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TERM 2 N1260 SKILLS 2 > FINAL EXAM > Flashcards

FINAL EXAM Flashcards

1
Q

What are 5 factors that can contribute to a falls risk?

A
  1. Falls in past year
  2. Impaired cognition/sensory perception
  3. Incontinence
  4. Wandering
  5. Improper footwear
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2
Q

What are the 6 components of the morse falls scale?

A
  1. Falls in past 3 months
  2. Secondary diagnosis
  3. Ambulatory aid
  4. IV
  5. Gait/transferring
  6. Mental status
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3
Q

What are 4 guidelines to documentation to keep you out of trouble?

A
  1. Documentation is proof of your care
  2. Nothing written, nothing done
  3. You will be judged by how you document
  4. Keep documenting until issue resolved
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4
Q

Why might immobility result in elevated nitrogen levels?

A

Amino acid breakdown

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5
Q

Why might immobility result in hypercalcemia?

A

Bone resorption

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6
Q

What is the term for alveolar collapse due to bronchial/bronchiolar blockage?

A

Atelectasis

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7
Q

What kind of lung infection may result from immobility?

A

Hypostatic pneumonia

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8
Q

What blood pressure difference defines orthostatic hypotension?

A

> 20mmHg systolic or >10mmHg diastolic

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9
Q

Which topical medication is used for ischemic heels?

A

Proviodine

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10
Q

What angle should HOB be kept at to prevent pressure injury?

A

<30 degrees

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11
Q

What angle should the knee gatch be kept at to prevent sliding down?

A

10-20 degrees

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12
Q

What are 3 factors that contribute to pressure injury development?

A
  1. Intensity
  2. Duration
  3. Tolerance
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13
Q

What is the term for the minimum amount of pressure required to collapse a capillary?

A

Capillary closing pressure

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14
Q

What is the term for skin fold dermatitis?

A

Intertriginous damage (ITD)

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15
Q

What are the 6 areas assessed on the Braden scale?

A
  1. Sensory perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction/shear
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16
Q

Define a suspected deep tissue injury (3)

A
  1. Persistent nonblanching deep red, maroon, or purple
  2. Epidermal separation revealing dark wound bed
  3. Blood filled blister
17
Q

Define a stage 1 pressure injury

A

Nonblanching erythema

18
Q

Define a stage 2 pressure injury (2)

A
  1. Partial thickness skin loss, exposed dermis
  2. Pink/red and moist wound bed, or serum filled blister
19
Q

Define a stage 3 pressure injury (3)

A
  1. Full thickness skin loss
  2. Fat visible
  3. May have granulation, epibole, eschar, slough, undermining/tunneling
20
Q

Define a stage 4 pressure injury

A

Exposed/palpable fascia, muscle, tendon, ligament, cartilage, bone

20
Q

Define a stage 4 pressure injury

A

Exposed/palpable fascia, muscle, tendon, ligament, cartilage, bone

21
Q

Define an unstageable pressure injury

A

Cannot be assessed due to obscuration by slough/eschar

22
Q

Name 8 components of a wound assessment

A
  1. Anatomical location
  2. Size
  3. Wound bed
  4. Wound edges
  5. Peri-wound skin
  6. Exudate
  7. Edema or induration
  8. Pain
23
Q

What terms are used to describe wound edges?

A

Epithelialization, epibole

24
Q

What are 4 stages of wound healing, and how long does each stage last?

A
  1. Homeostasis (Day 1)
  2. Inflammation (Day 1-4)
  3. Proliferation (Day 4-21)
  4. Remodeling (Day 21-2 yrs)
25
Q

How fast should normal wounds heal?

A

3mm per week or 30% reduction in size per 4 weeks (full healing in 12 weeks)

26
Q

What is the term for a wound that is unable to heal due to outside factors?

A

Maintenance wound

TERM 2 N1260 SKILLS 2 (3 decks)

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