Foundations - exam 2 - includes lab vales

Braden scale score that indicates a pressure injury risk

score below 18

what are hypotonic solutions used for?

dehydration (stimulates H2O movement into cells)

what are the 6 domains/assessment areas of the braden scale?

sensory perception, activity, mobility, moisture, nutrition, friction/shear

how often should you use the Braden scale for wounds?

every 2-3 days or when the condition changes

eschar

dead tissue

crepitus

gas in tissue

what stage pressure injuries are slightly open

stage 2

examples of intrinsic factors of wounds and healing

nutrition, age, impaired movement, immune suppression (patient specific)

extrinsic factor of wound healing

infection, pressure/friction, oxygen perfusion, moisture, smoking (modifiable factors)

unstageable wounds are…

cloudy (cannot see base of wound)

serous exudate

normal, watery and straw colored

sanguineous wound drainage

bloody

what type of wound drainage indicates infection?

purulent

brisk hemorrhage

rapid blood loss from BV hemorrhage (blood pools beneath patient)

dehisence

rupture of wound layer(s)

evisceration

total wound sever with organ protrusion

fistula

abnormal passage connecting organs

wound closure(s) with lowest infection risk

1. staples 2. adhesive strips

what phase of infection do new blood vessels form?

proliferation phase

what do fibroblasts produce during the proliferative phase?

collagen

epithelialization of wound healing

collagen remodeling

what is brought to the wound site on day 1?

neutrophils and fibroblasts

what is brought to wound by day 3-7?

macrophages

clean contaminated wound

surgical

primary intention wound healing

edges can be brought together, minimal to no tissue loss

secondary intention healing

edges can’t touch, heals inside to outside

tertiary intention healing

edges of wound are brought together after initial healing process

polycythemia

inc hematocrite (RBCs) (blood viscosity inc, oxygen perfusion dec)

what is in the epidermis?

5 distinct layers; contains keratinocytes (majority), langerhan cells, melanocytes, merkel cells (innervated)

what is in the dermis?

blood vessels, hair follicles, sweat glands, sebaceous (oil) glands, meissner’s capsules/innervated (scenes pain, deep pressure, vibrations, temp)

what is in the subQ layer of skin?

fat and connective tissue; cushions, insulates, and stores energy

nutrients that help skin integrity

zinc, iron, vit C, copper, protein

macuration

skin breakdown due to moisture

ulcer pathogenesis

BV pressure inc and BV rupture, blood pools

arterial ulcers patho

skin breakdown due to blocked artery

oliguria

low urine output

alepishia

hair loss

what hormone makes you thirsty

Ang II

daily fluid recommendation amount

2700 mL for women, 3700 mL for men

dehydration symptoms

fatigue/dizziness, dark urine, headache, muscle cramps, inc HR, V and D, weight loss 5%+

symptoms of fluid retention

pitting edema, rapid weight gain, stiffness, localized swelling

Renin-Angiotensin function

possible causes of hyponatremia

GI issues, diuretics, excessive ADH

aldosterone function

promotes Na adsorption

Thyroid hormone function

inc HR and kidney perfusion

BNP (Brain Neurotic Peptide) function

releases during heart failure from fluid overload

Renin release cascade stimulation

Ang I, Ang II - enzymes activate, aldosterone

normal Na range

136-145 mEq/L

normal K range

3.5-5 mEq/L

normal Ca range

8.6-10.2 mg/dL

what does Ca regulate in the blood?

vit D (increases Ca absorption) and PTH (parathyroid hormone)

symptoms of hypokalemia

muscle weakness, fatigue, muscle cramping, constipation, tingling/numbness, arrhythmia

symptoms of hypomagnesemia

muscle spasms, tremors, weakness, cramps, and abnormal heart rhythms. Early signs include nausea, vomiting, fatigue,

normal Mg range

1.7-2.2 mEq/L

where is Mg stored in the body

intracellular fluid and bones

what does Mg help facilitate?

nerve conduction, muscle contraction, steady heartbeat, immune sys, cellular metabolism

what vit may be low from chronic alcoholism?

Mg

normal phosphate range

2.4-4.4

recommended daily phosphate intake

700 mg

normal Cl range

98-106 mEq/L

normal bicarbonate range

22-30

lab values that indicate dehydration

inc hematocrit, BUN, creatinine, osmolarity

what medicine may cause high phosphorus levels

laxatives

Cl function in body

maintains fluid balance, BP, and pH levels

phosphate function in body

mineralized bones

what molecule inversely fluctuates with Ca

phosphate

hypervolemia

fluid overload

some hypervolemia syms

inc resp rate, jugular distention, shallow breaths, bounding pulse

isotonic solution %

0.9%

hypotonic solution %

0.45%

hypertonic solution %

2-5%+

intraosseous IV access

bone (in emergencies)

central IV access

long term

muscles that contract to open internal urinary sphincters

detrusor

renal choliculi

kidney stones

4 types of incontinence

stress, urge, functional, unconsciousness (incs neurological impairment)

anuria

lack of urine production

dysuria

painful urination

normal urinary pH level (range)

4.6-8 (8 < indicates UTI)

normal specific gravity of urine

1.005-1.030 (higher indicates dehydration, lower may indicate diabetes insipidus or renal/kidney issue)

urethritis

infection in urethra

cystitis

bacteria in bladder

pyelonephritis (deff, list one main sym)

kidney inf, back pain (dysuria, N & V, cloudy urine, hematuria, general malaise)

define bereavement

period of mourning

define mourning

actions and expressions of grief

disenfranchised grief

loss not socially supported or acknowledged

masked grief

grief expressed through change in behaviors

define brain death

only brain stem is functioning (no reflexes or electroencephalogram activity)

death definition

irreversible cessation of biological life sustaining functions

adjunctive analgesics examples

antidepressants, muscle relaxants (drugs with primary indications other than pain)

what are PCA pumps used for? what do you monitor

giving opioids, pulse ox

hyperplasia

extreme sensitivity to pain

things that affect pain levels

developmental state, culture, communication skills, past experiences…

refractory pain

severe, constant pain, not fixed by medical interventions

hormones that increase in body from unrelieved pain

ACTH, ADH, cortisol, GH

hormones that decrease from unresolved pain

testosterone and insulin

when is visual analog pain scale used? how to rate pain on scale

when patient can clearly communicate their pain, rate from least to worst pain

when is simple descriptor pain scale used?

when patient has trouble with numbers or visual scales, patient describes pain

when is FACES pain scale used

for kids and pple who are chronically impaired

TENS pain management tool

electric nerve stimulation