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114 Cards in this Set
- Front
- Back
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What is the largest organ of the body?
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integumentary system
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What is the outermost layer of the skin?
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epidermis
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What layer of skin forms hair, nails, and glands?
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epidermis
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What layer of skin has keratinocytes and melanocytes?
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epidermis
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What layer of skin is below the epidermis?
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dermis
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What layer of skin is tough connective tissue?
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dermis
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What layer os skin contains vessels, nerves, and lymphatic?
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dermis
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What is the deepest layer of the skin?
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subcutaneous
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What layer of skin consists of fat and connective tissue?
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subcutaneous
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What layer of skin is poorly vascularized?
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subcutaneous
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What type of cells are found in the dermis?
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fibroblasts
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What layer of skin supports and nourishes the epidermis?
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dermis
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What are the functions of the skin?
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-cosmetic
-protective barrier -sensation -water balance -temperature regulation -vitamin production |
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Which patient's may have decreased skin sensory function?
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-eldery
-diabetics |
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Which soap is most optimal for bathing pt to maintain skin health?
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dove
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What is the skin's pH?
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5.0-6.0 (acidic)
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What pH should cleansing products be?
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pH balance or neutral (7)
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What is the growing trend for bathing patients?
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chorahexadine (CHG) bathing wipes. it is an effective antimicrobial agent
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How does turgor change with aging?
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decreases
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Should skin assessment consider hair and nails?
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yes
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Is nutrition important in skin assessment?
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yes
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What do you assess during wound assessment?
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-type
-location -size -classification -% viable vs. non-viable -drainage |
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Always clean wounds with what?
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normal saline
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What should you always do before assessing a wound?
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clean it out for proper assessment
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Describe language in which we describe wounds. (standardized language)
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-length (head to toe)
-width (hip to hip) -depth (deepest point) -tunneling and undermining (clock) -color of ulcer base (red, yellow, black) -drainage (amount, color, odor) |
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What type of tissue is red, moist, beefy?
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granulation tissue
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What type of tissue indicates progression to healing?
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granulation tissue (red)
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What type of tissue is yellow, stringy substance that is attached to wound bed?
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slough tissue
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What does black tissue indicate?
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necrosis and it must be removed for healing to occur.
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What does periwound mean?
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skin around wound
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What are some words to describe the periwound (skin around wound)?
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-intact
-erythema -macerated -blistered |
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If a pt is complaining of increased pain at the wound site. The wound has increased drainage but it is not foul smelling. The RN may suspect what?
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possible wound infection
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What do we assess with the drains of wounds?
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-patency
-stabilization -amount of drainage -description of drainage |
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What are some other things needed to be assessed with wound healing?
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-circulation (blood volume, etc)
-nutrition (protein) -medication & Disease States (DM) |
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How do you know the wound is healing well?
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-wound bed is "beefy red"
-wound heals from edges -decreasing pain (but more pain when wound is open) -free of s/s of infection |
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What is HAPU?
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Hospital Acquired Pressure Ulcers (HAPU)
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What is the primary difference between a wound and a pressure ulcer?
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etiology
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What are never events?
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events that should never happen
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What is a pressure ulcer?
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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 friction.
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What is pressure?
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compresses underlying tissue and small blood vessels against the surface below. tissues can become ischemic and die.
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What is friction?
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the resistance created when one surface moves horizontally against another.
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What is shear?
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occurs when one layer of tissue slides horizontally over another, deforming and destroying blood flow.
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What do we use to assess risk for pressure ulcers?
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Braden Scale
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What is the first step in the prevention of pressure ulcers?
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risk assessment
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What does it mean to assess intrinstic and extrinsic factors for pressure ulcers?
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intrinsic factors
-advanced age -cognitive -chronic illness -immobility -poor nutrition extrinsic factors -pressure -friction -humidity -shear force |
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What is Braden Score 15-18?
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at risk
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What is Braden Score 13-14?
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moderate risk
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What is Braden Score 10-12
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high risk
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What is Braden Score less than 9?
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very high risk
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What are the staging of pressure ulcers?
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-deep tissue injury (DTI)
-Stage I -Stage II -Stage III -Stage IV -unstageable |
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What does it mean to say a pressure ulcer is unstageable?
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it is covered by eschar (necrotic tissue)
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What is a deep tissue injury (DTI)?
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from prolonged pressure or positioning within a short period of time that compromises tissue perfusion and creates a wound deep in the dermis that initially presents superficially.
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How soon can you see a deep tissue injury (DTI)?
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very soon
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What color will a deep tissue injury (DTI)?
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purple or maroon
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What do you do to a non-draining DTI?
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leave open to air
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What is incontinence-associated dermatitis (IAD)?
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perineal excoriation due to (d/t) incontinence
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What can you do to 1st identify the source of IAD?
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-antibiotics or tube feedings
-consult nutritionist -consider medications to slow diarrhea -medications that could cause diarrhea -underpads changed frequently -airloss mattress |
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When do you use rectal pouches?
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incontinent with feces.
-apply correctly with 2 people -stays for 1-2 days -effective in relieving IAD |
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What are the nursing interventions with IAD?
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-anticipate incontinence
-clean pt frequently with pH balance product -use protective barrier w/each cleaning -apply under pads to wick moisture away -PREVENTION is key -know difference of PU and IAD |
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What do you need MD orders for with pt who has excoriation w/fungal infection?
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antifungal barrier cream
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What are contact dermatitis?
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allergic reaction or "irritation"
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What questions must you answer if your pt has a drain from a wound?
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-why is the drain in? (purpose)
-who placed the drain? -How is the drain secured? (tape, sutures) |
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Where do you document wound drainage output?
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with normal I&O's. it helps make decisions about fluids in and out.
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How much protein is lost daily with wound drainage?
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up to 100 grams
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What does current evidence state for the first 48 hours of an incision?
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keep dressing intact.
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Negative pressure with negative pressure wound therapy stimulates what?
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angiogenesis
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What is a clear protective dressing typically called?
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tegaderm
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What type of infection at pt at risk for if they have Stage IV pressure ulcer?
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osteomyeolitis
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How do you calculate BMI?
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weight (pounds)
------------------------ x703 height (inches squared) |
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What is goal BMI?
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19-25
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What does ideal body weight mean?
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100lbs for 5ft tall woman - add 5lbs for every inch above 5ft.
105lbs for 5ft tall man - add 6lbs for every inch above 5ft. |
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How do we calculate energy requirements?
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1 kcal/hour/kg
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What does NPO mean?
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nothing by mouth
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What is a regular diet in the hospital?
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~2,000 cal/day
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What is a clear liquid diet?
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anything transparent
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What is a full liquid diet?
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-clear liquids
-anything liquid at room temperature (ice cream) |
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What is a soft diet?
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-less energy to chew, chop, pureed
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What are some restrictive diets?
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-low sodium
-renal diet -ADA diet -calorie reduced |
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If a pt is renal compromised what is watched and restricted on their diet?
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-low protein
-low potassium -low sodium -fluid restriction |
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If a pt has liver disease or liver failure what is watched or restricted on their diet?
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-low sodium
-low protein -fluid restriction |
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HF patients are on what type of diet typically?
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-restrict calories
-restrict fluid |
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Coronary Artery Disease (CAD) are on what type of diet typically?
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-restrict sodium
-restrict calories -restrict saturated fat -restrict cholesterol |
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A patient with burns may have what type of diet?
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-fluid replacement
-increase calories -increase protein -increase Vitamin C -increase B-complex vitamins |
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A patient with respiratory disease may have what type of diet?
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-soft diet
-high calorie -high protein |
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A patient with HTN may have what type of diet?
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-restrict calories
-restrict sodium |
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In the normal healthy adult how much of the stool is water?
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75%
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If a patient has altered bowel status what should be the first thing you think of?
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hydration
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How much fluid do you want to encourage your patient to intake?
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2000cc/daily
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How do narcotics effect bowel function?
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constipation
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How do antibiotics effect bowel function?
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diarrhea
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How do antacids effect bowel function?
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constipation or diarrhea
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What is the important thing to find out with a patient about their bowel function?
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find their baseline (normal)
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What is infrequent bowel movements, difficult evacuation of feces, straining or hard feces?
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constipation
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Why is feces hard in constipation?
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fecal mass has increased time to the intestinal wall and more water is absorbed making it hard.
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What is the result of unrelieved constipation?
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impaction
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What is increase in number of stools and the passage of liquid, unformed feces?
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diarrhea
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What does flatulence mean?
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accumulation of expelling gas
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What are dilated or engorged veins in the lining of the rectum?
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hemorrhoids
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What is the portion of GI tract that is brought to the abdominal wall?
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stoma
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If a stoma is at the large colon it is called what?
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colostomy
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If a stoma is at the ileium , what is it called?
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ileostomy
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What scope examines rectum and sigmoid colon?
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proctoscopy/sigmoidoscopy
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What scope examines colon up to ileocecal valve?
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colonoscopy
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What scope examines the esophagus, stomach, and duodenum?
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esophagogastroduodenoscopy (EGD)
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What does digital removal of stool mean?
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removing stool with your fingers (very embarrassing you must ensure privacy of pt)
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What are the six steps to the nursing process?
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-assessment
-diagnosis -outcome identification -planning -implementation -evaluation |
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What is a systematic problem-solving approach toward giving individualized nursing care?
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nursing process
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What is a clinical judgement about individual, family, or community responses to actual or potential health/life processes?
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nursing diagnosis
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What provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable?
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nursing diagnosis
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In the diagnosis phase what will the nurse do?
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-identify the patterns
-validates the diagnosis -formulates the nursing diagnosis statement |
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What describes a disease or pathology of specific organs or body systems?
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medical diagnosis
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What provides data for identifying nursing diagnosis?
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assessment
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Where does TPN get administered?
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central venous catheter (CVC)
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What is a form of nutritional support that supplies protein, carbohydrate, fat, electrolytes, vitamins, minerals, and fluids via the IV route?
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parenteral nutrition
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