Podcast
Questions and Answers
What is the primary risk associated with administering enemas to older adults and pregnant women?
What is the primary risk associated with administering enemas to older adults and pregnant women?
What makes normal saline enema the safest choice for infants and children?
What makes normal saline enema the safest choice for infants and children?
Which type of enema should not be used for infants or dehydrated patients?
Which type of enema should not be used for infants or dehydrated patients?
In which position should a patient typically be placed for a cleansing enema?
In which position should a patient typically be placed for a cleansing enema?
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What is the recommended length of time a patient should retain a medicated enema for optimal effect?
What is the recommended length of time a patient should retain a medicated enema for optimal effect?
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What is the characteristic appearance of sanguineous exudate?
What is the characteristic appearance of sanguineous exudate?
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What type of exudate is indicative of infection in a wound?
What type of exudate is indicative of infection in a wound?
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When cleansing a clean surgical wound, how should the process be conducted?
When cleansing a clean surgical wound, how should the process be conducted?
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What is the recommended pressure for irrigating a deep wound?
What is the recommended pressure for irrigating a deep wound?
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Which solution is NOT recommended for wound cleansing?
Which solution is NOT recommended for wound cleansing?
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What is the appropriate technique for irrigation of a wound?
What is the appropriate technique for irrigation of a wound?
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How should sutures and staples be managed during wound care?
How should sutures and staples be managed during wound care?
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What outcomes indicate the effectiveness of administering antimicrobials in wound care?
What outcomes indicate the effectiveness of administering antimicrobials in wound care?
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What is the highest value on the Glasgow Coma Scale indicating full consciousness?
What is the highest value on the Glasgow Coma Scale indicating full consciousness?
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What does the Romberg Test assess?
What does the Romberg Test assess?
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Which sensory function test involves asking a client to identify an object placed in their hand?
Which sensory function test involves asking a client to identify an object placed in their hand?
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What is the primary technique used in the Heimlich maneuver?
What is the primary technique used in the Heimlich maneuver?
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Which of the following describes bronchial breathing sounds?
Which of the following describes bronchial breathing sounds?
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What sign indicates early manifestations of hypoxia?
What sign indicates early manifestations of hypoxia?
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Which condition could cause a pleural friction rub sound?
Which condition could cause a pleural friction rub sound?
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What should be observed during the coordination assessment of motor function?
What should be observed during the coordination assessment of motor function?
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Where can cyanosis be assessed in darker skin tones?
Where can cyanosis be assessed in darker skin tones?
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What indicates bradypnea as a manifestation of hypoxia?
What indicates bradypnea as a manifestation of hypoxia?
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What does the pulse oximeter measure?
What does the pulse oximeter measure?
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Which abdominal injury is a risk when performing the Heimlich maneuver?
Which abdominal injury is a risk when performing the Heimlich maneuver?
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What sound is produced by air moving through thick mucus fluid?
What sound is produced by air moving through thick mucus fluid?
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In which breathing pattern does exhaling last longer than inhaling?
In which breathing pattern does exhaling last longer than inhaling?
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What characterizes dehiscence in a wound?
What characterizes dehiscence in a wound?
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What action should be taken immediately if a patient experiences evisceration?
What action should be taken immediately if a patient experiences evisceration?
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During which stage of wound healing does scar strengthening occur?
During which stage of wound healing does scar strengthening occur?
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What is the primary characteristic of healing by primary intention?
What is the primary characteristic of healing by primary intention?
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Which of the following is a risk factor for falls in older adults?
Which of the following is a risk factor for falls in older adults?
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What is a key preventive strategy for falls among patients?
What is a key preventive strategy for falls among patients?
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What type of gait involves swinging both legs past the crutches?
What type of gait involves swinging both legs past the crutches?
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What does the inflammatory stage of wound healing typically last?
What does the inflammatory stage of wound healing typically last?
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What is the major concern during the fall risk assessment for elderly patients?
What is the major concern during the fall risk assessment for elderly patients?
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What is a common outcome of healing by secondary intention?
What is a common outcome of healing by secondary intention?
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What is the required positioning of the patient experiencing evisceration?
What is the required positioning of the patient experiencing evisceration?
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Which of the following best describes tertiary intention healing?
Which of the following best describes tertiary intention healing?
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What emotional state should be maintained for a patient at risk of shock?
What emotional state should be maintained for a patient at risk of shock?
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What does the presence of heaves indicate in a patient?
What does the presence of heaves indicate in a patient?
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Which of the following heart sounds indicates the closure of the aortic and pulmonic valves?
Which of the following heart sounds indicates the closure of the aortic and pulmonic valves?
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Where is the apical pulse most accurately located?
Where is the apical pulse most accurately located?
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What is an indication of S3 heart sound?
What is an indication of S3 heart sound?
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What characterizes a stage 2 pressure injury?
What characterizes a stage 2 pressure injury?
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What should be used during a straight catheter insertion for a patient with a latex allergy?
What should be used during a straight catheter insertion for a patient with a latex allergy?
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Which dressing is most appropriate for maintaining a moist healing environment for a stage 2 pressure injury?
Which dressing is most appropriate for maintaining a moist healing environment for a stage 2 pressure injury?
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What is a common characteristic of skin in stage 1 pressure injuries?
What is a common characteristic of skin in stage 1 pressure injuries?
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What type of sound does a thrill resemble when felt at the heart?
What type of sound does a thrill resemble when felt at the heart?
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Which type of wound dressing is utilized for mechanical debridement?
Which type of wound dressing is utilized for mechanical debridement?
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Which finding indicates potential right-sided heart failure?
Which finding indicates potential right-sided heart failure?
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What does the Braden scale measure?
What does the Braden scale measure?
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What type of drainage is characterized by clear and watery fluid, often seen in the early healing process?
What type of drainage is characterized by clear and watery fluid, often seen in the early healing process?
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Study Notes
Glasgow Coma Scale
- Utilized for baseline and ongoing assessments of consciousness.
- Evaluates eye, verbal, and motor responses.
- Scale ranges from 3 (no response) to 15 (full consciousness).
Motor Function Assessment
- Coordination: Client extends arms, alternating touch to nose; expected response: smooth movements.
- Gait: Assessed without client’s awareness; expected: smooth and coordinated walking.
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Balance:
- Romberg Test: Stand with feet together, arms at sides, eyes closed for at least 5 seconds.
- Heel-to-Toe Walk: Walking in a straight line without losing balance.
- Muscle Strength: Client pushes or pulls against resistance; expected: equal or stronger on dominant side.
Sensory Functions (Eyes Closed)
- Pain Sensation: Alternating sharp/dull objects; client reports sensations.
- Temperature: Identify warm/cold tubes.
- Light Touch: Cotton ball touches skin; client indicates contact.
- Vibration: Tuning fork; client reports sensation timing and location.
- Position: Reposition limbs; client identifies orientation (up/down).
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Discrimination:
- Two-point discrimination: Measures minimal distance felt as two separate points.
- Stereognosis: Identify familiar objects by touch.
- Graphesthesia: Identify traced numbers on palm.
Aspiration Risk
- Assessment and precautions to prevent aspiration during care.
Heimlich Maneuver
- First-aid technique for conscious choking.
- Sharp upward thrusts below ribcage, 5 times; adjust for pregnant individuals by maneuvering above the sternum.
- Risks include potential injuries, bruising, or fractures.
Diaphragmatic Breathing
- Common in males and children; noticeable abdominal movement during deep breaths.
Breathing Sounds
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Expected:
- Bronchial: High-pitched, hollow sounds; exhalation longer than inhalation.
- Bronchovesicular: Medium-pitched; best heard between shoulders.
- Vesicular: Low and soft; inhalation longer than exhalation.
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Unexpected/Adventitious:
- Crackles: Bubbling sounds indicating fluid in the lungs; suggest pulmonary issues.
- Wheezes: High-pitched sounds from narrowed airways; associated with asthma or COPD.
- Rhonchi: Deep, snoring sound; indicates thick mucus; can usually be cleared by coughing.
- Pleural Friction Rub: Dry sounds indicating irritation of pleura; associated with breathing difficulty.
- Apylexis: Absence of breath sounds.
Cyanosis Assessment
- Light skin tones: bluish tint; darker tones: grayish skin in palms/soles; brown tones: yellowish.
- Indications of hypoxia or impaired venous return; commonly assessed at nail beds, lips, and mucous membranes.
Hypoxia Manifestations
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Early Signs:
- Increased respiratory rate, heart rate; restlessness, anxiety.
- Pale skin, elevated blood pressure, use of accessory muscles.
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Late Signs:
- Stupor, cyanosis, low respiratory rate, bradycardia, hypotension.
Oxygen Saturation
- Pulse Oximeter: Non-invasive device measures oxygen levels at various body sites.
Indwelling Urinary Catheter Assessment and Care
- Size/type for insertion varies by patient demographics; allergies necessitate specific materials.
- Routine care should include cleansing and monitoring for patency and kinks.
Wound Healing and Pressure Injury Classification
- Stage 1: Non-blanchable erythema; discomfort.
- Stage 2: Partial thickness loss; might resemble blister.
- Stage 3: Full thickness skin loss; may expose subcutaneous fat.
- Stage 4: Extensive tissue loss; muscles and bones may be visible.
- Unstageable: Escar obscures true depth; may indicate serious risk factors.
Wound Dressing Types
- Woven Gauze: Absorbs exudate; used for moderate to heavy drainage.
- Non-adherent Dressings: Prevent pain on removal; designed to avoid sticking.
- Hydrocolloid: Forms a seal, maintains moisture; stays for several days.
- Hydrogel: Provides moisture for dry wounds; soothing.
- Alginates: Highly absorbent; ideal for draining wounds.
Care of Wound Infection
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Clean wounds from least to most contaminated; use isotonic solutions for cleansing.
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For irrigation, maintain pressure and use appropriate tools; monitor for infection signs.### Wound Complications: Dehiscence and Evisceration
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Dehiscence: Partial or total separation of a sutured wound, typically affecting underlying skin layers.
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Presents with visible wound edge separation and serous drainage.
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Patients may report a popping sensation and feeling as though the wound has given way.
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Immediate actions: Notify healthcare provider, stay with the patient, cover the wound with a blanket or pillow, and apply pressure if coughing occurs.
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Evisceration: Severe dehiscence where organs protrude through the wound.
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Requires immediate coverage of the wound with a sterile saline-soaked towel or dressing to prevent bacterial contamination.
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Keep essentials nearby to avoid unnecessary movement.
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Patient Positioning: Supine position with hips and knees bent reduces tension on the wound.
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Observation: Monitor for signs of shock such as pallor, clamminess, rapid heart rate, and hypotension. Maintain a calm environment and keep the patient NPO until surgery.
Stages of Wound Healing
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Inflammatory Stage: Lasts 3 to 6 days, focusing on controlling bleeding and delivering immune response elements.
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Features vasoconstriction, fibrin accumulation, and macrophage activity for phagocytosis.
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Prolonged inflammation can occur due to inadequate or excessive responses.
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Proliferative Stage: Lasts from 3 to 24 days, characterized by tissue replacement and granulation.
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Involves collagen formation, wound contraction, and resurfacing with new epithelial cells.
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Maturation Stage: Begins around day 21, with scar strengthening and normalization of appearance.
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The process may take over a year and depends on the wound's extent.
Wound Healing Processes
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Primary Intention: Minimal tissue loss, with edges approximated, healing rapidly and presenting low infection risk. Example includes closed surgical incisions.
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Secondary Intention: Involves significant tissue loss with unapproximated edges, longer healing times, and a higher infection risk. Example includes pressure injuries.
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Tertiary Intention: Characterized by deep, widely separated wounds that initially remain open for infection control. Closure occurs later, extending healing time.
Fall Risk Assessment
- Defined as an unintended descent to the ground, making it a leading cause of accidental injuries, especially among older adults.
- Risk factors include unassisted toileting, altered cognition, mobility issues, and environmental hazards.
Fall Prevention Strategies
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Conduct fall-risk assessments at admission and regular intervals.
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Educate clients on using call lights and demonstrate proper usage.
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Ensure call lights are accessible, and offer timely bathroom assistance.
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Maintain good room lighting and familiarization with the environment.
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Ensure accessibility to assistive devices and safety elements like non-skid footwear.
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Document any falls in incident reports to identify patterns and refine prevention strategies.
Crutch Walking Techniques
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4 Point Gait: Alternates crutches and legs, providing stable support with three points on the ground.
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3 Point Gait: Both crutches move forward together while swinging the unaffected leg ahead.
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2 Point Gait: Moves one crutch with the opposite leg simultaneously, mimicking natural walking.
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Swing Through Gait: Involves swinging legs past crutches, requiring upper body strength for balance.
Other Mobility Considerations
- Utilize gait belts and various mobility assistance devices for safe ambulation.
Dosage Calculations
- Understand oral, parenteral, and injectable dosage calculations for effective medication management.
Tuberculin Test
- The PPD test is used for tuberculin testing, assessing for allergies or sensitivities to medications.
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Description
Test your knowledge on the Glasgow Coma Scale and its application in assessing a client's level of consciousness. This quiz covers the scale's components, including eye, verbal, and motor responses, as well as understanding the scoring system from 3 to 15.
