Tissue
unresponsive pt, poor mobility, poor nutrition, medical devices, recent surgery
what to do if your wound has a •Dehiscence?
•Cover with moistened sterile dressing and notify provider
A nurse give the wrong insulin dose and she tells the provider and does an RL. what is she demonstrating?
accountability
what is the difference between quantitative and qualitative?
•Quantitative research
•Uses numerical data to evaluate outcomes
•Qualitative research
•Uses narratives collected from participants
when does discharge planning begin
on admission
what is exudate? what dressing would you use with high levels of this?
•Serous
•Serosanguinous
•Sanguinous
•Purulent
•exudate is drainage
-Alginate dressings are highly absorptive and effective for managing wounds with moderate to high exudate.
•Serous- thin, watery wound drainage
•Serosanguinous- thin, watery drainage mixed with blood
•Sanguinous- bloody wound drainage
•Purulent- green/yellow wound drainage; typically indicates infection
what are the 3 phases of wound healing and explain
•Hemostatic/inflammatory phase
•Begins when injury occurs and lasts 3-6 days
•Proteins released that trigger activation of clotting factors to stop bleeding
•Once bleeding is controlled, histamine is released- vasodilation which increases bloodflow to injury, bringing white blood cells which clean the wound
•Proliferative phase
•3 days after injury up to 24 days
•Blood supply to wound continues to improve; granulation tissue develops, collagen strengthens wound
•Remodeling phase- last phase of wound healing
•Around day 21, can last for a year;
•Previous collagen is replaced with stronger collagen, wound closure continues
Hemostasis and inflammation controls bleeding and brings increased blood flow and WBCs to the area to begin the wound healing process. Because of increased blood flow the wound may be warm, darker than the surrounding skin, and edematous.
Whose role is it to help with setting up home health
SW and case manager
What is a Chiropractic medicine?
manual therapy and spinal manipulation, focusing on body’s physical structure and alignment of the spine
what should the charge nurse take into consideration when making the assignments?
•Charge nurse should consider unit census, proximity of rooms, patient diagnoses, acuity level, medication administration
what is a hematoma and who is at risk for developing an incisional hematoma?
•Hematoma- accumulation of blood- symptoms include swelling, pain, drainage at incision site
-Anticoagulant medications interfere with blood clotting mechanisms and place the client at risk for a hematoma.
explain what the 4 different types of stages of wounds are
•Stage 1- non-blanchable erythema; skin is intact
•Stage 2- partial thickness; open pink/red wound, or blister
•Stage 3- full-thickness skin loss; visible adipose tissue (fat is visible)
•Stage 4- full thickness skin and tissue loss; muscles, tendons, ligaments, and/or bone visible
•Lateral violence- incivility from a peer to peer
a CNA rolls their eyes to another CNA during cares
What is hypnosis and what kind of therapy is it?
mind and body
what do they use to help identify errors in nursing documentation?
nursing chart audits
what diet helps with wound healing?
a high protein diet
Protein is essential for wound healing and tissue repair. Burn injuries increase the body's need for protein to support the healing process, so encouraging a high protein diet is crucial to aid in recovery and prevent muscle wasting.
what is a chronic wound and what should you know?
•Chronic wounds- develop over time due to disruption in healing process; or due to conditions that cause alterations in bloodflow
Surgical removal of nonviable tissue will prepare the wound bed for healing.
What are barriers to interprofessional collaboration? Name at last 3
•Barriers to Collaboration
•Lack of knowledge of scope
•Poor communication (lack of as well)
•Lack of trust
•Lack of time
•Hierarchy of roles
What does PICOT stand for?
•PICOT (population, intervention, comparison, outcome, time)
A client is prescribed 150 mg of a medication. The medication is available as 600 mg per 4 mL.
Question: How many mL should the nurse administer?
mL to administer=Available DoseDesired Dose×Volume
1 mL
what should you know about antibiotics and skins infections?
take a culture- Antibiotics only work on bacterial infections, so knowing the type of infection is important. Different antibiotics are appropriate for different bacterial strains, so knowing the type of bacteria is also important.
what are the changes expect in older adults with their skin? name 3
increase in skin thinning, Decrease in subcutaneous tissue is correct. Decrease in skin hydration
What is a transactional leader?
•Establish standards, highlight obligations, concentrate on monitoring behaviors, and use rewards or punishments based on how tasks are completed
A nurse is holding a meeting about how to reduce pressure injuries on the unit. what step of the EBP is she doing?
sharing results
A provider orders 80 mg of a medication IM. The medication is supplied as 400 mg per 2 mL.
Question: How many mL should the nurse prepare and administer?
0.4 mL