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when treatments result in worsening of the original condition rather than improving it
Leaving heat packs in place longer than 45 minutes can cause constriction of vessels instead of dilation. This is known as ..?
List six safety precautions when applying a warm pack
- have a barrier between the skin and pack
- leave on for 20-30 minutes
- check skin every 15-20 minutes
- Check temp. before applying >105 F
- If too hot, have pt ring call bell
- assess skin every 5 minutes
How does cold therapy help with pain in sprains?
- Cold therapy casues vasoconstriction
- reduces the amount of fluid that leaves the capillaries and leaks into the interstitial space
- results in less edema and pain
How long do you use cold therapy after an injury?
For the first 48-72 hours after the injury occurs
When do you use a hyperthemia blanket use?
- To reduce high fevers 105F +
- Disease or stroke
What do you use to treat phlebitis?
What heating device can cause orthostatic hypotension?
What are you observing for with skin assessment after cold therapy that would indicate cold therapy was applied for too long?
- Pallor - pale or white
- Mottling - Purplish blue, irregular blotches
List two complications of cold therapy
List six techniques used during physical assessment?
Signs vs Symptoms
- Signs - Uses four senses, objective, measurable
- Symptoms - Verbalized by pt, subjective, not directly measurable
Establishing a rapport with a surgical patient
- Greet pt using his or her surname
- Provide privacy
- introduce yourself and explain intent
- exhibit open and relaxed posture
- be professional
- demonstrate active listening
- be attentive to pt responses and needs
- be aware of cultural influences and restrictions
- be sincere
- be nonjudgmental
- use touch purposefully and judiciously
What can cause hypoactive bowel sounds?
What slows down in the elderly population that can cause constipation?
What do you do if you are having difficulty auscultating heart tones?
Have pt lean forward and to the left
How would you know the pt's condition is deteriorating after MVA?
- Level of orientation
- Assess orientation of person, place, time, and situation
When do you do daily weights?
- Before breakfast
- wearing the same type of clothing
What is included in assessing the skin?
What supplies would you gather for a simple dressing change?
- sterile field
- sterile dressing
- clean and sterile gloves
- sterile solution
What is sterile technique and sterile field?
Sterile technique - method used to prevent contamination during invasive procedures, or procedures that involve entering body cavities
sterile field - an area that is free from all microorganisms
How do you add items to a sterile field?
You drop the item onto the sterile field
When do you use sterile techniques and with what procedures?
- Open sterile packages
- Peel the pack away from you
How do you know sterile gloves are the appropriate size for you?
- They should fit closely
- no wrinkles
- no excessive materials at fingertips
- no bowing due to tightness
What are the three phases of healing?
Describe the Inflammatory healing stage
- wound is fresh
- includes hemostasis and phagocytosis
- signs include warmth, redness, pain, and edema
Describe the reconstruction phase of healing
- wound begins to heal, lasting for about 21 days after injury
- there is a presence of fibroblasts = produce collagen
- as new tissue begins to grow and fill wound, it looks red and semitransparent
Describe the maturation phase of healing
- wound contracts and scar strengthens
- healing ridge develops
- phase can last from 1 - 2 years
- scar thins and lightens in color, becomes firm and less elastic than skin around it
Why do you irrigate a wound from superior to inferior area?
you want to clean from the least contaminated to the most contaminated
When is it appropriate to use a hydrocolloid?
When a wound has minimal drainage
When do you use a jackson-pratt drain?
The suction drains fluid out into container
Describe the first stage of wound healing
- its dry
- edges are approximated
- wound sutures are closed
Describe the second stage of wound healing
- greater tissue loss
- wound edges are irregular
- must be left open to gradually heal by filling in with granulation tissue
Describe the third stage of wound healing
- wound is left open for a time to allow granulation tissue to form
- sutured close
- Superficial open wound
- ex: scratches, scrapes
open wound when a sharp item pierces skin - round hold in skin extends down into deeper tissue
offending object remain embedded in tissue
open wound made by accidental cutting or tearing of tissue
wound from pressure and friction
What would be signs of an infected wound?
- purulent - containing pus
- necrotic tissue - dead tissue
- erythema - redness
- increased warmth
- edema - swelling
How would you treat a wound evisceration?
cover exposed organs with sterile dressing soaked in saline and call for help
There are no orders for a dressing change. What would you do?
Mark dressing and reinforce
You are doing a focused assessment on CV system. what are you assessing for?
- BP and Pulse
- Skin color, moisture, and temp
- color of mucous membranes
- jugular vein distention
- heart sounds
- capillary refill
- activity tolerance
What items are disinfected instead of sterilized after each pt use?
- IVAC and poles
- over bed table
- bedside commode
- tube feeding pumps
- wound vac
drowsiness or mental sluggishness
hard, dry, dead tissue that has a leathery appearance
reduced blood flow to an area
Name 4 assessments included in a neurological exam
- vital signs
- response to simple commands
- speech clarity facial symmetry
IF YOU DONT KNOW THE ANSWER YOU SHOULD PUT...
What should you assess on a diabetic patient?
numbness or decreased sensation
- 1. inspect
- 2. ausculate
- 3. palpate