Card Set Information
When would you need surgical asepsis?
•During procedures that require intentional perforation of the client’s skin
•When the skin’s integrity is broken as a result
of trauma, surgical incision or burns
-During procedures that involve insertion of catheters or surgical instruments into sterile body cavities
What are the common shapes of lesions?
-Target, or Iris
What is the ABCDE rule of the self skin exam?
–E—elevation and enlargement
What to do inspect when looking over someone's nails?
-Shape and Contour
-Capillary Refill Time (CRT)
What are the functions of the skin?
1. Protection: physical, chemical, thermal and light
2. Prevents penetration & loss of fluids
: touch, pain, temperature, pressure
4. Temperature regulation via sweat & adipose layer
7. Wound repair
8. Absorption and excretion
9. Production of Vitamin D
What are the symptoms of chronic pain?
-Continues for 6 months or longer
-Types are malignant (cancer related) and nonmalignant
-Does not stop when injury heals
What are symptoms of acute pain?
-Follows a predictable trajectory
-Dissipates after injury heals
What are the sources of pain?
-Deep somatic pain
What is Neuropathic Pain?
-Abnormal processing of pain message
-Most difficult type of pain to assess and treat
-Damaged/dysfunctional/injured nerve fibers
What are the typical changes to aging adult's?
-Temp:decrease fevers, increase risk hypo/hyperthermia, decrease sweating
-Pulse: Normal range, but often irregular
: decrease Tidal Volume
-BP: Systolic generally increases with age
What are the Korotkoff’s sounds?
-I, the systolic pressure
-IV, muffling of sounds
-V, the diastolic pressure
What are physiologic factors controlling blood pressure?
-Peripheral vascular resistance
-Volume of circulating blood
What does the pulse pressure equal?
Systolic BP - Diastolic BP
what does systolic pressure equal?
Left ventricular contaction
What are the routes of temperature measurement?
-Electronic (via central line)
What are the signs of developmental competence of an adolescent?
-May examine alone without parent or sibling
-Give feedback that they are developing normally
-Do not treat like a child or adult
-Focus on health teaching
-Examine genitalia last and quickly
What are the responsibilities of an RN?
-Clean the equipment
-Set Clean vs. dirty area for handling equipment
-Prevent Nosocomial infections
-Follow Standard precautions
What area of the body requires a different order of skills?
What is the order?
What are the order of skills?
What are the characteristics of percussion notes?
•Resonant= clear, hollow
•Tympany= musical & drum like
•Dull= muffled thud
•Flat= absolute dullness
What is the purpose of percussion?
-Purpose- to assess underlying structures
•Map location and size of organs
•Signal density of a structure by a characteristic note
•Detecting superficial abnormal mass
(penetrate ~5cm deep)
•Elicit pain if underlying structure is inflamed
•Elicit deep tendon reflex using percussion hammer
What is the purpose of palpation?
•Swelling, vibration or pulsation
•Rigidity or spasticity
•Presence of lumps or masses
•Presence of tenderness or pain
What is a part of the nursing process evaluation?
-Refer to established outcomes
-Evaluate individual’s condition and compare actual outcomes with expected outcomes
-Summarize results of evaluation
-Identify reasons for failure to achieve expected outcomes
-Take corrective action to modify plan of care
-Document evaluation in plan of care
What is a part of the nursing implementation phase?
-Determine patient readiness
-Review planned interventions
-Collaborate with other team members
-Supervise by delegating appropriate responsibilities
-Counsel person and significant others
-Involve person in health care
-Refer for continuing care
-Document care provided
What is a part of the nursing process planning stage?
-Set time frames for outcomes
-Document plan of care
What are the goals of the outcome identification?
-Identify expected outcomes
-Individualize to patient
-Ensure outcomes are realistic and measurable
-Include a time frame
What are the parts of the nursing diagnosis?
-Identify clusters of cues
-Compare clusters of cues with definitions and defining characteristics
-Identify related factors
-Document the diagnosis
What is involved in the assessment in the nursing process?
-Review of clinical record
-Cultural and spiritual assessment
-Review of the literature
What is the nursing process?
What is objective data?
Observed when inspecting, percussing, palpating, and auscultating patient during
What is dementia?
–More common in elderly
: Alzheimer’s,Parkinson’s, CVA, HIV, head trauma
What is Delirium?
–Young or old
: infection, intoxication, withdrawal, hypoxia, F&E imbalance, post head trauma, postop
What are important developmental signs for children?
Differentiated crying by 4 weeks
Cooing at 6 weeks
One word sentences at 1 year
Multi-word sentences by 2 years
What are subjective?
Statements from the patient that are not verifiable.
Mental Status exam?
What are the orentation times 4?
Person, place, time and purpose
What are the 4 main headings of mental status assessment?
What is a mental disorder?
•a significant behavioral or psychological pattern associated with
: distress or
disability and has a significant risk of pain, disability, or death, or a loss
–Organic disorder: brain disease of known specific organic cause
–Psychiatric mental illness: no organic etiology established
What is mental status?
•a person’s emotional and cognitive functioning.
–Optimal functioning aims toward
simultaneous life satisfaction in work, caring relationships, and within the self
–Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally
What does R.E.S.P.E.C.T stand for?
R= Realize that you must know the heritage of yourself and your patient.
E= Examine the patient within the cultural context.
S= Select questions that are simple and speak them slowly.
P = Pace questioning throughout the exam.
E = Encourage patient to discuss meaning of health and illness with you.
C = Check patient’s understanding and acceptance of recommendations.
T = Touch the patient within the
boundaries of his or her heritage.
What are some Health-Related Behaviors Affected by Religion?
Willingness to undergo physical examination
Truthfulness about how patient feels
Maintenance of family viability
Hoping for recovery
Coping with stress
Genetic screening and counseling
Living with a disability
Caring for children
What is culturally competent?
•Understanding and attending to
total context of patient’s
-Immigration status, Stress factors, Social factors, & Cultural similarities and
What is culturally appropriate?
•Applying underlying background
knowledge necessary to provide the best possible health care
What is culturally sensitive?
•Possessing basic knowledge of and
constructive attitudes toward diverse cultural populations
What is Illness?
The loss of the person’s balance, within one’s
being—physical, mental and/or spiritual—and
in the outside world—natural, communal, and/or metaphysical
What is Health?
The balance of the person, both within one’s
being—physical, mental and/or spiritual—and
in the outside world—natural,communal, and/or metaphysical, is a complex, interrelated phenomenon
What are factors that effect wound healing?
Chronic health condition
When doing pain assessment what do you want to know?
Stop, look, and listen
Before, during, and after
Medication and results
When cleaning and irrigating a wound how should you move?
-Least to most contaminated
-Clean to dirty
-Top to bottom
What is the goal of cleaning a wound?
Remove dead tissue and debris, which impedes healing
Nursing Diagnosis for wounds
Impaired Tissue Integrity
Risk for Infection
Disturbed Body Image
Deficient Knowledge (wound care)
What types of drainage come from a wound?
What is important with a Jewish patient who has died?
Typically need to be buried before sundown
What do you do to asses a wound bed?
Wound dimensions (size and depth)
Tunneling and undermining
Margins and surrounding skin
What is required with escar tissue?
Risk Factors for Alteration in Skin Integrity
-Limited activity levels
-Impaired nutritional status
-Altered level of consciousness
-Friction and shear injury
-Medications that delay healing
-Decreased blood flow to lower extremities
Numeric value for 6 risk factors related to impaired skin integrity
Total score <18 = risk
6 risk factors:
Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction & Sheer
Skin self-examination, using the ABCDE rule?