Wound/Woundcare
Wounds cannot heal if there is ___________ or ____________ present
Slough or Eschar
Producing less than 50mL/day of urine
Anuria
LEARNED
NG tubes are measured in
French
14-18 french are normal sizes for an adult
How might a person impair skin integrity?
- papercut (superficial)
- getting an injection
- pressure injuries
* many different factors can impair skin integrity
The first stage of wound healing is considered
Hemostasis (ceasing of blood flow)
This intervention is done to relieve urinary retention without the need for a collection bag. Removed once enough urine has been eliminated from bladder
Straight Catheter
Decreased fluid intake may lead to
Chronic constipation / less frequent bowel movements
TPN has a ____________ solution
Hypertonic
For immobile patients, it is recommended that they are
turned and repositioned q2hr or around the clock to prevent pressure injuries from developing
This stage is accompanied by deep tissue loss/full thickness loss, as well as damages to subcutaneous tissues. The tissue is lost with necrosis. The wound may tunnel and may present as a crater
Stage 3 Pressure Injury
What interventions can a nurse implement to resist CAUTI? (more than 1 answer)
- Sterile technique
- Avoid using indwelling catheters for long periods of time
- Peri-care done after each episode of incontinence
What is considered to be constipation?
NO Bowel movement in 3 days or more
- Bowel movement is hard, dry, or incomplete passage
Name a considerably high risk for NG tube placement
- Aspiration d/t NG tube placed down the trachea
T/F: Every pressure injury is preventable
False
every pressure injury may not be preventable, but as the nurse, it is imperative to implement interventions to try and prevent
Patient with a JP drain to RLQ has thick, bloody drainage in the drain, and complains of abdominal pain. This drainage is considered to be
Sanguineous drainage
What size are catheters measured in and what is the appropriate size for an adult?
French - use smaller size to prevent tissue trauma
14-18 french
A colostomy is
Surgical opening that is anywhere on the length of the large intestine
Your patient is placed on a diet that contains laxative effects. Name a food that the patient should consume
- onion, cabbage, cauliflower, beans, coffee
The yellow, tan, grey to brown non-viable tissue over the wound is considered?
Slough
This stage of wound healing involves granulation tissue formation, that grows from the bottom of the wound towards the superficial skin. The tissue is characterized as beefy red and smooth. This TISSUE is considered ?
Granulation tissue
What are the two waste products from the kidneys?
(hint - they can be determined by lab values)
- BUN
- Creatinine
T/F: A patient on iron salts will need an additional stool softener to facilitate the passage of stool along the digestive tract
TRUE
If the GRV is = 300 mL, as the nurse, you should...
Call the physician to report finding
- pt is at risk for aspiration or absorption deficet
Pressure intensity is
When the outside pressure is greater than the capillary pressure
- causes cellular necrosis and ischemia of cells