Nursing 101 exam 5 Set 2

Card Set Information

Nursing 101 exam 5 Set 2
2013-09-22 23:27:34
nursing fundamentals

exam 5
Show Answers:

  1. What are Home care assessments
    • Self-care abilities for wound care
    • Self-care abilities for medication administration
    • Self-care abilities for hygiene
    • a where of Facilities
    • Family caregiver availability, skills responses
    • Other susceptible cohabitants
    • Community Resources
  2. Home Care Assessment
    Self-Care Abilities for wound care is
    • Client understands importance of wound care
    • Client is able to change dressing and care for the wound
  3. Home Care Assessment regarding infection: Self-care abilities for hygiene
    • Client understands the importance of hygiene
    • how to contain potentially infectious material
    • Knows the importance of hand washing
  4. Home Care Assessment regarding Infection: Self-care abilities for medication administration
    • Client understands medication therapy
    • knows expected outcomes and potential risks
    • Client has physical dexterity to take or administer medications
  5. Home Care Assessment Infection: Facilities
    Presence of running water, trash containers to facilitate wound care and contain potentially infectious material
  6. Home care Assessment infection: Family Caregiver availability, skills, response
    • Caregiver understands the importance of wound care and can contain potentially infectious material
    • Caregiver is avail when client needs them
    • Caregiver is able to care for the client
  7. Home care assessment infection: Other susceptible cohabitants
    is there anyone else in the home that are susceptible/ high risk for infection
  8. Home Care Assessment Infection: Community Resources
    • Availability of and familiarity with sources of finance, supplies, home health
    • Health Department
  9. What is the rationale for using Montgomery Straps?
    • They are used for wounds that require frequent changing.
    • The straps stay on the skin and tie across the bandage
    • They prevent skin irritation that would happen if the tape was taken on and off many times
  10. What is the rationale for using transparent dressing?
    • you can see the wound
    • self adhesive
    • keeps it moist, promotes healing
    • stays on joints
  11. Serous Exudate
    • consists of serum (the clear portion of blood)
    • Looks watery
    • has few cells
  12. Purulent Exudate
    Thicker than serous because of the presence of pus
  13. What makes up pus
    Leukocytes, liquid filled dead tissue debrisand both dead & living bacteria
  14. Sanguineous Exudate
    • consists of large amounts of RBC 
    • damage to capillaries that is severe enough to allow the escape of RBC
  15. What is Maceration?
    • tissue softened by prolonged wetting or soaking
    • can be caused by moisture from incontinence
  16. What is Excoriation?
    • area with loss of the superficial layers of skin
    • denuded area
  17. What is the rebound effect in application of heat or cold?
    Once the maximum amount of therapeutic time is up the heat or cold begins to have the opposite effect
  18. What is heat used for?
    • Promotes tissue healing
    • Causes Vasodilation blood flow bringing O2, nutrients, antibodies and leukocytes to the site
    • Used for joint stiffness, musculoskeletal problems, arthritis, contractures and low back pain
  19. What are the Contraindications to the use of heat?
    • 1st 24 hr after injury heat increases bleeding and swelling
    • Can causes edema or worsen existing edema because it increases capillary permeability
  20. What are the Physiological effects of heat?
    Too much heat causes vasodilation which drops the blood pressure and can cause fainting
  21. Vasodilation causes,....
    • increases bleeding
    • increases capillary permeability which increases edema
  22. Never use heat
    • on skin disorder that causes redness or blisters
    • Localized Malignant Tumors
  23. Why can't heat be used on malignant tumors
    heat increases cell metabolism and increases circulation which may speed up metastases
  24. What is cold used for?
    • Sports injuries
    • sprains
    • strains
    • fractures
    • To limit swelling and bleeding
  25. What are the psychological effects of cold?
    Too much cold can increase BP and induce shivering and if left too long can cause tissue damage
  26. Contraindications to cold
    • Open Wounds -causes tissue damage due to increased blood flow
    • Impaired circulation -can further impair nourishment of the tissue and cause damage
  27. What is the meaning of Asepsis
    Freedom of disease causing microorganisms
  28. Sterile
    Free of microorganisms including sproes and viruses
  29. Latrogenic Infection
    caused by testing or treatment
  30. Nosocomial infection
    originates in the hospital
  31. Medical asepsis
    practices intended to confine a specific microorganisms to a specific area, limiting the number, growth and spread
  32. Surgical Asepsis
    practices that keep an area or object free of all microorganisms, also called sterile technique
  33. Standard Precautions Begins and ends with ......
    Hand Hygiene
  34. What should you do if your sterile field is contaminated?
    Start over with new sterile package
  35. RYB color code, what does red mean?
    • Protect and cover
    • These wounds are in late regeneration phase
    • change infrequently to decrease chance of tissue disruption
    • Gentle cleanse
    • protect periwound with alcohol free barrier film
    • USE clear absorbent hydrocolloid dressing
  36. RYB Color Code What does Yellow tell us?
    • characterized by liquid to semiliquid "slough" that is often seen with purulent drainage or previous infection
    • cleanse remove dead tissue using moist saline dressing and irrigate
    • use absorbent dressing like hydrogel or alginate
    • apply topical antimicrobial to minimize bacteria growth
  37. RYB Color Code what is Black
    • wounds covered with thick necrotic tissue
    • Debridement
    • then treat as red or yellow
  38. RYB which wound should be treated first
    Black then yellow and then red
  39. the four debridement techniques
    • Sharp- cut dead tissue away
    • Mechanical - scrubbing wet to dry
    • chemical - collagen enzyme cleaning solution
    • autolytic - fly larvae
  40. what is shearing forces?
    • a combination of friction and pressure
    • as patient slides down in the bed from Fowlers Position
    • Deep internal tissues move downward
    • while skin tissues remain in place
    • Causes damage to blood vessels and tissue
  41. Friction
    • causes abrasions
    • caused by nurses moving pt up in the bed by scooting
  42. intentional wounds
    • surgical/therapeutic
    • incision
  43. Unintentional wounds
    occur by accident
  44. Closed Wound
    No break in the skin
  45. open wound
    skin is open
  46. Ischemic Wound
    decreased blood supply and O2
  47. What is a clean wound?
    • uninfected, usually closed
    • minimal inflammation
    • Not in tracts (resp, GI, Urinary)
  48. What are Clean Contaminated Wounds?
    • Surgical wound
    • entered resp, GI, Urinary, or genital tract
    • No s/s of infection
  49. What is a contaminated wound?
    • open, fresh,
    • accidental
    • major break in sterility or large spillage form GI tract
    • s/s of infection
  50. What is a Dirty/Infected Wound?
    • contains dead tissue
    • clinical evidence of infection
  51. how can shearing force be prevented?
    • bed wrinkle free
    • client in position where they will not slide
  52. risk factors for pressure ulcers
    • immobility
    • friction and shearing
    • inadequate nutrition
    • Fecal and Urinary incontinence
    • Decreased Mental Status
    • Diminished Sensation
    • Excessive body heat
    • advanced age
  53. What nursing measures promote skin integrity
    keep skin clean and dry
  54. what would a nurse see in a client with arterial or venous insufficiency?
    • decreased circulation
    • weaker pulses in feet and legs
    • wounds on limbs take longer to heal
  55. what are the stages of pressure ulcers?
    • I-nonblanchable erythema signaling potential ulceration
    • II- partial thickness skin loss involving epidermis and possibly the dermis
    • III- full thickness skin loss involving damage of necrosis of subcutaneous tissue that may extend down to the fascia (deep crater)
    • IV- full thickness skin loss with tissue necrosis or damage to the muscle, bone or supporting structure
  56. when cleaning incision site what method should you use>
    • start at the center
    • circular motion moving outward
    • 3 times
    • CLEAN to DIRTY
    • Do Not Dry
  57. Cleaning staples on long incision
    • top to bottom
    • inside to outside
    • clean to dirty
    • new swab with each stroke
    • 1 down the middle
    • 2 away from you
    • 3 side towards you
    • 4 away
    • DO NOT DRY
  58. when wrapping bandage what direction should be used and why
    • wrap from distal to proximal
    • to increase blood flow return
  59. order of applying PPE
    • wash hands
    • apply clean gown, try neck, tie back over lapping in back
    • apply mask, tie top, tie bottom
    • apply goggles
    • apply gloves
  60. removing soiled PPE
    • remove gloves (do not Touch)
    • wash hands
    • remove goggles
    • remove gown when ready to leave room
    • remove mask
    • If gown, goggle, and mask are soiled Put On A New Pair Of Gloves before removing them
  61. what are standard/universal precautions
    use same precautions for every patient regardless of Dx or possible infection
  62. what is the most affective nursing action for controlling the spread of infection
    thorough hand hygiene
  63. What is body substance isolation (BSI)?
    generic infection control precautions for all clients except those with diseases transmitted through the air
  64. What are three modes of transmission?
    • Contaminated Sharps
    • Skin Contact
    • Contact with Mucous Membrane
  65. comprehensive assessment includes:
    • Normal defense mechanisms (are they compromised?)
    • Ability to care for themselves
    • mode of transmission
    • what care procedure is being done
    • PPE?
    • visitors understanding, knowledge of situation
  66. principles of infection control and asepsis
    • Microorganisms live everywhere
    • Microorganisms can be good or bad
    • Effect can vary with in situation
    • 3 major modes of transmission (Contaminated "sharps", skin contact, mucous membrane contact)
  67. Independent Nursing Actions and responsibilities to prevent transmission of microorganisms
    • Begins with Hand washing  seconds
    • clients hands also need washed
  68. Hygiene
    • washes away microorganisms
    • not sterile
  69. Nutrition Supporting defense
    Protein promotes healing
  70. Fluids Supporting defenses of the patient
    Helps flush
  71. Sleep supporting defenses
    body restores itself while sleeping
  72. how does the nurse decide whether a reddened area is beginning stages of pressure sore
    • the time it takes to go back to normal
    • it should take 1/2 to 3/4 to amount of time that person was laying on that spot
  73. Reactive Hyperemia
    bright red flush of skin that appears after pressure is removed.
  74. what nursing action would be most appropriate if Evisceration or Dehiscence occurs?
    • wound should be quickly supported by a large sterile dressing soaked in saline. 
    • Place the client in the bed with the knees bent to decrease pull on the incision.
    • Notify Surgeon
  75. Evisceration
    the protrusion of the internal viscera through an insicion
  76. Dehiscence
    is the partial or total rupturing on a sutured wound