Final Exam Flashcards
rNCLEX provides the __________ standard for knowledge of practice.
minimum
Nursing student graduate is minimally competent
National Nurses Association - ANA
Official professional nursing organization for nurses in the US; establishes standards for profession and tracks legislation on health care and how it impacts nurses
American Nurses Association
National Nurses Association - NLN
Sets the standards for nursing education programs; establishes criteria that all schools of nursing must follow
National League for Nursing
Roles of Nurse
caregiver, educator, leader, advocate, researcher
Inpatient vs outpatient
Inpatient = higher acuity and level of care
Maslows hierarchy of needs
Physiological (ABC’s)
Safety
Love/Belonging
Esteem
Self actualization
PICO(T)
Evidence based practice
Patient/Population
Intervention
Comparison
Outcome
Time (optional)
Decreased mobility = increased risk of
falling
Orthostatic hypotension
sudden drop in BP at different positions (lying, sitting, and standing)
Transferring Patients According to Dependency Level:
Mechanical lift with full sling
Complete dependence: immobile
Mobility Aids: Canes
Sizing:
* Top of cane should reach top of hip joint
* 30 degrees elbow flexion
Teaching:
* Hold cane on stronger side
* Distribute weight evenly
* Advance cane and weaker side simultaneously, and then stronger side
* Avoid leaning over
Mobility Aids: Walker
Sizing:
* Top of walker should reach top of hip joint
* 30 degree elbow flexion
Teaching:
* Pick up walker and advance it as you step ahead
* Do not slide, unless it has wheels
Mobility Aids: Crutches
Sizing:
* Axillary crutch pad should be 3 fingerbreadths below axilla
* Slight flexion of elbows
* Axilla should not rest on crutch pad
Teaching:
* Tripod position
* Lead with unaffected leg when going up stairs and to lead with affected leg coming down
Intrinsic fall causes
Orthostatic hypotension
Meds: for new and dose changes
* Psychotropics
Extrinsic fall causes
unsafe environment
Guidelines for restraints
o Never ordered as needed (PRN)
o Require order within 1 hour
o Must be re-ordered every 24 hours
o Assess and document frequently
What is the #1 way to stop the spread of infection?
HAND HYGIENE
Use friction
Stages of infection
o Incubation: period of time between invasion of the pathogen and the first signs or symptoms of infection
o Prodromal: most infectious, appear as vague symptoms
Not all infections have a prodromal phase
o Illness: signs and symptoms present
o Decline: symptoms fade, # of pathogens decline
o Convalescence: tissue repair, return to health
2 Tiers of protection per CDC
Tier 1- Standard precautions
Tier 2- Transmission based precautions
Tier 1- Standard Precautions
▪ Apply to all patients
▪ Hand hygiene, surgical mask, proper sharp disposal, cover mouth and nose when sneezing/coughing
Tier 2- Transmission based precautions
▪ Patients with known or suspected infection or colonization with pathogens
- Contact precautions: gown and gloves
o MRSA, CDiff (enhanced) - Droplet precautions: gown, gloves, mask, eye protection
o COVID, pertussis, pneumonia, meningitis, flu - Airborne precautions: gown, gloves, N95 mask
o TB, varicella, measles, SARS
Critical thinking
intellectual process
Clinical reasoning
the thinking process by which a nurse reaches a clinical judgement. enables you to synthesize, knowledge, experience, and information from various sources to develop an effective plan of care for a client.
Clinical judgement
Contains thinking and reasoning
conclusion or outcome for patient scenario
outcomes of thinking, doing, and caring
NCSBN
creator of NCLEX
Layers of CJM
o Layer 0: clinical decisions
o Layer 1: comprises the outcome = clinical judgement
o Layer 2: form, refine hypotheses; evaluation
o Layer 3: recognize cues, analyze cues, prioritize hypotheses, generate
solutions, take action, evaluate outcomes
▪ Not linear
o Layer 4: context (individual and environmental factors)
Nursing process
ADPIE
ADPIE
Assessment
Collecting subjective and objective data
▪ Recognize cues
ADPIE
Diagnosis
Analyze cues and prioritize hypotheses
* Cues = unexpected findings (abnormal)
ADPIE
Plan
Prioritize hypotheses and generate solutions
ADPIE
Implementation
Take action
* Doing, delegating, and documenting
ADPIE
Evaluation
Evaluate outcomes
* Goal oriented
o Examples:
▪ Inability to walk → ambulate patient
▪ Risk for falls → make sure room is clear of clutter
subjective data
what the pt says/tells us
Primary: obtained directly from patient and/or nurse
Secondary: received from caregiver or another person on team
objective data
what we observe
factual data- vital signs, lab data
Nursing diagnosis- patient problems the nurse can treat independently
assessing and analyzing ques/data
Internal respiration
oxygen is exchanged to provide oxygen to the tissues (tissue perfusion)
External respiration
oxygen is diffused from the alveoli in the pulmonary circulation to the capillary system (CO2 is released from circulation into the alveoli)
Pulse oximetry
measures O2 saturation in hemoglobin
does not test for tissue perfusion
Ventilation: mechanical
Movement of air into and out of the lungs
Respiration: chemical
Exchange of the gases in the lungs
Where does diffusion of gases take place (O2 and CO2 exchange)?
Alveoli: tiny air spaces with thin walls surrounded by a fine network of capillaries
Oxygen deficiency in body tissues
Hypoxia
Oxygen deficiency in the blood
Hypoxemia
Nursing intervention to promote oxygenation
o Positioning for maximum lung excursion:
▪ High fowlers → best position for patients who have difficulty
breathing
o Pursed lip breathing: exhalation is twice as long as inhalation
▪ COPD patients
Oxygen delivery system: Non-breather
AKA mask w/ reservoir bag
delivers 100% oxygen to pt
do not use on copd pts
Minimum urine output
30mL/hr
Is urinary incontinence a normal part of aging?
no
UTI’s can cause __________ in elderly patients.
AMS
Before giving pt’s antibiotics for UTI, what diagnostic test should be completed?
Urine culture to determine which bacteria you are treating
Where do you collect urine specimen from when pt has a cath?
From specimen port
Not the collection bag
How do you prevent CAUTI?
asepsis technique, keep bag below bladder, no kinks in tubing
How to properly obtain clean catch sample?
o Wash hands in warm soapy water
o Open contain without touching inside of cup or cover
o Using towelette clean urinary opening
o Begin urinating in toilet and bring container into the stream to collect a clean, mid-stream sample
Process by which the body converts food to energy
Metabolism
Nutrition is esp. important for post op patients, why?
promotes optimal healing
What macronutrient promotes healing?
protein
Constipation
increase fluid and fiber intake
Diabetic pts diet
low glycemic
Essential for energy supply
carbs
Essential for brain and nerve function
fats
First step after placing NG tube on pt, before giving any meds or food
radiographic (x-ray) verification is the most reliable
method for confirming tube placement and must be
performed before the first feeding is administered
Diets meant for short term use
NPO, clear liquid, full liquid
Surgery and diet progression
NPO → clear liquid → full liquid → surgical soft → regular diet
o NPO used prior to surgery to prevent aspiration
o Progression used to prevent vomiting —> can cause
incision to open
NPO
Nothing by mouth
Used prior to surgery to prevent aspiration
Clear liquid diet
- Clear juices, popsicles, jello, clear broth, tea
Full liquid diet
- All liquids: milk, supplemental drinks, ice cream
Surgical soft diet
- Mashed potato, pureed meats, veggies, pudding
Act of bearing down to defecate
Valsalva maneuver
Do not perform on clients with heart disease, glaucoma, increased ICP, or a new surgical wound
▪ Increases risk for cardiac arrythmias
Vagal response
Dizziness, ringing ears
Is increased GI motility (peristalsis) a healthy response to intestinal infection?
yes
Vasovagal syncope
passing out
Meconium
dark green to black tarry sticky odorless stool in infants
Best position for enema
left lateral Sim’s position
Florence Nightingale
founder of modern nursing
reduced death rates by improving hygiene
Benner’s models of novice to expert
novice
advanced beginner
competent
proficient
expert
Carbon monoxide poisoning
pt will be bright red in color
Ways to prevent pneumonia
early mobilization
upright position
turn, cough, deep breathe
incentive spirometer
Nosocomial infection
infection acquired during hospitalization
Important w/ inhalers
ask pt to demonstrate inhaler technique, take as prescribed
Diagnostic testing for oxygenation status
ABG’s
peak flow monitoring
What type of finding is a cue?
abnormal finding
What does a nurse mean w/ a pt outcome
goals for the pt
Chain of infection - 6 components
Infectious agent- pathogen such as bacteria, virus, fungi, parasite.
Reservoir- source of infection
Portal of Exit- most frequent= bodily fluids
mode of transmission ( direct/indirect)
Portal of entry - body openings
Susceptible host- person at risk of infections
Contact precautions
gloves and gown
First void after cath removal needs to be
measured
For IV contrast- its important to check for
iodine allergy
Responses to enema are governed by
height of solution container
speed of flow
concentration of the solution
resistance of the rectum
Hypertonic enema
fleet: sodium
maintain pressure on bottle until empty
Kayexalate enema
Remove excess potassium
What do you do if the pt you are administering an enema complains of abdominal cramping
slow the flow
Ostomy should be
pink & moist
ADPIE matches up with CJM Layer
Layer 3
Components of CJM Layer 3
recognize & analyze cues
prioritize hypotheses
generate solutions
take action
evaluate outcomes
Absent bowel sounds could indicate
paralytic ileus
Impaired peristalsis leading to bowel obstruction can cause
Perforated bowel
Occult blood test
blue =
postive
Causes of false positive occult blood test
o Hemorrhoids
o Food
o Supplements and medications
o Iron
Causes of false negative occult blood test
Vitamin C
Promotion of bowel movement
o Exercise, water, fiber, minimize use of laxatives, go when you feel the urge
Increase fluid and fiber consumption: first line of treatment/prevention
Overuse of laxative can cause strengthening of the bowels.
True or False
False
Overuse can cause weakening of the bowels leading to chronic constipation
Safest form of laxatives
bulk forming
Stool softeners
Lubricant action, no effect on peristalsis
Osmotics
Drawing water into bowel from surrounding tissue
* Bowel distention
Stimulants
Bowel irritants
* Stimulate peristalsis
o Increased GI motility (peristalsis) =
healthy response to intestinal infection
What do you include in shift report to oncoming nurse?
demographics, relevant med hx, current treatments, pt’s response to interventions, pending labs, procedures, current status, plan of care, concerns
Use I-SBAR-R
Assertive communication
SBAR, open, direct, honest, and non-judgmental
Passive vs Aggressive communication
Passive- I don’t count, you do.
Aggressive- I count, you don’t.
What is the primary purpose of the chart?
Communication
The EMR documentation system is problem oriented.
What are the patient issues an interdisciplinary team of professionals work on called?
Collaborative problem
Cardinal rule of documentation
If it wasn’t documented; it did not happen
Documentation guidelines
Be clear and concise
Use correct terminology, spelling, and grammar
Timely
Signature
When to document
o Admission
o Transfer
o Discharge
o Ongoing care per policy
o Change in condition
o Communication
Potential HIPAA violations
Discussing patients in public areas
Leaving charts out
Not logging off computers
Copying forms
Social media
*Providing report to incoming nurse or to patient’s provider does not break confidentiality —> because they are in charge of patient’s care
VORB
o VORB: verbal order read back
*Must be signed by prescriber ASAP
TORB
TORB: telephone order read back
*Must be co-signed within 24 hours
*Pronounce digits of numbers separately
* 50mg 5, 0mg
Spell unfamiliar names
Record with date, time, and TORB(V)
Read back is used to reduce
errors and any miscommunications –> accuracy
What is charting by exception?
Chart only significant findings/exceptions to norms
Reduces charting time for nurses = more time w/ the pt
Omissions are the biggest problem
Are incident reports only for patients?
No. Can be for employees (ex: needle stick)
Do you reference incident report in the pt’s chart?
No
What do you include in incident report?
-Only state facts
-Do not place any blame
-Does not go in pt’s chart
Adverse event
An event in which care resulted in an undesirable clinical outcome
Near miss event
Caught before hand
Sentinel event
An event that results in death, permanent harm, or severe temporary harm
Examples of sentinel event
-Pt abduction
-Pt suicide
-A foreign body, such as sponge or forceps that was left in a patient after surgery
-A hospital operates on the wrong side of the patient’s body
-Hemolytic transfusion reaction involving major blood group incompatibilities
What time should be used when documenting?
The time the assessment/procedure was completed
What do you include in hand-off reporting?
Demographics
Relevant medical history
Current treatments and patient’s response
Pending labs, procedures
Current status
* Significant assessment findings
* Significant occurrences over last 24 hours
Plan of care
* Patients progress
* Priority areas to focus
Concerns
Best environment for therapeutic communication
quiet, private, comfortable temperature, free of unpleasant smells
How to correct an error in the chart
Strikethrough, write “mistaken entry”, date, and initial
Do not use whiteout
When can PHI be released?
For payment, treatment, and normal healthcare operations
MAR
Medication Administration Record
Comprehensive list of all ordered medications for pt
Ways to enhance therapeutic communication
Address the pt, listen actively, establish trust, be assertive, interpret body language, use silence when appropriate, explore issues, validate feelings, clarifying statements, sit at eye level
Six Rights of Medication Administration
Right Drug
Right Dose
Right Route
Right Time
Right Patient *Important to preventing errors
Right Documentation *Avoids medication overdose
At what points do you triple check medications?
When pulling meds, before leaving med room, and at bedside before pt receives meds
Vulnerable populations
Homeless, poor, sexual orientation, mentally ill, physical disabilities, young, elderly, some ethnic and racial minority groups, gender
I-SBAR-R
o Intro
o Situation
o Background
o Assessment
o Recommendation
o Read back
Appropriate times to use silence
Conveys empathy
- Patient pauses during the conversation
- Discussing heavy or emotional diagnoses
- Patient exhibits emotional distress
Barriers to therapeutic communication
o Asking why —> *projects blame and judgement
o Offering advice —> *reframe, allow patient to make their own decisions
o Expressing approval or disapproval
o Changing subject inappropriately
o Asking too many questions
o Fire-hosing information
Can you give personal advice/opinion to pt’s and their families?
no
Process for safe medication administration
-Know your patient history (HX, labs and assess your patient)
-Follow the orders
-Perform the Rights of Safe Med. Administration
-Triple check the medications against the MAR before the patient takes them
-Reassess your patient afterwards and document
What is the goal of inter professional education (IPE)?
inter professional practice (IPP)
Medication error
is an adverse event unless patient is harmed
Stereotype vs archetype
Archetypes- something recurrent, based on facts; usually not negative
Ex: eye or skin color based on region or geographic data
Stereotypes- Widely held unsubstantiated beliefs that have no basis in facts; negative beliefs
Ex: “Naturally athletic” “Naturally intelligent”
Discrimination
When a person acts on prejudice (stereotypes) and denies another person one or more of his/her fundamental rights
Ex: Not giving suspected drug user pain meds
Universals
values, beliefs, and practices that people from all cultures share
Specifics
values, beliefs, and practices that are special/unique to a culture
Race is strictly related to
biology
How to enhance cultural awareness
Self assessment for bias and prejudices
What is needed to deliver culturally competent care?
Cultural awareness and sensitivity
What should you tell a trained interpreter before beginning any translations?
Advise them to translate everything that is said and leave nothing out
Be sure to use interpreter when obtaining consent
How to complete a cultural assessment
-Open-ended questions
-Allow patient time to explain
-Listen with respect and remain non-judgmental
Advise pt you want to provide the best care by identifying their cultural practices
If patient is unable to swallow —> find same medication, just different form
- *Cut scored pills only (line down middle)
- Crush – if able
o *NOT extended release - Mix with thickened liquids or pudding/applesauce
- Check to see if drug comes in liquid form FIRST
Buccal
inner cheek
Sublingual
under tongue
Most common adverse effect of meds
abd discomfort
Parameters for Nitroglycerin
-Check vitals before and after each dose
-1 SL tab every 5 minutes for a maximum of 3 doses
-Must wear gloves
-Make sure pt doesn’t take Cialis/Viagra or any other ED medications
-Warn pt before first dose about wicked headache
-Instruct pt to hold med under tongue, and not to chew-
-If patient’s HR is below 60 or Systolic BP (SBP) is less than 90 hold dose and notify HCP
How to administer ear drops for adults and kids
-Use solutions at room temperature – too cold leads to dizziness
-Pull pinna up and back for adults, down and back for children
-Push on tragus to instill meds
Should you give food with NSAIDs?
Yes. Upset stomach without it.
What should be considered when administering the Albuterol?
-Check vitals before and after administering. Medication raises HR.
-Oral care to reduce risk of thrush
-If pt is unable to use hands, use a spacer.
Ampule is a __________ dose only. Use __________ needle when drawing up medication to avoid chards of glass.
single; filter
Smaller the needle gauge
Larger the diameter of the needle
Insulin injections are
Subcutaneous (subq)
General rules for subq injections
-Max. injection is 1 mL
-Sites include upper arm, abdomen, upper back, lower back, and top of thighs
-Rotate sites
-45-90 degree angle
How should you draw up insulin?
Inject air into each vial first and then draw up regular (clear) insulin before long acting insulin (cloudy)
Nancy Reagan, RN
General rules for intramuscular injections
-Z track method
-Max. injection is 1 mL to 5 mL depending on site
-Deltoid, Vastus Lateralis, and Ventrogluteal
Max. injection & landmark for Deltoid is
1 mL
2 fingerbreadths below the acromion process in the middle third of the muscle
Max. injection & landmark for Vastus Lateralis is
3 to 5 mL
Between greater trochanter and the lateral femoral condyle - injection site is the middle third of the muscle
Max. injection & landmark for Ventrogluteal is
3 to 5 mL
Place your palm on the greater trochanter and thumb towards the groin avoiding the anterior superior iliac spine and iliac crest inject in the muscle
General rules for intradermal injections
-Max. injection is 0.1 mL
-5-15 degree angle
-Sites include forearms, upper chest, and upper back
-Ex: TB skin test
Culturally competent model of care
ASKED
Awareness- Take an honest look at your own biases
Skills- Ability to conduct a cultural assessment with sensitivity
Knowledge- Information about cultural worldviews
Encounters- Takes practice to become competent
Desire- Must want to be culturally competent
What type of needle must be used when drawing up insulin?
Insulin needle (orange) only because it is in units
Must be dual verified by another RN
Regulates and defines the scope of nursing practice
- State Nurse Practice Acts
Motivated by the desire to increase well-being
health promotion
Motivated by the desire to prevent illness
health prevention
Primary purpose of incident report
root cause analysis
How do you define the pain experience?
- It is what the patient says it is
o Subjective experience
o Can be protective and have purpose
How do you manage pain for nonverbal or cognitively impaired patients?
Monitor vital signs, treat pathological condition, look for non-verbal cues
Health prevention
Primary
Prevent/slow onset of disease
* Education and prevention
Health prevention
Secondary
Detect and treat illness in early stages
* Screenings
o Purpose = early diagnosis and early detection
o Examples: BP, mammo, cancer, PSA, glucose, lipid levels
Health prevention
Tertiary
Stop disease progression; return to pre-illness state
* Rehab
Transtheoretical Model of Change
o Precontemplation
o Contemplation
o Preparation
o Action
o Maintenance
o Termination
Precontemplation
no intention to change behavior in the foreseeable future
Contemplation
seriously thinking about overcoming a problem
Preparation
intending to take action in the next month
Action
the plan is implemented
Maintenance
working to prevent relapse
Support groups, diet, exercise
Termination
changed the behavior
Numerical indicator that determines the amount of stress someone is under
Life-Stress Review
Purpose of health screenings
early detection
Nursing interventions for health promotion
o Role modeling
o Education
o Providing support
Health promotion programs
o Disseminating information
o Changing lifestyle and behavior
o Environmental control
o Wellness assessment/health risk appraisal
Factors affecting pt learning
o Motivation
o Readiness
o Timing
o Feedback
o Repetition
o Learning environment
Barriers to effective learning
o Stress/anxiety
o Pain
o Fatigue
o Nausea
o Emotional distress
o Low literacy
o Communication gap
o Lack of perceived need
Can pt teaching be delegated?
No. Should always be done by the RN first.
When does d/c planning start?
At time of admission
What is the goal of d/c planning?
ensure continuity of care
High risk populations that need special arrangements
o Complex conditions – multisystem disease process
o Major surgical procedures
o Chronic or terminal illness
o Elderly
o Emotional or mental instability
o Lack of transportation
o Homeless
o Financial insecurity
o Unsafe home environment
Involving pt support system in d/c planning ensures
adherence to discharge plan and patient safety
Evidence of effective education
o Adherence to POC
o Verbal explanation
o Demonstration
Kubler-Ross 5 stages of grieving
o D: denial
o A: anger
o B: bargaining
o D: depression
o A: acceptance
Categories of loss
o Actual: can be identified by others
Death of loved one or relationship, theft, natural disaster
o Perceived: internal, only identified by the person
STD, perceived loss of purity or health
o Physical: any injuries (amputating leg), organ removal, loss of function (paralysis)
o Psychological: areas of control, trust
Losing youth or beauty, body disfigurement (burn victim)
o External: losing objects with sentimental value
o Environmental: change in familiar
18yo moving out, starting a new job
o Loss of significant relationships
Uncomplicated grief
natural response to loss, expected
Intense, but gradually diminishes over time
Dysfunctional grief
maladaptive, suicidal, depressed
Chronic: unable to rejoin normal life
* Cannot move on
Masked grief
expressing grief through other types of behavior
* Excessive shopping
Delayed: busy, not processing emotions
Disenfranchised grief
not socially supported or acknowledged/validated
Losing a foster child or mistress
Anticipatory grief
experienced before loss occurs
Dementia, heavy diagnoses like cancer
Palliative care
Pain control comfort measure
Manage symptoms to increase QOL
Hospice care
Terminally ill patient that are anticipated to die in 6mo
Nursing role in end-of-life
o Educate patient and families of diagnosis, what to anticipate during dying phase, pain management, consult chaplain, advocate for patient needs
Physiological stages of dying
o 1 – 3mo: withdrawal from world and people, excessive sleep, no appetite
o 1 – 2wks: decrease BP, yellowing, changes in pulse rate, agitation/delirium, dyspnea
o Days to hours: surge of energy, Cheyene-Stokes (irregular increase in length and depth following by period of apnea), dehydrated, dysphagia, dry skin, congestion, liver failure, cerebral hypoxia, stool impaction, fatigue
o Moments prior: does not respond to touch or sound, cannot be awakened
Nursing priorities:
* Oxygenation, patient safety, personal hygiene, controlling pain
Facilitating grief
o Express feelings
o Recall memories
o Find meaning
High risk scenarios for difficult or complicated grieving
o Unexpected, sudden death
o Argumentative grief, unresolved conflict
o Previous or multiple loses
Helping families after the death
o Express sympathy
o Acknowledge pain and loss
Providing postmortem care
o Rigor mortis: 2 – 4hrs
Close mouth and shut eyes
o Place pillow under head and shoulder to prevent pooling of blood
o Remove tubing, unless going to ME
o Clean and prepare patient for family
Classification of pain by origin
Cutaneous/superficial
Deep somatic
Visceral
Radiating/referred
Phantom: surgically removed
Psychogenic: no physical cause identified
Classification of pain by cause
Nociceptive: aching
Neuropathic: burning, itching, pins and needles
Classification of pain by duration
Acute: up to 6mo, rapid onset
Chronic: 3 – 6mo, interferes with QOL and ADLs
Intractable: chronic that is highly resistant to pain interventions
Classification of pain by description
Quality: what does it feel like?
Periodicity: when did it start, is it constant?
Intensity: how bad does the pain feel?
Nonpharmacological measures for pain management
Guided imagery
Deep breathing
Acupuncture
Pharmacological measures for pain management
Nonopioid:
* NSAIDs: high risk of gastric irritation – avoid prolong use
* Acetaminophen: kills liver
Opioid:
* Drowsiness, n/v, constipation, sedation
Increasing dose of medication to achieve desired effects
Tolerance
Reasons why a pt may refuse pain meds
Hx of addiction
o Investigate why patient does not want it
Non-verbal signs of pain
o Vital signs change
Elevated pulse, BP
o Facial expression
Grimacing, crying, or moaning
o Posture/body position
Guarding, use of accessory muscles
o Behavioral manifestations
Irritable, agitated, use of profanity
*provide medication based on pathologic parameters
Assessing pain in adults
o Numeric rating scale: 0 – 10
Assessing pain in peds
o Wong-Baker faces
Factors affecting skin integrity
Age, Immobility, Malnourishment, Dehydration, Lack of sensation, Medications, Impaired circulation, Excessive exposure to moisture (urinary incontinence) , Fever (find source), Infection. Lifestyle (Tanning, bathing, piercings, tattoos)
Any break in the skin increases the risk for
infection
Classification of wounds
Open
break in skin or mucous membrane
Abrasion, lacerations, puncture wounds, surgical wounds
Classification of wounds
Closed
no break in skin
Bruise, tissue swelling
Classification of wounds
Acute
short duration, heal spontaneously
Classification of wounds
Chronic
exceed expected length of recovery
Complex, pressure injuries, diabetic ulcers, colonized with bacteria
Classification of wounds
Clean
uninfected wounds, minimal inflammation
Surgical incision
Classification of wounds
Clean contaminated
surgical incision that is inside GI, respiratory, or GU tract
High risk for infection
Classification of wounds
Contaminated
open traumatic wounds or surgical incision where there is a major break and sepsis
Impaled with rusty pipe
Classification of wounds
Infected
erythema, swelling, fever, foul odor, sever or increase pain, large amounts of drainage, warmth surrounding soft tissue area
Classification of wounds
Superficial
epidermal layer
Classification of wounds
Partial thickness
extends to epidermis, but not through dermis
Classification of wounds
Full thickness
extends to subcutaneous tissue/fat
Classifications of wounds
Penetrating
Wounds of internal organs
Priority nursing goal for open wound
wound free from infection throughout healing process
At risk populations for wounds
o Paralysis
o Sedated patient
o High risk pregnancy
o Cast or devices
o Altered sensory perception
o Diabetics
o PVD
o Post op
__________ patients are at an increased risk for wound healing
o Especially post op, PVD, and diabetics
Malnourished
Primary wound intention
o Primary: clean surgical incision
Edges approximated
Minimal scarring
Secondary wound intention
o Secondary: heals from inner layer to surface
Remain open
Wound edges not approximated
Tissue loss
Tertiary wound intention
o Tertiary: delayed closure of wound edges
Granulating tissue brought together
Phases of wound healing
o Inflammatory: 1 – 5days
Hemostasis: stopping of blood
Inflammation: edema, erythema, migration of WBC, elevated temperature, scab formation
o Proliferative: 5 – 21days
Formation of granulation tissue
o Maturation: remodeling phase
Formation of scar tissue strengthens wound
Types of exudate
Straw colored
Serous exudate
Types of exudate
bloody drainage
Bright red or brown
Sanguineous
Types of exudate
mix of bloody and straw-colored fluid
New wounds
Serosanguinous
Types of exudate
yellow, contains pus
Thick, malodorous
Purulent
Types of exudate
contains blood and pus
Infected wound
Purosanguineous
Separation or splitting of open layers of a surgical wound
Apply abdominal binder
o Dehiscence
Extrusion of viscera or intestine through a surgical wound
Medical emergency
Major risk for infection cover with sterile towels immediately and remain in bed with knees flexed
o Evisceration
Predicts how likely a pressure ulcer will form
Braden scale
Braden scale is based on
Sensory perception, moisture, activity, mobility, nutrition, and friction or shear
o Total score less than 18 = at risk
Stages of Pressure injuries
Stage 1: non-blanchable erythema (redness) of intact skin
Stage 2: partial-thickness skin loss involving epidermis, dermis, or both
Stage 3: full-thickness skin loss damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia
Stage 4: full-thickness skin loss with exposure of muscle, bone, or supporting structures
Unstageable: base of wound cannot be seen due to being covered by necrotic tissue, slough, or escar
* Sloth: soft, moist, white or yellow
* Escar: black, dry, thick necrotic tissue
Unrelieved pressure to an area, resulting in ischemia cause
Pressure injuries
Nursing interventions for pressure injuries
Prevention
Frequent repositioning
Meticulous skin care and moisture control
Therapeutic mattress
Adequate nutrition
Client/family teaching
Elevating heels
Is stress always negative?
No, can be protective or motivating
Internal stressors
diarrhea, anxiety, negative self-talk
External stressors
death of family member, natural disaster, financial issues
Developmental stressors
occur at specific phase in life
Peer pressure: teens
Exploring environment and learning rules: toddler
Navigating parents: young adults
Situational stressors
car accident, natural disaster, illness, unemployment
Psychosocial stressors
work, family dynamics, living situation, relationships, daily life
Physiological stressors
underlying illness, diarrhea
General adaptation syndrome
o Alarm: fight or flight
Increase HR, BP, RR, dilated pupils, headaches, nail biting, chest pain, dry mouth, decreased wound healing, increased pain, stiff neck, appetite changes, difficulty sleeping
o Resistance: adaptation (coping mechanisms)
o Exhaustion: illness or death
Signs of inflammation
o Redness
o Heat
o Swelling
o Pain
o Loss of function
Long term stress effects
o Sleep difficulties, increased pain, decreased wound healing, HTN, dry mouth, increased RR
Metric abbreviations:
o cc: cubic centimeters
o mEq: milliequivalent
o mL: milliliter
o mg: milligram
o g: gram
o kg: kilogram
o L: liter
o mcg: microgram
o unit: unit (*do not use ‘U’)
Time abbreviations
o AC: before meal
o PC: after meal
o QH: every hour
o QHS: at bedtime
o PRN: as needed
o STAT: immediately
o QD: daily
o BID: 2x daily
o TID: 3x daily
o QID: 4x daily
Route abbreviations
o IV: intravenous
o IVP: intravenous push
o IVPB: intravenous piggyback
o NEB: nebulizer
o MDI: metered-dose inhaler
o S&S: swish and spit/swallow
o SQ: subcutaneous
o IM: intramuscular
o SL: sublingual
o PO: by mouth
o PR: by rectum
o NGT or NG: nasogastric tube
Liquid conversions
30 mL = 1 oz
3 tsp = 1 tbsp
1 tsp = 5 mL
1 tbsp = 15 mL
1 pt = 500 mL
1 qt = 1 L = 1000 mL
Metric conversions
1 gr = 60 mg
1 kg = 1000 g
1000 mcg = 1 mg
1000 mg = 1 g
Temp. conversions
C = (F – 32) / 1.8
F = (C x 1.8) + 32
Weight conversions
1 kg = 2.2 lbs
1 lb = 16 oz
Intervention for pt at risk for falls and is not responding to instructions?
bed alarms, family at bedside
Refusing to give a known drug abuser pain meds is
discrimination
