Med Sug Exam 2 Flashcards
What are the functions of the skin?
body temp regulation, vitamin D production, absorption, elimination
What is self care?
Capable of managing their personal health independently once oriented to the bathroom
What is partial care?
Receive morning care of bedside or seated near sink in the bathroom. Require assistance with body that are difficult to reach
What is complete care?
Require nursing assistance with all aspects of personal hygiene
At what angle do you brush dentures?
45 degree angle
What is the purpose of a Yankeur suction device
use on patients that need help with oral care to prevent infection
T/F wrap dentures in a napkin after cleaning
false; possible losing them
T/F you use hot water to clean dentures
false; room temp
Why don’t you want dentures to sit out after washing them?
it causes them to dry out which then causes them to easily break and remove the plastic in the dentures
How do you properly care for dentures after washing?
Put them in water at room temp over night in a cup
When performing normal perineal care, where do you start cleaning?
from least contaminated to most contaminated
For females, you wipe
front to back(top to bottom)
When performing perineal care, you want to use
non soap cleaners that are pH balanced as soap dries out the skin
When performing perineal care on a male, you want to
clean the head of the penis in a circular motion then move to shaft
Pressure ulcers
Compromised circulation related to pressure over bony prominences or combined with friction
Venous ulcers
Result in injury and poor venous return, incomplete valves or obstruction
In venous ulcers, you
have a pulse
Arterial Ulcers
Injury and underlying ischemia caused by underlying conditions of atherosclerosis or thrombus
In arterial ulcers, you
have no pulse
Neuropathic ulcers(diabetic ulcers)
Result of diabetic neuropathy, peripheral arterial disease which leads to poor sensation
-pts report numbness and tingling=check feet
Risk factors of skin breakdown
poor nutrition, immobility, neurological status, diabetes, incontinence
Stage 1 pressure ulcer
Non-blanchable erythema(redness ) of intact skin
-changes in sensation, temp, and firmness
Stage 1 ulcer may precede visual changes so you can check if its stage 1 if its
warm to touch(palpable) and painful to touch
“My ass hurts” is an example of
stage 1 pressure ulcer
In stage 1, color changes
do not include purple, maroon discoloration as these indicate deep tissue injuries
Stage 2 ulcer
Partial thickness(dermis), skin loss with expose dermis-blood exposed
-wound bed is viable; pink pr red, moist. May present as intact or ruptured serum filled blister
Stage III ulcer
Full thickness(dermis) skin loss, subq fat may be visible
-complete skin breakdown-yellowish border
-Bone, tendon, muscle are not exposed-does not involve underlying fascia
Stage IV ulcer
Full thickness skin and tissue loss with exposed bone, tendon and muscle
Unstageable ulcer
Area covered by slough and/or eschar in wound bed
-black and yellowish- cant see what stage it is because of the slough and eschar
-needs to be derided-cleaned out(not done by nurse)
Characteristics of venous(stasis) ulcers
-warm, a lot of swelling
-wound usually seeping/draining
-palpable pulse
-use compression socks to aid in circulation
When you have a venous ulcer, elevation causes
decreased pain
Arterial ulcer
-no palpable pulse
-skin shiny and hairless
-foot is pale and cool to touch
When you have a arterial ulcer, elevation causes
increased pain
Characteristics of ulcer prevention
-Protective footwear of socks and boots
-avoid massage over boney prominence
-apply emollient to keep skin pliable
-avoid most environments
-avoid cold, caffeine, nicotine and constrictive garments
-avoid use of thermal devices such as hot water during skincare
When a patient is bed bound, change their position every
2 hours
When a patient is chair bound, change their positions every
hour
Prevention of Neuropathic ulcers
-control blood glucose(controls sugar)
-daily check of feet
-avoid applying heat
The Braden pressure risk assessment is used to
identify patients at risk of ulcers
A high score indicates a person is at
low risk of developing ulcers
19-23
The assessment measures which 6 things?
sensory perception, moisture, activity, mobility, nutrition, and friction/shear
Interventions for preventable mild/low risk(15-18)
-regular turning schedule
-activity
-protect heels
-use pressure redistribution surfaces
Skin pallor can indicate
anemia
Skin cyanosis can indicate
hypoxemia
Preventing skin breakdown by
-assisting with feedings
-monitor albumin/pre-albumin levels
-check weights daily/weekly
The main factor of preventing skin breakdown is
avoiding use of more than one incontienent containment on bed such as brief chux or draw sheet as it causes more friction and skin breakdown
Asepsis
The practice of activities to prevent infection or stop spread of microorganisms
Medical asepsis(clean technique)
Involves procedures and practices that reduce the number and transfer of pathogens
Hand hygiene and wearing gloves is used in
medical asepsis
Examples of medical asepsis conditions
pressure wound, arterial and venous ulcers
Surgical asepsis(sterile technique)
Used to keep objects and areas free from microorganisms
Examples of surgical asepsis
Inserting an indwelling urinary catheter, central lines and post op surgical wounds
T/F compression therapy is not used with pressure ulcer injuries
true
Purpose of a wound vac
draws fluids out to allow wounds to heal
With large wounds you want to monitor
fluid and electrolytes
Pressure ulcer scale for healing(PUSH)
determines if wounds are healing or not
-evaluates: length/width, exudate amount, tissue types present in wounds
Serous fluid
clear liquid in which drainage is pale yellow and watery
RYB wound classification
Red=protect
Yellow=cleanse
Black=debride
Example of serous fluid
fluid from a blister
Serosanguineous fluid
drainage is pale pink and yellow and is thin and contains plasma and red cells
Sanguineous fluid
drainage is bloody such as acute laceration
Purulent
pus where drainage contains white cells and microorganisms and occurs when infection is present
Phases of wound healing consist of
hemostasis, inflammatory phase, proliferation phase, and maturation phase
Hemostasis phase
-Occurs immediately after initial injury
- involves blood cells constricting and blood clot begins
-exudate is formed such as swelling and pain
-increased perfusion which leads to heat and redness
-platelets and other cells migrate to injury and promote healing
Inflammatory phase
-follows hemostasis and last 4-6 days
- white blood cells move to the wound
-macrophages enter wound area and remain for an extended period and they digested debris and release growth factors that attract fiberblasts to fill in the wound
Proliferation phase
-Begins within 2 to 3 days of injury last up to 2 to 3 weeks
-new tissue is built to fill the wound space through action of fibroblasts -capillaries grow over wound and epithelial cells
-granulation forms foundation for scar
Maturation phase
-Begins after 3 weeks and last 6 months after injury
-collagen is remodeled and new is formed
-scar is flat thin and white line
Principles of wound healing
- Intact skin is the first type of defense
- Careful hand hygiene prevents spread
- Adequate blood supply is essential for normal body response to injury(homeostasis-local, adaption syndrome-inflammation response-local)
- Normal healing is prompted wound is free from foreign material
- Response to a wound is more effective if proper nutrition is maintained
A patient has a wound that is healing by secondary intention. To best support healing of
the wound, the nurse should expect the practitioner’s order to state, “Clean wound with:
1. Betadine and apply a dry sterile dressing.”
2. Normal saline and cover with a gauze dressing.”
3. Normal saline and apply a wet-to-damp dressing.”
4. Half peroxide and half normal saline and apply a wet to dry dressing.”
- Normal saline and apply a wet-to-damp dressing.
The nurse must collect the following specimens. Which specimen collection does not
require the use of surgical aseptic technique?
1. Stool for ova and parasites
2. Specimen for a throat culture
3. Urine from a retention catheter
4. Exudate from a wound for culture and sensitivity
- Stool for ova and parasites
To interrupt the transmission link in the chain of infection, the nurse should:
1. Wash the hands before and after providing care to a patient
2. Position a commode next to a patient’s bed
3. Provide education about a balanced diet
4. Change a dressing when it is soiled
- Wash the hands before and after providing care to a patient
The nurse must make the decision to give a patient a full or partial bed bath. This decision
depends on the:
1. Physician’s order for the patient’s activity
2. Immediate needs of the patient
3. Time of the patient’s last bath
4. Wishes of the patient
- Immediate needs of the patient
A patient is incontinent of urine and stool. For which patient response should the nurse
be most concerned?
1. Confusion
2. Dehydration
3. Altered sexuality
4. Impaired skin integrity
- Impaired skin integrity
Which condition identified by the nurse places a person at the greatest risk for self-care
toileting and elimination problems?
1. Amputation of a foot
2. Early dementia
3. Fractured hip
4. Pregnancy
- Fractured hip
The nurse identifies that additional teaching about skin care is necessary when an older
adult says, “I should:
1. Bathe twice a week.”
2. Rinse well after using soap.”
3. Humidify my home in the winter.”
4. Use a bubble-bath preparation when I take a bath.”
- Use a bubble-bath preparation when I take a bath.”
A patient is incontinent of loose stools and is mentally impaired. What should the nurse
do to help prevent skin breakdown?
1. Wash the buttocks with strong soap and water
2. Frequently check the rectal area for soiling
3. Gently put a pad under the buttocks
4. Place the call bell in easy reach
- Frequently check the rectal area for soiling
The nurse must bathe the feet of a patient with diabetes. What should the nurse do
before bathing this patient’s feet?
1. File the nails straight across with an emery board
2. Ensure a physician’s order for hygienic foot care is obtained
3. Teach the patient that daily foot care is essential to healthy feet
4. Assess for additional risk factors that may contribute to foot problems
- Assess for additional risk factors that may contribute to foot problems
The nurse identifies that a patient’s pressure ulcer has just partial-thickness skin loss
involving the epidermis and dermis. The nurse documents that the patient’s pressure
ulcer is:
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
- Stage II
An immobilized bed-bound patient is placed on a 2-hour turning and positioning
program. The nurse explains to the family members that this is done primarily to:
1. Support comfort
2. Promote elimination
3. Maintain skin integrity
4. Facilitate respiratory function
- Maintain skin integrity
The nurse is transferring a patient from a bed to a wheelchair. To quickly assess this
patient’s tolerance to the change in position, the nurse should:
1. Obtain a blood pressure
2. Monitor for bradycardia
3. Determine if the patient feels dizzy
4. Allow the patient time to adjust to the change in position
- Determine if the patient feels dizzy
Which stage pressure ulcer requires the nurse to measure the extent of undermining?
1. Stage 0
2. Stage I
3. Stage II
4. Stage III
- Stage III
A patient is diagnosed with a stage IV pressure ulcer with eschar. Which medical treatment
should the nurse anticipate the physician will order for this patient?
1. Heat lamp treatment three times a day
2. Application of a topical antibiotic
3. Cleansing irrigations twice daily
4. Débridement of the wound
- Débridement of the wound
Which is the earliest nursing assessment that indicates permanent damage to tissues
because of compression of soft tissue between a bony prominence and a mattress?
1. Nonblanchable erythema
2. Circumoral cyanosis
3. Tissue necrosis
4. Skin abrasion
- Nonblanchable erythema
A client who is confused and disoriented is wearing a restraint that was applied following the
manufacturer’s directions. The client struggles against the restraint. Which does the nurse conclude is the primary reason for this behavior?
1. A restraint should not cause discomfort if it is applied correctly and checked frequently.
2. Confused, disoriented clients who are restrained may become agitated and respond in a reflex-like way; attempts to gain control
require problem solving, which they usually are unable to perform.
3. A client usually struggles against a restraint to get free, not to manipulate staff.
4. Disoriented and confused clients do not always have the cognitive ability to understand what is happening to them
and often struggle against restraints.
- Disoriented and confused clients do not always have the cognitive ability to understand what is happening to them and often struggle against restraints.
A nurse on the evening shift in the hospital is caring for a slightly confused client. Which is the most effective nursing intervention to prevent disorientation at night?
1. Although checking on the client regularly is something the nurse should do, it will not prevent disorientation.
2. The client has to be oriented enough to be aware of the presence of the call bell before it can be used.
3. A small night-light in the room provides enough light for visual cues for a minimally confused client, which should help
prevent or limit disorientation when the client awakens at night.
4. The client may not remember the description of the environment on awakening and may become disoriented in the dark.
- A small night-light in the room provides enough light for visual cues for a minimally
confused client, which should help
prevent or limit disorientation when the client awakens at night.
A nurse is caring for an older adult on bedrest. Which should the nurse provide to best prevent a pressure
(decubitus) ulcer in this client?
1. An air mattress distributes body weight
over a larger surface and reduces pressure
over bony prominences.
2. Although bathing removes secretions and promotes clean skin, it can be drying, which can compromise skin integrity.
3. Protein does not prevent pressure (decubitus)
ulcers. Protein is the body’s only
source of nitrogen and is essential for building, repairing, or replacing bodytissue. It requires a primary health-care provider’s prescription.
4. An indwelling urinary catheter should never be used to prevent a pressure (decubitus) ulcer; however, a catheter may be
used to prevent contamination of a pressure(decubitus) ulcer after it is present in a client who is incontinent of urine. It requires a primary health-care provider’s prescription.
- An air mattress distributes body weight over a larger surface and reduces pressure over bony prominences.
Which are the reasons why restraints are used when caring for clients? Select all that apply.
1. ____ The purpose of restraints is not to limit movement.
2. ____ Restraints can increase agitation; if used when a client is severely agitated, they can cause injury.
3. ____ Immobilization is not the purpose of
restraints. Restraints should be snug, yet loose enough for some movement.
4. _ _ _ The primary reason for the use of restraints is to prevent client injury; restraints are used only as a last resort
to protect the client from self-injury
or from hurting others.
5. __ _ In an emergency a client may be placed in restraints when a client’s activity threatens the safety of others.
- _ _ _ The primary reason for the use of restraints is to prevent client injury; restraints are used only as a last resort
to protect the client from self-injury
or from hurting others. - __ _ In an emergency a client may be placed in restraints when a client’s activity threatens the safety of others.
How do you assess cognition?
through orientation, memory, spatial ability, attention, and reasoning
Levels of consciousness
alert, verbal stimuli, painful stimuli, and unresponsive
-assess with Glasgow Coma scale
Characteristics of Delirium
-acute
-fluctuating
-lasts days to weeks
-altered consciousness
-impaired attention
-Increased/decreased psychomotor changes
-usually reversible
Characteristics of Dementia(think Alzheimer’s)
-chronic
-progressive
-months to years
-clear consciousness
-normal attention, except in severe cases
-often normal psychomotor changes
-rarely reversible
Confusion
agitated and disoriented which causes altered awareness and easily distracted
Wong Baker FACES Pain Scale
rates pain from 0-10 based off pictures of faces-ask them to point to a photo they identify with
Mild:0-3
Moderate:4-6
Severe:7-10
The Wong Baker FACES Pain Scale is based for
early dementia patients that are alert/awake and have a good attention span
FLACC scale
assesses face, legs, activity, cry, consolably
0-2 rating
The FLACC scale is used when
a patient is unconscious and cant properly communicate
Interventions for patients that are awake
-Observe for at least 2 to 5 minutes -observe legs and body uncovered -reposition patient or observe activity; assess body for tenseness and tone
-initiate counseling intervention as needed
Interventions for patients who are asleep
-Observe for at least 3 minutes or longer
-observe body and legs uncovered -if possible reposition patient
-touch body and assess for tenseness and tone
When communicating with patients who are confused, use
-Frequent face-to-face contact to communicate
-speak calmly, simply and directly to the patient
-orient and re-orient patient to environment
-orient patient to time, place and person
-communicate that patient is expected to form self-care activities
-offer explanation for care
-reinforce reality if patient is delusional
What are the reporting obligations
Nurses are obligatory reporters for abuse, rape and communicable diseases
-abuse includes physical, verbal, sexual or emotional neglect which more than half of the reported cases are in elderly
When using restraints,
Keep bed in lowest position possible and have at least one side rail down
T/F all restraints need to be based off doctors orders
true
Factors of using restraints
-least restrictive
-discontinue as soon as possible
-assess every 15 minutes and assessment by RN with physician order renewal 2-4hrs
Restraint assessment: Physical status
Check vital signs, assess skin, nutrition status, hydration status, circulation in extremities with restraints, range of motion, hygiene, elimination, and physical comfort
Restraint Assessment: Psychological/emotional status
Physiological comfort in maintaining of dignity, safety and patient rights
Glaucoma: Open Angle
-Fluid moves out
-open
-decreased peripheral vision
-blurry vision
Glaucoma: Closed(Narrow) Angle
-Pain as fluid backs up into the eye
-decreased peripheral vision
-blurry vision
How do we determine a patients arousal?
Through Reticular Activating System(RAS)
Consciousness
Delirium, dementia, confusion, normal consciousness, somnolence, minimally conscious state, locked in syndrome
Unconscious
-Asleep, stupor, coma
-Veg state
Sensory Deprivation
-Environment with decreased or monotonous stimuli
-impaired ability to receive environmental stimuli
-inability to process environmental stimuli
Example of sensory deprivation
patients in the ICU
Sensory overload
-Patient experiences so much that the brain is unable to respond meaningfully or will ignore stimuli
-out of control and exhibit manifestations observed in sensory deprivation
-nurse works on decreasing stimuli and help patient gain control over the environment
How do you stimulate a patient senses?
Interact with them by playing games
When caring for a visually impaired patient, you should
-Acknowledge yourself when you enter the room
-speak in a normal tone of voice -explain reason for touching patient before doing it
-keep call light within reach
-orient patient to sounds in environment
-orient patient to room arrangement and furniture
-assist with ambulation by walking slightly ahead of person
-stay in vision field
-let them know when you’re leaving
How to communicate with an unconscious patient
-Be careful what is being said in their presence; hearing is the last sensory lost
-speak in normal tone voice
-speak to patient before touching
-keep environmental noise at low levels
