Exam Study Flashcards
Vitamins and minerals to enhance wound healing
Protein Carbohydrates Lipids Vit A Vit C Vit B1 Vit B5 Iron Zinc Copper
Recommended daily fluid intake for wound healing
2500 mL unless contraindicated
Foods with vitamin C
Broccoli, cabbage, fruits, vegetables, cantaloupe, cauliflower, citrus fruits, green pepper, kiwi, strawberries
Foods with vitamin A
Fat-containing and fortified dairy, liver, orange and deep-green fruits and vegetables
Foods with vit B1
Pork, legumes, peanuts, thiamin-enriched whole grain products
Foods with vitamin B5
Nuts, meats, pro vitamin tryptophan in most proteins
Foods with zinc
Meats, seafood, whole grains
Steps for donning PPE
- Explain to client what u are doing
- Wash hands
- Don a clean gown. Tie it snugly
- Don face mask by tying top strings first, then lower strings.
- Don eyewear
- Don clean gloves. Pull gloves over gown cuffs
Removing soiled PPE
- Remove gloves first since they are most soiled
- Wash hands
- Remove mask by untying lower strings first
- Remove gown when preparing to leave room
- Remove eyewear
Sites to assess for pressure ulcers
Heels, sacrum, elbows, scapulae, back of head, ankles, knee, greater trochanter (lateral prominence near femoral head), ilium, shoulder, ear, side of head, toes, genitals, breasts, cheek, pelvis, vertebrae
Guidelines for assessing pressure sites
- Good lighting
- Regulate room temp
- Inspect pressure areas for whitish or reddened spots
- Inspect for abrasion/excoriation
- Palpate to assess skin temperature
- Palpate to assess for edema
Decadron (dexamethasone) drug class
Corticosteroid
Corticosteroids effect on immunity
Decrease inflammation, depressing immune system
Corticosteroid effect on wound healing
May inhibit wound healing due to immunity suppression
Ulcer stage “suspected deep tissue injury”
purple/maroon area of dis colored but, intact skin. May present as blood blister from shearing between tissues
Suppuration
The process of pus formation due to bacteria in an infected wound
Effect of suddenly stopping corticosteroid without tapering
Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia).
Assessment comparing a patient’s current health status to data obtained some time ago
Time-lapsed assmt
Assessment performed at the beginning of the nursing process, on admission to facility.
Initial assmt
Assessment that tracks the status of a problem identified during the initial assmt by reassessing periodically during care. May also identify new problems not seen during the initial assmt.
Ongoing assmt
Assmt occurring during a crisis situation focused on identifying life-threatening problems.
Emergency assmt
Assessment comparing a patient’s current health status to data obtained some time ago
Time-lapsed assmt
Assessment performed at the beginning of the nursing process, on admission to facility.
Initial assmt
Assessment that tracks the status of a problem identified during the initial assmt by reassessing periodically during care. May also identify new problems not seen during the initial assmt.
Ongoing assmt
Assmt occurring during a crisis situation focused on identifying life-threatening problems.
Emergency assmt
How long after tetracycline administration should pt wait before drinking milk?
Pt should wait at least two hours before drinking milk. Tetracycline can bond with certain ions like calcium.
Tetracycline class
Anti-infective used against unusual organisms like chlamydia and ricksettsia.
Best way to keep a four year old from trying to remove a wound dressing
Place a similar dressing on the pt’s teddy bear. Also, allow the to see and touch the items being used. Preschoolers are “egocentric”.
How to keep an infant from removing a wound dressing
Place mittens on their hands
Are insulin syringes calibrated in mL?
No, insulin syringes are calibrated in “units.” Each syringe holds 100 units.
How would you draw up 112 units of NPH insulin?
Use two U100 syringes soy ou can measure 112 units precisely.
What is the purpose of a hydrocolloid wound dressing?
To keep the wound bed moist and promote granulation. It has an inner absorbent layer that forms a moist gel over the wound and promotes granulation.
Gauze used to remove nectrotic tissue
Moist-to-dry gauze is used to remove necrotic tissue
What is the goal of moist dressing use?
Effective tissue regeneration
What does the presence of IgM antibodies in the blood on lab analysis mean?
Presence of IgM indicates current infection
What is the most helpful source of info about a patient?
Shift report gives important, up to date info and provides continuity of care.
Pt teaching, such as verbalizing the desired outcomes of medications, occurs during what phase of the nursing process?
Pt teaching occurs during the planning phase of the nursing process.
Identifying patterns in pt behavior, prioritizing nursing diagnoses and determining the etiology of pt problems all occur during what phase of the nursing process?
Analysis phase
Which is a psychological effect of prolonged stress?
a. Sensory overload
b. Decreased ability to solve problems
c. Increased ability to retain facts
d. Increased perceptual ability
b. Decreased ability to solve problems. Prolonged stress affects concentration and focus
General adaptation syndrome
Physiologic (biochemical) model of the body’s response to stress. Classified by three stages: alarm reaction, stage of resistance, stage of exhaustion.
Alarm reaction stage of general adaptation syndrome
Person perceives a specific stressor and various defense mechanisms are activated.
Fight-or-flight system activates during this stage.
Stage of resistance
Body attempts to adapt to the stressor. Vital signs, hormone level and energy production return to normal.
Exhaustion stage of general adaptation syndrome
Exhaustion results when the adaptive mechanisms are exhausted. The body no longer has defense against the stressor. The body will either rest and return to normal or reach total exhaustion and die.
The three stages of general adaptation syndrome (stress response)
- Alarm (fight or flight)
- Resistance (vitals normalize and adaptation to stressor begins)
- Exhaustion (unable to cope with the stressor)
Stages of therapeutic nurse-patient relationship
- Pre interaction phase- data collection
- Introductory (orientation) phase - opening the relationship and identifying roles and contracts
- Working phase- explore thoughts and feelings. Develop a care plan that includes actions and goals
- Termination- review events of the process, express feelings about termination of the process. Supply references for follow up care.
