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Foundations > Test 2 > Flashcards

Test 2 Flashcards

1
Q

What is the first line of defense against infection?

A

Intact skin

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2
Q

What does regular bathing remove?

A

perspiration, bacteria, and oil from the skin

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3
Q

What does regular bathing do?

A

Increases circulation, maintaines muscle and joint mobility, promotes relaxation, provides a sense of well-being and comfort, time for assessment and interaction

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4
Q

What is self-care?

A

The ability to independently perform functions of: bathing, dressing, feeding, and toileting.

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5
Q

What does self-care independence enhance?

A

health and emotional well-being, dignity

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6
Q

Washing principles

A

Wash from clean to dirty, maintain privacy and dignity, incorporate patient preferences and values. Distal to proximal motion increases venous return

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7
Q

Evidence Based Practice: Basin Bath

A

Basin bath is associated with increase in infection areas

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8
Q

Evidence Based Practice: Peri-Care

A

Peri-Care is often omitted; associated with UTI

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9
Q

EVP: what do you do with an unconscious pt for oral care?

A

Turn them to their side

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10
Q

Oral Care

A

Helps maintain strong and healthy teeth and gums, prevent tooth loss, increase saliva, taste, comfort, prevent pneumonia

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11
Q

Types of baths

A

tub, shower, sit-down shower. bed bath (partial/complete), bag bath or towel bath, partial bath (sink bath)

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12
Q

What are some things to consider when bathing the patient?

A

consider energy, ability of pt, choose bath type that enhances independence while providing benefits. Provide supplies, assist as needed

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13
Q

In what situation would you give a partial bath?

A

If patient was already bath for the day but was incontinent

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14
Q

Foot Care

A

Disease state, ROM, and perfusion affect needs and abilities related to foot care

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15
Q

Foot Care assessment and patient aducation

A

Assess for temperature, circulation, sensation, and wounds. Educate- daily VSE (visual surveillance of extremities), good shoes, report changes
*Pat pts feet when towel drying, don’t rub

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16
Q

Shaving

A

Shave in direction of hair growth. Electric shaver if in anticoagulant treatment

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17
Q

Glasses & contacts/ Hearing aids

A

clean glasses daily/ check battery, clean per policy, replace

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18
Q

Feeding: Dysphagia

A

Difficulty swallowing. Assess patients for dysphagia before feeding. Watch them closely and have assistive devices. Thickened liquids are easier to swallow. Separate flavors, don’t mix them

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19
Q

Toileting

A

Assess level and type of assistance needed. Assist to bathroom. Provide privacy while maintaining safety, provide hand hygiene for patient, assess need for assistance with peri-care

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20
Q

When are linens changed?

A

In conjunction with bathing

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21
Q

What is a pressure ulcer?

A

A localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination w/shear and/or friction

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22
Q

Stage 1 pressure ulcer

A

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence

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23
Q

Stage 2 pressure ulcer

A

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, with slough

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24
Q

Stage 3 pressure ulcer

A

Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed.

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25
Q

Stage 4 pressure ulcer

A

Full-thickness tissue loss with exposed bone, tendon, or muscle.

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26
Q

Unstageable

A

Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. True depth of wound cannot be assessed until slough/eschar is removed

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27
Q

Risks for pressure ulcers

A

Immobility (unable to move independently), Impaired Perception (numbness, paralysis), Altered LOC (confused-perceive pain/pressure but cant communicate/relieve pressure, coma: no perception plus immobility

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28
Q

Shearing

A

Skeleton, muscle slide one way, skin stays or moves the other way

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29
Q

Friction

A

Top layers of skin, sliding across coarse linens, seats, position changes w/o lifts

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30
Q

Wound Healing: Primary Intention (surgical wound)

A

Clean edges, approximated (closed), low risk of infection, quick healing, fine scar

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31
Q

Secondary Intention

A

Trauma, ulcer, dehisced wound. Open- wound healing, filled by scar tissue, granulation over time-deep scar. Slow healing= increased risk for infection

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32
Q

Wound Dressings

A

Protection (against contamination, pain from air), Homeostasis (pressure, clot, edges), Increased Healing (absorb drainage, debride depending on type), Moist environment

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33
Q

Which dressing?

A

Depends on wound assessment, purpose. Purpose is to provide the right environment to enhance and promote wound healing

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34
Q

What do dressings do?

A

Moist healing environment stimulates cell proliferation and encourages epithelial cells to migrate. Provide barrier against bacteria and absorb fluid. Decrease or eliminate pain

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35
Q

Assessment of wound care

A

Is the wound copiously draining? Is it dry? Does it need added moisture? Does it need debridement? Is it infected?

36
Q

Dehiscence

A

Wound has opened up. Most often 4-5 days post op

37
Q

Types of dressings and uses

A

Gauze- draining wounds, necrotic wounds, those requiring debridement or packing, wounds with tunnels, tracts, or dead space, surgical incisions, burns, dermal ulcers, and pressure ulcers. Some gauze may be integrated with antimicrobial (IV sites, and full thickness wounds are examples)

38
Q

Transparent films

A

Lets oxygen pass through to the wound and moisture vapor escape. Not always absorbent

39
Q

When would transparent films be used?

A

Partial-thickness wounds, stage 1 and 2 pressure ulcers, superficial burns, donor sites, as a secondary dressing

40
Q

Foam

A

Nonadherent and nonocclusive. Hydrophillic, polyurethane, or film coated gel

41
Q

When would foam be indicated?

A

Stage 2 and 4 pressure ulcers, partial and full thickness wounds with minimal to heavy drainage, surgical wounds, dermal ulcers, under compression wraps

42
Q

Composite dressings

A

Combinations of two or more different products in one. Bacterial barrier, absorptive layer, foam, hydrocolloid, or hydrogel. Semi-adherent or nonadherent

43
Q

When are composite dressings indicated?

A

Partial and full-thickness wounds, minimally to heavily draining wounds, dermal ulcers, and surgical incisions

44
Q

Heat and Cold therapy: Heat

A

Increases blood flow- vasodilation. Increases oxygen and nutrients to infected area

45
Q

Heat and Cold therapy: Cold

A

Vasoconstriction- decreases blood flow.

46
Q

Wound Care

A

Least to most contaminated

47
Q

What is increased to promote healing?

A

Increase protein, increase vitamin C, increase calories for healing

48
Q

What does the integumentary system consist of?

A

Skin, hair, nails

49
Q

Skin

A

The largest organ of the body

50
Q

How does the skin protect?

A

Regulates body temperature, maintains fluid and electrolyte balance, can repel micoorganisms, can alarm the body that something is wrong, many sense receptors to allow the use of touch

51
Q

Epidermis

A

Lacks its own blood supply (Avascular), Keratin makes the outer layer (Stratum corneum) waterproof

52
Q

Vitamin D

A

Is activated in the epidermis by UV light, then distributed to the intestines where it promotes the uptake of calcium

53
Q

Melanocytes

A

Give color to the skin. Person of color has bigger melanocytes, not more. Patches of melanin make freckles, birth marks and age spots

54
Q

Hair

A

Hair follicles are located in the dermis, but are extended from epidermal layer. Hair growth occurs in cycles. Hair color is genetically determined by the persons melanin production. Permaneant baldness (female and male) is genetic

55
Q

Nail Assessment

A

Assess for color, shape, thickness, texture and any lesions

56
Q

Nail Color

A

Depends on nail thickness, # of RBCs, arterial blood flow and pigment deposits

57
Q

Nail thickness and shape

A

Nail thickness increases with aging. Shape: check for clubbing, splitting, separation or increased thickness. Blanch the nail beds

58
Q

Skin Assessment

A

History (ask about OTCs, herbal meds, allergies, nutritional status, current health problems), color, vascularity and moisture

59
Q

Skin: Bacterial Infections- folliculitis, furuncle, cellulitis

A

Folliculitis- isolated pustules, may have hair growing from it. Furuncle- pus filled lesions. Cellutlitis- darker with red tone

60
Q

Skin: Viral Infections- Herpes Simplex and Zoster

A

Simplex- patches, vesicles evolve to postules, which rupture, weep and crust
Zoster- Similar to simplex but present in a iine, along a cranial or spinal nerve

61
Q

Skin: Fungal Infections-Candidiases

A

Skinfolds, reddened, macular, oral: whitish plaques

62
Q

Wound Healing: First Intention

A

A laceration or incisonal wound, edges are brought together with skin approximated and held in place. Closing the wound immediately helps the connective tissue repair

63
Q

Wound Healing: Second Intention

A

Deeper injuries with tissue loss (pressure ulcer) have a cavity open wound that has to heal from gradual filling up the wound with connective tissue

64
Q

Wound Healing- Third Intention

A

Delaying closing the wound, waiting for infection or erythema to decrease and then closing it by primary intention.

65
Q

Wound Exudate: Serosanguinous exudate

A

Blood tinged fluid consisting of serum and RBCs

66
Q

Wound Exudate: Purulent exudate

A

Creamy yellow, beige or green pus, usually have an odor

67
Q

Contact Dermatitis

A

An acute or chronic rash caused by direct contact of an irritant or allergen

68
Q

Atopic Dermatitis

A

Chronic rash that occurs with respiratory allergies and atopic skin disease

69
Q

Psoriasis

A

Lifelong, no cure, may be genetic. An auto immune reaction, scaling disorder with dermal inflammation underneath

70
Q

Benign Tumors: Cysts

A

Firm, flesh colored nodules, moves and indents on palpation

71
Q

Benign Tumors: Nevus

A

Well defined borders, uniform in color

72
Q

Benign Tumors: Seborrheic Keratosis

A

Most common in older people. Brown, tan or black, rough wartlike texture

73
Q

Benign Tumors: Keloids

A

Overgrowth of a scar with excessive collagen. More common in AA

74
Q

Skin Cancer: Squamous Cell Carcinoma

A

Cancer of the epidermis

75
Q

Skin Cancer: Basal Cell Carcinoma

A

Come from the basal cell layer of the epidermis

76
Q

Skin Cancer: Melanoma

A

Pigmented cancer cells that come from the melanin producing epidermal cells. Highly metastatic

77
Q

Environmental Safety

A

A safe environment includes- meeting basic needs, reducing physical hazards, reducing transmission of pathogens, maintaining sanitation, and controlling pollution

78
Q

Incident Report

A

Required for any accident/injury in healthcare setting. Not part of a medical record. Includes: what happened, patient assessment, interventions provided

79
Q

Restraint Use

A

Must have a physician order (may apply in emergency, then get order), Order must be rewritten every 24 hours, Restraint policies are specific to health care setting, documentation every 2 hours

80
Q

Sub Q angle, Intradermal angle, Intramuscular angle

A

45, 15, 90

81
Q

Therapeutic effect

A

Expected or predictable

82
Q

Side effect

A

Predictable and often unavoidable

83
Q

Adverse effect

A

Unintended, undesirable, and often unpredictable severe response

84
Q

Toxic effect

A

Medication accumulates in the blood stream

85
Q

Isisyncratic reaction

A

over or under to a medication

86
Q

Allergic Reaction

A

Unpredictable response to a medication

87
Q

Medication Interactions: Synergistic Effects

A

A synergistic effect occurs when the combined effect of two medications is greater than the effect of the medications given separately

Foundations (4 decks)

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