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137 Cards in this Set
- Front
- Back
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what is the contribution had Florence Nightingale towards nursing proffession? |
she was the first practicing nurse epidemiologist and my statastical analyses connected poor sanitation with cholera and dysentry
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who was Clara Barton?
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She founded the American Red Cross and attended to soldiers on the battlefields during the CivilWar. |
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Harriet Tubman
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she was active underground Railroad movement and assisted in leading over 300 slaves to freedom.
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Mary Mahoney
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First professionaly trained African American nurse. She was concerned with relationships between cultures and races
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Isabel Hampton Robb
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She helped found the Nurses' Associated Alumnae of the United States and Canada in 1896 which later became the American Nurses Association in 1911.
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Lillian Wald and Mary Brewster
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Opened the Henry Street Settlement, which focused on the health needs of poor people who lived in tenements in New York City
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Mary Adelaide Nutting
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Became first proffesor of nursing at Columbia Universsity Teachers College in 1906
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What are the Characteristics of a nursing profession ?
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1) Requies an extended education of its members as well as basic liberal education. 2) has a theoretical knowledge leading to defined skills, abilities to norms. 3) Provides a specific service. 4) Members have autonomy in decision-making and practice. 5) Has a code of ethics for practice.
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what is Nursing's Meta Paradigm ( Domain)
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1) Describes the central phenomena of interest to the profession. 2) A paradigm links science, philosophy and theories accepted and applied by the profession. 3) includes interrelationship of four elements: person, health, environment/situation and nursing.
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What so important about nursing theory?
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1) it generates nursing knowledge for use in practice 2) theories explains phenomena 3) Guide how to design each individual's nursing interventions. 4) Provides nurse with a perspective to view the patient situation, a way to organize data and a method to analyze the interpret information. 5) provides direction to nursing research. 6) Nurses require a theoretical base to demonstrate the science and art of their profession.
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What is definition of ANA (American Nurse Association) of nurse Practice?
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Nursing protects, promotes and optimizes health and abilities, prevents illness and injury, alleviates suffering through the diagnosis and treatment of human response and advocates for the care of individuals and families, communities, and population.
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what are the ANA standard of practice and standard of professional persormance?
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1) Assessment: The RN can analyze the assessment data which is relavent to patient's health situation. 2) Diagnosis: The RN analyse the data to determine the diagnosis or issues. 3) Outcome identification: The RN identifies the expected outcome for a patient based on patient's situation. 4) Planning: The RNs develop a plan to achieve expected outcome for patient. 5) Implementation: The RNs implements the identified plan using co
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what are the most common forms of advanced dirctives?
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1) Living wills: details a person's care preferences in regrads to issues like, mechanical ventilation, artifical hydrationor nutrition, dialysis and antibiotics. 2) Durable power of attorney for health care - (DPOA) - name a specific person as a proxy or surrogate to make halth care decisions in the event that a person temprary or permanent looses the capacity for decision making.
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what are the 7 dimentions of Patient-Centered Care?
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1) Respect values, Preferences and Expressed need 2) Coordination and Integration of care 3) Informatio, communication and Education. 4) Physical Comfort. 5) Emotional support and relief of fear and anxiety 6) Involvement of family and friends 7) Transition and continuity 8) Access to care
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what categories of people are more likely to be a part of vulnerable populations?
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individuals living in poverty, older adults, homeless, individuals in abusive relationships, mentally ill, new immigrant (language barrier)
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What is HIPPA?
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Health Insurane Portability and Accountability Act ( HIPPA) by congress in 1996 to limit the ability of an employer to deny health insurance coverage to employees with preexisting medical conditions.
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What are the common health problems in community dwelling older adults?
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hypertension, cancer, arthritis, visual impairment, Alzheimer's
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what are the main rules of HIPPA?
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1) the privacy rules of set standards for the protection of health info. 2) Patient's info record is confidential. 3) all individual data for health info like birth date, address, SSN, MR #, past, present or future mental health or condition, any past, present, future payment for health care. These all info are limited to health care facilities.
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what is the purpose of Pateint Self-Determination Act ?
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The main goal of PSDA to encourage patients to indicate their preferance for end of life care before the need arrives
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identify six level of care are commnly offered and what are their focus?
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1) Primary care: fouces on improved health outcome for entire population: prenatal and baby well care, family planning, nutrition counseling, exercise classes 2) Prevention care : edecation and prevention: BP, cancer screening, immunizations, mental health counceling and crisis prevention, and community legislation i.e seat belt, bycle helmet, air bags 3) Secondary: Emergency treatment critical care, exp: emergency care, acute medical surgical care, radiological procedures for acute care (x-rays, CT scan) 4) Tertiary care: intensive care, subacute care. 5) Restorative care: Health care setting in which patients who are recovering from illness or disability receive rehabilation and supportive care Exp: sports medicine, spinal injury program, home care, 6) Continuing care: For long period of time, people who are disabled: assisted living, psychiatric and older adult day care, extended care facilities.
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How can nurses help facilitate the PSDA?
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the ANA recommends the nurses ask patients these question: 1) do have basic info about advance care like living wills, power of attorney. Do you wish to initiate an advance directive? If you have already prepared, can you provide it now? Have you dissucused your end of life choices with your family or designated surrogate and health team worker?
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what is the code of ethics and how important for nursing proffession? |
Set of guiding principles that all members of a profession accept.
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What is definition of ICN of nurse Practice? |
simillar to ANA and addition to advocacy, promotion of safe environment, research, participation in shaping health policy and in patient and health system management, and education are also key nursing roles. |
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what is abrasion?
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wound that caused by superficial damage to skin. No deeper than epidermis |
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what is contusion?
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A contusion (aka bruise) is an area of skin discoloration. A bruise occurs when small blood vessels break and leak their contents into the soft tissue beneath the skin. |
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what is ischemia?
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insufficient blood flow to tissues, not enough oxygen. Compression of pressure point for prolonged period of time by bony prominences or external sources cause tissue death.
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what is lacertation ?
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deep cut or tare
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what is puncture ?
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injured by pointed object
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What is stab?
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deep stab, penetration
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what is pressure ulcer?
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localized injury to the skin and underlying tissue over a bony prominence as a result of pressure/friction of shear.
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How wound can described in diffrent stages?
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abrasion, contusion, incision, inchemia, lacertation, puncture, stab, pressure ulcer
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what are the four phases of full thickness wound repair?
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hemostasis, inflammatory phase, Proliferative phase, Remodeling
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Where are common locations for pressure ulcers?
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bony prominences
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Where are common locations of venous ulcers?
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above the ankle
on the medial lower leg |
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Where are common locations for arterial ulcers
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lower leg, dorsum of the foot, malleolus, toe joints, lateral border of the foot
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What are common locations for diabetic/neuropathic ulcers?
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plantar surface of foot, metatarsal heads, heels, lateral border of foot
(many of the same places as arterial) |
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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/or friction
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Pressure Ulcer: Stage I
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nonblanchable erythema
intact skin with non–blanchable redness of a localized area usually over a bony prominence darkly pigmented skin may not have visible blanching, but its color may differ from the surrounding tissues |
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What may a pressure ulcer stage I feel like?
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may be painful, firm, warmer or cooler as compared to adjacent tissue
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What do you do to check if there's a stage I pressure ulcer?
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change position and if it still has a nonblanchable reddness, then it's a stage one
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What is the best time to treat a pressure ulcer?
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stage one
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Pressure Ulcer: Stage II
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partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
May present as an intact or open/ruptured serum–filled blister |
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Do you have an open area in stage II?
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yes
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What is the depth of a stage II pressure ulcer?
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nothing beyond 0.2 cm
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Can you use stage II to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation?
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no
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What do you do if you can't see the bottom of the wound (wound base)
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you cannot stage it
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What is a maceration from?
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sitting in a wet environment
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Do you have an open area in stage II?
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yes
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What is the depth of a stage II pressure ulcer?
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nothing beyond 0.2 cm
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Can you use stage II to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation?
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no
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What do you do if you can't see the bottom of the wound (wound base)
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you cannot stage it
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What is a maceration from?
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sitting in a wet environment
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What is an excoriation from?
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moisture site
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Pressure Ulcer: Stage III
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*full thickness tissue loss
*subQ fat may be visible but bone, tendon, or muscle are not exposed *slough may be present but does not obscure the depth of tissue loss *may include undermining and tunneling *bone–tendon is not visible or directly palpable |
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What stage is bone/tendon visible and directly palpable?
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stage IV
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What is the depth of a Stage III?
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greater than 0.2 cm, but you are not able to see bone/tendon
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Pressure Ulcer: Stage IV
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*full thickness tissue loss with exposed bone, tendon, or muscle
*sloud or eschar may be present on some parts of the wound bed *often includes undermining or tunneling *exposed bone/tendon is visible or directly palpable |
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Pressure Ulcer: Unstageable
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full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in thewound bed
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What colors are slough?
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yellow, tan, gray, green or brown
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What colors are eschar?
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tan, brown, or black
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What must you do in order to stage an unstageable pressure ulcer?
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remove enough slough and/or eschar to expose the base of the wound, as well as the true depth
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What stages must be reported to the state?
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stage 3, 4, or unstageable
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Pressure Ulcer: Suspected Deep Tissue Injury
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purple or maroon localized area of discolored intact skin or blood–filled blister due to damange of underlying sotft tissue from pressure and/or shear
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What may precede a suspected deep tissue injury?
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tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue
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What must be done with a suspected deep tissue injury?
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it MUST be caught early, then it may be able to be reversed
otherwise, it may break open and cause death |
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What may occur with pressure ulcers (tip of the iceberg)
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may get worse before it gets better
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What is reverse staging of pressure ulcers?
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once the ulcer is staged, that remains the stage and would severity diagnosis
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What would you call a pressure ulcer that was staged as a stage III and now appears to be a stage II after it has begun healting?
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a healing Stage III pressure ulcer
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What is a venous ulcer?
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lesion caused by insufficient backflow of blood into the venous system, failure of calf muscle pump to improve venous return, and bacflow causes capillary distenstion, fluid extravasation, tissue ischemia leading to ulceration and decreased delivery of oxygen and nutrients to the skin caused by capillary fibrin cuffing and white cell trapping
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What can be done to support venous blood flow?
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compression therapy
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What is the main cause of a venous ulcer?
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valve incompetence in perforating veins
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What will you feel like with a venous ulcer?
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tired when active and resting makes it better
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What will you feel like with an arterial ulcer?
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better when feet are down and active; hate resting
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Arterial ulcer
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lesion caused by narrowing and eventual occlusion of the extremity artery
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What do a lot of arterial ulcers look like?
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precise lesions
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What is neuropathy
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a chronic complication fo diabetes in which the nerves have been damaged so the person's foot is primarily insensate and does not feel pressure, injuries, or infection
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What are partial–thickness wounds?
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shallow, involves the epidermins and dermis, moist, painful, pink–red color, up to 0.2 cm
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Full–Thickness wound
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*extends to subcutaneous layer or deeper: over 0.2 cm depth
*may include necrotic tissue or infection *often extensive tissue damage |
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When is pressure ulcer documented?
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on admission
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What length of the ulcer do you measure
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the longest length in cm measured from head to toe (12:00–6:00)
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What width of the ulcer to you measure?
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longest width in cm measured from side to side (9:00–3:00)
the widest portion that is still perpendicular |
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What is the wound depth
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distance from visible skin surface to wound bed
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How can you assess wound depth
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by using a clean cotton–tipped applicator or a cm measuring device placed in the deepest part of the wound, marking it, and then measuring it upon removal
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What is a sinus tract/tunnel?
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channel that extends from any part of the wound through subcutaenous tissue or muscle
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How do you document a tunnel?
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measuring depth and noting location using face of clock as a guide
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Undermining
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Tissue destruction that occurs under intact skin around the wound perimeter
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How do you document/measure undermining?
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measure depth and note location using face of the clock as a guide
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Necrotic tissue
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tissue that has died and lost is physical properties and biologic activity
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Eschar
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black or brown necrotic, devitalized tissue
*can be loose or firmly adherence, hard, soft or boggy |
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If eschar is one the heels and hard, firm, well attached and has no sign of infection, what do you do?
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leave it
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If the heel is boggy, draining and has infection what do you do?
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remove it
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Slough
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soft, moist, avascular (necrotic or devitalized) tissue
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What may slough look/feel like?
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white, yellow, tan or green
loose or firmly adherent slippery |
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Granulation tissue
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deep pink/ red moist tissue comprised of new blood vessels, connective tissue, fibroblasts, and inflammatory cells that fill an open wound when it starts to heal
*surface is granular, berry like or cobblestone in appearance |
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Clean, non granulating tissue
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absence of granulation on wound surface
*appears smooth and red but not granular, berry like or cobblestone appearing |
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Epithelial tissue
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regenerated epidermis across the wound surface
*pink color and dry appearance |
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How do you describe hte amount of tissue in the wound bedd
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a transparent measuring guide with concentric circles dividing into four pie shaped quadrants that can help to determine percentage of wound involved
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Exudate
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drainage of the wound
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Blood exudate
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thin, bright red
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serous exudate
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thin, watery, clear
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Serosanguineous exudate
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think, watery, pale red to pink
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purulent exudate
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thin or thick and opaque tan to yellow
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foul purulent exudate
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thick, opaque yellow to green with offensive odor
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No exudate
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wound tissues dry
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Scant exudate
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wound tissues moist; no measurable exudate
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Small exudate
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wound tissues wet; moisture evenly distributed in wound; wound drainage invovles less than or equal to 25% of the dressing
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Moderate exudate
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wound tissues saturated; drainage may or may not be evenly distribuated in wound
drainage involves great than 25% to less than or equal to 75% of dressing |
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Large exudate
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wound tissues bathed in fluid; drainage freely expressed; may or may not be evenly distributed in wound; drainage involves over 75% of dressing
**get moisture off of the wound! |
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What is amount of exudate important?
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when choosing dressing and what compression therapy to use
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What do you do before assessing a wound?
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clean it first, use deodorizer in the air and then smell clean wound to see if it smells
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What do you do if you think the wound smells
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ensure that its the wound and not the dressing that smells
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What is induration
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firm skin that goes in
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What are some conditions that may happen to the periwound skin?
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callus, maceration, edema, skin color surrounding wound, peripheral tissue induration, temperature
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What do you do for venous insufficiency ulcers?
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compress
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What do you do for arterial ulcers?
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open up circulation
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What is important for diabetic ulcers?
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get the right footwear! Find a place that measures and fits the foot!
get footwear as seamless as possible where you're able to move the toes |
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What should you do before debridement?
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make sure the patient has been provided pain relief
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What are some conditions that may happen to the periwound skin?
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callus, maceration, edema, skin color surrounding wound, peripheral tissue induration, temperature
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What do you do for venous insufficiency ulcers?
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compress
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What do you do for arterial ulcers?
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open up circulation
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What is important for diabetic ulcers?
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get the right footwear! Find a place that measures and fits the foot!
get footwear as seamless as possible where you're able to move the toes |
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What should you do before debridement?
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make sure the patient has been provided pain relief
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What do you check in wound before healing?
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dead tissue
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How do you remove necrotic tissue?
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pulse lavage, soften tissue, ultrasound mist, debride
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What are local factors?
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presence of devitalized tissue, moistness of the wound bed (not wet but moist), presence of bacterial infection
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What are some systemic factors
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age, bodybuild, stress, diabetes, previous medical history, oxygen, nutrition, steroids, prealbumin
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What can build up protein/albumin?
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whey protein
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What do you do before getting a would culture?
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clean the would with saline, then once clean, twirl applicator along wound and into depth/ tunnel to get a good sample
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What are some objectives to treatment
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protect from further trauma, optimal and moist environment, remove devitalized tissue, optimal systemic conditions
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What can you do to protect pressure ulcers?
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pressure relief and patient movement
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What can do you do protect venous ulcers?
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compression
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What can you do to protect arterial ulcers?
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restore circulation
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What can you do to protect diabetic ulcers?
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offload
wear shoes any time out of bed |
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What are some ways to maintain optimal moist healing environment?
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wound hydration and dressing selection
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What can you do for debridement?
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surgical, sharp, enzymes, polyurethane dressings, irrigations, wet to moist dressings
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What are some optimal systemic conditions for healing?
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nutritional status, diabetes control, stress, patient and family involvement, oxygen, sterois
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What is the most effective treatment for pressure ulcers?
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PREVENTION |
