NUR 155 Exam 3

Clean wounds are uninfected wounds with minimal inflammation Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered, such wounds show no evidence of infection Contaminated wounds are a wound with bacteria present resulting from trauma, a break in sterile technique during surgery or spillage of bowel contents or other bacteria-laden material during surgery Dirty or infected wounds are wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage Define pressure ulcer Localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure or pressure in combo w/ shear or friction Ischemia Lack of blood supply laceration jagged wound Abrasion Scrape of the skin due to something abrasive contusion bruise puncture wound a deep hole made by a sharp object such as a nail Skin tear a traumatic wound resulting from separation of the epidermis from the dermis Avulsion An injury in which soft tissue is torn completely loose or is hanging as a flap. What are some risk factors for pressure ulcers? -friction & shearing (ask patient to help with moving themselves) -immobility/pressure -inadequate nutrition (poor intake- elders especially) -fecal & urinary incontinence -decreased mental status (Alzheimer's, dementia, etc.) -diminished sensation (do not know if in pain) -excessive body heat (causes maceration of tissue) -advanced age -chronic medical conditions friction and shearing Friction is a force acting parallel to the skin surface while a shearing force is a combination of friction and pressure Stage 1 pressure ulcer nonblanchable erythema of intact skin Stage 2 pressure ulcer partial thickness skin loss involving epidermis, dermis, or both stage 3 pressure ulcer Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon. stage 4 pressure ulcer Full-thickness tissue loss with exposed bone, muscle, or tendon unstageable pressure ulcer base of ulcer covered by slough and/or eschar in the wound bed suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Braden Scale for Predicting Pressure Sore Risk 19-23 not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk Less than or equal to 9 very high risk Primary intention healing Occurs where the tissue surfaces have been approximated, and there is minimal or no tissue loss Secondary intention healing wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring Tertiary intention healing Wound is left open for 3-5 days to allow edema or infection to resolve then closed by sutures, staples, or adhesive Inflammatory phase of wound healing 3-6 days Hemostasis (cessation of bleeding) Phagocytosis (cells ingesting other cells) Proliferative phase of wound healing (3 to 21 days) - New tissue forms to close wounds - Capillary budding and granulation eschar dead matter that is sloughed off from the surface of the skin, especially after a burn Serous Fluid clear, watery plasma Serosanguineous Fluid Pale, red, watery: mixture of clear and red fluid Sanguineous Fluid Bright red; indicates active bleeding purulent fluid pus or infected discharge from wound or incision Suppuration the formation or discharge of pus maturation phase of wound healing Begins about day 21 & can extend 1 or 2 yrs after injury. Fibroblasts continue making collagen whose fibers reorganize into more orederly structure. Wound is remodeled & contracted. Scar becomes stronger but area is never as strong as original tissue. Dehiscence partial or total separation of wound layers Evisceration protrusion of viscera through an incision Erythrocytes red blood cells Hematocrit percentage of blood volume occupied by red blood cells Hemoglobin Oxygen carrying pigment in red blood cells Tachypnea rapid breathing bradypnea slow breathing upnea normal breathing apnea absence of breathing Cheyne-Stokes respiration rhythmic variation in depth of respiratory movements alternating with short periods of apnea Biot's respirations shallow breaths interrupted by apnea orthopnea ability to breathe only in an upright position stridor strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx. Requires immediate action. expectorate cough or spit out phlegm from the throat or lungs postural drainage use of body positioning to assist in removal of secretions from specific lobes of the lung, bronchi, or lung cavities pneumothorax air in the pleural cavity hemothorax blood in the pleural cavity pleural effusion accumulation of fluid in the pleural cavity isotonic exercise activity that combines muscle contraction with repeated movement isometric exercise exercise in which muscle tension occurs without a significant change in muscle length isokinetic exercise exercise involving muscle contractions with resistance varying at a constant rate aerobic exercise Activity during which the amount of oxygen taken in the body is greater than that used to perform the activity. Cardio anaerobic exercise Involves activity in which the muscles cannot draw out enough oxygen from the bloodstream; used for endurance training Sensory reception the process of receiving data about the internal or external environment through the senses kinesthetic awareness of position and movement of body parts Stereognosis ability to recognize objects by feeling their form, size, and weight while the eyes are closed sensory perception involves the conscious organization and translation of the data or stimuli into meaningful information sensory deprivation the absence of normal levels of sensory stimulation sensory overload condition resulting from excessive sensory input to which the brain is unable to meaningfully respond sensory deficit impaired or absent functioning of one or more senses acute confusion delirium chronic confusion dementia Nasal cannula flow rate 2-6L/min, FiO2 24-45% Simple mask flow rate 5-8L/min, FiO2 40-60% Venti mask flow rate 4-10L/min, FiO2 24-50% Partial rebreather mask flow rate 6-10 L/min, FiO2 60-90% nonrebreather mask flow rate 10-15 L/min, FiO2 95-100% face tent flow rate 4-8 L/min, FiO2 30-50% Transparent dressing (tegaderm) -stage 1 ulcer -provides protection against contamination and friction. Keeps area moist and prevents fluid evaporation but allows the exchange of oxygen between atmosphere and wound bed. Impermeable to bacteria and water. Hydrocolloid dressing (DuoDerm) -Stage 2-4 pressure ulcer Can be worn up to 7 days, absorb exudate and forms a hydrated gel over the wound. Keeps wound moist. Prevents shearing. Silver - Alginate dressing Used to pack wounds and absorb 20x their weight Denial (Defense mechanism) A manager tells an employee he may have to fire him. On the way home, the employee shops for a new car. Displacement (Defense mechanism) A student who has received a low grade on a term paper blows up at his girlfriend when she asks about his grade. Dissociation (Defense mechanism) A woman has amnesia for the events surrounding a fatal automobile accident in which she was the speeding driver. Fantasy (Defense mechanism) A student struggling through graduate school thinks about a prestigious, highpaying job she wants. Identification (Defense mechanism) After hospitalization for minor surgery, a girl decides to become a nurse. Intellectualization (Defense Mechanism) A man learns from his doctor that he has cancer. He studies the physiology and treatment of cancer without experiencing any emotion. Introjection (Defense Mechanism) A woman who prefers a simple lifestyle assumes the materialistic, prestigeoriented values of her husband. projection (defense mechanism) A man who is quite critical of others thinks that people are joking about his appearance. Rationalization (defense mechanism) A man cheats on his income tax return and tells himself it's alright because everyone does it. reaction formation (defense mechanism) A woman who dislikes her mother-in-law is always very nice to her. Regression (defense mechanism) A man exposes his genitalia to women he sees in public places. Repression (defense mechanism) A man is jealous of a good friend's success but is unaware of his feelings. Suppression (Defense Mechanism) A student taking an examination is upset about an argument with her boyfriend, but deliberately puts it out of her mind so she can finish the test. Undoing (Defense Mechanism) A young woman realizes that she has just insulted her boyfriend and spends the rest of the evening compli- menting him on his looks and his athletic ability. S1 sound (lub) normal closure of mitral and tricuspid valves, beginning of ventricular systole S2 sound (dub) normal closure of aortic and pulmonary valves; marks beginning of ventricular diastole Systole Heart ejects blood into pulmonary and systemic circulation; contraction Diastole When ventricles fill with blood; relax Right heart pump receives deoxygenated blood from the body tissues and pumps it to the lungs Left heart pump receives oxygenated blood from the lungs and pumps oxygenated blood to the body Automaticity The ability of the heart to generate and conduct electrical impulses on its own (AV) Block koz myocardial infarction (MI) Death of cardiac muscle due to ischemia Ischemia Lack of blood supply due to obstructed circulation troponin and creatine kinase enzyme that is released into the blood during MI as a result of cell damage decreased cardiac output inadequate blood pumped by the heart to meet metabolic demands of the body elevated homocysteine A converted amino acid that damages arterial walls and promotes formation of plaque Symptoms of MI Diaphoresis, nausea, chest pain & pain in left arm and/or jaw, shortness of breath, fatigue Symptoms of heart failure dyspnea, fatigue, exercise intolerance, fluid retention, increased heart rate, orthopnea Promoting blood circulation Vascular- elevate the legs no more then 15° of knee flexion, encourage leg exercises, frequent positioning changes Cardiac- High Fowler's, severe heart failure may require fluid restriction signs of anemia chronic fatigue, pallor, SOB, hypotension Cardiac Output (CO) SV x HR Cardiac output Rapid heart rates (more then 150 BMP) will not allow the ventricles to fill causing CO to fall Stroke Volume (SV) The amount of blood pumped out of the heart with each contraction. Contractility of the heart Stroke volume will decrease if contractility is poor, reducing cardiac output. Inotropic drugs affect contractility. Can be positive or negative. Preload degree of stretch of the cardiac muscle fibers at the end of diastole. Preload is amount of blood entering the heart from venous circulation. Afterload resistance that must occur during systole to eject blood from the left ventricle S3 heart sound ↑ventricular filling pressure (e.g., mitral regurgitation, HF), common in dilated ventricles Cardiac arrest symptoms Apnea, absence of carotid arteries, dilated pupils Pulmonary Edema Occurs from left sided heart failure. Vessels of the pulmonary system become congested or engorged with blood. This may cause fluid to escape into the alveoli and interfere with gas exchange. heart failure symptoms Pulmonary congestion, SOB, dyspnea, increased heart rate, s3 heart sound, increased RR, distended neck veins Conditions that increase preload -hypervolemia -valvular disorders such as mitral regurgitation -congenital defects such as patent ductus arteriosus Conditions that increase afterload hypertension and atherosclerosis Conditions that affect myocardial function Myocardial infarction, cardiomyopathy, coronary artery disease attitude are mental positions or feelings toward a person, object, or idea (e.g., acceptance, compassion, openness). Typically, a/an _________________ lasts over time and are judged as bad or good, positive or negative Beliefs are interpretations or conclusions that people accept as true. They are based more on faith than fact. ________________ are judged as correct or incorrect altruism is a concern for the welfare and well-being of others. In professional practice, _______________ is reflected by the nurse's concern for the welfare of patients, other nurses, and other health care providers. autonomy is the right to self-determination. Professional practice reflects ________________ when the nurse respects patients' rights to make decisions about their health care. Human dignity is respect for the inherent worth and uniqueness of individuals and populations. In professional practice, __________________ is reflected when the nurse values and respects all patients and colleagues. Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. _________________ is reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession. Social justice is acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation. values clarification process by which people come to understand their own values and value system Morality refers to private, personal standards of what is right and wrong in conduct, character, and attitude. Sometimes the first clue to the ___________ nature of a situation is an active conscience or an awareness of feelings such as guilt, hope, or shame. Nonmaleficence duty to do no harm Beneficence doing good Justice fairness fidelity be faithful to agreements and promises veracity telling the truth atelectasis collapsed lung associated with ventilation Alveolar gas exchange Diffusion of oxygen from the alveoli and into pulmonary blood vessels occurs after ventilation Vision Loss What sensory disturbance is caused by an increased blood glucose reading? Hearing Loss What sensory impairment can be caused by long term treatment of Lasix/ Furosemide? Stimulus an agent or act that stimulates a nerve receptor Receptor the ability to convert the stimulus to a nerve impulse. Ex) visual, auditory, or touch Impulse conduction the ________________ travels along the nerve pathways to either the spinal cord or directly to the brain Perception awareness and interpretation of the stimuli in the brain Stimuli, receptor, impulse conduction, and perception What aspects of the sensory process should the nurse assess the client? somnolent Extreme drowsiness but will respond to stimuli semicomatose Can be aroused by extreme or repeated stimuli Disturbed thought processes NANDA- applied when cognitive abilities (e.g., dementia) interfere with the ability to accurately interpret stimuli 1, 2, 4, 5 A client is experiencing changes in taste. What can the nurse do to improve this clients gustatory sense? Standard Text: Select all that apply. 1. Suggest eating each food separately. 2. Offer foods with a variety of flavors. 3. Recommend eating foods that are cold. 4. Promote sips of water between eating different foods. 5. Encourage the client to consume foods of different textures. full consciousness Alert; oriented to person, time, place; understands verbal and written words Clinical Manifestations of sensory deprivation Excessive sleeping Confusion at night Anger over minor issues Easily distracted Apathy Somatic complaints Clinical Manifestations of sensory overload Ongoing pain Inability to sleep Anxiety/worry Sleeplessness and fatigue Racing thoughts Types of wounds Intentional or unintentional Open or closed Acute or chronic Partial thickness, full thickness, complex transparent film autolytic debridement, semi-permeable allows skin to breathe. uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears how do you apply an abdominal binder? start at typhoid, fasten from the bottom up used for support to keep dressing intact remove every two hours to asses underlying skin and wound Risk factors for pressure ulcers Fecal and unitary incontinence Friction and shearing immobility inadequate nutrition (decreased protein, Vitamin C, zinc) Decreased mental status excessive body heat (moisture) advanced age chronic conditions Diminished sensation Incorrect positioning Signs of infected pressure ulcer? Change in color, odor, or drainage. Sever infections cause fever and increased WBC. During your assessment of a new patient, the nurse notices a Stage I pressure ulcer, what are the signs that this nurse is correct about this pressure ulcer being a stage one? Non-blachable No opening What do you do for a stage I pressure ulcer? Apply barrier creams Reposition patient Q2hr As you assess your new patient you notice a sore on a bony premise that is blisterlike, with partial thickness skin loss, pt is complaining of pain where the wound is present which stage is this pressure ulcer? Stage II What type of dressing do you use for a stage II pressure ulcer? Mepaplex or Duoderm Full thickness skin loss, involving damage or necrosis of subcutaneous is what stage pressure ulcer? Stage III Full thickness skin loss with tissue necrosis, damage to the muscle and bone, wound goes through nerves and not painful with tunneling present, which stage is this wound? Stage IV Treating pressure ulcers Minimize direct pressure Reposition Q2hr Schedule and DOCUMENT position change use assistive devices Dressing changes as ordered Keep sheets dry and wrinkle free Keep pt dry if incontinent ROM 3reps 2x daily What is regeneration? replacement of destroyed tissue by the same kind of cells Primary intention healing tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring Secondary intention healing wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring and greater risk of infection tertiary intention Wounds that are left open purposely for 3-5 days to allow edema and infection to resolve. serous clear, watery plasma purulent containing pus, milky like sanguineous dark bloody drainage Serosanguineous bright red blood Purosanguineous pus in the blood When should you use heat therapy? Vasodilation Chronic Increase capillary permeability, cellular metabolism, inflammation musculoskeletal problems joint stiffness arthritis contractures and back pain When do you use cold therapy? Vasoconstriction acute pain often used for sport injury (sprains, strains, fractures) decreased capillary permeability, cellular metabolism, inflammation Factors that affect respiratory function? Age Environment lifestyle health status medications stress eupnea normal breathing Tachypnea rapid breathing bradypnea slow breathing apena absence of breathing hypoventilation very shallow breathing, may cause increased levels of carbon dioxide. or high levels of oxygen Hyperventilation very rapid breathing more CO2 is eliminated than provided. orthopnea ability to breathe only in an upright position Dyspena difficulty breathing Hypoxia Low oxygen saturation of the body, not enough oxygen in the blood Signs and symptoms of hypoxia Rapid pulse rapid shallow respirations increased restlessness or lightheadedness flaring of the nose substernal or intercostal retractions cyanosis (bluish discoloration of the skin, nails beds, and mucus membranes due to reduced hemoglobin-oxygen levels) hypoxemia too much oxygen in the blood Hydrogels used to liquefy necrotic tissue or slough, rehydrate the wound bed and fill in dead space, partial thickness wounds, skin tears and pressure ulcers Alginate used to eliminate dead space or pack wounds and to support debridement. How do you irrigate a wound? use pressure and start from the inside and make your way out to the edges of the wound. should always be done after the soiled dressing has been removed. Dehiscence partial or total separation of wound layers Evisceration The displacement of organs outside of the body. Notify PCP immediately what are the conditions that decrease cardiac output? CHF, hypovolemia How do you promote oxygen use? Change position frequently ambulating exercise semi fowlers or high fowlers allow for maximum chest expansion in clients who are confined to bed What can you do to implement oxygen therapy? Check vital signs and O2 levels raise head above 30 degrees use methods of delivery of oxygen (liter flow per min) What are the factors affecting skin integrity? Gentetics & Heredity Age Chronic Illnesses & treatments Medications (antibiotics cause diarrhea, steroids increase BP, Diabetes) Poor nutrition What is an Intentional wound? Trauma during therapy Example: operations/Venipunctures What is an Unintentional Wound? Accidental Example: fractured arm in auto collision Wound depth is confined to the skin, that is the dermis & epidermis; healed by regeneration? Partial thickness In wound contamination, what kind contaminated wound is a surgical wound in which the respiratory, GI, genital/urinary tract has been entered, but show no signs of inflammation? Clean-Contaminated wounds What wound type penetrates the skin/underlying tissues, is usually unintentional, and is an open wound? Example: bullet wound Penetrating wound What is the way of closing a wound that only lasts about 7-10 days, has a jagged laceration, and is normally for deep tissue wounds? Sutures What is the type of wound that is caused by a sharp instrument (ex: surgical cut), can be deep or shallow? Incision When classifying wounds by depth, what type of wound involves the dermis, epidermis, subcutaneous tissue, and possibly muscle & Bone, and will require connective tissue repair? Full thickness What kind of wound is cause by a blow from a blunt instrument (ex: baseball bat), skin is bruised because of damaged blood vessels? Contusion In wound contamination, what are the infected wounds in which there is minimal inflammation, and the respiratory, GI, genital/Urinary tracts are NOT entered, and are primarily closed wounds? Clean wounds What are the sutures that dissolve/not removed, and are used in deep tissues? Absorbent Sutures What kind of wound is primarily a surface scrape? Abrasion In wound contamination, what wounds include open, fresh, accidental wounds, and surgical wounds that had a major break in the sterile field/or had a large spill from the GI tract, and show evidence of inflammation? Contaminated Wounds What kind of wound is an open wound that penetrates the skin and often the underlying tissues by a sharp instrument (goes in-out, traps bacteria? Puncture wound In closing a wound, what is used for 5-7 days, used for superficial wounds, fall off by themselves, and allow the wound to breathe? Steri-strips In wound contamination, what includes wounds containing dead tissue/wounds with evidence of a clinical infection, such as purulent drainage? Dirty/Infected wounds In wound classification, what type of wound is where tissues are torn apart, often from accidents (ex: machinery), and the open wound edges are often jagged? Laceration wound When a patient has a skin tear what kind of wound closing technique would you use? Surgical Glue When measuring wounds what should you check for? length, width, diameter, depth, redness, drainage, and tunneling, What kind of closing technique is used for 2-3 weeks, is lightweight titanium, used for high-tension areas (head, joints, hips---Can NOT use on hands, feet, neck, and face)? Surgical Staples What is a WOUND VAC? Vacuum-Assisted Wound Care A piece of foam attached to a pump to remove drainage---decreases inflammation-- - What are the common drains? Penrose Drain Jackson-Pratt Drain Hem-o-vac What is the Penrose drain? It is an open-ended drain, and non-measurable What does the Wound Vac promote in the healing process? Promotes healing by secondary and tertiary intention Promotes Exudate How does the Jackson-Pratt drain function? It used suction as a way of pulling the fluid off the body. What kind of pressure is used when using a Wound Vac? Negative Pressure When using a Wound Vac, what is negative pressure and how does it function? Negative pressure is placed on foam filled wounds to create a vacuum. The pressure improves healing by reducing edema from swollen tissues. What does the negative pressure applied in a Wound Vac promote in the healing process? Negative pressure promotes granulation (by stretching cells) by removing exudate and infectious material. When emptying a wound vac canister, what is the first step? turn it off!! How does a Hem-O-Vac funtion? It uses a suction to remove fluid off the body. When emptying a wound vac canister, what is the second step? Clamp it What are the purposes for wound dressing? Protection, Homeostasis, absorb drainage, debride the wound, splint the wound site, prevent drying out, provide comfort to patient, and keeping surrounding tissue dry and intact. When choosing what kind of dressing you should use for a wound, what are the questions you should ask yourself? Does it achieve the purpose listed above Can it be removed without further damage How long should this dressing be in place What kind of dressing is used on postoperative dressing over staples/sutures, and is an example of Aquaphor gauze? Impregnated nonadherent dressing What kind of dressing is used for pressure ulcers stage II-IV; partial thickness wounds, and has an example of DuoDERM? Hydrocolloids dressing What kind of dressing is Tegaderm absorbent? Clear Absorbent acrylic What kind of dressing is used to maintain a transparent membrane for easy wound bed assessment and provides protection from bacteria/shearing? Examples of when to use this dressing are: pressure ulcers, skin tears, surgical wounds, wounds undergoing chemical debridement agents Clear Absorbent acrylic What is it when there is a 1st sign of increased heart rate, drop of blood pressure, and increase in respirations? Hemorrhage At what time is a patient at greatest risk for hemorrhaging? the first 48 hours post op What should you do for a patient that is hemorrhaging? Apply pressure & monitor VS What are the signs of infection? change in color, odor, pain, or drainage What are the severe signs of infection? severe signs of infection are fever and increased WBC When is the time of highest risk of infection for a patient? Surgical infections are highest risk 2-11 days post-op What type of wound dressing would you use to absorb heavy amounts of exudate? Polyurethane Foam Dressing What wound dressings have examples of Allevyn, Lyofoam, VigiFOAM, curafoam? Polyurethane Foam Dressing What type of wound dressing would you use for a patient that has a light --> heavy exudating wounds, or pressure ulcers? Polyurethane Foam Dressing What kind of wound dressing assists with stopping a bleed? Collagen Wound Dressing What wound dressing has examples of AligiDerm & Curasorb? Alginates Wound Dressing What wound dressing is used to eliminate dead space/pack wounds & to support debridment? Alginates Wound Dressing What are wound dressing has examples of BioStep, NU-GEL? Collagen Wound Dressing When bandaging a wound, what position should you consider placing the damaged limb in? bandage the part in its normal position with the joint slightly flexed What considerations should be evaluated when placing a bandage on a skin surface? always pad between skin surfaces over the bodys bony prominences What is a special consideration when applying bandages that have occurred in more than one area of the body? ALWAYS bandage body parts distal-proximal end Based on the etiology of pressure ulcers, before documenting when the area appears pale, then reactive, what are some questions should you ask yourself? A) Did reactive hyperthermia disappear? B) Does the area blanch? When assessing a reddened area on a patient, what should you do to further identify if the patient is at risk for a pressure ulcer? poke, and see if blanching occurs. If still red, come back 30 minutes later to try and blanch it again. If a patient has an area that could be considered a pressure ulcer due to area not blanching, what should you do? Document it as a Stage 1 breakdown What is the FIRST step of assessing a pressure ulcer? 1st- area appears pale What is SECOND step in assessing a pressure ulcer? 2nd- reactive hyperthermia What is the THIRD step in assessing a pressure ulcer? 3rd- reassess the area What is the Risk Assessment Tool? Braden scale for predicting pressure sore risk. How does the Braden Scale Work? Total score of 23= Perfect Anyone below 18= at risk for a pressure ulcer What stage pressure ulcer is partial thickness loss, abrasion, blister, or shallow crater, involves epidermis and possible dermis, and is painful? Stage II pressure ulcer What wound dressing would you use on a Stage II pressure ulcer? Mepaplex or a Duoderm What stage of pressure ulcer is full thickness loss, damage of necrosis of subcutaneous, and may extend down to but Not through the fascia? Stage III pressure ulcer What are tools that you would use for a Stage III pressure ulcer? Normal saline Daicins Wet---> dry dressing What stage pressure ulcer is full thickness loss with tissue necrosis, damage to muscle, bone, supporting structures, through the nerves (not painful), and has tunneling? Stage IV Pressure Ulcer What kind of tissue is black, leathery, dead tissue that needs to be debrided for healing to being? Eschar Tissue What kind of tissue is cheesy, yellowish sometimes white or grey in color? Slough Tissue What phase of healing begins immediately and lasts 3-6 days, and involves homeostasis, phagocytosis, scabs, edema, redness, and warmth? Inflammatory Phase What phase of healing begins day 3 or 4 and lasts until day 21 days, and under the scab there is granulation, regeneration, new blood, scab dissolves, collagen, granulation tissue, and eschar? Proliferative Phase What phase of healing begins day 21 and can last 1-2 years, and has epithelization/remodeling of the wound, and scars are 80% as strong as original tissue? Maturation Phase In exudate (mass of cells and fluid), what is the name of the fluid that appears to be clear, amber liquid in color and thin and watery? Serous Fluid In exudate (mass of cells and fluid), what is the name of the fluid that appears milky or sometimes green, and pus like? Purulent fluid In exudate (mass of cells and fluid), what is the name of the fluid that appears as dark blood, deeper in the tissue, and you should not see this from a superficial standpoint? Sanguineous Fluid In exudate (mass of cells and fluid), what is the name of the fluid that appears as bright red/pink thin and watery blood? Serosanguineous Fluid In Exudate (mass of cells and fluid), what is the name of the fluid that appears as pus and blood? Puro sanguineous Fluid In oxygenation, what term is used for very shallow breathing, may lead to increased levels of C02, or low levels of oxygen, and many COPD patients may exhibit signs of this? Hypoventilation In oxygenation, what term is used for very rapid breathing, the rate and depth of RR increase, and more CO2 is eliminated than is produced? Hyperventilation What is the breathing called when a patient is dealing with hyperventilation that accompanies metabolic acidosis in which the body attempts to compensate (gives off excess body acids) by blowing off CO2 through deep and rapid breathing? Kussmaul's breathing What is the name off condition that is rhythmic waxing and waning of respirations from very deep--> very shallow and is often associated with cardia failure, increased intracranial pressure, brain damage and often times death (DEATH RATTLE)? Cheyne-Stokes respirations In oxygenation, what is the term for inability to breathe easily unless sitting upright or standing (TRIPOD POSITION)? Orthopnea In oxygenation, what is the term for difficulty breathing or the feeling of being short of breath (NOSTRIL FLARING)? Dyspnea In oxygenation, what is the term for for insufficient oxygen anywhere in the body? Hypoxia What are the S/S of Hypoxia? rapid pulse rapid, shallow RR and dyspnea increased restlessness or light-headedness flaring of the nares substernal or intercostal retractions Cyanosis (bluish discoloration of skin) In oxygenation, what is the term for reduced levels of oxygen in the blood? Hypoxemia What are the S/S of hypoxemia? Increased HR and increased cardiac output In oxygenation, what are the S/S of Chronic Hypoxemia? Barrel Chest, Clubbed Finger In oxygenation, what are the conditions that decrease cardiac output? CHF Hypovolemia patients What examples of Primary intention healing? A clean incision that has been closed with staples, sutures, or steri strips. What are examples of Secondary intention healing? Dog bite, and has a great risk for infection What are examples of Tertiary intention? Wounds that are left open for 3-5 days to allow infection to resolve and then closed with sutures, staples, or steri-strips. How are some ways that a nurse could promote oxygen exchange? change position frequently ambulate patient exercise place in fowlers position or high fowlers position to maintain maximum lung expansion What is oxygen considered? Oxygen is an RX- only a primary care provider can order this What is a handheld medical device used to help patients improve the functioning of their lungs? Incentive Spirometer What are the interventions when using Incentive Spirometer? Place Spirometer upright Inhale slow and deep/Exhale Normally/hold for 2 secs-6 secs Seal lips tightly cough after effort/deep breaths loosen secretions relax and repeat several times 4-5 daily 10 times on the hour when pt is awake What are some things that the incentive spirometer is used to do? Improve pulmonary ventilation Counteracts effects of anesthesia/hypoventilation Loosens secretions Facilitates gaseous exchange in lungs Expand collapsed alveoli What are SMIs in respiratory? Soft-Mist Inhalers What do SMIs designed to do? -Soft-Mist Inhalers are designed to mimic natural sighing/yawning by encouraging the client to take a long, slow, deep breath. This help to elevate the cylinder in the chamber---- after sealing the mouth over the mouthpiece. What are some oxygen safety precautions? Educate family/friends to not smoke near oxygen Avoid use of flammable materials like oils, grease, alcohol near the oxygen. What is the oxygen delivery system that requires a flow rate of only 2-6L/min, delivers 24% of oxygen, and is indicated for low-flow, low percentage of supplemental oxygen? Nasal Cannula What is a finding you should play close attention to when supplying a patient with a Nasal Cannula? Watch for skin breakdown Which oxygen delivery system delivers 100%, stores oxygen in reservoir while the patient breathes out, has a high O2 at low flow rate, and has a flow rate of ONLY 2-6L/min? Reservoir Nasal Cannula Which O2 delivery system has a high percentage supplemental O2, has a flow rate of 5-8L/min, delivers 40-60%, has lateral portions permit exhale CO2 to escape, and permits humidification? Simple Face Mask Which O2 delivery system has a flow rate of 6-10L/min, delivers 40-60% O2, exhale allows CO2 to escape, recycles the O2, has a reservoir bag that allows the patient to rebreathe about the first third of air exhaled in junction with oxygen but the bag must not totally deflate during inspiration? Partial Nonrebreather Which O2 delivery system has a flow rate of only 4-8L/min, delivers 30-50% of oxygen, and is used for patients who can NOT tolerate a Nasal Canula or after having Nasal surgery this must be used? Face Tent Which O2 delivery system delivers the HIGHEST O2 95/100%, has a flow rate of 10-15L/min, and uses a bag reservoir? Non-rebreather Which O2 delivery system has flow rate of 4-10L/min, delivers 24-40% of O2, and is uses a graduated dial to set FiO2 or color adapters? Venturi What is the O2 delivery system that provides support to keep your airway open while asleep, has constant airflow provided VIA face mask, and the pressure of air is determined based upon patient needs, and is meant to prevent both apnea and snoring? CPAP- Continuous Positive Airway Pressure What is the O2 delivery system that delivers alternate inhale pressure and exhale pressure, and helps patients breathe easier as the machine reduces the pressure level during exhalation which allows the patient to exhale more easily and breathe more comfortably? BiPAP-- Bilevel or two-level Positive Airway Pressure What node of the cardiac cycle is the pacemaker of the heart, has the AV node that backs it up, and has the components of a bundle of His and the of Purkinje fibers? The SA node When it comes to the heart sounds, what is the sound that S1 makes? LUB, Lub, Lub Which heart sound is the beginning of the ventricular systole, and is the sound caused by closure of the atrioventricular valves (the tricuspid & mitral valves)? S1 heart sound (LUB) In heart sounds, how does S2 sound? Dub, dub, dub Which heart sound is the beginning of Ventricular DIASTOLE, and the sound is caused by closure of the semilunar valves (aortic & pulmonic valves)? S2 Heart sound (DUB) What is cardiac output? Cardiac Output is the amount of blood ejected each minute. What is it called the amount of blood ejecting each heartbeat? Stroke Volume What is the equation used to determine cardiac output? SV (stroke volume) x HR (heart rate) = CO (cardiac output) What happens when heart rate is increased and what happens to cardia output? It increases cardiac output What is preload in cardiac output? it is the degree to which muscle fibers in the ventricle are stretched at the end of the relaxation period (diastole). In Circulation, what is it called when the natural ability of cardiac muscle fibers to shorten or contract? Contractility In circulation, what is the resistance that the ventricle must overcome during systole to eject blood into circulation called? Afterload In lifespan considerations, what is a consideration of newborns when it comes to circulation? Newborns do NOT have contractility. In lifespan considerations, what is a consideration of older adults when it comes to circulation? In older adults, when the heart rate goes down it DECREASES circulation, BP raises, and the arteries and heart valves harden. What is it called when the arteries of heart valves harden? Atherosclerosis What are nonmodifiable factors of cardiac circulation? age sex genetics (family/personal medical history) What is an example of nonmodifiable factors of the cardiac circulation? a patient has a family history of heart attacks What are the modifiable factors of the cardiac circulation? Weight Exercise stress levels-- True or false? - women tend to have an acute myocardial infarction at an older age than men, and they also are more likely to have complications. True T or F? - do men have more pain free AMI's than women? False. Women have more pain free AMI's. T or F? African Americans have a higher average BMI than Caucasians. True. T or F? --African Americans have a higher incidence of diabetes than other populations. True. T or F? -- African Americans have a greater incidence, greater mortality & Severity of strokes. True. What are some factors to consider when it comes to assessing a patient for circulation? Family history of CVasc. problems (High BP, High cholestorol level, heart attach, and stroke. Family history of diabetes and Resp. disorders. Exercise level History Tobacco use Diet intake, caffeine, and chocolate What are some S/S of abnormal cardiac output? pain SOB dizziness Fatigue palpitations cough fainting In physically assessing Cardiac circulation, what are some things to do? -check blood pressures in both arms -palpate peripheral pulses for strength and equality -look for abnormalities in Apical pulse on rate, rhythm, and quality heart sounds. In diagnostic studies of the cardiac circulation, what are some tests to run? -Cardiac Monitoring -Blood tests In diagnostic studies of the cardiac circulation, what are the Blood Labs needed for diagnosing? -Electrolytes & Hemoglobin -Creatine Kinase: released after/during myocardial infarction. -Troponin: released DURING Myocardial Infarction. -Hemodynamic Studies In Diagnosing Myocardial Infarction (heart attack), what are some things to consider? -Decreased Cardiac Output -Risk for peripheral neurovascular dysfunction -Activity Intolerance In the PLANNING process of a MI (heart attack), what are some things to consider adding to the plan? -Maintain/Improve tissue perfusion -Maintain/Restore adequate cardiac output -Promote transport of O2 and CO2 by optimizing CO2 by reducing stress, plan appropriate activities & position client for improved vascular blood flow In the IMPLEMENTING of the nursing process to promote circulation, what are some things to do? -Change position frequently - Exercise -promoting Vascular circulation -promote Cardiac Circulation - Provide medications - Prevent Venous Stasis - Place on SCDS In the IMPLEMENTING of the nursing process what are some things a nurse can do to promote Vascular circulation? -position legs elevated to promote venous return -No more than 15 degrees knee flexion (improve blood flow to lower extremities) -Encourage leg exercises like flexion &extension of feet -Provide position changes In the IMPLEMENTING of the nursing process what are some things a nurse can do to promote Cardiac Circulation? -Position client in Fowler's position to decrease preload and reduce pulmonary congestion. -Monitor Intake and Output In the EVALUATION of the nursing process, what is the nurse supposed to do if goals are not met? -Go back and evaluate if not met In the Nursing process DIAGNOSING, PLANNING, AND IMPLEMENTATION what are some things for the nurse to do? -Positioning: prop feet up to promote venous return/ sit up to reduce pulmonary congestion -Ambulate to promote circulation -Exercise: passive/active ROM -BP: hold meds if BP lower than 90/60 -Hold Beta Blocker if HR is lower than 60 In Activity and Exercise, what is Aerobic Exercise, WITH oxygen (running, swimming, -- increases cardiovascular)? Isotonic exercise In Activity and Exercise, what is Anaerobic Exercise, WITHOUT O2 (Weight lifting, sprinting)? Isometric Exercise In Muscular exercise, what are the benefit of regular exercise? -Strengthens bones, improves flexibility, and increases oxygen. In Cardiovascular exercise, what is the benefit of regular exercise? - Strengthens heart muscles -improves blood supply -increases heart rate: protective barrier of stress In the Respiratory system, what is the benefit of regular exercise? - improves lung capacity (pooling secretions & gas exchange) In the GI Tract, what is the benefit of regular exercise? -It increases appetite. In the Metabolic system, what is the benefit of regular exercise? - Regular exercise speeds of metabolic processes. In the Endocrine system, what is the benefit of regular exercise? - lowers blood sugar levels -lowers cholesterol (LDL) -increases HDL In the Urinary System, what is the benefit of regular exercise? - clear urine -increases circulation to the kidneys In the Immune system, what is the benefit of regular exercise? -strengthens lymph nodes by filtering (jumping on trampoline) In the Neurological system, what is the benefit of regular exercise? -improves mood -relieves stress & anxiety -improves sleep In Cognitive, what is the benefit of regular exercise? -improves focus -improves decision making Spiritually, what is the benefit of regular exercise? -improves mind, body, spirit connection When it comes to skin, what is the benefit of regular exercise? -regular exercise helps to filter impurities When it comes to Strength, what is the benefit of regular exercise? - increased strength decreases risk for falls in elderly What is the basis of time in exercise daily? -30 minutes of moderate exercise daily What is the basis for daily ROM? -2 times/day & 3 times each joint What are the safety precautions for regular exercise? -proper technique -stay hydrated -comfortable clothing -stretch before and after When it comes to factors that affect body alignment, when is immobilization/bed rest considered? -Stroke/trauma -Neuromuscular disorder -Chronic Debilitating illness Why is immobilization/bed rest considered for patients with a chronic debilitating illness? - to help decrease cardiovascular complications What are some things to do for a patient with a chronic debilitating illness that has caused them to be bed rest? - perform Dorso-flexion exercises How does bed rest/immobilization complicate the integumentary system? -skin breakdown (pressure ulcers) -reduced skin turgor How does bed rest/ immobilization complicate the Musculoskeletal system? -osteoporosis (bone loss) -atrophy -contractures -stiffness -joint pain How does bed rest/ immobilization complicate the Cardiovascular system? -diminished cardiac reserve -increased use of the Valsalva Maneuver -Venous Vasodilation -Stasis dependent edema -Thrombus Formation What patient is at greatest risk of thrombus formation? -A patient that sits at a desk and smokes is at greatest risk for thrombus formation. When it comes to complications caused by bed rest/immobilization, how will it effect the Respiratory System? -Decreased respiratory movement -Pooling of secretions -Atelectasis (lung collapse/or lobe collapse) -Hypostatic Pneumonia When it comes to complications caused by bed rest/immobilization, how will it affect the Metabolic Process? -Decreased Metabolic rate -Decreased Nitrogen Balance -Anorexia -Decreased Calcium Balance How does bed rest/ immobilization cause complications in the Urinary System? - Urinary Stasis -Renal calculi -Urinary Retention -UTI's How does bed rest/immobilization cause complications in the GI Tract? -Constipation How does bed rest/immobilization cause complications in Psychoneurological? -Depression How does immobilization cause systemic effects on the fingers? -Loss of function in the immobilized part -Can lead to CONTRACTURE of FINGERS What are some factors that affect alignment & activity? -Growth & Development -Nutrition -Personal Values & Attitdues -External Factors -Prescribed Medications How is plantar flexion affected in patients that are immobilized? -Foot Drop caused by contractures How do you help a patient that is dealing with foot drop? -Place a foot board at the end of the bed. What are some factors to consider when assessing a patients activity and exercise? -History -Physical assessment (BMI, Ht, Wt, Pain, Sensation and assessing ADL's) How can a nurse prevent effects of immobilization in the cardiovascular system? -SCD's -ROM -Ambulate -Pressure Devices How can a nurse prevent the effects of Immobilization in the Respiratory System? -Place an Incentive Spirometer on the patient How can a nurse prevent the effects of immobilization in the GI System? -Use medications such as MiraLAX and stool softener's How can a nurse prevent the effects of bed rest in the Muscular system? -Increase ROM -Use Isometric exercises How can a nurse prevent the effects of bed rest in the Urinary System? -Increase fluids How can a nurse prevent the effects of bed rest in Skin? -Turning schedules -Lotions How can a nurse prevent the effects of bed rest on the brain? -Activities -Games -Entertainment What is the term used for receiving stimuli or data? -Sensory reception What is the term used for conscious organization & translation of data into meaningful information Sensory Perception What is a agent or act that stimulates a nerve receptor? Stimulus In the sensory process, what is a sensory receptor? the ends of nerves within the body that responds to stimuli. What is Impulse Conduction? an impulse is simply the movement of action potentials along a nerve cell. What is Perception in the Sensory Process? -Sensory perception involves detecting, recognizing, characterizing and responding to stimuli. What are factors influencing Sensory Function? -Development -Culture -Stress level -Medications and illness -Lifestyle & Personality What patients are at MOST risk for sensory deprivation? -Isolation Patients (greatest risk) -PT's with depression -Brain dysfunction -Paralyzed patients - patients that visually/hearing prepared What patients are at MOST risk for sensory overload? -Restless patients -Dementia Patients -ICU patients -Brain injuries -patients in pain What patients are at MOST risk for Sensory Deficits? -Blind -Deaf -these patients have 1 or more reception or perception problems. What are some signs of Sensory Deprivation? -excessive yawning, sleepiness -decreased attention span -impaired memory -General confusion -Hallucinations -Crying/Irritable/small matters/Depression -Apathy (emotional liability) What are some signs of Sensory Overload? -Fatigue -Irritability/anxiety -General disorientation -Decreased Problem-solving skills -Muscle tension -Scattered attention In assessing a patient who might be at risk for Sensory issues what should the nurse consider on history of the patient? -do you have any hearing issues, trouble sleeping, any pain, trauma, and any medications that you should consider. In assessing a patient who might be at risk for Sensory issues what should the nurse consider in the mental health status examination of the patient? -Data on mental status -----LOC, Orientation, memory, and attention span. "Is the patient alert and oriented? " In assessing a patient who might be at risk for Sensory issues what should the nurse consider in the physical examination? - eyeglasses -hearing aids In assessing a patient who might be at risk for Sensory Issues what should the nurse consider in the clients environment? -What kind of stimuli is at home In assessing a patient who might be at right for Sensory Issues what should the nurse consider in the client's social support network? -Does the client live alone? -Social Deprivation? What is a good nurse implementation to help a patient who has impaired vision? -Good lighting -clutter-free -provide phone with large numbers -provide brale to patients who cannot see at all What is a good nurse implementation to help a patient who has impaired hearing? -Speak in normal voice -Speak clearly -use simple words -have good lighting What a good nurse implementation to help a patient who has impaired olfactory (smell)? -date things -CO2 detector -check gas annually -educate on use of ammonia or bleach to clean bathroom what are good nurse implementations to help a patient who has impaired tactile? -use tape markers to show hot/cold -do a good skin assessment What are good nurse implementations to help a patient who has impaired Gustatory? -Tell the patients to drink lots of water What is the confusion that has delirium and decreased ability to focus, and was disoriented in the last 12 hours? Acute Confusion What is delirium? -acute confusion. What can you do to help a patient that has delirium? -orient them back to reality -Figure out if they have a UTI or head injury What can you do help a patient with Acute Confusion? -Place a calendar in clients room (mark holidays) -Speak clearly/calmly to patient so they process -Keep eyeglasses/hearing aids within reach -Keep room well-lit during wake hours What is chronic confusion? -Dementia (play in their world, dont orient back to reality) In Values, ethics, and advocacy what is a concern for the welfare and well-being of others? -Altruism In values, ethics, and advocacy what is the right to self-determination? Autonomy In values, ethics, and advocacy what is the respect for the inherent worth & uniqueness of individuals and populations? Human Dignity In Values, ethics, and advocacy what is the acting in accordance with an appropriate code of ethics & accepted standards of practice? Integrity In values, ethics, and advocacy what is acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability or sexual orientation? Social Justice When it comes to moral principles, what is the right to make one's own decisions? Autonomy When it comes to moral principles, what is the term to do No harm? Non-maleficence When it comes to moral principles, what is the term to only do good? Beneficence When it comes to moral principles, what is the term used for FAIRNESS? Justice When it comes to moral principles, what is the term used for faithful to agreements and promises? Fidelity When it comes to moral Principles, what is the term used for telling the truth? Veracity When it comes to Values, ethics, and Advocacy, what is the book of formal statements from a groups ideals & values? -Code of Ethics Based on the Code of Ethics, what are the two main considerations we should take in as nurses? -Protect our patients -Advocate for your patients How do you advocate for a patient? -express and defend another -support clients decision making In Legal Aspects of Nursing, what is the constitutional aspect? -Due to process -Equal Protection In Legal Aspects of Nursing, what is the Statutory (Legislative) aspect? -Nurse practice Acts -Good Samaritan Acts -Child & Adult Abuse Laws -Living Wills -Sexual Harassment Laws -American's With Disabilities Act In Legal Aspects of Nursing, what is the Criminal (public) aspect? -Homicide -Theft -Arson -Active Euthanasia -Sexual assault -Illegal possession of controlled drugs In Legal Aspects of Nursing, what is the contracts (private/civil) aspect? -Nurse & Client -Nurse & Employer -Nurse & Insurance -Client & Agency In Legal Aspects of Nursing, what is the Torts (private/civil) aspect of nurisng? -Professional Negligence/malpractice -Libel & Slander -Invasion of Privacy -Assault & Battery -False Imprisonment -Abandonment What are the unintentional Torts? -Negligence -Gross Negligence -Malpractice What 6 elements must be present for a case of nursing professional negligence to be proven? -duty -breach of duty -foreseeability -causation -harm/injury -damages What is negligence (unintentional torts)? -misconduct or practice that is below the standard expected of an ordinary. What is gross Negligence (unintentional Torts)? - involves extreme lack of knowledge, skill or decision making that the person clearly should have known would put others at risk for harm. What is Malpractice (unintentional torts)? - professional negligence What makes intentional torts different from unintentional torts? -no harm needs to be caused by intentional torts for liability to exist. What are the Intentional torts? -Assault -Battery -False Imprisonment -Invasion of Privacy -Defamation (false truth communicated-slander= defamation by spoken word) What is Assault (intentional tort)? -an attempt to threaten or touch another person unjustifiability. What is Battery (Intentional tort)? - willful touching another person ( or persons clothes) that may or may not cause harm. What is False Imprisonment (intentional tort)? - unjustifiable detention of a person without legal warrant to confine the person. What is Invasion of Privacy (intentional tort)? -a direct wrong of a personal nature. What is defamation (intentional tort)? -communication that is false, or made with a careless disregard for the truth. -Example: Libel= defamation by print, pictures What are the standards of care ? -skills & learning commonly possessed by members of a profession. What are the Internal Standards of Care? Internal Standards of Care for Nurses: -job description -education -expertise -institutional policies and procedures What are the External Standards of Care? External Standards of Care for Nurses: -Nurse practice arts -professional organizations -Nursing specialty practice organizations -Federal Organizations & Federal guidelines What is Expressed Consent? -may take the form of either an oral or written agreement What is implied consent? -Exists when the individual's nonverbal behavior indicated agreement What are the exceptions for patients that cannot give consent? Patients that Cannot give consent: -Minors -Unconscious group or injured group -Mental Illnesses What is the legal documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences? -Advanced Health Care Directive When there is a patient incident, the nurse should do what first and then what second? 1. assess patient/intervene to prevent injury 2. Document Incident Report What are the different types of stress? -Internal/External -Developmental -Situational What is Internal stress? -originates within person; Example: infection/depression What is External Stress? -Originate outside the individual Example: moving to another city, a family death, and peer pressure. What is Developmental Stress? - occurs at predictable times throughout an individual life. What is Situational Stress? -Unpredictable or may occur at any time during life; positive or negative Example: family death, marriage/divorce, childbirth, new job, illness. How many stages of General Adaption Syndrome (GAS)? 3 stages What is the first stage of GAS (General Adaption Syndrome)? 1. Alarm Stage- fight or flight What happens in the first stage, Alarm Stage, of GAS (General Adaption Syndrome)?> Its fight or flight: -stimulated sympathetic nervous system -alerts body's defenses -increases mental alertness, pupils dialate, and vessels constrict. What is SECOND stage of GAS (General Adaption Syndrome)? -Resistance Stage What happens in the 2nd, Resistance Stage, of General Adaption Syndrome (GAS)? -Attempts maintenance of Homeostasis -When body's adaption takes place -Where coping mechanisms are usually successful (stages can usually stop here) What is the 3rd stage of General Adaption Syndrome (GAS)? Exhaustion/Recovery Stage What happens in the 3rd Stage, Exhaustion/Recovery stage in GAS (General Adaption Syndrome)? -if adaption was not met in 2nd stage -Chronic Illness can result What are some indicators of stress? -Pupils dialate -Sweat increases -HR and cardiac output increase -Skin pallid -Sodium and water retention -Rate/depth of Respirations increase -Decreased Urinary output -Dry mouth -Decreased GI tracts--constipation&flatus -Increased Muscle Tension -Increased Blood Sugar What is a state of mental uneasiness apprehension, dread related to impending or anticipated unidentified threat to self or significant relationships? -Anxiety In Anxiety, what type of anxiety is a feeling of mild restlessness that prompts a person to seek information and ask questions? Mild Anxiety In Anxiety, what type of anxiety is feelings of tension, nervousness or concern; attention focused more on a particular aspect of a situation than on peripheral activities? -Moderate Anxiety In Anxiety, what type of anxiety is unable to focus on what is really happening, focuses on ONLY one detail of the situation generating the anxiety? Severe Anxiety In Anxiety, what type of anxiety is overpowering, frightening level of anxiety causing the person to lose control? Panic Axiety What is an emotion/feeling of apprehension aroused by impending or seeming danger, pain, or another perceived threat? -Fear What is an emotional state of consisting of subjective feeling of animosity or strong displeasure? -Anger What is an extreme feeling of sadness, despair, dejection, lack of worth, or emptiness, and affects millions of Americans a year? -Depression What are the coping strategies? -Adaptive Coping -Maladaptive Coping How does Adaptive Coping help a patient? -helps the person deal with stress and minimize distress associated with stress situations -make healthy choices that decrease negative effects of stress What is Maladaptive Coping? -can cause unnecessary distress for the person and others associated with the person or stressful event. T/F? Maladaptive Coping helps promote adaption. False; maladaptive coping has a negative impact Example: alcohol or drugs What are some ways to minimize stress & anxiety? -Listen -provide caring and trust for patient -stay with clients to promote safety and feelings of security -Minimize stressful environmental factors -Implement suicide precautions when needed -Talk in short clear sentences -Educate clients on: ----importance of exercise, balanced diet, adequate rest ------Avoid caffeine, sugar, salt, fat What are some relaxation techniques to reduce anxiety and fear? -Breathing exercises -Massage -Progressive Relaxation -Imagery -Biofeedback -Yoga -Meditation -Therapeutic Touch -Music -Humor and laughter What defense mechanism is blocking out painful or anxiety-including events or feelings? -Denial What defense mechanism is discharging pent-up feelings on people less dangerous than those who initially aroused the emotion? Displacement What defense mechanism is handling emotional conflicts, or internal/external stressors, by a temporary alteration of consciousness or identity? -Dissociation What defense mechanism is unconscious assumption of similarity between oneself and another? -Identification What defense mechanism is acceptance of anothers values and opinions as ones own? -Introjection What defense mechanism is attributing ones own unacceptable feelings and thoughts of others? -Projection What defense mechanism is a falsification of experience through the construction of logical or socially approved explanations of behavior? - Rationalization What defense mechanisms are unacceptable feelings disguised by repression of the real feeling and by reinforcement of the opposite feeling? -Reaction Formation What defense mechanisms is reverting to an earlier stage of development? -Regression What defense mechanism is unconsciously keeping unacceptable feelings out of awareness? -Repression What defense mechanism is consciously keeping unacceptable feelings and thoughts out of awareness? -Suppression What is the Good Samaritan Law? Rendering voluntary emergency care (cannot be a legal obligation or job to do so or if you caused a problem) What hormones are released in the "Fight-Or-Flight" stage? -Epinephrine -Norepinephrine Delirium Reversible state of confusion-usually caused by a medical condition Depression Mood disorder; sense of hopelessness and persistent unhappiness dementia a gradual and irreversible loss of intellectual function Hemiparesis weakness on one side of the body *damage from right side of the brain affects the left side of the body and vis versa Types of sensory deficits and examples Tactile: touch; peripheral neuropathy Smell: Olfactory; anosmia Taste: Gustatory; decreased gustatory cells Hearing: Auditory; conductive hearing loss, sensorineural hearing loss, and presbycusis (age related hearing loss) Equilibrium: motion sickness or Meniere's disease Vision: Visual; myopia, presbyopia (far sightedness-age related), cataracts (lens of the eye affected), glaucoma (pressure on optic nerve), diabetic retinopathy (blood vessels of eye are damaged due to diabetes), and macular degeneration If patient begins to complain of pair or if resistance to joint movement is met, range of motion exercises should be_____ Range of motion exercises should be stopped; never hyperextend or flex a joint beyond position of comfort page 560 safety practice alert The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound? 1. Hydrogel dressing 2. Transparent dressing 3. Antimicrobial dressing 4. Calcium alginate dressing 2. Transparent dressing A stage 1 pressure injury is characterized by intact skin with non