505 exam 1

DEBRIDEMENT

DEHISCENCE

DERMIS

DESICCATION

EPIDERMIS

EPITHELIALIZATION

ESCHAR

EVISCERATION

EXUDATE

fistula

friction

granulation tissue

ischemia

maceration

necrosis

negative-pressure wound therapy (NPWT)

pressure ulcer

purulent drainage

shearing force

sinus tract

subcutaneous tissue

wound

Incontinence Associated Dermatitis

Intertriginous Dermatitis

Moisture associated skin damage

Pressure injury

incontinence associated

incontinence

Pressure Ulcer Scale for Healing (PUSH)

braden's scale

3 or 4 categories = Mod to Low impairment
Total points possible: 23
Risk Predicting Score: 16 or Less
9 or Less = very high risk

physical, mental, activity, mobility, incontinence;
20 minimum risk
5 maximum risk

approximated wound edges

ecchymosis

erythema

jaundice

Phases of Wound Healing

Hemostasis _{PHASES OF WOUND HEALING}

Inflammatory days _{PHASES OF WOUND HEALING}

Proliferation _{PHASES OF WOUND HEALING}

Maturation _{PHASES OF WOUND HEALING}

RYB Classification

Red _{RYB CLASSIFICATION}

Yellow _{RYB CLASSIFICATION}

Black _{RYB CLASSIFICATION}

Braden Scale

Pressure Ulcer Scale for Healing (PUSH)

clean technique

intentional vs unintentional

open vs closed

Acute  vs. chronic

Partial thickness

Tertiary intention

Healing
3 stages

Primary intention

Secondary intention

full thickness

tunneling

undermining

Stage I

Stage II

Stage III

Stage IV

unstageable

wound assessment

measuring wounds and pressure ulcers

stable, temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles.

acute coronary syndrome; death of heart tissue due to lack of oxygen; a heart attack

measurement of the blood pH, arterial oxygen/carbon dioxide in the aortic arch and the carotic bodies

chemoreceptors in aortic arch and carotid bodies; proprioceptors in muscles and joints; the medulla

incomplete lung expansion; collapse of alveoli; obstruction of airway by foreign bodies; airway constriction; pneumonia, pulmonary edema

location of chemoreceptors

breath activated; requires less manual dexterity;

most common symptom of hypoxia

arrhythmia; disturbance of automaticity; abnormal effects of the SA node

electrocardiogram, identifies myocardial ischemia/infarction, electrolyte imbalances

often method of choice; uncomfortable, and easy to manipulate w/ tongue; inserted through nose or mouth into trachea

Risk factors

Ischemia _{PRESSURE INJURY STAGING}

Suspected deep tissue _{PRESSURE INJURY STAGING}

require chest tube

use sterile gloves, goggles, and a mask; pre-oxygenate; monitor for cyanosis, heart rate, & anxiety

prevent hypoxemia by pre-oxygenating the patient; removes oxygen from the respiratory tract; may irritate the mucosa;

fatty deposits and fibrous tissue in the lining of arterial blood vessel walls; creating blockages and narrowing the vessels, reducing blood flow

s/s --> pain, anxiety, nausea, vomiting, indigestion, dyspnea,  hypoxia; atherosclerosis

to use, the patient must activate the device while continuing to inhale

the most common used oxygenating device

the treatment continues until all the medication in the cup has been inhaled; dispersed fine particles

oxygenated capillary blood passes through body tissues

air into and out of the lungs

noninvasive tech; measures arterial blood gas saturation; result reported as ratio, or %

upper right atrium; initiates the transmission of electrical impulses; atrial contraction; pacemaker

1st assist pt to semi-Fowlers position, an instrument that measures lung volumes and airflow; promote breathing while recovering from surgery

a detergent-like phospholipid; prevents the collapse of the lungs by reducing surface tension between the alveoli membranes

serous membrane lining the lungs and the thoracic cavity

procedure of puncturing chest wall and aspirating pleural fluid; patient is in sitting up position, assisted by RN

the intake of oxygen; the output of CO2; made possible by pulmonary ventilation, perfusion, & respiration; diffusion

lower right atrium; cause contraction of the ventricles

check the patients record for health problems affecting oxygenation status

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

s/s --> dyspnea, low pulse pressure, pallor, increased pulse rate

epitaxis

a nurse in the emergency department sees a pt w acute asthma exacerbation.  which testing method would the Rn use first?

A) pulse oximetry
B) spirometry
C) thoracentesis
D) diffusion capacity

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?

A) suction
B) pulse oximetry
C) diffusion capacity 
D) spirometry

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

A) reduce anxiety
B) maintain Fowler's position whenever possible
C) eat meals 1 to 2 hours before respiratory therapy
D) refrain from exercise

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?

A) high fowlers
B) lying position/half on abdomen and half on side
C) trendeleberg position
D) left side with pillow under chest wall 

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

A) rate will be no more then 2 to 3 L/min or less
B) arterial blood gases will be drawn every 4 hours to assess flow rate
C) O2 must be humidified
D) the rate will be 6 L/min or more

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

growth, infection, fever, stress, heat/cold, adrenaline, thyroid hormones

kg/m² 

lbs./in² x 703

190 lbs/(69in)² x703 =______BMI

6 classes of nutrients

Nutrients that supply energy

Nutrients that regulate body processes

0.8 g/kg of body weight; 10% to 35% total calorie intake

50g to 100g of need of this essential nutrient to prevent ketosis

RDA (recommended daily allowance) not established
No more than 20% to 35% total calorie intake

Triglycerides

insoluble in blood; 95% in diet come from triglycerides

Macrominerals include

Microminerals include

Enteral _{ALTERNATIVE DELIVERY METHODS}

Parenteral _{ALTERNATIVE DELIVERY METHODS}

Alternative deliver methods

Nasogastric tube (NGT) _{ENTERAL METHOD}

Gastric tube (G-tube) _{ENTERAL METHOD}

Total Parenteral Nutrition (TPN) _{PARENTERAL METHOD}

Peripheral Parenteral Nutrition (PPN) _{PARENTERAL METHOD}

NGT _PRIORITIES

NGT _{PRIORITIES: SAFETY}

NGT _{SHORT TERM}

NGT _{MEASURE TUBE FOR PLACEMENT FOR PLACEMENT}

NGT _{Confirm placement before use and throughout use}

Thigh strengthening _ELIMINATION

24-hour _{URINE SPECIMEN}

Urinary Retention

Mixed _{URINARY INCONTINENCE}

Overflow _{URINARY INCONTINENCE}

Urge _{URINARY INCONTINENCE}

Total _{URINARY INCONTINENCE}

Functional _{URINARY INCONTINENCE}

Reflex _{URINARY INCONTINENCE}

Stress _{URINARY INCONTINENCE}

Transient _{URINARY INCONTINENCE}

Urinary Catheterization _Indications

found only in animal products

organic compounds; coenzymes; required for metabolism; do NOT provide calories

inorganic elements found in all bodily fluids & tissues in the form of salts (NaCl); or combined with organic compounds (Fe+Hb)

most vital nutrient; it participates in in many chemical rxns and it is not stored in the body; universal solvent

through evaporation from the skin, this vital nutrient helps regulate body temperature

measurements used to determine body dimensions; takes age differences into consideration

to pull from tube

allow 1-hr interval after patient has received medication; if feeding is continuous, perform this task when feeding can be withheld

Implementation _OXYGENATION

Abdominal settings _ELIMINATION

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 _______. 

position the patient with the head of the bed elevated at least 30-45 degrees or as near normal position for eating as possible

cleanse the skin with an alcohol swab before performing this skill

recap the container immediately.  check that the code for the test strips matches the code number on the monitor screen

56 yo male pt w/ COPD refuses to eat.  Which Rn intervention will most stimulate his appetite?

A) admin pain meds after meals
B) schedule respiratory therapy before each meal
C) reinforce the importance of his eating exactly what is delivered to him
D) encourage food from home when possible

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

A) provide 30 minute rest before mealtime
B) puree all foods to liquid consistency
C) feed pt solids first, then liquids
D) place head of bed @ 30 degree angle 

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

A) explore w/ pt why she does not want to eat her food
B) remove tray from room
C) administer an antiemetic and encourage the pt to take small amounts
D) offer high-calorie snacks such as pudding and ice cream

RDA for adults is 0.8 g/kg of body weight, 10% to 35% total calorie intake

Digestion occurs largely in the small intestine; Most concentrated source of energy in the diet; No more than 20% to 35% total calorie intake

BMI ≥30

type 1 & 2 diabetics; high-fiber, sodium and saturated fats are limited

fiber limited to <10g/day

sodium limit may be set at 500-3000 mg/day

includes broth, coffee, tea, clear fruit juices, gelatin, popsicles

watermelon, raw vegetables, nuts&seeds; foods are chopped, ground, mashed, or soft

easy-to-chew and easy-to-swallow foods; low in fiber, fat and connective tissue; yes to BUNs!!!

NO BUN!

includes dairy; may cream of wheat; may potato soup; plus all clear liquids

pureed diet

bolus

process of emptying bladder; urination

peoples whose bladder is no longer controlled by the brain; d/t injury & disease; void by reflex only

involuntary loss of urine

urine produced normally but is not excreted completely from bladder

involuntary loss of urine that occurs soon after feeling an urgent need to void; diuretics can increase urine production resulting in increased urge;

decreased bladder contractility may lead to urine retention and stasis, effects of aging;
woman at greater risk

involves surgical creation of an alternative route for excretion

the preferred method is to catheterize the stoma

Normal output is 800-2000 mL/24 hours (≈ 60mL/H);
Minimum is 1 mL/hour

Milk Products, some Cereals; NO raisin brain, NO shredded wheat; soft fruits & cooked veggies; fish & meatloaf

Document number of times; Provide CHG baths prn; Any notable characteristics

appliance should protect skin, collect fecal discharge, and control oder

stoppage of breathing or the lack of reaching the lungs

abnormal passage from internal organ to the skin or from one internal organ to another

cavity or channel underneath the wound that has potential for infection

aspiration of fluid or air from the pleural space (procedure of puncturing the chest wall aspirating pleural fluid)

voluntary contraction of the abdominal wall muscles, fixing the diaphragm, and closing the glossitits that increase intra-abdominal pressure and aids in expelling faces

indicator of the changes in body muscles and whether fat is in proportion to their height

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

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

2nd nursing priority is to assist patient to dorsal recumbent position for what skill

1st step is to adjust bed to elbow height

when do u remove a catheter

expected outcome of foley removal

when do u empty drain bag for foley?

hygiene for foleys

Managing Urinary Retention

Catheter _{STRAIGHT VS FOLEY}

self care bath vs bath

movement of air into and out of lungs.

fecal impaction

fecal incontinence

abdominal incisions and direct manipulation of the bowel during abdominal surgery inhibits peristalsis

bowel incontinence

ileostomy vs colostomy

nursing priorities for oxygenation revolve around maintaining

for whom would u use peak flow meter

Fluid, pus, inflammation in alveoli.

pus in the pleural cavity.

Air in pleural space

Blood in pleura

Chest Drain System is indicated when?

saturation of peripheral capillary oxygen

Based on available hemoglobin; Hgb; reflects the number of RBCs in the blood

saturation of peripheral capillary oxygen; oxygen saturation of arterial blood

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.

CK and isozymes; Troponin

this helps to reinflate the alveoli and prevent atelectasis due to hypoventilation

one way valves that promote expiration

FiO₂

1-6 L/min; low flow; humidification set on wall

atmospheric oxygen

4% = 1 L/min; oxygenation; supplemental oxygen ratio

12 L/min; high flow; 100%

4-10 L/min; HIGH FLOW

ETT indicated when?

High flow O₂ therapy nasal cannula using warmed, humidified air; Up to 8 L/min for infants; Up to 40 L/min for adults