Semester 2 Nursing School

Front 1

What is a wound

Back 1

A break or disruption in the normal integrity of the skin and tissues

Front 2

how are wounds categorized

Back 2

intactness of skin
length of healing time
layer of skin involved
how it was aquired

Front 3

Intactness of skin

Back 3

open- trauma to tissue, skin is broken
Closed- damage to tissue under skin

Front 4

Length of healing time

Back 4

acute - short healing time, edges aproximated, low risk of infection
chronic- months/years to heal, remain in the inflamatory phase to heal, edges not aproximated

Front 5

Layer of skin involvement

Back 5

superficial- empidermis (friction)
Partial thicknes- dermis & epidermis
full thickness- bone
penetrating - internal organs

Front 6

how acquired

Back 6

intentional - surgery
unintentional - trauma

Front 7

Pressure Ulcer

Back 7

wound with localized area of tissue necrosis

Front 8

Stage 1 pressure ulcer

Back 8

begin with white area followed by persistent redness that does not go away for 60-90 mins

Front 9

stage 2 pressure ulcer

Back 9

superficial wound, epidermis

Front 10

Stage 3 pressure ulcer

Back 10

Damage to subQ

Front 11

Stage 4 pressure ulcer

Back 11

full thickness wound

Front 12

Arterial wound

Back 12

inadequate O2 circulation/ small round, shiny thin dry skin, painful, little or no drainage

Front 13

venous wound

Back 13

to much blood in the legs due to damage of vein valves. common below knee, pitting edema in legs, aching rather than pain, diffuse edges

Front 14

Clean wound

Back 14

no affected, usually closed, minimal inflamation, don't enter tracts of body that are sterile

Front 15

clean contaminated

Back 15

clean wound that has entered an area that should be sterile, no obvious infection

Front 16

contaminated wound

Back 16

open wounds, break in sterile technique.

Front 17

dirty

Back 17

infected, 100,000+ bacteria

Front 18

primary intention healing

Back 18

first intention healing, minimal tissue lost, skin surfaces are close together, minimal scaring, low infection risk

Front 19

secondary intention

Back 19

wound is extensive tissue is lost, healing occurs by grannulation, rich blood supply

Front 20

tertiary intention

Back 20

extensive damage, wound left open, delayed wound closure

Front 21

phases of wound healing

Back 21

hemostasis
inflammatory
proliferative
maturation

Front 22

fistula

Back 22

an abnormal opening between two organs/ body cavities, or between an organ and the outside of the body. cause by infection.

Front 23

Albumin level

Back 23

less then 3.5= work on nutrition

Front 24

leukocyte count

Back 24

too low or two high = infection

Front 25

hemoglobin level

Back 25

O2 level if too low, pt is not getting enough oxygen

Front 26

Exudate

Back 26

material such as fluid and cells that escape from blood vessels during the inflammation process, aka wound drainage

Front 27

serous

Back 27

clear drainage

Front 28

purulent

Back 28

thicker than serous, smelly, infected

Front 29

sanguineous

Back 29

large red blood cells, bloody

Front 30

serosanguineous

Back 30

combination of clear and bloody

Front 31

purosanguineous

Back 31

combination of puss and blood

Front 32

sterile

Back 32

without life, inatimate objects, not humans

Front 33

surgical asepsis

Back 33

technique used to eliminate all pathogenic organisms from a object or surgical enviornment. reduce infection

Front 34

rules of surgical asepsis

Back 34

sterile can only touch sterile
sterile to clean or contaminated = dirty
if a sterile item touches questionable item= dirty

Front 35

4 observations before opening a sterile supply

Back 35

exp date
package sealed
sterilization tape
wrapper not torn

Front 36

red yellow black code

Back 36

red= keep wound moist, covered
yellow=wound irrigation and dressing
black= eschar- debride wound

Front 37

frequency of dressing changes

Back 37

no standard frequency/ surgeon preforms first dressing change/ do not allow dressing to become saturated

Front 38

wet to dry gauze

Back 38

used to soften and remove necrotic tissue. apply saline to gauze, place dry dressing on top, allow wet to become dry, dead tissue sticks and is pulled off when tissue is removed

Front 39

transparent adhesive films

Back 39

used for uninfected wounds, small amt of drainage, iv sites,

Front 40

hydrocolloids

Back 40

permeable to water and O2/
wounds with alot of drainage/ left in place 3-5 days

Front 41

mepilex

Back 41

vapor permeable membrane/ used to protect and does not do harm

Front 42

hydrogels

Back 42

moist / cooling/

Front 43

alginates

Back 43

derivative of seaweed, autiolific effect, absorbs exudate

Front 44

foams

Back 44

used in circumcisions, chronic wounds maintain moist wound enviornment

Front 45

silver

Back 45

reduce/ prevent infection, wounds with a lot of drainage

Front 46

collagens

Back 46

skin grafts, partial& full thickness wounds

Front 47

wound packing

Back 47

clean wound first
moisten gauze
pack tunneling first
do not allow packing to cover wound edges

Front 48

open drainage

Back 48

do not have a collection device
passive draining
saftey pin

Front 49

closed drainage

Back 49

emptied q sift
jackson pratt, hemovac
sutured to skin
allow acurate measuring
negative suction device

Front 50

drainage management

Back 50

patent and functioning
wear gloves to empty
record i&o
keep compressed
take care not to remove!

Front 51

pathogen

Back 51

the ability to cause a disease

Front 52

pathogenicity

Back 52

ability of organism to cause infection

Front 53

virulence

Back 53

ability of an organism to cause disease in a small amount

Front 54

infections happen when microgorganisms

Back 54

attach
invade
multiply

Front 55

defense mechanisms

Back 55

intact skin
anti-infective secretions
mechanical movements
phagocytic cells
immune process
inflammatory process

Front 56

opportunistic pathogens

Back 56

need impaired defense mechanisms to thrive
caused by drug resistance organisms
may be life-threatening

Front 57

antiobiotic-resistant microorganisms caused by

Back 57

taking antibiotics wrong way
not taking full dose

Front 58

antibiotic resistant microorganisms, most common

Back 58

mrsa, vre

Front 59

how do microorganisms become rx-resistant

Back 59

produce enzymes to inactivate rx
modify target sites for rx
change cell wall structure
efflux
modify binding target
bacteria can exchange genetic material

Front 60

antimicrobials are classified according to

Back 60

pathogen destroyed
and chemical family

Front 61

antimicrobials include

Back 61

antibacterial, antiviral, and antifungal

Front 62

bacteriocidal

Back 62

kills infection, used for serious infection

Front 63

bacteriostatic

Back 63

slows the growth of microorganisms

Front 64

how do antimicorobials work

Back 64

intefere with creation of cell wall
inhibit cell from producing protein
disturbs cell membrane
keeps microorganism from reproducing
inhibits cell metabolism and growth

Front 65

what is the goal of antimicrobial therapy

Back 65

to eradicate the organism and return the host to full physiological functioning

Front 66

anaphylaxis

Back 66

5-30 mins, with IV or IM, vasodilation, increased fluid in lungs leading respiratory distress

Front 67

superinfection

Back 67

secondary infection, occurs when treating primary infection, occurs when pt has rx resistance to antimicrobial

Front 68

administer antibiotics accurately

Back 68

rx should be given at an evenly spaced timeline

Front 69

antiemetic

Back 69

Rx used to treat N & V

Front 70

Nausea

Back 70

unpleasant sensation of abdominal discomfort, accompanied by a desire to vomit

Front 71

vomiting

Back 71

forceful expulsion of gastric contents out of mouth

Front 72

pathophys of vomitting

Back 72

signal sent from czt, cerebral cortx, sensory aparatus & vestibular apparatus.
Vomiting center stimulates salivary center and causes glotis to close, diaphram to contract, relaxation of gastro sphincter, reverse peristalsis

Front 73

cause of N & V

Back 73

infection
rx
motion
chemo
cv and neuro disorder
surgery
pain
overeating
preganancy
psychogenic

Front 74

containdication for use of an antiemetic

Back 74

prevent or delay diagnosis
mask s &s of drux toxicity

Front 75

Phenothiazines
thorazine

Back 75

block dopamine from receptor sites in CTZ
Ineffective in motion sickness
cause sedation
*used only when other antiemetics are ineffective

Front 76

antihistamines

Back 76

Not all are effective anitemetics
adverse effects:
dizziness, drowsiness, urinary retention, dry mouth, blurred vision, tachycardia

Front 77

corticosteriods

Back 77

used for chemo pts and post op
mild side effects if used short term

Front 78

Benzodiazepine

Back 78

not an antiemtic, antianxiety.
mixed with antiemetic

Front 79

prokinetic
Reglan

Back 79

decrease nv associated with gastric retention of food and fluids
increase effects of alcohol

Front 80

5 hydoxytryptamine receptor
zofran

Back 80

used for nv with chemo radiation, post op
iv/po
metabolized in liver

Front 81

substance p/neurokinin

Back 81

treat nv ass with chemo, and to prevent post-op nv, eliminated by liver

Front 82

RX selection - antiemetic

Back 82

serveral rx's given together for chemo pts.
5HT are first choice for post op pts.
drugs causing minimal sedation are prefered fro ambulatory pts

Front 83

antiemetic oral route

Back 83

for prophylactic use (preventative)

Front 84

Penicillin

Back 84

OCP/ watch for allergies/ when giving IV infuse slowly and do not mix with other meds, dilute

Front 85

carpenems

Back 85

seizure activity/ severe diarrhea, dizziness, seizures

Front 86

cephalosporins

Back 86

watch for PCN allergy/ no antacids or iron <> 2 hours/ OCP/ alcohol/ hypotensive/ tachycardia

Front 87

aminogycosides

Back 87

mice/ can't hear, can't pee, can't feel

Front 88

fluoroquinolones

Back 88

not for use in peds/ pregnant women/ administer 4 hours before of after ingestion magnesium/aluminum hydroxide

Front 89

tetracyclines

Back 89

no children >8 no pregnant women.

Front 90

sulfonamides

Back 90

use: UTI, otis media/strep infection/
drink plenty of h2o- metabolized through urine

Front 91

macrolides

Back 91

use: upper resp infection
intefere OCP

Front 92

ketolides

Back 92

use: upper respitory
interfere with OCP

Front 93

Glycyclines

Back 93

watch for superinfection/ last resort/ denal enamel hypoplasia/ interfer with OCP

Front 94

antitubercular

Back 94

permanently discolor soft contact lenses, red orange secretions/
Side effects: nv cramps, parasthesias, dizziness, hepatoticity

Front 95

anitviral agents

Back 95

used for: influenza, hiv, herpes, virals hepatitis, OCP

Front 96

topical/systemic antifungal

Back 96

asses for allergic reactions

Front 97

antiparasitic

Back 97

asses for travel history

Front 98

preop assesment

Back 98

establish a baseline
teach post op care

Front 99

preop health history

Back 99

age/allergies/meds/ previous surgeries/ mental status/ smoking/ sub abuse/ adls

Front 100

pre op med history

Back 100

cardiovascular disease: risk for hemorrhage/ shock/ hypotension
Resp disease: increase risk for resp depression r/t anesthesia. post op pneumonia
Kidney & liver disease: alter response to anesthesia, wound healing
Endocrine disease: risk for hypoglycemia, cv comps, slow wound healing - diabetes

Front 101

PAT

Back 101

preadmission test
48 hours - 28 days before admission
baseline data about health status and previous complications

Front 102

Common pre-op lab tests

Back 102

urinalysis
cbc
electrolyte levels

Front 103

Common pre-op radiographic tests

Back 103

chest x-ray- if prone to resp problem
ecg= id preexisting conditions

Front 104

PAT

Back 104

preadmission test
48 hours - 28 days before admission
baseline data about health status and previous complications

Front 105

Common pre-op lab tests

Back 105

urinalysis
cbc
electrolyte levels

Front 106

pre-op nursing responsibilities

Back 106

check orders
were tests preformed and are the results in the chart?
are there any abnormalities
that require MD notification?
H&P must be on chart

Front 107

teaching surgical events

Back 107

when is surgery?
how long will surgery last?
describe before, during, and after events
tour of OR
describe who pt will see in OR

Front 108

Common pre-op radiographic tests

Back 108

chest x-ray- if prone to resp problem
ecg= id preexisting conditions

Front 109

pre-op nursing responsibilities

Back 109

check orders
were tests preformed and are the results in the chart?
are there any abnormalities
that require MD notification?
H&P must be on chart

Front 110

teaching surgical events

Back 110

when is surgery?
how long will surgery last?
describe before, during, and after events
tour of OR
describe who pt will see in OR

Front 111

teaching surgical sensations

Back 111

pt will:
have dry mouth
feel drowsy before surgery
have sore throat after surgery
have pain
feel cool in OR
notice bright lights in surgical suite

Front 112

teaching pain management

Back 112

pain med will be ordered scheduled or prn
pt should ask for pain before pain becomes severe
little danger of addiction
alt methods of pain relief

Front 113

teaching of physical activities

Back 113

deep breathing- keeps aveoli from collapsing
leg exercises
coughing with pillow splint
turn in bed every 2 hours

Front 114

pre-op check list

Back 114

rn responsibility
NPO, pre-op teaching, skin prep, bladder elim
admister pre-op meds

Front 115

operative site marking

Back 115

surgeon uses surgical pen to ID left or right site
verify site with h&p, affirm with pt
mark site
pt can be medicated once site is marked
document operative site marked

Front 116

members of surgical team

Back 116

pt-most imp
surgeon-performs procedure
nurses
surg tech
anesthesiologist
nurse anesthestist
ancillary staff

Front 117

circulating nurse

Back 117

coordinates and documents care in operating room

Front 118

scrub role

Back 118

scrobs and dons surgical atires, prepares and hands instruments
rn or surg tech

Front 119

RN first assistant

Back 119

practices under supervision of surgeon

Front 120

OR documentation

Back 120

PICIS, manages all documentation

Front 121

3 zones of OR

Back 121

unrestricted= street clothes
semi-restricted= scrob clothes and cap
restricted= srub clothes, shoe covers, caps, masks

Front 122

surgical hand scrub-

Back 122

2 min scrub,
all surfaces with brush and scrub

Front 123

airborne bacteria is a concern

Back 123

or ventilation is 15 air exhange per hour
temp 20-24deg celsius
humidity 30-60%
+ pressure

Front 124

stage 1 of general anesthesia

Back 124

beginning -
inhalation of anesthesia gas
warmth, ringing, roaring
inability to move extemities
major noise exaggerated

Front 125

stage 2 of general anesthesia

Back 125

excitement:
movement, struggling, talking.
CAN BE AVOIDED

Front 126

stage 3 of anesthesia

Back 126

surgical anesthesia:
cont admin of inhalation agent
small pupils, continue to react
maintained on several planes
light to deep

Front 127

Stage 4 of anesthesia

Back 127

medullary depression:
too much
depression of all vitals
cardiac arrest
pupils fixed and dilated

Front 128

2 types of general anesthesia agents

Back 128

inhalation
IV

Front 129

risks of general anesthesia

Back 129

CV depression
Resp depression
liver/ kidney damage
MH
broken teeth
swollen lips, face
vocal cord trauma
sore throat

Front 130

capnography to monitor ventilation

Back 130

CO2 monitor
measures exhaled levels of co2
normal 30-40

Front 131

bispectral index monitoring

Back 131

bis - monitors cerebral electrical activity, provides # that correlates sedation level

Front 132

regional anesthesia

Back 132

local, anesthetic agent injected around nerves:
epidural
spinal
local condution block

Front 133

indications for regional anesthesia

Back 133

ga contraindicated,
previous adverse reaction to ga
pt pref
pain mngmt enhanced

Front 134

benefits of regional anesthesia

Back 134

pt is sedated, but can follow directions
gag and cough reflexes
risk of aspiration
decrease risk of hypoventilation

Front 135

epidural

Back 135

conduction block, blocks sensory motor and autonomic function
differs from spinal, from site of injection and dose amount

Front 136

spinal

Back 136

conduction nerve block
anesthesia of lower extremities, perineum, lower abd

Front 137

Time out

Back 137

ivolves entire team, must be documented
correct: pt, site, side, procedure, pt position, tools

Front 138

anaphylaxis

Back 138

life threatening acute allergic reaction

Front 139

hypoxia

Back 139

inadequate o2 supply
brain damage occurs in mins

Front 140

malignant hyperthermia

Back 140

rare inherited muscle disorder that is chemically induced by inhalation anesthesia and muscle relaxants

Front 141

signs of malignant hyperthermia

Back 141

increased ETCO2
trunk rigity
increased temp

Front 142

treatment for malignant hyperthermia

Back 142

stop agents, adminiter dantrolene
cool pt temp

Front 143

suseptible people for malignant hyperthermia

Back 143

strong, bulky muscles, history of muscle cramps, family history

Front 144

hypovolemia

Back 144

h2o and electrolytes are lost in the same proportion, excessive internal or external blood loss.

Front 145

clinical manifestations of hypovolemia

Back 145

decreased skin turgor, oliguria, weak and rapid heart rate, decrease venous prssure, cool, clammy skin, thirst, anorexia, nausea, muscle weakness, and cramps

Front 146

pacu nurse

Back 146

strong assment skills
frequent monit or pts status
assist in reintubation
handle emerg
excellent education skills

Front 147

2 stages of pacu nursing

Back 147

immediate- while pt is in pacu
ongoing- until pt is fully recovered

Front 148

immediate post op care

Back 148

asses q 10-15 mins
goal - prevent complications from surgery & anesthesia
average stay - one hour

Front 149

PACU resp status

Back 149

assess: rhythm, depth, rate
breath sounds
o2 sat
airway patency- administer humididfied 02
ineffective resp function
excessive secretions

Front 150

most common pacu emergency

Back 150

respiratory obstruction

Front 151

cause of respiratory obstruction

Back 151

obstruction my tongue
laryngospasm- violent contraction of vocal cords
laryngeal edema

Front 152

pacu cv status

Back 152

assess: vs, hypotension, hypertension, hypothermia
pulses, urine output, skin color, mental status, ekg monitor

Front 153

pacu CNS assessment

Back 153

pt response to stimuli
orientation to person, place, time

Front 154

pacu fluid status

Back 154

assess: skin turgor, urine output(30cc/hr)
wound drainage
iv intake

Front 155

pacu wound status

Back 155

assess: amount, color, consistancy of drainage
report abnormal drainage: lg amnt of bright red drainage, reslessness, pallor, moist skin, decrease BP, elevated pulse (shock)

Front 156

Pacu pain management

Back 156

goal - early admin of analgesia
pharamcological and non pharmacological

Front 157

pacu general condition assesment

Back 157

continual reorientation
continual reassessments
proper position
maintain saftey

Front 158

discharge from pacu

Back 158

pt is fully recovered from anesthetic
pt is stable- bp, urine output 30 cc/hr, nv under control
family notified
**** pacu nurse gives verbal report to unit nurse******
anesthesiologist or anesthetist discharges pt from pacu

Front 159

recieving pt vs check

Back 159

q15 min x 1 hr
q 30 min x 2 hrs

Front 160

hemorrhage

Back 160

excessive bleeding,
caused by- slipped stich, disloged clot, stress on surgical site, meds
stop bleeding, replace fluid volume, prepare for or

Front 161

ss of hemorrhage

Back 161

restlessness, frank bleeding, weak thready pulse, decrease urine output, thirst

Front 162

shock

Back 162

body's response to peripheral circulatory collapse,
s&S same as hemorrhage

Front 163

interventions for shock

Back 163

mainatin airway
lie flat with legs elevated
monitor vs, hematocrit, blood gas results
admin o2
maintain body warmth
admin iv meds, fluid, blood

Front 164

pulmonary embolis

Back 164

major emergency
blood clot breaks loose and lodges in pulmonary vessel

Front 165

pulmonary embolis s&s

Back 165

dypnea
uncontrollable cough
chest pain
cyanotic
rapid breathing
tachycardia
anxiety