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Questions and Answers
Which of the following is NOT a risk factor for melanoma?
Which of the following is NOT a risk factor for melanoma?
The Braden Scale is used to assess the risk of falls.
The Braden Scale is used to assess the risk of falls.
False
To prevent pressure ulcers, it is recommended to avoid hot water and soap when cleaning the skin.
To prevent pressure ulcers, it is recommended to avoid hot water and soap when cleaning the skin.
True
What is the term for the bluish mottling of the skin due to decreased perfusion and increased levels of deoxygenated blood?
What is the term for the bluish mottling of the skin due to decreased perfusion and increased levels of deoxygenated blood?
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What is the first action to take in the event of a needlestick injury?
What is the first action to take in the event of a needlestick injury?
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Which of the following is NOT a stage of pressure ulcer development?
Which of the following is NOT a stage of pressure ulcer development?
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Which cranial nerve is responsible for the sense of smell?
Which cranial nerve is responsible for the sense of smell?
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Match the following terms with their descriptions:
Match the following terms with their descriptions:
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What is the term for the protrusion of visceral organs through a wound opening?
What is the term for the protrusion of visceral organs through a wound opening?
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A ______ is the term for a bluish-purple color of the skin.
A ______ is the term for a bluish-purple color of the skin.
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What is the medical term for a sensation of spinning or dizziness?
What is the medical term for a sensation of spinning or dizziness?
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What is the term for a condition where the arms are folded in tight against the chest and the legs are extended and rigid?
What is the term for a condition where the arms are folded in tight against the chest and the legs are extended and rigid?
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Which of the following is NOT a potential complication of immobility?
Which of the following is NOT a potential complication of immobility?
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The larger the gauge of a needle, the smaller the needle diameter.
The larger the gauge of a needle, the smaller the needle diameter.
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What is the term for a condition where the arms are extended outward, the wrists are outward, and the back is arched?
What is the term for a condition where the arms are extended outward, the wrists are outward, and the back is arched?
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Which of the following is NOT a recommended nursing intervention for transferring a client?
Which of the following is NOT a recommended nursing intervention for transferring a client?
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A sterile field is considered contaminated if it is exposed to air for an extended period.
A sterile field is considered contaminated if it is exposed to air for an extended period.
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A sterile field is considered contaminated if it is wet.
A sterile field is considered contaminated if it is wet.
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REMs sleep is important for tissue repair and regrowth.
REMs sleep is important for tissue repair and regrowth.
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The edges of a sterile field are considered contaminated.
The edges of a sterile field are considered contaminated.
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Which of the following is a sign of a potential pressure ulcer?
Which of the following is a sign of a potential pressure ulcer?
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The Romberg Test is used to assess hearing problems.
The Romberg Test is used to assess hearing problems.
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What is the primary nursing intervention to prevent falls?
What is the primary nursing intervention to prevent falls?
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Match the following terms relating to sleep with their descriptions:
Match the following terms relating to sleep with their descriptions:
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A patient with a Braden Scale score of 15 is independent with regards to nursing care.
A patient with a Braden Scale score of 15 is independent with regards to nursing care.
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A patient with a Braden Scale score of 6, requires total nursing care.
A patient with a Braden Scale score of 6, requires total nursing care.
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Syncope is a type of spinning sensation.
Syncope is a type of spinning sensation.
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The ______ test is used to assess hearing loss by comparing the conduction of sound through air and bone.
The ______ test is used to assess hearing loss by comparing the conduction of sound through air and bone.
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The Weber test is used to assess a patient's ability to balance.
The Weber test is used to assess a patient's ability to balance.
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What are the recommended nursing action if a client falls?
What are the recommended nursing action if a client falls?
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Incontinence is a contributing factor to the development of pressure ulcers.
Incontinence is a contributing factor to the development of pressure ulcers.
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Which of the following is NOT a physiological change associated with aging?
Which of the following is NOT a physiological change associated with aging?
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Muscle strength is rated on a scale of 0-10, with 10 being the strongest.
Muscle strength is rated on a scale of 0-10, with 10 being the strongest.
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Study Notes
Pressure Ulcer Management/Prevention
- Reposition patients every 2 hours if at risk for skin breakdown.
- Elevate the head of the bed (HOB) to 30 degrees or less.
- Use a mechanical lift to assist patients in bed.
- Provide meticulous incontinent care to prevent moisture.
- Clean incontinent areas with a no-rinse perineal cleanser and apply a moisture barrier ointment.
- Keep skin dry.
- Avoid hot water and soap, as this increases dryness.
- Ensure skin is completely dry before applying moisturizer.
Pressure Ulcer Identification
- Stage 1: Non-blanchable erythema of intact skin.
- Stage 2: Partial-thickness skin loss with exposed dermis.
- Stage 3: Full-thickness skin loss.
- Stage 4: Full-thickness skin and tissue loss.
- Unstageable pressure injury: Full-thickness skin and tissue loss obscured by slough or eschar.
- Deep-tissue pressure injury: Localized area of non-blanchable dark discoloration, or epidermal separation with a dark wound bed or blood-filled blister.
Skin Cancer Prevention
- The most critical risk factor is exposure to ultraviolet (UV) radiation from the sun and tanning beds.
- Increased risk of melanoma is linked to a higher number of sunburns.
- A family history of skin cancer increases risk.
- Certain medications increase risk.
- Lighter skin that burns easily is more susceptible to skin cancer (lack of melanin).
- Protect yourself by reducing midday sun exposure, wearing protective clothing and sunglasses, applying high SPF sunscreen, avoiding indoor tanning, and performing regular self-skin checks.
Assessing Cyanosis
- Bluish mottling due to decreased perfusion and raised levels of deoxygenated blood.
- Non-specific; assess other clinical signs—associated with shock, cardiac arrest, heart failure, chronic bronchitis, and congenital heart disease.
- Lighter skin: central—generalized dusky blue color; peripheral—dusky nail beds.
- Darker skin: skin may appear dull, lifeless, and difficult to detect; check conjunctivae, oral mucosa, and nail beds.
Skin Assessment
- Color: Assess skin tone.
- Temperature: Palpate skin using the back of the hand.
- Turgor: Evaluate skin elasticity by gently pinching the skin.
- Lesions: Identify any sores, wounds, or unusual skin markings.
- Bruising: Determine if any marks or discoloration are present.
- Moisture: Assess moisture content of the skin.
Needlestick Injuries
- For puncture wounds and small cuts, wash with soap and water for 15 minutes.
- Know the location of wash stations in your facility.
- Control bleeding from lacerations using direct pressure.
- Seek medical attention immediately.
Needle Safety
- Wash hands thoroughly before each injection.
- Gather all necessary supplies (syringe, needle, alcohol).
- Properly draw up the medication.
- Follow the "5 rights" of medication administration.
- Educate patients on essential information.
- Always use the smallest available syringe for the correct dose.
- Before each injection, clean the injection site for 15 seconds with an alcohol wipe.
- Use the appropriate needle size for the given route.
- Use safety needles where available.
- Never recap needles.
- When performing subcutaneous injections, grip skin and withdraw needle.
Pallor
- Loss of red-pink tones due to decreased oxygenated hemoglobin.
- Associated with anemia, shock, arterial insufficiency, and vasoconstriction.
Cyanosis
- Bluish or purplish discoloration due to increased deoxygenated blood.
- Non-specific, assess other clinical signs.
- Associated with shock, cardiac arrest, heart failure, chronic bronchitis, and congenital heart disease.
Erythema
- Intense redness due to excess blood in dilated superficial capillaries.
- Expected with fever, inflammation, and emotional responses, and can occur with many medical conditions.
Jaundice
- Yellowish tone due to increased bilirubin.
- May occur normally in newborns or occur in conditions such as hepatitis, sickle cell disease, cirrhosis, transfusion reactions, or hemolytic disease.
Cranial Nerves
- Detailed information on cranial nerves, including their functions and assessments.
Corneal Reflexes
- Assess the corneal reflex using a wisp of cotton and touching the cornea.
- Normal response is blinking. Assess the reflex if a patient has abnormal facial sensation or facial movement abnormalities.
Neurological Assessment
- Screening neurological examination on individuals without significant previous history.
- Complete neurological examination for persons with concerns.
- Neurological re-check examination for patients with evident deficits.
- Essential steps for a complete neurological examination: mental status, cranial nerves, motor functions, sensory system, and reflexes.
Identifying a Client's Level of Consciousness
- Easy arousal to verbal/tactile stimulation.
- Lethargic: easily aroused by calling name but drowsy.
- Obtunded: increased stimulus needed to rouse.
- Stuporous: intense and repeated stimulation needed to rouse.
- Semi-coma: movement only with vigorous stimulation.
- Coma: no response to any stimulus.
Glasgow Coma Scale
Assess of levels of consciousness using a numeric scale for each category of response (eye opening, motor, and verbal). A score of 6 denotes severe impairment, needing full nursing care; a 15 suggests independence.
Assessing Hearing Abnormalities
- Weber's test: vibrating tuning fork placed on the head. Normal hearing identifies sound equally in both ears.
- Rinne test: assess air and bone conduction. Normal is air conduction greater than bone conduction (AC > BC).
- Romberg test: evaluates balance, discussed in another lecture.
Assessing Muscle Strength
- Test strength of major muscle groups for each joint.
- Ask the patient to flex and hold while applying opposing force.
- Muscle strength should be equal bilaterally and fully resist the opposing force.
- Rate muscle strength on a scale of 0 (no contraction) to 5 (full range of motion against gravity with full resistance).
Complications of Wound Healing
- Hemorrhage: bleeding from the wound site.
- Infection: invasion of microorganisms (symptoms include erythema, green/yellow drainage).
- Dehiscence: partial or complete separation of the wound layers.
- Evisceration: protrusion of internal organs through the wound opening.
Braden Scale
- Predicts the risk of pressure ulcers.
- Assess sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
Preparing a Sterile Field
- Sterile objects remain sterile when touched by another sterile object.
- Only sterile objects can be placed on a sterile field.
- Objects outside the line of sight or below the waist are considered contaminated.
- Exposure to air contaminates objects. Movement should be minimized.
- Wet surfaces are contaminated.
- Fluids adhere to the force of gravity.
- Edges of the sterile field are contaminated.
Disposal of Contaminated Dressings
- Remove soiled dressings using non-sterile gloves and dispose of them in biohazard receptacles.
Insomnia
- Difficulty falling asleep, sustaining sleep, or experiencing restorative sleep.
Stages of Sleep
- REM sleep (25%): rapid eye movement, muscle atonia, important for memory and learning.
- NREM sleep (75%): increased brain activity, important for tissue repair and growth.
IM Injection
- Larger gauge = smaller needle.
- Provide specific needle geometries for common routes of administration (ID, SC, IM).
Vertigo vs. Syncope
- Vertigo involves rotational spinning associated with neurological disease in the brainstem or inner ear. Objective is if the room is spinning; subjective feeling the room is moving.
- Syncope involves a sudden loss of strength and temporary loss of consciousness, usually due to low blood pressure (low BP).
Abnormal Posturing
- Decorticate: arms flexed and pulled into the chest. Indicates a cortical lesion.
- Decerebrate: arms extended and stiff. Signifies a brain stem lesion. Decerebrate is more severe than decorticate posturing.
Cranial Nerve Function and Assessment
- Detailed table of cranial nerves: their type, function, and assessment methods.
Dressings By Pressure Injury Stage
- Different types of dressings for various stages of pressure injury, with notes pertaining to how long the dressing should remain in place and what other aspects to consider when making the choice of dressing materials for the pressure injury.
Range of Motion
- Explains specific movements (abduction, adduction, circumduction, inversion, eversion, extension, flexion, pronation, supination, retraction, rotation, external rotation, internal rotation, dorsiflexion, and plantar flexion) related to joints.
Complications of Immobility
- Potential complications of inactivity, including respiratory (pneumonia, atelectasis, pulmonary embolism), cardiovascular (postural hypotension, cardiac muscle atrophy, deep vein thrombosis), neurological (depression, anxiety), musculoskeletal (osteoporosis, muscle atrophy, contractures), metabolic (glucose intolerance, negative nitrogen balance), renal (calculi, nephritis), skin (pressure ulcers), and gastrointestinal (constipation, fecal impaction).
Musculoskeletal Abnormalities
- Diagrams and descriptions of normal and abnormal spinal curvatures (lordosis, kyphosis, scoliosis) and arthritis.
Transferring a Patient
- Pre-Transfer: Assess weight-bearing ability, ensure abdominal muscles, back, neck, pelvis and feet are aligned, and avoid twisting.
- Transfer: Bend at the knees and keep feet apart; use appropriate assistive devices and techniques focusing on positioning.
- Post-Transfer: Consider patient needs and provide support.
- Interventions: Plan, obtain equipment, remove obstacles, and explain the process to the patient.
Transferring Nursing Interventions
- Plan the transfer, obtain equipment, remove obstacles, and inform the patient on what you're doing.
Physiological Changes with Age
- Describes the effect of aging on the body's physiological functions, including muscle mass and strength loss, bone density decrease (osteoporosis), tendon/joint breakdown, posture changes, gait and mobility, and risk of falls.
Mobility Considerations for Patients
- Inpatient: Assess patient needs, provide appropriate aids (braces, slings, walkers, wheelchairs), clear obstacles, and use appropriate footwear.
- Motivations: Encourage patient, provide motivation, and consider family involvement.
Interventions to prevent falls/during falls/ post fall
- Prevention - devices and planning
- During Fall - proper procedure for assisting a fall
- Post-Fall - precautions for safety and further monitoring.
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Description
Test your knowledge on the management and identification of pressure ulcers. This quiz covers preventive measures, proper care techniques, and the stages of pressure injuries. Enhance your understanding of best practices in patient skin care.
