Week 4 Lab Only
Skin Care
Skin Care
Of the following, Which is NOT an intervention for pressure injuries?
A. Encourage protein in diet
B. Turn patient every 2 hours in bed
C. Only assess skin if patient has complaints
What is C? We assess skin ASAP when a patient is admitted and then regularly after that. Even if they have a wound, another may occur.
This scale measures if a patient can independently bathe, dress, toilet, transfer, mobilize, and feed themselves.
What is the Katz Index? This measures basic ADLs which are one category of functional ability.
This type of health promotion or prevention includes getting a mammogram for women over 40 and a prostate check for men over 50.
What is Secondary Prevention? Also includes ALL screening tools (Braden, Katz, MOCA, Spices) and vision screening on children.
Your patient is a 17 year old female, with a history of depression, who tells you that she is struggling in school. She states she argues with her parents regularly and her boyfriend broke up with her. As you assess her she says, I just don't think I can keep on trying to make everyone happy. You know it is important to assess for this.
What is self-harm or suicide? It is critical as this group is at higher risk and she has multiple stressors. Additionally assessing stress and coping skills will let you know the best way to help this patient forward.
Secondary screening assessment for dementia or cognition issues.
What are the Mini-cog and Montreal?
This is the two types of forces that mechanically cause pressure injuries.
What are shearing force and Friction? Shearing is when the skin slides down the bed causing the skin to pull one way while the body goes the other way. Friction is the rubbing of skin on the bed, chair, on anything that is constantly present.
If you are on the very low end of this tool, you may experience frequent cold/shivering, malnutrition and missed periods. If you are on the very high end you may be hot often, frequenly have joint pain and have increased risk for heart and blood pressure problems.
What is BMI or Body Mass Index?
When a person gets personal satisfaction from their work they are meeting this dimension of wellness.
What is occupational? Workbook page 111
Three positive coping skills to help patients (and nurses) handle stress.
What are music, exercise, counseling, meditation, education, and talking to friends? Anything similar, there are many good answers to this question.
You know as a nurse that both eustress and distress can negatively affect the body and add up in effect. An example of eustress is this.
What is getting married, having a baby or starting a new job? Eustress are positive stressors but they still affect the body.
This tool measures things such as moisture, mobility, sensory perception and nutrition and is used to assess the patient's risk of pressure injuries.
What is the Braden scale? Found on page 85 in workbook
For this procedure the nurse will:
*Check Placement
*Check Residual
*Flush
*Feed Patient
*Flush again
What is administering a NG Tube feed?
Your patient states she has pain in her left ankle that is 5 on a scale of 1-10, and it feels sharp. She has told you these letters of the Pain assessment tool.
What are Q, R & S? Quality-sharp, Region-left ankle, Severity is 5/10.
Your best friend at work has started showing up late, and calling off frequently. When she works, she is negative and making poor judgement calls. You are concerned about this.
What is burnout or Nursing Burnout?
This is an adverse affect of narcotics like morphine that the nurse must assess for regularly.
What is respiratory depression? This is slowing or stopping of breathing
Your patient is a young athlete who is startled to find out the blister on the back of his heel is actually THIS stage of pressure injury.
What is stage 2? It is partial thickness loss of dermis(skin) it may have clear drainage or present as a serum filled blister
These 3 things can cause impairment to a persons cognitive status.
What are Substance use, stroke, infection, traumatic brain injury, some medications and dementia? Will accept any of these 3 or similar answers.
You notice your patient's blood pressure has decreased while his pulse increased. Additionally when you assess the skin on his chest, you note poor turgor (tenting). When he urinates it is dark yellow. You are concerned about this issue.
What is dehydration?
Your patient is taking a medication digoxin and her lab digoxin level is slowly rising. The doctor finds she is having kidney failure and you know that is causing the dangerous buildup of digoxin. The name for this buildup is what.
What is toxicity or drug toxicity?
Normal capillary refill is this length of time.
What is less than 3 seconds?
This byproduct of wounds is usually pale yellow or tan and may cover the bottom of a pressure injury making it unstageable.
What is slough?(workbook page 84 slough yellow-tan, eschar is tan, brown or black and crusty looking. Either make a wound unstageable if they cover the wound bed.
This very dangerous event can occur if
*Patient with mechanical soft diet given regular tray
*Patient eats alone soon after a stroke
*Patient with NG tube is put in supine position.
What is aspiration/aspiration pneumonia?
You assess your patient's pupils and record PERRLA in the chart. You know this means what.
Pupils are Equal, Round and Reactive to Light & Accommodation.
The part of the eye where you place eye drops.
What is the conjunctival sac?
Your patient had thyroid cancer and the Thyroid gland was removed. This is the name of the medication you expect they will be taking.
What is Synthroid or levothyroxine?