505 exam 1

  1. DEBRIDEMENT
    cleaning away devitalized tissue and foreign matter from a wound
  2. DEHISCENCE
    surgical complication in which a wound ruptures along a surgical incision
  3. DERMIS
    middle layer of "skin" between subcutaneous and epidermis
  4. DESICCATION
    dehydration
  5. EPIDERMIS
    superficial layer of the skin
  6. EPITHELIALIZATION
    epithelial cell migration to the wound bed
  7. ESCHAR
    necrotic tissue
  8. EVISCERATION
    removal of viscera (internal organs, especially those in the abdominal cavity)
  9. EXUDATE
    fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and WBCs
  10. fistula
    an abnormal passage from an internal organ to the skin or from one internal organ to another
  11. friction
    injury resembles an abrasion and can also damage superficial blood vessels directly under the skin
  12. granulation tissue
    red connective tissue; evolves into scar tissue
  13. ischemia
    deficiency of blood in a particular area
  14. maceration
    over hydration
  15. necrosis
    death of cells and tissue
  16. negative-pressure wound therapy (NPWT)
    the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid
  17. pressure ulcer
    any lesion caused by unrelieved pressure that results in underlying tissue
  18. purulent drainage
    pus point of exit
  19. shearing force
    force created when layers of tissue move on one another
  20. sinus tract
    blind-ended tract that extends from the skin's surface to an underlying abscess cavity
  21. subcutaneous tissue
    • fat below dermis 
    • poor circulation
  22. wound
    injury that results in the disruption in the normal continuity of a body tissue
  23. Incontinence Associated Dermatitis
    • "perineal dermatitis;"
    • clinical manifestation of MASD related to  incontinence; severe MASD w/ erosion
  24. Intertriginous Dermatitis
    skin folds dermatitis, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation
  25. Moisture associated skin damage
    prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva
  26. Pressure injury
    do not heal in the reverse order from which they progressed.

    ◦Replaced with new tissue that is never of the same texture or quality as the original skin and is always more likely to breakdown again.
  27. incontinence associated
    infx r/t to inability to voluntary control the discharge of urine or feces
  28. incontinence
    inability to voluntary control the discharge of urine or feces
  29. Pressure Ulcer Scale for Healing (PUSH)
    • size, exudate, tissue type
    • 17 max risk
    • 0 no risk
  30. braden's scale
    • 1) sensory 
    • 2) friction & shear
    • 3) moisture
    • 4) activity
    • 5) mobility
    • 6) nutrition
  31. 3 or 4 categories = Mod to Low impairment
    Total points possible: 23
    Risk Predicting Score: 16 or Less
    9 or Less = very high risk
    braden's scale
  32. physical, mental, activity, mobility, incontinence;
    20 minimum risk
    5 maximum risk
    Norton’s Pressure Area Risk Assessment (NPARA)
  33. approximated wound edges
    • edges of a wound that are lightly pulled together 
    • epithelialization of wound margins
    • edges touch, wound is closed
  34. ecchymosis
    discoloration of an area resulting from infiltration of blood into the subcutaneous tissue
  35. erythema
    redness or inflammation of an area as a result of dilation and congestion of capillaries
  36. jaundice
    condition characterized by yellowness resulting from excess bilirubin in the blood
  37. Phases of Wound Healing
    • Hemostasis
    • Inflammatory
    • Proliferation
    • maturation
  38. Hemostasis PHASES OF WOUND HEALING
    • immediate
    • Vasoconstriction
    • Vasodilation
  39. Inflammatory days PHASES OF WOUND HEALING
    • WBCs           
    • malaise
  40. Proliferation PHASES OF WOUND HEALING
    • weeks
    • “Fibroblastic”
    • granulation tissue
  41. Maturation PHASES OF WOUND HEALING
    • weeks
    • Remolding
    • strengthening
    • scar formation
  42. RYB Classification
    • Red
    • Yellow
    • Black
  43. Red RYB CLASSIFICATION
    • Protect
    • granulation tissue
  44. Yellow RYB CLASSIFICATION
    • Cleanse
    • slough
  45. Black RYB CLASSIFICATION
    • Debride 
    • eschar/necrotic tissue
  46. Braden Scale
    • RISK FOR PRESSURE ULCER ASSESSMENT TOOL
    • Sensory
    • ◦1-4
    • ◦Moisture
    • ◦1-4
    • ◦Activity
    • ◦1-4
    • ◦Mobility
    • ◦1-4
    • ◦Nutrition
    • ◦1-4
    • ◦Friction
    • ◦1-3
    • ◦Total 23
  47. Pressure Ulcer Scale for Healing (PUSH)
    A tool to assess the healing progress of a venous ulcer over time
  48. clean technique
    • strategy to reduce transmission of microorganisms between persons. 
    • includes hand hygiene, clean field, gloves, sterile instruments, and preventing cross-contamination
  49. intentional vs unintentional
    surgical incision vs scraped leg
  50. open vs closed
    cut open vs internal bleeding
  51. Acute  vs. chronic
    healing normally vs wound won’t heal
  52. Partial thickness
    interference of epi and dermis
  53. Tertiary intention
    Delayed primary closure
  54. Healing
    3 stages
    • Primary Intention
    • Secondary intention
    • Tertiary Intention
  55. Primary intention
    Surgical incision
  56. Secondary intention
    • Longer repair time
    • Greater scarring
    • Increased (↑) susceptibility to infection
  57. full thickness
    interference of dermis, subQ, bone
  58. tunneling
    passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin
  59. undermining
    areas of the tissue destruction underneath intact skin along the margins of a wound; associated with stage 3 or 4 pressure ulcers
  60. Stage I
    • Erythema that does not blanch
    • Intact skin
  61. Stage II
    • Partial thickness
    • Abrasion
    • open blister
    • indicates "at risk" persons
  62. Stage III
    • Full thickness
    • May extend through subcutaneous fat
  63. Stage IV
    • Full thickness tissue loos
    • extends to muscle, bone, tendons
    • Undermining, tunneling likely
  64. unstageable
    until slough/eschar is removed sufficiently, true depth cannot be determined, therefore stage is unknown
  65. wound assessment
    • Intentional or unintentional?
    • Open or closed?
    • Acute or chronic?
    • Partial or full-thickness?
  66. measuring wounds and pressure ulcers
    • size of the wound
    • depth of the wound
    • wound tunneling
  67. stable, temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles.
    angina
  68. acute coronary syndrome; death of heart tissue due to lack of oxygen; a heart attack
    myocardial infarction
  69. measurement of the blood pH, arterial oxygen/carbon dioxide in the aortic arch and the carotic bodies
    arterial blood gas
  70. chemoreceptors in aortic arch and carotid bodies; proprioceptors in muscles and joints; the medulla
    regulation of the respiratory systerm
  71. incomplete lung expansion; collapse of alveoli; obstruction of airway by foreign bodies; airway constriction; pneumonia, pulmonary edema
    atelectasis
  72. location of chemoreceptors
    aortic arch
  73. breath activated; requires less manual dexterity;
    dry powder inhaler
  74. most common symptom of hypoxia
    dyspnea
  75. arrhythmia; disturbance of automaticity; abnormal effects of the SA node
    dysrhythmia
  76. electrocardiogram, identifies myocardial ischemia/infarction, electrolyte imbalances
    ECG
  77. often method of choice; uncomfortable, and easy to manipulate w/ tongue; inserted through nose or mouth into trachea
    endotracheal tube
  78. Risk factors
    • External pressure
    • Wound status
    • Health status
    • Life style
  79. Ischemia PRESSURE INJURY STAGING
    • -hypoxia
    • -presents as pale/white over the area under pressure
  80. Suspected deep tissue PRESSURE INJURY STAGING
    Discolored intact skin or blood filled blister
  81. require chest tube
    hemothorax
  82. use sterile gloves, goggles, and a mask; pre-oxygenate; monitor for cyanosis, heart rate, & anxiety
    suctioning of the airway
  83. prevent hypoxemia by pre-oxygenating the patient; removes oxygen from the respiratory tract; may irritate the mucosa;
    suctioning (nasopharyngeal, oropharyngeal)
  84. fatty deposits and fibrous tissue in the lining of arterial blood vessel walls; creating blockages and narrowing the vessels, reducing blood flow
    atherosclerosis
  85. s/s --> pain, anxiety, nausea, vomiting, indigestion, dyspnea,  hypoxia; atherosclerosis
    myocardial ischemia
  86. to use, the patient must activate the device while continuing to inhale
    metered-dose inhaler
  87. the most common used oxygenating device
    nasal cannula
  88. the treatment continues until all the medication in the cup has been inhaled; dispersed fine particles
    nebulizer
  89. oxygenated capillary blood passes through body tissues
    perfusion
  90. air into and out of the lungs
    pulmonary ventilation
  91. noninvasive tech; measures arterial blood gas saturation; result reported as ratio, or %
    pulse oximetry
  92. upper right atrium; initiates the transmission of electrical impulses; atrial contraction; pacemaker
    sinoatrial node
  93. 1st assist pt to semi-Fowlers position, an instrument that measures lung volumes and airflow; promote breathing while recovering from surgery
    spirometer
  94. a detergent-like phospholipid; prevents the collapse of the lungs by reducing surface tension between the alveoli membranes
    surfactant
  95. serous membrane lining the lungs and the thoracic cavity
    pleura
  96. procedure of puncturing chest wall and aspirating pleural fluid; patient is in sitting up position, assisted by RN
    thoracentesis
  97. the intake of oxygen; the output of CO2; made possible by pulmonary ventilation, perfusion, & respiration; diffusion
    gas exchange
  98. lower right atrium; cause contraction of the ventricles
    atrioventricular node
  99. check the patients record for health problems affecting oxygenation status
    using a pulse oximeter
  100. adjust bed to comfortable working height, usually elbow level of caregiver; position Pt in semi-Fowlers if conscious; position in lateral side-lying if Pt unconscious
    suction naso/oropharyngeal
  101. s/s --> dyspnea, low pulse pressure, pallor, increased pulse rate
    hypoxia
  102. epitaxis
    nose bleed
  103. a nurse in the emergency department sees a pt w acute asthma exacerbation.  which testing method would the Rn use first?




    B)
  104. a nurse in long-term care facility, wants to assess pt for recent onset of s/s associated w/ chronic asthma.  what testing method would Rn use?




    C)
  105. a rn in long-term care facility is teaching patients with COPD about self care.  what would the nursing priority be here?




    C)
  106. a nurse is providing postural drainage for a pt w/ cystic fibrosis.  in which position should the nurse place the patient to drain the right lobe of the lung?




    D)
  107. rn planning care for a pt w/ chronic lung disease who is receiving O2 through nasal cannula.  what does the rn expect?




    B)
  108. energy required to carry on the involuntary activities of the body at rest; the energy needed to sustain the metabolic activities of cells and tissues
    basal metalbolism
  109. growth, infection, fever, stress, heat/cold, adrenaline, thyroid hormones
    BMR factors
  110. kg/m2 

    BMI
  111. lbs./in2 x 703
    BMI
  112. 190 lbs/(69in)2 x703 =______BMI
    • BMI= 28.1
    • 190 lbs.
    • 5ft 9in
  113. 6 classes of nutrients
    • Carb
    • Protein
    • Fats
    • Vitamins
    • Minerals
    • water
  114. Nutrients that supply energy
    • ◦Carbohydrates
    • ◦Protein
    • ◦Lipids
  115. Nutrients that regulate body processes
    • ◦Vitamins
    • ◦Minerals
    • ◦Water
  116. 0.8 g/kg of body weight; 10% to 35% total calorie intake
    RDA protein
  117. 50g to 100g of need of this essential nutrient to prevent ketosis
    RDA carbohydrates
  118. RDA (recommended daily allowance) not established
    No more than 20% to 35% total calorie intake
    fats
  119. Triglycerides
    major storage form of fat in the body
  120. insoluble in blood; 95% in diet come from triglycerides
    lipids
  121. Macrominerals include
    calcium, phosphorus, and magnesium
  122. Microminerals include
    iron, zinc, manganese, and iodine
  123. Enteral ALTERNATIVE DELIVERY METHODS
    • NGT
    • G-Tube
  124. Parenteral ALTERNATIVE DELIVERY METHODS
    • TPN
    • PPN
  125. Alternative deliver methods
    • enteral 
    • parenteral
  126. Nasogastric tube (NGT) ENTERAL METHOD
    • ◦Short-term nutrition
    • ◦Nurse placement
  127. Gastric tube (G-tube) ENTERAL METHOD
    • ◦Long-term nutrition
    • G-tube = PEG tube
    • percutaneous endoscopic gastrostomy
    • post-op period
  128. Total Parenteral Nutrition (TPN) PARENTERAL METHOD
    • central line = CLASBI
    • ◦CONCENTRATED 
    • ◦HYPERTONIC
  129. Peripheral Parenteral Nutrition (PPN) PARENTERAL METHOD
    • ◦IV therapy 
    • ◦nurse placement
    • ◦Short term
  130. NGT PRIORITIES
    • Safety
    • Feedings
    • medications
  131. NGT PRIORITIES: SAFETY
    • Short term
    • High fowlers
    • Measure tube for placement
    • Confirm placement before use and throughout use
  132. NGT SHORT TERM
    • ◦less than 4 weeks
    • ◦High risk for aspiration!
  133. NGT MEASURE TUBE FOR PLACEMENT FOR PLACEMENT
    • ◦Tip of patient’s nose
    • ◦Extend tube to tip of patient’s ear
    • ◦Extend tube to tip of patient’s xiphoid process
    • ◦Mark the tube with Sharpie
  134. NGT Confirm placement before use and throughout use
    • ◦Chest X-ray 
    • ◦Aspirate pH (> 6 & bile)
    • ◦Check tube length
  135. Thigh strengthening ELIMINATION
    ◦flexed knee, up to chest, one at a time
  136. 24-hour URINE SPECIMEN
    • 1) Post a sign
    • 2) Ask patient to void, discard
    • 3) and then begin for 24 H 
    • 4) Preservative or refrigeration
    • 5) Last void is added to collection
  137. Urinary Retention
    • ◦older men
    • ◦spinal injury
    • ◦narcotic use
  138. Mixed URINARY INCONTINENCE
    • 2+ types of incontinence
    • Too little tone (STESS), too much activity (URGE)
  139. Overflow URINARY INCONTINENCE
    • just cant hold anymore (chronic retention)
    • i.e. dribbling
  140. Urge URINARY INCONTINENCE
    • Too much activity
    • i.e. void on the way to the bathroom
  141. Total URINARY INCONTINENCE
    • ◦continuous, unpredictable loss of urine
    • ◦i.e. trauma
  142. Functional URINARY INCONTINENCE
    • caused by factors outside the urinary tract
    • i. e. loss of memory
  143. Reflex URINARY INCONTINENCE
    • ◦void w/o sensation
    • ◦i.e. spinal cord injury
  144. Stress URINARY INCONTINENCE
    • Too little tone
    • i.e. coughing, sneezing
  145. Transient URINARY INCONTINENCE
    • lasts 6 months or less
    • i.e. infection, acute illness
    • manifests as confusion
  146. Urinary Catheterization Indications
    • Urinary retention
    • Sterile urine specimen
    • Surgical procedures
    • renal function in critically ill
    • comfort for terminally ill
  147. found only in animal products
    cholesterol
  148. organic compounds; coenzymes; required for metabolism; do NOT provide calories
    Vitamins
  149. inorganic elements found in all bodily fluids & tissues in the form of salts (NaCl); or combined with organic compounds (Fe+Hb)
    minerals
  150. most vital nutrient; it participates in in many chemical rxns and it is not stored in the body; universal solvent
    water
  151. through evaporation from the skin, this vital nutrient helps regulate body temperature
    water
  152. measurements used to determine body dimensions; takes age differences into consideration
    anthropometric
  153. to pull from tube
    aspiration
  154. allow 1-hr interval after patient has received medication; if feeding is continuous, perform this task when feeding can be withheld
    pH measurement of gastric contents
  155. Implementation OXYGENATION
    • 1.Patent Airway
    • 2.Supplemental O2
    • 3.Lung expansion
    • 4.Mobilize secretions
    • 5.meds
  156. Abdominal settings ELIMINATION
    ◦supine, tighten and hold abdominal muscle x 6 seconds
  157. after multiple steps have been taken to ensure that the feeding tube is located in the stomach or small intestine, aspirate all gastric contents w/ syringe and measure to check for _______. 
    gastric residual
  158. position the patient with the head of the bed elevated at least 30-45 degrees or as near normal position for eating as possible
    nursing priority for administering a tube feeding
  159. cleanse the skin with an alcohol swab before performing this skill
    patient priority in performing glucose testing
  160. recap the container immediately.  check that the code for the test strips matches the code number on the monitor screen
    nursing priority for glucose testing
  161. 56 yo male pt w/ COPD refuses to eat.  Which Rn intervention will most stimulate his appetite?




    B)
  162. a nurse is feeding pt who is experiencing dysphagia.  Which nursing intervention would the nurse initiate?




    B)
  163. patient reports nausea during feeding time.  what is nursing priority?




    A)
  164. RDA for adults is 0.8 g/kg of body weight, 10% to 35% total calorie intake
    protein
  165. Digestion occurs largely in the small intestine; Most concentrated source of energy in the diet; No more than 20% to 35% total calorie intake
    fats
  166. BMI ≥30
    obsesity
  167. type 1 & 2 diabetics; high-fiber, sodium and saturated fats are limited
    constant carb
  168. fiber limited to <10g/day
    limited
  169. sodium limit may be set at 500-3000 mg/day
    limited
  170. includes broth, coffee, tea, clear fruit juices, gelatin, popsicles
    clear liquid diet
  171. watermelon, raw vegetables, nuts&seeds; foods are chopped, ground, mashed, or soft
    mechanical soft
  172. easy-to-chew and easy-to-swallow foods; low in fiber, fat and connective tissue; yes to BUNs!!!
    dental soft
  173. NO BUN!
    Mechanical soft
  174. includes dairy; may cream of wheat; may potato soup; plus all clear liquids
    Full fluids
  175. pureed diet
    thickened liquids
  176. bolus
    NG feeding
  177. process of emptying bladder; urination
    voiding
  178. peoples whose bladder is no longer controlled by the brain; d/t injury & disease; void by reflex only
    autonomic bladder
  179. involuntary loss of urine
    incontinence
  180. urine produced normally but is not excreted completely from bladder
    urinary retention
  181. involuntary loss of urine that occurs soon after feeling an urgent need to void; diuretics can increase urine production resulting in increased urge;
    • urge incontinence
    • older adults more at risk
  182. decreased bladder contractility may lead to urine retention and stasis, effects of aging;
    woman at greater risk
    increases the likelihood of urinary tract infection
  183. involves surgical creation of an alternative route for excretion
    urinary diversion
  184. the preferred method is to catheterize the stoma
    urine specimens from a urinary diversion
  185. Normal output is 800-2000 mL/24 hours (≈ 60mL/H);
    Minimum is 1 mL/hour
    normal fluid output
  186. Milk Products, some Cereals; NO raisin brain, NO shredded wheat; soft fruits & cooked veggies; fish & meatloaf
    • both mechanical soft 
    • and
    • dental soft
  187. Document number of times; Provide CHG baths prn; Any notable characteristics
    measuring urinary output for an incontinent person
  188. appliance should protect skin, collect fecal discharge, and control oder
    ostomy
  189. stoppage of breathing or the lack of reaching the lungs
    asphyxiation
  190. abnormal passage from internal organ to the skin or from one internal organ to another
    fistula
  191. cavity or channel underneath the wound that has potential for infection
    sinus tract
  192. aspiration of fluid or air from the pleural space (procedure of puncturing the chest wall aspirating pleural fluid)
    thoracentesis
  193. voluntary contraction of the abdominal wall muscles, fixing the diaphragm, and closing the glossitits that increase intra-abdominal pressure and aids in expelling faces
    valsalva manuever
  194. indicator of the changes in body muscles and whether fat is in proportion to their height
    BMI
  195. client says "I was laid off from my job yesterday.  after all those years with that company!  they had no right to lay me off!"  the nurse says "it sounds like youre feeling pretty angry." what is enhancer that RN used
    reflection
  196. client says "i havent been going to work lately.  i have onl been going a couple times a week.  its not the money really.  i just cant seem to get there." nurse says "it sounds like your job isn't really satisfying you anymore
    interpretation
  197. 2nd nursing priority is to assist patient to dorsal recumbent position for what skill
    female foley
  198. 1st step is to adjust bed to elbow height
    male and female foley
  199. when do u remove a catheter
    when there is an order
  200. expected outcome of foley removal
    patient voids minimum of 250 mL 6-8 hours after removal
  201. when do u empty drain bag for foley?
    • 1/2 to 2/3 full
    • or 
    • Q3 to Q6 hours
  202. hygiene for foleys
    • perineal care
    • CHG
    • Q6h

    • bath
    • 10 wash cloths
    • 3 towels
    • 4 oz bottle of CHG
    • Qd
  203. Managing Urinary Retention
    • Cholinergic Medication
    • Straight catheterization
    • Indwelling (Foley) Catheterization
    • Suprapubic catheter
  204. Catheter STRAIGHT VS FOLEY
    • Straight
    • ◦Single Lumen
    • ◦Self
    • "intermittent"
    • reduce risk of UTI
    •  Indwelling (Foley)
    • ◦Double lumen
    • ◦Bladder Irrigation
    • ◦Nurse
  205. self care bath vs bath
    • self: face + soap/water
    • nurse: around eyes + soap/water & CHG everywhere else
  206. movement of air into and out of lungs.
    ventilation
  207. fecal impaction
    prolonged retention, hardened mass in the rectum
  208. fecal incontinence
    involuntary or inappropriate passing of stool or flatus
  209. abdominal incisions and direct manipulation of the bowel during abdominal surgery inhibits peristalsis
    paralytic ileus
  210. bowel incontinence
    inability of the anal sphincter to control the discharge of fecal and gaseous material
  211. ileostomy vs colostomy
    liquid feces vs formed feces
  212. nursing priorities for oxygenation revolve around maintaining
    a patent airway
  213. for whom would u use peak flow meter
    asthma; before attack
  214. Fluid, pus, inflammation in alveoli.
    pneumonia
  215. pus in the pleural cavity.
    empyema
  216. Air in pleural space
    pneumothorax
  217. Blood in pleura
    hemothorax
  218. Chest Drain System is indicated when?
    pneumothorax
  219. saturation of peripheral capillary oxygen
    SpO2
  220. Based on available hemoglobin; Hgb; reflects the number of RBCs in the blood
    Oxygen saturation of arterial blood.
  221. saturation of peripheral capillary oxygen; oxygen saturation of arterial blood
    Pulse Oximetry
  222. Acidity (pH); levels of O₂ and CO₂ in the blood from an artery; evaluates lungs ability to move O₂ into the blood and remove CO₂ from the blood.
    Arterial Blood Gases
  223. CK and isozymes; Troponin
    cardiac biomarkers
  224. this helps to reinflate the alveoli and prevent atelectasis due to hypoventilation
    incentive spirometer
  225. one way valves that promote expiration
    non-rebreathing mask
  226. FiO2
    • always expressed as %
    • ambu-bag
    • venturi mask
    • non-rebreathing mask
  227. 1-6 L/min; low flow; humidification set on wall
    nasal cannula
  228. atmospheric oxygen
    21%
  229. 4% = 1 L/min; oxygenation; supplemental oxygen ratio
    • 4% on top of 21% 
    • ex. 4 L/min = 16% + 21%
  230. 12 L/min; high flow; 100%
    non-rebreather oxygen mask
  231. 4-10 L/min; HIGH FLOW
    venturi mask
  232. ETT indicated when?
    pneumothorax
  233. High flow O₂ therapy nasal cannula using warmed, humidified air; Up to 8 L/min for infants; Up to 40 L/min for adults
    vapotherm
Author
BodeS
ID
342419
Card Set
505 exam 1
Description
wounds oxygenation nutrition elimination (+ nursing process infection control hygiene mobility)
Updated