Nursing exam 1 part 2

Difference in dehiscence vs evisceration

Dehiscence- Partial or complete separation of the wound edges, usually involving surgical incisions.

Evisceration- A severe form of dehiscence where internal organs (usually intestines) protrude through the open wound

Dehiscence

What Happens: The wound opens up, but internal organs do not protrude.

Causes:

- Poor wound healing (infection, malnutrition, diabetes)

- Increased intra-abdominal pressure (e.g., coughing, vomiting)

- Inadequate suturing

- Obesity or smoking

Signs/Symptoms:

- Sudden "popping" sensation

- Visible wound separation

- Serosanguinous discharge

- Mild to moderate pain

Evisceration

What Happens:

The wound opens completely and viscera (organs) protrude through the incision site.

This is a Surgical Emergency.

Signs/Symptoms:

- Open wound with visible abdominal organs

- Often preceded by dehiscence

- Patient may report a popping sensation followed by pain and protrusion

Stages of pressure injuries

- Stage 1: non-blanchable erythema of intact skin

- Stage 2: partial-thickness skin loss with exposed dermis

- Stage 3: full-thickness skin loss

- Stage 4: full-thickness skin and tissue loss

- Unstageable: obscured full-thickness skin and tissue loss

- Deep tissue pressure injury: persistent non-blanchable deep red, maroon, or purple discoloration

Stage 1: Non-blanchable Erythema

Skin Intact but:

Red (erythematous) area that does not blanch (turn white) when pressed.

May feel warmer or cooler, softer or firmer than surrounding skin.

Pain, itching, or discomfort may be present.

⚠️ Early warning sign — if caught early, it's reversible

Stage 2: Partial-Thickness Skin Loss

Skin is broken, involving:

Epidermis and possibly dermis.

Appears as:

Shallow open ulcer with a red/pink wound bed.

Or as a blister (intact or ruptured).

No slough, eschar, or deeper tissue exposure.

Stage 3: Full-Thickness Skin Loss

Full-thickness loss of skin involving:

Epidermis + Dermis + Subcutaneous tissue

May see:

Undermining or tunneling

Slough or eschar may be present (but not obscuring the depth).

No exposure of bone, tendon, or muscle

Stage 4: Full-Thickness Tissue Loss

Deep wound with exposed bone, tendon, or muscle.

Often includes:

Undermining, tunneling

Slough or eschar may be present.

Very high risk of osteomyelitis or sepsis.

Unstageable Pressure Injury

Full-thickness skin and tissue loss, but the depth is unknown due to:

Obscuring slough (yellow/green) or eschar (black/brown).

Must be debrided before it can be properly staged

Deep Tissue Pressure Injury (DTPI)

Intact or non-intact skin with:

Persistent non-blanchable deep red, maroon, or purple discoloration

Or a blood-filled blister

Indicates damage to deeper tissues (e.g., muscle) before skin breaks.

May evolve rapidly into Stage 3 or 4

Pressure injury risk factors

Intrinsic (Patient-related) Factors:

- Immobility (bed- or wheelchair-bound)

- Poor nutrition or hydration

- Incontinence (moisture-associated skin damage)

- Reduced sensory perception (e.g., spinal cord injury, neuropathy)

- Chronic conditions (e.g., diabetes, vascular disease)

- Age (older adults have thinner, more fragile skin)

- Low body weight or obesity

- Altered mental status (confusion, sedation)

Extrinsic (Environment-related) Factors:

- Pressure over bony prominences (e.g., sacrum, heels, hips)

- Shear (e.g., sliding down in bed)

- Friction (skin rubbing against bedding or clothing)

- Moisture (sweat, urine, feces)

Pressure injury prevention strategies

1. Skin Assessment

- Perform daily skin checks, especially over bony prominences.

- Look for redness, discoloration, warmth, or breaks in the skin.

2. Repositioning

Turn and reposition every:

- 2 hours in bed

- Every 15–30 minutes in a chair

- Use a turning schedule or care chart.

3. Support Surfaces

- Use pressure-relieving mattresses, cushions, or heel protectors.

- Avoid donut-shaped cushions (can reduce blood flow).

4. Skin Care

- Keep skin clean and dry.

- Apply moisturizers to prevent dryness.

- Use barrier creams for patients with incontinence.

5. Nutrition & Hydration

- Ensure adequate protein and calorie intake.

- Monitor hydration status.

- Consider a nutrition consult for at-risk patients.

6. Minimize Shear and Friction

- Lift, don’t drag, patients during transfers.

Elevate the head of the bed to ≤30° to reduce sliding.

- Use draw sheets or transfer aids.

7. Mobility Promotion

- Encourage early ambulation or physical therapy.

- Even passive range-of-motion exercises can help circulation

Braden Scale- what factors are incorporated.

Norton Scale

• Braden scale: Sensory perception, moisture, activity, mobility, nutrition, and friction or shear• Total score less than 18 = risk

• Norton scale: Patient's physical condition, mental state, activity, mobility, and incontinence

Examination of hair and scalp

Assess, Inspect, and Palpate scalp and hair for surface characteristics, hair distribution, texture, thickness, quantity, cleanliness, color, dryness, oiliness.

• Surface characteristics: Smooth without flaking, scaling, redness, lesions, or parasites

• Should be shiny and soft.

• Quantity and distribution: Balding patterns and hair loss; male patterned.

Inspect facial and body hair for distribution, quantity, and texture.

Examination of nails

Inspect for nails for shape, contour, color, consistency, thickness, and cleanliness.

• Edges: smooth and rounded

• Contour: flat and slightly rounded

• Consistency: note grooves, depressions, pitting, and ridges

• Color: pink, blanched in light-skinned clients; yellow/brown with vertical lines in dark-skinned clients

• Thickness: smooth, uniform

• Inspect for cleanliness

• Palpation: Texture, assess texture and consistency, capillary refill

Skin turgor

Test unexposed area (below clavicle, sternum, forehead)

Pinch the skin

Note its return when you release it

• should return immediately to its original position

• Tenting – decreased turgor, skin takes several seconds to return to original position (seen in dehydration or normal aging)

Infants – check on abdomen

Older adults – over sternum/clavicle

Pallor (pale)

Possible causes:

- Anemia

- Shock

- Poor perfusion

- Check palms, soles, lips, and mucous membranes

- In dark skin, may appear gray/yellow or ashen

Erythema (redness)

Possible causes:

- Inflammation

- Infection

- Fever

- Pressure

- In light skin: red or flushed

- In dark skin: may look darker, purple, or feel warm/firm

Cyanosis (bluish)

Possible causes:

- Hypoxia

- Heart or respiratory failure

- Light skin: lips, nail beds, face

- Dark skin: grayish or whitish around mouth, conjunctiva, nail beds

Jaundice (yellow)

Possible causes:

- Liver dysfunction

- Hemolysis

- Best seen in sclera, palms, and mucous membranes

- In dark skin: look at sclera and hard palate

ABCDE of mole assessment

• Asymmetry

• Border

• Color

• Diameter

• Elevation

Accident prevention and risks in the home

Scalds and burns

Hot water, grease, sunburn, cigarettes

Prevention

Guardrails by fireplace

Turning pot handles

Care with candles

Sunscreen

Care when warming food in microwave

Fall prevention and risks

Prevalent in those older than 65 years

Slippery floors, stairs, tubs; low toilet seat; high bed

Prevention: Nonskid shoes, tidy clothes, proper lighting, grab bars/rails, no scatter rugs

Fire Safety

Cooking fires, smoke inhalation, home heating equipment

Prevention

Smoke alarms

Caution with cigarettes

Fire extinguisher

No candles unattended

Safety with holiday lights

Care with electrical cords

The Six Rights of Medication Administration

• Right Drug

• Right Dose

• Right Patient

• Right Route

• Right Time

• Right Documentation

Types of Medication Orders

Standing – used for treating a particular set of symptoms

PRN – as needed

Single (one-time dosing) – given only once at specified time

STAT - immediately

Standard/Routine – given until provider alters or D/C’s

Written Medication Orders

• Requirements:

• Date

• Name and dosage of drug

• Route and frequency

• Physician's signature

Verbal Medication Orders

• Extra requirements:

• Verbal order read back (VORB or RBV)

• Physician's name

• Nurse's signature

• Order repetition for verification

Intradermal (ID)

injected into the dermal layer of skin just below the epidermis

◼ TB skin test, allergy testing

◼ Forearm

Subcutaneous (SC, Sub-Q)

injected into the subcutaneous fat between dermis and muscle

◼ Upper arms, abdomen, back, thighs

Intramuscular (IM)

injected into a muscle

◼ Deltoid, dorsogluteal, ventrogluteal, vastus lateralis

Intravenous (IV)

injected into a vein directly into the bloodstream

◼ Back of hands, forearms, antecubital

Route: Intradermal

Volume: 0.01-0.1 ml

gauge: 25 -27

Length: 3/8 - 5/8"

Route: Subcutaneous

Volume: 0.5 - 1 ml

Gauge: 25 - 27

Length: 1/2 - 5/8"

Route: Intramuscular

Volume: 0.5 - 3 ml (Adult)

1- 2 ml (Child)

Gauge: 22 - 23 (Adult)

25 - 27 (Child)

Length: 1 - 1.5 or 2" (Adult)

½ - 1" (Child)

5/8" (Newborn)

Route: Intravenous

Volume: 1- 2000ml

Gauge: 20-22 ga (sol)

15 - 19 ga (bld)

Length: ½ -1¼" (butterfly)

½ - 2" (reg needle)

Enteral - refers to the GI tract

◼ Oral (by mouth) - tablets, capsules, liquids, sublingual

◼ Rectal

◼ Nasogastric/gastrostomy - for patients unable to swallow

Parenteral (injected)

-involves injecting medication into a blood vessel, muscle, or spinal column.

◼ Intradermal

◼ Subcutaneous (Sub-Q, SC)

◼ Intramuscular (IM) - Z-track method

◼ Intravenous (IV) - IV push, IV piggyback, IV drips

Administration of Ophthalmic Medications

Wash hands

Instruct client to look up

Gently pull conjunctival sac down

Administer drops into center of sac

Apply gentle pressure to lacrimal duct with cotton ball.

Instruct client to keep eyes closed

For ointments, apply from inner corner to outer.

Administration of Otic Drops

 Wash hands

 Have client tilt head slightly toward unaffected side

. For child – pull pinna down & back

 For adult (3 yrs & up) – pull pinna up & back

 Instill drops into ear canal

 Have client maintain position for 5-10 min.

 Can place cotton ball in ear

Z Track Method

Technique for giving an IM injection-used with irritating or staining meds (iron)

Always change needle after drawing med, before injection

Skin is displaced with non-dominant hand

Still aspirate

Give medication (wait 10 sec)

Withdraw needle while replacing the skin to seal off med

Why do we aspirate on IM injections?

Aspirating during intramuscular (IM) injections is a technique used to check whether the needle has accidentally entered a blood vessel before injecting medication.

Practices for safely administering medications

• Follow six "rights" consistently

• Learn essential information about med to be given

• Interpret prescriber's orders accurately

• Read medication label carefully

• Accurately calculate & measure medication dose

• Check expiration date on medication

• Check for patient allergies!!!

• Compare to medication administration record

• Check medication at least 3 times

• Verify patient before administering med (2identifiers)