Fundamentals Exam 2 TMR

what are the 3 main layers of the skin

1. epidermis
2. dermis
3. hypodermis (subcutaneous)

what are factors that can affect skin integrity

- mobility/activity
- nutritional status
- impaired tissue perfusion or circulation
- sensory perception
- moisture
- shearing/friction
- chronic illness
(diabetes or PVD)

open wound- an injury in which the skin is interrupted, exposing the tissue beneath

closed wound- an internal injury with no open pathway from the outside

what are the 3 terms used to describe wound measurements

length, width, depth

wound classification

- underlying cause
- skin integrity
- wound depth
- amount of contamination
- healing process

clean vs contaminated wounds

- clean wounds do not have any foreign material or debris inside
- while contaminated or infected wounds may have dirt, bacteria, or other foreign objects

- clean: clean wounds w/ low risk of infection

- clean-contaminated: clean wounds with a higher risk of infection

- contaminated: had contact w/ something from external environment

- dirty/infected: current exposure to objects, debris, pus, feces, etc & is showing signs of infection

- colonized: organisms are found on the surface via swab culture, but no signs of infection

acute vs chronic (healing process)

- a chronic wound starts as an acute wound
- a wound becomes chronic when it doesn't move through an expected or predictable rate of healing through each stage of wound healing

phases of wound healing (3)

- inflammatory
- proliferative
- maturation

inflammatory phase

- 3 days
- coagulation cascade

proliferative phase

- several weeks
- granulation tissue

maturation phase

- up to 1 yr
- scar tissue

3 types of healing intentions

- primary (edges are approximated by intervention or naturally)
- secondary (edges can't be approximated due to tissue loss)
- tertiary (wound is left open & later closed due to risk of infection/poor healing)

what are factors that affect wound healing

- o2
- infection
- age/sex
- chronic illness (diabetes or obesity)
- stress
- nutrition
- medications

dehiscence vs evisceration

dehiscence is a partial or complete separation of tissue layers during healing, while evisceration is the total separation of tissue layers, allowing protrusion of visceral organs thru incision

stage 1 pressure injury

non-blanchable erythema of intact skin

stage 2 pressure injury

partial-thickness loss w/ exposed dermis (blisters)

stage 3 pressure injury

full thickness skin loss w/ undermining and/or
tunneling

stage 4 pressure injury

full thickness skin & tissue loss (osteomyelitis: bone infection)

unstageable pressure injury

- obscured full-thickness skin & tissue loss
- can't be assessed until eschar in wound bed is removed

deep tissue pressure injury

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

what increases the risk for pressure injuries

- impaired sensory perception
- excess moisture
- decreased activity/mobility
- friction & shear
- incontinence
- poor nutrition
- poor circulation

what is used for a risk assessment for pressure ulcers

braden scale & norton assessment tool

what assessments need to be done when a patient has wound

- location
- size
- is there tunneling or undermining
- drainage
- conditions of wound edges & surrounding tissues

serous- clear & thin

serosanguineous- mixture of serum & blood; pinkish color

sanguineous- primarily blood

purulent- thick, white, pus-like (indicator of infection)

What is COCA

Color

Odor

Consistency

Amount

maceration- softening & breakdown of skin due to excess moisture

what are ways to prevent pressure injuries

- proper hygiene & nutrition
- adequate incontinence care
- barrier creams
- avoid skin trauma (wrinkle free bed, reduce shearing, draw sheet use)
- rotate patient position (q2)

JP drain

to prevent the collection of fluid underneath the incision site

hemovac drain

placed under your skin during surgery; removes any blood or other fluids that might build up

penrose drain

a straight, flexible tube that drains fluid from a surgery site

wound vac

- gently pulls fluid from the wound over time
- can help clean the wound & remove bacteria & pull the edges of the wound together
- may stimulate the growth of new tissue that helps the wound close

exposed vs infection

exposure means coming into contact with a virus or bacteria, infection happens when someone is exposed & actually becomes sick from the exposure

asepsis vs sepsis

the state of being infected is called sepsis, asepsis refers to freedom from & prevention of disease causing contamination

lines of defense

1. normal flora
2. inflammatory response
3. immune response

systemic defenses

1. integumentary
2. respiratory system
3. GI system

sterile body areas

areas of body not exposed to external environment
(ie: blood, CSF, pleural fluid, bone marrow)

non-sterile body areas

parts of the body that are exposed to the external environment and may contain microorganisms
(ie: bladder, digestive tract, lungs)

what normal body flora may cause problems

c. diff from disease process or antibiotic

s/s of inflammation

- swelling
- redness
- warmth
- pain

antigens vs antibodies

antigens are foreign substances that enter the body & create an immune response, while an antibody is a protein produced by your immune system to attack & fight off antigens

innate vs acquired immunity

- innate immunity is non-specific & acquired at birth (ie: cough reflex)
- acquired immunity is specific & develops after exposure or vaccines

types of acquired immunity

active & passive

passive immunity

transfer of antibodies produced by 1 person to another; short immunity 1-6 wks
(ie: a baby receives a mother's antibodies through the placenta or breast milk)

active immunity

protection produced by a person's own immune system; usually lasts for many years
(ie: chicken pox)

steps in the chain of infection

- agent/germs (virus)
- reservoir/where the germs live (people)
- port of exit
(mouth)
- mode of transmission (droplets/sneezing)
- portal of entry (mouth)
- susceptible host/next sick person (baby)

healthcare acquired infection (HAI)

an infection that a patient develops while receiving care for another condition in a healthcare setting

what is the most effective method of fighting infection

good hygiene; wash your hands!

acute vs chronic infection

acute we acquire, then treat & the infection goes away while
chronic is the continued presence of an infection following the primary infection, usually lasting 6+ mo

systemic s/s of infection

- confusion or delirium
- fever or hypothermia
- hypotension
- tachycardia
- chills
- H/A & lightheadedness

what patients are at a higher risk of infection

- babies
- pregnant
- immuno-compromised
- elderly
- obese
- chronically ill

WBC counts (infection)

increased; above 10,000/mm3

ESR (infection)

degree of inflammation in the body, increased; above 100mm/hr

C&S (infection)

used to identify any present organisms like bacteria or fungi; positive culture

WBC differential (infection)

shows amount of each type of WBCs
- neutrophils: bacterial
- lymphocytes: viral
- monocytes: long-term infections, blood disorders, or autoimmune disorders

who should we use standard precautions with

everyone

do we have to wear gloves for every patient

wear gloves every time you touch:
- blood
- bodily fluids
- bodily tissues
- mucous membranes
- broken skin

contact isolation

- transmitted directly or indirectly from an infected person to another
- gowns & gloves

airborne isolation

- N95, negative pressure room
- small particles in the air move into airspace of another person

droplet isolation

- droplets from coughs, sneezes, or talking come in contact w/ mucosa of host
- surgical mask

protective isolation

used for patients who have compromised immune systems

medical vs surgical asepsis

medical is clean technique & surgical is sterile technique

pain

- an unpleasant sensory & emotional experience associated w/ actual or potential tissue damage
- pain is whatever the patient says it is

nociception- perception of pain

pain threshold vs pain tolerance

pain threshold is the the point at which a person perceives pain, pain tolerance is the level of pain a person can endure

acute pain vs chronic pain

- acute pain occurs abruptly after injury/disease & persists until healing occurs (less than 6 mo)
- chronic pain lasts for a prolonged period of time & persists beyond normal healing period (6+ mo)

nociceptive pain

- physiologic pain in response to trauma, injury, or inflammation
- most common
- visceral or somatic

visceral vs somatic pain

visceral pain refers to organs of the body while somatic refers to skin, muscles, bones, & joints

neuropathic pain

- pain from damage to neurons
- nerve injury or phantom pain

phantom pain

pain or discomfort felt in an amputated limb

psychogenic pain

no physical cause but can be caused by mental, emotional, or behavioral factors

physiologic consequences of uncontrolled pain

increased HR, BP, RR, & intracranial pressure

differences in response/VS in patients w/ acute vs chronic pain

a patient who lives with chronic pain may have a high pain rating but not outwardly display their pain bc they are used to it vs a person who is experiencing acute pain who may visibly display the affects of their pain more

diversity considerations across life spans

- traditions, customs, & spirituality.
- uses of gender roles & sexual orientation
- issues related to pain, suffering, & distress
- attitudes about discussing serious illness & death

SOCRATES

Site

Onset

Character

Radiates

Associated s/s

Time/duration

Exacerbating &/or relieving factors

Severity

*used for adult pain assessments

VAS pain assessment scale

consists of a straight line with the endpoints defining extreme limits such as 'no pain at all' & 'pain as bad as it could be

Wong-Baker FACES pain rating scale

a pain assessment tool that uses six caricatures of a child's face representing no hurt to biggest hurt a child could ever have

FLACC scale

a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain

Face
Legs
Activity
Cry
Consolability

what is the purpose of documenting

- if you didn't chart it... it didn't happen!
- protects yourself & the patient
- keeps the health-care team informed

what is the purpose of patient records

- communication
- reimbursement
- care planning
- education
- quality review

timing guidelines when documenting

for each notion documentation of date & time of recording & assessment or intervention is essential

confidentiality guidelines when documenting

assess is restricted to health professionals involved in giving care

permanence guidelines when documenting

all entries on client's record are made in black ink so the record is permanent & changes can be identified

signature guidelines when documenting

each recording is signed by the nurse making it & should include name & title

accuracy guidelines when documenting

it is essential that all notions are on record to be accurate & correct; consisting of facts & exact observations

sequence guidelines when documenting

the nurse should document events in order in which they occur; never document before completing a task

appropriateness guidelines when documenting

only info that pertains to patient's health problem & care is recorded

use of abbreviations guidelines when documenting

use only commonly accepted abbreviations, symbols, & terms specified by agency

formats of nursing documentation

- initial nursing assessment
- kardex care plan
- plan of nursing care
- critical & collaborative pathways
- progress notes
- flow sheets
- discharge & transfer summary
- home healthcare documentation

components of the flow sheet

- graphic sheet
- 24 hr fluid balance record
- medication record
- 24 hr patient care record

what are some common problems w/ documentation

- not in accordance w/ healthcare organization standards
- doesn't include description of situations that are out of the ordinary
- doesn't reflect patient needs
- content implies attitudinal bias or risk situation

EMR vs EHR

an EMR has info from a single care provider & is only avaliable to them, EHRs are designed to be used by multiple care providers & healthcare organizations

CPOE

computer physician order entry

MAR

medication administration record

what are issues associated w/ not giving a good report

when a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, & delays or omissions in care often occur

what is SBAR used for

communication between healthcare providers

SBAR

Situation

Background

Assessment

Recommendation

incident report

when an unusual & unexpected event involving a patient, visitor, or staff member occurs it is reported to document details of incident immediately to ensure accuracy

what is the importance of using informatics in nursing

help manage medical data & develop & maintain data systems that are designed to improve patient outcomes & performance of HCOs

DIKW (& what does it mean)

Data

Information

Knowledge

Wisdom

- provides a theoretical framework for defining the scope of practice for nursing informatics

what is BCMA used for

Bar

Code

Medication

Administration

- used as part of the process of medication administration, fewer errors are made

stroke volume

amt of blood ejected from left ventricle w/ each contraction

cardiac output

amt of blood ejected from the left ventricle each min

preload

end diastolic pressure

afterload

resistance to left ventricular ejection

perfusion vs ventilation

- ventilation is the process of moving gases into & out of lungs
- perfusion is the pumping of oxygenated blood to tissues & the return of deoxygenated blood to lungs

hypoxia vs hypoxemia

hypoxia is inadequate tissue oxygenation while hypoxemia is low levels of oxygen in blood

health assessment

OLDCARTS

respiratory assessment

- breathing (deep, shallow, labored... any wheezing?)
- pulse
- o2 sat
- lung sounds

types of diagnostic tests of gas exchange

- pulmonary function test (PFT)
- CBC
- BMP (renal function, electrolyte status)
- ABG
- chest xray
- sputum specimens for C&S

nasal cannula

- up to 6 L/min
(24-44% o2)
- help people who are having difficulty breathing

simple face mask

- 35-50% at liter flows of 6-12 L/min
- provides o2 therapy for pts who are experiencing conditions such as angina & dizziness, as well as mouth breathers
- interferes w/ eating & talking

rebreather masks

- capable of delivering higher concentrations of o2
- non-rebreather: 60-90% o2, 10-15 L/min, valve
- partial rebreather: 40-60% o2, 6-10 L/min, no valve

main purpose of non-rebreather mask

to stabilize pt if they are in sudden distress

venturi mask

- 24-50% w/ o2 flow rates of 4-12 L/min, flow-control meter (most precise)
- for pts who have a low to moderate o2 requirement but at risk for hypercarbia w/ uncontrolled oxygen therapy (usually COPD)

metered-dose inhaler (MDI)

- convenient
- requires hand-mouth coordination
- spacer is helpful
- aerosol drug delivery used to treat respiratory disorders

aerosol mask for nebulizer

- acute & long-term care settings
- more med lost to atmosphere
- used to deliver a liquid (solution) medication via inhalation directly into the lungs

bag-valve-mask device

- used w/ o2
- used in emergency
- airway management technique
- allows for oxygenation & ventilation of patients until a more definitive airway can be established

incentive spirometry

- presence of atelectasis
- risks of atelectasis: post-op adnominal/thoracic surgery, post-op patients w/ acute or chronic lung disease, & chest trauma
- 10 times/hr while awake

BiPAP

- continuous positive pressure
- higher setting for inspiration
- lower setting for expiration
- used in COPD

CPAP

- continuous positive pressure
- 1 pressure setting
- used for obstructive sleep apnea

types of pharyngeal airways

oropharyngeal & nasopharyngeal

oropharyngeal airway

- relieve upper airway obstruction
- bite block w/ oral endotracheal tubes
- decreases LOC
- able to breath on own

nasopharyngeal airway

- less traumatic than nasal suctioning
- better tolerated in alert patients
*complications: sinusitis, otitis media, nasal necrosis

endotracheal tube vs tracheostomy

ET tubes are placed into the mouth & down the throat to provide oxygen via a machine, trachs includes surgical incisions in the trachea & a ventilator is not always needed

concerns regarding trach patients w/ laryngectomy

a laryngectomy has no connection to the mouth or nose, if airway is lost there is no other way to get o2

emergency equipment for trachs

- extra trach: same size
- extra trach: smaller size
- inner cannulas: same size
- obturator @ bedside
- suction catheters
- wall suction set up
- ambu bag

emergency equipment for chest tubes

- vaseline gauze (prevent air)
- hemostats x2 (soft tip)
- oxygenation equipment

where does the drainage system go that is attached to chest tube

- remain upright for the water-seal chamber to function correctly
- must be lower than the chest to facilitate drainage and prevent back flow

What are some important considerations for the guidelines for documenting?

TIMING

CONFIDENTIALITY

PERMANENT

SIGNATURE

ACCURACY

SEQUENCE

APPROPRIATNESS

USE OF ABBREVIATIONS