HTN and Perfusion
138/91 Blood pressure stage?
What is Stage 2 HTN?
(140+ or 90+)
Non-blanchable redness over intact skin defines this stage.
What is a stage 1 pressure injury?
This occurs after only a few days of bed rest and affects legs first.
What is muscle atrophy?
This fracture type breaks the skin.
What is an open/compound fracture?
A bedridden patient develops constipation. This is the underlying physiologic cause
What is decreased peristalsis and increased water absorption in stool?
This is the MOST concerning long-term complication caused by endothelial injury from hypertension.
What is atherosclerosis leading to cardiovascular disease (e.g., stroke, MI)
This force distorts microvasculature and is MORE dangerous than friction.
What is shear?
This complication results from shortened Achilles tendon and nerve entrapment.
What is foot drop?
The MOST life-threatening early complication of femur fractures.
What is hemorrhage?
Drainage that contains a large amount of fresh red blood (hint- usually the first kind of drainage)
What is sanguineous drainage?
Serosanguinous- mixture of red blood and straw colored fluid
Serous- straw colored fluid
Purluent- Thick, pus filled
A patient with HTN, BMI 31, and high sodium intake—this is the PRIORITY lifestyle intervention. (Hint- diet)
What is reducing sodium intake (DASH diet)?
(DASH emphasizes fruits, vegetables, and low-fat dairy. Limit sodium intake to under 2.3 grams daily)
Priority intervention for a bedridden patient with early pressure injury.
What is reposition every 2 hours?
Priority intervention to prevent atelectasis in immobile patients.
What is incentive spirometer use?
These are the “6 P’s” indicator of this emergency condition.
What is compartment syndrome?
Pain (out of proportion/early sign), Paresthesia (numbness/tingling), Pressure (tense/firm), Pallor (pale skin), Paralysis (late sign), and Pulselessness (late/rare sign)
Derived from seaweed, these are highly absorbent and ideal for wounds with moderate to heavy drainage
What are Alginate Dressings?
Symptoms like headache or confusion, visual changes, chest pain, and neurologic deficits raise concern
What is a hypertensive crisis?
(180+ or 120+)
A wound with slough obscuring depth is classified as this.
What is an unstageable pressure injury?
This assessment tool identifies fall risk if >12 seconds.
What is the Timed Up and Go (TUG)?
This embolism is associated with long bone fractures.
What is a fat embolism?
Risk with long bone fractures (femur, humerus). Fat and marrow are released into circulation. Manifestations similar to pulmonary embolism.
Pulmonary- Greatest risk with pelvic or hip fractures. Clot travels through venous system to pulmonary vasculature. Signs: acute dyspnea, pleuritic chest pain, tachycardia, hemoptysis.
A nurse notes a wound with dry necrotic tissue. The BEST dressing choice is:
What if the wound needs debridement?
What is a hydrogel dressing?
Gauze is for debridement
Differentiate: This type of hypertension has an identifiable cause (e.g., renal disease).
What is secondary hypertension?
Match the wound type:
Medial ankle
Wet, irregular
Edema
What is a venous ulcer?
Arterial: distal, punched-out, painful—revascularization consult
Venous: medial ankle, irregular wet base, edema—compression
Neuropathic: pressure points, insensate—offloading and foot care
This is the BEST body mechanics principle to prevent nurse injury.
What is use legs, not back (bend knees, no twisting)?
Priority nursing action for evisceration.
What is cover with sterile saline dressing (do NOT push organs back in)?
The exact pathophysiologic sequence leading to tissue breakdown
Pressure → decreased capillary blood flow → ischemia → cell death → pressure injury