Funds exam 2 R. Garcia TAMUCC

What is tissue integrity?

The ability of the human body to regenerate and maintain normal physiologic functioning.

What structures act as defense mechanisms for the body?

Skin, cornea, subcutaneous tissue, and mucous membranes.

What are some risk factors for the development of pressure injuries?

Skin frailty, age, mobility issues, weight, and conditions such as spina bifida and cerebral palsy.

How does aging affect the skin?

Skin becomes thinner, loses elasticity, has less subcutaneous fat, has sluggish blood supply, and becomes less hydrated.

What are the most susceptible areas for pressure injuries?

Heels, toes, sacrum, hips, elbows, shoulders, and back of the head.

How are pressure injuries classified?

According to the amount of tissue loss observed in the wound, using a scale of 1-4.

What does a Braden score indicate?

It assesses and documents a patient's risk for developing pressure injuries; a higher score indicates lower risk.

What is Stage 1 of the pressure injury scale?

Non-blanchable erythema of intact skin.

What characterizes Stage 2 pressure injuries?

Partial thickness skin loss with exposed dermis.

What is the definition of Stage 3 pressure injuries?

Full thickness skin loss.

What does Stage 4 pressure injury indicate?

Full thickness skin and tissue loss.

What does 'unstageable' mean in pressure injuries?

Obscured full thickness skin and tissue loss.

What is a deep tissue pressure injury?

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

What does the TIME mnemonic stand for in wound assessment?

Tissue integrity, Inflammation or infection, Moisture, Edge of wound.

What are the three phases of the wound healing process?

Hemostatic or inflammatory, Proliferative, Remodeling.

What is primary healing or first intention?

Occurs in clean lacerations and surgical incisions, closed with skin adhesives or sutures.

What is secondary healing or second intention?

Wound healing that occurs when the wound is left open to heal.

What is delayed primary closure?

A combination of primary and secondary healing where the wound is left open for 5-10 days before closure.

What is blanching in the context of skin redness?

Blanchable erythema disappears when pressure is applied; non-blanchable does not and indicates structural damage.

What are the two methods for measuring wound size?

Tracing the wound circumference and measuring the length and width of the wound.

What is surgical debridement?

The removal of accumulated debris and dead tissue with a scalpel or scissors to decrease bacteria and stimulate healing.

What types of wound dressings are there?

Dry or wet dressings, varying based on wound base, healing rate, and amount of exudate.

What are some major complications of wounds?

Infections, dehiscence, eviscerations, hematomas/seromas, and fistulas.

What is mobility?

Freedom and independence in purposeful movement, requiring functional musculoskeletal and nervous systems.

What is immobility?

Inability to move freely and independently, which can be temporary or permanent.

What does the assessment of mobility focus on?

Mobility, range of motion, gait, exercise status, activity tolerance, and body alignment.

What is activity tolerance?

The ability to perform physical activities without excessive fatigue.

What is activity intolerance?

The inability to perform activities of daily living (ADLs) due to physical limitations.

What are activities of daily living (ADLs)?

Basic self-care tasks such as bathing, dressing, eating, and mobility.

What factors affect mobility?

Health status, age, alterations in muscles, injuries to the musculoskeletal system, poor posture, and impaired central nervous system function.

What are the integumentary system effects of mobility?

Increased pressure on skin leading to ischemia and potential pressure injuries.

What respiratory issues can arise from decreased mobility?

Decreased respiratory movement, stasis of secretions, decreased cough response, and risk of atelectasis and hypostatic pneumonia.

What cardiovascular effects can result from prolonged immobility?

Orthostatic hypotension, decreased cardiac output, increased cardiac workload, and risk of thrombus development.

What metabolic changes occur due to immobility?

Altered endocrine function, decreased basal metabolic rate, negative nitrogen balance, and loss of muscle mass.

What urinary complications can arise from immobility?

Urinary stasis, risk of renal calculi, and urinary tract infections (UTIs) due to decreased fluid intake.

What musculoskeletal changes occur due to prolonged immobility?

Decreased muscle endurance, strength, mass, impaired balance, and atrophy.

What are the four properties of muscle?

Contractibility, excitability, extensibility, and elasticity.

What are the three main types of muscle?

Cardiac (involuntary, heart), smooth (involuntary, blood vessels and organs), and skeletal (voluntary, attached to bones).

What is flexion in terms of movement?

Bending a limb to reduce the angle between bones.

What is extension in terms of movement?

Straightening a limb.

What is abduction?

Moving a limb away from the midline of the body.

What is adduction?

Bringing a limb closer to the midline of the body.

What is pronation?

Turning a body part to face backwards.

What is supination?

Turning a body part to face forwards.

What is circumduction?

Circular movement of a limb.

What is rotation?

Side-to-side movement of a body part.

What is inversion?

Turning a body part inward.

What is eversion?

Turning a body part outward.

What is dorsiflexion?

Drawing the toes upward towards the body.

What is plantarflexion?

Pointing the toes downward away from the body.

What are common types of postural misalignments?

Lordosis, kyphosis, flat back, sway back, and scoliosis.

What is enteral nutrition?

Nutritional intake through the gastrointestinal tract, either orally or via a feeding tube.

What are the types of enteral feeding tubes?

Nasogastric tube (NGT), gastronomy tube (GT), and jejunostomy tube (JT).

What complications can arise from enteral nutrition?

Aspiration, diarrhea, constipation, tube occlusion, tube displacement, cramping, nausea, vomiting, and electrolyte imbalances.

What is gastric residual volume (GRV)?

A measure used to verify if the patient's GI system is functioning and tolerating feedings.

What is the recommended frequency for changing dressings in a healthcare setting?

At least every shift.

What are the two types of parenteral nutrition?

Partial parenteral nutrition (PPN) and total parenteral nutrition (TPN).

How is parenteral nutrition administered?

Intravenously through a large vein.

What is the purpose of verifying tube placement?

To ensure the tube is correctly positioned and to assess the patient's GI function.

What is the normal pH for gastric aspirate from an NG tube?

Usually <5.

What pH level is typically expected from a J tube?

Usually <6.

What does gastric residual volume (GRV) indicate?

It verifies if the patient's GI system is functioning and tolerating feedings.

How often should GRV be measured for continuous feedings?

Every 4-6 hours.

What should be done if a single GRV is greater than 500 mL?

Stop feeding, assess the patient, and call the doctor if indicated.

What are some signs of aspiration to assess in a patient?

Changes in level of consciousness, worsening breathing, changing vitals, wet cough, bloating.

What organization accredits hospitals based on safety performance?

The Joint Commission (TJC).

When was The Joint Commission established?

In 1951.

What is the purpose of TJC facility evaluation performance scores?

To quantify and identify safety performance measures and track action plans.

What are National Patient Safety Goals (NPSG)?

Established relevant safety practices that healthcare institutions should accomplish.

How many standards of compliance are there currently?

Over 250 standards.

What is a near miss in healthcare?

A potential error or event that could have caused harm but was caught and avoided.

What defines a sentinel event?

A critical, unexpected adverse event that causes severe harm, including death or permanent injury.

What is the significance of unexpected events in healthcare?

They can indicate areas for improvement in patient safety and care.

What should ongoing assessments focus on regarding aspiration risk?

Monitoring signs and symptoms that indicate potential aspiration.

What is the role of the pH of gastric aspirate in tube placement verification?

It helps confirm that the tube is in the correct location.

What actions should be taken if a patient shows signs of aspiration?

Assess the patient and implement appropriate interventions based on findings.

What is the importance of ongoing assessments in patient care?

To ensure early detection of complications such as aspiration risk.

What is the purpose of root cause analysis (RCA)?

To probe potential or actual errors and determine whether human error or systems failure led to the error, and to establish a corrective action plan.

Who should advocate for reporting unexpected events and near misses in healthcare settings?

Administration, risk management, and nurse leaders.

What are some barriers to event and near miss reporting?

Fear of repercussions, lack of time, unclear policies, bullying, insufficient education, lack of understanding of roles, and favoritism.

What is the GI tract composed of?

The liver, pancreas, gallbladder, and a series of hollow organs that originate at the mouth and terminate at the anus.

What role does the epiglottis play in digestion?

It prevents food and liquid from entering the airway.

What is peristalsis?

The process that moves food downward through the digestive tract.

What happens to food in the stomach?

Food and liquid mix with digestive secretions before being emptied into the small intestine.

What occurs in the large intestine?

Liquid is absorbed from waste byproducts, and stool begins to form.

What are some age-related considerations affecting digestion?

Decreased chewing ability, declining peristalsis, slowed esophageal emptying, impaired mucosal absorption, and decreased muscle tone.

What are the characteristics to assess in bowel movements?

Color, viscosity, odor, sediment, and presence of blood.

What are the types of colostomies?

Ileostomy, ascending, transverse, descending sigmoid, loop or double barrel, end, ileoanal reservoir, and continent ileostomy.

What complications can arise from an ostomy?

Fluid and electrolyte deficiency, constipation, dumping syndrome, skin breakdown, rashes, folliculitis, and ulcerations.

What are key considerations for ostomy care?

Assessment, delegation considerations, pouching, irrigating, nutritional considerations, psychological considerations, and bowel training.

What should be assessed in an ostomy?

Frequency of emptying, character of feces, appearance of stoma, condition of peristomal skin, pouching system, daily care, diet, and emotional state.

What are the three preoperative phases?

Preoperative, intraoperative, and postoperative.

What is involved in the preoperative assessment?

Confirming client identifiers, obtaining a complete client history and consent, and promoting safety by identifying high-risk clients.

What is the focus of the intraoperative phase?

The time during which clients are moved onto the bed in the operating room until they are transferred to recovery.

What characterizes the postoperative phase?

It occurs immediately after surgery and can last a few hours or include rehabilitation and recuperation.

What should be included in client teaching during the preoperative phase?

Information relevant to the client's individual needs and safety measures.

What is the importance of two identifiers in preoperative assessment?

To confirm the identity of the client and ensure safety.

What factors should be considered in the assessment of bowel movements?

Characteristics such as frequency, presence of urge or pain, and conditions like incontinence, constipation, or diarrhea.

What are the steps of physical assessment for bowel health?

Inspect, auscultate, percuss, and palpate.

What should be monitored for in patients with an ostomy?

Weight loss, electrolyte imbalances, and emotional state.