NFDN 2003 MIDTERM STUDY GUIDE WITH COMPLETE SOLUTIONS

NFDN 2003 MIDTERM STUDY GUIDE WITH COMPLETE SOLUTIONS “What does SBAR stand for? - CORRECT ANSWER Situation Background Assessment Recommendation" "Concept Map - CORRECT ANSWER -another method of recording a nursing care plan -the nursing process is recorded in a visual diagram of patient problems and interventions that illustrates the relationships among clinical data" "What is the purpose of dressing? pg. 1318 - CORRECT ANSWER -Like a second skin to something that has been broken -to control bleeding, to prevent infection, to absorb blood -aids in homeostasis -provides a moist environment" "What type of wounds need dressing? - CORRECT ANSWER wounds with extensive tissue loss" "What is gauze? - CORRECT ANSWER -Absorbent and WICK away any drainage. -Does not irritate the wound." "What assessment do you do pre/post dressing change? - CORRECT ANSWER -When you go in, what do you see? Is there drainage on the top, moist, what type of drainage and how much? -If the were medicated, and how they tolerated the procedure" "Complex wound irrigation - CORRECT ANSWER -we irrigate from CLEAN to DIRTY -use a single squeeze 100mL saline bottle this delivers saline at the proper pressure to avoid trauma to the wound bed -used to flush the area with a constant low-pressure flow -cleans wounds of exudate and debris -do not leave irrigant pooled in wound bed, allow gravity to assist in drainage" "pressure ulcer stage 3 - CORRECT ANSWER -full thickness loss of skin -adipose (fat) is visible -slough, eschar, or both may be visible -undermining and tunnelling may occur -fascia, muscle, tendon, ligament, cartilage, and bone are NOT exposed" "pressure ulcer stage 4 - CORRECT ANSWER -full thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone -undermining, tunnelling or a combination of these can occur" "Risk factors of pressure ulcers - CORRECT ANSWER -decreased sensory perception -moisture -friction and shear -decreased activity or mobility -poor nutrition" "Unstageable - CORRECT ANSWER -full thickness skin and tissue loss which can not be confirmed because it is obstructed with slough or eschar. -if slough or eschar is removed a stage 3 or 4 will be revealed" "How do you add items to a sterile field? - CORRECT ANSWER Banana peel or open making sure that the sterile items do not become contaminated and drop sterile item onto the sterile field" "Asepsis (Define) - CORRECT ANSWER the process for keeping away disease-producing microorganisms -aseptic technique refers to practices designed to render an area and objects free from microorganism" "Aseptic Technique Principles - CORRECT ANSWER 1. Sterile to sterile, only sterile objects may be placed on a sterile field 2. Hands in sight at all times with sterile gloves 3. A sterile object or field out of range of vision or an object held below a persons waist is contaminated 4. A sterile object or field becomes contaminated by prolonged exposure to air 5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action 6. Fluid flows in the direction of gravity therefore a sterile object becomes contaminated if gravity causes contaminated liquid to flow over the object's surface 7. The edges of a sterile field or container are considered to be contaminated" "Sterile gloves vs. clean gloves - CORRECT ANSWER -Sterile gloves are used when an object, or your hands are going inside of the body, or when cleaning objects that go inside of the body. Eg. when cleaning a trach, or packing a wound with out sterile tongs -clean gloves are used when touching peri skin of the patient that does not have an open wound. you may use clean gloves to hold sterile tongs which are allowed to enter a persons body cavity when cleaning a wound" "What is the best time to take a specimen of sputum? - CORRECT ANSWER in the morning" "What color would sputum specimen be if there was an infection? - CORRECT ANSWER Yellow, green, dark" "what medication would be given for thick tenacious secretions? - CORRECT ANSWER Mucolytics" "How do we measure O2 saturation? - CORRECT ANSWER -pulse oximeter -normal is 95-100%" "Nasal Cannula - CORRECT ANSWER -1-6L/min flow -low flow device -O2 concentration of 24-44% -flow rates greater than 4L/min are typically not used via nasal cannula b/c of the drying effect on the mucosa -if flow rate is greater than 4L/min humidification is required" "Venturi Mask - CORRECT ANSWER -4-12L/minute -high flow device -O2 concentration of 24-60% -entrains room air to achieve a consistent and precise oxygen concentration -good for patients with COPD who require low constant oxygen concentrations" "Tracheostomy - CORRECT ANSWER -surgical creation of an opening into the trachea through the neck" "Ways to increase ventilation - CORRECT ANSWER -start O2 -body position for chest expansion= Raise Head of Bed -decrease stressors -decrease obstruction -medication" "What is the priority oxygenation assessment? - CORRECT ANSWER Airway Patency" "Dyspnea - CORRECT ANSWER -breathlessness (bronchospasm), shortness of breath" "Abnormal breath sounds - CORRECT ANSWER wheezing (high pitched sound, may be associated with asthma, acute bronchitis or pneumonia), crackles (fluid in the lungs)" "pursed lip breathing - CORRECT ANSWER - deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse -commonly used for COPD clients" "Common O2 saturation for COPD client - CORRECT ANSWER 88-92%" "High O2 levels for _______ client will decrease their _______ level which is their incentive to breathe - CORRECT ANSWER COPD, arterial blood gasses" "What assessments determine adequate kidney function? - CORRECT ANSWER X-rays (kidney stones, enlarged kidneys, tumours), ultrasounds (, and bladder scans" "When will you have to irrigate the bladder? - CORRECT ANSWER -to maintain patency after urogenital surgery, or to prevent blood clots from occluding the bladder" "If you have an open catheter system how can you prevent infection? - CORRECT ANSWER alcohol swab both ports" "What is adequate urine output? - CORRECT ANSWER 30ml/hr" "what is the normal adult urine output per day? - CORRECT ANSWER ml/ day pg. 1209" "in addition to removal of waste products of metabolism, what is another role of the kidneys? - CORRECT ANSWER fluid and electrolyte balance pg. 1209" "the urine may appear cloudy because of the presence of WBC or? - CORRECT ANSWER bacteria" "Anuria - CORRECT ANSWER absence of urine" "Oliguria - CORRECT ANSWER Decreased urine output" "polyuria - CORRECT ANSWER excessive urination" "Nocturia - CORRECT ANSWER excessive urination at night" "Residual - CORRECT ANSWER Urine left in the body after normal void" "Retention - CORRECT ANSWER unable to void for some reason" "prompted voiding is most appropriate for? - CORRECT ANSWER patients with urinary obstruction pg. 1209" "the nurse can provide support to the patient with incontinence by: - CORRECT ANSWER referring to local continence services and websites. -catheter is a last resort pg. 1209" "What assessment can determine if the bladder is full? - CORRECT ANSWER -bladder distention, light palpation" "What procedure can a PN student not perform? - CORRECT ANSWER bladder scan" "long term catheter - CORRECT ANSWER -more than 14 days -bladder outlet obstruction pending surgery or if the patient is not suitable for surgical intervention -chronic retention related to neurological disease if intermittent catheterization is not feasible -stage 3 or 4 pressure injury or perineal skin breakdown in incontinent patients -intractable urinary incontinence if alternate approaches have been tried but not successful" "how to collect sterile urine sample - CORRECT ANSWER -straight in and out catheter, collect in sterile specimen cup, label it and send to lab" "Hematuria - CORRECT ANSWER blood in the urine" "Continuous bladder irrigation (CBI) - CORRECT ANSWER -continuous irrigation used after bladder or prostate surgery to control bleeding -closed system, must have order -3 ports, irrigation, balloon" "Intermittent bladder irrigation (IBI) - CORRECT ANSWER -intermittent irrigation is used for tissue or clot blockage in an indwelling catheter -open system is more prone to infections, must have order -make sure you swab both ports" "What are the two types of dialysis - CORRECT ANSWER hemodialysis and peritoneal dialysis" "Renal failure - CORRECT ANSWER irreversible damage to the glomeruli or renal tubules causes decline in kidney function and leads to end stage renal disease End stage renal disease: there is severely reduced or absent urine output from the bladder" "hemodialysis - CORRECT ANSWER -uses a machine equipped with a semipermeable filtering membrane (artificial kidney) that removes accumulated waste products and excess fluids from the blood -blood exchange outside of the body -usually done x3 / week at a facility" -patient needs to be completely ready for surgery -all abnormal findings must be identified and reported `" "define intraoperative phase - CORRECT ANSWER -during the surgery -primary focus of intraoperative care is to prevent injury and complications related to anaesthesia, surgery, positioning, and equipment used" "intraoperative potential complications - CORRECT ANSWER -Nausea & Vomiting -Anaphylaxis -Hypoxia or Other Respiratory Complications -Hypothermia -Malignant Hyperthermia = rare muscle disorder that is chemically induced by anesthetic agents, unexplained temp elevation" "What type of pain management gives a client some autonomy? - CORRECT ANSWER patient controlled analgesic (PCA)" "Common postoperative Complications - CORRECT ANSWER -Airway compromise -Breathing-respiratory insufficiency -Cardiac compromise -Neurological compromise -Hypothermia -Pain -Nausea/Vomiting -Side Effects of Analgesia -Delayed healing -Wound Dehiscence" "define post operative phase - CORRECT ANSWER -after surgery care" "general anesthesia - CORRECT ANSWER -results in an immobile, quiet patient who does not recall the surgical procedure -given during major surgery by anesthesiologist" "local anesthesia - CORRECT ANSWER Local anesthesia: involves loss of sensation at the desired site, it may be injected locally or applied topically -commonly used for minor procedures" "a patient who smokes 2 packs of cigarettes per day is most at risk postoperatively for? - CORRECT ANSWER pneumonia pg. 1409" "family members should be included when the nurse teaches the patient preoperative exercises so that they can: - CORRECT ANSWER coach the patient postoperatively pg. 1409" "in the PACU, one measure taken to maintain airway patency is to: - CORRECT ANSWER position the patient so that the tongue falls forward pg. 1409" Priority Setting - CORRECT ANSWER -Self actualization -esteem -belonging -safety -physiological" "first order - CORRECT ANSWER ABC'S (airway, breathing, and circulation)" "second order - CORRECT ANSWER Actual problems needing immediate help (elimination, pain, and nutrition)" "Third Order - CORRECT ANSWER comfort, coping, early actual or potential problems (Prevention)" "Fourth oder - CORRECT ANSWER Potential problems in the future" "clinical pathways - CORRECT ANSWER Tools for tracking a patients progress toward achieving positive outcomes within a specific timeframe -plan from admission to discharge -benchmarks for patient to meet -case management for client care -developed using research, and clinical outcomes -used for specific medical injuries" "variance record - CORRECT ANSWER Any deviation off the clinical pathway" "Roles of the practical nurse when using clinical pathways - CORRECT ANSWER -monitor progress -each event takes place including interventions -monitor results -document progress" "Care Mapping - CORRECT ANSWER Clinical guidelines to help facilitate the coordination of care and education throughout hospitalization and discharge -outlines stages of the patient -more of an algorithm: gives desired outcomes -clients will be continually assessed -no set timeframes: more base on assessment" "Legal and Ethical Principles - CORRECT ANSWER -Canada health act -CLPNA competencies -Policies of agency -standards of practice" "chronic venous insufficiency/ Post thrombotic syndrome - CORRECT ANSWER Results from obstruction of the venous valves" "chronic venous insufficiency/ Post thrombotic syndrome (Clinical Manifestations) - CORRECT ANSWER -might notice symptoms more in the mornings -will cause edema, altered pigmentation, pain, and status dermatitis -difficult to treat -statis ulcers develop as a result: causing brownish discolouration of the tissues" "chronic venous insufficiency/ Post thrombotic syndrome (Complications) - CORRECT ANSWER -Venous ulcerations" "chronic venous insufficiency/ Post thrombotic syndrome (Management) - CORRECT ANSWER -elevate the legs -compression stockings" "Leg ulcers - CORRECT ANSWER -an excavation of the skin that occurs when inflamed necrotic tissue sloughs off" "Leg ulcers (Pathophysiology) - CORRECT ANSWER -inadequate exchange of oxygen and other nutrients in the tissue is the metabolic abnormality that underlies the documentation of leg ulcers" "Leg ulcers (Clinical manifestations) - CORRECT ANSWER -depends on whether the problem is material or venous in origin" "arterial ulcers - CORRECT ANSWER -disease is characterized by intermittent claudication, which is pain caused by activity and relived after a few minutes of rest -typically, arterial ulcers are small, circular, deep, ulcerations on the tips of the web spaces of the toes" "Venous ulcers - CORRECT ANSWER -characterized by pain, described as aching or heavy -large, superficial, and highly exudative -venous hypertension causes exudation of blood which discolours the area" "Medical management of ulcers - CORRECT ANSWER -managed by advanced practice nurses or wound care, ostomy, and continence nurses in collaboration with phycisians" "Pharmacological therapy for ulcers - CORRECT ANSWER -antibiotic therapy is prescribed when the ulcer is infected -the specific antibiotic agent is base din the culture and sensitivity that results" "compression therapy for ulcers - CORRECT ANSWER adequate compression therapy involves the application of external or counter pressure to the lower extremities to facilitate ceos return to the heart" "debridement therapy for wounds - CORRECT ANSWER -promotes healing, the wound is kept clean of drainage and necrotic tissue -surgical debridement: fastest -nonselective debridement: accomplished by applying a isotonic saline dressing of fine mesh gauze -enzymatic debridement: application of enzyme ointments may be prescribed" "Topical therapy for wounds - CORRECT ANSWER remove devitalized tissue and keep the ulcer clean and moist while healing takes place" "semiocclusive/occlusive dressing - CORRECT ANSWER -Prevent evaporative water loss for the wound and retain warmth -May be commercially made inexpensively from sterile or non-sterile gauze squares or wrap" "Wet dressing - CORRECT ANSWER Wet compress applied to the skin" "Moisture retentitive dressing - CORRECT ANSWER Can perform the same functions as a wet compress but are more efficient at removing exudate because of their high moisture vapour transmission rate" "Hydrogel dessing - CORRECT ANSWER -high moisture content makes them ideal for autolytic debridement of wounds -semitransparent allowing for wound inspection without dressing removal" "Hydrocolloid dressing - CORRECT ANSWER -as water evaporates over the wound, water is absorbed in the dressing, which softens and discolors with increased water content -this dressing can be removed without damage to the wound" "foam dressings - CORRECT ANSWER -consists of microporous polyurethane with an absorbent hydrophilic surface that covers the wound and a hydrophobic backing to block leakage of exudate -a moist environment is maintained -this dressing can be removed without damage to the wound" "Calcium alginate - CORRECT ANSWER -Derived from seaweed and consists of tremendously absorbent calcium alginate fibres -As the exudate is absorbed, the fibres turn into a viscous hydrogel" "stimulated healing - CORRECT ANSWER -Tissue engineering human skin equivalent is a skin product cultured from human dermal fibroblasts and keratinocytes used in combination with therapeutic compression -stimulates the production of growth factors" "hyperbaric oxygenation - CORRECT ANSWER Accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen" "Negative pressure wound therapy - CORRECT ANSWER Uses vacuum assisted closure devices to decease time for healing complex wounds that have not healed in a 3 week period" "Oozing wounds - CORRECT ANSWER wet dressing and smoothing lotions" "Dry and scaly wounds - CORRECT ANSWER Water soluble emulsions, creams, ointments, and pastes" "5 rules of wound care - CORRECT ANSWER 1. Categorization 2. Selection 3. Change 4. Evaluation 5. Practice" "inflammatory phase of healing - CORRECT ANSWER -takes 1-4 days -signs include edema, erythema, heat, and pain at the site of wound -blood clot develops: forms a fibrin matrix -scabs prevent contamination -histamine is released and causes increase in blood and nutrients to the wound -neutrophils move into the wound and ingest bacteria and small debris - Macrophages clean the wound by phagocytosis preparing it for healing" "proliferation phase of healing - CORRECT ANSWER -takes 3-24 days -granulation tissue fills the wound bed, contraction (inward movement of edges) of the wound and resurfacing of the wound by epithelialization -wound closes by epithelialization: epithelial cells grow to cover the wound bed but epithelial cells only migrate across a moist surface, therefore a moist environment facilitates wound closure" "maturation phase of healing - CORRECT ANSWER -Takes more than a year -scar may not achieve maximum strength or up to 2 years -collagen undergoes remodelling -increase calories helps with wound healing -soft skin breakdown for moisture surrounding a wound= masseration" "Primary intention healing - CORRECT ANSWER -Cut in the skin (clean straight wound) -easiest would to heal -these wounds will have sutures or staples -edges should be well approximated" "Tertiary intention healing - CORRECT ANSWER -deep wounds that have been re-sutured or delayed sutured -wider scar -healing happens from the bottom up" "serous drainage - CORRECT ANSWER clear watery plasma (could be yellow)" "sanguineous drainage - CORRECT ANSWER Bright red and bloody" "serosanguineous drainage - CORRECT ANSWER mixture of plasma and red blood cells (pale red and watery)" "purulent drainage - CORRECT ANSWER Necrotic tissue, pus; thick and yellow, green, tan, or brown color (indicated infection)" "Blood tests: CBC WBC Neutrophils - CORRECT ANSWER Check for the presence of infection" "Blood tests: Pre-albumin Albumin - CORRECT ANSWER Low: not enough nutrition causing slow healing" "Blood tests: Glucose level - CORRECT ANSWER Tissue with sugar in it doesn't heal as well" "Diagnostic tests: radiological studies - CORRECT ANSWER X-ray" "Signs of infection - CORRECT ANSWER -Fever -Woud drainage -Swelling -Tenderness -Increased WBC -Malaise (fatigue)" "Hemovac drain - CORRECT ANSWER -empty when the drain is half full to maintain suction -pin below the wound allowing for drainage to flow -self suctioning and collection of drainage, often secured with a suture" "Jackson-Pratt drain - CORRECT ANSWER -Ensure drains stabilized to prevent drain from falling out -Maintain patency -closed bulb self-suction and collection of drainage, often secured wth a suture" "Drain complications - CORRECT ANSWER -Infection into the wound -When removing the drain ensure that it is intact -Kinks: not draining -Blood clot clogging the drain -If not draining: assess the system, cleanse/redress and notify the doctor -Can be painful -Suctioning doesn't work: re-prime it, check for placement, and check for any holes (notify the doctor) -too much drainage (notify the doctor)" "complex wounds - CORRECT ANSWER -would healing from the bottom up -not approximated -jagged edges" "venous stasis - CORRECT ANSWER -Elevate legs 15-30 minutes every 2 hours -check popliteal area for cut circulation -don't sit with legs crossed or dangling -Compression stocking: Put on after legs have been elevated -Intermittent claudication: Pain (ischemic) while walking, from poor blood flow" "Assessing respiratori status (tests) - CORRECT ANSWER -blood work -Pulmonary function test -arterial blood gases -sputum tests -imaging -CXR,CT, MRI, PET scans -pulmonary angiography -VQ scan" "Low flow systems - CORRECT ANSWER -Nsal cannula: 1-6L/min (24-44%) -Simple mask 6-8L/min (40-60%) -Partial rebreather: 8-11L/min (50-75%) -non rebreather: 12-15L/min (80-100%)" "High flow systems - CORRECT ANSWER Venturi mask" "interventions for oxygenation - CORRECT ANSWER -administer medication -positioning -opening airways -improving efficiency -reduce anxiety" "chest tube assessment - CORRECT ANSWER -Mark Drainage amnt every few hrs -Keep chest tube upright and below level of patients chest -Tidaling should be present, bubbling should not -assess dressing for entactness" "Chest tube rules - CORRECT ANSWER -notify physician of drainage greater than 100ml/hour -never milk or clamp the tubing -secure all connections with occlusive tape -may discontinue suction but leave the suction vent open -unit but be kept below the chest level at all times" "Pneumococcal vaccine - CORRECT ANSWER -people 65 or older -immunocompromised -chronic illness -disability -high risk environments" "chest physiotherapy - CORRECT ANSWER -promotes clearance of bronchial secretions -postural drainage -chest percussions -vibration" "Nasopharyngeal suctioning - CORRECT ANSWER -assess -position -oxygenate -set up -suction 100-150mmHg: wall 10-15cm Hg portable oxygenate -assess" "Patient teaching for tracheostomy - CORRECT ANSWER -purpose of o2/hazards of o2 -deep breathing and coughing -using metres dose inhaler -using an incentive spirometer -diaphragmatic breathing -pursed lip breathing" "Health history for elimination - CORRECT ANSWER -smoking -alcohol -medications -family history -UTI history -chemical exposure -neurological disorders -previous diagnostic tests" "Physical assessment for elimination - CORRECT ANSWER -genitourinary system -GI system -respiratory (any fluid overload, crackers?) -Peripheral vascular (CTEMPS) -respirations: SPO2 -BP: kidney failure= high BP" "Urinalysis - CORRECT ANSWER breakdown protein in the urine" "specific gravity - CORRECT ANSWER -monitors hydration -high specific gravity indicates low fluid intake -low specific gravity indicates high fluid intake -level will stay the same if kidney disease is present" "Creatine clearance - CORRECT ANSWER creatine filtration through the kidneys will have increased levels in the blood with kidney problems" "BUN (blood urea nitrogen) - CORRECT ANSWER Filtration of urea nitrogen in the kidneys" "urodynamic tests - CORRECT ANSWER electrodes or catheterization to assess bladder muscle function" "KUB - CORRECT ANSWER bladder X-Ray" "nuclear scan - CORRECT ANSWER Inject nuclear isoscope through an IV and monitor how the kidneys filtrate this in the blood" "retrograde pyleogram (RP) - CORRECT ANSWER catheter inserted through ureters" "angiogram - CORRECT ANSWER Catheter inserted through femoral/axila artery into renal artery" "Risk for urinary tract infection (UTI) - CORRECT ANSWER -elderly -women -anyone with a catheter -sexually active -immunocompromised" "What is used to treat urinary tract infections? - CORRECT ANSWER Antibiotics" "stress incontinence - CORRECT ANSWER physical stress, coughing, sneezing, high impact, and decreased estrogen" "urge incontinence - CORRECT ANSWER sudden strong urge to void, cannot make it to the restroom on time, high muscle contraction" "reflex incontinence - CORRECT ANSWER no urge to void, and no sensation of full bladder" "overflow incontinence - CORRECT ANSWER bladder unable to release urine until it overflows" "functional incontinence - CORRECT ANSWER not able to connect the fact that hey have to void with going to the bathroom. Also can't physically get tot he bathroom" "Treatments for incontinence - CORRECT ANSWER -voiding diary -monitor fluid intake -avoid caffeine, alcohol -time voiding -bladder retraining" "urinary retention - CORRECT ANSWER inability to empty the bladder -Over 100ml of residual urine= urinary retention" "residual urine - CORRECT ANSWER urine that remains in the bladder after urination" "Risk for urinary retention - CORRECT ANSWER -pregnancy -infection -post op -prostate enlargement -trauma" "Symptoms of urinary retention - CORRECT ANSWER -bladder distention -pain -restlessness -small amounts of urine frequently" "Complications of urinary retention - CORRECT ANSWER -infection -stones -leakage causing skin irritation -hydronephrosis" "length of urethra - CORRECT ANSWER Female: 3-6cm Male: 13-16cm" "bladder capacity - CORRECT ANSWER -600-1000 mL -at 200ml we will feel the urge to urinate -at 500ml we will start to feel uncomfortable" "What is catheterization used for? - CORRECT ANSWER -urinary retetnion -post op: to monitor output -icu: monitor output -prostate removal/bladder surgery: to irrigate the bladder -palliative care: comfort -ulcers that will not heal" "Rules for catheter insertion - CORRECT ANSWER -never force the catheter in -monitor pain while inflating the bulb -use sterile technique -secure the catheter to thigh -patient teaching: keep bag below bladder level, do not pull on the tubing, and practice good pericare" "Function of the skin - CORRECT ANSWER -primary line of defence -protection of the body -a disruption results in loss of fluid and risk for infection" "Wound healing complications - CORRECT ANSWER -inflammation -edema -heat -pain -infection -hemorrhaging -fistula -dehiscence -evisceration" "hemorrhaging - CORRECT ANSWER -can occur post-op or post-injury -clotting usually occurs quickly -may need to apply pressure dressing -watch for distention, swelling, obvious bleeding, increased drainage, assess BP, and observe for hypovolemic shock" "fistula - CORRECT ANSWER abnormal passageway between two organs or between an internal organ and the body surface" "Dehiscence - CORRECT ANSWER refers to partial or total separation of wound edges" "Evisceration - CORRECT ANSWER protrusion of internal organs through the incision" "Goals of wound care - CORRECT ANSWER -remove necrotic tissue to promote healing -prevent, eliminate or control infection -absorb drainage (exudate) -maintain moist-wound environment -protect the wound from further injury -protect the surrounding skin" "Reducing risk for wounds - CORRECT ANSWER -monitoring the client -cleansing the skin -moisturizing -providing nutrition -positioning the client q2h -encouraging the client to maintain ADL's -client teaching -promote adequate nutrition" "Interventions to promote healing - CORRECT ANSWER -cleansing the wound -maintain moist wound bed -dress wound -drain the wound -drain care to help promote healing -removing sutures and staples -apply heat or cold -drugs to help pain" "Penrose drain - CORRECT ANSWER open flat tube (passive)" "Impaired wound healing - CORRECT ANSWER -infection -malnutrition -age -obesity -impaired oxygenation -smoking -drugs -vascular disease -radiation -wound stress" "Assessment of wounds - CORRECT ANSWER -type -location -size -color -surrounding skin -odor -drainage/drains -temperature -wound closures -pain/tolerance -dressings removed/ applied" "Principles of Sterile Technique - CORRECT ANSWER 1. A sterile object remains sterile only when touched by another sterile object 2. only sterile objects may be placed on a sterile field 3. a sterile object or field out of range, vision, or an object held below a persons waist is contaminated 4. a sterile object or field becomes contaminated by prolonged exposure to air 5. when a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action 6. fluid flows in the direction of gravity therefore a sterile object becomes contaminated if gravity causes contaminated liquid to flow over the objects surface 7. the edges of a sterile field or container are considered to be contaminated" "Documentation of wounds - CORRECT ANSWER -describe wound and where it is -describe the dressing that was removed -describe the drainage and how much of it there is -describe wound according to your assessment -describe your interventions -describe the new dressings used -describe clients tolerance to the procedure" "Drain care promoting healing - CORRECT ANSWER -maintain patency -secure the drain -monitor the drainage (COCA) -empty fluid form the drain and measure/record -maintain dressing around drain" "Red wound - CORRECT ANSWER -healing wounds -granulated tissue -need to be kept clean and moist" "yellow wound - CORRECT ANSWER -fibrous slough or exudate -infected and not ready to heal -require removal of slough" "black wound - CORRECT ANSWER -presence of eschar (necrotic tissue) -not ready to heal -must have eschar removed for healing" "endoscopy - CORRECT ANSWER Procedure allowing view of internal organs" "bronchoscopy - CORRECT ANSWER visual examination of the lungs and airways" "thorascopy - CORRECT ANSWER visual examination of the chest, plural cavity, and thoracic cavity" "Tharacentesis - CORRECT ANSWER a needle is inserted into the pleural space to remove excess liquid" "Chest tube care - CORRECT ANSWER -assess patient -assess dressing -assess the system (patency/leaks) -check for tidaling -water level in the chambers" "Tidaling - CORRECT ANSWER rise and fall when inspirations and expiration occur" "Wet chest tube systems - CORRECT ANSWER Water is used to prevent air from re-entering the chest. -The amount of suction is determined by the amount of water instilled in the suction chamber." "Dry chest tube system - CORRECT ANSWER -does not use water in the suction chamber. -The automatic control valve (ACV) continuously balances the force of the suction with the atmosphere" "Chest Tube Rules - CORRECT ANSWER -Notify the doctor of drainage more than 100ml/h -never milk or clamp the tubing -secure all connections with occlusive tape -if going for test, may be discontinued but leave suction vent open -unit must be kept below chest level at all times" "Nasopharyngeal suctioning - CORRECT ANSWER removing secretions from the throat through a nasally inserted catheter -assess -position -oxygenate -set up -suction wall unit: 100-150mmHg portable: 10-15cmHg -oxygenate -assess" "Documentation for urine tests - CORRECT ANSWER -What test was performed -time left unit/time returned to unit -stretcher/wheelchair/portable oxygen? -condition of the patient leaving/returning -what was the procedure? -what post procedure instructions you followed? -how did you leave the patient in the room" "UTI teaching - CORRECT ANSWER -take full course of antibiotics -s/s of yeast infection (prevention) -vitamin c or cranberry juice -increase fluid intake" "indwelling catheter - CORRECT ANSWER remains inside the body for a prolonged time based on need" "intermittent catheter - CORRECT ANSWER short-term catheter, inserted as needed several times a day to drain urine from the bladder" "suprapubic catheter - CORRECT ANSWER indwelling catheter inserted directly in the bladder through an abdominal incision above the pubic bone that includes a collection system that allows urine to be drained into a bag; used in patients requiring long-term catheterization" "continuous bladder irrigation - CORRECT ANSWER A three-way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots—one lumen is for inflating the balloon (30 mL); one lumen is for instillation (inflow); one lumen is for outflow." "closed bladder irrigation - CORRECT ANSWER Flushing sterile fluid through the catheter to help dislodge any items blocking the tubing" "open bladder irrigation - CORRECT ANSWER " "CPAP (continuous positive airway pressure) - CORRECT ANSWER a device that is commonly used to regulate breathing during sleep as a treatment for sleep apnea" "BiPAP (bilevel positive airway pressure) - CORRECT ANSWER Mask that ventilates either by facial or nasal mask with inspiratory pressure is higher and expiratory pressure is lower" "acute renal failure - CORRECT ANSWER -oliguria -decreased glomerular filtration rate -increased creatine -increased BUN (blood urea nitrogen) -hypovolemia -hypotension -decreased cardiac output -obstruction -nephrotoxic medications" "End stages of renal failure (chronic renal failure) - CORRECT ANSWER -Uremia develops -metabolic acidosis -peripheral neuropathy -hypertension -heart failure -anemia -uremic bone disease -edema" "hemodialysis - CORRECT ANSWER -toxins/waste removed by diffusion -dialysate solution -dialyzer: synthetic semipermeable membrane -ultrafiltration: removes excess water" "Dialysis sites - CORRECT ANSWER -Ateriovenous fistula (AV fistula): placed from an artery connecting to a vein -hemodialysis vascular access device: inserted directly into the veins" "Hemodialysis complicaitons - CORRECT ANSWER -worsened anemia -nausea and vomiting -diaphoresis (sweating) -dizziness -tachycardia -hypotension -fatigue" "peritoneal dialysis - CORRECT ANSWER peritoneum acts as a semi-permeable membrane -dialysate into peritoneal cavity by gravity -left in cavity for a period of time to absorb wastes and excess fluid by diffusion and osmosis -fluid drained into collection bag and discarded" "complication of peritoneal dialysis - CORRECT ANSWER -peritonitis: Cloudy dialysate drainage, abdominal pain, and rebound tenderness -leakage -bleeding" "How to treat peritonitis - CORRECT ANSWER raid exchanges of dextrose to clean out the membrane, and then antibiotic agents are added tot he next exchanges" SBAR - CORRECT ANSWER situation, background, assessment, recommendation" "clinical pathways - CORRECT ANSWER used in management of care" "care mapping - CORRECT ANSWER care mapped out day by day from admission day to discharge" "1. - CORRECT ANSWER do it yourself" "2. - CORRECT ANSWER influence others" "3. - CORRECT ANSWER assign someone" "4. - CORRECT ANSWER do nothing" "5. - CORRECT ANSWER collaboration" "priority setting - CORRECT ANSWER based on Maslow's hierarchy of needs" "skin - CORRECT ANSWER primary line of defence, protects body from microorganisms" "cause of a wound - CORRECT ANSWER intentional vs. unintentional" "skin integrity - CORRECT ANSWER open, closed, acute, chronic" "depth of a wound - CORRECT ANSWER partial thickness or full thickness" "cleanliness of a wound - CORRECT ANSWER clean, clean-contaminated, contaminated, infected" "red wound - CORRECT ANSWER healing, granulation, inflammatory, maturation phase" "yellow - CORRECT ANSWER fibrous slough/exudate, infected" "black - CORRECT ANSWER presence of eschar, must have necrotic tissue removed in order to heal" "phases of healing - CORRECT ANSWER inflammatory, proliferative, maturation" "what is the purpose of a drain - CORRECT ANSWER removes lymph, serum, blood and other accumulating fluids" "braden scale high score - CORRECT ANSWER low risk" "assessments for O2 - CORRECT ANSWER respiratory, cardiac, vitals, skin inspection" "sputum showing infection - CORRECT ANSWER yellow/green/rusty, pink tinged, foul smelling" "med to assist with thick secretions - CORRECT ANSWER mucolytic drugs" "atelectasis - CORRECT ANSWER partial or complete lung collapse" "stress incontinence - CORRECT ANSWER dribbling of urine with increased abdominal pressure" "urge incontinence - CORRECT ANSWER sudden desire to urinate" "functional incontinence - CORRECT ANSWER unpredictable" "reflex incontinence - CORRECT ANSWER unexpected with loss of sensation" "total incontinence - CORRECT ANSWER inability to control" "autonomic dyreaflexia - CORRECT ANSWER spinal cord injury patients, relfex of autonomic nervous system in response to stimulation of bladder" "hemodialysis - CORRECT ANSWER removes accumulated wastes and excess fluid from the blood, cleans the blood and acts as an artificial kidney" "peritoneal dialysis - CORRECT ANSWER cleansing blood and waste products using diffusion and osmosis, instilled into peritoneal cavity" "perioperative - CORRECT ANSWER surgical patients are cared for throughout specific areas in the hospital" "preoperative - CORRECT ANSWER baseline, hospital gown, dentures out, jewlery put away, consent signed" "intraoperative - CORRECT ANSWER client in surgery" "postoperative - CORRECT ANSWER recovery, vitals, continuously reassessing" "general anestheia - CORRECT ANSWER inhalation/iv, puts client to sleep" "spinal anestheia - CORRECT ANSWER inserted between L4-5 into spinal fluid, numbs part of the body" "regional anestheia - CORRECT ANSWER nerve block to a certain part of the body" "local anestheia - CORRECT ANSWER specific spot on the body, injectable or topical" "transfer types - CORRECT ANSWER intra-agency, special care unit, step down, inter-agency" "Clinical (critical) pathways - CORRECT ANSWER -directs the entire health care team in the daily care goals for select health care problems -includes: nursing care plan, specific interventions, and a documentation tool -it describes the patient care required at specific times in the treatment -multidisciplinary approach" "Purpose of clinical pathway - CORRECT ANSWER Critical to meet expected outcomes Standardize care Reduce delays in care Reduce costs" "What is the purpose of SBAR? - CORRECT ANSWER -All events are critical to meet outcomes -Standardization of Care -Can be individualized -Reduces duplication and delays in care -Reduces cost of care" "What does SBAR do? - CORRECT ANSWER -Communication Framework -Clear & Direct communication with Care Providers -Clinical Pathways -Care maps -Effective & Efficient Processes -Care mapped from entry to exit" "Why would we use gauze? - CORRECT ANSWER It gathers lots of secretions, for something that is draining lots" "Telfa - CORRECT ANSWER -Non-adherent gauze -Telfa can be used over clean wounds with little or no drainage. -Does not stick and drainage can pass through to the gauze." "When would we use occlusive dressing? - CORRECT ANSWER -Anytime we do not want something to go in/out of the wound because it is impermeable to external bacteria and other contaminants -eg. chest tube" "Occlusive (Hydrocolloid) - CORRECT ANSWER -Adhesive and occlusive. -Interacts with wound fluid to provide a moist environment -Surface touching the wound forms a gel and maintains a moist environment. -Can be used on clean, granulating wounds as well as for wounds that need debriding. -They slowly liquify necrotic tissue. -Can be left in place until seal is broken, allowing for enhanced healing. -Use on ulcer type wounds. -WATCH CAREFULLY AS SOME HYDROCOLLOIDS CAN LEAVE RESIDUE IN WOUND THAT LOOKS LIKE PUS -minimal absorption, maintains wound med moisture -impermeable to external bacteria and other contaminants -must be left in place for 5-7 days -should NOT be used in heavily draining, or full thickness infected wounds" "complex wound packing - CORRECT ANSWER -first you must assess size, depth, shape, tunnelling, and undermining -wound should not be packed too tightly, use a light touch -overpacking the wound causes pressure on the tissue bed, decreasing blood flow to the area = prevents healing -amount/type of packing placed should be documented" "serous - CORRECT ANSWER -clear, watery plasma -doesn't contain blood cells or platelets i.e. fluid in blister" "Serosanguineous - CORRECT ANSWER -Pale, red, watery: mixture of clear and red fluid -commonly seen in surgical incisions" "sanguineous - CORRECT ANSWER -bright red: indicates active bleeding" "simple wound - CORRECT ANSWER - eg. surgical incision" "Complex wound - CORRECT ANSWER - eg. a wound where there is tunnelling, undermining (pressure ulcer)" "Acute Wound - CORRECT ANSWER Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity Causes: surgical incision Implications for healing: wounds are usually cleaned and repaired. wound edges are clean and intact" "Chronic Wound - CORRECT ANSWER -Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity -Cause: vascular compromise, chronic inflammation, or repetitive insults to the tissue -implications for healing: continued exposure to insult impedes wound healing" "Primary intention - CORRECT ANSWER -wound that is closed -Cause: surgical incision, wound that is suture or stapled -Implications for healing: healing occurs by epithelialization, heals quickly with minimal scar formation" "Secondary Intention - CORRECT ANSWER -Wound edges are not approximated -Cause: pressure wounds, surgical wounds that have tissue loss -Implications for healing: wound heals by granulation tissue formation, wound contraction, and epithelialization" "Tertiary Intention - CORRECT ANSWER -wound is left open for several days, wound edges are approximated -Causes: wounds that are contaminated and require observation for signs of inflammation -Implications for healing: closure of wound is delayed until risk of infection is resolved" "Pressure ulcer stage 1 - CORRECT ANSWER -Intact skin with nonblanchable redness of a localized area -indicators may include changes in skin temperature, tissue consistency and or sensation -redness in lightly pigmented skin and may appear red, blue, or purple in darker skin tones" "pressure ulcer stage 2 - CORRECT ANSWER - partial thickness loss of skin with exposed dermis - ulcer is superficial and presents as an abrasion, blister, or shallow crater -adipose (fat), and deeper tissues are NOT visible" "What does low albumin indicate? - CORRECT ANSWER malnutrition, which in turn slows wound healing" "lab test: pre-Albumin - CORRECT ANSWER -poor nutrition for a short while, acute" "Lab test: Albumin - CORRECT ANSWER -poor nutrition for a long while, chronic" "What does the body need for healing? - CORRECT ANSWER protein and vitamin C" "What type of patient will heal slowest from a wound? - CORRECT ANSWER Diabetic patient" "how to prevent dehiscence? - CORRECT ANSWER - Encourage splinting the abdomen - provide support to the area" "What should nurse do if dehiscence occurs? - CORRECT ANSWER -position patient to put least amount of strain on the operated side & call doctor!" "Dehiscence - CORRECT ANSWER -partial or total separation of wound edges -if at risk for poor wound healing, you are at risk for dehiscence -obese patients at risk for dehiscence because of strain placed on wound, and poor healing qualities of fat tissues -May occur when removing sutures therefore many dr's order every other suture out on 1st day and then the remaining sutures removed the next day" "Evisceration - CORRECT ANSWER -total separation of wound layers -protrusion of visceral organs through wound opening -emergent condition which requires surgical repair" "what should nurse do if evisceration occurs? - CORRECT ANSWER -quickly place sterile towels soaked in sterile saline over the extruding tissues to reduce change of bacterial invasion and drying of the tissues -contact the physician immediately -if organs protrude through the wound blood supply to the tissues is compromised, patient should not receive anything NPO -nurse needs to observe for signs and symptoms of shock, and prepare patient for emergency surgery" "how to collect Culture of wound - CORRECT ANSWER -a culture sample should never be collected from old drainage -first the wound is cleaned with normal saline to remove skin flora, then collect culture of wound" "What happens if the peri-skin is not kept dry? - CORRECT ANSWER -it will macerate and rot away" "What is the purpose of a drain - CORRECT ANSWER Placed during surgery to help remove fluid from the surgical site Used to monitor color, amount, and type of drainage Examples: Hemovac, Jackson Pratt, Penrose, T-tube, Negative pressure device -removes excess fluid from site, allows body to heal quicker" "How do you clean a drain - CORRECT ANSWER -Clean incision first (cleanest) -Then drain site away from incision (least contaminated, to most contaminated) -clean around the drain moving in circular rotations outward from a point closest to the drain" "What are the assessments of a drain? - CORRECT ANSWER -amount of drainage: colour, consistency -peri-skin, is it dry and intact? if it is wet this can cause maceration increase in drainage may indicate infection" "How to discontinue a Jackson Pratt? - CORRECT ANSWER -empty drainage then decompress -place dressing. Record & Report any Variances" "How to discontinue a Hemovac? - CORRECT ANSWER - remove stitch (find on surgical op form) - cleanse peri-skin - place dressing. Record & Report any Variances" "complications that can arise for geriatric clients via chest physiotherapy - CORRECT ANSWER -chest physio consists of: postural drainage, chest percussion, and vibration -Rib Fractures & Osteoporosis Fractures" "What is the position for secretion removal from the body? - CORRECT ANSWER Trendelenburg position" "Mucolytics - CORRECT ANSWER Mucoactive agents are a class of drugs which aid in the clearance of mucus from the upper and lower airways, including the lungs, bronchi, and trachea" "Oral Suctioning guidelines - CORRECT ANSWER 10-15 seconds, if client desaturates less than 5 seconds suction, ambu bag O2 breaths, and 3 minutes inbetween suctions" "What are the reasons for chest tubes - CORRECT ANSWER chest tubes are inserted to remove air and fluids from the pleural space, prevent air/fluid from re-entering the pleural space, and re-establish normal intrapleural and intrapulmonic pressures -a catheter inserted through the thorax to remove fluid or air" "pneumothorax - CORRECT ANSWER -collection of air in the pleural space, causes lung to collapse -air removal -pain may be sharp and pleuritic -dyspnea is common and worsens as the size of the pneumothorax increases" "Hemothorax - CORRECT ANSWER -accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae usually as a result of trauma -fluid/blood -can also be caused by pneumonia or TB -in addition to pain, and dyspnea signs and symptoms of shock can develop if blood loss is severe" "Wet vs. Dry suction - CORRECT ANSWER This refers to the type of suction only, has nothing to do with anything else" "Where does appliance need to be kept when suctioning? - CORRECT ANSWER Below chest level" "What does bubbling mean during suctioning of chest tube - CORRECT ANSWER -common during set up -continuous bubbling means air leak or lung is reinflated -no tidaling -means tubing kinked, or lung re-inflated" "how to do trach suctioning - CORRECT ANSWER -accomplished through an artificial airway, endotracheal tube/tracheostomy tube -to avoid trauma to the mucosa of the lug, never apply suction pressure while inserting the catheter, and maintain suction rpessure less than 150mmHg i adults -apply suction intermittently ONLY as the catheter is withdrawn -rotating the catheter will enhance removal of secretions that have adhered to the sides of the endotracheal tube" "If trach is dislodged what do you do? - CORRECT ANSWER priority = call for help" "What is the assessment for trach care? - CORRECT ANSWER O2 sat, respiratory assessment, LOC, skin colour, trach ties secure, dressing under flange to protect the periskin" "When can a client speak with a trach? - CORRECT ANSWER when it is fenestrated" "New trachs have cuffs _______ to decrease ________ of secretions - CORRECT ANSWER inflated, aspiration -If plugging is being trialed make sure cuff is deflated otherwise they have no way of getting air again" "What lab test will determine if the kidney is functioning well? - CORRECT ANSWER Urinalysis" "Urinalysis - CORRECT ANSWER -Determines if bacteria are present and if so, what kind and how much -Shows kidney function -helps diagnose disease" "why does reflex incontinence happen to spinal cord injury clients? - CORRECT ANSWER They do not have the sensation of the urge to void and are unaware of the bladder feeling, which means they do not have the feeling to urinate." "what are the reasons for catheter insertion? - CORRECT ANSWER -only when indicated by a DR order -urinary incontinence -decreased urine output -used long term in people with spinal cord injuries -intermittent catheterization can be used to collect a sterile specimen in patients who are unable to provide a midstream specimen" "what does PVR stand for? - CORRECT ANSWER post void residual" "indwelling catheter (foley) Purpose, and appearance - CORRECT ANSWER Purpose: - Gradual decompression of an over-distended bladder -Continuous bladder drainage Appearance: -2 or 3 lumen -balloon" "Intermittent (Straight) Catheter - CORRECT ANSWER Purpose: - Drains bladder for short periods of time (5-10 minutes) -Used to obtain a sterile specimen -single use Appearance: -single lumen -no balloon" "Suprapubic catheterization purpose and appearance - CORRECT ANSWER Purpose: -Continuous drainage -Inserted through a small incision above pubic area Appearance: -may or may not have a balloon" "Complications of catheter insertion - CORRECT ANSWER pain: -little or no lubrication -pain upon balloon expansion (if it is not in the right spot) -if in wrong spot deflate advance catheter(2.5 - 5cm) or 0.5/1 inch and then re-inflate balloon -if there is a spasm hold catheter and penis firmly allow to relax" "short term catheter indications - CORRECT ANSWER -fewer than 14 days -goes with select surgical procedures/postoperative care -accurate monitoring of urine output ever 1-2 hours in critically ill patients -prolonged immobilization due to trauma -acute urinary retention or bladder outlet obstruction -instillation of medications into the bladder -end of life care only if required for comfort" "peritoneal dialysis - CORRECT ANSWER -indirect method of cleaning the blood of waste products and excess fluid using osmosis and diffusion -exchange of fluid introduced into the peritoneal cavity -drained out using osmosis to decrease toxins and waste -side effects = bleeding from catheter site, and infections" "perioperative phase - CORRECT ANSWER -includes care before you have surgery to when you go home -perioperative nurse serves as an advocate for the patient during surgery, and protects the patients dignity and rights at all times" "define preoperative phase - CORRECT ANSWER -The preoperative phase begins with the client's decision to have surgery and ends with the actual entry of the client into the operating room" "preoperative assessments checklist - CORRECT ANSWER -Baseline V/S -Routine Hygiene -In hospital gown -Nail polish removed -Dentures out -Allergy/ID bands checked and on -No jewellery on, valuables secured -Consent form signed -Charts prepared and ready to go -Has history and physical. Labs, DI been done?