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NUR 231 Test 2 Study Guide

by: Issy Notetaker

NUR 231 Test 2 Study Guide NUR 231

Issy Notetaker
GPA 3.96
Fundamental nursing skills
Marsann Shafer, Jane Edwards, Kathryn Humphrey

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About this Document

Study guide out of all the notes taken on the chapters
Fundamental nursing skills
Marsann Shafer, Jane Edwards, Kathryn Humphrey
Study Guide
50 ?




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This 30 page Study Guide was uploaded by Issy Notetaker on Sunday October 4, 2015. The Study Guide belongs to NUR 231 at Ball State University taught by Marsann Shafer, Jane Edwards, Kathryn Humphrey in Summer 2015. Since its upload, it has received 45 views. For similar materials see Fundamental nursing skills in Nursing and Health Sciences at Ball State University.

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Date Created: 10/04/15
Chapter 31 0 Medication is used in diagnosis treatment cure relief and prevention 0 Every HC facility plays a role in the safe administration of medication and the evaluation of the effects 0 Nurses are responsible in all settings for the evaluation of the effects teaching about medications and effects adherence to dosage schedule and evaluating ability to selfadminister Scienti c Knowledge Base What do you have to know in order to give medication 0 Medication in Legislation and Standards Federal Regulates pharmaceutical industry to protect people 0 What else 0 What is Medwatch State and Local mainly control what Health Care Institutions and Medication Laws 0 More restrictive than governmental Medication Regulations and Nursing Practice 0 What do the Nurse practice acts do 0 PharmacologicalConcepts Medication Names 0 Types and examples Classi cation 0 Indicates effect of medication on the body symptoms relieved desired effects 0 Can one medication have more than one classi cation What are the different Medication Forms and why is this important 0 Pharmacokinetics as the basis of Medication Actions What is this Absorption De ne Each routedifferent absorption rate Skin Mucus membranes and Respiratory system Oral IV 0 Ability of medication to dissolve depends on what 0 Blood Flow to Administration Site 0 Body SA Lipid Solubility o What does this mean Distribution depends on what o Moved to site of action Circulation 0 Membrane Permeability o 0 Protein Binding 0 Metabolism de ne Biotransformation o Occurwhere Liver o How does function hold up over time Excretion De ne Organs used 0 Types of Medication Action Therapeutic Effects 0 Expected or predicted effect Side EffectsAdverse Effects 0 Side Predicable and unavoidable secondary effects Adverse Unintended and undesirable unpredictable severe responses 0 If this occur what le is lled out Toxic Effects De ne Idiosyncratic Reactions unpredictable overunder reaction or has a different reaction to the medication that is not normal Allergic Reactions Unpredictable immunoglobulin reactions 0 What is the most common medication for this 0 Medication Interactions When one medication modi es the action of another medication What is a Synergistic effect 0 Timing of Medication Dose Responses MEC minimum effective concentration Toxic Concentration Therapeutic Range 0 Peak Trough Onset Plateau Biological 12 life To maintain a therapeutic plateau how often must a drug be administered A hospital needs to identify 0 Time critical medications Non time critical 0 Routes of Administration Oral routes SublingualAdministration o Buccal Administration 0 Parenteral Route 0 Four sites 0 o o o TopicalAdministration Direct or in the body cavity Apply by 0 o o o Transdermal disks or patches Explain evaluations that need to be made when these are applied Mucus membrane administration methods include Inhalation Through nasal and oral passages Endotracheal or tracheostomy tubes are also used if inserted Absorbed quickly into the rich vascularized lungs Local or systemic effects Intraocular What is the most common type 0 Systems of Medication Measurement Proper administration depends on ability to correctly calculate and measure dosages Metric System 0 Basic units 0 Length 0 Weight 0 Volume 0 Zero is always placed where Household Measurements Most familiar to people Inaccurate Include o Solutions Usedfor o 0 Concentration when dissolved is known as o What medications require a second nurse to calculate 0 Clinical Calculations To calculate doses mix solutions perform other activities 0 Ratio Proportion Method 0 0 Relationship between two numbers shown by Steps 0 Formula Method 0 0 First memorize the formula dose ordereddose on handX Amount on hand Amount to Administer Steps 0 Dimensional Analysis 0 O Factorlabel or unit factor method Steps 0 Which method is most accurate Pediatric Doses Children are at 3x higher risk for having a medication errors Calculations require caution bc small errors can create big problems 0 Guidelines 0 O O O O o Prescriber s Role Can be physician NP or PA Written or verbal or telephone order 0 Telephone requires a read back and verify Each order must include 0 Types and Orders in Acute Care Agencies Orders are commonly based on FrequencyUrgency of administration 0 Change in status Standing orders or Routine Medication Orders 0 Pharmacist39s Role prn Orders Make sure pt weight is in kg Doses are much smaller lM doses don39t exceed 1mL for a child or 5 ml for an infant Subcutaneous usually don39t exceed 5 mL Medications aren39t round off to nearest tenth Less than 1 mL measure in syringe with 110 markings Estimate does before beginning Compare and Evaluate amount ordered over 24 hour to dose about to give Single OneTime Orders STAT Orders Now Orders Prescriptions Prepares and distributes medication 0 Distribution Systems AMDS Systems for storage and distribution of medications What is a Unit Dose 0 Bene ts Automated Medication Dispensing System 0 Bene ts Nurse39s Role 0 Medication Errors There is room for administration of medication one hour before or after time Federal regulations are in place to enforce correct administration times o If these are broken When occurred what should be done Report all errors What is Medication Reconciliation Critical Thinking explain a little about each 0 Knowledge 0 Experience 0 Attitudes What ones Explain each 0 Standards 0 What are the 6 rights of mediation administration Explain each Right Medication Compare label on medication wo MAR 3 times 0 Before removal from container drawer self 0 Amount ordered is removed from container 0 At pt bedside before administration 0 Only administer medication that is personally prepared 0 Use clinical judgement wen giving prn medications 0 Give pain meds to the pt before starting assessment o If a mistake is made speak up Right Dose Right Patient 0 Use 2 identi ers before administering a medication Right Route Right Time Right Documentation 0 Never document that a medication was given until it has been given 0 Never place medication in the room and then leave 0 Check mouth to ensure ills were swallowed What are the Patient39s Rights Nursing Process 0 Assessment Begin assessment by asking questions 0 Medication management RouUne Ability to afford medications Beliefs and expectations attached to medication History 0 Review medical history Why Allergies Who should be informed Medications What information needs to be known about each 0 Diet History Why is this important 0 Pt Perceptual or Coordination Problems Why is this important Pt Current Condition 0 Why is this important Pt Attitude About Medication Use c What does this reveal Pt Understanding of and Adherence to Medication Therapy In uences what Pt Learning Needs 0 Diagnosis Common diagnosis 0 Planning Organize so there is no rushing and ensure safe administration Rushing makes error Goals and Outcomes Contribute goals to safety 0 Provide most important information about the medication rst 0 At discharge ensure pt is able to receive medications 0 Implementation Health Promotion 0 What can be done to do this 0 Pt and Family Teaching 0 Bene ts of medication how to make the medication correctly symptoms and side effects use and storage 0 Help to establish a routine 0 Provide information on Who needs special teaching Acute Care 0 Receiving Transcribing and Communicating Medication Orders 0 Must include 0 Check all orders for accuracy at least 3 times before administration and always when medication is ordered 0 Always determine if medication is compatible with condition and other medications 0 Once medication is deemed safe it is place on the MAR or eMAR Includes all information about medication order AND room an bed number medical record numbers medical or food allergies other patients 0 Verify accuracy of medications before each administration What do you do if there is missing information 0 Follow 6 rights of medication administration Accurate Dose Calculation and Measurement 0 Use standard measuring containers for liquids 0 Calculate each dose when preparing the medication 0 Correct Administration What is done to ensure this 0 Recording Medication Administration What is done Special Consideration for Administering Medications to Speci c AgeGroups Infants and Children 0 Doses are lower 0 Special caution is needed for preparation 0 Older Adults Polypharmacy 0 Evaluation 0 De ne Essential Gather data and create a holistic evaluation Goal What Pt Outcomes need to be assessed Medication Administration 0 Oral Administration By Mouth Easiest and most desirable way Food may decrease the effect Protect pt from aspiration how Special care needs to be given to those with a feeding tube such as o Topical Medication Application Use gloves Medication goes through the skin 0 Use sterile technique when 0 Cover well but not overly thick layer 0 Some are given through a transdermal patch 0 Guidelines Nasal lnstillation Different positions will reach different sinuses EyelnsUHann Eye drops and ointments Guidelines lntraocularAdministration Ear lnstillation Internal ear structures are sensitive Drainage may indicate eardrum rupture Don t force in medication Drops should be at what temperature Sterile solutions are used when eardrum is ruptured Nonsterile solutions into the middle ear can result in Vaginal lnstillation Suppositories foam jellies creams Rectal lnstillation Suppos ones o Administering Medications by Inhalation Aerosol Spray mist powder penetrating lungs Used for maintenance or rescue Differeniate pMDl chemical propellant Explain BAls Medication is released upon raising a lever and inhaling What releases medication DPls Aerosol is created upon inhaling through reservoir 0 What releases medication Education on when medication is empty and needs replacing o Administering Medications by lrrigations Wash out body cavity or consistent stream of solution What is used Aseptic when 0 Parenteral Administration of Medications Injection into body tissues lnvasive Aseptic techniques Risk of infection Equipment Synnges o LuerLok o NonLuer Lok 0 Number of sizes 0 Prepacked w needle 0 Tuberculin Needles Stainless steel 0 Disposable 0 Parts Hub Shaft Bevel 0 Size is chosen based on size weight and tissue of pt IM Subcut Disposal Injection Units 0 There are pre lled syringes and needles Preparing and Injection From an Ampule Contain single dose of medication 0 Glass w constricted neck that is snapped off for access to the medication Aspirate medication into syringe using and lter needle Preparing and Injection From a Vial Single or multidose vial w a rubber seal 0 Liquid or dry forms of medication 0 Closed system 0 Air must be injected for easy removal 0 After mixing multidose note date and time of mixing concentration and refrigerate rest of solution Mixing Medications Mixing Medication From and Vial and an Ampule 0 Prepare medication from vial rst using same syringe and needle then ampule Mixing Medication from 2 Vials 0 Principles 0 Method Insulin Preparation Prescribed in concentrations of 100 mL of solution or 500mL more rare Classi ed by rate of action 0 What should you know about each You can mix insulins IF they are compatible 0 Rules 0 Administering Injections Injection route varies based on tissue Tissue characteristics in uence rate of absorption 0 Before injection Nerve and bone damage can occur when a medication is wrongly administered Tissue damage and extreme pain can also occur Minimize discomfort by Subcut How 0 Best Sites 0 Alternative sites Quickest absorption for insulin 0 Site should be alternated w each injection 0 Degree of insertion Faster absorption More risks 90 degree angle insertion Sites 0 Ventrogluteal Safest for all 0 Vastus Lateralis Good site 0 Deltoid Not as well developed and more injury risk Use of ZTrack Method in IM injections 0 Explain method Used for skin testing Potent medications Absorption is slow Sites Use tuberculin or small hypodermic Angle f insertion Safety in Administering Medications by Injection Needless Devices 0 Safety syringes have a sheath to cover needle upon withdrawal Methods Advantages Large Voume Infusions 0 Mix medications w large volumes of uids 0 Safest and easiest 0 Risk of fatal side effects are minimal 0 Disadvantages 0 Steps Intravenous Bolus quotPUSHquot o Concentrated dose into systemic circulation O O Advantage Most dangerous method why 0 Volume Controlled Infusions 0 000 0 Small amounts of compatible IV uids Secondary connects to primary line or to a separate tube that is inserted into the primary line Advantage Piggyback Explain VolumeControl Administration Explain MiniInfusion Pump Explain Intermittent Venous Access 0 What is it 0 Advantages Chapter 38 0 Regular exercise enhances all aspects of life 0 Overview of Exercise and Activity MM and Nervous system maintain balance posture and proper alignment Ifl proper reduction in injury risk Body Alignment De ne Balance Importantce Friction Force in direction of opposition of movement Exercise and Activity 0 What is it 0 Regular activity increase function of all body systems 0 Combination of De ne each and give example 0 O O isotonic isometric resistive isometric 0 Regulation of Movement Skeletal System 0 Support protection movement mineral storage hematopoiesis Joints 0 O O 0 Connection bw bones Fibrous Ca rtilaginous Synovial Ligaments Tendons and Cartilage O Lig o Tendons O Skeletal MM Cartilage Contraction allow mm 0 MM w Movement 0 Near skeletal region 0 Lever system 0 MM w Posture 0 Low level of continuous contraction MM Groups de ne o Antagonistic MM 0 Synergistic MM 0 Antigravity MM Nervous System Regulates movement and posture Voluntary motor area lmpulses are neurotransmitters Proprioception De ne Balance What controls it o Principle of transfer and Positioning Safe pt transfer and positioning for techniques Pathological In uences Congenital defects What are these Disorder of Bones Joints MM Examples CNS Musculoskeletal trauma Examples 0 Nursing Knowledge Base 0 In uencing Factors Developmental Changes 0 Infant through school age 0 Infant spine is exible and only in C shape 0 Toddler has protruding abdomen walks w feet far apart Adolescent 0 Growth spurt uneven o Awkward and uncoordinated 0 Female Changes 0 Male Changes 0 Young to Middle Adult 0 Correct alignment and posture selfcon dent coordinate Older Adults 0 Progressive bone mass loss 0 Inactivity changes in hormones increased osteoclastic activity Behavioral Aspects Explain Environmental Issues explain each 0 Work Site 0 Schools 0 Community Cultural and Ethnic explain Family and Social Support Why is this important 0 Nursing Process 0 Assessment Note changes in growth and development deviations from the norm and learning needs First assess alignment 0 Standing What are you looking at What is normal Sitting What are you looking at What is normal Mobility Determine coordination and balance ability to perform ADL ROM de ne Gait de ne What are you looking for 0 Exercise Bene ts Activity Tolerance de ne 0 Implementation Health Promotion 0 Encourage to engage in a regular program 0 Include warm ups and cool downs 0 Why What kinds 0 Body Mechanics de ne o What is done to improve these Acute Care Stretching and isometric exercises Active ROM exercises 0 Types Musculoskeletal Examples Joint Mobility Examples Walking Purpose 0 Method Aids Explain each and the advantages Walkers Canes Crutches 0 Measuring how is this done 0 Gait 3 Point Explain 4 Point Explain 2 Point Explain Swing through Explain 0 Walking on Stairs How is this done 0 Sitting How is this done Restoration and Chronic Illness Explain importance of exercise in each 0 CHD 0 Hypertension 0 COPD Diabetes Chapter 45 Elimination 0 Basic function 0 If fais all organs are affected 0 Psychological alterations can occur Embarrassment Scienti c Knowledge Base 0 All parts need to be intact and functional 0 Kidneys Remove wastes from blood Nephron is functional unit 0 Forms urine Fluid and electrolyte balance Output 12001500 mLday Produce erythropoietin renin Vasoconstriction complex w angiotensin aldosterone water retention prostaglandin and prostacyclin substance to convert Vit D into active form 0 Ureters Transport form kidneys to bladder o Bladder Holds until urge to urinate o Urethra Exit from body Shorter in women 152 inches Men 0 Also passage for 8inches o Urination All aspects of system must be working properly Cerebral Cortex Hypothalamus Thalamus and Brainstem What do these do 24 hrs 24 months neurological function is developed to potty train As the volume increases what occurs Re ex incontinence Explain Over ow Incontinence Explain Factors In uencing Pathophysiological acute and reversible or chronic and irreversible sociocultural psychological uid balance diagnostic procedures medications Disease affects 0 Renal function V or quality micturition act or both Explain 0 Diabetes and NM disease change nerve functions Explain 0 Renal Tissue damage End Stage Renal Disease Explain Treatments Differentiate bw forms of dialysis Sociocultural Example Psychological Examples Fluid Balance 0 Varies w food intake 0 Input should output Polyuria Oliguria Anuria How do surgical procedures effect How do medications effect How do Diagnostic Exams in uence Alterations in Elimination Unable to store empty fuIIy permanent or temporary changes Urinary Retention De ne 0 Post void residual regular catheter beating down increase uid intake UTI 0 Most common health care infection 0 Stages Lower UTI is burning when urinating Infection worsens fever chills nausea vomiting Cystitis irritation to bladder causes frequent voiding Cystitis and irritation to mucosa leads to blood n urine hematuria Upper UTI Pyelonephritis ank pain fever chiII Urinary Incontinence De ne and explain 0 Functional 0 Stress o Urge 0 Mixed o Over ow Urinary Diversions o Bladder cancer radiation to bladder chronic urinary infections may need 0 Drain urine from bIadder o Reservoir are created o Urine drains continuously ostomy pouch o Nephrostomy Ostomy directly on kidney 0 Nursing Knowledge Base 0 Infection Control and Hygiene Tract is sterile so sterile technique is needed 0 In uencing factors Age environment medication psychological factors mm tone uid balance surgical procedures disease Growth and Development explain the changes 0 Infants and children Toddlers Pregnancy MM Tone Explain Nursing Process 0 Assessment Identifying Urinary Alterations Assess history physical assessment and tests 0 Be aware of culture and language History 0 Review of elimination patterns and symptoms 0 Pattern What is normal 0 Symptoms Examples Physical Assessment 0 Assessment of Urine o IntakeOutput Daily average intake Change in output V shows alterations in kidney function Measure output For precise measurements use urimeter Report large increases or decreases 0 Concentration of Urine Color Explain meaning of each Pale straw amber Dark Red 0 Bright Red 0 Dark Amber Clarity Normal 0 Standing 0 Renal Disease Bacteria Odor More concentrated means more odor Stagnant Diabetes 0 Infection Urine Testing 0 Label w name date time Timely transport 0 Collection Method 0 Common Test Explain each 0 Urinalysis 0 Speci c Gravity 0 Culture 0 Implementation Health Promotion Pt Education 0 Teach about elimination problems 0 Learn symptoms and meanings Maintaining habits 0 Try to follow normal routine as much as possible Fluid Intake 0 Maintain optimal intake 22002700mL a day Complete Bladder emptying 0 Wait till stop in ow void again if needed 0 Schedule toilet times and care 0 Compress downward on bladder Preventing Infection Methods Acute Care Maintaining habit How Medications How do they effet Catheterization 0 Types De ne and explain each Intermittent Indwelling Insertion Does this require an order Closed Drainage Explain and bene ts Perineal Hygiene Frequency Fluid Intake What should be avoided Preventing Infection Keep system closed break means infection risk Bacteria grow in pools of urine prevent back ow into the bladder Irrigations and Instillations o Flushing w sterile solution 0 Irrigation can ush pus or blockage back into bladder Removal of Indwelling Cath What is needed What are the important steps When should the next voiding occur Alternatives to Cath o Suprapubic Cath OOOOO o Condom Cath 0 Others Restorative Care Chapter 47 Strengthening Pelvic Floor mm o Kegel exercises Bladder Retaining 0 Reduce frequency Retaining normal bladder function Urological consultation is helpful Never refuse to toilet a pt Suppress voiding for 15 minutes and increase by 15 each week 0 Void every 34 hours Habit Training Purpose and methods SeIfcath 0 Teach structure of system aseptic tech adequate uid intake frequency 0 56 times a day Skin Integrity How do you maintain Comfort How do you maintain OOOO Mobility is used for many purposes Name some 0 Scienti c Knowledge 0 Nature of Movement Complex Coordination bw musculoskeletal and Nervous system Body Mechanics Importance Alignment and Balance What is this Importance Gravity and Friction What are these Importance in lifting Importance in kin integrity 0 Physiology and Regulation SkeIetaI System Bones What is responsible for each 0 Firmness o Rigidity o Elasticity Aids in Ca2 regulation Bone marrow creates blood cells SkeIetaI MM Contract and Relax Working element Functional Purpose Concentric tension Eccentric Tension MM Movement and Posture o Leverage is created 0 MM in posture maintenance are short and featherlike MM of lower extremities trunk neck and back 0 Stabilize MM Regulation of Posture and Movement 0 Depend on Nervous System Purpose 0 Pathological In uences on Mobility Postural Abnormalities Congenital or acquired Affect MM Abnormalities Dystrophies Direct Trauma to MuscquskeIetaI System Common cause 0 Nursing Knowledge Base 0 Safe Pt Handling Manually lifting increases risk for injury Laws mandate safe handling Ergonomics De ne 0 Factors in uencing MobiIityImmobiIity Bedrest affect what Systemic Effects Explain each All systems work better w movement Metabolic Changes Respiratory Changes Cardiovascular Changes 0 Orthostatic Hypotension Requirements 0 Thrombus De ne 0 Increased Cardia Workload MuscquskeIetaI Changes 0 Permanent or temporary disability 0 Loss in endurance strength and mm mass 0 MM Effects 0 Skeletal Effects Impaired Ca2 metabolism Joint abnormalities How is Urinary Elimination affected Integumentary 0 Pressure on skinD Pressure Ulcers 0 Pressure Ulcer De ne Psychological Effects 0 Nursing Process 0 Assessment Altered sleep patterns increased anxiety hostiIity depression emotional behavioral sensory and coping alterations Mobility ROM De ne o CPM De ne 0 Importance 0 Passive or active De ne each Gait heel strike of one leg and heel strike of anther 0 Shows Tolerance type and amount of exercise pt is able to perform 0 Needed fr planning of interventions 0 Monitor for Alignment o Siting Standing Laying down 0 Determine o What aids are used lmmobility effects Frequency of assesments 0 Diagnosis Metabolic System 0 What assessments are made Respiratory System 0 Wat assessments are made Cardiovascular System 0 What assessments are made Musculoskeletal System 0 Assessments lntegumentary o Assessments Elimination o Assessments Psychosocial Assessment 0 Assessments Frequency Examples 0 Planning Communicate w respiratory nurses wound care nurses and others 0 Implementation Health Promotion Education Prevention and early detection Prevention of Work Related How 0 Back injury from lifting and bending Strain in lumbar Exercise enhance WB and improve health Bone Health in Osteoporosis Pt 0 Increased risk should be screened diet assessment for adequate Ca2 intake and Vitamin D intake Acute Care Hazards of Respiratory status orthostatic hypotension impaired skin integrity Metabolic System How to Reduce impact of immobility Respiratory How to Reduce impact of immobility Cardiovascular How to Reduce impact of immobility 0 Reducing Orthostatic Hypotension 0 Reducing Cardiac Workload Discourage from using Valsalva Maneuver De ne this 0 Preventing Thrombus Formation Musculoskeletal How to Reduce impact of immobility lntegumentary How to Reduce impact of immobility Elimination How to Reduce impact of immobility Psychological Changes How to Reduce impact of immobility Developmental How to Reduce impact of immobility Positioning o Pillows folded sheets blankets towels are great aids o Trochanter roll prevents hip rotation o Trapeze bar allows pt to pullassist in transfer 0 Unsupported jointsimpaired alignment 0 Use bed to help as much as possible 0 Low Fowlers 15 degrees 0 SemiFowlers 30 degrees 0 Fowlers 45 degrees 0 Supported Fowler39s Position 4560 degree elevation o Supine Good alignment Pillows and rolls for arms and hands 0 Prone Face or chest down Head turned to side Bene ts in acute respiratory distress o Trendelenburg 0 Reverse Trendelenburg o SideLying Position Most weight on hip or shoulder 30 degree lat Position 0 Sim s Position Weight on anterior ileum humerus clavicle Enema and Suppository Transfer Techniques 0 Use algorithm 0 Use pt strength 0 Moving Pt Safety is rst Various levels of assistance are needed Non slip shoes aids assistance gait belt Stand on stronger side unless use of aid Remove obstacles o Transferring Bed to Chair Move obstacles Ensure there is help Explain procedure place chair next to bed 0 Bed to Stretcher gt200 pounds use friction reducing and 3 caregivers Restorative and Continuing Care 0 Max functional mobility and independence 0 Functional for ADLs and lADLs functional beyond self care 0 ROM 0 Ensure joint mobility 0 Provide passive when needed 0 Walking 0 Asses activity tolerance strength pain balance coordination o Hemiplegia and hemiparesis Chapter 48 Skin and Wounds Skin is 5 of body weight Protective barrier lnjury triggers a healing complex Scienti c Knowledge Base 0 Skin Two layers separated by dermalepidermal junction Epidermis Layers ExplainDe ne each Stratum corneum BasalLayen Dermis Tensile strength mechanic support protection Aging makes skin more vulnerable 0 Pressure Ulcers Bedsores Goal is Found more in What are they Shear and friction force Factors Pathogenesis Pressure intensity de ne 0 Tissue ischemia can result in tissue 0 When an area that was on pressure is elevated If it turns red vasodilationD hyperemia If it blanche when pressedljBlanching hyperemia and is overcoming ischemic epEode If it does not blanch deep tissue damage is likely o Blanching will not show in those with dark pigmented skin 5 what other method of detection are theregt Duration 0 Low pressure over a long time and high pressure over a short time are both concerns 0 Can cause irreversible tissue damage in 90 minutes 0 Tissue Tolerance De ne o Depends on o Extrinsic vs Systemic factors Risk Factors for Development Impaired Sensory Perception Impaired Mobility Alteration in Level of Consciousness Shear De ne and explain process in pressure ulcer formation 0 Friction De ne and explain process in pressure ulcer formation 0 Moisture De ne and explain process in pressure ulcer formation 0 Moisture from 0 Classi cation Explain and de ne aspects of each stage Stage I Stage II Stage III Stage IV UnstageableUnclassi ed Suspected Deep Tissue Injury Assess tissue at wound base 0 Amount percent Color of viable vs nonviable o Granulation o Slough o Eschar Measurement 0 Shows size changes and indicates healing 0 Length width depth Exudate 0 Amount color consistency odor When 0 Acute are admission and change is status o LTC Once weekly for 4 weeks and then 3 times a year 0 Classi cation of Wounds Wound De ne Classi ed by status of skin integrity cause severity cleanliness descriptions Process of Healing Grated physiological processes 0 Loss of tissue Name the types 0 Without loss of tissue Name types Tertiary Intention De ne Wound repair 0 Partial thickness 0 Shallow 0 Loss of epidermis o Heal by regeneration 0 Components of healing In ammatory response Epithelial reproduction Migration Reestablishment of epithelial layer occurs FullThickness Wound Repair 0 Four Phases Hemostasis In ammatory Phase 0 Process 0 WBC Macrophage Proliferative Phase Remodeling Complications of Wound Healing o Hemorrhage de ne Indicates 0 Infection De ne o Dehiscence De ne o Evisceration De ne Nursing knowledge 0 Prediction and Prevention of Pressure ulcers Maintain skin integrity Risk assessment Purpose Braden scale is the most widely used 0 6 subscales What are they What does a lower score mean What are the quotcut offquot scores Prevention 0 Priority 0 Economic Consequences 0 Factors In uencing Formation and Healing Explain how each effect heaHng Nutrition Tissue Profusion Infection Age Psychosocial Impact Diabetes Mellitus Corticosteroid Therapy Chemo an Radiation Stress Immunosuppression Systematic Conditions affecting health Hematopoietic blood disorders 0 Nursing Process 0 Assessment Create a baseline Identify pressure ulcer risk development Skin Continual assess for uIcer formation Visual and tactile inspection Determine baseline and individualize care Accurately assess a dark skinned person Pay close attention to boney prominence areas or under casts Document what 0 Observe for blanching Pressure Ulcers Explain effects of each Predictive Measures Mobility Nutritional Status 0 Body Fluids 0 Pain Wounds Assess under two conditions what are they 0 Obtain information about cause and history of wound Emergency Setting De ne each wound O 0000 Abrasion Laceration Puncture Inspect for foreign bodies Size is inspected next Deep requires sutures Bone or tissue that is exposed that needs to be protected Determine tetanus shot status 0 Stable Setting 0 Assess wound and determine progress of healing Wound Appearance What are you looking for 0 Character of Drainage 0 Amount 0 Color 0 Odor 0 Consistency Drains 0 Assess for what 0 lf uid collects this inhibits healing and increases infection risk Wound Closures o Staple o Suture o Wound closures o Dermabond Palpitation 0 Observe for swelling or separation of edges Cultures o If you detect purulent drainage take a sample when needed Explain guidelines 0 Planning Those w chronic or infected wounds have multiple needs Priorities are set based on assessment 0 Acute Immediate intervention 0 Chronic and stable Hygiene is priority Eliminating friction and shear forces 0 Promotion of wound healing 0 Implementation Health Promotion Most important 0 Prevention of pressure Ulcers 0 Assess risk factors 0 Skin care and management of incontinence Methods 0 Mechanical loading and supportive devices Positioning Reposition how often Acute care 0 Management of Pressure Ulcers o Reassess for location stage size tissue type and amount exudate surrounding skin 0 Close monitoring is required 0 Pressure Ulcer treatment Explain 0 Document Wound Management 0000 000000 0 Maintain local wound environment Prevent and manage infection Clean wound Viable tissue is redpink moist and granulation Ussue Remove nonviable tissue Debridement method de ne each 0 Mechanical Autolytic Chemical SharpSurgical Purpose Maintain moist environment Why Protect wound Irrigation is a common wound cleaning method Education What should be taught Nutritional Status Protein Status Why is this important Hemoglobin First Aid for Wounds Explain each 0 Stabilize Cardiopulmonary system 0 Hemostasis 0 Cleaning Gentle Vigorous Forminor 0 Protection Dressings o Purposes O O O Protection How Hemostasis promotion from pressure How Supports wound site Protect pt from seeing wound Thermal insulation of wound Moist environment Absorbs drainage Layers What does each do Contact primary layer Absorbent layer Outer protectivesecondary layer Type of dressing applied will depend on the purpose and wound Changing frequency will also depend on the dressing wound and purpose 0 Types of Dressings Describe and explain bene ts of each 0 Easy to apply comfortable materials promote heaHng o Dressing to treat pressure ulcers can39t be too moist in order to prevent skin breakdown Pressure ulcer dressing depends on stage Gauze sponges are common Nonadherant Gauze Telfa Selfadhesive transparent lm Hydrocolloid dressings Hydrogel Foam are used around drainage tubes Calcium alginate form a gel and are highly absorbent Moist to Dry 0 Pressure 0 Synthetic Changing Dressings 0 Know type of dressing presence of underlying drainstubes and supplies for wound care Clean technique I only appropriate in some cases Sterile is usually used Guidelines Prep 0 Sterile Technique Packing a Wound 0 Assess size shape and depth 0 Dressing should be exible o In contact w entire wound 0 Don39t pack to tightly 0 Negative Wound Therapy vaccum Secure Dressings What is normally used 0 Type depends on dressing and placement drainage frequency of dressing changes 0 Assess skin at every dressing change 0 Don39t place tape over irritated skin Comfort 0 Be careful when removing tape 0 Gently clean edges of the wound o Careful turning and repositioning 0 Pain meds 30 minutes before Cleaning skin a debris 0 Hand hygiene and aseptic techniques 0 Basic skin cleaning Noncytotoxic solutions added to gauze or irrigation Principles Direction 0 What about w a drain Gentle friction 0000000 O 0000 0 Flow of solution should be from least to most 0 Irrigation Flush w low pressure Cleans exudate and debris Sterile when on open wound Suture Care 0 PO is required to remove 0 To remove Explain the steps 0 NEVER PULL AREA OF SUTURE THAT IS EXPOSED TO THE AIR INTO THE WOUND Drainage Evaluation What is documented Bandage and Binders 0 Extra protection what do they do 0 Gauze bandages are lightweight and permit circulation 0 Elastic exert pressure 0 Principles for Application What are they 0 Binder Application Abdominal is common 0 Support large abdominal incisions Secured in a variety of ways 0 Slings Purpose 0 Bandage Application Purpose 0 Heat and Cold Therapy 0 Assessment of Tolerance What are you assessing 0 Body responses to heat and cold Systemic De ne Heatloos mechanisms De ne Heat Promotion De ne Local HeatBurning sensation ColdNumbness 0 Local Effects Heat Ck d 0 Factors Short exposure is better tolerated Some areas are more sensitive Body can respond to minor changes Less tolerance when larger area is exposed Tolerance depends on age and physical condition 0 Application What are the bene ts of each methods of application What should the order say Warm Moist compress Warm Soaks Sitz baths Hot Packs Cold Moist Compress Cold Soaks Ice BagsCollars


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