mepilex dressing on his client’s sacrum. The dressing was dated and initialed for earlier that day. the dressing was attached on all edges with no visible drainage present. Which of the following is most appropriate for the student nurse to document regarding the assessment.
A. base. site assessment clean, dry, intact
B. peri wound clean, dry, intact
C. wound healing ridge clean, dry, intact
D. dressing clean, dry, intact
D
What do you assess when assessing a wound
location- anatomical area
size- length and width in centimeters
appearance- peri wound (skin surrounding wound itself)
drainage- amount, color, any drains, odor
redness
swelling
What are the colors of wound base
pale pink, pink, red (granulating tissue, tissue that is starting to heal)
yellow (slough?), green, (infection?)
black (necrotic tissue?)
What does eschar look like
may be tan, brown or black in the wound bed
What does slough look like
may be yellow, tan, gray, green, or brown in the wound bed
What does granulation tissue look like
deep pink or red, moist, shiny, with irregular granular surface
What to look for when assessing periwound skin and wound edges?
periwound pain
edema (swelling)
induration (hardness)
erythema (redness)
maceration (white-wet)
What is an abrasion
a wearing away of the upper layer of skin as a result of applied friction
what is a laceration
a deep cut or tear into the skin
What is ecchymosis/ some characteristics of it
characterized by reddish to bluish (sometimes purple) discoloration of the skin; which results from the rupture of small capillaries beneath the skin and accumulation of blood in the surrounding tissue
What is a hematoma
a localized swelling filled with blood, resulting from a break in a blood vessel
The client calls the nurse to the room and states, “look, my incision is popping open where they did my hip surgery!” the nurse notes that the wound edges have separated 1 cm at the center and there is straw colored fluid leaking from one end. The nurse’s best action is to:
A. notify the surgeon stat
B. place a clean, sterile 4x4 over the incision and monitor the drainage
C. wrap an ace bandage firmly around the area dn have the client maintain bedrest
D. immediately cover the wound with sterile towels soaked in normal saline and call the surgeon
B
What are some characteristics of wound dimensions
measure length, width, and depth of wound
tunneling/ undermining?
describe the wound as a clock with patient’s head at 12:)) and feet at 6:)) to promote consistency in description
what are ways to close wounds
adhesive strips
sutures
surgical staples
surgical glue
What is the mnemonic to remember when assessing wound drainage
T= type
A= amount
C= consistency
O= odor
What is serous exudate
thin, clear, watery plasma
What is sanguineous
bloody drainage
What is serosanguineous
thin, watery, pale red to pink plasma cells with red blood cells
What is purulent
thick, opaque drainage that is tan, yellow, green, or brown
What is purosanguineous exudate
contains blood and pus
What are the variations of amount of drainage
none- wound tissues are dry
scant- wound tissues are moist, but there is no measurable drainage
small (minimal)- wound tissues are very moist or wet; the drainage covers less than 25% of the dressing
Moderate- wound tissues are wet; the drainage involves more than 25 to 75% of the dressing
Large (copious)- wound tissues are filled with fluid that involves more than 75% of the dressing
What are the two types of consistency with drainage
low viscosity- thin and runny
high viscosity- thick or sticky, doesn’t flow easily
what are the two classifications of odor with drainage
none- no odor noted
strong/ foul/ pungent/ fecal/ musty/ sweet
What are nephrons and some characteristics
basic structural and function units of the kidney
one million in each kidney
serve as a microscopic filter
excretion/ retention of fluids/ solutes
What are ureters and some characteristics
transportation system from renal pelvis to bladder
tubular structures
drainage is always sterile
peristalsis moves urine
kidney stone- obstruction in ureter
each kidney had one ureter
What is some characteristics of the bladder
hollow muscular organ
position in pelvic cavity
can hold 450 ml but can expand to more
can palpate when full or distended
What are urethra and some characteristics
urine travels from bladder through the urethral meatus
fast flow to wash out bacteria
women: 1.5-2.5 inches long
Men: 8 inches
What are some factors affecting urinary elimination
personal- anxiety, lack of time, lack of privacy
sociocultural- religious requirements
nutrition- caffeine, sodas, chocolate
hydration, activity level, medications, surgery and anesthesia
What are some pathological conditions affecting urinary elimination
bladder/ kidney infections
kidney stones
hypertrophy of the prostate
mobility problems
decreased blood flow through glomeruli
neurological conditions
communication problems
alteration in cognition
terms to know:
nocturia
polyuria
oliguria
anuria
dysuria
diuresis
enuresis
nocturia: going at night
polyuria: excessive urination
oliguria: decreased urine output
anuria: absence of urine
dysuria: pain when urinating
diuresis: increased urine production
enuresis: involuntary loss of urine
terms to know:
frequency
urgency
residual urine
bladder training
proteinuria
pyuria
hematuria
pyelonephritis
cystitis
frequency: urinating in short intervals
urgency: uncontrollable need
residual urine: urine left in bladder
bladder training: behavioral/ schedule
proteinuria: protein in the urine
pyuria: pus in the urine
hematuria: blood in the urine
pyelonephritis: infection that spreads to urinary tract
cystitis: bladder infection
ways to promote normal urination
provide privacy
assist with position
facilitate toileting routines
what is a way to manage/ intervention urinary retention
catheter
what is some nursing care interventions for indwelling catheters
prevent UTIS
prevent backflow of urine
encourage fluids
ensure perineal hygiene
what are some things to do after removing a catheter
assess urine output
document output
bladder scan
post void residual check
what are interventions for managing urinary incontinence
prevent skin breakdown
encourage/ teach lifestyle modifications
implement bladder training
encourage client to perform kegel exercises
use anti- incontinence devices as needed
pharmacological interventions
surgical interventions
parental teaching for enuresis
what are 4 things to look for when assessing urine
color
odor
clarity
amount
terms to know
defecation
feces
peristalsis
flatus
defecation: elimination of waste
feces: semi solid mass of fiber/ undigested food
peristalsis: contraction movement
flatus: moving of gas
factors that affect bowel elimination
developmental stage
personal factors
sociocultural factors
nutrition/ hydration
medications
procedures
pregnancy
common diagnostic test for bowel elimination
direct visualization: colonoscopy
radiographic views: flat plate of the abdomen
what is some things to look for in a bowel function assessment
elimination pattern
routine
appetite/ diet/ fluid intake
gi surgery, diagnoses
medications
exercise and mobility
stool characteristics
what are things to look for in a stool assessment
color
amount
consistency
ways to promote regular defecation
provide privacy
correct position
timing
encourage fluids
proper diet
exercise
what are common alterations in defecation
diarrhea
constipation
fecal impaction
bowel diversions (colostomy bag)
ways to manage diarrhea
monitor stools to quantify diarrhea
assess and monitor for fluid imbalance
monitor for alterations in perineal skin integrity
proper diet teaching
antidiarrheal medications (chronic)
ways to manage constipation
increases intake of high fiber foods
increase fluid intake
increase activity/ exercise
provide privacy
position
uninterrupted time
there is a 24 hr urine collection in process for a client. the nursing assistive personnel inadvertently empties one specimen into the toilet instead of the collection hat. the nurse should
A. continue with the collection of urine until the 24 hr time period is over
B. dispose of hte urine already collected and begin an entirely new 24 hr collection
C. make a note to the lab to inform them that one specimen was missed during the collection
D. begin filling a new collection container and take both containers ot the lab at the end of the collection period
B
you are caring for a patient who had an indwelling catheter removed 12 hrs ago. the patient has not voided. What action should you take?
assess/ palpate
bladder scan
possible interventions
the nurse is assisting the client in caring for her ostomy. The client states “oh this is so disgusting. I’ll never be able to touch this thing. the nurses best response is:
A. it sounds like you are really upset
B. yes, it is pretty messy, so i’ll take care of it for you today
C. you should very angry. should i call the chaplain for you?
D. im sure you will get used to taking care of it eventually
A
how would you trouble shoot no urine output in a drainage bag
bladder scan
check catheter- no kins, in place
what is considered a normal urine output per hour
30-60 mL
list risk factors for constipation
medications, low diet in fiber, dehydration, low physical activity
how do pressure ulcers form
moisture
friction and shear
pressure on bony prominences
what braden scale score leaves a patient at risk for skin integrity issues
> 18
in what timeframe could a pressure injury occur
1-2 hours
define sanguineous
bloody drainage
define serous
thin, clear, watery plasma
define purulent
thick, opaque drainage that is tan, yellow, green or brown
define serosanguineous
thin, watery, pale, red to pink plasma cells with red blood cells
what is the difference between sleep vs rest
sleep: cyclical states/ altered consciousness
rest: mild to no activity
why do we need sleep
affects almost every tissue in the body
important regulator of energy metabolism
improves learning an adaptation
reduce stress and anxiety
strengthens the immune system
how much sleep do adults needs
7-8 hours a night
terms to know
circadian rhythm
reticular activating system
electroencephalogram
circadian rhythm: internal clock
reticular activating system: collection of nerve cells that are responsible for maintaining wakefulness
electroencephalogram: way to check sleep patterns and seizures
light sleep and slowing brain and body processes are associated with which stage of NREM
a. NREM 1
B. NREM 2
C. NREM 3
D. REM
B
what are some factors that affect sleep
age
lifestyle factors: food and alcohol, caffeine, sleep habits, medications
an illness
environmental factors- temperature, noise and light, noxious odor
what is insomnia
the inability to fall or remain asleep or go back to sleep
the nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, i don’t know what is wrong with me. i have been napping all day and can’t seem to think clearly. the nurse’s best response is:
A. you are sleep deprived, but that will resolve in a few days
B. you are experiencing hypersomnia, so it will be important for you to walk in the hall more often
C. there has beena. disruption in your circadian rhythm. what can i do to help you sleep better at night?
D. i will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep
C
what is restless leg syndrome
uncontrollable movement of legs during sleep/ rest
what is hypersomnia
excessive sleeping, especially during the daytime.
sleep related or disease related
can be related to depression
what is sleep apnea
periodic breathing cessation for at least 10 seconds during sleeping
what is narcolepsy
chronic disorder caused by the brain’s ineffectiveness in regulating sleep wake cycles normally
uncontrollable episodes of sleep during the day
for which sleep disorder would the nurse most likely need to include safety measures in the client’s plan of care?
A. snoring
B. enuresis
C. narcolepsy
D. hypersomnia
C
nursing interventions for sleeping interventions
cluster/ schedule nursing care to avoid interrupting sleep
create a comfortable/ restful environment
promote comfort relaxation
support bedtime rituals/ routines
what are macronutrients and what are the sources
they supply the body with energy
sources: carbohydrates, proteins, lipids
what are micronutrients and what are the sources
help manufacture, repair, and maintain cells
sources: vitamins and minerals
what are carbohydrates and what are the functions
primary energy source for body
functions: supply energy for muscle and organ function
spare protein
other physiological factors
what are proteins
tissue building
nitrogen balance
amino acids
what are lipids
fats
back up energy source
organ insulation/ protection
what is the purposes of water
makes up large percentage of body weight
solvent for chemical processes
transports substances
form for tissues
maintains body temperature
lubricant
how is energy in nutrients measured
calories
lories in must equal?
calories burned
what is BMR (basal metabolic rate)
amount of energy required at rest
what are some factors that affect BMR
body composition
growth periods
body temperature
environmental temperature
disease process
prolonged phsycial exerction
what are some factors affecting nutrition
developmental stage- age
lifestyle choices
ethnicity/ culture
religious practices
disease processes
functional limitations
identify the client with the greatest risk for developing protein- calorie malnutrition
A. a client who has multiple sclerosis and is in a wheelchair
B. a client weighing 300 lb who has entered the hospital for cardiac bypass surgery
C. a client with a broken arm and femur who is running a fever of 101.5
D. a client who is of native american heritage
C
what are some alterations in overweight/ obesity nutrition
consuming nutrients in excess amounts
more than needed for activity, gender, height, and weight
overweight BMI> 25-29.9
obesity BMI>30
what are some alterations in underweight/ undernutrition
insufficient intake of protein, fat, vitamins, minerals
consuming less calories than needed according to activity, gender, height, and weight
underweight BMI <18.5
what are ways for identifying nutritional imbalances
general survey
alterations in vital signs
poor skin turgor, wound healing
pale conjunctiva
concave abdomen
change in muscle mass
what are etiologies for undernutrition and overweight
under: difficult chewing/ swallowing, alcoholism, metabolic disorders, vomiting
over: overeating, lack of exercise, metabolic/ endocrine problems
what are some interventions of supporting special nutritional needs (NPO and older adults)
NPO: provide oral hygiene, advise family not to eat or drink in front of patient
older adults: eat nutrient dense food first, more frequent meals in smaller amounts
what are some interventions for impaired swallowing
provide/ use assistive devices
avoid use of straw
assist patient to put food at back of mouth, unaffected side
check mouth for pocketing of food after eating
monitor weight and hydration
what is aspiration and who are at risk for it
food enters the respiratory tract
risk: decreased level of alertness
decreased gag and cough reflex
clients who drool and pocket food
client with dysphagia
clients with stroke diagnosis
what are some precautions for aspiration
apply pulse oximetry
place the client upright
chin tuck position
minimize distractions
do not rush
what are some warning signs of aspirations
cough during eating
change in voice tone or quality after swallowing
facial droop
abnormal movements of the mouth, tongue, or lips
delayed swallowing and slow eating
interventions for weight loss
assist client in setting realistic goals
plan healthier foods to eat
assist in designing an exercise calendar
encourage 7-8 hours of sleep every night
keep a food diary
find an emotional support person
interventions for undernutrition
encourage client to seek counseling for eating disorder management
devise strategies to improve client’s appetite
enteral nutrition
parenteral nutrition
what are a few ways to stimulate appetite
offer frequent small meals
suggest smokers refrain for 1 hour before a meal
restrict liquid intake with meals
frequent oral hygiene
