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125 Cards in this Set
- Front
- Back
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What is the body's first line of defense?
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SKIN
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What prevention is the best cure for a pressure sore?
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Reposition every 2 hours, align, & support body.
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How is the severity of burns measured? (two factors)
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Extent of the surface involved & the depth of the injury.
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Describe the treatment of fissure.
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Tx clean & dry depends on depth or presence of infection.
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Define fissure.
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A fissure is a linear crack from the epidermis to dermis.
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Define dehiscence?
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(Comes Apart) A partial or complete wound separation.
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Describe Evisceration
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Organ comes out (EVICT)
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How do you check for skin turgor?
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Tenting of skin. (It tells you the fluid amt in the skin)
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Describe the stages of skin breakdown (Stage one)
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Documentation, Assessment, & Treatment begin.
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Why would you maintain skin integrity?
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It affects the functioning ability & overall well being of the pt.
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Why does the Elderly have increased skin problems?
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They have translucent loose hanging skin which can get caught & easily injured.
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Why is diet important?
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Our diet can help obtain a healthy immune system & ultimately a healthier life.
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Fluids are used to?
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Prevent dehydration of cells.
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Proteins are used for?
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Tissue repair.
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Vitamins & Minerals are?
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Needed for body & cell functions.
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What is the correct procedure to measure a dressing w/drainage?
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Circle the drainage & write the time & date on the dressing.
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Describe a Braden Scale & what it's used for?
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A commonly used scale to evaluate skin integrity for the risk of pressure.
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Categories of the Braden Scale
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Sensory perception, moisture, activity, mobility, nutrition, friction, & shear.
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What is important in dealing with an incontinent pt?
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Wet skin can cause skin breakdown & other skin integrity problems.
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What is Macerate?
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To soften by wetting or soaking.
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What is important to know in regards to an obese pt?
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Fat tissue has decreased vascularity & resilience w/tendency to have increased pressure on the bony promininces & less muscle mass. (Poor circulation from decreased vascularity)
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What is a wet to dry dressing?
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Dressing that is used for a wound that needs cleaning out, Exudates collected, debris cleaned out, & healing from the inside out.
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What is Eschar?
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Black leathery tissue covering on a wound.
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What is Purulent?
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Yellow, thick consistency, & a bad odor.
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Abnormal accumulation of fluid in the interstitial space.
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EDEMA
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How does poor diet affect a person's skin integrity?
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Decreased immunity; (our bodies get weak & can't fight off infection) Obesity; decreases vascularity (Poor circulation) & decreases the ability to heal ones self. (not enough protein for tissue healing.
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Agents used to clean the skin?
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Topical Anti-microbial.
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Relieves s/s of an allergic reaction
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Antihistamines
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Cellulitis
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Diffuse inflammatory process within solid tissue; S/S- edema, redness, pain, interferes with function.
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What are different types of edema?
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Pulmonary edema, Pitting edema, generalized swelling.
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What are different types of drainage wounds?
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Sanguineous- fresh blood, Serous- thin clear & a little thicker than water, Seroprululent- similar to serous but cloudier; can be slightly yellow, Purulent - thick milky appearance; can be green, yellow, brown, or white almost sure sign of infection.
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Why is Cellulitis dangerous?
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It can become an overwhelming infection by spreading to a large area (sepsis) Can be treated with antimicrobial's.
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At what stage of a decubitus ulcer should you begin documentation, Assessment, & Treatment in?
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The best treatment is prevention of the sores, by always documenting the skin integrity of a patient.
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What is a hospital acquired infection?
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Nosocomial infection.
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The insulin sliding scale is?
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Insulin therapy; Dose is based off on your blood sugar level before meals. The higher your blood sugar, the more insulin you take.
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Types of insulin versus oral meds for diabetes.?
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Insulin cannot be given orally because it would be destroyed by the digestive enzymes.
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Which insulins should not be combined?
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NPH & Lantus
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How do you maintain blood glucose control in a IDDM pt?
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Teach the pt the effect of diet, exercise, & insulin on blood glucose levels.
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Most common & dangerous complication of diabetic insulin therapy?
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HYPOGLYCEMIA
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Hypoglycemia
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Medical emergency that involves abnormally low glucose in the blood. (low blood sugar)
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Describe the S/S of hyperglycemia?
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Heart palpitations, fatigue, pale skin, shakiness, anxiety, sweating, hunger, irritability, tingling around the mouth, crying out during sleep. Severe: Confusion, visual disturbance, seizures, loss of consciousness.
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How do you treat the symptoms of a hypoglycemic reaction?
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A half - cup of regular Sprite soft drink.
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A1C (glycosylated hemoglobin test) is used to?
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Tell if their average carbohydrate consumption is within acceptable limits.
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Type l & Type ll diabetes, Common symptoms:
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Thirst, Polyuria, & Hunger.
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What would you see if a child with diabetes needed insulin?
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Red lips & fruity odor on the breath.
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Ketoacidosis
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A serious diabetic complication where the body produces excess blood acids (ketones) Sugar is too high for too long. Life- threatening.
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Kussmaul respirations
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It's function in diabetes is; Ketoacidosis.
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Pt teaching on diet, exercise, & insulin on blood glucose level?
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Routine diabetic diet; helps normalize blood glucose by having a balanced diet, Exercise; Increases the absorption rate of insulin & promotes overall health.
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When dealing with insulin the most important lifestyle change is?
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Accepting responsibility to self care & maintaining the general health of an adult diabetic.
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Skin & foot care needs in diabetics?
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Daily skin inspections & checking of peripheral pulses, Apply moisturizing lotion to the feet, *Except the spaces between the toes* & inspect all surfaces of the feet daily.
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Rotate insulin sites to prevent?
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Lipoatrophy of subcutaneous fat.
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Cells responsible for the production of insulin?
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The Beta cells in the Islets of Langerhans.
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Why do we test the urine in diabetic pt?
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Looking for ketones & evaluating for hyperglycemia.
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How can pneumonia affect a diabetic?
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It may have sufficient endogenous insulin to prevent Ketosis, but puts you at risk for development of hyperglycemia & hyperosmolar coma.
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Which test would be done preoperatively to evaluate the size & shape of the heart?
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Chest X-ray.
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Permission for a test or procedure in which a signature is obtained from pt or guardian?
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Informed Consent.
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What would detour the signing of informed consent?
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If any medication was given within the last two hours.
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What dietary changes does a pt need in their diet to build tissue & repair tissue for surgery?
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Proteins
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What is an allergic reaction?
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Immunes response to a foreign object.
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What drug would help alleviate the symptoms of an allergic reaction?
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Antihistamines
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Describe the communication techniques?
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Give pen & paper if unable to talk.
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What is the top priority management after surgery?
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PATENT AIRWAY! Observe for bleeding, pain control, & infection.
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What is the older person's difficulties when recovering from surgery?
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Availability of support systems, impaired mental functioning, & co- existing medical conditions.
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Who are at risk for respiratory complications following surgery?
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Elderly & Smokers
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What are signs of internal hemorrhage?
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INCREASED HR, restlessness, diaphoresis, dizziness, nausea, low BP, pallor, increased Resp rate, decreased urine output.
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What is blood tinged sputum?
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Hemoptysis
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What sign would you see first?
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Restlessness
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What nursing intervention is necessary for a wound evisceration?
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Cover with a moist sterile dressing.
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What would the nursing intervention be post op for a pt with laryngectomy (cancer of the larynx)?
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Have a pad & pencil or magic slate available.
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What would be the priority assessment following a laryngectomy?
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Open Airway.
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When would you use O2 therapy?
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To decrease Hypoxia.
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What is the top priority in the post op phase?
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Early ambulation & turning can allow for maximum lung expansion, prevent stasis, & assist GI mobility.
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What is a nosocomial infection?
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A hospital acquired infection.
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How would you know if a pt is dealing with his/her change in body image post op?
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If the patient looks at or touches the body part during dressing changes.
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What post op interventions can allow for maximum lung expansion, prevents stasis, & assist with GI mobility?
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Turning & early ambulation.
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What do you need to do because of a major side effect from anticoagulants?
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Watch for bleeding.
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What is a major risk factor for respiratory complications after surgery?
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Elderly & Smokers.
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What would you use to monitor O2 saturation?
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A Pulse Oximetry is the quickest way to assess oxygen saturation.
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Post Op what position would you use for a new tracheotomy pt?
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Mid Fowler's
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Pulmonary
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Lungs
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What is the flow of circulation?
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R Atrium - R Ventricle - Pulmonary arteries & veins - L Atrium & ventricles - Aorta - Body.
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Describe the circulation of the lungs?
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Pulmonary arteries & Pulmonary veins.
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What is the goal of oxygen therapy?
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It is given to lessen hypoxia.
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What medications are used to relieve inflammation & to suppress systems in asthma & COPD?
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Corticosteroids
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What factors place a pt at risk of having Lung Cancer?
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Smoking & working around chemical exposures.
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What is the O2 flow rate for a COPD pt?
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2L/min. It's low to prevent Hypoxemia.
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What nursing intervention is best to keep airway clear of secretions?
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Coughing & DB every 1-2 hrs.
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What information should the nurse provide to the pt about a Bronchoscopy?
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Explain the procedure.
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When should a chest tube be removed?
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When the patient's lung has fully expanded.
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What instructions would the nurse give for pt on decongestants?
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Pt education: Use for only a few days to avoid rebound congestion, Avoid using if Cardiac, has diabetes, or thyroid conditions are present. Discontinue if side effects such as nervousness, tremors, palpitations, or headaches occur.
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Hemoptysis
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Blood tinged sputum
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What is the most important chemical regulator in the blood for respiration?
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O2 & CO2
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Define O2 saturation?
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Amount of hemoglobin on RBC
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What procedure should be done on a dyspenic pt with plural effusion?
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Thoracentesis
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What is the action of Anticholergenics?
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Reduce strength & frequency of the urinary bladder.
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What is a diuretic?
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Promotes production of urine.
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A urinary diversion in which the urine flow is controlled by a nipple like valve?
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Knock's pouch.
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What is Polycystic disease?
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A genetic disease characterized by the development of multiple fluid filled sacs on the kidney.
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Foreskin on an uncircumcised male that becomes tight or impossible to pull away?
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Phimosis
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Enlargement of the kidneys due to the backup of urine?
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Hydronephrosis.
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Vasectomy
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Surgical procedure for male sterilization.
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A practical treatment for kidney failure that is scheduled 3x a week & lasting 3-6 hrs.
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Hemodialysis
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Describe the phases of renal failure?
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Stage 1- normal function, Stage 2- mildly reduced, Stage 3- moderately reduced, Stage 4- Severely reduced, Stage 5- Very severe..End stage renal failure.
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What is expected during the Oliguric phase of acute renal failure?
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Bun & Creatinine blood levels increase & urine output decreases.
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What does a 24 HR urine test assess in the kidneys?
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Glomerular Filtration Rate: measures level of kidney function.
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What infectious process of the kidney is usually preceded by another form of infection such as a sore throat?
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Acute Glomerulonephritis
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Excess fluid in the interstitial spaces?
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Interstitial fluid
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Define Orchitis?
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Inflammation of the testes.
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Inflammation of the bladder?
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Cystitis
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List 4 different types of incontinence?
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Stress, Functional, Urge, & Overflow
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Functional Incontinence
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Chronic impairment of physical & or cognitive function that prevents a pt from accessing the commode or bathroom.
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Glomerulonephritis
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A group of diseases that injure the part of the kidney that filters blood (called glomeruli) Acute- happens suddenly, Chronic - developes silently over the years
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Hypoxia
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Body is deprived of adequate oxygen; Insufficient oxygen supply.
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Hypoxemia
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Abnormally low oxygen levels in the blood.
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Inflammation of the kidney due to a bacterial infection?
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Pyelonephritis
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The measurement of nutritional status?
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Albumin levels.
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Nephrostomy
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Artificial opening created between the kidney & the skin which allows for the urinary diversion directly from the upper part of the urinary system.
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Surgical procedure to remove all or part of the kidney?
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Nephrectomy.
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Enlargement of the kidneys due to the backup of urine?
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Hydronephrosis
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What two conditions can happen to a non circumcised male if his foreskin is not cared for properly?
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Phimosis & Paraphimosis.
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A diagnostic test to assess the glomerular Filtration Rate?
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24 HR urine specimen
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What do you do to ensure accurate daily weight?
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Weigh pt at the same time everyday, on the same scale, & wearing the same type of clothing.
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Corticosteroids?
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Relieves inflammation & to suppress systems in asthma & COPD.
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Stress Incontinence?
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Loss of urine associated with laughing & coughing.
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Lithotripsy?
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The use of ultrasonic shock waves to break up kidney stones into smaller fragments.
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