Fund 19-20 Flashcards
to turn skin white, or on dark skin, turn skin pale
blanch
dental cavities
caries
waxy substance secreted by the ceruminous glands; earwax
cerumen
excessive sweat production; perspiration
diaphoresis
slough produced by a thermal burn. corrosive material, or ganrene
eschar
increase in severity of a disease or any of its symptoms
exacerbation
bad breath
halitosis
area of the skin that feels hard
induration
the softening of tissue that increases the chance of trauma or infection
maceration
process in which the blood rushes to where there is a decrease in circulation
reactive hyperemia
gland that secretes an oily substance called sebum
sebaceous
oily substance secreted by the sebaceous glands
sebum
fainting
syncope
illness that results when most or all of the body is exposed to a high dose of radiation, usually over a short period of time
acute radiation sickness (ARS)
the phenomenon of nurses becoming desensitized to patient care alarms and missing or delaying their response to the alarm
alarm fatigue
biologic agent or condition that can be harmful to a person’s health
biohazard
the release of pathogenic microorganisms into a community to achieve political and/or military goals
bioterrorism
(1) the process or act of supplying a house or room continuously with fresh air; (2) exchange of air between the lungs and atmosphere
ventilation
(know) the skin is the first line of defense in protecting the body from bacteria and other invading organisms. It protects tissues from thermal, chemical, and mechanical injury
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(know) Changes in aging : loss of elastic fibers and adipose tissue in the dermis and subcutaneous layers causes skin to be thinner and more transparent, with wrinkling and sagging. Loss of collagen fibers in the dermis makes the skin more fragile and slower to heal. Decreased sebaceous gland activity causes dry and itchy skin. Temperature control is altered by the decreased sebaceous gland activity and the loss of skin density. This results in cold intolerance and puts the person at risk for heat exhaustion. Hair becomes thin and grows more slowly because of a decrease in the number of hair follicles. Hair loses its color from the loss of melanocytes at the hair follicles. Nail growth decreases and the nails thicken.
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when assessing dark skin color changes pressure areas may have ___
purple hues
(know) pressure injury risk factors : immobility. Inactivity. moisture. malnutrition. advanced age. altered sensory perception. lowered mental awareness. friction and shear. dehydration. obesity. edema.
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Medicare will not reimburse health care facilities for “reasonably preventable” pressure injuries. Pressure injuries present on admission must be documented thoroughly and accurately. Treatment for stage 3 or 4 pressure injuries will be reimbursed at a higher rate if they are documented in the medical record within ___ days of inpatient admission
2 days
(know) if you note a reddened area when repositioning a patient, reassess later to see whether reactive hyperemia is present. If the redness remains and the skin does not blanch to fingertip pressure, then the patient has a stage 1 pressure injury
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An area of intact skin that is red, deep pink, or mottled skin that does not blanch with fingertip pressure. In people with darker skin, there may be discoloration of the surrounding skin. Warmth, edema, and induration in comparison to surrounding tissue may be signs of a ___ pressure injury
stage 1
partial-thickness skin loss with exposed dermis. The wound bed is pink or red and moist, and may appear as an intact or ruptured blister
stage 2
full-thickness skin loss that looks like a deep crater and may extend to the fascia. Subcutaneous tissue is damaged or necrotic; fat is visible. undermining and tunneling may be present. There may be damage to the surrounding tissue. Can’t go back. Becomes a healed stage ___
stage 3
full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures; sinus tracts may be present. Infection is usually widespread. The injury may appear dry and black, with a buildup of tough, necrotic tissue, or it can appear wet and oozing
stage 4
loss of full thickness of tissue. The base of the injury is covered by eschar (tan, brown, or black) in the wound bed, or the base of the injury contains slough (yellow, tan, gray, green, or brown)
unstageable
localized discolored intact skin that is maroon or purple or a blood-filled blister resulting from damage to underlying soft tissue from pressure or shearing
deep tissue pressure injury
(know) document the location of any abnormality, its color and size, and reaction to the blanch test. Add other descriptive terms as they apply, including induration, blisters, drainage, odor, or eschar. Some institutions use forms with an outline of a body so you can draw the location of the area(s) involved
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A braden score of ___ or below indicates pressure injury risk
18
What are the four basic purposes of bathing
#1 cleanse the skin #2 promote comfort #3 stimulate circulation #4 remove waste products secreted through the skin
What temperature should bath water be
105F or 40.6C
(know) if there has not been damage, then you expect the redness to subside in 30 to 45 minutes
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(know) patient should only be in a wheelchair for 1 hour
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Starch or oatmeal baths, using plain instant oatmeal, are used for patients with ___
dermatitis
(know) whirlpool baths can make wounds worse, get an order
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Cooling bath ___, get an oder
brings down fever
Sitz baths are used with ___
maternity
(know) alcohol, astringents, or water may be used to loosen hair strands that are tangled or matted
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(know) mouth care for the unconscious patient : raise bed level to a comfortable working height. Turn patient laterally on side of bed nearest you. Lower side rail. With patient’s head turned to the side, intermittently rinse the mouth by gently squirting water in with the syringe; use the suction device to remove water and debris
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(Know) denture care : rinse well in tepid water and place in denture cup or emesis basin that is half filled with cool water. Clean the patient’s mouth with a soft brush and toothpaste
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(know) the hair of african americans tends to be fragile and may be easily injury or damaged. It should be washed every 7 to 14 days. It can be rinsed daily. This type of hair breaks easily, and a wide-toothed “pick” comb should be used to comb out tangles. The hair should be combed while wet. A leave-in type of conditioner should be used daily. Do not use heat for drying the hair. A satin pillowcase, scarf, or cap may be desired for sleep to decrease tangling. Alternatively, the hair may be plaited or tied back for sleep, making sure it is not too tight. Style is a matter of individual preference
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(know) a written, informed consent is necessary to cut a patient’s hair
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(know) check the patient’s medical record to see whether the patient has any bleeding tendencies or is receiving medication that would contraindicate the use of a safety razor. A safety razor should not be used when a patient has a low platelet count, is receiving an anticoagulant, is undergoing chemotherapy, or is on aspirin therapy.
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(know) never cut the toenails of a patient with diabetes or circulatory disease of the lower extremities without a written order. Nails must be filed by a nurse not a tech in that case
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(know) if crusting is noted, soak the eyelid with a warm, damp washcloth for 2 to 3 minutes to soften the crust and ease its removal.
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(know) if a lens suction cup is not available, check with a colleague who wears such lenses and is familiar with the procedure for assistance
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What are the 5 types of hearing aids
#1 behind-the-ear (BTE) #2 Mini (BTE) #3 In-the-ear (ITE) #4 in-the-canal (ITC) #5 Completely-in-canal (CIC)
maintaining airflow out of the room
positive air flow
maintaining airflow into the room
negative airflow
(know) patients with transmittable respiratory diseases or burns require a negative airflow room
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What is the first action you would take in the event of a fire?
Rescue any patients in immediate danger by removing them from the area. Activate the fire alarm system. Contain the fire by closing all doors and any open windows. Extinguish the flames with an appropriate extinguisher or evacuate.
Biohazard substance, what must be stored in a unit?
SDS
(know) The Main cause of noise at hospitals are nurses talking and laughing
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Circulatory disease, need toenails trimmed?
Best practice is to call a podiatrist and let them do it. Also, instead of trimming you could file their nails but a nurse must be the one to do that. You need a doctor’s order to cut the nails.
What actions would you take to promote patient safety?
Side rails up, bed low position, call light
(know) Index and middle finger needs to fit in between devices on patient
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Need to know about therapeutic bath (4)
A therapeutic bath means having healing or medicinal qualities. A whirlpool bath (get an order, can make wounds worse), starch or oatmeal bath (used for patients with dermatitis), sitz bath (used for maternity), cooling sponge baths (used to bring down fever, get an order)
If someone is diuretic and skin flush and cool what action would you take?
Need to offer more fluids, patient needs to be dried well after bath
Appropriate hygiene goal for the elderly?
skin thin, dry, have decrease sweat don’t need daily shower
(know) When documenting pressure ulcers need to know how ALWAYS MEASURE
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Someone prefers a side lying position where they would most likely get a pressure ulcer?
Shoulder. Perineum. Anterior knee. Malleolus. Trochanter. Ilium. Side of head.
Know how to do a Complete bed bath to unconscious patient
Wash eyes without soap if eyes matted can use baby soap but try warm compress with just water
Know how to get Tangles out of someone’s hair
Brush from the bottom up. Hold the hair between the scalp and the area you are brushing or combing. Braiding the hair helps to reduce tangles. Alcohol, astringents, or water may be used to loosen hair strands that are tangled or matted.
Prevention of pressure ulcers?
Dont position anyone directly on bone
Safety measures for patient during ambulation
Use a gait belt, make sure bed and chair wheels are locked, determine amount of assistance needed
Common factors that predispose person to falls
Impaired physical mobility, altered mental status, and sensory and/or motor deficits
How often do you remove safety devices and what to do ?
every two hours ; ROM
