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fundamentals 3 > Final test > Flashcards

Final test Flashcards

1
Q

what are some constipation foods?

A

cheese, lean meats, eggs, pasta

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2
Q

What is constipation?

A

Having a bowel movement fewer than every 3 days, hard, dry stool; difficult to eliminate, excessive straining, bloating, and the sensation of a full bowel.

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3
Q

Clients with what conditions should avoid straining during BM

A 
Cardiovascular disease
glaucoma
increased intracranial pressure
surgical wounds
increased blood pressure
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4
Q

What are some causes of constipation?

A

not enough fiber in the diet, lack of physical activity, some medications, milk, cheese, irritable bowel syndrome, changes in life or routine such as pregnancy, aging, and travel. Laxative misuse, ignoring the urge to have a bowel movement, dehydration, specific diseases or conditions such as stroke, problems with colon and rectum

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5
Q

complications of constipation?

A

Hemorrhoids: dilated veins in rectum from straining, painful; itchy. can be internal or external.
Impaction: feces/stool obstruction. liquid stool may ooze or leak around hardened stool.
Flatulence: Excess or trapped gas. Can result from slowed mobility.
Incontinence.

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6
Q

Individuals at high risk for constipation?

A

Patients on bed rest taking constipating medicines
Patients with reduced fluids or bulk in their diet
Patients who are depressed
Patients with central nervous system disease or local lesions that cause pain
Patients on NARCOTICS

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7
Q

Promoting regular bowel habits

A

Timing: after meals and exercise
Positioning: bedside commode or toilet vs. bedpan
Privacy
Nutrition: fluids, fiber, fruits, and veggies
Exercise

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8
Q

Rectal suppositories

A

Some soften, lubricate, stimulate, for pain or symptom management, lubricant, insertion, retention, retention. Glycerin suppositories for infants and children.

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9
Q

What is diarrhea?

A

An increased number of stools and the passage of liquid, unformed feces, associated with disorders affecting digestion, absorption, and secretion.

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10
Q

Name two complications associated with diarrhea?

A

A.contamination and risk for skin ulceration

B.fluid and electrolyte or acid-base imbalances

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11
Q

An Enema is

A

Instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.

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12
Q

Types of Enemas

A

Cleansing: to relieve constipation or impaction to empty for surgery, to clear out for exams, to establish bowel function during training.

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13
Q

Diarrhea causes & prevention

A

Viruses and bacteria from people or surfaces
C-diff infections now highly contagious and has become health care associated infection.
Wash your hands and those of the patients.

Prevention:
Hand-washing

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14
Q

Treatment of Diarrhea

A

Acute diarrhea-hours to days

  • Rehydration is most important
  • skin care
  • antidiarrheal meds usually after bacteria R/O

Chronic Diarrhea-3-4 weeks or more

  • many causes and treatments
  • immodium, lomotil, kaopectate, peptobismol
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15
Q

What is the definition of critical thinking?

A
  • An active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others.
  • Also recognizing an issue exist, analyzing information, evaluating information, and making conclusions.
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16
Q

what are the 3 levels of critical thinking?

A

1) Basic critical thinking
2) Complex critical thinking
3) Commitment

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17
Q

Why is it essential to be a critical thinker?

A
  • To manage complex dilemmas
  • for empowerment & liberation
  • To exchange views and information
  • to broaden or change our thinking and learning
  • for self-actualization
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18
Q

What is concept mapping?

A

A visual representation of client problems and interventions that illustrates an interrelationship

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19
Q

Reflection/Reflective journaling?

A

A tool used to clarify concepts through reflection by thinking back or recalling situations.

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20
Q

What are the five components of critical thinking?

A
  • Knowledge base
  • Experience
  • Critical thinking competencies
  • Attitudes
  • standards
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21
Q

A rise in temperature of 1 F may cause an increase in pulse rate of _____ beats per minute

A

4

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22
Q

The most appropriate goal for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection is?

A

once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern.

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23
Q

Factors affecting bowel elimination

A
  1. Interference with normal functioning
  2. Developmental stage
  3. Daily patterns
  4. Amount or quality of fluid/food intake
  5. Level of activity
  6. Lifestyle
  7. Emotional states
  8. Pathological processes
  9. Medications
  10. Procedures (diagnostic procedures/ surgeries)
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24
Q

Normal characteristics of stool

A
  1. Volume
  2. Color
  3. Odor
  4. Consistency
  5. Shape
  6. Constituents
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25
Q

Constipation in the older adult is usually the result of

A

decreased fiber & fluid.

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26
Q

nursing intervention for constipation

A

add fiber, establish routine time for defacation

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27
Q

for an adult patient who will receive an enema, the nurse recognizes the tube should be inserted

A

3-4 inches and the height of the bag for a regular enema should be 12 inches above the anus

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28
Q

Temperature

A

the difference between heat produced by bodily functions and heat lost to the environment. -normal 96.8 to 100.4 F

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29
Q

Pyrexia (Fever)

A
  • An alteration in the hypothalamic set point.

- actually a body defense; it will destroy invading bacteria and viruses.

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30
Q

signs and symptoms of a fever

A 
Hot dry, flushed skin, 
headache
thirst
loss of appetite
malaise
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31
Q

Critical signs and symptoms of a fever

A

Rapid heart rate
dehydration
decreased urinary output
seizures.

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32
Q

What are the effects of fever?

A 
Increased oxygen demand
increased HR and cardiac output
untreated may lead to: dehydration 
acid-base & electrolyte imbalances
cardiac dysrhythmia 
neurological damage.
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33
Q

Pulse

A
  • The palpable bounding of blood flow noted at various points of the body.
  • indicates circulation status
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34
Q

stroke volume

A

Amount of blood ejected with each contraction of left ventricle

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35
Q

Cardiac output

A

Pulse rate X stroke volume

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36
Q

Tachycardia

A

Pulse faster than 100 beats per minute

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37
Q

Bradycardia

A

Pulse slower than 60 beast per minute.

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38
Q

Dysrhythmia

A

Any disturbance or abnormal in a normal rhythmic pattern, specially irregularity in the normal rhythm of the heart

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39
Q

Pulse Strength

A 
0 Absent 
1+ Thready 
2+ normal 
3+full 
4+bounding
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40
Q

Tachypnea

A

Rapid respiration rate; exercise and fever increase respiratory rate.

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41
Q

Bradypnea

A

A slow respiratory rate, below 12 per minute

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42
Q

Dyspnea

A

Difficulty breathing

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43
Q

Apnea

A

A lack of spontaneous respirations

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44
Q

Cheyne-stokes respirations

A

An abnormal pattern of respiration; alternating patterns of apnea and deep, rapid breathing

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45
Q

Blood Pressure

A

The pressure exerted by the circulating volume of blood on the arterial walls, veins and chambers of the heart.

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46
Q

Systolic

A

The higher number, represents the pressure when the ventricles are contracting

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47
Q

Diastolic

A

The second number, represents the pressure within the artery between beats

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48
Q

Pulse Pressure

A

Difference between the systolic and diastolic pressures

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49
Q

HAI’S

A

Health care associated infections

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50
Q

Asepsis

A

absence of disease-producing microorganisms

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51
Q

Standard precautions

A
  • Follow hand hygiene techniques
  • Wear clean non-sterile gloves when touching blood, bloody fluids
  • change gloves between task on the same pt as necessary
  • wear ppe
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52
Q

Airborne precautions

A

used for pts who have infections that spread through the air, such as TB
-place PT in private room that has negative pressure

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53
Q

Contact precautions

A

-Use for pts who are infected or colonized by a microorganism that spreads by direct contact
-place pt in private room, if available
wear PPE

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54
Q

Sterile Field

A

-only a sterile object can touch another sterile object.
- only sterile objects can be placed on a sterile field.
-a sterile object out of the range of vision or below waist is contaminated.
-sterile objects or fields become contaminated by prolonged exposure to air.
A wet field is considered contaminated if the surface immediately below is not sterile.

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55
Q

Personal Hygiene

A

The self care which involves bathing, toileting, general and grooming. it is highly personal.

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56
Q

factors that influence urinary elimination

A

anxiety; increased fluid intake; diabetes mellitus; narcotic analgesics; long term use of indwelling catheters

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57
Q

characteristics of normal urine

A

pale, straw to amber color; transparent; characteristic odor

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58
Q

urine output measurement

A

use a graduated receptacle to accurately measure up to 100-200 ml of urine; use of a separate plastic graduated measuring receptacle obtains a more precise urine measurement from a drainage bag

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59
Q

midstream specimen

A

a clean-voided specimen

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60
Q

types of urinary incontinence

A

functional; stress; urge; mixed; overflow; hyperactive/overactive bladder

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61
Q

functional

A

loss of urine caused by factors outside the urinary tract that interfere with the ability to respond in a socially appropriate way (environmental barriers, sensory, cognitive, mobility issues)

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62
Q

stress

A

involuntary leakage of urine during increased abdominal pressure in the absence of bladder muscle contraction

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63
Q

urge

A

involuntary passage of urine after a strong sense of urgency to void

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64
Q

mixed

A

combination of urge and stress signs and symptoms

65
Q

appropriate measures for prompting pt’s normal urinary elimination

A

maintain elimination habits; maintain adequate intake of food; promote complete bladder emptying; stimulate micturition reflex

66
Q

evidence-based practices to avoid CAUTI

A

insert indwelling urinary cath (according to established evidence-based guidelines that address) limiting use & duration to situations necessary for pt care and using aseptic technique for site prep, equip, supplies; manage indwelling caths (according…) securing caths for unobstructed urine flow & drainage, maintaining the sterility of the urine collection system, replacing the urine collection system when required, & collecting urine samples; measure and monitor cath-associated uti prevention processes and outcomes in high-vol areas by selecting measures using evidence-based guidelines or best practices, monitoring compliance with evidence-based guidelines or best practices, and evaluating the effectiveness of prevention efforts.

67
Q

nasal canula

A

28%-44% O2
up to 6L
at 4L, add water for humidity

68
Q

Suctioning

A 
Removal of secretions by a catheter connected to suction
Sterile technique
Types
-Pharyngeal- Oral, Nasal
-Nasotracheal
-Endotracheal
-Trach
69
Q

Artificial Airways

Oropharyngeal=

A

Can suction along side the airway
Often seen post-op in post anesthesia care units
Stimulate gag reflex, will often spit out
Do not tape in place
Mouth care needed

70
Q

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient?

A

Nasal Cannula

71
Q

A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions?

A

A Disadvantage of this Therapy is that it Dislodges Easily; The Client Should Form a Habit of Checking its Position; Oxygen Toxicity is a Complication; Manifestations of Oxygen Therapy Are: Nonproductive Cough, Substernal Pain, Nasal Stiffness, Nausea, Vomiting, Fatigue, Headache, Sore Throat, and Hypoventilation

72
Q

Removing indwelling catheters

A

clamping to strengthen bladder muscles, remove all the fluid in the balloon maybe even twice, clean the area after with soap and water, access for voiding afterwards

73
Q

Enema administration

A
  1. Not sterile, gloves, privacy, warmed solution as ordered, adult 750-1000 ml
  2. Assess for abdominal distention, bowel sounds
    * 3.Left side, sim’s position (follow natural curve of colon), insert lubricated tip, adult 3-4 inches
  3. Open clamp and allow to flow slowly, raise to appropriate height, can cause cramping if flow rate too rapid
  4. If order, “enemas until clear”, repeat until fluid passed is clear, up to 3 total
74
Q

what are the methods of bathing?

A
  • Completed bed bath; totally dependent client in bed.
  • Partial bed bath
  • sponge bath at sink; client can perform a portion
  • tub bath: immersion/ may need assistance
  • shower; chair in shower
  • bag bath: travel bath
75
Q

what are the bathing guidelines?

A
  • provide privacy
  • maintain safety
  • maintain warmth
  • promote independence
  • anticipate need.
76
Q

Key principles of bathing a client

A

Wash the face first: begin the bath at the cleanest area and work downward toward the feet.
use long firm strokes from wrist to shoulder, to promote circulation by increasing venous return.
while bathing assess skin for any redness or discolorations (possible pressure ulcers)

77
Q

Common bed positions?

A 
Fowler
Semi-fowler
trendelnburg
Reverse trendlenburg 
flat
78
Q

Bed-making

A 
Infection control
Preserve skin integrity
comfort
client safety 
your safety
79
Q

Safety while making bed

A

Side rails as appropriate
bed in low position
walkways clear and free debris and are dry
minimize clutter
call light/bed control/ phone in client’s reach.

80
Q

Basic needs

A

Oxygen

Nutrition

81
Q

components of a safe environment

A 
Meets basic needs
reduces physical hazards
reduces transmission of pathogens
controls pollution 
prevents or minimizes terrorism
82
Q

What is the most important a nurse can do to prevent the transmission of pathogens

A

HANDWASHING

83
Q

Restraints

A

must have physician order, based on a face-to-face assessment of the client
order must have restraining type, location, time limit and specific client behavior
cannot be order as prn
restrains must ne periodically removed ans patient reassessed for need of restraint.

84
Q

Physiologic hazards associated with restraints

A

-Suffocation from entrapment
- impaired circulation
altered skin integrity
diminished muscle and bone mass
fractures
altered nutrition and hydration

85
Q

seizure precautions

A

Protect the client from injury

  • -pre-seizure: inspect for potential safety hazards in client’s environment , have padding for bed rails and head boars.
  • -During a seizure: place client in safe position, especially protecting head, and position for ventilation and oral secretion drainage
86
Q

fire safety

A

-Leading cause of fire-related death is careless smoking
-oxygen is combustible not explosive
-use the mnemonic RACE to set priorities in case of fire
R-Rescue
A-Activate the alarm
C-confine the fire by closing doors and windows
E-Extinguish the fire using an extinguisher.

87
Q

Factors that contribute to falls

A

-age>65
-history of falls
-impaired vision or balance, weakness
-altered gait or posture, impaired mobility
medication regimen
postural hypotension
slowed reaction time
confusion or disorientation
unfamiliar environments / environmental hazards

88
Q

8 rights of medication

A 
Right medication 
right patient 
right dosage 
right route 
right time 
right documentation 
right reason 
right education
89
Q

nurses’ six right’s for safe medication admiration. The right to:

A
  • A complete & clearly written order
  • have the correct drug route and dose dispensed
  • have access to information
  • have policies on medication administration
  • administer medication safety and to identify problems in the system
  • stop, think, and be vigilant when administering medications.
90
Q

Oral medication

A 
Solid form: tablets, capsules pills.
-Scored  
-enteric 
-extended release
Liquid forms: elixirs, suspensions, syrups May be water based or alcohol-based.
91
Q

Oral route

A

Stay with pt while they swallow medication

do not leave it at the bedside.

92
Q

Enteral route

A

Administering drug through an enteral tube

93
Q

Sublingual administration

A

placing drug under the tongue should not be swallowed offer drink of water or oral care prior to administration

94
Q

Buccal administration

A

Placing drug between tongue and check
should not swallowed
offer drink of water or oral care prior to administration.

95
Q

Intradermal Injections

A 
Into the dermis
longest absorption time 
used for sensitivity test 
site: inner of forearm, upper back 
 needle size: short and fine 
Small amt of fluid: less than 0.5 ml
flat angle: 10-15 degrees
96
Q

Intramuscular injections

A

Vastus lateralis
ventrogluteal
deltoid
dorsogluteal

97
Q

Vastus lateralis

A 
Anterolateral aspect of thigh 
no large nerves or vessels 
does not cover a joint 
preferred site for infants
divide thigh into thirds horizontally and vertically 
injection given in outer middle third
98
Q

Ventrogluteal site

A

Gluteus medius and gluteus minimus
large muscle mass
no major nerves or blood vessels
patient can be on back, abdomen or side
palm of hand over greater trochanter
index finger on the anterosuperior iliac spine
injection given in the center of the triangle

99
Q

Giving IM injections

A 
Stretch skin taut
dart to insert
aspirate 
inject slowly and withdraw 
gentle pressure over site
do not massage 
alternate sites
100
Q

Body mechanics

A

Using alignment, posture, and balance in a purposeful and coordinated effort during activity to prevent injury

101
Q

Principles of safe client transfer and positioning

A
  • The wider the base of support, the more stable the body.
  • the lower the center of gravity, the more stable the body
  • facing the direction of movement prevents abnormal twisting of spine
  • dividing balanced activity between arms and legs
  • pelvic tilt, helps protect the lowest back from injury
  • less energy is needed to keep an object moving.
  • leverage, rolling, turning, pivoting are less work than lifting.
102
Q

mobility

A

the ability to engage in activity and move about freely

103
Q

Exercise

A

is a type of physical activity defined as a planned, structured and repetitive bodily movement performed to improve or maintain physical fitness

104
Q

Physical Activity

A

is bodily movement produced by skeletal muscle contraction that increases energy expenditure

105
Q

ROM

A

is the ability to move a joint through the full extent of intended function

106
Q

Activity Tolerance

A

Is the type and amount of exercise or work that a person is able to perform

107
Q

Gait

A

the style or character of a person’s walk

108
Q

Pressure Ulcer

A

Localized injury to skin or underlying tissue, usually over a body prominence.

109
Q

What are the three pressure-related factors which contribute to pressure ulcer development

A

Intensity
duration
tissue tolerance

110
Q

Collecting a Timed Urine Specimen

A

This is required for tests of renal function and urine composition.
The entire volume of urine from a designated time period is collected.
Testing begins after discarding first specimen and ends with a final voiding at the end of the time period.
If urine is accidentally discarded or contaminated or the patient is incontinent, restart the time period.

111
Q

Guidelines for Appropriate Catheter Selection

A
  • Size: Determined by size of client’s urethral canal, French scale=larger the number, the larger the catheter, children 8-10 Fr.,women 14-16 Fr.,men 16-18 Fr. (Box 45-8)
  • Catheter material selection: Plastic catheters are only used for intermittent. Silicone and teflon are best suited for long-term use.
  • Balloon size: Children, 3ml., Adults 5-10ml. (most common). 30ml may be used for prostatectomies to help with hemostasis.
  • Use only sterile water to inflate the balloon.
  • If leakage around the catheter, may need to insert larger size catheter.
112
Q

Routine indwelling catheter care

A
  • Secure the catheter
  • Perineal hygiene at least t.i.d. (3 times/day) with soap and water. With male client, always reposition the foreskin after care.
  • When cleansing the catheter, always stabilize the catheter and cleanse from the meatus down the catheter in a circular motion.
  • Maintain adequate intake of fluids.
  • Maintain closed system.
  • Prevent pooling of urine in the tubing and reflux of urine into the bladder.
  • Keep drainage bag below the level of the bladder.
    * Empty bag at least every 8 hours.
113
Q

Timed Urine Specimen

A

Required for tests of renal function and urine composition.
The entire volume of urine from a designated time period is collected.
Begins after discarding first specimen and ends with a final voiding at the end of the time period

114
Q

Collecting a midstream urine specimen

A

Patient needs to clean urethra meatus
initiate stream into toilet and then pause to collect urine into an assessment container and then pause again to move container out of the way & proceed to empty their bladder into the commode.

115
Q

Nonrebreather Mask

A

60-95% concentration of oxygen
6-10 L/minute
Highest concentration of oxygen

116
Q

ASPIRATION PRECAUTIONS

A

*30 minute rest before/after eating
*Sit upright, slightly flex head to chin down position
*Try different consistencies of food/fluids
*Four levels of dysphagiadiet:
*Puree, Mechanically altered, advanced, regular
*Four levels of liquid:
*Thin, Nectarlike, Honeylike, Spoon-thick
ADDITIONAL: Utensil placement, verbal coaching

117
Q

Clear Liquid

A

Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles

118
Q

Full Liquid

A

As for clear liquid, with addition of smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt

119
Q

Enteral Tube Feeding

A 
Deliver nutrients through GI tract via:
*Nasogastric tube
*Nasointestinal tube
*Gastrotomy tube
Jejunostomy Tube
PEG/PEJ Tube
120
Q

Parenteral Tubes

A 
Deliver nutrients intravenously 
Used when enteral feedings can't be absorbed e.g.
-sepsis
-head injury
-burns
121
Q

Cognitive

A

Includes all intellectual behaviors and requires thinking

122
Q

Affective

A

Deals with expression of feelings and acceptance, opinions or values

123
Q

Psychomotor

A

Involves acquiring skills that require integration of mental and muscular activity

124
Q

Cognitive Domain Teaching methods

A

Discussion (one-on-one or group)

* Involves nurse and one patient or a nurse with several patients
* Promotes active participation and focuses on topics of interest to patient
* Allows peer support
* Enhances application and analysis of new information

• Lecture
Is more formal method of instruction because it is teacher controlled
• Helps learner acquire new knowledge and gain comprehension

• Question-and-answer session

* Addresses patient's specific concerns
* Assists patient in applying knowledge

• Role play, discovery

* Allows patient to actively apply knowledge in controlled situation
* Promotes synthesis of information and problem solving

• Independent project (computer-assisted instruction), field experience

125
Q

Affective Domain Teaching Method

A
  • Role play
    * Allows expression of values, feelings, and attitudes
    • Discussion (group)
      • Allows patient to receive support from others in group
      • Helps patient learn from others’ experiences
      • Promotes responding, valuing, and organization
    • Discussion (one-on-one)
      • Allows discussion of personal, sensitive topics of interest or concern
126
Q

Psychomotor Domain Teaching

A

Demonstration
•Provides presentation of procedures or skills by nurse
•Permits patient to incorporate modeling of nurse’s behavior
•Allows nurse to control questioning during demonstration

• Practice

  • Gives patient opportunity to perform skills using equipment in a controlled setting
  • Provides repetition
  • Return demonstration
  • Permits patient to perform skill as nurse observes •Provides excellent source of feedback and reinforcement

• Independent projects, games

  • Requires teaching method that promotes adaptation and origination of psychomotor learning
  • Permits learner to use new skills
127
Q

Password Safety

A
  • Do not share your computer password with anyone under any circumstances.
  • A good system requires frequent and random changes in personal passwords to prevent unauthorized persons from tampering with records.
  • Most staff have access only to patients in their work area.
  • Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess.
128
Q

HIPPA

A

First federal legislation to protect automated patient records

129
Q

what are the contributing factors to ulcer development

A
  • impaired mobility
  • impaired sensory perception
  • fecal and/or urinary incontinence
  • poor nutrition
  • aging skin
  • chronic illnesses
  • altered level of consciousness
  • spinal cord and brain injuries
  • neuromuscular disorders
130
Q

what are the risk factors for pressure ulcers

A

Friction- the force of two surfaces moving across one another
Shear-the force exerted parallel to the skin resulting from gravity pushing down on the body and resistance (friction) between the client and a surface
Moisture- reduces the skin’s resistance to other physical factors as pressure and shear force.

131
Q

Classification of pressure ulcers

A

Stage I, Stage II, Stage III, stage IV, unstageable

132
Q

Stage I ulcer

A

Intact skin with nonblancable rednedd of a localized area usually over a bony prominence

133
Q

Stage II ulcer

A

Partial-thickness skin loss involving epidermis and/ or dermis presenting as a shallow open ulcer with a red pink would bed, without slough, abrasion, blister or shallow crater

134
Q

Stage III ulcer

A

Full thickness tissue loss with visible fat involving damage or necrosis of subcutaneous tissue bone, tendon or muscle are not exposed. slough may be present by does not obscure the depth of the tissue loss. May be undermining and tunneling.

135
Q

Stage IV ulcer

A

Full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed. often includes undermining and tunneling

136
Q

unstageable

A

Full thickness tissue loss in which the base of the ulcer is covered by slough and eschar until enough slough and or eschar is removed to expose to the base of the wound, the true depth and therefore stage, cannot be determined.

137
Q

Slough

A

Stingy tissue attached to wound bed which is tissue that must be removed before healing can proceed. Yellow, tan, gray, green or brown

138
Q

Eschar

A

Must be removed before healing can proceed. Tan, brown or black in the wound bed.

139
Q

Granulation

A

red, moist tissue indicated progressing toward healing

140
Q

Exudate

A

amount, color, odor, consistency, of wound drainage.

141
Q

Serous

A

clear, watery

142
Q

Purulent

A

yellow, green, tan, or brown

143
Q

Serosanguineous

A

pale, red, watery, mixture of clear and red fluid

144
Q

Sanguineous

A

Active bleeding

145
Q

Dressings

A
  • Dry to moist (gauze)
  • Hydrocolloid (protects the wound from surface contamination
  • Hydrogel (maintains a moist surface to support healing
  • Wound V.A.C (uses negative pressure to support healing)
146
Q

Primary intention

A

surgical wounds, skin edges are approximated and risk of infection low

147
Q

Secondary Intention

A

Involves loss tissue such as burn or pressure ulcer. heals by secondary intention.

148
Q

Nursing implications-Hygiene

A
  • Decresed frequency of bathing.
  • Avoid excessive use of soap.
  • Moisture skin after bath.
  • Protect from injury from hot water/burns.
149
Q

Patient’s rights regarding medication

A

To be informed of the name, purpose, action, and potential desired effects of a medication.
To refuse a medication regardless of the consequences.
To have qualified nurses or physicians assess a medication history, including allergies and use of herbals.
To receive labeled medications safely without discomfort in accordance with the six rights of medication administration.
To receive unnecessary medications.
To be informed if medications are a part of a research study.

150
Q

Passive ROM

A

Patient is unable to move independently and nurse moves each joint. Begins as soon as the patient’s ability to move the extremity or joint is lost. Carry out movements slowly and smoothly, just to the point of resistance. Never force a joint beyond its capacity. When performing passive ROM exercises stand at the bed side of the bed closest to the joint being exercised.

151
Q

Dressings Changing

A

Know the type of dressing, placement of drains,and equipment needed.

  • Securing-Tape, ties, or binders
  • Comfort measures
  • carefully remove tape
  • gently cleanse the wound
  • administer analgesics 30-60 minutes before dressing change
152
Q

Rectal suppositories

A

Rectal suppositories are thinner and more bullet-shaped than vaginal suppositories. The rounded end prevents anal trauma during insertion. Rectal suppositories contain medications that exert local effects such as promoting defecation or systemic effects such as reducing nausea. Rectal suppositories are often stored in the refrigerator until administered. Sometimes it is necessary to clear the rectum with a small cleansing enema before inserting a suppository

153
Q

Administering Rectal Suppositories

A

Cannot be delegated to nursing assistive personnel.
Equipment needed: Rectal suppository, water-soluble lubricating jelly, clean gloves, drape or sheet, tissue, medication administration record.
Help patient into sim’s position
Expose anal area only
Adequate lighting to visualize anus.
Examine conditions of anus externally and palpate rectal walls as needed.
Apply new pair of gloves and remove supporitory from wrapper and lubricate rounded end.
Lubricate index finger of dominant hand.
Ask patient to take a slow deep breath through mouth and relax anal sphincter.
Retract buttocks with nondominant hand. Insert suppository gently through anus, past internal sphincter and against rectal wall, 10 cm (4 inches) in adults, 5 cm (2 inches) in children and infants (see illustration). Apply gentle pressure to hold buttocks together momentarily if needed to keep medication in place.

154
Q

Risk Factors for HAI’s

A
  • Number of health care employees having direct contact with a client.
  • The type and number of invasive procedures.
  • The therapy received
  • Length of hospitalization.
155
Q

Pre hypertension

A

120/80-150/100

156
Q

Hypertension Stage 1

A

140/90-150/100

157
Q

Stage 2, Hypertension

A

150/100-180/120

158
Q

Urine output

A

An individuals daily output generally ranges from 1200-1500 mL of urine.
***Adult hourly output: 30 mL/hour

fundamentals 3 (8 decks)

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