Podcast
Questions and Answers
Which action is most important when applying sterile gloves using the open gloving technique?
Which action is most important when applying sterile gloves using the open gloving technique?
- Adjusting the gloves after both are on to ensure a snug fit.
- Touching only the inside surface of the first glove with the ungloved hand. (correct)
- Using the sterile gown sleeve to pull the gloves over the wrist.
- Keeping the hands above waist level and away from the body.
A nurse is preparing to irrigate a wound. What is the primary reason for performing this procedure?
A nurse is preparing to irrigate a wound. What is the primary reason for performing this procedure?
- To prevent the formation of a scar.
- To remove debris and bacteria. (correct)
- To stimulate the growth of new granulation tissue.
- To decrease the amount of serous drainage.
Which intervention is most appropriate for a client at risk of skin breakdown?
Which intervention is most appropriate for a client at risk of skin breakdown?
- Elevating the head of the bed to 45 degrees to facilitate breathing.
- Using pillows to keep bony prominences from direct contact. (correct)
- Repositioning the client every 4 hours to relieve pressure.
- Applying a thin layer of talcum powder to bony prominences.
When assessing a client with a pressure ulcer, the nurse notes that the base of the ulcer is covered with eschar. How should the nurse classify this ulcer?
When assessing a client with a pressure ulcer, the nurse notes that the base of the ulcer is covered with eschar. How should the nurse classify this ulcer?
Which of the following is an expected finding when assessing skin turgor in a healthy young adult?
Which of the following is an expected finding when assessing skin turgor in a healthy young adult?
A client has a wound with thick, yellow drainage. How should the nurse document this type of exudate?
A client has a wound with thick, yellow drainage. How should the nurse document this type of exudate?
Which of the following is the priority nursing intervention to prevent pressure injuries in a client with limited mobility?
Which of the following is the priority nursing intervention to prevent pressure injuries in a client with limited mobility?
The nurse is assessing a dark-skinned client for pallor. Which anatomical location is most appropriate to assess?
The nurse is assessing a dark-skinned client for pallor. Which anatomical location is most appropriate to assess?
In a wet-to-dry dressing change, what is the primary purpose of the wet gauze?
In a wet-to-dry dressing change, what is the primary purpose of the wet gauze?
A nurse is caring for a client with cellulitis of the lower extremity. Which intervention is most important?
A nurse is caring for a client with cellulitis of the lower extremity. Which intervention is most important?
A nurse is preparing a sterile field for a dressing change. What area of the sterile field is considered contaminated?
A nurse is preparing a sterile field for a dressing change. What area of the sterile field is considered contaminated?
Which finding indicates that a client is at high risk for developing a pressure injury according to the Braden Scale?
Which finding indicates that a client is at high risk for developing a pressure injury according to the Braden Scale?
The nurse is assessing a client's capillary refill and notes that it takes 5 seconds for the color to return. What does this finding indicate?
The nurse is assessing a client's capillary refill and notes that it takes 5 seconds for the color to return. What does this finding indicate?
A nurse is caring for an older adult client with dry skin. Which intervention is most appropriate to maintain skin integrity?
A nurse is caring for an older adult client with dry skin. Which intervention is most appropriate to maintain skin integrity?
Which of the following pulses is typically assessed first when evaluating lower extremity arterial circulation?
Which of the following pulses is typically assessed first when evaluating lower extremity arterial circulation?
A patient with a stage 3 sacral pressure ulcer has a consistently low serum albumin level. How does this lab value impact wound healing?
A patient with a stage 3 sacral pressure ulcer has a consistently low serum albumin level. How does this lab value impact wound healing?
A nurse is teaching a client about nutritional needs for wound healing. Which nutrient plays the most significant role in collagen synthesis?
A nurse is teaching a client about nutritional needs for wound healing. Which nutrient plays the most significant role in collagen synthesis?
When irrigating a deep wound, what is the MOST important principle to follow to ensure effective and safe wound cleansing?
When irrigating a deep wound, what is the MOST important principle to follow to ensure effective and safe wound cleansing?
A client with a history of diabetes mellitus develops a foot ulcer. The nurse anticipates that which physiological change will most significantly impair the healing process?
A client with a history of diabetes mellitus develops a foot ulcer. The nurse anticipates that which physiological change will most significantly impair the healing process?
Suppose you are tasked with selecting the optimal dressing for a Stage 2 pressure ulcer exhibiting minimal exudate. Which of the following dressings would best promote moist wound healing while preventing maceration of the surrounding tissue?
Suppose you are tasked with selecting the optimal dressing for a Stage 2 pressure ulcer exhibiting minimal exudate. Which of the following dressings would best promote moist wound healing while preventing maceration of the surrounding tissue?
Prior to initiating a surgical hand scrub, what is the nurse's first action?
Prior to initiating a surgical hand scrub, what is the nurse's first action?
When opening a sterile pack, which action compromises the sterility of the supplies?
When opening a sterile pack, which action compromises the sterility of the supplies?
What is the primary purpose of using a wet-to-dry dressing?
What is the primary purpose of using a wet-to-dry dressing?
A nurse is preparing to add a sterile solution to an established sterile field. Which action would maintain the field's sterility?
A nurse is preparing to add a sterile solution to an established sterile field. Which action would maintain the field's sterility?
When performing wound irrigation, at what distance above the wound should the syringe be held?
When performing wound irrigation, at what distance above the wound should the syringe be held?
A nurse has prepared a sterile field for a central line dressing change. Which action by the nurse would require the field to be discarded and a new one prepared?
A nurse has prepared a sterile field for a central line dressing change. Which action by the nurse would require the field to be discarded and a new one prepared?
A client undergoing dressing change reports increasing pain at the wound site. The nurse's initial action should be to:
A client undergoing dressing change reports increasing pain at the wound site. The nurse's initial action should be to:
What is the MOST appropriate method for cleaning a wound?
What is the MOST appropriate method for cleaning a wound?
What is the primary rationale for using sterile gloves when applying a dressing to a new surgical wound?
What is the primary rationale for using sterile gloves when applying a dressing to a new surgical wound?
When assessing a client with cellulitis of the lower extremity, which clinical finding necessitates immediate notification of the healthcare provider?
When assessing a client with cellulitis of the lower extremity, which clinical finding necessitates immediate notification of the healthcare provider?
Which of the following actions is essential when removing a dressing from a wound?
Which of the following actions is essential when removing a dressing from a wound?
A client with a wound is prescribed a diet high in protein. Why is protein important for wound healing?
A client with a wound is prescribed a diet high in protein. Why is protein important for wound healing?
A nurse is caring for a client at risk of developing pressure injuries. Which intervention is aimed at reducing the effects of shear?
A nurse is caring for a client at risk of developing pressure injuries. Which intervention is aimed at reducing the effects of shear?
A nurse assesses a client’s skin and notes an area of intact skin that is red and does not blanch when touched. What stage of pressure injury is this?
A nurse assesses a client’s skin and notes an area of intact skin that is red and does not blanch when touched. What stage of pressure injury is this?
Which documentation indicates proper technique for assessing a client’s pedal pulses?
Which documentation indicates proper technique for assessing a client’s pedal pulses?
A nurse is teaching a client about preventing pressure injuries. Which statement indicates the client understands the teaching?
A nurse is teaching a client about preventing pressure injuries. Which statement indicates the client understands the teaching?
What is the most reliable method for assessing skin temperature?
What is the most reliable method for assessing skin temperature?
A nurse is caring for a client with a Stage 3 pressure ulcer. What type of drainage would the nurse document if the drainage is thick, yellow, and malodorous?
A nurse is caring for a client with a Stage 3 pressure ulcer. What type of drainage would the nurse document if the drainage is thick, yellow, and malodorous?
A client with a history of peripheral vascular disease has a small wound on their lower leg. Which factor will most significantly impact the healing process?
A client with a history of peripheral vascular disease has a small wound on their lower leg. Which factor will most significantly impact the healing process?
What is the primary purpose of performing hand hygiene before and after wound care?
What is the primary purpose of performing hand hygiene before and after wound care?
A client is being treated for a wound infection. Which laboratory value would the nurse monitor to assess the effectiveness of the treatment?
A client is being treated for a wound infection. Which laboratory value would the nurse monitor to assess the effectiveness of the treatment?
A nurse is caring for a client with a deep wound requiring packing. What is the best technique for applying the packing material?
A nurse is caring for a client with a deep wound requiring packing. What is the best technique for applying the packing material?
In which client would the nurse assess for pallor primarily in the oral mucous membranes?
In which client would the nurse assess for pallor primarily in the oral mucous membranes?
A nurse notes that a client's wound is contracting. What does wound contraction indicate?
A nurse notes that a client's wound is contracting. What does wound contraction indicate?
A client has a Braden Scale score of 14. Which nursing intervention is most appropriate based on this score?
A client has a Braden Scale score of 14. Which nursing intervention is most appropriate based on this score?
Which action by the nurse follows the principles of surgical asepsis?
Which action by the nurse follows the principles of surgical asepsis?
When preparing a sterile field, what area is considered contaminated?
When preparing a sterile field, what area is considered contaminated?
A nurse is assessing a client’s skin turgor. Which finding indicates normal hydration?
A nurse is assessing a client’s skin turgor. Which finding indicates normal hydration?
A client is diagnosed with osteomyelitis as a complication of a chronic wound. What does osteomyelitis indicate?
A client is diagnosed with osteomyelitis as a complication of a chronic wound. What does osteomyelitis indicate?
Which nursing intervention is MOST important for preventing infection in a client with a wound?
Which nursing intervention is MOST important for preventing infection in a client with a wound?
What is the priority nursing intervention to promote circulation in a client with a lower extremity wound?
What is the priority nursing intervention to promote circulation in a client with a lower extremity wound?
A nurse is preparing to administer an antibiotic to a client with cellulitis. Which action is most important prior to administration?
A nurse is preparing to administer an antibiotic to a client with cellulitis. Which action is most important prior to administration?
A client has a non-healing wound with significant protein deficiency. Which nutritional supplement would best support wound healing?
A client has a non-healing wound with significant protein deficiency. Which nutritional supplement would best support wound healing?
During a wound assessment, the nurse notes the presence of slough covering the entire wound bed. How should the nurse classify this wound?
During a wound assessment, the nurse notes the presence of slough covering the entire wound bed. How should the nurse classify this wound?
A client reports tingling and numbness in their lower extremities. Which cranial nerve assessment would best provide data related to this report?
A client reports tingling and numbness in their lower extremities. Which cranial nerve assessment would best provide data related to this report?
A nurse is caring for a client with edema. How should the nurse document "obvious distortion" indicating the highest degree of pitting?
A nurse is caring for a client with edema. How should the nurse document "obvious distortion" indicating the highest degree of pitting?
Following a surgical procedure, a client experiences wound dehiscence. What is the initial nursing action?
Following a surgical procedure, a client experiences wound dehiscence. What is the initial nursing action?
Which of the following actions demonstrates proper technique for opening a sterile package?
Which of the following actions demonstrates proper technique for opening a sterile package?
While donning sterile gloves using the open gloving technique, what part of the first glove can be touched with the ungloved hand?
While donning sterile gloves using the open gloving technique, what part of the first glove can be touched with the ungloved hand?
When adding sterile solution to an existing sterile field, what action maintains the sterility of the field?
When adding sterile solution to an existing sterile field, what action maintains the sterility of the field?
In which clinical scenario is the closed gloving technique most appropriate?
In which clinical scenario is the closed gloving technique most appropriate?
Which area of a sterile field is considered contaminated?
Which area of a sterile field is considered contaminated?
What is the primary rationale for using sterile technique during wound care?
What is the primary rationale for using sterile technique during wound care?
When preparing a sterile field, which action will compromise its sterility?
When preparing a sterile field, which action will compromise its sterility?
Which action is contraindicated when establishing and maintaining a sterile field?
Which action is contraindicated when establishing and maintaining a sterile field?
A nurse is preparing to irrigate a client's wound. What equipment is most suitable for this procedure?
A nurse is preparing to irrigate a client's wound. What equipment is most suitable for this procedure?
During wound irrigation, at what distance should the syringe tip be held above the wound bed to ensure effective cleansing without causing tissue damage?
During wound irrigation, at what distance should the syringe tip be held above the wound bed to ensure effective cleansing without causing tissue damage?
A nurse is irrigating a deep wound. What assessment finding indicates that the irrigation should be stopped?
A nurse is irrigating a deep wound. What assessment finding indicates that the irrigation should be stopped?
Which intervention is essential to perform before initiating wound irrigation?
Which intervention is essential to perform before initiating wound irrigation?
When performing wound irrigation, what is the most important rationale for positioning the client to allow gravity to assist with the procedure?
When performing wound irrigation, what is the most important rationale for positioning the client to allow gravity to assist with the procedure?
A client has a wound with a moderate amount of thick, yellow drainage. How should the nurse document this type of exudate?
A client has a wound with a moderate amount of thick, yellow drainage. How should the nurse document this type of exudate?
What characteristic is associated with serous drainage?
What characteristic is associated with serous drainage?
A nurse is assessing a wound and documents 'sanguineous' drainage. Which characteristic aligns with this documentation?
A nurse is assessing a wound and documents 'sanguineous' drainage. Which characteristic aligns with this documentation?
A client's wound is showing signs of contraction. What does wound contraction indicate?
A client's wound is showing signs of contraction. What does wound contraction indicate?
What does the 'C' stand for in the 4 C's of wound care?
What does the 'C' stand for in the 4 C's of wound care?
A nurse is assessing a client with a suspected bacterial infection of the lower extremity. Which clinical finding would the nurse expect to observe?
A nurse is assessing a client with a suspected bacterial infection of the lower extremity. Which clinical finding would the nurse expect to observe?
Following the assessment of a patient with cellulitis, the nurse marks and dates the area of inflammation. What is the primary rationale for this nursing intervention?
Following the assessment of a patient with cellulitis, the nurse marks and dates the area of inflammation. What is the primary rationale for this nursing intervention?
A nurse is caring for a client with cellulitis of the leg. Which intervention is most important to include in the plan of care?
A nurse is caring for a client with cellulitis of the leg. Which intervention is most important to include in the plan of care?
A client is diagnosed with cellulitis. The physician orders antibiotics and blood cultures. What is the priority rationale for obtaining blood cultures?
A client is diagnosed with cellulitis. The physician orders antibiotics and blood cultures. What is the priority rationale for obtaining blood cultures?
A client with diabetes mellitus develops cellulitis on their lower leg. Which physiological factor associated with diabetes will most significantly impair wound healing?
A client with diabetes mellitus develops cellulitis on their lower leg. Which physiological factor associated with diabetes will most significantly impair wound healing?
What is the recommended daily fluid intake for a client to promote optimal wound healing, assuming no contraindications exist?
What is the recommended daily fluid intake for a client to promote optimal wound healing, assuming no contraindications exist?
A client with a pressure injury has a history of poor dietary intake. Which nutritional intervention would be most beneficial for promoting wound healing?
A client with a pressure injury has a history of poor dietary intake. Which nutritional intervention would be most beneficial for promoting wound healing?
A client is prescribed a diet high in Vitamin C to promote wound healing. Which physiological process is most directly supported by Vitamin C?
A client is prescribed a diet high in Vitamin C to promote wound healing. Which physiological process is most directly supported by Vitamin C?
A patient presents with a wound that has been slow to heal. The nurse suspects nutritional deficiency. Identify the most appropriate lab value to assess.
A patient presents with a wound that has been slow to heal. The nurse suspects nutritional deficiency. Identify the most appropriate lab value to assess.
A client reports a diminished sense of smell following a head injury. Which cranial nerve should the nurse assess first?
A client reports a diminished sense of smell following a head injury. Which cranial nerve should the nurse assess first?
A nurse is preparing to assess a client's gag reflex. Which cranial nerve is being evaluated?
A nurse is preparing to assess a client's gag reflex. Which cranial nerve is being evaluated?
The nurse is preparing to assess a client’s trigeminal nerve (V). Which assessment is most appropriate for this nerve?
The nurse is preparing to assess a client’s trigeminal nerve (V). Which assessment is most appropriate for this nerve?
A nurse is assessing the acoustic nerve (VIII). Which assessment technique would be most appropriate?
A nurse is assessing the acoustic nerve (VIII). Which assessment technique would be most appropriate?
To accurately assess a client's skin color, especially in those with darker skin tones, the nurse should first examine which area?
To accurately assess a client's skin color, especially in those with darker skin tones, the nurse should first examine which area?
A dark-skinned client is being assessed for pallor. Where would the nurse best assess for this change in skin color?
A dark-skinned client is being assessed for pallor. Where would the nurse best assess for this change in skin color?
A nurse assesses a client and notes the presence of cyanosis. What assessment finding would the nurse observe?
A nurse assesses a client and notes the presence of cyanosis. What assessment finding would the nurse observe?
A nurse performing a skin assessment on an older adult notes 'tenting' when assessing skin turgor. What physiological change best explains this finding?
A nurse performing a skin assessment on an older adult notes 'tenting' when assessing skin turgor. What physiological change best explains this finding?
A nurse is assessing an older adult client and observes several small, flat, brown macules on the client's hands and arms. Which term best describes these findings?
A nurse is assessing an older adult client and observes several small, flat, brown macules on the client's hands and arms. Which term best describes these findings?
What Braden Scale score indicates the highest risk?
What Braden Scale score indicates the highest risk?
A client has a Braden Scale score of 17. What does this score indicate?
A client has a Braden Scale score of 17. What does this score indicate?
Which of the following Braden Scale categories assesses the client's ability to change and control body position?
Which of the following Braden Scale categories assesses the client's ability to change and control body position?
Assuming all other factors constant, which patient do you expect to have the lowest Braden scale score?
Assuming all other factors constant, which patient do you expect to have the lowest Braden scale score?
Flashcards
Surgical Asepsis
Surgical Asepsis
Practices that keep areas and objects free from microorganisms. Used in operating rooms, special diagnostic areas, and for procedures like injections and wound dressings.
Sterile Field
Sterile Field
An area free of microorganisms, used during surgical procedures. Only sterile objects should touch the sterile field. The edges are considered unsterile.
Capillary Refill Assessment
Capillary Refill Assessment
Gently press on the nail bed until it turns white, then release. Normal return is typically less than 2-3 seconds.
Assessing Peripheral Pulses
Assessing Peripheral Pulses
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Integumentary System
Integumentary System
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Cyanosis
Cyanosis
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Edema
Edema
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Pressure Ulcers
Pressure Ulcers
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Exudate
Exudate
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Serous Drainage
Serous Drainage
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Sanguineous Drainage
Sanguineous Drainage
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Purulent Drainage
Purulent Drainage
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Wound Irrigation
Wound Irrigation
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Preventing Tissue Damage
Preventing Tissue Damage
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Pressure Injuries Pathophysiology
Pressure Injuries Pathophysiology
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Pressure Ulcer Stage 1
Pressure Ulcer Stage 1
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Pressure Ulcer Stage 2
Pressure Ulcer Stage 2
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Pressure Ulcer Stage 3
Pressure Ulcer Stage 3
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Pressure Ulcer Stage 4
Pressure Ulcer Stage 4
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Unstageable Pressure Ulcer
Unstageable Pressure Ulcer
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Surgical Asepsis Steps
Surgical Asepsis Steps
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Applying Sterile Gloves
Applying Sterile Gloves
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Closed Gloving Technique
Closed Gloving Technique
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Wound Care 4 C's
Wound Care 4 C's
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Purpose of Wound Irrigation
Purpose of Wound Irrigation
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Syringe for Wound Irrigation
Syringe for Wound Irrigation
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Technique for Wound Irrigation
Technique for Wound Irrigation
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Preparing a Sterile Field
Preparing a Sterile Field
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Opening a Sterile Package
Opening a Sterile Package
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Cellulitis Cause
Cellulitis Cause
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Cellulitis Symptoms
Cellulitis Symptoms
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Cellulitis Treatment
Cellulitis Treatment
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Physical Skin Examination
Physical Skin Examination
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Normal Skin Turgor
Normal Skin Turgor
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Abnormal Skin Turgor
Abnormal Skin Turgor
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Braden Scale
Braden Scale
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Nursing Actions to Prevent Tissue Damage
Nursing Actions to Prevent Tissue Damage
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Maintaining Skin Hygiene
Maintaining Skin Hygiene
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Nutrition for Skin Health
Nutrition for Skin Health
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Wound Cleansing
Wound Cleansing
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Post-Cleansing Care
Post-Cleansing Care
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Examining Darker Skin Tones
Examining Darker Skin Tones
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Impaired Wound Healing Risk Factors
Impaired Wound Healing Risk Factors
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Maximizing Skin Integrity
Maximizing Skin Integrity
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Promoting Patient Mobility
Promoting Patient Mobility
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Maintaining a Sterile Environment
Maintaining a Sterile Environment
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Using Sterile Objects
Using Sterile Objects
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Olfactory Nerve Assessment (I)
Olfactory Nerve Assessment (I)
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Optic Nerve Assessment (II)
Optic Nerve Assessment (II)
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Oculomotor, Trochlear, Abducens Nerves Assessment (III, IV, VI)
Oculomotor, Trochlear, Abducens Nerves Assessment (III, IV, VI)
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Trigeminal Nerve Assessment (V)
Trigeminal Nerve Assessment (V)
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Facial Nerve Assessment (VII)
Facial Nerve Assessment (VII)
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Acoustic Nerve Assessment (VIII)
Acoustic Nerve Assessment (VIII)
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Glossopharyngeal Nerve Assessment (IX)
Glossopharyngeal Nerve Assessment (IX)
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Accessory Nerve Assessment (XI)
Accessory Nerve Assessment (XI)
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Hypoglossal Nerve Assessment (XII)
Hypoglossal Nerve Assessment (XII)
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Study Notes
Surgical Asepsis
- Surgical asepsis requires applying a hair cover, mask, protective eyewear, and shoe covers.
- Surgical asepsis requires performing a hand scrub, applying a sterile gown and sterile gloves.
- Hand hygiene and maintaining a sterile field are key aspects of surgical asepsis.
- The use of PPE, sterilization, disinfection, and proper waste disposal are essential.
Sterile Gloves
- Requires opening the outer packaging, removing the inner glove packaging, and placing the inner packaging on a flat surface at waist height.
- Fold back the edges of the inner wrapper to expose the gloves, avoiding touching the inside of the wrapper.
- Pinch the cuff of the dominant hand glove using the thumb and forefinger of the nondominant hand, only touching the inside surface of the glove.
- Lift the glove off the wrapper and carefully apply it to the dominant hand without touching the outside surface; do not adjust if misaligned.
- Use the gloved hand to slide fingers under the cuff of the remaining glove.
- Lift the glove off the wrapper, only touching the outside surface, and apply it to the nondominant hand.
- After applying both gloves, adjustments can be made for comfort and fit.
Closed Gloving Technique
- Use the sleeve of the sterile gown to grasp the cuff of the nondominant hand glove, ensuring hands remain hidden within the gown sleeve.
- Position the glove in the palm of the nondominant hand, with the opening facing away from the body.
- Pinch the glove at the cuff with the nondominant hand and pull it over the end of the sleeve.
- Repeat the same steps on the dominant hand.
- Once both gloves have been applied, adjust as necessary, ensuring the cuff of the sleeve is completely covered by the glove.
Wound Care
- Key components, referred to as the 4 C's, are color, contraction, consistency, and circulation.
Wound Care Supplies
- Includes wound irrigation supplies.
Preparing for Wound Irrigation
- Maintaining privacy, introducing self, performing hand hygiene, donning PPE, verifying client ID, assessing for allergies, and providing client education are all vital.
- Assess for pain, implement interventions, gather supplies, clear the area, and position a waste receptacle nearby.
- Adjust bed height, assist the client into a comfortable position, cover to expose the wound area, and place an absorbent pad underneath.
Removing an Old Dressing
- Requires loosening tape or adhesive edges in the direction of hair growth.
- Lift the corner of the dressing with the dominant hand while using the other hand to gently push the skin away.
Wound Cleansing
- Using sterile technique, prepare a sterile work area with supplies, and open the sterile cleaning solution into a sterile container.
- Apply sterile gloves, and position the sterile basin below the wound.
- Fill the syringe with the sterile solution.
- Direct a stream of solution into the wound, keeping the syringe tip about an inch above the edges.
- Stop when the solution flows clearly.
- Dry the surrounding skin with gauze and apply a skin protectant if needed.
- Dispose of used materials properly, remove gloves, and perform hand hygiene.
- Apply sterile gloves unless it is a chronic wound or pressure injury, then apply the prescribed sterile dressing to the wound bed, including packing if prescribed.
- Extend the sterile gauze dressing 1 inch beyond the wound edges.
- Verify that the date and time are on the label and place it on the dressing.
- Ensure the client is in a safe position and has the call light within reach before leaving the room.
Removing and Applying a Dry Dressing
- Requires privacy, hand hygiene, and PPE.
- Requires allergy review, client education, pain assessment, and supply gathering.
- Requires proper bed adjustment and client positioning with wound exposure and absorbent pad placement.
- Apply clean gloves.
- Requires gently loosening tape and adhesive edges.
- Small amounts of sterile water can loosen the dressing if it sticks to the wound.
- Note drainage quantity and color.
- Assess the wound’s size, appearance, drainage, sutures, and drains.
- Remove soiled gloves and perform hand hygiene.
- The procedure continues with a sterile technique, involving a sterile work area and opening supplies.
- Clean the wound top-to-bottom or center-out.
- Use a new sterile swab with each wipe, and discard used materials appropriately.
- If it is not a chronic wound or pressure injury, use sterile gloves.
- Once the wound is cleaned and dry, apply a skin protectant to the healthy skin around it.
- After cleaning, place a layer of sterile gauze dressing over the wound, extending at least 1 inch past the edges, applying with forceps if needed. Apply a surgical or abdominal pad over the gauze and tape to dressing edges.
- Requires the procedure and wound condition documentation.
- Final steps include proper arrangement of the client, bed, and call light, along with a round of hand hygiene.
Wound Irrigation
- Flushes debris and bacteria from open wounds.
- Is especially important for wounds sustained outdoors due to the increased risk of infection from dirt contamination, and requires determining tetanus vaccination status.
Nursing Interventions for Wound Irrigation
- Administer analgesics 30 minutes prior.
- Position the wound to allow gravitation solution flow.
- Use sterile supplies and don sterile gloves.
- Use a 35 mL syringe with a large-bore (i.e., 18-19 gauge) angiocatheter and fill with irrigation solution.
- Hold the syringe tip 1 inch above the wound.
- Flush the wound with low, continuous pressure, irrigating downward from the top edge.
- Continue flushing until the solution is free from debris and exudate.
- Dry the surrounding skin with sterile gauze and apply a dressing.
Preparation of Sterile Field
- Used for central line dressing changes, urinary catheter insertions, tracheostomy care, suctioning, and certain dressing changes.
- Requires gathering supplies, clearing an area, closing doors, checking packaging integrity and expiration date, positioning the client, and selecting a work surface.
- To prepare the field, open the outer layer (plastic covering) of the sterile package and place the package on the work surface.
- Grasp the outer surface of the outermost tab of the sterile package and open this tab away from the body.
- Select the next available tab and pull it to the side, keeping it flat, and continue until all sides are flat on the table.
- When adding to the sterile field, open the package and drop the item onto the surface.
- Requires donning sterile gloves that may come in a sterile dressing packet.
- Touch only sterile surfaces and items within the field.
Cellulitis
- Is a bacterial infection caused by staphylococcus aureus or streptococcus.
- Can result from an insect/animal bite, cut, abrasion, or open wound that leads to infection and inflammation of subcutaneous tissue.
Risk Factors for Cellulitis
- Diabetes mellitus, insect bites, immunosuppression, peripheral vascular disease, and IV recreational drug use.
Clinical Features of Cellulitis
- Typically unilateral, most common in the lower extremities.
- Involves redness, warmth, edema, pain, chills, sweating, and enlarged lymph nodes.
Addressing Cellulitis
- Involves antibiotics with possible blood cultures, using gowns and gloves for body fluids, marking the affected area daily, and elevating the extremity.
- Warm compresses.
- Preventing exposure to moist linens and wearing nonrestrictive clothing can assist.
Skin Color
- Even skin color appropriate to the patient’s age and race, without foul odors, is a normal finding.
- Abnormal signs are pallor, cyanosis, erythema, and abnormal loss of melanin.
Turgor Assessment
- Skin turgor is checked to see how quickly it returns to its original position after pinching.
- Normally, the skin quickly returns to its original position.
- A delayed return may indicate dehydration or aging.
Swelling (Edema) Assessment
- Requires inspection for swelling and palpation to check for pitting.
- Pitting degrees: slight, deeper pit, pit obvious, and pit remains.
Documentation Findings
- Including skin color, turgor, and swelling assessments—to ensure thorough and precise patient records.
Additional Considerations for Skin Assessment
- Pay special attention to skinfolds, moist areas, and pressure points during inspection.
- Ensure good lighting to identify color variations and lesions.
- Remove medical or assistive devices for a complete assessment.
Braden Scale
- Assesses risk of developing ulcers including sensory perception and skin moisture.
- Scales for activity, mobility, nutrition, and friction/shear.
- Scores range from 6 to 23; lower scores mean higher risk; less than 18 is a big indicator of pressure injuries.
Pressure Ulcers
- Are injuries to skin due to pressure,
- Categorized in stages of severity from nonblanchable Erythema (1) to full thickness tissue loss (4).
Exudate
- Fluid that leaks from blood vessels and indicates the presence of an infection.
Serous Drainage
- Clear, watery fluid that comes from wound and indicates normal healing.
Sanguineous
- Fresh blood that comes from a wound.
Purulent
- Thick and yellow drainage with signs of infection.
Integumentary System
- Includes the skin, nails, hair, and glands.
- Protects damage to organs.
Cyanosis
- Bluish tint color from poor oxygen.
Edema
- Swelling from excess fluid.
Continence
- Ability to control bowel functions.
Glasgow Coma Scale
- Level of consciousness based on eye/motor responses.
- Lower score indicates more impairment.
Skin Trauma Prevention
- Requires proper lifting and positioning, as well as assessment of breakdown over bones.
Devices
- Special mattress that protects the areas.
Skin Hygiene
- Use cleansers, moisturizing agents, and barrier protection.
Proper Nutrition
- Monitor weight and ensure protein, calories, and iron intake; hydration supports skin health.
Damage to Skin and Tissues
- Ischemic lesions are caused by prolonged external pressure that impairs blood flow, leading to tissue necrosis and ulceration.
- These often develop over bony prominences but can occur anywhere on the body subjected to pressure, friction, or shearing forces.
- When pressure is applied to the skin for an extended period, it distorts capillaries and disrupts normal blood flow.
- If the pressure is not relieved, microthrombi form, leading to ischemia and hypoxia in the tissues, resulting in cell death and tissue necrosis.
Staging of Pressure Ulcers
- Stage 1: Intact skin with nonblanchable erythema.
- Clinical therapy involves cleansing the area, applying barrier cream, using protective dressings, and frequent repositioning.
- Stage 2: Partial-thickness loss of the dermis, presenting as a shallow open wound or blister.
- Clinical therapy includes cleansing the area, applying moisture-retaining dressings, assessing for infection, and providing comfort measures.
- Stage 3: Full-thickness tissue loss with visible subcutaneous tissue, possibly exposing fat.
- Clinical therapy involves cleansing the area, debriding necrotic tissue, applying medicated dressings, and managing pain.
- Stage 4: Full-thickness tissue loss with exposed bone, muscle, or tendon.
- Clinical therapy is similar to Stage 3, with additional surgical interventions if necessary.
- Unstageable: Full-thickness tissue loss where the base of the ulcer is covered by slough or eschar.
- Clinical therapy involves debridement to expose the wound base for accurate staging.
- Deep Tissue Pressure Injury: Intact skin with localized purple or maroon discoloration.
- Clinical therapy includes cleansing the area, applying moisturizers or barrier creams, and monitoring for progression.
Treatment of Pressure Injuries
- Deep Tissue Injury and Stage 1:
- Clinical manifestations: Intact skin with nonblanchable erythema.
- Clinical therapies: Cleanse the area, apply barrier cream, use protective dressings, introduce support surfaces, and reposition frequently.
- Stage 2:
- Clinical manifestations: Partial-thickness loss of dermis, presenting as a shallow open wound or blister.
- Clinical therapies: Cleanse the area, apply moisture-retaining protective dressings, assess for necrosis and infection, reposition frequently, and provide comfort measures.
- Stage 3:
- Clinical manifestations: Full-thickness tissue loss with visible subcutaneous tissue.
- Clinical therapies: Cleanse the area, debride necrotic tissue, apply medicated moisture-retaining dressings, assess for infection, and manage pain.
- Stage 4:
- Clinical manifestations: Full-thickness tissue loss with exposed bone, muscle, or tendon.
- Clinical therapies: Similar to Stage 3, with additional surgical interventions if necessary.
- Unstageable:
- Clinical manifestations: Full-thickness tissue loss where the base of the ulcer is covered by slough or eschar.
- Clinical therapies: Debridement to expose the wound base for accurate staging.
Nursing Actions and Equipment for Wound Cleansing and Irrigation
- Preparation:
- Gather all necessary supplies and equipment.
- Perform hand hygiene and don appropriate personal protective equipment (PPE), such as gloves.
- Assessment:
- Assess the wound for size, depth, and signs of infection.
- Check the patient's pain level and administer pain relief if needed.
- Cleansing:
- Use sterile saline or prescribed solution to cleanse the wound.
- Gently irrigate the wound using a syringe to remove debris and exudate.
- Dressing:
- Apply a new, sterile dressing to the wound.
- Secure the dressing with tape or bandages as needed.
- Documentation:
- Document the procedure, including the condition of the wound and any observations.
- Equipment:
- Sterile gloves. Sterile washcloths or wipes.
- Sterile saline or prescribed cleansing solution
- Syringe for irrigation
- Sterile gauze and dressings
- Tape or bandages
- Waste disposal bags for soiled materials.
Skin Assessment in Clients with Darker Skin Tones
- Assessment Techniques:
- Examine the least pigmented areas like the buccal mucosa, lips, tongue, nail beds, palms, and soles.
- Identify pallor and cyanosis: Pallor may appear as a yellowish-brown tinge or ashen gray; cyanosis is noticeable in nail beds, lips, and buccal mucosa.
- Check for jaundice: Assess the palms and soles, as yellow pigmentation in the sclerae can be misleading.
- Inspect for pressure injuries, looking for areas darker than the surrounding skin, taut, shiny, or indurated. Moisturizing helps highlight color changes.
- Expected Findings:
- Normal: Even skin tone appropriate to the individual's ethnicity.
- Abnormal: Yellowish-brown or ashen gray pallor, cyanosis in mucous membranes, and yellow discoloration in jaundice.
Age-Related Changes in Skin
- Assessment Techniques:
- Inspect skin color and texture, noting changes in pigmentation, texture, and the presence of lesions.
- Palpate for temperature and moisture, assessing for warmth, dryness, or excessive moisture.
- Evaluate skin turgor, checking for decreased elasticity by gently pinching the skin.
- Expected Findings:
- Normal:
- Older Adults: Paler skin due to decreased melanin and vascularity, drier skin, and less perspiration.
- Children: Smoother skin with minimal exposure to elements.
- Abnormal:
- Older Adults: Increased dryness, presence of age spots, and decreased skin turgor.
- Children: Any signs of abnormal lesions or unusual dryness.
- Normal:
Maximizing Skin Integrity in Older Adults
- Factors Involved:
- Chronic Diseases: Conditions like diabetes, chronic lung disease, and cardiovascular disease impair oxygen delivery and blood flow, hindering healing.
- Nutritional Deficiencies: Reduced RBCs and leukocytes impede oxygen delivery and inflammatory response.
- Vascular Changes: Atherosclerosis and capillary atrophy reduce blood flow to wounds.
- Cellular Changes: Slowed cell renewal, collagen synthesis, and decreased macrophage activity delay healing.
- Nursing Interventions:
- Skin Assessments:
- Perform thorough skin assessments with each repositioning, focusing on heels and bony prominences.
- Use paper tape and tape remover to prevent skin tears.
- Nutrition and Hydration:
- Ensure adequate intake of calories, proteins, and vitamins A and C.
- Encourage smaller, frequent meals and nutritional supplements if needed.
- Mobility:
- Reposition patients regularly to prevent pressure injuries.
- Encourage simple exercises to improve blood flow.
- Infection Control:
- Maintain strict aseptic techniques during wound care.
- Educate patients on proper hand hygiene and wound care.
- Comfort and Safety:
- Use mechanical devices for patient transfer.
- Ensure proper positioning to reduce pressure and improve circulation.
- Skin Assessments:
Surgical Asepsis and Sterile Field in Wound Care
- Surgical Asepsis:
- Surgical asepsis involves practices that keep areas and objects free from all microorganisms.
- It is used in operating rooms, special diagnostic areas, and for procedures like injections, wound dressings, catheterizations, and IV therapy.
- Sterile Field:
- A sterile field is an area free of microorganisms, used during surgical procedures.
- Only sterile objects should touch the sterile field, and edges (1-inch margin) are unsterile.
- Key Principles:
- Sterile objects must be sterile, checking for intact packaging and expiration dates.
- Sterile objects become unsterile when touched by unsterile objects.
- Handling:
- Use sterile gloves or forceps to handle sterile items.
- Keep sterile items in view and above waist level.
- Environment:
- Minimize air movement to reduce airborne contamination.
- Maintain cleanliness and use sterile barriers to prevent moisture contamination.
- Sterile Dressing:
- The procedure: Cleanse hands, donning sterile gloves, and using sterile supplies to cover the wound.
- Wet to Dry Dressing:
- The purpose: Used to debride wounds; wet gauze is applied to the wound, allowed to dry, and then removed to pull away dead tissue.
- Negative Pressure Wound Therapy:
- The mechanism: Uses a vacuum to promote healing by drawing out fluid and increasing blood flow.
- Sterile Technique:
- Involves hand scrubbing, wearing sterile gloves, and maintaining a sterile field.
Capillary Refill Assessment
- Method: Gently press on the nail bed or skin of the finger or toe until it turns white, then release the pressure and observe the time it takes for the color to return.
- Normal Findings: The color should return quickly, typically in less than 2 to 3 seconds.
- Abnormal Findings: A prolonged or sluggish refill time indicates poor perfusion; 3 seconds or more is considered abnormal, especially in children.
- Lifespan Considerations:
- Children: A refill time of 3 seconds or more is considered abnormal and may indicate circulatory issues.
Peripheral Pulses Assessment
- Purpose: To determine the adequacy of blood flow (perfusion) to a specific area of the body.
- Method:
- Assess the pulse on one side of the body and then the corresponding pulse on the other side for comparison.
- Example: Assess the right dorsalis pedis pulse and then the left dorsalis pedis pulse.
- If pulses are the same on both sides, they are considered bilaterally equal.
- If a pulse is not felt at a distal site, check more proximal sites. Example: if dorsalis pedis is absent, check posterior tibial, then popliteal.
- Pulse Sites:
- Upper Body:
- Temporal: Temple of the head.
- Carotid: Side of the throat.
- Apical: Over the heart's apex, medial to the left nipple.
- Brachial: Lateral side of the inner elbow.
- Radial: Lateral side of the inner wrist, above the thumb junction.
- Lower Body:
- Femoral: Groin.
- Popliteal: Back of the knee.
- Posterior Tibial: Back of the ankle.
- Dorsalis Pedis: Center top of the foot, closer to the ankle.
- Upper Body:
- Expected Findings:
- Normal: Pulses are bilaterally equal and palpable.
- Abnormal: Differences in pulses can indicate reduced arterial flow.
Nutritional Support for Wound Healing
- Hydration: Ensure the patient consumes at least 2500 mL of fluids daily, unless contraindicated by other health conditions.
- Essential Nutrients: Adequate intake of protein, vitamins (C, A, B, B5), and zinc is crucial for wound healing.
- Dietary Consultation: Collaborate with a registered dietitian to tailor the patient's nutritional needs.
- Personal Preferences: Consider the patient's personal and religious food preferences when planning meals.
- Balanced Diet: Encourage a diet high in protein, carbohydrates, and vitamins to support the healing process.
- Detailed Explanation:*
- Hydration: Proper hydration is vital as it helps maintain skin integrity and supports cellular functions necessary for healing.
- Nutrient Intake:
- Protein: Essential for tissue repair and regeneration.
- Vitamins:
- Vitamin C: Promotes collagen synthesis.
- Vitamin A: Supports immune function and epithelialization.
- Vitamin B Complex (including B5): Aids in energy production and cell proliferation.
- Zinc: Important for DNA synthesis and immune function.
- Dietary Consultation:* A dietitian can provide specific recommendations to ensure the patient receives the right balance of nutrients.
- Personal Preferences:* Respecting the patient's dietary preferences can improve compliance and overall nutritional intake.
Assessment of the 12 Cranial Nerves
- Olfactory (I):
- Assessment: Test the ability to smell scents (e.g., soap, coffee) with each nostril.
- Normal Findings: Equal sense of smell in both nostrils.
- Abnormal Findings: Anosmia (inability to smell). Considerations: Smell decreases with age; tobacco use can alter the sense of smell.
- Optic (II):
- Assessment: Visual acuity and visual fields.
- Normal Findings: Clear vision and normal visual fields.
- Abnormal Findings: Visual field defects.
- Oculomotor (III), Trochlear (IV), Abducens (VI):
- Assessment: Pupillary light reflex, eye movements.
- Normal Findings: Pupils constrict rapidly; eyes move smoothly.
- Abnormal Findings: Pupils do not constrict; abnormal eye movements.
- Trigeminal (V):
- Assessment: Corneal reflex, facial sensation, jaw movements.
- Normal Findings: Blink reflex, normal sensation, strong jaw movements.
- Abnormal Findings: Absent blink, decreased sensation, weak jaw movements.
- Facial (VII):
- Assessment: Facial movements, taste.
- Normal Findings: Symmetrical facial movements, normal taste.
- Abnormal Findings: Asymmetrical movements, altered taste.
- Acoustic (VIII):
- Assessment: Hearing and balance tests.
- Normal Findings: Normal hearing and balance.
- Abnormal Findings: Hearing loss, balance issues.
- Glossopharyngeal (IX):
- Assessment: Gag reflex, swallowing.
- Normal Findings: Normal gag reflex, effective swallowing.
- Abnormal Findings: Absent gag reflex, difficulty swallowing.
- Spinal Accessory (XI):
- Assessment: Shoulder shrug, head turn.
- Normal Findings: Strong shoulder shrug, head turn.
- Abnormal Findings: Weakness in shoulder shrug, head turn.
- Hypoglossal (XII):
- Assessment: Tongue movements.
- Normal Findings: Smooth, coordinated tongue movements.
- Abnormal Findings: Deviated or weak tongue movements.
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