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Exam 3
Skills 1
| Question | Answer |
|---|---|
| Assessment findings to discontinue ambulation | sudden facial pallor; "I'm feeling funny"; HR or RR significantly exceeds baseline; changes in vital signs; dyspnea, chest pain, dizziness |
| Assisted fall procedure | stay close to pt, use gait belt, secure hands on both sides of gait belt, put chest to pts back, place foot between pt's feet, use legs to control fall, let pt slide down leg, protect pt's head, check for injuries, document fall, reassess fall risk |
| active ROM exercises | pt moves each joint of body; maintain or increase muscle strength and endurance |
| Passive ROM exercises | another person moves each joint of pt; no value in maintaining muscle group strength; maintains joint flexibility; never force, always support |
| Fowlers position | natural sitting/laying position w/ HOB at 45-60 degrees |
| high fowlers | HOB at 90 degrees |
| semi-fowlers | HOB less than 30 degrees |
| supine | lie body flat, HOB at 0 degrees; can cause decrease in SPO2 in obese pts |
| Side-lying/lateral | 0 degrees but body is turned; used when pts need Q2H turns |
| Sims position | pt on stomach w/ leg up and pillow under thigh; most comfortable for pregnant women; stomach pains; unconscious client to promote drainage from mouth; paralyzed pt to reduce pressure over sacrum and hip |
| Prone position | flat on stomach w/ head turned to one side; not used for rest; could be used in surgery; promotes drainage from mouth; only used when pts back is correctly aligned and hort period of time |
| Orthopneic (tripod) position | sitting position where pt leans slightly forward w/ arms propped; used when experiencing SOB; decreases work necessary to breath and allows greater chest expansion; increases ability to use accessory muscles |
| Stage 1 pressure injury | intact skin with nonblanchable redness |
| Stage 2 pressure injury | partial-thickness skin loss involving epidermis, dermis, or both |
| Stage 3 pressure injury | Full-thickness tissue loss with visible fat |
| Stage 4 pressure injury | Full-thickness tissue loss with exposed bone, muscle, or tendon |
| Risk factors for PI | friction, shearing, immobility, inadequate nutrition, fecal/urinary incontinence, decreased mental status, diminished sensation, excessive body heat |
| Measuring PIs | draw the shape and describe it, measure the head-to-toe length, side-to-side width, and depth---use the greatest measurement for length, width, and depth |
| Documenting PIs | note the location of the wound by describing it in relation to the nearest anatomic landmark such as bony prominences. Document the size of the wound. Document concerns or changes from previous assessment |
| Incision | cutting or sharp instrument, wound edges well approximated and aligned, surrounding tissue undamaged, least likely to become infected, purposeful |
| Contusion | Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma |
| Abrasion | Friction; rubbing or scraping epidermal layers of skin; top layer of skin scraped away; dirt and germs often embedded and can become infected |
| Laceration | Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, not purposeful, often with loose flaps of skin and tissue; frequently contaminated with dirt or other material ground into the wound and likely to become infected |
| Puncture | blunt or sharp instrument puncturing the skin; intentional or accidental; consider penetrating object when considering infection probability |
| Penetrating | Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues |
| Avulsion | Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structure |
| Wound drainage: serous | clear, watery plasma |
| Wound drainage: purulent | thick, yellow, green, tan, or brown |
| Wound drainage: serosanguineous | pale, pink, watery; mixture of clear and red fluid |
| Wound drainage: sanguineous | bright red; indicates active bleeding/open wound |
| Wound drainage: puro sanguineous | pus and blood often from infected wound (WBCs and bacteria) |
| Functions of skin | protection/barrier; temp regulation; psychosocial (self-esteem); sensation; vitamin D production; triggers immune response when broken; absorption; elimination through sweating |
| Infant skin considerations | the skin is thinner and weaker, mucous membranes are injured more easily and are more susceptible for infection |
| Elderly skin considerations | skin loses turgor and is more fragile, decreased secretion of enzymes and absorption of nutrients which increases risk for delayed wound healing, increased risk of infection |
| When to use transparent dressings | wounds that are small; partial thickness, stage 1 PIs, wounds with minimal drainage, secure IV catheters, remain in place for 4-7 days |
| When to use hydrocolloid dressings | partial and full-thickness wounds, stage 2/3 PIs, 1st and 2nd degree burns, not for wounds that are infected, prevention at high-risk friction areas |
| When to use hydrogel dressings | partial and full-thickness wounds, stages 2-4 PI, necrotic wounds, dry wounds, infected wounds |
| When to use foam dressings | partial and full-thickness wounds, stages 2-4 PIs, surgical wounds, absorb light to heavy amounts of drainage, not for use with wounds with dry eschar |
| Psychological impact of prolonged immobilization | depression, loss of sense of self, apathy, stress and emotional responses become exaggerated, a normal support system may be difficult to maintain, social isolation can occur |
| Techniques for moving patients with >40 BMI | use your legs to lift; bend your knees and keep your back straight; make bed slightly higher than stretcher when moving; allow gravity to help you; start with broadening the base of support; bring object as close to your body as possible |
| Benefits of anerobic exercise | builds muscle strength, increases bone density, boosts power |
| Benefits of aerobic exercise | promotes cardiovascular health, increase blood flow, increased efficiency of heart, improves mood, increases heart rate and metabolic demand for oxygen over time |
| Isometric exercise | muscle contraction without shortening (ex. holding yoga pose, holding plank) |
| Isotonic exercise | muscle shortening and active movement (ex. ADLs, independent ROM, swimming, walking, jogging, cycling) |
| Considerations for repositioning a client that is immobile | use pillows, wedges or specialty beds to avoid pressure injuries; trapeze bars are available to support upper body strength/prevent deconditioning; boots |
| Transfer from bed to stretcher | ensure bed is in a good working height for caregiver; locked wheels; beds aligned and next to each other; may use lateral assist device (sheet under pt and on top of board); smooth unison distributes work |
| Katz index of daily living | assessment of mobility that looks at pts level of ability when bathing, dressing, toileting, transferring, and eating |
| Values for Katz index | 6 = full independence, 3-5 = moderate independence, 2 or less = severe impairment |
| What is the katz index used for | to measure the older adult's capacity to care for oneself and assist nurses to detect subtle changes in health and prevent functional decline |
| Pressure points | back of head, shoulder, elbow, butt, heel, toes, ear, hip, thigh, leg, base of spine |
| Factors that can lead a patient to physical atrophy/immobility | poorly nourished; existing cardiovascular, pulmonary, or neuromuscular problems; unconscious; mental health; sedentary lifestyle; smoking; values; stress |
| Restraint rationale | used to limit the physical activity of a client or part of the body; ensures safety to pt, staff, and others; less restrictive options have failed |
| How often should you assess restraints? | every 15 minutes |
| How to document restraints | behavior before, during, and after; type of restraint used; explanation to client/family; other less restrictive measures failed; consent; time applied, removed, and frequency of care |
| What is included in the Braden Scale | sensory perception, moisture, activity, mobility, nutrition, friction |
| What are the risk level values for the Braden scale | 19-23 = no risk; 15-18 = low risk; 13-14 = moderate risk; 10-12 = high risk; 9 or lower = very high risk |
| RYB color code | color classification system that can be used for wound assessment and help direct treatment for open wounds; when all colors are present, the wound is treated first for the most serious color: black |
| RYB: red | protect; in proliferative stage of healing and reflect color of normal granulation tissue |
| Red interventions | gently cleansing, use of moist dressings, only change dressings when necessary |
| RYB: yellow | cleanse; yellow may indicate exudate or slough; characterized by oozing from tissue covering wound, often w/ purulent drainage |
| Yellow interventions | use of wound cleansers and irrigation |
| RYB: black | debride; indicates eschar (necrotic tissue) |
| Black interventions | debridement of eschar, usually by APRNs; after debridement, wound is treated as yellow |
| Phases of healing | Hemostasis, inflammatory, proliferation, maturation |
| Hemostasis stage | occurs immediately after initial injury to stop bleeding and active WBC to fight invading bacteria; involved blood vessels constrict and blood clotting begins |
| Fibrin clot | temporary clot that's dissolved by fibrinolysis---stimulates other cells to migrate to injury |
| Inflammatory stage | lasts about 2-3 days; leukocytes arrive to ingest bacteria and cellular debris; growth factors attract fibroblasts that help fill in the wound |
| Proliferation stage | new tissue is built to fill the wound space, mostly through fibroblasts; capillaries grow across the wound and brings O2/nutrients required for healing |
| Fibroblast | connective tissue cells that synthesize and secrete collagen and produce specialized growth factors |
| Granulation tissue | forms foundation for scar tissue development |
| Maturation stage | begins about 3 weeks after injury; collagen deposited in wound is remodeled-- makes wound stronger and more like adjacent tissue |
| Proper techniques for moving pts and keeping nurse safe | use gait belt, lift, slide sheet, etc; avoid rotation and stooping; many facilities are using "no lift" policies or limit lifting to 35 lbs |
Created by:
julie.russell