PCC-2:test 3 Flashcards
1
Q
turgor:
A
The degree of elasticity of skin, sometimes referred to as skin turgor. The assessment of skin turgor is used clinically to determine the extent of dehydration, or fluid loss, in the body.
2
Q
Debridement:
A
the removal of damaged tissue or foreign objects from a wound.
3
Q
adhesion:
A
an abnormal union of membranous surfaces due to inflammation or injury.
4
Q
perfusion:
A
is the passage of fluid through the circulatory system or lymphatic system to an organ or a tissue, usually referring to the delivery of blood to a capillary bed in tissue. The word is derived from the French verb “perfuser” meaning to “pour over or through”.
5
Q
Epithelium
A
the thin tissue forming the outer layer of a body’s surface
6
Q
Granulation:
A
Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size.
7
Q
Dehiscence:
A
Wound dehiscence is a surgical complication in which a wound ruptures along a surgical incision. Risk factors include age, collagen disorder such as Ehlers–Danlos syndrome, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery.
8
Q
Evisceration:
A
Evisceration is the removal of viscera (internal organs, especially those in the abdominal cavity)
9
Q
Keloid:
A
an area of irregular fibrous tissue formed at the site of a scar or injury.
10
Q
slough:
A
Slough is defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed. This wound bed has both yellow stringy slough as well as thick adherent slough. Slough on a wound bed should be surgically debrided to allow for ingrowth of healthy granulation tissue.
11
Q
The first of three biological defense mechanisms that protect the body is:
A
skin and mucous membranes
anatomic/biochemical barrier
12
Q
second line of defense:(mechanical clearance):
A
skin sloughing, respiratory cilia, and urination and inflammatory response-isolate, neutralize, destroy invaders locally
13
Q
third line defense:
A
immune response-long lasting and sometimes permanent protection
14
Q
tissue integrity:
A
the state of structurally intact and physiologically functioning epithelial tissues such as the integuments(including the skin and SUB Q tissue) and mucous membranes
15
Q
tissue integrity ranges from:
A
Intact skin and tissue, to partial thickness injury, to full thickness injury
16
Q
If skin becomes impaired and the protection/barrier is broken, it can lead to:
A
infection, injury, and foreign bodies getting in.
*and if wounds can’t repair they become chronic wounds
17
Q
Infants skin:
A
- Lanugo and vernix caseosa at birth(thin,smooth,elastic)
- infants skin is inefficient at birth but improves with growth, since the skin is thin, and subcutaneous layer is thin,it is more permeable to heat and fluid loss.
- infants pigment system is also immature.
18
Q
Adolescents skin:
A
- changes due to increased granular activity-skin becomes oily
- primary problem is acne
- health promotion needs: education about tanning, skin care, safety
19
Q
Older adults skin:
A
- Loss of elasticity caused by loss of elastin, collagen, and subcutaneous fat.
- Layers thin and flatten- it becomes wrinkly and tears more easily
- decreased gland function causes dry skin
- fragile, unsupported vessels
- hair-melanocyte function decreases and leads to grey hair
- these changes in the elderlys skin causes decreased protection, decreased temp regulation, decreased ability to repair, less ability to absorb and secrete, and decreased vitamin D production
20
Q
Categories of tissue integrity:
A
Trauma injury: abrasion(1) incision(2) laceration(3) perfusion disruption(4) immune reaction(5) infection(6) infestation(7) thermal injury(9) radiation injury(10) lesions(11)
21
Q
At risk populations include young and old populations because of
A
changes in the skin, decreased sensation, and decreased movement
22
Q
Individuals at risk for tissue integrity includes:
A
- people exposed to the environment(sun/wind/water)
- chronic disease that changes perfusion, motility, and tissue moisture
- malnutrition-over or under
- immunosuppression(people whose immune systems are compromised)
23
Q
To prevent tissue damage you need:
A
good hygiene, good nutrition, and to prevent injuries from wounds, sun exposure, and pressure
24
Q
Information to get/look for in a tissue integrity assessment:
A
obtain a history that includes past skin integrity issues plus any recent changes.
-Do a mole assessment-ABCDE
Look at patients skin color, hydration, and their hygiene
-Lab and diagnostics;culture(follow lab instruction on how to obtain), biopsy, woods lamp, serum protein(albumin/prealbumin)
25
BRADENS scale:
-you don't just perform and record: this is a call to action!
facilities will have a policy of when to do a Bradens scale and what to do with the results
*it is an interactive tool: you need to interact with the person to collect the data
*when in doubt of rating, use lower score
* theres is a Braden Q-pediatric version, which has an added tissue perfusion and oxygenation category- which looks at blood pressure and O2 stats
Limitations of Bradens scale includes that it doesn't count previous or present pressure ulcers, and doesn't document cognition
Norton scale and Waterloo Scale are similar scales, less commonly used
26
Good Samaritan WOC guidelines:
Bradens scale done on each patient once every shift
On all patients with a Bradens score of 18 or below:
-pressure reduction mattresses(most beds are)
-pressure reduction cushions in all chairs
- float heels at all times
-30 degree turns every 2 hours
-Head of bed elevated less than 30 degrees if possible
-Not in chair for over 2 hours
-get a nutrition consult
*WOC referrals made for Bradens score of 12 and under
27
three phases in wound healing:
inflammatory phase
granulation phase
maturation phase
28
Injury/ surgical wound healing stages:
primary intention
secondary intention
tertiary intention
29
Factors that influence tissue integrity/wound healing:
*Hygiene: what irritates skin? what can get into wound?
What are the cultural norms on basic hygiene?
*Nutrition-optimal for prevention, including WATER
*Environment: outdoor, indoor, chemical, occupational
*Chronic conditions like diabetes
* Mobility: perfusion and pressure-what's good for the heart is good for everything else in the body
*Medications-sun sensitivity with certain meds
*Socio-economic factors:influence hygiene, nutrition, environment, and preventative care
30
Delayed wound healing and complications:
* Poor Nutrition
- Need:Protein 1-2 grams per kg/day equally divided
- Need Vitamins A and C, and zinc(mineral)
* Poor Perfusion caused by PAD,PVD, smoking, diabetes, obesity, anemia
* Infection
* Immunosuppression-corticosteroids
* AGING
31
Operative effects on tissue integrity include:
incisions, tissues and body cavities open, loss of protection of skin, decreased perfusion, pressure, loss of protective response
32
Assessment of surgical incisions and sutured lacerations:
Assessment:
- Be descriptive, include dressing type and drainage, drainage amount, color, odor, and viscosity, and any drains in place
- Be aware of any signs and symptoms that should raise concern: fever, pain, growing readiness, foul odor, excessive drainage ect.
* Before doing a dressing change, do an assessment, and see what patient may need: anti anxiety meds, pain meds, distractions in place
33
Nursing priorities (things to watch for in early post-op period and through healing period):
-Hemorrhage
-Infection
-Dehiscence/evisceration(splitting apart of incision site)
Risks increased for this in abdominal wounds/incisions, and obesity. Prevention includes: abdominal binders, splinting and grading incision with movement, calm and quiet patient, cover with moist sterile dressings, notify surgeon if any problems arise.
splint abdominal incisions(hug pillow or use arms) when coughing, deep breathing, and moving
-need to monitor bleeding with careful documentation
34
Home care:
* assess readiness to learn(acceptance, pain, support)
* assess current knowledge level
* Important s/s to watch for and report (unit information sheets-will have to update and personalize) *Inform patient signs of infection/bleeding
* teach patient how to manage soiled dressing, and how, when, and where to obtain supplies
35
Medical Device related pressure ulcers:
In children, the head is larger in relation to their trunk, so their heads are the most common site of pressure ulcers, use caution when anchoring, taping devices to skin, rotate sights of things as much as possible(like )2 saturation probes), use even more caution in patients who cannot communicate discomfort, or turn/reposition themselves, and use protective barriers-stat locks, film dressings ect.
36
pressure ulcers pathophysiology:
Always tissue damage caused by pressure: to epidermis, dermis, Subcutaneous tissue, or vessels
**Incidence/prevalence has increased 80% in past 10 years
37
Pressure ulcer risk factors:
```
hospitalized patients, ICU patients, decreased cognition, decreased sensation, poor perfusion, plus Bradens categories:
Sensory perception.
Moisture.
Activity.
Mobility.
Nutrition.
Friction and Shear.
*This is not only an older person problem!
```
38
Medical Device-Related pressure ulcers caused by:
use of therapeutic medical devices
*not stageable according to current staging protocols
-caused by essential equipment
-mucous membranes and skin
-Not over bony prominences
Examples: IV lines, sequential stockings, blood pressure cuffs, ecg electrodes, catheters, et tubes,
-consequences include pain, infection, length of stay increases
39
Staging and measurement of pressure ulcers:
```
6 stages:
-unstageable
-suspected deep tissue injury
1,2,3,4
*Push tool evaluates wound progress
```
40
Dressings considerations:
* Reasons for wound drainage
- environment for wound dressing
- to absorb drainage
- to immobilize
- to protect from mechanical and bacterial
- to control bleeding
- and to provide comfort
* type of dressing used determined by reasons for applying it
41
Dressing selection for a cavity wound with heavy exudate-Deep and Wet:
used to:maintain moist environment:absorb exudate, obliterate dead space, protect and insulate.
*Absorptive Filler + cover dressing
Filler: Calcium alginate, Hydrocellular, Guaze and specialty gauze, foam cavity dressing
Cover: Gauze pad, ABD, etc., thin film(transparent adhesive), polyurethane film
42
Dressing selection for a cavity wound with minimal to no exudate: Deep and Dry:
used to: maintain moist environment, obliterate dead space, protect, and insulate
*Moisture retentive or hydrating Filler +cover Dressing
Filler: Amorphous gel, damp gauze packing, hydrocellular damp, Biafine
Cover: Gauze pad, ABD ect., Thin film(transparent adhesive), polyurethane film
43
shallow wound with moderate to heavy Exudate (Shallow and wet)
used to: maintain moist environment, absorb exudate, protect, insulate, protect surrounding tissue
*Absorptive Cover Dressing
-Hydrocolloid(with or without paste/powder)
semi-permeable polyurethane foam, calcium alginates, Gauze, Contact layer( with a cover dressing)
44
Shallow wound with minimal - no exudate (Shallow and Dry):
Used to: maintain moist environment, protect: insulate
* Moisture Retentive or Hydrating Cover Dressing
-Amorphous or solid gel dressings
thin hydrocolloid
thin polyurethane foam
thin film(transparent film)
non-adherent gauze
45
Packing a wound:
when packing a wound use only one continuous piece of gauze to avoid a smaller piece not being seen and getting left inside the patients wound
46
Prevention of skin tears:
- avoid pulling or sliding
- keep environment free of obstacles
- maintain safe environment free of obstacles
- maintain safe environmental lighting
- keep skin moist
- use tape cautiously
- encourage long sleeves and pants
47
How to manage skin tears:
- gently place torn skin in its approximate normal position
- clean with normal saline or other nontoxic cleaner
- pat or air dry
- apply dressings and change per protocol or product requirements
- photograph if permitted
- Document all findings including how it happens if known
48
Cellulitis:
Inflammation of skin and sub-q tissue
common causes are staph-aureus or strep
Lower leg is most common site
can be caused by insect bites
poor skin integrity contributes to breaks and entry portal
Risk factors include: same as tissue integrity, + IV drug abuse, lymphedema,
Treatment is oral antibiotics, clean wound care
Complications: systemic infection, necrotizing fascitis
49
Normothermia:
is the normal body temperature (ranges between 97.7 and 99)
50
Hypothermia:
is a body temperature below 97.2
51
Hyperthermia:
is an extremely high body temperature above 106.7
52
Fever:
is elevation in body temperature due to change in the hypothetical set points
53
Hypothalamus:
is the master regulator of heat, manages the production, conservation, and loss of heat
54
Heat is created by:
metabolism-muscles, liver
epinephrin increases metabolic rate
shivering
55
Heat is conserved through:
vasoconstriction and decreased sweating
56
Heat loss:
radiation, conduction convection (LOSS)
- sweating
- vasodilation
- metabolic slowing
57
Older adults and thermoregulation:
older adults have:
- reduced metabolism
- diminished circulation
- decreased sweating
- decreased shivering
- diminished perception
58
Infants and thermoregulation:
infants lack heat conservation ability
they have brown fat-increased metabolism
Flexed
blood vessels are close to the skin
59
Hyporthermia definition:
caused by loss of heat or failure to create enough heat. can be external, metabolic,or pathologic. Damage is dependent upon duration of hypothermia: long term hypothermia causes reduced circulation, coagulation, further hypothermia, tissue ischemia, and even death
60
Fever definition:
Heat set point is raised by Pyrogens
Exogenous-immunological protein binds to macrophage, which causes synthesis of cytokines
Endogenous-interleukin 1,6, 8, Tumor necrosis factor eat.
61
Hyperthermia definition:
Elevated temperature with unchanged heat set point
caused by the inability to cool, too much heat produced, pathology. Consequences include:
Sodium loss, dehydration, hypotension, tachycardia, decreased perfusion, coagulation, cerebral edema, CNS damage, kidney damage, and even death
62
Risk factors for thermoregulation issues include:
```
age: very young or elderly
socioeconomic status
occupation
altered nutritional staus
AND comorbidities including:
-autoimmune disorders
-burns
-hypothalamic injury
-infections/inflammation
-surgery
-hyper/hypothyroidism
-prematurity
-trauma
-obesity
-asplenia
```
63
assessment of thermoregulation includes:
obtaining vital signs
core temp may be critical
pulse, respirations, BP, and O2Sats
Also check level of consciousness and output
64
Management of variations of temperature include:
Prevention:
- appropriate clothing
- environmental controls
- adjusting physical activity
- Be alert to needs across the lifespan for extra warming or cooling measures, prevention of exposure
* Screen for family members with malignant hyperthermia(after surgery)
65
Management of hypothermia:
stop cooling action
mild: passive and active external warming
severe: warm IV fluids or Lavage, heated O2
* Cardiac monitoring is critical
66
Management of hyperthermia:
remove from heat, hydration, electrolyte replacement, cool packs, lukewarm bath
severe: cool lavage
67
FEVER management:
treat to relieve discomfort, be extremely careful to give correct dose of acetaminophen
*Evidence does not support using antipyretics to prevent febrile seizures
68
The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan?
- Cleansing the wound
| - Managing pain
69
The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant?
- Applying over-the-counter lotions to skin that is not broken
- Covering the client who complains of being cold with more blankets
- Placing a sterile gauze pad over broken skin to contain drainage
- Assisting the client with frequent turning to prevent pressure ulcers
70
The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments?
Oral steroids and
| Topical steroids
71
To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide?
- Wear sunglasses.
- Apply sunscreen 30 minutes prior to exposure.
- Consume fish oil and vitamin E.
72
A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions?
- Offer nutritional supplements and frequent snacks.
| - Turn the patient at least every 2 hours.
73
Which of the following should the nurse consider when having informed consent forms signed for surgery and procedures on children?
The risks and benefits of a procedure are part of the consent process.
74
The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include which of the following?
Tell the child procedures are never a form of punishment.
75
The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse she wants her mother with her “like before.” The most appropriate nursing action is to
grant her request.
76
Which of the following would be helpful word(s) to substitute for the word “shot” when working with a 4-year-old?
Medication under the skin
77
When should clear liquids be stopped before scheduled surgery?
Two hours before surgery
78
Which of the following is a potential cause of a postoperative decrease in blood pressure?
Vasodilating anesthetic agents
79
The nurse is caring for an unconscious 10-year-old child. Skin care should include which of the following?
Use a draw sheet to move the child in bed to reduce friction and shearing injuries.
80
An appropriate intervention to encourage food and fluid intake in a hospitalized child is which of the following?
Give high-quality foods and snacks whenever the child expresses hunger.
81
A 3-year-old child has a fever. Her mother calls the nurse reporting a fever of 38.8º C (102º F) even though the child had acetaminophen 2 hours ago. The nurse’s action should be based on which of the following?
Fevers such as this are common with viral illnesses.
82
The nurse wears gloves during a dressing change. When the gloves are removed, the nurse should do which of the following?
Wash hands thoroughly.
83
A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, the nurse should do which of the following?
Place the child in a side-lying position.
84
Which of the following is an important nursing intervention when performing a bladder catheterization on a young boy?
Insert 2% lidocaine lubricant into the urethra.
85
The nurse needs to do a heel stick on an ill neonate to obtain a blood sample. Which of the following is recommended to facilitate this?
Wrap the foot in a warm washcloth.
86
When giving liquid medication to a crying 10-month-old infant, which approach minimizes the possibility of aspiration?
Administer the medication with a syringe (without needle) placed along the side of the infant’s tongue.
87
When administering a gavage feeding to a school-age child, the nurse should do which of the following?
Position the child on the right side after administering the feeding.
88
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates
slow capillary refill
89
The nurse identifies which priority nursing invention for a patient with hyperthermia?
Removing excess clothing
90
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action?
Adjusts the bed to the Trendelenburg position
91
A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members?
core rewarming with warm fluids
92
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?
Increased pulse rate
93
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia?
Stupor
94
Infection is:
the invasion and multiplication of microorganisms in body tissues, which may be clinically unapparent or result in local cellular injury due to competitive metabolism, toxics, intracellular replication, or antigen-antibody response.
95
Categories of infection include:
bacterial infection, fungal infection, parasitic or protozoal infection, or fungal infection
96
Ways to categorize an infection include:
Location: Localized or systemic, Duration-acute or chronic, Source-where did the patient acquire the infection-hospital? community?
We also decide if it is a primary infection or a secondary one.
97
Endemic:
regularly found among particular people or in a certain area.
98
Epidemic:
a widespread occurrence of an infectious disease in a community at a particular time.
99
Pandemic
prevalent over a whole country or the world.
100
Risk factors for infection include:
| when you do an assessment for infection you take these things into consideration
age, low socioeconomic status, immunodeficiency,
commorbitidities,
environment, naive immunity
101
symptoms of susceptible host include:
cancer, medications, commorbitities, burns, injuries, immunocompromised, very young, very old, stress fatigue, overcrowding,poor nutritional status, naive immunity
102
Localized signs and symptoms include:
swelling, redness, pain, purulent exudate
103
Systemic infection signs and symptoms:
fever, chills, malaise,
Pathogen/site dependent
-diarrhea
-cough
104
Diagnostic tests include:
```
Laboratory tests
complete blood count(with WBC differential)
culture and sensitivity
C-reactive protein
Erythrocyte Sedimentation rate(ESR)
Serologic tests to detect specific antibodies or viruses
Radiographic studies:
X-rays
MRI
CT
PET and indium scans
```
105
Neutrophils
(40–80%)
106
Lymphocytes
20-40%
107
Monocytes
2-10%
108
Eosinophils
1-6%
109
Basophils
1-2%
110
Normal WBC count is about
4500-10,000
111
Bands
3-5%
112
Signs and symptoms of sepsis:
```
known infection plus: body temp over 101.3 or under 95
Heart rate over 90bpm
Hypotension
Respiratory rate of 20 or more breaths per minute
CO2 tension less than 32mm/Hg
need for mechanical ventilation
decreased urine output
WBC>12000/mm3 or <4000 or
Bands >10%
```
113
Assessment continued-history:
travel, potential exposures,immune status, treatments that could interfere with immunity,
cancer status, surgeries, contact with crowds, animal contact
114
Differences across the lifespan:
```
decreased resiliency and strength of mechanical barriers
decreased t-cell responsiveness
decreased suppressor t cells
decreased t-cell antibody responsiveness
decreased CD4, CD8 cells
Atrophy of thymus
comorbitities
nutritional deficiencies common
diminished febrile response
decrease physiological reserves
```
115
Primary preventions:
immunizations, optimize health/maintain defenses, nutrition, exercise, hygiene, stress, environment, water, food, air, sleep, take care of skin, crowding, zoonosis, sanitation
116
Secondary prevention:
Screening: most common with STIs, HIV,
Hep C
Environmental Screaning
117
Treatments of infection:
```
nutrition, hydration, maintain/improve breathing circulation, eradicate the infection
-antibiotics
-antivirals
-antifungals
-antiprotozoans
-prevent secondary infections
limit damage
-support immune function
-support healing
```
118
Standard precautions are used for:
all body fluids, secretions, excretions, except sweat, non intact skin, and mucous membranes may contain transmissible infectious agents
119
Transmission based precautions include:
contact precautions, droplet precautions, and airborne precautions
