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Clients admitted into the ER may experience behavior changes due to what?
Sensory Overload
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When performing a history, the nurse assesses sensory perceptions such as what?
Mental Status
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Peripheral neuropathy and parestesias become the etiology for other nursing diagnoses. An example of such a diagnosis is what?
Risk for injury
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Nurses can increase environmental stimuli for clietns with sensory defecit by what?
Establishing a routine identified with each meal
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A client has impaired vision. An intervention to best adapt the environment to this loss includes what?
Keeping the room pathways free of clutter.
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Which statement by a client with decreased hearing indicates a need for a sensory aid in the home?
I can't hear people knocking at the door.
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Which statement by a hospitalized client indicates she needs further orientation to time, place, person, or situation?
I'm tired of sitting in this train station
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Which client is most likely to experience sensory deprivation?
A deaf 88-year-old single client with +4 edema who lives in an upstairs apartment
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Clinical manifestations of Sensory Overload
- -C/o fatigue, sleeplessness
- -Irritability, anxiety, and restlessness
- -Periodic or general disorientation
- -Reduced problem solving abiity and task performance
- -Increased muscle tension
- -Scattered attention and racing thoughts
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Clinical Manifestations of Sensory Deprivation
- -Excessive yawning, drowsiness, and sleep
- -Decreased attention span and problem solving, difficulty concentrating
- -Hallucinations or delusions
- -Apathy and emotional liability
- -Preoccupation with somatic complaints
- -Crying, annoyance over small matters and depression
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Assessment of Sensory-Perceptual Function
- -Nursing history
- -Mental status exam
- -Physical exam
- -Environment
- -Social Support Network
- -Identification of clients at risk
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Risk Factors for Sensory Deprivation
- -Nonstimulating or monotonous environment
- -Impaired vision or hearing
- -Mobility restrictions
- -Inablility to process stimuli
- -Emotional disorders
- -Limited social contact
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Risk Factors for Sensory Overload
- -Pain or discomfort
- -Admission to an acute care facility
- -Monitoring in intensive care units
- -Invasive tubes
- -Decreased cognitive ability
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Orientation Strategies for Client with Acute Confusion/Delirium
- -Wear a readable nametag
- -Address the person by name
- -Introduce yourself frequently
- -Keep room well lit during waking hours
- -Orient the client to place if indicated
- -Identify time and place if indicated
- -Ask the client "where are you?"
- -Place a calendar and clock in client's room
- -Mark holidays with ribbons, pins etc.
- -Speak clearly and calmly, allowing time for words to be processed and for a response
- -Encourage family to visit frequently
- -Provide clear concise explanation of each treatment, procedure or task
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Olfactory
Provide aromatic stimuli that may include client's favorites
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Gustatory
- -Provide mouth care
- -Place different tastes on tongue
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Kinesthetic
- -ROM
- -Change client's position in bed
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Delirium
Characterized by a disturbance of consciousness and a change in cognition such as impaired attention span and disturbances of consciousness that develops over a short period of time.
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Dementia
Develops more slowly and is characterized by multiple cognitive defecits that include impaired memory
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Amnestic Disorder
Characterized by loss in both short-term memory and long-term memory, sufficient to cause some impairment in the person's functioning
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Depression
- -Gradual with excerbation during crisis or stress
- -Difficulty concentrating, forgetfulness, inattention
- -LOC not altered
- -Lethargy, lack of motivation, poor sleep
- -Extreme sadness, apathy, anxiety, irritability
- -Speech is slow, flat, and low
- -It is reversible with proper and timely treatment
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Delirium can occur:
- -More frequently in elderly
- -Postoperative
- -Drugs
- -Cardiovascular disease
- -CHF
- -Children with fever
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Symptoms of Delirium
- -Disturbance in consciousness, thinking, memory, attention, perception
- -Develop over a short period
- -Fluctuates during the day
- -Progressive disorientation to time and place
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Common causes of Delirium
- -Infections
- -Postoperative states
- -Metabolic abnormalities
- -Hypoxic conditions
- -Drug withdrawal
- -Drug intoxications
- -Polypharmacy
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Nursing concerns with Delirium
- -Assisting with proper health management to eradicate the underlying cause
- -Preventing physical harm due to confusion, agression, or electrolyte and fluid imbalance
- -Use supportive measures to relieve distress
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Nursing Diagnosis Associated with Delirium
- -Risk for injury
- -Fluid volume defecit
- -Acute confusion
- -Sleep pattern disturbance
- -Impaired verbal communication
- -Self-care defecits
- -Impaired social interaction
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Dementia
- -Marked by progressive deterioration in intellectual functioning, memory, and ability to solve problems and learn new skills
- -Judgement, moral and ethical behaviors decline as personality is altered
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Etiology of Dimentia
- -Neurodegenerative
- -Vascular
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Types of Dimentia
- -Alzheimer's type
- -Pick's disease
- -Creutzfeldt-Jakob
- -Multiinfarct
- -Parkinson's
- -Korsakoff's syndrome
- -Huntington's disease
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Clissifications of Dimentia
- -Primary-is not reversible, prgoressive, not secondary to any other disorder
- -Secondary-result of some other pathological process
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Pseudodementia
- -Mimics dimentia
- -Drug toxicity
- -Metabolic disorders
- -Infections
- -Nutritional deficiencies
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Causes of Alzheimer's
- -Unknown
- -Hypotheses:
- -Neurochemical changes
- -Genetic defects
- -Abnormal proteins
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Pathological Changes due to Alzheimers
- -Neurofibrility tangles
- -Senile plaques
- -Granulovascular degeneration
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Four Signs of Alzheimer's
- -Aphasia: loss of language ability
- -Apraxia: loss of purposeful movement
- -Agnosia: loss of sensory ability to recognize objects
- -Mnemonic disturbance: loss of memory
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Cognitive Assessment Tools for Alzheimer's
- -Mini-Mental Status Examination
- -Clock drawing test
- -Geriatric Depression Scale
- -Functional Assessment (Katz)
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Mild Alzheimer's (Stage 1)
- -loss of short term memory
- -Aware of problem
- -Depression
- -Not diagnosible
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Moderate Alzheimer's (Stage 2)
- -Progressive memory loss
- -Withdrawn from social activities
- -Declines in ADL's
- -Depression increasingly common
- -Problems intensified when stressed, fatigued, or out of own environment
- -Needs in home assistance or day care
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Severe Alzheimer's (Stage 3)-Late
- -Family recognition disappears
- -Forgets how to eat
- -Has problems with mobility
- -Incontinence
- -Return of infantile reflexes
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Nursing Diagnoses for Alzheimers
- -Risk for injury
- -Impaired verbal communication
- -Chronic confusion
- -Disturbed sleep pattern
- -Imabalanced nutrition
- -Caregiver role strain
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Anti-Alzheimer's Drugs
- -Cognex
- -Aricept
- -Exelon
- -Razadyne
- -Namenda-Stage 3
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A nursing diagnosis appropriate for a client with Alzheimer's disease, regardles of the stage would be
risk for injury
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Which problem is not considered a causative agent in delirium?
Down Syndrome
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The daughter of a petient with early familial Alzheimer's Disease asks how AD can be detected. The nurse describes early warning signs of AD including what?
Having no memory of preparing a meal and forgetting to serve or eat it
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A petient with Alzheimer's Disease had a nursing diagnosis of disturbed thought processes related to effects of dementia. An appropriate intervention for the patient is to what?
Maintain familiar routines of sleep, meals, drug administration, and activities
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Which event would a client with early Alzheimer's Disease have greatest difficulty remembering?
What the client ate for breakfast
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A 69-year old patient is admitted to the hospital with a urinary infection and a possible bacterial sepsis. The patient is disoriented and has a disturbed sleep-wake cycle. The nurse administers a mini-mental state examination to differentiate among various cognitive disorders, primarily because what?
Delirium can be reversed by treating the underlying causes
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Health
A dynamic and relative state that applies to individuals, families, and groups, and is described in degrees of wellness/illness resulting from met or unmet needs.
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Wellness
- -Self-responsibility
- -Daily decision making about health, involving whole being
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Basic Human Needs Model of Health
Basic human needs are elements that are necessary for human survival and health. Example: Maslow's Hierarchy of Needs
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Health Continuum Model
Death on one end and high-level wellness on the other
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Health Belief Model
- -Addresses the relationship between a person's beliefs and behaviors.
- -Explains why some people maintain health and treat illness while others fail to protect themselves
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Health Promotion Model
- -Complimentary counterpart to models of health protection
- -Increasing a clients level of well-being
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Hollistic Health Models
- -Clients are seen as the ultimate experts regarding their own health
- -Interventions are complimentary and alternative
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Primary Prevention
- -True prevention
- -Immunizations
- -Physical activites
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Secondary Prevention
- -Experiencing health problems and at risk for complications
- -Screening techniques
- -Treating early stages
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Tertiary Prevention
- -Defect is permanent or irriversible
- -Rehab activites
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Using Maslow's Model, which statement characterizes the highest level of need?
I'm very proud of receiving that Employee of the Month reward at my hospital
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Which is an example of the emotional component of wellness?
A client expresses frustration with his diabetic regimen
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A 55-year old teacher decides to have a colonoscopy. Which factor was likely a cue to action?
The recent death of a friend from colon cancer
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A 24-yr-old diabetic client comes to the clinic with a 200 blood sugar. He says he wants to control his diabetes, but finds it hard to fit appropriate eating, fingersticks and insulin into his very active life. Best nursing diagnosis?
Ineffective therapeutic regimen management
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Based on the fact that health is a personal perception, which person is likely to consider themselves healthy?
Honors student who uses a wheelchair and volunteers for a suicide hotline
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Client: I was born to be fat. I can lose weight fine, but I don't have the willpower to keep it off.
Using the health promotion model, what will the nurse focus on to help the client?
Perceived self-efficacy
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Epidermis
Avascular superficial layer
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Dermis
Supportive connective tissue
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Subcutaneous tissue
Attaches skin to underlying tissues and organs
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acute wound
Occur suddenly, move rapidly and predictable through the repair process and result in durable closure
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chronic wound
Frequently caused by vascular compromise, chronic inflammation, or repetitive insult to the tissue, and either failt to close in a timely manner or fail to result in durable closure
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Phases of Wound Healing
- -Inflammatory Phase: begins at time of injury and lasts 3 to 4 days
- -Proliferative or Reconstructive: 4 to 21 days
- -Maturation or Remodeling Phase: 3 to 4 weeks
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Perineal Dermatitis
A contact dermatitis in the perineal region, with the physical signs of one or any combination of erythema, swelling, oozing, vesiculation, crusting, and scaling.
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Preventing Perineal Dermatitis
- -Identify patients at risk for incontinence
- -Gentle cleansing
- -Moisturize
- -Protect skin from irritants
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Skin Tears
A traumatic wound occuring principally on the extremeties of older adults, as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis or which separate both the epidermis and the dermis from underlying structures.
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Prevention Highlights for Skin Tears
- -Identify patients at risk
- -Avoid skin care products that dry the skin
- -Avoid scrubbing and rubbing skin
- -Use good transferring, positioning, turning and lifting techniques to reduce friction and shear
- -Use protective padding
- -Encourage patients to wear long sleeves and pants to protect skin
- -Avoid adhesives or remove with care
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Pressure Ulcer
A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
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Stage One Pressure Ulcer
- -Intact skin with non-blanchable redness of a localized area.
- -Painful, firm, soft, warmer, or cooler
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Stage Two Pressure Ulcer
- -Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough
- -intact or open/ruptured serum-filled blister
- -Shiny or dry shallow ulcer without slough or bruising
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Stage Three Pressure Ulcer
- -Full thickness tissue loss
- -Subcutaneous fat may be visible
- -Slough may be present but does not obscure the depth of tissue loss
- -Undermining and tunneling may be included
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Stage Four Pressure Ulcer
- -Full thickness tissue loss
- -Exposed bone, tendon, or muscle
- -Slough or escar may be present on some parts of wound bed
- -Often include undermining and tunneling
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Unstageable Pressure Ulcer
- -Full thickness tissue loss
- -Base of ulcer covered by slough and/or eschar in the wound bed
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Suspected Deep Tissue Injury
- -Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear
- -Preceeded by tissue that is painful, firm, mushy, boggy, warmer or cooler to adjacent tissue
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Prevention of DTI
- -Cleanse skin after each incontinence episode and dry
- -Reduce friction and shearing forces
- -Do not massage skin
- -Use skin barriers
- -Avoid foam rings and donuts
- -Reposition q 2 h
- -Maintain adequate nutrition
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Wound Debridement
any wound acute or chronic when necrotic tissue or foreign bodies are present or if the wound is infected
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Types of Wound Debridement
- -Sharp: scalpel
- -Mechnical: Whirlpool
- -Enzymatic
- -Autolytic: Own enzymes
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Surgical Wounds
a healthy and uncomplicated break in the skin's continuity resulting from surgery
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Complications of Surgical Wounds
- -Hemorrhage
- -Infection
- -Dehisence
- -Evisceration
- -Fistula
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Burns
Acute wound caused by exposure to thermal extremes, causatic chemicals, electiricty or radiation
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Venous Ulcers
Chronic skin and subcataneous lesions usualy found on the lower extremity at the pretibial and the medial supra malleolar areas of the ankle
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Preventing Venous Ulcers
- -Treat varicosities
- -Compression therapy to improve venous return
- -Strengthening calf muscles
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Diabetic Neuropathic Foot Ulcers
- -Due to the complication of diabetes, which may make the foot insensitate to forces of friction, shear and pressure.
- -lead to dryness, cracking, callus formation and fissuring of the extremities with resulting ulcerations
- -greater risk of infection, gangrene, and possible amputation
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Aterial Ulcers
- caused by impairment in the arterial circulation that results in ischemia, necrosis and eventually ulcerations.
- -moist wound dressing
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Mixed Venous-Arterial Ulcers
-symptoms of both venous and arterial insufficiency
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Assessment of Impaired Skin Integrity
- -Health History: medical and psychosocial
- -Diagnostic Tests: cbc, albumin levels, sedimentation rate
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Wound Measurement
-location, size, color, surrounding skin, drainage, pain, temperature
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Undermining
- a closed passageway under the surface of the skin that is open only at the skin surface.
- -often develops from shearing forces
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Braden Skin Scale
- -Sensory Perception
- -Moisture
- -Activity
- -Mobility
- -Nutrition
- -Friction and Shear
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Assessment of Wounds
- -Serous
- -Sanguiness
- -Serosanguiness
- -Purulent
- -Red-Yellow-Black
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Factors Affecting Skin and Wound Healing
- -Lifestyle: personal hygeine, nutrition and fluid status, activity and exercise, smoking, substance abuse
- -Developmental: elderly
- -Physiological: age, immunosupression, hypoxemia, diabetes, infection, neurological impairment, procedures, medication
- -Environmental: moisture, friction, and shear
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Nursing Diagnosis-Wound
- -Risk for impaired skin integrity
- -Impaired skin integrity
- -Impaired tissue integrity
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Cold
local anesthetic effect
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Applying Heat and Cold
- -apply both in dry or moist forms
- -apply for 20-30 minutes
- -rebound phenomenon
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Contraindications to Heat
- -1st 24 hours after injury
- -active hemorrhage
- -localized malignant tumor
- -skin disorders that cause redness or blisters
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Contraindications to Cold
- -open wounds
- -impaired circulation
- -allergy or hypersensitivity to cold
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When changing the dressing on a full thickness wound, the nurse charts, "wound bed covered with granulation tissue." On inspection, the nurse found that the wound bed tissue was?
beefy, red, moist, and granular
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The nurse assess a surgical client the morning of the first postoperative day. Signs of a local inflammatory response that the nurse expects to find include?
redness and heat of the incision
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A pressure ulcer is an example of what type of wound?
Chronic wound, open, possibly contaminated
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Your client has yellow drainage from her wound. What does this indicate?
It is unclear if this wound is infected
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A basic principle of wound management for all open wounds is to what?
Protect new granulationand epithelial tissue
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When documenting normal findings of an assessment of the patient's skin, which of the following entries by the nurse is most appropriate?
Skin brown, slightly moist and warm; turgor immediate return; no lesions noted; states no problems with skin
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A patient's 6'3cm leg wound has a 2-mm black area surrounded by yellow-green semi liquid material. Which dressing will the nurse anticipate using for wound care?
Hydrocolloid dressing (DuoDerm)
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