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EKGs are used to determine ____________ cardiac functioning, response to cardiac _____________ or interventions, investigate chest __________, or evaluate the ___________ of the heart.
baseline, medications, pain, condition
1. The normal expected EKG rhythm is __________________.
Normal Sinus Rhythm
Nurses can help ensure an accurate reading by applying the leads in the correct _______________, ensuring the leads are _______________ well, instructing the patient to __________________.
positions, adhered, hold still
______________ is an unexpected reading that often results from lead ______________ or patient ______________.
artifact, nonadherence, movement
When applying a 3 or 5 lead EKG, the nurse places the __________ lead on the right and uses snow over ___________, ____________ over fire, and __________ near the heart to place the remaining lead colors
white, grass, smoke, chocolate
With a 12 lead EKG the nurse places the first lead to the ________________ of the sternum at the ________________ intercostal space.
right, fourth
Infection control is important because it helps prevent complications that often require additional therapies and ___________________ or have the potential to __________ the patient or _____________ their stay.
treatment, harm, extend
Standard precautions, including donning ________________ or a _____________, are utilized for any and ______________ patients when there is a risk for exposure to _____________________________ .
gloves, gown, all, bodily substances
Nurses help decrease the spread of infection by eliminating one or more of the pieces in the ___________ of infection.
chain
Vital signs are an excellent indicator of the presence of health _______________ or changes in the health ______________ of a patient
stressors, status
What can happen if a nurse uses a BP cuff that is too small or too large for a patient?
elevated = too small, decreased = too large
The ______________ pulse is the most accurate site for counting a heart rate;
apical
In addition to the rate, the _________, ___________, and ______________ should also be noted for respirations.
depth, rhythm, effort
What is the greatest concern when obtaining a rectal temperature?
A stage I pressure ulcer is red, non-_____________ and closed/intact,
blanchable
stage IV pressure ulcer is open and extends all the way to ________ or internal structures
bone
The nurse can help prevent and treat pressure ulcers by providing frequent turning and ________________, assessing for signs of ____________, keeping skin clean and dry, utilizing ____________ aids and barrier devices, and ______________ medical equipment.
repositioning, breakdown, padding, positioning
List 3 common areas for pressure ulcers to develop for a patient in a side lying position:
Ear, shoulder, hip
What factors increase the risk of developing a pressure ulcer?
incontinence, inability to move, malnutrition (advanced age, diabetes etc.)
Poor oxygenation poses many risks since it can result in confusion, decreased level of ___________________, diminished system _______________, or tissue _________.
consciousness, functioning, death
Supplemental oxygen also poses risks as the equipment can cause _____________ sores and increase the risk for falls and fires
pressure
Prolonged or too much oxygenation can also cause ______________ damage or decrease a patient's ____________ drive.
tissue, respiratory
_________________, confusion, and ___________ are often early indicators of respiratory distress while oxygen ____________ changes, and ___________, or retractions are late signs of distress.
restlessness, anxiety, saturation, cyanosis
The nurse's initial response to respiratory concern should be to ____________ the patient and promote ________ conservation.
position, energy
Oxygen should be applied ___________ according to the patient's needs
incrementally
Typically, the nurse should start with a __________________ before applying a face mask or ___________.
nasal cannula, non-rebreather
The venturi mask is used to deliver a ___________ amount of oxygen.
specific
Suctioning can be utilized for patients with difficulty maintaining and clearing their airway, such as those with ______________ impairment, a weak or __________________ cough, or those with decreased _______________ capabilities.
neurologic, non-productive, swallowing
The nurse should stop suctioning if the patient becomes _________________ or displays signs of respiratory distress, such as _____________ or a drop in ______________________.
bradycardic, cyanosis, oxygen saturation
Peak flow meter
test those with asthma to measure how quickly the patient can expel air (prompts adjustment to medications/treatments)
Incentive spirometer
device that helps patients exercise their breathing muscles (inhale to expand lungs)
Chest physiotherapy
consists of coughing, chest wall percussion, vibration, postural drainage, designed to improve airway clearance
Coughing and Deep Breathing
Exercises help persons with res piratory problems.
PPE for contact precautions
gown and gloves
PPE for droplet precautions
Gown, mask, goggles, gloves
How can isolation precautions affect the holistic well-being of a patient?
Feeling of being lonely, fear, embarrassment, shame, decreased exercise
Name 3 procedures that require surgical asepsis.
urinary catheterization, lumbar puncture, tracheal suctioning (CVC or wet-to-dry dressing change)
Stage II pressure ulcer
partial thickness skin loss involving epidermis, dermis, or both (skin loss, abrasion, blister, shallow crater)
Stage III pressure ulcer
Full-thickness tissue loss (no bone, tendon, or muscle visible, tunneling occurs)
Appropriate and accurate documentation ensure a ________ source of patient information, clear _____ among the healthcare team, a way to measure patient ______ and outcomes, and legal ______ of care provided.
beneficial, communication, responses, evidence
To ensure accuracy and appropriateness, the should document ______ or immediately ______ a procedure, as well as ensure the documentation is ______, _________, and organized.
during, after, thorough, fact-based
Under HIPAA regulations, all sources of ______ and patient information must be protected.
charting
Medical staff are not to reveal any patient information or identifying ________ without prior consent from the patient.
characteristics
Dressings are selected based on their ability to _______ the wound, reduce the prescence of _______, control or contain __________, or provide immobilization or debridement.
protect, bacteria, bleeding/damage
They should be able to be removed without further ______ and promote a ______ wound bed while protecting the integrity of _________ tissue.
trauma, moist, surrounding
Debriding a wound is beneficial as it helps clear ______ tissue and promotes _______ and granulation.
dead, circulation
This can be done with a _________ dressing or by using special _________ agents.
wet-to-dry, chemical
The process should not cause extensive _______ or trauma to the wound bed.
bleeding
What dressing provides wound protection and waterproofing?
Transparent dressing
What dressing is useful for a wound with excessive drainage?
Alginate
Elastic bandages can provide wound _______ or support, restrict _________, or stimulate _________.
pressure, mobility, circulation
To promote blood return to the heart, they should always be applied in a _______ to ________ manner.
distal, proximal
What tasks can the NAP perform in regards to wound and drain care?
Observation
Wound healing is affected by numerous factors, including the severity and ________ of tissue involvement, the occurrence of additional or repeated ______, prescence of ________, and the overall ______ and well-being of a patient.
extent, trauma, infection, health
Risk factors for impaired wound healing include decreased _________, diabetes, malnutrition, advanced ______, and _______.
circulation, age, smoking
Primary intention healing
wound that is surgically closed
Secondary intention healing
wound is left open to heal (from inward to outward)
Tertiary intention healing
wound left open to heal for 2-3 days and then is surgically closed
hemostasis phase
first phase of wound healing, blood vessels constriction
Inflammatory phase
second stage of wound healing, erythema, warmth, swelling (Initial phase, occurs at time of injury)
Proliferative phase
begins a couple of days after injury, wound is rebuilt with new tissue
Maturation phase
the third phase of wound healing, in which scar tissue forms
__________ drainage often indicates infection
Purulent
________ drainage indicates a wound is healing
Serous
What factors need to assessed and documented for wounds?
Drainage, redness, swelling, odor
Irrigation is performed to remove _______
debry
What needs to be monitored in regards to surgical drains?
Changes in drainage or drain itself and skin around the drain
Negative pressure wound therapy
helps keep drainage off of a wound, stimulate granulation, and promote circulation and secondary intention in a wound.
What seal is used for a negative pressure wound therapy?
air-tight seal
How should the nurse intervene if a wound demonstrates dehiscence?
Reinforce with sterile moist dressing
Sutures are often removed after how many days?
7-10 days
Promotes continues wound intention
steri strips