NR 224 Exam 2

Ch. 40

100

What are some things that can help with dry and flaky skin?

-Decreasing the amount of baths

-Avoid hot water or harsh soap

-Rinse all soaps off to prevent irritation/breakdown

-Add moisture to air with humidifier

-Increase fluid intake

-Use moisturizing cream to aid in heal, and use of creams to clean skin that is dry or allergic to soaps and detergents. (Emollients).

200

What are some changes to the skin in aging?

-Excessive bathing or environment with low humidity can cause the skin to become dry and flaky.

-Age cell replacement slows, skin thins, lose resiliency. 

-Be careful with bathing, turning, and repositioning older patients

300

What is acne, how do you treat it?

It is inflammatory, skin eruption, usually involves bacterial breakdown of sebum; appears on face, neck, shoulders, and back.

Infected material within pustules spreads if area is squeezed or picked. Permanent scarring can result.

Wash hair and skin thoroughly each day with warm water and soap to remove oil. Use cosmetics sparingly. Oily cosmetics or creams accumulate in pores and make condition worse. Implement dietary restrictions if necessary (eliminate foods that aggravate condition from diet.) Use prescribed topical antibiotics for severe forms of acne.

400

Define skin rashes? How do you treat?

-Eruptions that result from overexposure to sun or moisture or from allergic reaction (flat or raised, localized or systemic pruritic or nonpruritic). If skin is scratched continually inflammation and infection may occur. Rashes also cause discomfort.

-Wash area thoroughly and apply antiseptic spray or lotion to prevent further itching and aid in healing process. Apply warm or soaks to relieve inflammation if indicated.

500

What is contact dermatitis? Treatment.

Inflammation of skin characterized by abrupt onset with erythema; pruritus; pain; and appearance of scaly, oozing lesions. Dermatitis is often difficult to eliminated because the person is usually in continual contact with substance causing skin reaction. Substance is often hard to identify.

Treatment:

Avoid causative agents (ex. cleansers and soaps).

600

What are abrasion? Treatment.

-Scraping or rubbing away of epidermis that results in localized bleeding and later weeping of serous fluid.

-Infection occurs easily because of loss of protective skin layer.

-Treatment:
Be careful not to scratch patient with jewelry or fingernails. Wash abrasions with mild soap and water; dry thoroughly and gently. Observe dressing or bandage for retained moisture because it increases risk of infection

700

What are some factors that can result in pressure injuries?

Immobilization (Dependent body parts are exposed to pressure from underlying surfaces. The inability to turn or change position increases risk for pressure injuries).

Obesity (Cannot visualize skin properly and keep it clean and dry. Excessive adipose tissue creates pressure from weight, lack of air circulation, and an increase in moisture with poor tissue perfusion. Increases risk for pressure injuries.)

Reduced sensation caused by stroke, spinal cord injury, diabetes, local nerve damage. (Patient unable to sense skin injury. Does not receive normal transmission of nerve impulses when applying excessive heat or cold, pressure, friction, or chemical irritants for skin. Increases risk for pressure injuries.)

Altered cognition resulting from dementia, psychological disorders, or temporary delirium. (Patient unable to verbalize skin care needs. Does not realize effect of pressure or prolonged contact with excretions or secretions, requiring more vigilant assessment.)

Limited protein or caloric intake and reduced hydration... ex. fever, burns, GI alteration, poorly fitting dentures. (Predispose to impaired tissue synthesis. Skin becomes thinner, less elastic, and smoother with loss of subcutaneous tissue. Poor wound healing results. Reduced hydration impair skin turgor.)

Excessive secretions or excretions on skin from perspiration, urine, watery fecal material, and wound drainage. (Moisture is medium for bacterial growth and causes local skin irritation, softening of epidermal cells, and skin maceration).

Presence of external medical devices (ex. cast, restraint, bandage, dressing) (Devices such as casts, cloth, restraints, bandages, tubing, and orthopedic devices exert pressure or friction against surface of skin.)

Vascular insufficiency Arterial blood supply to tissues is inadequate, or venous return is impaired, causing decreased circulation to extremities. Tissue ischemia and breakdown often occur. Risk for infection is high.

800

What can cause dry mouth?

• Medications exposure to radiation, dehydration, and mouth breathing may impair secretion in the mouth, which increases the patient's risk for xerostomia or dry mouth.

900

What is proper hygiene to prevent gingivitis, dental caries, and periodontal disease?

• Avoiding fermentable carbs and sticky sweets
• Brushing twice a day
• 
  
  • Fluoride toothpaste & antimicrobial mouth
  • Aging: Enlarged handle with an easier grip.
  • Electric or battery-powered toothbrushes improve the quality of cleaning.
  • Do Not Use lemon-glycerin sponges because they dry mucous membranes and erode tooth enamel.

1000

What is a contraindication for flossing and what type of therapies put the person at risk?

-Do not use in someone with bleeding tendency

-Uses unwaxed floss and avoid vigorous flossing near gumline on patients on chemical therapy, radiation, and anticoagulant therapy.

1100

Poor oral care increases the risk of?

Aspiration pneumonia

• Patients that are unconscious patients often have a reduced gag reflex or they cannot swallow salivary secretions that accumulate in the mouth.
• 
  
  • Pooling of salivary secretions in the back of the throat harbors microorganism growth. (Pneumonia)

1200

A patient is receiving cancer chemotherapy, they can suffer from mouth ulcers (stomatitis) they are risk for?

Risk for infection

Impaired nutrition (reluctance to eat and drink)

1300

Ex. of an opportunistic infection in the mouth when normal flora is disrupted by broad-spectrum antibiotics.

Thrush

1400

How do you perform denture care?

• 
  
  • Clean on a regular basis to avoid gingival infection and irritation.
  • They must be removed at night to rest the gums and prevent bacterial buildup.
  • To prevent warping, keep dentures covered in water when they are not worn and always store them in an enclosed, labeled cup placed at the patient's bedside.
  • 
    
    • Never put them on a napkin or tissue because they may be thrown away.
    • Do not use hot or excessively cold water when caring for dentures.
    • Clean with a soft-bristled toothbrush or denture brush.

1500

What is a suggestion to prevent matting and tangling of hair?

• Frequent brushes keep hair clean and distributes oil evenly along hair shafts.
• Long hair becomes matted easily when a patient is confined to bed. When lacerations or incisions involve the scalp, blood and topical medications also cause tangling.
• Braiding helps to avoid repeated tangles; however, should unbraid periodically and comb.
• 
  
  • Braids that are too tight can lead to bald patches.

Ch. 40

100

Patients prone to bleeding (those receiving anticoagulants or high doses of aspirin or those with low platelet counts). If they had to shave what type of razor will you recommend?

Razor

200

How do your remove a tick? 

Use fine-tipped tweezers to grasp tick as close to the skin’s surface as possible. Pull upward with steady, even pressure. Don’t twist or jerk the tick; this can cause the mouth-parts to break off and remain in the skin. If this happens, remove the mouth-parts with tweezers. If you are unable to remove the mouth easily with clean tweezers, leave it alone and let the skin heal. After removing the tick, thoroughly clean the bite areas and your hands with rubbing alcohol and iodine scrub, or soap and water. Dispose of a live tick by putting it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet.

300

How to treat head lice?

Wearing gloves, check entire scalp by using tongue depressor or special lice comb. Use medicated shampoo for eliminating lice. Caution against use of products containing lindane because the ingredient is toxic and known to cause adverse reactions. Check hair for nits and comb with a nit comb for 2 to 3 days until all lice and nits have been removed. Vacuum infested areas of home.

400

How to treat body lice?

Bathe or shower thoroughly. After skin is dried, apply recommended pediculicide lotion. After 12 to 24 hours take another bath or shower. Bag infested clothing or linen until laundered in hot water. Vacuum rooms thoroughly and throw away bag after completion.

500

How to treat crab lice?

Shave hair off affected area. Clean as for body lice. If lice were sexually transmitted, notify partner.

600

What is basic eyecare?

-Soap irritants the cornea

• Never apply direct pressure over the eyeball
• Obtain a clean washcloth and clean from inner to outer canthus
• Using a different section of the washcloth
• Nerve use CHG solution or cloths to clean the eyes, ears, or face.

700

Patients that are sedated or in a coma who are unable to maintain effective eye closure:

• Secretion collect along the margins and inner canthus when the blink reflex is absent or when the eye does not close completely.
• Use an eye patch over it to prevent corneal drying and irritation.
• Apply lubricating eyedrops according to health care provider's orders

800

How to properly take care of contact lenses

• Must be removed periodically to prevent ocular infection and corneal ulcers or abrasions from infectious agents.
• Pain, tearing, discomfort, and redness of the conjunctivae indicate lens overwear.
• Do not use fingernail or lens to remove dirt or debris
• Don not use tap water to clean soft lenses
• Keep lenses moist or wet when worn
• Use fresh solution daily when storing and disinfecting lenses
• Thoroughly wash and rinse lens storage case on a daily basis with soap or liquid detergent. Rinse thoroughly with warm water, and air dry.

900

What is proper ear care?

• Cleaning the outer ear with a washcloth and warm water.
  • Rotating the washcloth gently into the canal
  • Gentle downward retraction at the entrance of the ear canal usually causes visible cerumen to loosen and slip out
  • Never use objects such as bobby pins, toothpicks, paper clips, or cotton-tipped applicators to remove earwax.
    • Can injure the ear canal and rupture the tympanic membrane.
    • Can also cause cerumen to become impacted within the ear canal.
      • Remove impacted cerumen by irrigation. Ask the patient have they ever had a perforated tympanic membrane which contradicts performing hygiene also infection.
        • Visually inspect the pinna and external meatus for redness, swelling, drainage, and presence of foreign objects. Also determine the patient's ability to hear in the affected ear before irrigation.

1000

How do you irrigate a patient's ear?

• Patient sit or lie on the side with the affected ear up
• For children over 3 and adults pull the pinna up and back. Under 3 pulled down and back. Using a bulb-irrigating syringe, gently wash the ear canal with warm solution.
  • Be careful not to occlude the can, which results in pressure on the tympanic membrane.
  • Direct the fluid slowly and gently toward superior aspect of the ear canal.
  • If the patient experiences pain, nausea, or vertigo.
    • The solution may be too hot or cold or too much pressure.

1100

Importance of CHG:

It may be sticky, DON'T RINSE OFF because it hinders antimicrobial effects.

It decreases vulnerability to infection

CHG helps reduce occurrence for health care-associated infection (HAI).

1200

Which patient have 

-has increased risk for foot problems

-you should inspect and prevent foot ulcers

Diabetic or anyone with peripheral circulation

1300

If you wear contacts too long?

It can cause corneal injury

1400

Uses for fowlers and semi fowlers

-Head of bed raised to angle of 45 to 90 degrees. While patient is eating during nasogastric tube insertion and nasotracheal suction. Promotes lung expansion. Eases difficult breathing. Promotes lung expansion, especially with ventilator-assisted patient.

-Head of bed raised approximately 30 to 45 degrees. Used when patients receive oral care and for gastric feedings to reduce regurgitation and risk or aspiration.

1500

Used for postural drainage. Facilitates venous return in patients with poor peripheral perfusion.

Trendelenburg

Ch. 40,48, 41

100

Positive reverse Trendelenburg's

Used infrequently

Promotes gastric emptying

Prevents esophageal reflux

200

Flat

Used for patient with vertebral injuries and in cervical traction

Used for patients who are hypotensive

Patients usually prefer for sleeping

300

Risk factors for pressure injury development

Impaired sensory perception

Impaired mobility

Alteration in level of consciousness

Shear

Friction

Moisture

400

What are the classifications of pressure injury? Deep-tissue injury? Unstageable pressure injury.

• Stage 1 Pressure injury: Non blanchable erythema of intact skin.
• Stage 2 Pressure injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister. (Adipose is not visible and deeper tissues are not visible)
• Stage 3 Pressure injury: Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges). Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location. Undermining and tunneling may occur. (Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
• Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible if it obscures vision, it is unstageable. Undermining and/or tunneling often occur.
• Deep-tissue injury: Persistent Non blanchable deep red, maroon, or purple discoloration.
• Unstageable Pressure Injury: Obscured full-thickness skin and tissue lose. Obscured by slough and eschar.

500

What layer of skin is loss in partial-thickness wounds and heals by?

Epidermis/superficial dermal layers

Heals by regeneration

600

What loss of the skin layers is seen in full-thickness wound?

Epidermis/dermis

Heals by forming new tissue (Seen stage III and stage IV pressure injuries)

700

What type of intention... 

A clean surgical wound is an example of a wound with little tissue loss. The skin edges are approximated, or closed, and the risk of infection is low. Healing occurs quickly, with minimal scar formation, as long as infection and secondary breakdown are prevented.

Primary intention

800

What type of intention?

Loss of tissue such as a burn, stage II pressure injury, or severe laceration. The wound is left open until becomes filled by scar tissue. It takes the wound longer to heal. Thus, the change of infection is greater.

Second intention

900

What are somethings you may observe with internal bleeding?

• looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock.

1000

What are some things you may observe in external hemorrhage?

• You observe dressings coverings a wound for blood drainage, and you observe for blood underneath the body.
  • If bleeding is extensive, the dressing becomes saturated and frequently blood drains from under the dressing and pools beneath the patient.
  • Observe all wounds closely, particularly surgical wounds, in which hemorrhage is great during the first 24 to 48 hours after surgery or injury.

1100

What is the total separation of wound layer and protrusion of visceral organs through a wound opening? What should you do?

• Total separation of wound layer, protrusion of visceral organs through a wound opening.
• Place a gauze soaked in sterile saline over the extruding tissues to reduce chance of bacterial invasion and drying of the tissues.
• *If the organs protrude through the wound, blood supply can be compromised*
• Contact surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for surgery.

1200

What is the braden score? What is the range? What does the number tell you?

• Risk Assessment: The "Braden Scale" is the most widely used risk-assessment tool for pressure injuries.
• Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure injury development. Not at risk is 18 and above.
• When a pressure injury occurs, the length of stay in a hospital and the overall cost of health care increase. These injuries are also costly to patients in terms of disability, pain, and suffering.

1300

Nonblanchable indicates

Structural damage to the capillary bed/microcirculation

1400

Define granulation tissue, slough, eschar?

• Granulation tissue: is the red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
• Slough is a soft yellow or white tissue (stringy substance attached to the wound bed) must be removed by a qualified clinician.
• Eschar is the black, brown, tan or necrotic tissue that need to be removed before healing can occur.

1500

___ lose the elastic recoil to the lungs and thorax. Patient has increased work of breathing.

COPD

Ch. 41 & 46

100

Decreased surfactant production can develop into?

Atelectasis (collapse of the alveoli)

200

What can decrease stroke volume?

(the amount ejected from the ventricle? Hemorrhage and dehydration.

300

S1 & S2 is the sound of what valve closing?

S1 AV valves closing (mitral and tricuspid)

S2 Semilunar valves closing (aortic and pulmonic)

400

What is the a condition that can cause decreased oxygen-carrying capacity of blood?

• Anemia (S&S fatigue, decreased activity tolerance, increased breathlessness, increased heart rate, and pallor- especially in the conjunctiva of the eye).
  • Compensation: Polycythemia (increased red blood cells).
  • Caused by:
    • Decreased hemoglobin production
    • Increased red blood cell destruction and/or
    • Blood loss
• Toxic substances

500

Hypovolemia

• Significant blood loss results in peripheral vasoconstriction and by increasing the heart rate to increase the volumes of blood returned to the heart. Results in hypoxia to body tissues.

600

Examples of what can cause decreased inspired oxygen concentration

Upper or lower airway obstruction

Decrease environmental oxygen (high altitudes)

Hypoventilation (occurs in opiate overdoses)

700

What happens to a COPD if they are given excessive oxygen?

They don't breathe.

800

What are some causes of hyperventilation?

Severe anxiety

Infection

Drugs

Acid-Base Imbalance

900

Name some lethal dysrhythmias

V-tach, v-fib, asystole

1000

Signs of left sided heart failure

• As the left ventricle continues to fail, blood begins to pool in the pulmonary circulation causing pulmonary congestion.
  • S&S:
    • Crackles in the bases of the lungs on auscultation
    • Hypoxia
    • Shortness of breath on exertion
    • Cough
    • Paroxysmal nocturnal dyspnea (difficulty breathing at night)
      • Awakens the patient, often after 1 to 2 hours of sleep, and is usually relieved in the upright position.

1100

Signs of right sided heart failure

• 
  
  • 
    
    • 
      
      • Blood begins to "back up" in the systemic circulation
        • S&S:
          • Weight gain
          • Distended neck veins (JVD)
          • Hepatomegaly
          • Splenomegaly
          • Dependent peripheral edema

1200

Define the difference between angina pectoris and MI

• Angina pectoris is a transient imbalance between myocardial oxygen supply and demand.
  • S&S
    • Chest pain (Aching, sharp, tingling, or burning or that feels like pressure).
    • Typically, chest pain is left sided or substernal and often radiates to the left or both arms, the jaw, neck, and back. In some patients, angina pain does not radiate.
    • It usually lasts from 3 to 5 minutes
    • Patients report that is often precipitated by activities the increase myocardial oxygen demand.
      • It is usually relieved with rest
      • Coronary vasodilators (nitroglycerin preparation)

MI

• results from sudden decreases in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion. Infarction occurs because ischemia is not reverses. Cellular death occurs after 20 minutes of myocardial ischemia.
• 
  
  • Chest pain associated with MI in men: Describes as crushing, squeezing, or stabbing. The pain is often in the left chest and sternal area; may be felt in the back; radiates down the left arm to the neck, jaws, teeth, epigastric area, and back.
  • 
    
    • It occurs at rest or exertion
    • Lasts more than 20 minutes
    • Rest, position change, or sublingual nitroglycerin administration does not relieve the pain.
    • Women:
    • 
      
      • Increases as they get older, leading cause death for women in the U.S.
      • Women have a greater blood cholesterol and triglyceride levels than men.
      • Obesity in women is more prevalent, which also increases risk for diabetes and cardiac disease.
      • Women symptoms differ from those of men.
        • The most common initial symptom in women is angina

1300

What is postural drainage?

• Postural drainage is a component of pulmonary hygiene, it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration. It aids in improving secretion clearance and oxygenation.
  • Those with head injuries, heart failure, or pulmonary embolus should not be placed in Trendelenburg position.
    • Percussion is contraindicated in patients with
      • Bleeding disorders
      • Osteoporosis
      • Fractured ribs
      • Avoid over burns, open wounds, or skin infections of the thorax

1400

Why are women more prone to UTI?

Shorter urethra.

1500

What is it called when the foreskin is too tight and can't be retracted in males?

Phimosis

Cn. 46 & 45

100

Urological emergency in uncircumcised males, in which the foreskin becomes trapped forming a tight band or constricting tissue.

Paraphimosis

200

How can you prevent CAUTI

• A key intervention to prevent infection is to maintain a closed urinary drainage system.
• Another key intervention is prevention of urine backflow from the tubing and bag into the bladder.
• You should monitor the system to prevent pooling of urine within the tubing and to keep the drainage bag below the level of the bladder.
• Avoid dependent loop in urinary drainage tubing
• Prevent the bag from touching or dragging the floor
• Use separate measure receptable for each patient when draining urinary drainage bag.
• Before transfers or activity, drain all urine from the tubing into bag and empty the drainage bag.
• Empty the drainage bag when half full
• Perform routine perineal hygiene daily and after soiling using antiseptic wipes. Be sure to use a wipe to clean the length of the exposed catheter.
• Obtain urine samples using the sampling port. Cleanse the port with disinfectant.

300

When should a long-term catheter be changed?

Every 4 to 6 weeks.

400

What is nutrient density? What is High and what is low?

• High–nutrient dense foods such as fruits and vegetables provide a large number of nutrients in relation to kilocalories.
• Low–nutrient dense foods such as alcohol or sugar are high in kilocalories but nutrient poor.

500

What is positive vs negative nitrogen balance and examples

Positive nitrogen balance (intake of nitrogen is greater than output) is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing.

The body uses nitrogen to build, repair, and replace body tissues.

Negative nitrogen balance occurs when the body loses more nitrogen than it gains

(e.g., with infection, burns, fever, starvation, head injury, and trauma).

The increased nitrogen loss is the result of body tissue destruction or loss of nitrogen-containing body fluids. Nutrition during this period needs to provide nutrients to put patients into positive balance for healing.

600

Name fat soluble vitamins? Water soluble?

Fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body.

People acquire vitamins primarily through dietary intake, although vitamin D comes from the sun. 

The body has a high storage capacity for fat-soluble vitamins

Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils.

Water-soluble vitamins are vitamin C and the B complex (which is eight vitamins).

The body does not store water-soluble vitamins

We need them provided in our daily food intake.

Absorb easily from the GI tract.

700

What is ovolactovegetarian, lactovegetarians, and vegans?

Ovolactovegetarian (avoid meat, fish, and poultry but eat eggs and milk)

Lactovegetarians (drink milk but avoid eggs)

Vegans (consume only plant foods).