Study Guide (Module 5 & 6)/ Final Exam 1460
Module 5:
Informatics – Computerization in nursing practice benefits
Technology at the point of care
Interprofessional communication technique
Safety and patient care
Quality care and regulatory agencies
Quality improvement processes
Health policy purpose and components
Module 6:
Anti-infective medications
Surgical risk and anti-inflammatory medications
Wound care – assessments, interventions, and treatment modalities such as dressings, drainage
systems, irrigation, etc.
Pressure ulcers – risks for, assessments and interventions
Infection – clinical manifestations and diagnostic procedures
Preoperative surgical phase – surgical risks, assessments and interventions, teaching, and preparation
of the patient for surgery
Intraoperative surgical phase – sterile techniques in the intraoperative surgical phase
Postoperative surgical phase – assessments and interventions
Postoperative complications – dehiscence and evisceration, respiratory, DVT, etc.
Pneumonia – assessment, treatment, and nursing implications/patient education
Appendicitis – assessment, treatment, and nursing implications/patient education
Influenza – assessment, treatment, and nursing implications/patient education
Dosage calculations
1. Priority Focus on Safety and Quality of Care
Nurses who practice medical-surgical nursing must have a broad knowledge base to meet the needs of patients. Rapid advances in
technology, massive increases in available knowledge, and dramatic changes in the health care delivery system require that medical-
surgical nurses use expert clinical judgment to ensure patient safety as the priority in practice.
2. The SBAR process includes these four steps:
• Situation: Describe what is happening at the time to require this communication.
• Background: Explain any relevant background information that relates to the situation.
• Assessment: Provide an analysis of the problem or patient need based on assessment data.
• Recommendation: State what is needed or what the desired outcome is.
Several modifications of SBAR include I-SBAR and I-SBAR-R. In these procedures, the “I” reminds the individual to identify himself or
herself. The last “R” stands for the response that the receiver provides based on the information given.
3. Informatics
Informatics involves using information and technology to communicate, manage knowledge, mitigate error, and support decision
making (QSEN, 2011; Yoder-Wise, 2011). The emphasis of the KSAs for informatics is documentation, electronic data access, and data
utilization.
Although most health care settings have information technology (IT) departments, nurses retrieve and use valuable information for
patient care. The largest application of health care informatics is use of the electronic health record (EHR) (also called electronic
patient record [EPR] or electronic medical record [EMR]) for documenting nursing and interdisciplinary care. Computers may be
located at the nurses' work station or at the patient's bedside (point of care [POC]) (Fig. 1-2) or near the nurses' station. Handheld
mobile devices are also popular because of their ease of use and portability.
4.
The RN is performing an assessment on an older adult client who is in congestive heart failure. Which skin finding during palpation of
the extremities is the nurse specifically concerned about?
A. Slight tears on the forearms
, B. Fairly widespread dry flakiness
C. Several smaller bruises on the extremities
D. Marked dependent pitting edema Correct
Dependent pitting edema may indicate venous and cardiac insufficiency in clients with congestive heart failure. Skin tears may occur
where adhesive tapes or dressings have been applied and removed, especially in older clients with fragile skin. Dry skin usually has
scaling and flaking, and may be especially marked in areas of limited circulation such as the feet and lower legs. It is a common
problem during the winter months when the air contains less moisture, in geographic areas with little humidity, and in the hospital
environment where humidity is often low. In older adults, bruising is common after minor trauma to the skin.
Awarded 1.0 points out of 1.0 possible points.
5. Nutrition Status
Document the patient's weight, height, body build and fat distribution, and food preferences. Protein deficiencies, vitamin
deficiencies, and obesity can increase the risk for skin lesions and delay wound healing. Fat-free diets and chronic alcoholism 421can
lead to vitamin deficiencies and related skin changes. Skin problems such as chronic urticaria and acne may be worsened by certain
foods or food additives.
Hydration influences overall skin health, and the skin reflects hydration status. Reduced fluid intake can lead to dry skin. Skin
manifestations of severe fluid losses are seen as loose skin that tents when pinched together. Fluid overload with edema can stretch
the skin, masking wrinkles and allowing the formation of skin “pits” (i.e., pitting edema) when pressure is applied to it.
6. Palpation
Skin inspection can be misleading in areas of color changes, tattoos, and piercings. Use palpation to gather additional information
about skin lesions, moisture, temperature, texture, and turgor (Table 24-4). Wash hands thoroughly before and after palpating a
patient's skin. Use gloves to examine non intact skin, and use Standard Precautions when skin areas are draining.
7. Cyanosis can be present when gas exchange is impaired. Examine the lips, tongue, nail beds, conjunctivae, and palms and soles for
subtle color changes (Jarvis, 2016). In a patient with cyanosis, the lips and tongue are gray and the palms, soles, conjunctivae, and
nail beds have a bluish tinge. To support these findings, assess for other indicators of hypoxia, including tachycardia, hypotension,
changes in respiratory rate, decreased breath sounds, and changes in cognition.
8. Minor Skin Irritations
Pathophysiology
Pruritus (itching) is a distressing condition caused by stimulation of itch-specific nerve fibers. It may or may not occur with skin
disease. Physical or chemical agents can directly trigger the nerve fibers or can activate chemical mediators (i.e., histamine), which
then act on the itch receptors.
Itching is a subjective condition similar to pain, and severity of the sensation varies among patients. Regardless of the cause, patients
often report that itching is worse at night when there are fewer distractions. Other conditions that make itching worse include skin
dryness, increased temperature, perspiration, and emotional stress.
9. Urticaria
Urticaria (hives) is a rash of white or red edematous papules or plaques of various sizes. This problem is usually caused by exposure
to allergens, which releases histamine into the skin. Blood vessel dilation and plasma protein leakage lead to formation of lesions or
wheals. Some common causes of urticaria include drugs, temperature extremes, foods, infection, diseases, cancer, and insect bites (
10. A wound without tissue loss, such as a clean laceration or a surgical incision, can be closed with sutures, staples, or adhesives.
The wound edges are brought together with the skin layers lined up in correct anatomic position (approximated) and held in place
until healing is complete. This type of wound represents healing by first intention in which the closed wound eliminates dead space
and shortens the phases of tissue repair. Inflammation resolves quickly, and connective tissue repair is minimal, resulting in less
remodeling and a thin scar. Fig. 25-2 shows the healing of a surgical incision over time.
Deeper tissue injuries with greater loss of tissue integrity, such as a chronic pressure ulcer or venous stasis ulcer, result in a cavity
that requires gradual filling in of the dead space with connective tissue. This represents healing by second intention and prolongs the
repair process.
Wounds at high risk for infection, such as surgical incisions into a nonsterile body cavity or contaminated traumatic wounds, may be
intentionally left open for several days. After debris (dead tissues) and exudate have been removed (débrided) and inflammation has
subsided, the wound is closed by first intention. This type of healing represents delayed primary closure (third intention) and results
in a scar similar to that found in wounds that heal by first intention. Healing can be impaired by many factors
11. A pressure ulcer (PrU) is a loss of tissue integrity caused when the skin and underlying soft tissue are compressed between a
bony prominence and an external surface for an extended period. Although they commonly occur over the sacrum, hips, and
ankles, pressure ulcers can occur on any body surface. For example, nasal cannula tubing that is too tight can cause pressure ulcers
behind the ears or in the nares).
Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and,
eventually, leading to cell death. Ulcers occur most often in people with limited mobility because they cannot change their position
Module 5:
Informatics – Computerization in nursing practice benefits
Technology at the point of care
Interprofessional communication technique
Safety and patient care
Quality care and regulatory agencies
Quality improvement processes
Health policy purpose and components
Module 6:
Anti-infective medications
Surgical risk and anti-inflammatory medications
Wound care – assessments, interventions, and treatment modalities such as dressings, drainage
systems, irrigation, etc.
Pressure ulcers – risks for, assessments and interventions
Infection – clinical manifestations and diagnostic procedures
Preoperative surgical phase – surgical risks, assessments and interventions, teaching, and preparation
of the patient for surgery
Intraoperative surgical phase – sterile techniques in the intraoperative surgical phase
Postoperative surgical phase – assessments and interventions
Postoperative complications – dehiscence and evisceration, respiratory, DVT, etc.
Pneumonia – assessment, treatment, and nursing implications/patient education
Appendicitis – assessment, treatment, and nursing implications/patient education
Influenza – assessment, treatment, and nursing implications/patient education
Dosage calculations
1. Priority Focus on Safety and Quality of Care
Nurses who practice medical-surgical nursing must have a broad knowledge base to meet the needs of patients. Rapid advances in
technology, massive increases in available knowledge, and dramatic changes in the health care delivery system require that medical-
surgical nurses use expert clinical judgment to ensure patient safety as the priority in practice.
2. The SBAR process includes these four steps:
• Situation: Describe what is happening at the time to require this communication.
• Background: Explain any relevant background information that relates to the situation.
• Assessment: Provide an analysis of the problem or patient need based on assessment data.
• Recommendation: State what is needed or what the desired outcome is.
Several modifications of SBAR include I-SBAR and I-SBAR-R. In these procedures, the “I” reminds the individual to identify himself or
herself. The last “R” stands for the response that the receiver provides based on the information given.
3. Informatics
Informatics involves using information and technology to communicate, manage knowledge, mitigate error, and support decision
making (QSEN, 2011; Yoder-Wise, 2011). The emphasis of the KSAs for informatics is documentation, electronic data access, and data
utilization.
Although most health care settings have information technology (IT) departments, nurses retrieve and use valuable information for
patient care. The largest application of health care informatics is use of the electronic health record (EHR) (also called electronic
patient record [EPR] or electronic medical record [EMR]) for documenting nursing and interdisciplinary care. Computers may be
located at the nurses' work station or at the patient's bedside (point of care [POC]) (Fig. 1-2) or near the nurses' station. Handheld
mobile devices are also popular because of their ease of use and portability.
4.
The RN is performing an assessment on an older adult client who is in congestive heart failure. Which skin finding during palpation of
the extremities is the nurse specifically concerned about?
A. Slight tears on the forearms
, B. Fairly widespread dry flakiness
C. Several smaller bruises on the extremities
D. Marked dependent pitting edema Correct
Dependent pitting edema may indicate venous and cardiac insufficiency in clients with congestive heart failure. Skin tears may occur
where adhesive tapes or dressings have been applied and removed, especially in older clients with fragile skin. Dry skin usually has
scaling and flaking, and may be especially marked in areas of limited circulation such as the feet and lower legs. It is a common
problem during the winter months when the air contains less moisture, in geographic areas with little humidity, and in the hospital
environment where humidity is often low. In older adults, bruising is common after minor trauma to the skin.
Awarded 1.0 points out of 1.0 possible points.
5. Nutrition Status
Document the patient's weight, height, body build and fat distribution, and food preferences. Protein deficiencies, vitamin
deficiencies, and obesity can increase the risk for skin lesions and delay wound healing. Fat-free diets and chronic alcoholism 421can
lead to vitamin deficiencies and related skin changes. Skin problems such as chronic urticaria and acne may be worsened by certain
foods or food additives.
Hydration influences overall skin health, and the skin reflects hydration status. Reduced fluid intake can lead to dry skin. Skin
manifestations of severe fluid losses are seen as loose skin that tents when pinched together. Fluid overload with edema can stretch
the skin, masking wrinkles and allowing the formation of skin “pits” (i.e., pitting edema) when pressure is applied to it.
6. Palpation
Skin inspection can be misleading in areas of color changes, tattoos, and piercings. Use palpation to gather additional information
about skin lesions, moisture, temperature, texture, and turgor (Table 24-4). Wash hands thoroughly before and after palpating a
patient's skin. Use gloves to examine non intact skin, and use Standard Precautions when skin areas are draining.
7. Cyanosis can be present when gas exchange is impaired. Examine the lips, tongue, nail beds, conjunctivae, and palms and soles for
subtle color changes (Jarvis, 2016). In a patient with cyanosis, the lips and tongue are gray and the palms, soles, conjunctivae, and
nail beds have a bluish tinge. To support these findings, assess for other indicators of hypoxia, including tachycardia, hypotension,
changes in respiratory rate, decreased breath sounds, and changes in cognition.
8. Minor Skin Irritations
Pathophysiology
Pruritus (itching) is a distressing condition caused by stimulation of itch-specific nerve fibers. It may or may not occur with skin
disease. Physical or chemical agents can directly trigger the nerve fibers or can activate chemical mediators (i.e., histamine), which
then act on the itch receptors.
Itching is a subjective condition similar to pain, and severity of the sensation varies among patients. Regardless of the cause, patients
often report that itching is worse at night when there are fewer distractions. Other conditions that make itching worse include skin
dryness, increased temperature, perspiration, and emotional stress.
9. Urticaria
Urticaria (hives) is a rash of white or red edematous papules or plaques of various sizes. This problem is usually caused by exposure
to allergens, which releases histamine into the skin. Blood vessel dilation and plasma protein leakage lead to formation of lesions or
wheals. Some common causes of urticaria include drugs, temperature extremes, foods, infection, diseases, cancer, and insect bites (
10. A wound without tissue loss, such as a clean laceration or a surgical incision, can be closed with sutures, staples, or adhesives.
The wound edges are brought together with the skin layers lined up in correct anatomic position (approximated) and held in place
until healing is complete. This type of wound represents healing by first intention in which the closed wound eliminates dead space
and shortens the phases of tissue repair. Inflammation resolves quickly, and connective tissue repair is minimal, resulting in less
remodeling and a thin scar. Fig. 25-2 shows the healing of a surgical incision over time.
Deeper tissue injuries with greater loss of tissue integrity, such as a chronic pressure ulcer or venous stasis ulcer, result in a cavity
that requires gradual filling in of the dead space with connective tissue. This represents healing by second intention and prolongs the
repair process.
Wounds at high risk for infection, such as surgical incisions into a nonsterile body cavity or contaminated traumatic wounds, may be
intentionally left open for several days. After debris (dead tissues) and exudate have been removed (débrided) and inflammation has
subsided, the wound is closed by first intention. This type of healing represents delayed primary closure (third intention) and results
in a scar similar to that found in wounds that heal by first intention. Healing can be impaired by many factors
11. A pressure ulcer (PrU) is a loss of tissue integrity caused when the skin and underlying soft tissue are compressed between a
bony prominence and an external surface for an extended period. Although they commonly occur over the sacrum, hips, and
ankles, pressure ulcers can occur on any body surface. For example, nasal cannula tubing that is too tight can cause pressure ulcers
behind the ears or in the nares).
Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and,
eventually, leading to cell death. Ulcers occur most often in people with limited mobility because they cannot change their position
