Fund 53 54 58 59 77 86 87 Flashcards
0
Q
Name the things you check for during PNA
A
Skin color Finger or toe motion sensation Distal pulses Cap refill under 3 secs Edema Pain Skin temp
1
Q
The term for evaluating the status of an extremity encased in a bandage and is done by RN
A
PNA
Peripheral Neurovascular assessment
2
Q
Overlapping application, alternating with ascending and descending wrapping with each pass of the bandage crossing over previous wrapping as in a figure eight
A
Figure eight
3
Q
Type of wrap that stabilizes joints such as wrist or ankle and helps maintain immobilization
A
Figure eight
4
Q
Wrapping a limb in ascending path partially covering previous wrapping while moving up the limb
A
Spiral
5
Q
Type of wrap that promotes venous return. Effective when a bandage needs to be applied around an arm leg or wrist. May be used to hold dressings in place
A
Spiral wrap
6
Q
Similar to spiral wrap except the bandage is folded back halfway through each process. The appearance of basket weave
A
Spiral reverse wrap
7
Q
Arms, legs, thighs
Used for extremities that are wider at one end than the other, cone shaped. Promotes venous return. Holds dressings in place.
A
Spiral reverse
8
Q
Wrapping with continuous application in same place such as a wrist. Stabilizes ankle wrist fingers and toes
A
Circular wrap
9
Q
Anchored at the top with several spiral wraps, then back and forth across the end of the extremity or head. Finish with spiral reverse or figure right
A
Recurrent wrap
10
Q
Binds amputation stumps in preparation for prosthesis fitting an also holds dressing on heads
A
Recurrent wrap
11
Q
basic bandage
Wrapped around limb to give support used to exert pressure over a bleeding point
All cotton elastic
A
ACE bandage
12
Q
Type of gauze used to hold dressing in place or to apply pressure
A
Kerlix
13
Q
Net or mesh type material
Finger sized to large body sized bandages.
Also called TUBE GAUZE
A
Stretch net bandages
14
Q
Bandages used in practitioners office or school offices
A
Stretch net bandages
Tube gauze
15
Q
anti embolism stockings are also known as
A
TEDS
16
Q
TEDS
Anti embolism stockings
are used for people with what disease
A
Thromboembolic disease
17
Q
The point of TEDs anti embolism stockings are to
A
Return venous circulation to the heart to prevent clotting
18
Q
Before nurse can apply TEDS anti embolism socks the nurse first must receive
A
A doctors order
19
Q
Before applying anti embolism socks on a pt the nurse must have pt____
A
Lay down for 15 minutes to prevent pooling of fluids in legs
20
Q
Perform PNA on a pt with TEDS every
A
2 hours
21
Q
Remove TEDs on a pt every
A
4-8 hours
22
Q
another device that promotes venous return is
A
PCD machine
23
Q
PCD names 3 types
A
PCD pneumatic compression device
SCD sequential compression device
ISCD intermittent sequential compression device
24
Clients immediately after surgery with circulatory disorders need application of
PCD machine
25
Wide flat fabric piece applied to support specific body part or hold a dressing in place usually ordered for women after child birth
Binders
26
Binder that holds perineal pads or bandages in place for incontinent or menstruating female
Fastened with Velcro or pinned
T binder
27
Wide flat piece of fabric that is secured around the trunk of clients body to support the abdomen or dressings on abdomen. Rarely used after child birth mostly after abdominal surgery
Abdominal binder
28
Skin softening and breakdown due to moisture accumulation and lack of circulation
Maceration
29
These straps allow dressings to be changed without having to remove tape with each change. Tie straps
Montgomery bandages
30
Anti embolism stockings should never be allowed to bunch or roll up bc
This could lead to constricting circulation
31
Anti embolism stocking are applied from toes or finger
Upward
32
Anti embolism stocking should be removed every 4-8 hours to check for
Redness, edema, skin discoloration
33
Enlargement of blood vessels is called
Vasodilation
34
Normothermia
Normal body temperature
35
SSI
Surgical site infections
36
WA
While awake
37
heat application causes
Vasodilation
38
Name a few things heat helps with
```
Vasodilation
Increasing O2
Aids in removal of wastes from tissues
Wound healing
Reduce inflammation
Promotes drainage
```
39
Types of dry heat
Heating blanket
Water filled heating pad
Aquathermia pad
Heat lamps and tx
40
Types of moist heat
Compresses
Paks
Soaks
Sits bath
41
Do not apply heat to abscess or infected appendix as this may cause
Rupture
42
Type of dry heating pad where distilled water flows through and used for muscle sprains and inflammation
Dry heat
Aqua K pad
| Aquathermia pad
43
Can any nurse use lamp tx on PTs?
No only specially trained personnel with specific education can
44
IR infrared does what for a pt
Relaxes muscles
Stimulate circulation
Relieves pain
45
UV ultraviolet does what for a pt
Mild UV radiation
| Not much affective as IR
46
US does what for pt
Deep penetrating heat to muscles and other tissues
47
To apply heat or cold first you must receive
Doctors order
48
steps in disassembling Aquathermia pad
1) clamp tubing until over sink
2) unplug unit
3) empty water and everything over sink
4) discard pad
5) return only heater pump to dept
49
Areas on the body too sensitive to heat
Eyelids
Neck
Inside arms
50
Less heat resistance PTs
Infants
Old
Fair thin skin
Pt with illnesses
51
Do not use heat application to PTs who are at risk for injury such as
Unresponsive
Anesthetized
Have dimentia or neurological issues or psychological disorders
52
PTs who are susceptible to burns
```
Impaired circulation
Metabolic diseases
Diabetic
Chemo pt
Paralysis
```
53
Temperature
| C 26.6-35 F 80-95 is considered
Tepid
54
Lamp or special heater that is mounted inside bed candle to provide dry heat
The heat cradle
55
Covered network of wires that emits heat
| Never use pins to clamp down
Electric heating pad
56
Type of moist heat
Used basin
Bath with tap water for only 15-20 minutes
Warm soaks
57
Prevents escape of heat from body by slowing circulation
Cold application
58
```
Slows or stops bleeding
Slows bacterial activity
Reduces swelling
Controls fluid loss and edema
Finishes muscle contractions and spasms
```
Cold applications
59
What type of application is used for pain in engorged breasts
Cold
60
What type of application is used in abdominal inflammation to prevent peristalsis
Cold
61
If client complains of numbness or if skin looks white or spotty during cold application
Stop
62
Reduces swelling and inflammation in soft tissues or after tooth extraction
Cold moist compresses
63
Dry cold application used for head
Ice cap
64
Dry cold application used for neck
Ice collar
65
Types of cold applications used by athletes
Single freeze
| Refer exabyte ice packs
66
Cold moist bath includes a
Tepid sponge bath
67
athroom not use alcohol during sponge baths as it
drys and cools quickly
68
Tepid baths are not used for these type of PTs
I elastic arteries
Arthritis
Children
69
Blanket that slows body processes
| And lowers temperature
Hypothermia blanket
70
cold moist treatment that is used for PTs with respiratory disorders
Cold humidity
| Humidifier
71
PTs with tracheostomy use
Teach mask
| Face tent
72
An abnormal opening or break in the skin
Wound
73
Stab wound is called
Puncture wound
74
Wound with turned edges
Laceration
75
Rubbing off skins surface
Abrasion
76
Sterile intentional and non self inflicted wound
Surgical incision
77
Do not massage any reddened or dis colored pressure points as this can add to
Skin breakdown
78
Type of wounds are DX by
MD
79
Avoid inspecting wounds under fluorescent lights as this can lead to incorrect wound
Diagnosis
80
Drainage loss of protein and cellular debris
Exudate
81
clear thin watery drainage
Serous
82
Composed of serous and blood type drainage
Serosanguineous
83
Bloody containing a lot of blood and serous
Sanguineous
84
DrainGe containing pus
Purulant
85
Presence of one or more channels within or underlying an open wound
Usually measured with sterile applicator
Tunneling
86
If tissue recedes beneath skin creating a shelf or free edge with a space underneath also measured with sterile applicator
Undermining
87
Type of wound edge
| softened by moisture
Macerated
88
Type of wound edge
| Very hard yellow or white
Calloused
89
Type of wound edge
| Healthy with tissue growth
Open
90
Erythema
Redness
91
Excoriated peri wound area means
Scratched or abrasion
92
Measurements
| Linear measurement uses
Ruler
93
Measurement
| Planimetry uses
Graph paper for flat wounds
94
Measurement
| Stereo photogrammetry uses
Non invasive video camera
95
Measurement
| Wound photography uses
Photo camera
96
Wound tracing used for what type of wounds
Flat
| Irregular wounds
97
Types of skin breakdown
| Limited to damage of dermis and epidermis
IAD
| Incontinence associated dermatitis
98
Type of skin breakdown
Cause by sheer friction
Bony prominences
Leads necrosis
Pressure ulcer decubitus
99
Type of skin breakdown
Developed in lower extremities
Hypoxia
Large WBC and no growth factors
Venous stasis ulcer
| Venous insufficiency ulcer
100
Type of skin breakdown
Diabetes mellitus
Impaired circulation
Difficult to treat
Diabetic ulcer
| Diabetic neuropathic ulcer
101
Types of scale used to predict pressure ulcer risk
Norton scale
| Braden scale
102
What can you use for easy removal of regular tape
Saline solution
103
Deep wounds must heal from the inside out or else an abcess will occur this is called
Granulation
104
Ways to prevent pressure ulcers
Turning schedule
Pillows
Padding
105
Ways to prevent shear friction normally seen on coccyx
Logroll turns
Foot board
Head 30 degrees or less
106
Prevention of perspiration wounds
Keep areas dry anti fungal powder
107
Prevention of arterial insufficiency
Elevate Edema legs
108
Sage of pressure ulcer
Redness
Blue purple coloring
Stage 1
109
Stage 1 is reversible by
Turning schedule
| Pressure relieving devices
110
Stage of pressure ulcer
Loss of epidermis and dermis
Blister no sloughing
Stage 2
111
This pressure ulcer is relieved in several weeks using special moisture saline dressings or occlusive dressings
Stage 2
112
Stage of pressure ulcer
Fat may be visible
Undermining or tunneling
Stage 3
113
Pressure ulcer healing in months with wet to dry dressings
Stage 3
114
Stage of pressure ulcers
Full thickness tissue loss
Exposed bones tendons or muscles
Slough or eschar
Stage 4
115
pressure ulcer taking years to heal and may require skin grafting
Stage 4
116
The base of a full thickness pressure ulcer covered by slough and eschar
Nonstageable ulcer
117
Deep tissue injury is called
Bruises
118
Healing
Occurs in tissues with minimal tissue loss
Seals rapidly minimal scarring
First intention healing
119
Types of first intention healing
Surgical incisions
| Sutured wounds
120
healing
Tissue loss
Granulate inside out
2nd intension healing
121
Healing
Delay in timing between opening and closing of wound
Infected
Granulate inward causing heavy scarring
Third intension healing
122
Antibiotic and antiseptics are applied to wound
Center not edges
123
Who does the first dressing change
Surgeon or MD
124
Basic dressing
Gauze
Telfa pads
Abdominal pads surgical pads
Dry to dry dressing
125
Type of dressing technique for debridement and cleansing
| Uses asking or sterile solution packing for infected wounds
Wet to dry dressing
126
Do not use saline to remove what type of dressing
Wet to dry
127
Type of dressing technique used on clean open wounds granulating in. Vaseline
Wet to wet dressing
128
Wound care product
Promotes debridement
Not used on heavy or infected wounds. Ex: tegasorb, duoderm,
Hydrocalloid
129
Wound care product
Exudate absorption
Does not stick
Helps keep shallow wound moist
Foam
130
Wound care product
Minimal to heavy absorption
Gels as it absorbs
Must be irrigated out of wound
Alginate or hydrofiber
131
Wound care product
Causes Maceration
Adds moisture to wounds
For necrotic or infected wounds
Hydrogel
132
Open drainage system
Penrose drain
133
Type of closed drainage system that allows to collect in a bulb
Jackson Pratt
134
Press on device drainage system
Hemovac
135
Drainage bottle with rubber bulb
| Balloon creates suction as it deflates
Pavol
136
Applies localized negative pressure to wound site
Used for stage 3&4 ulcers
Removes fluids and reduces swelling
VAC vacuum assisted closure
137
Manual irrigation are done by
Hand held syringe
138
Name the 6 stages of dying
```
Denial and isolation
Anger and rage
Bargaining
Depression
Acceptance
Detachment
```
139
This type of breathing is a result of acidosis
Kiss mauls breathing
140
Over 20 RPM
| Labored and deep breathing
Kussmauls breathing
141
Alternating periods of apnea and hyper apnea
Cheyne stokes Respirations
142
Irreversible cessation of heart and lung function
Biological death
143
Irreversible cessation of brain function
Brain death
| Cerebral death
144
When both Respirations and heart beat stops
Clinical death
145
For Clients on DNR and DNI you must document
Time of when heart stops and time when Respirations stop
146
Biological death have two exceptions
Drowning victims
| Overdoes victims
147
Continuous force on broken bones to keep them in natural position for fusion
Traction
148
Type of cast remains wet for 24-48 hours
Do not use intense heat to dry
Less expensive
Plaster cast
149
```
Type of cast
Drys I'm 15 minutes
Light
Able to wet a little
X-ray can see through material
```
Synthetic cast
150
If a client has to per while in cast use
Fracture bed pan
151
Types of skin traction
Only left on for 3 weeks or less
8-10lbs of pull
Bryant's or bucks
152
You of traction where physician inserts metal pins or wires into clients bones an traction is applied directly
Skeletal traction
153
Type of traction that is used to stabilize fractures in femur
Balanced suspension traction
154
Type of respiratory tx where the person is placed in a head downward position
Postural drainage
155
During auctioning through nasal passageway this entire procedure should not take more than
20 seconds
156
Oxygen simulating deep sea diving by increasing pressure
Hyperbaric
157
Transparent mask with simple nipple adapter that fits over Clients nose mouth and chin
Low flow delivery system
Simple mask
158
Low flow delivery system that uses a bag
Partial re breathing mask
| PRM
159
A nonrebreathing mask with valves on the outside
NRM
160
Type of mask with consistent flow of specific oxygen used for clients with COPD
Venturi mask
161
Type of breathing tx used for children or adults with chronic lung conditions
IPPB
| Intermittent positive pressure breathing
162
Aerosol mist tx is used to deliver
Anti inflammatory or anti asthma medications to lungs
163
Type of aerosol devices
Mini nebulizar
164
A more sanitary an more effective resuscitation than mouth to mouth
Ampu bag
| Manual resuscitation bag
165
A flexible plastic tube used as a temporary device to maintain a patent airway during intubation
Endotracheal ET tube
166
When a client cannot maintain breathing this device can be used
Mechanical ventilator
167
Mechanical ventilator can also be a called a
Respirator
168
Assist a client on a ventilator to turn every
2 hours
169
Strategy of weaning off ventilator where mechanical breathing gradually lessens
SIMV
| Synchronized intermittent mandatory ventilation
170
Type of weaning off ventilator where constant pressure is applied as person inspires
PSV
| Pressure support ventilation
171
Allows inspiration and expiration pressure to stay above atmospheric pressure
CPAP
| Continuous positive airway pressure
