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NURS 100 Fundamentals > Week 4 > Flashcards

Week 4 Flashcards

1
Q

What is the braden scale?

A

A mobility assessment

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2
Q

What does a higher score on the braden scale mean?

A

More mobile

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3
Q

What is stage 1 pressure ulcer?

A
  • Non-blanchable (skin does not change color after pressing down, stays red)
  • Lowered tissue perfusion
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4
Q

What is stage 2 pressure ulcer?

A

Partial skin loss

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5
Q

What is stage 3 pressure ulcer?

A

Full thickness skin loss down to ADIPOSE

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6
Q

What is stage 4 pressure ulcer?

A

Thickness skin loss exposing MUSCLE AND BONE

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7
Q

What procedure is done to remove eschar?

A

Debridement

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8
Q

Serous drainage

A

Clear, watery plasma

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9
Q

Sanguineous

A

Red, bloody

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10
Q

Serosanguineous

A

Light red to pink, blood tinged

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11
Q

Purulent drainage? What does it mean?

A

Yellow, thick with WBCs
- Infection

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12
Q

Purosanguineous

A

Pus and blood

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13
Q

Primary wound healing

A

-Wound is approximated/parallel
- Can stitch shut

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14
Q

Secondary Wound healing

A
  • Not approximated
  • Wound is left open to heal, we pack it with gauze
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15
Q

Delayed primary closure or tertiary wound healing

A

-Combination of primary and secondary
-Wound is left open for 5-10 days before it is closed with sutures

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16
Q

Dehiscence wound

A

Wound splits open

17
Q

Evisceration wound

A

Organs protrude out of wound

18
Q

Steps for enema?

A

1) Tube goes into rectum
2) Have patient lay in SIM’s position
3) Hang bag on IV pole 12 - 18 inches above rectum
4) They hold for 5 - 10 minutes, then can go to restroom

19
Q

What is a normal color of a stoma?

A

Red

20
Q

What is docusate sodium?

A
  • Stool softeners (for constipation)
21
Q

Pt. education for docusate sodium?

A
  • Takes 3-5 days to take effect
    -Take with glass of water
22
Q

What is bisacodyl?

A
  • A laxataive
23
Q

Pt. education for bisacodyl?

A
  • Do not give regularly because body will get used to it

NURS 100 Fundamentals (7 decks)

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