MIDTERM Flashcards
1
Q
What are routine precautions?
A
standard precautions day to day stuff like hand washing; you don’t know pt’s Dx, would don PPE as if your dealing with blood and bodily fluids
2
Q
what are transmission based precautions?
A
isolation precautions used when an active or suspected infection is present; know the Dx and if they have a communicable disease, and would don PPE according to type of infection.
3
Q
A patient is admitted for Tuberculosis and is not yet diagnosed. What type of precaution is required when caring for this patient? and what PPE would you need to don for this transmission
- contact transmission
- airborne transmission
- droplet transmission
A
airborne transmission
- glove
- gown
- N95 mask
4
Q
Mrs. Jones spilled orange juice on her bed and has asked you to help her change
her linens. She was admitted for persistent high blood pressure. is this a routine or transmission based precaution?
A
routine precaution
5
Q
Which of the following body fluids requires the use of Routine Precautions?
- Blood
- Saliva
- Urine
- All of the above
A
all of the above
6
Q
Care staff are attending to a patient on droplet precautions. What personal protective equipment is required?
- Gloves only
- Gloves and gown
- Gloves, gown, and mask
- Gloves, gown, and properly fitted N95 mask.
A
Gloves, gown, and mask
7
Q
S&S of purulent exudate?
A
thick creamy yellow/green brown (pus)
8
Q
S&S of serous exudate
A
clear watery plasma that’s light yellow in colour
9
Q
S&S of sanguineous exudate
A
bloody
10
Q
what are the S&S of a serosanguineous exudate
A
watery blood (pink)
11
Q
what is the meaning of malaise
- throbbing
- not feeling well
- constant pain
A
not feeling well
12
Q
what does exudate mean?
A
drainage clear watery fluid
13
Q
edema meaning?
A
swelling
14
Q
difference between tachycardia and tachypnea
A
tachycardia is fast heart rate, while tachypnea is fast breathing
15
Q
what does pyrexia mean?
A
means high temperature; anything above 36
16
Q
what does erythema mean?
A
redness
17
Q
what is 9 pm in 24hour clock format?
A
2100 hundred hours
18
Q
5 minutes to 1pm in 24hour clock format?
A
1255
19
Q
6:13 pm in 24hour clock format?
A
1813 hours
20
Q
10:29 in 24hour clock format?
A
2229 hours
21
Q
4:38 pm in 24hour clock format?
A
1638 hours
22
Q
A nurse is caring for a patient who is on bedrest. The time is 0850 hrs. The patient will need
to be transferred at 0900 hrs to x-ray by stretcher. Place the following skill in the correct
sequence from the beginning to end.
a. Make the patient’s bed
b. Have the client void
c. Assist the client in moving onto the stretcher
d. Elevate the stretcher head for comfort
A
B, C, D, A
23
Q
A nurse is caring for a patient with multiple needs. Which task should be addressed first?
a. A diabetic patient’s blood sugar is 60 mg/dL and they feel shaky.
b. A patient with a post-operative wound dressing needs to be changed.
c. A patient’s IV bag is almost empty and needs to be replaced.
d. A patient is requesting a pillow for comfort.
A
A
24
Q
You are the nurse caring for a group of patients. Which situation should you address first? rank these in highest priority
a. A patient with a fever of 100.8°F requesting an additional blanket.
b. A patient complaining of chest pain rated 8/10.
c. A patient needing education on a new medication.
d. A patient who needs assistance ambulating to the restroom.
A
B, D, A, C,
25
community acquired infection
developing an infection in a community setting which could be a restaurant, school, and grocery store
26
iatrogenic infections
infection happens after diagnostic procedure
27
nosocomial infections (hospital acquired infection AKA HAI)
infections that occur while receiving care in hospital example you go to hospital for broken arm and during care there you develop MRSA
28
Patient develops oral fungal infection happens after knee surgery? what type of infection is this
A. iatrogenic infection
B. nosocomial infection
C. community infection
Nosocomial infection
29
A child develops chickenpox after playing with an infected neighbor before any symptoms appeared. what type of infection is this
A. iatrogenic infection
B. nosocomial infection
C. community infection
community acquired infection
30
After undergoing a colonoscopy, a patient develops a bacterial infection due to improper sterilization of the endoscope used during the procedure. What type of infection is this
A. iatrogenic infection
B. nosocomial infection
C. community infection
iatrogenic infection
31
A patient recovering from a hip replacement surgery in the hospital develops a urinary tract infection (UTI) due to prolonged use of a Foley catheter. What type of infection is this
A. iatrogenic infection
B. nosocomial infection
C. community infection
Nosocomial infection
32
what are the different vital signs?
- radial pulse
- apical pulse
- pedal pulse (which include dorsalis pedis and posterior tibialis)
33
where is the radial pulse located?
on the wrist
34
where is the apical pulse located?
around the breast area or on under nipple
35
where is the dorsalis pedis located?
at the top of foot in between the big and small toe
36
where is the posterior tibialis located?
located on lower leg on lateral side
37
what is the process of the chain of infection?
1. infectious agent
2. reservoir
3. portal of exit
4. mode of transmission
5. portal of entry
6. susceptible host
38
what is a infectious agent?
they are microorganisms that has the ability to cause diseases Ex. virus, bacteria, fungi, and protozoa
39
what does pathogen mean?
disease causing
40
what does pathogenicity mean?
how capable the disease is to spread
41
what's the difference between resident flora and transient flora?
transient flora sits at the epidermis and can be easily washed off, resident flora is literally a resident that lives deep within your body and they don't cause harm.
42
what does communicable infection mean?
that the infection is contagious and transmittable
43
what's the difference between a endogenous and exogenous infection?
Endogenous (think internal environment) its where your own microorganisms harm you
Exogenous (think external environment) where outside microorganisms which don't belong in your body ex. kissing someone (a outside sources organisms are invading your external environment)
44
what is a reservoir and what are some examples?
Where the microorganism can live and thrive (Ex. Person, inanimate objects, food, water)
45
what does fomite mean?
are inanimate objects that can carry infections like door handles, phones, stethoscopes, and clothes.
46
what is a poral of exit and what are some examples?
where pathogens and microorganisms leave the reservoir in the human body these can be the nose, mouth, cuts or open wounds and rectum (any bodily openings)
47
what is a mode of transmission?
how microorganism's travel from reservoir to host
48
what are the different modes of transmission?
- contact transmission
direct, indirect, and droplet
- airborne
- vector borne
49
what is a poral of enrty?
where infectious agents/ pathogens enter the body (mouth, urethra, open cuts or wounds, nose, ears, eyes..)
50
what's a susceptible host? and what makes a host susceptible
is a person who's more vulnerable to infections ex elderly, babies, pregnant, immunocompromised
51
what does asepsis mean?
free from infection and no pathogens present
52
what is medical asepsis?
clean technique REDUCES and LIMITS the spread of microorganisms Ex of medical asepsis Hand hygiene, gloving, disinfecting equipment
53
what is a surgical asepsis?
sterile technique that ELIMINATES ALL MICROORGANISM and spores Ex of surgical asepsis Injection, blood collection, catheter, wound dressing
54
what are the 7 principles of surgical asepsis?
- sterile touching sterile is sterile
- 1 inch boarder
- prolonged period of air exposure makes sterile field contaminated
- only other sterile products can touch sterile field
- sterile object out of the range of vision or an object held below a person’s waist is contaminated
- fluid flows in direction of gravity
- anything wet touching sterile field makes field contaminated
55
what's the difference between infection and inflammation?
inflammation IS ALWAYS PRESENT in infection
infection is NOT ALWAYS PRESENT in inflammation
56
what is inflammation?
body's normal defense system used to fight pathogens
57
what is a infection?
A invasion and growth of germs in body
58
Is Infection ALWAYS present in Inflammation?
no
59
Is Inflammation ALWAYS present in Infection?
yes inflammation is always present in infection
60
how is MRSA transmitted and what PPE do you don?
contact transmission
DON
- gloves
- gown
61
how is C-diff transmitted and what PPE do you don?
contact mainly direct and indirect
DON
- gloves
- gown
62
how is influenza transmitted and what PPE do you don?
contact droplet
DON
- gloves
- gown
- surgical mask
63
how is hepatitis A, B, and C transmitted and what PPE do you don?
contact transmission
DON
- gloves
- gown
since hepatitis B and C your dealing with blood and bodily fluids its up the the nurse if they'd like to wear a mask and face shield
64
how is tuberculosis transmitted and what PPE do you don?
airborne transmission
DON
- gloves
- gown
- N95 mask
65
how are chicken pox's transmitted and what PPE do you don?
Airborne transmission
DON
- gloves
- gown
- N95 mask
66
how is malaria transmitted and what PPE do you don?
vector borne transmission
DONNING PPE is situational if dealing with blood and bodily fluid wear
- gloves
- gown
67
how are rabies transmitted and what PPE do you don?
vector borne transmission
regularly you would don
- gloves
- gown
if dealing with blood and bodily fluid wear a face shield or mask
68
what's the difference between isolation and reverse isolation
reverse isolation is where you don PPE to protect your immunocompromised patient
isolation is where you don PPE for your protection because client is the source of infection
69
Removes dirt, dust, and other soils from surfaces is this
- cleaning
- disinfection
- sterilization
cleaning
70
Kills harmful bacteria and viruses from surfaces
- cleaning
- disinfection
- sterilization
disinfection
71
Kills all microorganisms from surfaces and its spores
- cleaning
- disinfection
- sterilization
sterilization
72
what position is best to administer a suppository?
SIMS
73
what position is best to listen to patients lungs?
high-fowlers
74
in what position is the HOB raised to 30-60 degrees
semi-fowlers
75
in what position are patients feet up and head down?
trendelenburg
76
what position are the patients feet down and head up?
Reverse trendelenburg
77
what position is best for perineal care?
dorsal recumbent
78
what position is best for a prostate exam?
keen-chest
79
what position is pt sleeping with face down?
prone
80
what is the flat sleeping position called?
supine
81
in what position are your feet placed in stirrups?
lithotomy
82
patient lays on what?
- pillows
- soaker and slider
- mattress
soaker and slider
83
should you avoid or encourage this
shake linens as your taking them off and
hold linen to “dirty scrubs”
avoid
84
should you avoid or encourage this
perform hand hygiene before/after bed making
maintain good body mechanics
check linens for patient’s personal belongings
encourage
85
what is the reasoning of preforming ROM exercises?
to prevent stiffness, contractures, immobility, promote circulation, promotes DVT (deep vein thrombosis), prevents pressure sores and skin breakdown
86
what's the purpose of ROM exercises?
- to prevent contractures
- promote circulation
- prevents pressure sores
87
what are the hazards of immobility?
- joint stiffness and contractures
- atrophy (muscle wastage)
- urinary retention (urinary track infection)
- constipation
88
what is active ROM?
where pt is able to move joints without assistance during ROM exercises
89
what is passive ROM?
patient is unable to move joints so nurse is helping patient with moving their joints
90
what is a combination of active and passive range of motion?
is a mix of both active and passive ROM where nurse promotes independence and allows patient to do exercise but also intervenes when patient cant move their joints
91
what does the term TED mean?
thromboembolic deterrent
92
what to TED stockings do?
they promote blood flow back to the heart by being tighter at the ankles pushing the blood upwards, prevents DVT
93
what is DVT and what does it mean
deep vein thrombosis where clots form in deep veins in legs and pelvic region
94
can you apply TED stockings to a patient with edema?
yes
95
are TED stockings okay to give to a patient with cyanotic?
no if patient already lacks blood flow wearing ted stockings would further result in lack of blood flow instead you can dangle patients feet
96
what is ADPIE and what does it stand for?
ADPIE is used in the nursing process to come up with a nursing diagnosis ADPIE stands for
- assessment
- diagnosis
- planning (SMART goals)
- implementation
- evaluation
97
what's the difference between subjective and objective data?
subjective data is what the patient experiences and tells you like "I'm feeling pain on the left side of my abdomen"
objective data is what the nurse gathers through observing and assessing patient (if it involves numbers it's objective)
98
is this a partial bath or full bath?
oral care, face, hands, axilla, underneath skin folds, back and perineal care
partial bath
99
what's the purpose of a partial bath?
to clean the areas that odor and moisture builds up
100
what type of doctor is a podiatrist
foot doctor
101
when and why is a QPA preformed?
it's a 5 min assessment of a patient to asses their ABC, LOC, LOO, intake and out take, pain assessment
102
when and why is a pain assessment preformed?
every time a patient says there having pain we preform a pain assessment to get a better understanding of their pain and how to help it
103
when and why is a focused assessment preformed?
focused assessment is preformed when patient complains of certain areas hurting like stomach, abdomen, and no bowel movements making the nurse do a focused assessment on patients gastrointestinal track
104
when and why is a head to toe assessment preformed?
preformed once a shift or on admission of new patient to get an understanding of how the patients doing and what complications they have or if those complications are getting worse
105
what are the order of assessments of a physical examination? number them in order
palpate, auscultate, inspection
1. inspection
2. auscultation
3. palpation
touching the areas of inspecting first before auscultating can effect the noises
106
A nurse is preparing to perform a sterile dressing change. Arrange the following steps in the correct order:
1.
Open the sterile dressing tray, ensuring not to touch the inside of the tray or the sterile items.
2.
Gather all necessary supplies, including sterile gloves, dressings, and solutions.
3.
Perform hand hygiene.
4.
Don sterile gloves.
3, 2, 1, 4
107
A patient is admitted to rule out active Hepatitis B. The nurse understands that Hepatitis B is primarily transmitted through:
a) Respiratory droplets
b) Contaminated food
c) Blood and bodily fluids
d) Insect bites
blood and bodily fluids
108
The medical term for head lice is pediculosis capitis. How are head lice typically transmitted?
a) Through the air
b) Through contaminated water
c) Through direct contact with an infested person or their belongings
d) Through contact with animal feces
Through direct contact with an infested person or their belongings
109
A new quality assurance program has been instituted on the unit because of a higher than average infection rate. Which of the following could be factors responsible for this increase?
Select one or more:
a. Nurse A wears artificial nails.
b.Nurse B performs hand hygiene between patients.
c.Nurse C wears rings on her fingers.
d.Nurse D has fingernails less than ¼ inch long.
e.Nurse E has open cuts on her hand.
f.Nurse F has chipped nail polish.
A,C,E,F
110
A patient was hospitalized for surgical repair of a fractured hip. Her discharge was delayed because she developed a fever and respiratory distress. A chest x-ray confirmed left lower lobe pneumonia. Which type of infection best describes what this patient has?
a. An iatrogenic infection.
b.A health care-associated infection.
c.A systemic infection.
d.A local infection.
Health care acquired acquired infection
111
orbital edema happens where
around the eye sockets
112
peripheral edema is located where
the extremities (hands, legs, hands, feet)
113
where is general edema located
around the whole body (face, belly, lungs, limbs)
114
where is scrotal edema located
in the scrotum
115
where is dependent edema located
lower\dangling part of body (legs, feet)
116
what's the medical term for cut
laceration
117
what's the medical term for bruising
contusion
118
what is gingivitis
swelling and redness of the gums
119
medical term for head lice
pediculosis capitis
120
medical term for ear wax
cerumen
121
what is the method of physical examination that uses touch
palpation
122
listening to sounds produced by the lungs, intestines, and heart
auscultation
123
patients response to health problem gathered by data taken during the assessment is called what
nursing process
124
Hospital acquired infection is also known as:
nosocomial infection
125
The medical word used to describe that something is in place:
in situ
126
open narrow airways indicates what breathing sound
wheezing
127
When you are asking your patient questions that would determine whether they are
aware of their name, the place, and a time frame, you are assessing their:
level of orientation (LOO)
128
The normal range for bowel sounds per quadrant, per minute:
5-35 sounds
129
Is fear of surgery objective or subjective data?
Subjective because fear is something only they can feel
130
Is shooting pain in arm subjective or objective data?
Subjective; pain is always subjective because it’s something the patient experiences
131
A patient is hospitalized for treatment of severe dehydration caused by gastroenteritis. During their stay, they develop a urinary tract infection (UTI) due to the prolonged use of a urinary catheter. What type of infection is this?
a) Nosocomial infection
b) Iatrogenic infection
c) Community-acquired infection
nosocomial because UTI happen while their stay at hospital; catheter is an invasive device, it doesn't qualify as iatrogenic unless the infection is directly linked to poor technique of medical procedure
132
how do we check if patients nerve endings are still alive and intact
CWMS
133
what does CWMS mean
color warmth movement sensation
134
ostomites
surgically created openings
135
what are the things you assess for in the urine?
- colour; is it a clear amberish colour, or is it too dark indicating more fluids need to be consumed
- amount: for adults in a 24 hour period is 1500-2000mL
- odor: faint odor, foul, sweet/fruity smell
- clarity: is it clear, cloudy, presence of sediments or blood
136
Normal urine looks like
clear, transparent with faint odor, and with a 1500-2000mL amount
137
abnormal urine looks like
darker pigment, foul odor, cloudy with presence of sediments like blood, glucose, and protein
138
what does hematuria mean
blood in the urine
139
what does micturate mean
process of expelling urine
140
what does polyuria mean
excessive amount of urine
141
what does nocturia mean
excessive urination at night ex bed wetting
142
what does urinary incontinence mean
loss of control over bladder could be permanent or temporary
143
transient incontinence
temporary loos of bladder control usually with an underlying treatable condition ex, diabetes, pregnant, or infection
144
what does DIPPERS mean
D; delirium, confused or altered mental state
I; infection (UTI)
P; pharmaceuticals (diuretics)
P; psychiatric disorders like depression
E; endocrine disorders (diabetes)
R; restricted mobility
S; stool impaction
these are reasons why transient incontinence can occur
145
what type of incontinence is the sudden need to void now! or voiding more than every 2 hours
urge incontinence
146
what type of incontinence is...
putting pressure on the abdomen causing small amount of urine to be lost, less than 50mls. Ex laughing, sneezing, or lifting
stress incontinence
147
what type of incontinence is....
a combination of stress and urge incontinence
mixed incontinence
148
what type of incontinence is....
not being able to get to the bathroom in time due to obstacles like chair in the way or belt is on too tight or mobility issues like using a walker
functional incontinence
149
what type of incontinence is....
too much urine in the bladder causing overflow example spinal cord injuries where the body doesn't know when to release, enlarged prostates in men blocking the urethra
overflow incontinence
150
what type of incontinence is....
where neurological disorders don't let the brain and bladder communicate on when it needs to be emptied like spinal cord injuries or stroke, the bladder empties spontaneously
reflex incontinence
151
what type of incontinence is....
no control over when or how much urine is lost, continuous and unpredictable examples dementia, paraplegia
total incontinence
152
what does urinary retention mean
unable to empty the bladder completely
153
what does in situ mean
in place
154
what catheter is this...
used in men and women, who are unable to void and are retaining urine. Ex post-surgery, or palliative care
indwelling catheter (foley catheter)
155
what catheter is this...
this type of catheter is inserted for a brief period of time and is not left inside the bladder, used to collect sterile urine, made of stiffer tubing
straight in and out catheter (in and out)
156
what catheter is this...
don't have functioning urethra so catheter is inserted surgically
suprapubic catheter
157
what catheter is this...
used by male patients only who are incontinent , external catheter that has an attachment that fits over penis
- promotes independence for pt's who can care for themself
- freedom and movement
condom catheter
158
what is condom catheter care?
- remove daily to assess for skin integrity, open areas, infections, edema
- less risk for infection
- still at risk for backflow if legs or bladder bag is higher than bladder
159
what is indwelling catheter care?
- educate patient on keeping drainage bag lower than bladder to avoid backflow
- assess from site to source
bladder
kinks
in situ
leaks
160
what does oliguria mean
low urine output
161
urinalysis test
- should test the first void in the morning
- do urinalysis test within 2 hours of obtaining urine
- use dipstick and assess for presence of blood, protein, nitrates, leukocytes, ketones, and other solutes
162
sterile specimen test
- collect fresh sample from catheter port with needle and urine cup you need at least 30cc of urine for men and women
163
what causes a UTI
- instrumentation (catheter insertion)
- poor hand and perineal hygiene
- sexual activity
164
S/S of a UTI
- dysuria; difficulty urinating (burning)
- urgency to go
- hematuria; blood in urine
- cloudy urine
- foul odor
165
interventions for UTI
- increase fluid intake to flush out bacteria of the bladder
- cranberry juice to lower urine pH
- educate pt on not to hold in urine and go when they need to as that can cause a UTI
- hand and perineal hygiene
166
what is a digital rectal exam
insert finger into pt's rectum to assess for stool
167
occult blood test
- a stool sample that's assessed for blood
- you repeat it 3 times (once per day)
- if blue= positive, no change = negative
168
formation of gas in the rectum or colon is called what?
and once released it's called what?
flatus inside the body
flatulence outside the body
169
flatulence s/s, causes, interventions
s/s
- pain because of the pressure on the abdomen
- feeling bloated
- passing gas/ burping
causes
- immobility
- mouth breather
- drinking carbonated drinks, eating beans and cabbage
intervention
- movement
- drinking/eating less beans, cabbage, and carbonated drinks
- eat/drink slowly with mouth closed
170
diarrhea s/s, causes, interventions
s/s
- loose watery stools
- several stools a day
causes
- dairy intake
- certain medications
- overuse of laxatives
- food poisoning
interventions
- monitor fluid and electrolyte balance because of the excessive diarrhea
171
constipation s/s, causes, interventions
s/s
- excessively straining hard (Valsalva Manoeuver)
- pain / discomfort
- fatigue, headache, nausea
cause
- low fluid intake
- pregnancy
- poor diet (lack fiber)
interventions
- proper diet and fluid intake
- administer laxatives
172
fecal impaction s/s, causes, intervention
s/s
- N/V
- cramps and bloated abdomen
- abnormal mass around rectum
causes
- severe constipation
- high fiber intake with low fluid intake
interventions
- medications suppositories/enema
- disimpassion
173
normal stool is
brown in colour and soft in consistency, with 75% water and 25% solid material
174
abnormal stool has
melena present (black, tarry stool), hard dry stool or loose watery stool, large amount of undigested food
175
suppository vs enema
Suppository is solid and bullet-shaped while
Enema is medication in liquid form.
Suppository works within 20 to 30 min while
Enema works immediately or about 5 min.
176
cleansing enema
uses tap water or NS to cleanse the feces from the colon
177
oil retention enema
uses a mineral oil which feces absorbs and makes it easier to pass
178
what does undermining mean with wound care?
so peri wound is intact and okay but the tissues under are breaking down
179
what does eschar mean
necrotizing tissue
180
how many phases are there of wound healing?
4 stages
hemostasis: takes 5-10 mins prevents further bleeding from happening bc of platelets clotting the blood
inflammatory: takes 0-3 days causes erythema and vasodilation (open blood vessels) casing tender, red, and warmth to area
proliferative phase: 3-21 days wound starts to close and becomes a light pink colour
remodeling phase: up to 2 years to fully heal the wound scaring may occur
181
which type of wound phase is this
the edges contract until the tissue forms and close becomes a light pink colour, fibroblasts produce collagen strengthening the wound, 3-21 days
proliferative phase 3-21 days
182
which type of wound phase is this
in 5-10 mins body prevents further bleeding from happening bc of platelets clotting the blood
hemostasis
183
which type of wound phase is this
histamine releases and causing vasodilatation and erythema 20 mins after the wound happens, making the area red, tender, warm
inflammation phase
184
which type of wound phase is this
Increase in strength, scarring may occur
(minimal scarring on underarm and more on knee), up to 2 years
remodeling phase
185
what are the 3 stages of wound closure
- primary
- secondary
- tertiary
186
the ideal wound closure with minimal scarring, edges are brought together via staples, stiches, and skin glue
- primary
- secondary
- tertiary
primary
187
this wound heals inside out because of the chunk of skin or tissue missing, slower healing and lots of scarring packing required example pressure sore or burn
- primary
- secondary
- tertiary
secondary
188
chunk of tissue missing and debris present, infection may delay healing, packing required as wound being irrigated, wound left open to heal ex dog bite (An abdominal wound initially left open due to infection risk)
- primary
- secondary
- tertiary
tertiary
189
what is a ulcer
a break in the skin that stops normal functioning
190
what are the 4 different types of ulcers
- pressure
- arterial
- venous
- diabetic
191
what are the common terms for pressure ulcer
- pressure sore
- decubitus ulcer
- bed sore
192
tissue death because of tissue being compressed between bony prominence and external surface for long period of time example people who are on red rest
- pressure
- diabetic
- arterial
Pressure ulcer
193
how many stages are there of a pressure ulcer
5
194
what happens in stage one of a pressure ulcer? and the treatment
- skin is non-blanchable (capillaries are dead and blood cant return to cite
- can occur within a couple of hours
- pain and tenderness may be present
- only epidermis outer most layer of skin is affected
Tx: turn pt every 1-2 hours, apply barrier cream, and prevent moisture, apply silicone, zinc, dimethicone creams forms a barrier and prevents water from entering
195
what happens in a stage 2 pressure ulcer? and what is the treatment
- partial thickness skin loss meaning epidermis is gone and dermis is now being impacted
- the skin is open (or in a blister form)
- can look like a shallow crater/indent in skin
Tx:
- barrier cream around wound and not on top of wound so peri wound doesn't get affected
- apply dressing to open areas like mepore or allevyn
196
what happens in a stage 3 pressure ulcer and treatment?
- full thickness skin loss (epidermis, dermis, and subcutaneous layer are affected)
- slough (stringy white tissue) may be present
- may or may not have undermining
Tx:
- apply dressing over wound
- irrigation
- might need to pack the wound to pull extra fluid out
- mepore, allevyn, abdominal pad used for greater absorption
197
what happens in a stage 4 pressure ulcer and treatment?
- bones, ligaments, and tendons start showing
- Eschar is present (meaning tissues start to die)
- pain may be present (bc nerve endings are destroyed)
- leads to amputation
198
what happens in a stage 5 pressure ulcer and treatment?
- unstageable bc you don't know deep the damage is
- thick, black necrotic tissue
tx:
- debridement may need to be done to find out what stage and how deep the damage is
199
what happens in a arterial ulcer
- caused by lack of circulation and oxygen to the site
- commonly found below knee (furthest point blood needs to be pumped)
- common site would be tips of the toes
- pedal pulses may be absent because of the lack of blood flow going to the toes
Tx:
- dangle toes to promote circulation
200
what happens in a venous ulcer
- venous ulcers have problems with brining blood back up to the heart
- these ulcers are found in the ankles
- cause pooling of blood around ankles
Tx:
- raise the body part to help promote blood flow back to the heart and reduce edema
- or TED stockings to prevent pooling and promote blood flow back up to heart
201
what happens in a diabetic ulcer
- high blood sugar leads to nerve damage
- no sensation, may feel burning or numbness to area
- present most often in feet especially the pressure points heels or toes
202
what are the common sites of skin break downs
pressure ulcers
- bony prominences
arterial
- feet (the furthest part of the body)
venous
- ankles
diabetic
- the feet (toes and heels)
203
what are the 10 risk factors of pressure ulcers
1. immobility
2. friction
3. shearing force
4. sensory issues so you cant feel that you have a pressure ulcer
5. moisture which causes maceration (causing small tears)
6. altered level of awareness like dementia where you don't realize you need to move
7. poor nutrition
8. poor circulation
9. age
10. being emaciated (bone to surface) or obese (too much pressure on bones and skin)
204
what is pulse deficit
where radial pulse is less than apical pulse
205
what does Cheyne-stokes mean
pattern of abnormal breathing with hyperventilation and apnea; usually occurs during sleep
206
what does blood pressure mean
the force of blood that's hitting the arterial walls
207
what does systolic mean
higher number (when the heart contracts or squeezes)
208
what does diastolic mean
smaller number and when the heart relaxes
209
what does circadian rhythm mean
normal changes in body temp which are higher during day (around 1800 or 6:00pm) and colder in night (0100-0400)
210
normal rage for blood pressure
lowest is 100/70
highest is 140/90
211
normal range for temperature
36-38
212
normal range for pulse
60-100 beats per min
213
normal range for respirations
12-20 respirations per min
214
normal range for oxygen saturation SpO2
95-100 or 92-100
215
when assessing vs assess the...
- rate
- rhythm ; regular or irregular
- quality ; clear, shallow, easy (normal), faint, strong
216
what does PMI
point of maximal impulse (loudest beat)
217
Tachycardia
higher than 100 bpm
218
bradycardia
lower than 60 bpm
219
hypertension
high blood pressure over 140/90
220
hypotension
low blood pressure which could be different for all
221
dyspnea
difficulty breathing
222
tachypnea
rapid breathing
223
bradypnea
slow breathing
224
hypoxia
low oxygen in body
225
hypoxemia
low oxygen in blood
226
what does dysphagia mean
difficulty swallowing
227
DON'Ts of feeding
- not lying down
- dont force
- sleepy or tired
- no sipper cups
- no straws
228
DO's of feeding
- fowler's position
- eye level to check their throat
- teaspoon
- check for pocketing
- allow pts to eat on stronger side
- allow swallow time
- promote independence
229
causes of dysphagia
- weak nerves/muscles making it harder to swallow
- food too big blocking airway
- no swallowing reflex due to stroke so must remind to swallow
- throat muscles too weak causing pieces of food fall in throat resulting in aspiration (going down wrong pipe)
230
s/s of dysphagia
- coughing when drinking liquids bc water goes down too fast and muscles cant navigate it to right destination
- complains of food getting stuck in throat bc of valleculae
- choking or nasal regurgitation
- frequent respiratory tract infection bc food enters lungs
231
complications of dysphagia
- dehydration ; loss of fluids in body
- malnutrition ; not getting enough nutrients
- aspiration pneumonia ; infection because food went down wrong pipe and now in the lungs
232
fluid intake is anything...
that is fluid (water, juice) or is partially liquid (was once fluid) (jello, pudding, soup, yogurt)
233
what is a diuretic
a water pill that causes one to loss fluid
234
electrolytes are..
minerals in the body that carry an electrical charge
235
what are some electrolytes?
Na (sodium) and K (potassium)
236
what is hyponatremia and hypernatremia
hyponatremia = low sodium levels
hypernatremia = high sodium levels
237
what is hyperkalemia and hypokalemia
hyperkalemia = high potassium
hypokalemia = low potassium
238
true or false in a fluid balance record only fluids should be counted not solids
true your assessing the intake and output of patients
239
what is aldosterone
hormone release by adrenal glands causing body to retain fluid
240
what is ADH
antidiuretic hormone ; holds in the pee (water) in our body
241
what foes chewing mean
mastication
242
what does swallowing mean
deglutition
243
interventions of dysphagia
- proper position in a upright fowlers position with head slightly forward
- modification of food volume; cut up food into smaller
- allow patient time to swallow their food don't rush
- check for pocketing
- tube feedings
