question

Temperature - normal values

answer

97º-99ºF 36.1º-37.2ºC

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Pulse - normal values

answer

60-100 bpm

question

Respiration - normal values

answer

12-20 breaths/min

question

BP - normal, elevated and HTN values

answer

<120/<80 - normal 120-129/ systolic OR 90 or > diastolic - HTN stage 2 >180 systolic and/or >120 diastolic - Hyptertensive crisis

question

Bradycardia vs. Tachycardia

answer

Low HR vs. High HR

question

Define "sounds of Korotkoff"

answer

Sound heard thru stethoscope applied to brachial artery distal to cuff of sphygmomanometer that changes with varying cuff pressure; used to determine systolic and diastolic BP

question

Why is it important to utilize the correctly sized BP cuff? How are results affected by a BP cuff that is too small? Too large?

answer

To obtain correct reading. If cuff too small, can cause systolic BP measurement to be higher than actual; too big can cause it to be lower than actual.

question

Identify changes in vital signs associated with aging.

answer

↑RR, ↑BP, ↓ temp,

question

PQRST

answer

Provokes - Quality - Radiates - Severity - Time

question

What is a general survey? What are 6 factors included?

answer

Descriptive impression of a patient including: 1) Overall health 2) Posturing 3) Grooming 4) Hygiene 5) Facial expression 6) LOC

question

What is purpose of ROM activities?

answer

Maintain joint flexibility to allow for optimal function and patient care.

question

Difference between AROM, AAROM and PROM?

answer

AROM = active range of motion; patients actively move joints AAROM = active assisted ROM; patients assisted in moving joints PROM = passive ROM; patients does not assist

question

Consequences of loss of ROM

answer

Loss of function; impaired function Increased risk of skin breakdown Poor hygiene

question

What are basic nursing assessments of musculoskeletal system?

answer

CMS, ROM, muscle strength Balance Coordination Upper and lower extremities

question

How does a nurse assess upper and lower extremities?

answer

Upper - RAM's (rapid arm movement) by patting hand to thigh, pronate and supinate rapidly. Lower - toe tapping; run heel down opposite shin

question

Normal posture

answer

Cervical - concave Thoracic - convex Lumbar - concave Sacral - convex

question

Abnormal posture

answer

Kyphosis - hunchback *ky -> shy = close yourself off Lordosis - swayback (ie pregnancy) Scoliosis - S-shaped curvature of spine https://healthsurgical.com/wp-content/uploads/2016/02/abnormal-curvature-of-the-spine.jpg

question

Abnormal gait types (5)

answer

Propulsive - leaning forward, fast-paced, short steps Scissor - legs cross, short steps Spastic - jerking movements Waddling - twisting foot movements Steppage - foot drop, foot does not pronate

question

Definition of death

answer

Complete cessation of respiration, BP and heart beat

question

Nursing duties upon death of patient

answer

1) Record TOD 2) Notify appropriate people, departments or agencies 3) Plan for religious or cultural practices desired by pt or family 4) If not a private room, transport other patient 5) Make itemized list of possessions; give to family (have them sign receipt) 6) Prepare body for family or transport to morgue

question

Post-mortem care of body

answer

1) Place body in supine position w/ pillow under head 2) Close eyes, replace dentures, place small towel under chin 3) Remove lines, tubes (except in autopsy) 4) Remove soiled dressings, place disposable pad under pt 5) Wrap body in shroud 6) Transport to morgue or leave in room until mortician arrives

question

What are the changes in a body after death?

answer

1) Livor Mortis (decomposed blood settles in lower body parts closes to ground) 2) Algor Mortis "coldness" 3) Rigor Mortis "stiffness" of muscles and joints (stage 3) 4) Skin indentation *Mortis = death

question

Swallow screen EXCLUSION criteria

answer

- coughing on saliva - excessive saliva/drooling - hx of dysphagia - slurred/garbled speech - pocketing of food in cheek Keep pt NPO, no PO meds, get order for SLP

question

List swallow difficulty behaviors (6)

answer

Cough Throat clearing Wet, gurgly voice Multiple swallows per bite or sip Runny nose Watery eyes

question

Define surgical asepsis

answer

Elimination of all microorganisms

question

What contaminates a sterile field?

answer

- Touching "clean" items - Touching "questionable" items - Falling below waist - Falling out of range of vision - Becomes wet (via capillary action or gravity) - Prolonged exposure to air

question

What supplies will you need to perform a dressing change?

answer

Dressing supplies Tape Clean (or sterile) gloves (will need 2-3 pairs)

question

What do you need to do BEFORE a dressing change?

answer

- Verify MD order - Pre-medicate pt per order - Gather supplies - Wash hands - Check pt ID x 3 criteria - Explain procedure to pt - Provide privacy

question

What supplies will you need to perform a wound irrigation?

answer

- Irrigating set - Solution - Chux - Dressing supplies - Tape - Sterile and clean gloves - sterile container for "wetting" solution - Small trash bag

question

How do you assess a wound? What do you look for?

answer

Pain Color Odor Temp of skin Edema Drainage Signs of healing Size

question

How do you assess drainage?

answer

Color Odor Amount Consistency

question

Describe a Stage I pressure ulcer

answer

Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.

question

Describe a Stage II pressure ulcer

answer

Partial thickness loss of dermis presenting as a superficial, shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

question

Describe a Stage III pressure ulcer

answer

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (small opening, large wind under) and tunneling (narrow passage)

question

Describe a Stage IV pressure ulcer

answer

Full thickness tissue loss with expose bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

question

Debridement

answer

Removal of non-viable tissue from a wound

question

Dehiscence

answer

Failure of a wound to heal in which the surgical wound separates and opens to the fascial level

question

What factors contribute to wound dehiscence?

answer

Anemia, malnutrition, obesity and use of steriods.

question

Evisceration

answer

Failure of wound healing with total separation of the layers of the wound and protrusion of the internal organs through the wound.

question

What should the nurse do in the case of an evisceration in a pt?

answer

Cover the wound with a moist sterile saline dressing, notify surgeon immediately and prepare pt for emergent surgery.

question

Fistula

answer

An abnormal passage between two organs, or between an organ and the outside of the body.

question

Describe serous wound drainage

answer

Clear, watery plasma

question

Describe purulent wound drainage. What does this type of drainage indicate?

answer

Thick, yellow, pale green or white: indicates infection.

question

Describe serosanguinous wound drainage

answer

Pale, red, watery: mixture of serous and sanguineous

question

Describe sanguineous wound drainage

answer

Bright red: indicates active bleeding

question

Why does a wound heal best in a moist environment?

answer

Because it favors: 1) epithelial cell migration 2) promotes extracellular matrix formation 3) reduces fibrosis 4) decreases wound infection

question

What are dry gauze dressings primary used for?

answer

- Wound healing by primary intention with little drainage - Abrasions - Non-draining postoperative incisions

question

What are the disadvantages of dry gauze dressings?

answer

- Does not maintain a moist environment (unless wound is highly exudative) - Moisture evaporates quickly causing dressing to dry out - Increased infection rates

question

What is a "wet-to-moist" wound dressing? What is its purpose?

answer

Gauze moistened with appropriate solution. Primary purpose is to mechanically debride wounds

question

What types of wounds would you use a "wet-to-moist" dressing?

answer

- Full-thickness wounds healing by secondary intention - Wound with necrotic tissue

question

What is a transparent film dressing? Describe.

answer

A clear, adherent, non absorptive, polyurethane sheet. - Prevents tissue dehydration, allows for rapid, effective healing by speeding epithelial cell growth - Impermeable to fluids and bacteria

question

In what type of wound is a transparent film dressing appropriate?

answer

- Prophylaxis on high-risk intact skin - Superficial wounds with minimal or no exudate - Eschar-covered wounds when autolysis is indicated and safe - IV catheter insertion site - Secondary dressing to wound products (alginates and foam) -Stage 2 pressure ulcers

question

What type of tape is more likely to stay on an area that is moist?

answer

Plastic tape

question

What type of tape would you need to assess for an allergy before using?

answer

Plastic tape

question

What is purpose of Montgomery ties or straps over a dressing?

answer

To prevent skin breakdown due to frequent removal of dressings and tape

question

What type of dressing is generally used over a stage 2 pressure ulcer?

answer

Transparent dressing for easy wound inspection

question

What is the benefit of using gauze in a wound dressing that is healing by secondary intention?

answer

Absorbancy

question

What type of dressing is used for necrotic wounds?

answer

Moist-to-dry

question

When might packing strips be used in a wound?

answer

To fill a tunneled wound or fistula; to treat an infection

question

What does the "VAC" mean in Wound VAC? How does the Wound VAC work?

answer

Vacuum assisted closure It creates negative pressure in the wound, thus drawing the sides together

question

How is "slit" gauze dressing used around drain tubes? What other kinds of tubes are they used for?

answer

Place under and around wound drain tube to absorb, thus fitting better than a flat cause pad. Also used around tracheostomy tubes

question

How long after a surgical procedure can you expect sanguineous drainage?

answer

24-48 hours

question

What are the warning signs of melanoma?

answer

ABCDE Asymmetry, Border, Color, Diameter, Evolving

question

List indicators of risk for pressure ulcers

answer

1) Decreased mobility 2) Impaired neurological functioning 3) Decreased sensory perception 4) Decreased circulation

question

Define "tissue ischemia"

answer

Decreased blood flow

question

Define "blanching"

answer

Normal red tones of skin are absent

question

What is normal reactive hyperemia?

answer

Redness due to local. blood vessel dilation (decreased blood flow to underlying tissues); redness blanches with fingertip pressure

question

What is abnormal reactive hyperemia

answer

Non-blanching tissue, remains red with fingertip pressure (tissue damage)

question

What are contributing factors to pressure ulcers?

answer

Shearing Friction Moisture Nutrition Infection Impaired peripheral circulation Obesity Age

question

What is "shearing"?

answer

Skin sticks to mattress, underlying tissue moves

question

What are general principles for heat and cold application?

answer

Check MD's order - type of application, body site, frequency and duration of tx Assess pt's response to tx during and after Document tx, length of time applied, pt response Nursing dx to keep in mind - high risk for injury when it's too hot, too cold or on too long

question

What are general principles for heat application?

answer

Apply only 15-30 minutes If applied >1 hour, vasoconstriction occurs

question

What are general principles for cold application

answer

Apply 15-30 minutes If applied >1 hour, reflex vasodilation occurs

question

Autolysis

answer

Natural, spontaneous process of revitalized tissue being separated from viable tissue.

question

Blister

answer

Collection of fluid underneath the epithelial layer; fluid may be clear to pink/red in color

question

Cellulitis

answer

Inflammation of tissues presenting as edema, redness, pain and heat, often with hardness of the tissues and a demarcation (definite boundary line) of the red area.

question

Colonisation

answer

Multiplication of micro-organisms without a corresponding host reaction

question

Dry

answer

Dehydration of the skin presenting as flaky, scaly or thick skin plaques.

question

Eczematous

answer

Acute or chronic inflammation of the skin presenting as redness, irritation, weeping, crusting or scaly area.

question

Epithelialisation

answer

The final stage of wound healing where epidermal cells migrate across the surface of the wound from the wound margins and the remaining hair follicles. These cells are pink/white in color at the wound edges or in islands over granulation tissue.

question

Erythema

answer

Redness of the skin caused by congestion of capillaries in lower layer of skin, maybe due to injury, infection, inflammation or hyperemia (increased/excess blood in blood vessels of organ/tissue)

question

Eschar

answer

Scab consisting of dried serum and revitalized dermal cells

question

Exudate

answer

Fluid that leaks out of wound

question

Foam

answer

Dressing made from polyurethane - a soft, open cell sheets in single or multiple layers. Non adherent, can absorb large amounts of educate and can also be used as secondary dressings. Can be impregnated with charcoal and with waterproof backing.

question

Granulation

answer

During proliferation phase of healing, bright red tissue formed from new capillary loops or "buds" which are red/deep pink and moist with a bumpy appearance.

question

Hydrocolloid

answer

Waterproof occlusive dressing that has mixture of pectins, gelatins and produces a gel when mixed with exudate.

question

Maceration

answer

Softening or sogginess of the tissue, owing to retention of excessive moisture which presents as moist, red/white and wrinkled.

question

Necrosis

answer

Local death of tissue, often black/brown in color and leathery in texture

question

Proliferation

answer

Granulation tissue is formed to replace lost volume. Epithelial cells grow around the wound or in islets, to form a new protective covering.

question

Slough

answer

Viscous yellow layer which often cover the wound and is a strong adherent to it. Its presence is related to end of inflammatory stage of healing when dead cells have accumulated in the exudate.

question

VAC

answer

Vacuum assisted wound closure that creates a hypoxic environment within the wound bed in which aerobic bacteria cannot survive.

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