Fundamentals Final

2 things essential for promotion of wound healing

1. inc. protein

2. inc. vit. C

impaired blood flow

circulation can contribute to pressure injury

when are sutures removed

7-10 days

wound irrigation

cleanse with 0.9% sodium chloride before specimen collection and to remove debris.

wound cleaned at what temp

warm water

inflammation

first phase of wound healing

how long can cold press therapy be applied

20 minutes

partial thickness wounds

1st two layers

full thickness wounds

anything beyond that involves deeper layers of skin and tissue

evoision

is pulling away or tearing offof a body part or tissue.

wounds heal by

contractions

1st phase of wound healing

inflammatory phase

steroids

impair wound healing decreases formation of collagen and fibroblasts which are needed for wound healing

malnutrition

impairs wound healing pre albumin level below 15-36 indicates malnutrition

hemorrhage

pelvic fractures and breaks in long bones

dehiscence

nurse should place the client in a supine position with knees flexed to prevent further dehiscence and promote comfort

proliferation

phase of healing begins on the third or fourth day after an injury last 2 to 3 weeks

provider

decides how and when dressings are changed

Inflammatory phase

-begins immediately & lasts 1-4 days

-blood vessels constrict & clotting factors are activated

1st intention wound example

surgical wound made with sterile scapal

2nd intention wound healing

wound with tissue loss, edges dont meet, not approximate

Halo of redness on surrounding skin could be a sign of

infection

pt with urinary incontinence would be at risk for

impaired tissue integrity

4 signs of infection

swelling, warmth, odor, purulent drainage

immobile pt.s are at high risk for

pressure injuries

pt.s who are unresponsive or paralyzed

at risk for pressure ulcers

2nd intention or traumatic wounds are more likely to

become infected

when collecting a culture from a draining wound

irrigate until solution runs clear before collecting to remove slough

nursing action if you see dehiscence (opening of an incesion)

place client supine with knees flexed

nursing action if you see evisceration (protrusion out of a wound)

cover wound with normal saline & sterile gauze

yellow wound

layers of yellow fibrous debris (slough)

purulent drainage

yellow, thick, green or brown

purulent drainage would indicate

wound infection

If pt. is using a pen rose drain, nurse should place

perforated gauze around the drain

If using a hypothermic blanket nurse should monitor for

shivering

(T or F) Never put ice directly on skin or wound

True

skin traction or buckstraction purpose

promotes relief from muscle spasm

nursing intervention for pt. using bucks or skin traction

1. monitor peripheral pulses

2. examine skin under splint

3. asses temp of the affected extremity

If bucks traction or splint is on right leg, left leg will get

active range of motion

skeletal traction uses

external fixators (pins, scres, or tongs)

skeletal traction is used to

stabilize bone fragments during bone healing

signs of infection at external pin site

fever, purulent, drainage, odor

if pt. is using as assistive device because of a LEFT sided MUSKULOSKELETAL injury

theyll use the device on their RIGHT side

halo tractioin

pins & halos holding head straight up

when pt. has halo traction in place always

elevate the head of the bed

skeletal vs. skin traction

skeletal: better at reducing a fractors

skin: prevent muscle spasm

When using a skeletal traction, weight needs to be...

hanging freely from the bed

capillary refill

3 sec. or less (report a cap refill higher longer than 3 secs)

skin under a cast is warm to the touch, this could mean

infection & needs to be reported

When irrigating a wound, irrigate until..

solution runs clear

subjective vs objective data

subjective: symptom, pt. reports

objective: sign, verifiable

MRI

remove all metal

nursing action after a barrium swallow

push fluids

why are laxatives given after barrium swallow?

to eliminate the barrium, because it hardens

before fecal occult testing pt. should stop taking

anticoagulant's / blood thinners (ex. aspirin)

OSA (obstructive sleep apnea) physical findings

low engery

1st step after opening a sterile cath kit

gloves

temporary problem after removal of urinary catheter

urine retention

position of pt when removing catheter

supine

pt. with illeostomy will NOT be allowed

enteric-coated medications

Priority tast to delegate

Lab work (ABG)

restraining a pt. that wants to leave would be an example of

false imprisonment

Restraints must be tied with

slip knot

A nurse should monitor a pt. using a cooling or hypothermic blanket for

shivering

pt. receiving TPN, monitor IV site for

infection

As you get older what vision change is expected?

Reduced depth perception

When transferring a pt. with one sided weakness be sure to

lock wheels of wheelchair

when preparing to reposition a pt. toward head of bed nurse needs to

look toward head of bed

when repositioning a pt. toward head of bed pt. needs to be in what position

supine

why perform passive range of motion?

improve or maintain joint flexibility

age related change to musculoskeletal

dec. joint flexibility

proper technique when lifting

good posture, keep back straight

nursing action for pt with constipation

push fluids

synovial joint

fluid filled cavity

when administering eye drops block the

lacrimal duct (tear duct)

converting household measurements 1 cup=

1 cup = 240 ml

when administer otic medication (ear drops)

warm med to room temp

good nursing practice to prevent accidental needle injuries

replace SHARPS container when full

before administering a multidose inhaler

shake it

monitor IV sites for

infiltration

wearing special vests to administer meds helps to

decrease medication errors

before administering food to a post op pt. nurse should

check for bowel sounds

when administering otic (ear) drops to a 2 year old

pull down & back

2 pt identifiers

name and dob

angle for IM injection

90 degrees

when using a glass ampule always use

a filter needle

1st priority after a medication error

monitor patient

If you notice a med dose seems too high

speak to the available provider

pt. position when administering a suppository

left sims

final medication check is performed where?

at the bedside

medications are checked ______ times before administration

3

passive safety deceive

sheath to protect needle

6 steps of using a metered dose inhaler

1. shake

2. exhale slowly

3. place lips firmly

4. inhale slowly while pressing down

5. hold breath 10 sec.s

6. exhale slowly

1st thing to do after an accidental needle stick

wash with soap and water

assault

verbal threat

battery

physically holding pt down

two tenths should be written as

0.2

IM injection safety precaution

always use a needle that retracts

precaution for a cancer pt

protective environment or reverse isolation

apical pulse location

left midclaviular and 5th intercostal space