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Exam 4; fundamentals of nursing Flashcards

1
Q

What are some factors that affect skin integrity

A

impaired mobility, nutrition and hydration, impaired circulation, medications, fever, contamination or infection, lifestyle

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2
Q

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

A

C

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3
Q

What is an open/ closed wound

A

open: a break in the skin or mucous membranes
closed: no breaks in the skin, tissue swelling

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4
Q

What is acute/ chronic wound

A

Acute: new fresh wound
Chronic: ongoing

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5
Q

What is clean/ contaminated/ infected wound

A

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

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6
Q

What is superficial/ partial or full thickness wounds

A

superficial: epidermal layer caused by friction and shear
Partial: epidermis layer but not dermal layer
Full thickness: subq layer and beyond

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7
Q

What is penetrating wounds

A

penetrating: indicated that wound involves internal layers

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8
Q

What are some complications of wound healing

A

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)

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9
Q

What is the difference between dehiscence and evisveration

A

Dehiscence: bursting open of a wound
Evisceration: removal of the contents of a cavity or protrusion of the viscera.

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10
Q

What are some nursing interventions related to wound care?

A

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

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11
Q

What are some intrinsic risk factors of pressure injury developing

A

immobility
impaired sensation
aging
fever
infection
edema
dehydration

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12
Q

What are some extrinsic risk factors of pressure injury developing

A

friction
pressure
shearing
moisture

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13
Q

What are some nursing assessments of pressure injuries

A

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

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14
Q

What are some defining characteristics of stage one pressure injuries

A

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

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15
Q

What are some defining characteristics of stage two pressure injuries

A

pressure injury is open and shallow and with a red pink wound bed.
no slough
may be intact or shallow opening

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16
Q

What are some defining characteristics of stage three pressure injuries

A

full thickness skin loss with damage or necrosis of subq tissue.
adipose visible
bone tendon is not visible

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17
Q

What are some defining characteristics of stage four pressure injuries

A

full thickness skin loss with extensive destruction of tissue
exposed bone and tendon
eschor and slough visible
ebole (rolled edges)

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18
Q

What are some defining characteristics of stage deep tissue injury pressure injuries

A

intact or non intact skin
pain and temperature change and color changes

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19
Q

What are some defining characteristics of stage unstageable pressure injuries

A

full thickness skin loss. base of wound is obscured by slough or eschar

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20
Q

when do risk assessments start for patients? What patients do you do risk assessments on?

A

ALL patients require a risk assessment at time of admission

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21
Q

When are reassessments done for risk assessments?

A

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.)

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22
Q

when do skin inspections assessments start for patients? What patients do you do skin assessments on?

A

All patients require full skin inspection upon admission: inspect and palpate skin from head to toe

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23
Q

What are some ways to integrate skin inspection with your assessment of the patient?

A

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

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24
Q

What is the braden scale

A

a test to measure risk for skin breakdown

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25
how is the braden scale scored
the lower the number, the more you're at risk 6-23 is range
26
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
27
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
28
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
29
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
30
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
31
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?)
32
What does eschar look like
may be tan, brown or black in the wound bed
33
What does slough look like
may be yellow, tan, gray, green, or brown in the wound bed
34
What does granulation tissue look like
deep pink or red, moist, shiny, with irregular granular surface
35
What to look for when assessing periwound skin and wound edges?
periwound pain edema (swelling) induration (hardness) erythema (redness) maceration (white-wet)
36
What is an abrasion
a wearing away of the upper layer of skin as a result of applied friction
37
what is a laceration
a deep cut or tear into the skin
38
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
39
What is a hematoma
a localized swelling filled with blood, resulting from a break in a blood vessel
40
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
41
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
42
what are ways to close wounds
adhesive strips sutures surgical staples surgical glue
43
What is the mnemonic to remember when assessing wound drainage
T= type A= amount C= consistency O= odor
44
What is serous exudate
thin, clear, watery plasma
45
What is sanguineous
bloody drainage
46
What is serosanguineous
thin, watery, pale red to pink plasma cells with red blood cells
47
What is purulent
thick, opaque drainage that is tan, yellow, green, or brown
48
What is purosanguineous exudate
contains blood and pus
49
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
50
What are the two types of consistency with drainage
low viscosity- thin and runny high viscosity- thick or sticky, doesn't flow easily
51
what are the two classifications of odor with drainage
none- no odor noted strong/ foul/ pungent/ fecal/ musty/ sweet
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
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
60
ways to promote normal urination
provide privacy assist with position facilitate toileting routines
61
what is a way to manage/ intervention urinary retention
catheter
62
what is some nursing care interventions for indwelling catheters
prevent UTIS prevent backflow of urine encourage fluids ensure perineal hygiene
63
what are some things to do after removing a catheter
assess urine output document output bladder scan post void residual check
64
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
65
what are 4 things to look for when assessing urine
color odor clarity amount
66
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
67
factors that affect bowel elimination
developmental stage personal factors sociocultural factors nutrition/ hydration medications procedures pregnancy
68
common diagnostic test for bowel elimination
direct visualization: colonoscopy radiographic views: flat plate of the abdomen
69
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
70
what are things to look for in a stool assessment
color amount consistency
71
ways to promote regular defecation
provide privacy correct position timing encourage fluids proper diet exercise
72
what are common alterations in defecation
diarrhea constipation fecal impaction bowel diversions (colostomy bag)
73
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)
74
ways to manage constipation
increases intake of high fiber foods increase fluid intake increase activity/ exercise provide privacy position uninterrupted time
75
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
76
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
77
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
78
how would you trouble shoot no urine output in a drainage bag
bladder scan check catheter- no kins, in place
79
what is considered a normal urine output per hour
30-60 mL
80
list risk factors for constipation
medications, low diet in fiber, dehydration, low physical activity
81
how do pressure ulcers form
moisture friction and shear pressure on bony prominences
82
what braden scale score leaves a patient at risk for skin integrity issues
>18
83
in what timeframe could a pressure injury occur
1-2 hours
84
define sanguineous
bloody drainage
85
define serous
thin, clear, watery plasma
86
define purulent
thick, opaque drainage that is tan, yellow, green or brown
87
define serosanguineous
thin, watery, pale, red to pink plasma cells with red blood cells
88
what is the difference between sleep vs rest
sleep: cyclical states/ altered consciousness rest: mild to no activity
89
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
90
how much sleep do adults needs
7-8 hours a night
91
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
92
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
93
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
94
what is insomnia
the inability to fall or remain asleep or go back to sleep
95
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
96
what is restless leg syndrome
uncontrollable movement of legs during sleep/ rest
97
what is hypersomnia
excessive sleeping, especially during the daytime. sleep related or disease related can be related to depression
98
what is sleep apnea
periodic breathing cessation for at least 10 seconds during sleeping
99
what is narcolepsy
chronic disorder caused by the brain's ineffectiveness in regulating sleep wake cycles normally uncontrollable episodes of sleep during the day
100
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
101
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
102
what are macronutrients and what are the sources
they supply the body with energy sources: carbohydrates, proteins, lipids
103
what are micronutrients and what are the sources
help manufacture, repair, and maintain cells sources: vitamins and minerals
104
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
105
what are proteins
tissue building nitrogen balance amino acids
106
what are lipids
fats back up energy source organ insulation/ protection
107
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
108
how is energy in nutrients measured
calories
109
lories in must equal?
calories burned
110
what is BMR (basal metabolic rate)
amount of energy required at rest
111
what are some factors that affect BMR
body composition growth periods body temperature environmental temperature disease process prolonged phsycial exerction
112
what are some factors affecting nutrition
developmental stage- age lifestyle choices ethnicity/ culture religious practices disease processes functional limitations
113
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
114
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
115
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
116
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
117
what are etiologies for undernutrition and overweight
under: difficult chewing/ swallowing, alcoholism, metabolic disorders, vomiting over: overeating, lack of exercise, metabolic/ endocrine problems
118
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
119
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
120
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
121
what are some precautions for aspiration
apply pulse oximetry place the client upright chin tuck position minimize distractions do not rush
122
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
123
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
124
interventions for undernutrition
encourage client to seek counseling for eating disorder management devise strategies to improve client's appetite enteral nutrition parenteral nutrition
125
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

Nursing Skills (16 decks)

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