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Rebound phenomenon
when treatments result in worsening of the original condition rather than improving it
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Leaving heat packs in place longer than 45 minutes can cause constriction of vessels instead of dilation. This is known as ..?
Rebound phenomenon
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List six safety precautions when applying a warm pack
- have a barrier between the skin and pack
- leave on for 20-30 minutes
- check skin every 15-20 minutes
- Check temp. before applying >105 F
- If too hot, have pt ring call bell
- assess skin every 5 minutes
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How does cold therapy help with pain in sprains?
- Cold therapy casues vasoconstriction
- reduces the amount of fluid that leaves the capillaries and leaks into the interstitial space
- results in less edema and pain
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How long do you use cold therapy after an injury?
For the first 48-72 hours after the injury occurs
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When do you use a hyperthemia blanket use?
- To reduce high fevers 105F +
- Disease or stroke
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What do you use to treat phlebitis?
Warm compress
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What heating device can cause orthostatic hypotension?
Sitz Bath
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What are you observing for with skin assessment after cold therapy that would indicate cold therapy was applied for too long?
- Pallor - pale or white
- Mottling - Purplish blue, irregular blotches
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List two complications of cold therapy
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List six techniques used during physical assessment?
- Interview
- Inspection
- Auscultation
- Percussion
- Palpation
- Olfaction
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Signs vs Symptoms
- Signs - Uses four senses, objective, measurable
- Symptoms - Verbalized by pt, subjective, not directly measurable
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Establishing a rapport with a surgical patient
- Smile
- Greet pt using his or her surname
- Provide privacy
- introduce yourself and explain intent
- exhibit open and relaxed posture
- be professional
- demonstrate active listening
- be attentive to pt responses and needs
- be aware of cultural influences and restrictions
- be sincere
- be nonjudgmental
- use touch purposefully and judiciously
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What can cause hypoactive bowel sounds?
Anesthesia
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What slows down in the elderly population that can cause constipation?
Peristalsis
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What do you do if you are having difficulty auscultating heart tones?
Have pt lean forward and to the left
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How would you know the pt's condition is deteriorating after MVA?
- LOC
- Level of orientation
- Assess orientation of person, place, time, and situation
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When do you do daily weights?
- Before breakfast
- wearing the same type of clothing
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What is included in assessing the skin?
- Color
- temp
- moisture
- turgor
- integrity
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What supplies would you gather for a simple dressing change?
- sterile field
- sterile dressing
- clean and sterile gloves
- sterile solution
- googles
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What is sterile technique and sterile field?
Sterile technique - method used to prevent contamination during invasive procedures, or procedures that involve entering body cavities
sterile field - an area that is free from all microorganisms
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How do you add items to a sterile field?
You drop the item onto the sterile field
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When do you use sterile techniques and with what procedures?
- Open sterile packages
- Peel the pack away from you
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How do you know sterile gloves are the appropriate size for you?
- They should fit closely
- no wrinkles
- no excessive materials at fingertips
- no bowing due to tightness
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What are the three phases of healing?
- Inflammatory
- reconstruction
- maturation
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Describe the Inflammatory healing stage
- wound is fresh
- includes hemostasis and phagocytosis
- signs include warmth, redness, pain, and edema
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Describe the reconstruction phase of healing
- wound begins to heal, lasting for about 21 days after injury
- there is a presence of fibroblasts = produce collagen
- as new tissue begins to grow and fill wound, it looks red and semitransparent
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Describe the maturation phase of healing
- wound contracts and scar strengthens
- healing ridge develops
- phase can last from 1 - 2 years
- scar thins and lightens in color, becomes firm and less elastic than skin around it
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Why do you irrigate a wound from superior to inferior area?
you want to clean from the least contaminated to the most contaminated
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When is it appropriate to use a hydrocolloid?
When a wound has minimal drainage
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When do you use a jackson-pratt drain?
The suction drains fluid out into container
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Describe the first stage of wound healing
- its dry
- edges are approximated
- wound sutures are closed
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Describe the second stage of wound healing
- greater tissue loss
- wound edges are irregular
- must be left open to gradually heal by filling in with granulation tissue
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Describe the third stage of wound healing
- wound is left open for a time to allow granulation tissue to form
- sutured close
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Abrasion
- Superficial open wound
- ex: scratches, scrapes
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Puncture
open wound when a sharp item pierces skin - round hold in skin extends down into deeper tissue
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Penetrating
offending object remain embedded in tissue
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Lacerations
open wound made by accidental cutting or tearing of tissue
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Pressure Ulcers
wound from pressure and friction
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What would be signs of an infected wound?
- purulent - containing pus
- necrotic tissue - dead tissue
- erythema - redness
- increased warmth
- edema - swelling
- pain
- odor
- drainage
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How would you treat a wound evisceration?
cover exposed organs with sterile dressing soaked in saline and call for help
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There are no orders for a dressing change. What would you do?
Mark dressing and reinforce
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You are doing a focused assessment on CV system. what are you assessing for?
- BP and Pulse
- Skin color, moisture, and temp
- color of mucous membranes
- jugular vein distention
- heart sounds
- capillary refill
- edema
- activity tolerance
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What items are disinfected instead of sterilized after each pt use?
- IVAC and poles
- over bed table
- bedside commode
- wires
- tube feeding pumps
- wound vac
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Lethargy
drowsiness or mental sluggishness
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Eschar
hard, dry, dead tissue that has a leathery appearance
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Ischemia
reduced blood flow to an area
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Name 4 assessments included in a neurological exam
- vital signs
- response to simple commands
- speech clarity facial symmetry
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IF YOU DONT KNOW THE ANSWER YOU SHOULD PUT...
lethargy
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What should you assess on a diabetic patient?
parasthesia
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Parathesia
numbness or decreased sensation
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Abdomen Assessment
- 1. inspect
- 2. ausculate
- 3. palpate
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