Infection
A normal drainage of fluid from a wound or incision site after surgery. The serum is a thin, often slightly yellow fluid that's mostly water, with a light pink tinge (the sanguine, or blood, element in the fluid). It typically lasts a few days as a wound heals.
What is serosanguinous?
Amoxicillin, Azithromycin, Ciprofloxacin
work by killing bacteria or stopping them from multiplying
What are antibiotics? Do you know the most common side effects of antibiotics?
The sacral area of the client is red. When gently touched, the sacral area with your fingertips there is no blanching in the area.
What is a stage 1 pressure ulcer?
"Pain whose cause cannot be removed and, according to generally accepted medical practice, the full range of pain management modalities appropriate for this patient has been used without adequate result or with intolerable side effects."
What is intractable pain?
Completed when a patient is admitted, according to the order or facility policy, a minimum of every 4 hours when found out or normal range, every 15 minutes or less if unstable
What are vital signs?
Soft plastic bulb
Held in by sutures
The bulb should be compressed at all times, except when you’re emptying the drainage.
Milk the tubing to prevent blood clots.
Empty every 8 hours
What is a JP drain?
Sinus tachycardia and increased blood pressure
Adventitious lung sounds, crackles
dyspnea from pulmonary congestion or edema
What are signs/symptoms of excess fluid?
Delayed primary wound healing after 4–6 days. This occurs when the process of secondary intention is intentionally interrupted and the wound is mechanically closed. This usually occurs after granulation tissue has formed.
What is the third intention or tertiary healing?
moaning, crying, restless, guarding, grimacing, eyes closing - may be tightly
What are objective signs of pain?
Ask the patient to describe
Ask the patient if it radiates to another part of the body
Ask when it started
What are some questions related to pain assessment?
The wound is erythematous, warm, and has odorous, serous pus.
What is an infected wound?
uncross legs
ask if there is any reason not to check on either upper extremity
Ask if the patient knows their baseline
What needs to be done before checking blood pressure on an upper extremity?
When a wound has ______ on top of it, the pressure injury can’t be classified. This is because eschar is dead tissue that makes it difficult to see the wound underneath.
What is eschar?
This type of assessment data is important; however, this type of data is not easily measured. Symptoms
What are subjective data/assessment findings?
An abnormally slow breathing rate. It's a symptom of an underlying health condition, which may include hypothyroidism, head injuries or opioid or heavy alcohol use. Associated symptoms may include dizziness, confusion and feeling tired.
What is bradypnea?
Direct contract
Indirect contact
Vectors
What is mode of transmission?
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shearing
What risk factors are assessed on the Braden scale?
A special tool is required. Do not pull up while depressing the handle of the tool or change the angle of your wrist or hand. The use of steri strips is typical after this procedure.
What is staple removal?
Describes pain spreading to the somatic regions far from the site of noxious stimulation
Brain freeze
Left shoulder pain without problem with left shoulder problem
What is referred pain?
The body is responding to an underlying condition.
It is an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace. It’s a form of hyperventilation.
Often a response to metabolic acidosis. [ex. DKA]
What is Kussmaul Breating?
any organism (vertebrate or invertebrate) that functions as a carrier of an infectious agent between organisms of a different species
What is a vector?
In Lyme disease, the mosquito is the vector.
Acute
Chronic
Neuropathic
Nociceptive
Radicular
Somatic
Visceral
Musculoskeletal
What are different types of pain?
Done on admission
May need to take a photo
Measure the size, determine the stage
Document what was assessed on admission
Follow facility policies
What is needed when a pressure injury is found on admission assessment?
The nurse is required to do this after any nursing intervention.
What is reassessment?
Be sure to document this reassessment.
Avoiding a large meal
Removing electronic devices such as cell phones and televisions
Being physically active during the day
Being consistant
What are some good sleep habits?