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Exam 4 PN Class #89

Ch 15-18

What Kinds of Routine care are generally used? 1. Early Morning (a.m.) Care 2. Morning (a.m.) Care 3. Afternoon (p.m.) Care 4. Bedtime (h.s.) Care
What is Hygiene? Used to describe keeping oneself clean and well groomed.
What are Activities of Daily Living (ADL's)? Activities that prepare us for our day, including but not limited to: bathing, washing and styling hair, brushing and flossing teeth, dressing, and shaving.
What are the major benefits of bathing? 1. Keeps skin clean 2. Maintains fresh scent 3. Helps prevent infection**
What is Maceration? Softened skin due to continuous exposure to moisture. *Think pruney skin after staying in a bath for an extended period of time.
What is Excoriation? Scrapes on the skin, may be due to scratching or due to care.
What is the method of washing during a Bed Bath? Always wash distally to proximaly: Hand up arm or foot up the leg to increase circulation, specifically venous return.
What is Venous Return? Blood return from the extremities back to the heart.
What is Mottling? Purplish blotching of the skin when circulation slows greatly.
What are the main benefits of bathing? 1. Cleanses the skin 2. Opportunity for skin assessment 3. Increases circulation 4. Increases sensation 5. Provides comfort and relaxation 6. Improves self-esteem 7. Helps establish nurse-patient relationship
What is the main function of head hair? Keeps the head from losing body heat.
What are the main functions of nails? Protect the fingertips and toes.
What is the main function of Sebaceous glands? To secrete Sebum (oil) onto skin or hair for lubrication, This helps prevent skin breakdown which could contribute to pathogen entry.
What causes Body Odor? The breakdown of skin sweat by bacteria.
When planning personal care what must ALWAYS be taken into consideration? The patient's personal preferences: Timing, Culture, Abilities, and how much Assistance they need.
What is Self-care? Patients who are able to perform ADL's without assistance.
What is Assisted-care? Patients who need some assistance from a caregiver: Ex. help washing hard to reach areas during bathing.
What is Total-care? Patients are able to do hardly anything or nothing for themselves.
What are the 8 types of baths mentioned in the book? 1. Complete bed bath 2. Assisted or help bath 3. Partial bath 4. Tub bath 5. Shower 6, Therapeutic bath 7. Towel or blanket bath 8. Bag Bath
What is a bath blanket? A large lightweight flannel blanket, used during bathing to prevent exposure of the patient.
What are the 8 things to remember while giving a bed bath? 1, Cover patient. 2. Washcloth around hand. 3. Wash from cleanest to dirtiest. 4. Wash extremities distal to proximal. 5. Wash body parts farther from you first. 6. Change water when it is dirty. 7. Perform perineal care. 8. Have patients help when able.
What are Leukoplakia? White patches on the tongue or oral mucosa, can be precancerous lesions.
When performing oral care for an unconscious patient, what is not recommended for cleaning? Using Lemon-glycerin swabs is not recommended, these cause additional drying of the oral mucosa.
What is Special Mouth Care? Oral care for patients whos conditions result in a need for more frequent care and who need assistance for this care.
What can you do to perform mouth care on someone who exhibits the natural "jaw bite" reflex? Turn the cleaning tool sideways down the side of the mouth, or use a padded tongue blade to keep the mouth open during care.
What should you avoid when cleaning dentures that include metal parts? Avoid using denture tablets, instead, place them in water ALONE overnight.
When shaving a patient who is taking anticoagulant medication, what type of razor should you use? An electric razor, nothing with a blade. This is due to the risk for getting cut and the blood having trouble clotting.
When giving nail care to a diabetic patient, what is the safest way to shorten the nails? Using a file instead of clippers. This reduces the risk of them getting cut and having trouble healing.
What are lesions? Open sores, often can be found on a patients head.
What is Tinea Capitus? Ringworm: a fungal infection that can affect any area of the body, showing up as round reddish patches, and spread from one person to another.
What is Seborrhea? Often shows up as thick, oily scales on the scalp, and represents an overproduction of sebum.
What are Lice and Nits? Lice are tiny parasites that live on a persons scalp, and Nits are their tiny white eggs.
What is the first step to ANY procedure? Wash yo' hands, and put on gloves!
What are 2 things to remember when washing a patients hair? 1. Tilt head back when rinsing and washing to keep soap and water out of their eyes. 2. Always test the water temperature on your own skin (not gloved hands) before using it on a patient.
How should you clean a patient's glasses? With warm water and a soft cloth. Avoid using paper towels or tissues cause they can scratch the lenses.
When removing contacts what is one thing to remember when putting them in the case? Make sure they are placed on the corresponding eyes container. Right eye lens in R side, and left eye lens in L side.
What is an Ocular Prosthesis? An Artificial Eye (often glass).
What must some newer hearing aids be kept away from? Moisture, including being kept in a special moisture-absorbing medium when not in use.
What are 4 things to be aware of to improve the patient's environment? 1. Noise 2. Odors 3.Clutter 4. Equipment
What are the 3 most common ways to keep an unoccupied bed in a clinical setting? 1. Open bed 2. Closed bed 3, Surgical bed- linens completely to one side
What must be in use anytime you are rolling a patient in bed? The opposite side bedrail(s), to keep the patient from rolling out.
What is a Draw Sheet? Used to protect the bottom sheet from minor soiling and to help lift a turn heavier patients.
What is a Mitered Corner? A slanted corner, used at the bottom of clinical beds.
What is Footdrop? Where the foot remains in a permanent state of plantar flexion (pointed down to the floor). **This impairs he patient's ability to ever walk again.
What type of water can cause damage to dentures? Hot water. Always use cool water to clean dentures.
What causes immobility? Lack of activity and movement.
What are common complications of immobility? 1.Blood clots 2.Pneumonia 3. Bone demineralization 4. Kidney stones 5. Constipation (slowed peristalsis) 6. Pressure injuries 7. Urinary retention 8. Depression
What are Contractures? Shortening and tightening of the muscles due to disuse.
What is Muscle Atrophy? Muscle decreases in size, tone, and strength as a result of disuse. **Muscle structure and function can change as early as 4-6 days after immobility.
What is Osteoporosis? Condition that occurs due to loss of bone minerals; leads to an increased risk of skeletal fractures. **Demineralization can occur as early as 2-3 days from the onset of immobility.
What is the Supine Position? Encourages proper body alignment, lying on the spine/back with arms to the side, ankles and toes upwards to 90 degrees.
What is Dorsiflexion? Ankles and toes upward to 90 degrees.
What is Plantarflexion? When the toes are allowed to fall toward the foot.
What is permanent plantarflexion? Footdrop. Causes permanent damage to the patient's mobility.
What is a Trochanter Roll? A rolled towel, or cylindrical device placed snugly against the lateral aspect of the patient's thigh to prevent the leg from rotating outward.
What effects does bedrest have on a patient's cardiovascular system? 1. 50% reduction of bloodflow to the legs 2. contributes to Venous Stasis, or pooling of blood in the veins of the lower legs
What is an Embolus? A traveling blood clot.
What are the 3 most Detrimental types of Embolus? 1. Lung clot: pulmonary embolus (PE) 2. Heart clot: heart attack, Myocardial Infarction (MI) 3. Brain clot: stroke, cerebral vascular accident (CVA)
What is Orthostatic Hypotension? AKA postural hypotension: is decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position.
What is Syncope? Fainting
Why is it extremely important that you, the nurse remain with the patient the first time they get out of bed? If dizziness or syncope occurs, you will be there to prevent patient injury.
What are 3 nursing interventions used to prevent respiratory and circulatory complications of immobility? 1. Turning 2. Deep breathing 3. Coughing
What is Peristalsis? Natural movement of the intestines.
What is required if the patient has not had a bowel movement (BM) within 3 days? Administer a laxative or enema, according to health care providers orders.
What does immobility contribute to getting a UTI? Urine can pool in the renal pelvis of the kidney.
Not being able to sit upright can contribute to what issue in the urinary system? Urinary retention
What is the rule for encouraging fluids? **Encourage intake of 8 ounces or more every 2 hours, unless the patient is on a fluid restriction.
What is a Pressure injury? AKA skin breakdown or** Decubitus Ulcer: when constant pressure to one area of the body causes reduced or stopped blood flow, followed by skin or tissue death.
What is Shearing? Occurs when the skin layer is pulled accross muscle and bone in one direction and a bedsheet pulls the skin surface in the opposite direction.
What are 5 common support surfaces and specialty beds? 1. Mattress overlays 2. Specialized mattresses 3. Air-fluidizing bed 4. Combination low-air-loss and lateral rotation bed 5. Continuous lateral-rotation bed
What are 4 common Psychological effects of immobility? 1. Depression 2. Anxiety 3. Hostility 4. Fear
What can decreased sensory stimulation cause in patients? Patients may experience auditory or visual hallucinations.
What must a nurse remember to maintain safe patient handling? 1. Always lock wheels of beds or chairs 2. Elevate bed to a comfortable height 3.After care, place the bed in the lowest position
What is the Position of Function? Means placing the extremities in alignment to maintain the potential for their use and movement.
What is the Orthopneic position? Sitting upright with head of bed elevated 90 degrees, or on side of the bed with feet flat on floor, patient leaning slightly forward with arms raised and elbows flexed, supported by an over bed table.
What is the Orthopneic position used for? **Most often used to improve severe respiratory distress. Ex. a patient who has COPD
What is a Trapeze Bar? A triangular device suspended above the patient in an over bed frame, allows patient to help lift for care.
What is a Logroll? The patient is turned in the same way as a log would be rolled, everything straight and moved together.
What is the correct number of people required to safely complete a Logroll? 3 staff members
What are the 5 most common ways to transfer patients? 1. Transfer belt- AKA gait belt around waist 2. Slide sheets- nylon 3. Slide Boards- to or from stretcher 4. Sit-to-stand lifts- partial weight bearing 5. Lifts- AKA hoyer lifts, no weight bearing
What is Fowler's position? In bed, head elevation level varies from 45-90 degrees, legs also elevated to a slightly bent position: semi-sitting position.
What qualifies a patient as being Obese? They are more than 30% overweight.
What are the 6 Vital Signs? Five Objective: 1. Temperature (T) 2. Pulse (P) 3. Respirations (R) 4. Blood Pressure (BP) 5. Oxygen Saturation (Sp02) One Subjective: 6. Pain
If you cannot tell what exactly is wrong with a patient, what should you do? Reassess vital signs and go with your "gut feeling".
What are 2 things that constitute frequent vital sign checks? 1. At least every 4 hours whenever one or more vital signs are abnormal. 2. Every 5-15 mins when the patient's condition is unstable, such as after delivery, surgery, or trauma. (often 15 min checks)
What is Body Temperature? Difference between amount of body heat the body produces and the amount of heat gained or lost to the external environment.
What is Core Temperature? The most important measurement to maintain as it determines the conditions in which the brain, heart, and other internal organs survive.
What is Thermogenesis? The production of heat. Heat is a byproduct of metabolism.
What is the Basal Metabolic Rate? AKA Resting metabolic rate. The amount of heat produced by the body when at total rest.
What organ creates 15% to 20% body heat in the resting state? The Liver.
What is the main part of the brain that controls body temperature regulation (thermoregulation)? The Hypothalamus.
What are 8 factors that affect body temperature? 1. Environment 2. Time of Day 3. Gender 4. Exercise 5. Medications 6. Food intake 7. Stress 8. Illness
What are the 6 main routs to take a temperature? 1. Oral 2. Axillary 3. Tympanic 4. Skin 5. Temporal artery 6. Rectal
Where must the thermometer be placed when taking an Oral Temperature? The sublingual pocket under the tongue, with the tongue holding it in place.
When taking a Rectal Temperature, what is the correct length of insertion to prevent intestinal perforation? 1 to 1.5 inches for an Adult. 1 inch for a child. 1/2 inch for an infant.
What is Vasodilation? When blood vessels expand (uncoil) and blood travels to extremities.
What is Vasoconstriction? When blood vessels get smaller (recoil) and blood travels back to the vital oragans.
What is the normal range for temperature? 97 -99.6 degrees F. The average Temp is 98.6 degrees F.
What is Febrile? Term used to indicate the state of having a fever.
What is Afebrile? Term used to indicate the state of being without fever.
At what temperature do body cells begin to suffer damage? 105 degrees F
What is an Antipyretic? **Fever reducing medications: such as Salicylates (Aspirin), Acetaminophen (Tylenol) and Ibuprofen.
Where is the primary/central pulse site and where is it located? Apical pulse, located over the apex of the heart where the contraction is the strongest.
What is a Pulse Deficit? When the radial pulse is slower than the apical pulse.
What is the central most accurate pulse site? The Apical pulse site, located at the apex of the heart.
What are the 8 peripheral pulse sites? 1. Temporal 2. Carotid 3. Brachial 4. Radial 5. Femoral 6. Popliteal 7.Posterior Tibialis 8. Dorsalis Pedis
During Pulse Assessment what 3 characteristics will you check? 1. Rate 2. Rhythm 3. Volume (Strength)
What is Bradycardia? A pulse less than 60 bpm.
What is Tachycardia? A pulse greater than 100 bpm.
How does Age affect pulse rate? The older you get, the slower your pulse tends to be.
When the blood fluid wave is reaching the pulse points, what is it doing? Purfusing
What are the 5 characteristics required to assess Respirations? 1.Rate per minute 2. Depth 3. Rhythm 4. Pattern 5. Respiratory effort
How long are respirations to be assessed? For a full minute.
What is the normal rate for Respirations per minute? 12-20 breaths per minute (bpm)
What are Eupnea? Normal breathing
What is Badypnea? Respiratory rate below 12 respirations per minute.
What is Tachypnea? When the repiratory rate is above 20 respirations per minute.
What is the Tidal Volume? The average amount of air inhaled in one breath: between 300 and 500 mL.
What is Repiratory Effort? The amount of work required to breath.
What is Dyspnea? Labored or difficulty breathing.
What is Hypoxemia? Decreased oxygen level in the blood.
What is Orthopnia? Difficulty breathing unless sitting in an upright position.
What is Stridor? An audible, high-pitched crowing sound that results from partial obstruction of the airways.
What is Kussmal's Respirations? Respirations are increased in rate and depth, with long, strong, blowing or grunting exhalations. Consistent pattern. **Associated with Diabetic Ketoacidosis and Renal Failure.
What are the 4 circulatory qualities of Blood Pressure (BP)? 1. Strength of heart contraction 2. Blood Viscosity- thickness 3. Blood Volume 4. Peripheral Vascular Resistance- elastic recoil
What is Stroke Volume? Amount of blood ejected from the heart in one pump.
What is Cardiac Output? Volume of blood pumped from the heart in a full minute.
What is Arteriosclerosis? Hardening of the arteries.
What are the 11 factors affecting blood pressure? 1.Age 2. Race 3. Exertion or exercise 4. Circadian Rhythm 5. Anxiety, stress and emotions 6. Medications 7.Nicotine and Caffeine 8. Obesity 9. Level of Hydration 10. Hemorrhage 11. Increased Inracranial Pressure
What is Systolic Pressure? Measurement of the force exerted by the blood against the walls of arteries during contraction (Work) of heart ventricles. Written as the top number on a BP reading.
What is Diastolic Pressure? Measurement of the pressure exerted by the blood on the artery walls while the heart ventricles are not contracting (Rest). Written as the bottom number on a BP reading,
What is Pulse Pressure? Measurement of the difference between the systolic and diastolic pressures (subtract the smaller from the larger number).
What is the normal range for BP? Systolic: 120 or below Diastolic: Less than 80
What is the normal range for a Sp02 reading? 96%-100%: anything under 90% must be reported immediately and reqiures additional O2 measures.
What is Acute pain? Pain that has a sudden onset, may have severe symptoms, and runs a shorter course. ** Does impact Vital Signs!
What is Chronic pain? Pain that has a longer duration or is ongoing with little change or progression. Does not affect Vital Signs.
How is the Wong-Baker FACES Pain Rating Scale used? Series of 5 faces with increased emotional/physical distress. numbered 0-10, 0 being no hurt to 10 being Hurts Worst.
What is Vasodilation? Increase of the size of the cavity or space inside the blood vessel, allowing for increased oxygen-rich blood to the site.
What are Interstitial Spaces? The spaces between cells.
What is Phlebitis? Inflammation of the vein due to IV therapy.
What are the indications for heat therapy to be used? 1. Relaxation of muscle spasms 2. Pain relief 3. Support the healing process 4. Reduction of edema once it's stabilized 5. Elevation of body temperature
What is Phagocytosis? Cells that surround, engulf, and digest the offending microorganisms and debris in the cells and exudate, which helps to prevent infection.
What are White Blood Cells? Cells that help prevent infection, phagocytes- they eat bad microorganisms.
What is Metabolism? Chemical and physical process required to build and maintain body tissues.
What is Edema? Swelling that occurs when excessive fluid leaves the vascular system and remains in the interstitial spaces.
What is Hypothermia? A condition that occurs when an individual's core body temperature drops below 95 degrees F.
What are Contraindications? Situations when a certain treatment should NOT be used.
What are common contraindications of heat therapy? Suspected appendicitis, bleeding wound or injury, newly injured joints, Large areas of the body in certain cardiac patients.
What is the recommended amount of time to leave a heating pack on a patient? 20-30 mins
What can happen when a heating pack is left on for 45 mins or more? Can cause constriction of vessels instead of dilation: AKA rebound phenomenon.
What is always important to remember when using a heat or cold therapy pack? Always place a cloth between the pack and the skin so there is no direct contact.
Created by: merelisen3