Nursing 101 exam 5 Set 2
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. What would you like to do?
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
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
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
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
Home Care Assessment Infection: Facilities
Presence of running water, trash containers to facilitate wound care and contain potentially infectious material
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
Home care assessment infection: Other susceptible cohabitants
is there anyone else in the home that are susceptible/ high risk for infection
Home Care Assessment Infection: Community Resources
- Availability of and familiarity with sources of finance, supplies, home health
- Health Department
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
What is the rationale for using transparent dressing?
- you can see the wound
- self adhesive
- keeps it moist, promotes healing
- stays on joints
- consists of serum (the clear portion of blood)
- Looks watery
- has few cells
Thicker than serous because of the presence of pus
What makes up pus
Leukocytes, liquid filled dead tissue debrisand both dead & living bacteria
- consists of large amounts of RBC
- damage to capillaries that is severe enough to allow the escape of RBC
What is Maceration?
- tissue softened by prolonged wetting or soaking
- can be caused by moisture from incontinence
What is Excoriation?
- area with loss of the superficial layers of skin
- denuded area
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
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
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
What are the Physiological effects of heat?
Too much heat causes vasodilation which drops the blood pressure and can cause fainting
- increases bleeding
- increases capillary permeability which increases edema
Never use heat
- on skin disorder that causes redness or blisters
- Localized Malignant Tumors
Why can't heat be used on malignant tumors
heat increases cell metabolism and increases circulation which may speed up metastases
What is cold used for?
- Sports injuries
- To limit swelling and bleeding
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
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
What is the meaning of Asepsis
Freedom of disease causing microorganisms
Free of microorganisms including sproes and viruses
caused by testing or treatment
originates in the hospital
practices intended to confine a specific microorganisms to a specific area, limiting the number, growth and spread
practices that keep an area or object free of all microorganisms, also called sterile technique
Standard Precautions Begins and ends with ......
What should you do if your sterile field is contaminated?
Start over with new sterile package
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
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
RYB Color Code what is Black
- wounds covered with thick necrotic tissue
- then treat as red or yellow
RYB which wound should be treated first
Black then yellow and then red
the four debridement techniques
- Sharp- cut dead tissue away
- Mechanical - scrubbing wet to dry
- chemical - collagen enzyme cleaning solution
- autolytic - fly larvae
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
- causes abrasions
- caused by nurses moving pt up in the bed by scooting
occur by accident
No break in the skin
decreased blood supply and O2
What is a clean wound?
- uninfected, usually closed
- minimal inflammation
- Not in tracts (resp, GI, Urinary)
What are Clean Contaminated Wounds?
- Surgical wound
- entered resp, GI, Urinary, or genital tract
- No s/s of infection
What is a contaminated wound?
- open, fresh,
- major break in sterility or large spillage form GI tract
- s/s of infection
What is a Dirty/Infected Wound?
- contains dead tissue
- clinical evidence of infection
how can shearing force be prevented?
- bed wrinkle free
- client in position where they will not slide
risk factors for pressure ulcers
- friction and shearing
- inadequate nutrition
- Fecal and Urinary incontinence
- Decreased Mental Status
- Diminished Sensation
- Excessive body heat
- advanced age
What nursing measures promote skin integrity
keep skin clean and dry
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
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
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
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
when wrapping bandage what direction should be used and why
- wrap from distal to proximal
- to increase blood flow return
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
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
what are standard/universal precautions
use same precautions for every patient regardless of Dx or possible infection
what is the most affective nursing action for controlling the spread of infection
thorough hand hygiene
What is body substance isolation (BSI)?
generic infection control precautions for all clients except those with diseases transmitted through the air
What are three modes of transmission?
- Contaminated Sharps
- Skin Contact
- Contact with Mucous Membrane
comprehensive assessment includes:
- Normal defense mechanisms (are they compromised?)
- Ability to care for themselves
- mode of transmission
- what care procedure is being done
- visitors understanding, knowledge of situation
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)
Independent Nursing Actions and responsibilities to prevent transmission of microorganisms
- Begins with Hand washing seconds
- clients hands also need washed
- washes away microorganisms
- not sterile
Nutrition Supporting defense
Protein promotes healing
Fluids Supporting defenses of the patient
Sleep supporting defenses
body restores itself while sleeping
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
bright red flush of skin that appears after pressure is removed.
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
the protrusion of the internal viscera through an insicion
is the partial or total rupturing on a sutured wound
What would you like to do?
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