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Fundamentals Final Chapters

Peripheral Neurovascular assessment The formal term for evaluating the status of an extremety encased in a bandage or cast
Roller Bandages All Cotton Elastin (ACE) & Kerlix
All Cotton Elastic (ACE) Can be wrapped around a limb for support or to hold a dressing on an extremety or the trunk; Can be used to exert pressure over a bleeding point
Kerlix Used to hold dressings in place or to apply pressure; stretchy gauze on a long roll
Stretch Net Bandages Tube Gauze; A net or mesh type material that is very stretchy. used to hold a wound dressing in place and are used in first aid and burn care
Antiembolism Stockings (TED) Used post operative, elastic stockings that cover foot, not the toes, and the leg up to knee or mid thigh. that help ensure adequate return circulation to the heart and may prevent blood clots
Pneumatic Compression Device (PCD) or intermittent sequential compression device (iscd) Provides alternating pressure to the legs, used for surgery patients or clients with circulatory disorders
Binders A wide flat piece of fabric that is applied to support a specific body part or to hold a dressing in place
T-Binder Rarely used today; Gets name from its shape. Used to hold rectal or perineal dressings in place
Abdominal Binder A wide flat piece of fabric that is secured around the trunk of the body to support the abdomen or dressings on the abdomen
Tape Hypoallergenic; used to hold a clients dressing in place
Maceration Skin softening and breakdown due to moisture accumulation and lack of circulation
Montgomery Straps Allows the dressing to be changed without having to remove tape from the clients skin with each change
If the client complains of pain or itching while a bandage is in place, what could this be a sign of? An allergic reaction to tape; many people are allergic to tape
Aquathermia pad produces dry heat to treat muscle sprains and mild inflammations and for pain relief
Sitz Bath To provide moist heat to the pelvic or perineal and perianal area. Allows for warm water to flow freely over area
Tepid Sponge Bath A bath with water below body temperatyre, usually in the range 80 - 95 degrees; first effect of water is blood vessel constriction
Vasoconstriction Shrinkage of blood vessels caused by cold, thus decreasing the blood flow to an area
Vasodilation Enlargement of blood vessels caused by heat thus increasing the amount of blood flow to an area.
Heat Can: Reduce pain, stiffness, achyness, assist in wound healing, reduce inflammation, make a chilly client more comfortable, raise the body temp and promote drainage
Warm Soaks Can: Improve circulation, increase blood supply to an infected area, assist in break down of infected tissue, Apply meds, clean draining wounds and loosen scabs and crusts from encrusted wounds
Cold Can: Slow or stop bleeding, slow bacterial activity, relieve some pain, reduce swelling, prevent peristalsis, relieve pain in engorged breast, control pain and fluid loss in initial treatment of burns and diminish muscle contraction and spasm
What are the 5 P's of neurovascular function? Pulse, Pallor, Paresthesia, paralysis and pain
When you use the SD(Sequential Compression Device) what else will you eed to use? The TED (antiembolism) stockings
How often do you need to take the TED's off? Every 8 hours
What are the different types of heat? Heating pad, heat lamp; the moist are: Hot Soaks, Warm compresses and the sitz bath
What are the different types o cold? Ice pack, Hypothermia blanket, cold compress and tepid bath
What are two things to watch for when applying cold to a client? Frostbite and Hypothermia
How do you prevent injury when applying heat? Use a barrier between the client and the source of heat and keep a close eye on them
What is an abrasion? When the skin is rubbed off
What is sloughing? Dead skin that comes to the surface
What is a decubitus ulcer? A bed sore
What is drainage? A liquid coming out of a wound
What is a suture? Stitches
What is eschar? Crust of dead black tissue
What is exudate? Drainage with puss in it
What is a wound? An abnormal opening of the skin
What is a shear? A tear to the skin where the top layer seperates from the layer below
What is a laceration? A cut with rough edges
What is friction? When two things rub togetherand it rubs skin cells off
What is a pressure ulcer? A sore that was caused by constant pressure to an area
What is maceration and how is it caused? Skin breakdown and the cause is wetness of the area
What is a puncture? A hole that should not be there.
What is a clear/yellowish drainage called? Serous Drainage
What is a clear/yellow drainage mixed with blood called? serosanguinous drainage
What is plain blood drainage called? Sanguinous Drainage
What is an are of the body where the bone protrudes or sticks out, ie your elbow or ankle Bony Prominence
What is a clear/yellowish drainage called? Serous Drainage
What is a clear/yellow drainage mixed with blood called? serosanguinous drainage
What is plain blood drainage called? Sanguinous Drainage
What is an are of the body where the bone protrudes or sticks out, ie your elbow or ankle Bony Prominence
What are the causes of skin breakdown? Unrelieved pessure and/or moisture, poor nutrition and/or hydration, impaired mental status and/or immune system, fragile skin and cancer
If we notice a red spot on a clients leg when we roll them over, should we massage immediately to stat circulation? No this could cause more skin breakdown
How often do e turn a patient? At least every two hours
How do we know if a wound is becoming infected? Redness, swelling, heat, painful and loss of function that persists
What is the Braden scale and what does it measure? The Braden Scale measures a persons risk for skin breakdown.
What are the highest risk body sites for skin breakdown? rim of ear, shoulder, elbow, knee, heel, shoulder, perineam, side of head
How are ice bags applied to an injury and for how long? Ice bags are placed on an injury usually for 15 - 20 minutes at a time
What is a hypothermic blanket and how is it used? A plastic mattress pad through which vry cold water flows through. It is used to decrease body temperature, often used in surgery to slow body processes.
How do you know a hypothermmia blanket is working? You monitor the clients temperature to seethat it is lower
What do you watch for when using this blanket? Watch to be sure the temp does not dip too low.
What is a DNR? A "do not resuscitate" order.
What is a DNI? A "Do Not Intubate" order.
What is a DNH? A "Do Not Hospitalize" order
What are the signs of approaching death? Failing Circulation, Failing senses, Change in respirations, One Last "Good Day" and they might tell you goodbye
What are the steps of post mortem care? Pronouncement (RN/MD, follow policy) utopsy(Y or N), Handle the Family, Prepare the body for the family (remove tubes, straighten and clean up, Gather personal items for family), Call LOPA, Bag for the morgue or prep for funeral home, ask questions
Created by: 1078380780