Exam 3 Review PDF

Exam 3 Review Anna and Olivia Pressure ulcer management/prevention - Reposition patient every 2 hours if patient is at risk for skin breakdown - Elevate HOB 30 deg or less - Use chuck to boost patient in bed - Need good incontinent care to prevent moisture - Incontinence episodes:...

Exam 3 Review Anna and Olivia Pressure ulcer management/prevention - Reposition patient every 2 hours if patient is at risk for skin breakdown - Elevate HOB 30 deg or less - Use chuck to boost patient in bed - Need good incontinent care to prevent moisture - Incontinence episodes: clean area with no-rinse perineal cleaner and protect skin with moisture barrier ointment.. Keep skin dry - AVOID HOT WATER AND SOAP: increases dryness - Make sure skin is completely dry and apply 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 dark wound bed or blood-filled blister Skin Cancer Prevention - Most important risk factor: exposure to UV radiation from sun and tanning sources - Increased risk for melanoma related to increased number of sunburns - Family history - Certain medication therapies - Fair skin that burns easily (lack of melanin) - TO PREVENT: reduce sun exposure during midday, protective clothing, sunglasses, sunscreen SPF 15 or high with protection against both UVA and UVB rays, avoid indoor tanning, annual screenings, self checks (well-lighted room using full length and handheld mirrors) Assessing cyanosis Skin Assessment Color Temperature: use back of hand to palpate Turgor Lesions Bruising Moisture Needlestick Injuries - FIRST action for sticks: Wash puncture and small wounds with soap and water for 15 minutes. Be aware of wash station locations in your facility based on what shift you’re working. - Apply direct pressure to lacerations to control bleeding and seek medical attention. Needle Safety Pre-Injection: - Wash your hands!!! - Gather supplies (syringe, needle, alcohol) - Draw up your medication using clean technique. - Complete the 5 rights. - Patient Education Other info: - Always use smallest available syringe for medication volume and measurement of dose (ie. units vs. ml’s). - Be sure to swab the skin for 15 seconds with an alcohol prep pad for EVERY injection. - Choose needle size based on route. - Always use safety needles when available. NEVER RECAP A NEEDLE! ⬤Subcutaneous (pinch and let go after the needle is in the skin, then administer. Administering while holding the skin fold decreases the space available and can cause mild tissue injury).  Loss of red-pink tones from oxygenated hemoglobin Associated with: anemia, shock, arterial insufficiency, Pallor vasoconstriction Bluish mottling due to decreased perfusion, increased level deoxygenated blood Color Cyanosis Non-specific – assess other clinical signs Associated with shock, cardiac arrest, heart failure, chronic bronchitis, congenital heart disease Intense red color due to excess blood in dilated superficial capillaries Changes Erythema Expected with fever, inflammation, emotional reactions May be associated with other medical conditions Yellowish tone due to increased bilirubin in blood Jaundice Physiologic jaundice may occur normally in newborn Otherwise abnormal; may occur with hepatitis, sickle cell disease, cirrhosis, transfusion reactions, *hemolytic disease in newborn Cranial Nerves Corneal Reflexes - Trigeminal Nerve - Assess corneal reflex is person has abnormal facial sensations or abnormalities of facial movement *** Take a wisp of cotton and touch the patient's cornea*** Normal response is to blink  Use following sequence for complete neurologic examination: mental status, Neurological Assessment cranial nerves, motor system, sensory system, reflexes 1. Mental status (level of alertness, - Perform a screening neurologic appropriateness of responses, orientation to examination on well persons with no date and place) significant findings from history 2. Cranial nerves (II–visual acuity, pupillary light reflex; III, IV, VI–eye - Perform a complete neurologic movements; VII–facial strength (smile, eye examination on persons with closure); VIII–hearing neurologic concerns 3. Motor function: Strength (shoulder - Perform neurologic recheck abduction, elbow extension, wrist extension, examination on persons with finger abduction, hip flexion, knee flexion, demonstrated neurologic deficits who ankle dorsiflexion); coordination (fine require periodic assessments finger movements, finger to nose); gait (casual, tandem) 4. Sensation (one modality at toes can be light touch, pain/temperature, or proprioception) 5. Reflexes: Deep tendon reflexes (biceps, patellar, Achilles); plantar responses Identifying a Client’s Level of Consciousness Level of Consciousness Easily arousable/ arousable to voice/ touch/ sternal rub ***Lethargic: can easily arouse by calling name, but the patient remains drowsy during the conversation.** Obtunded: needs more stimulus to wake up Stuporous: needs intense and repeated stimulus to wake up and once woken up will fall back to sleep. Semi-coma: will move when vigorously stimulated, otherwise will not respond to external stimuli Coma: will not respond to any stimulus Glasgow Coma Scale The Glasgow Coma Scale. Because the terms describing levels of consciousness is hard, the Glasgow Coma Scale (GCS) is an accurate and reliable quantitative tool. The GCS is a standardized, objective assessment that defines the level of consciousness by giving it a numeric value. - Three categories of eye opening response, motor response, and verbal response. ***someone who scores a 6 would need total nursing care, someone who scores a 15 would be independent**** Assessing Hearing Abnormalities Assessing Muscle Strength Test the strength of major muscle groups for each joint. ask the person to flex and hold as you apply opposing force. Muscle strength should be equal bilaterally and fully resist your opposing force Rate them on a scale of: 0- No contraction to 5- Full ROM against gravity, full resistance. ****complete range of motion against gravity with full resistance is scored as a 5**** Complications of Wound Healing Hemorrhage: ○ Bleeding from wound site Infection: ○ Invasion of microorganisms ○ s/s: erythema, green/yellow drainage Dehiscence: ○ Partial or total separation of wound layers Evisceration: ○ Protrusion of visceral organs through wound opening ○ Cover area with sterile moist dressing Braden Scale Predicts pressure sore risk Preparing a Sterile Field Know principles of surgical asepsis on p478 p&P 1. Sterile objects remain sterile only when touched by another sterile object 2. Only sterile objects must be placed on a sterile field 3. A sterile object or field outside of the range of vision or an object held below the person's waist is considered contaminated 4. A sterile object or field becomes contaminated by prolonged exposure to air – minimize movement in the area, talking or laughing without masks, 5. If a sterile surface becomes wet, it is contaminated 6. Fluid flows in the direction of gravity 7. The edges of a sterile field are considered contaminated Disposal of Contaminated Dressing - Nonsterile gloves: remove soiled dressing, dispose in biohazard Insomnia: Difficulty falling asleep, staying asleep or getting high quality sleep All about SLEEP Stages of Sleep: - REM - 25% of sleep - Increased brain activity with rapid eye movement and muscle atonia - Important for memory and learning - NREM: - 75% sleep - Important for tissue repair and regrowth IM injection The larger the gauge the smaller the needle Vertigo vs Syncope - True vertigo: rotational spinning caused by neurological disease in brainstem or ear - Objective: Do you feel room is spins? - Subjective: Do you feel that you are spinning? - Syncope: sudden loss of strength & temporary loss of consciousness - r/t lack of blood flow ( low BP) Abnormal Posturing - Decorticate: arms folded in tight against chest - Lesion of cerebral cortex - Decerbrate: arms out to the side and wrists outward, back is arched - Lesion of the brain stem at brain at midbrain or upper pons - MORE SEVERE RANGE OF MOTION Abduction—Moving a limb away from the midline of the body Adduction—Moving a limb toward the midline of the body Circumduction—Moving the arm in a circle around the shoulder Inversion—Moving the sole of the foot inward at the ankle Eversion—Moving the sole of the foot outward at the ankle Extension—Straightening a limb at a joint Flexion—Bending a limb at a joint Pronation—Turning the forearm so the palm is down Supination—Turning the forearm so the palm is up Retraction—Moving a body part backward and parallel to the ground Rotation—Moving the head around a central axis External rotation- rotating away internal rotation- rotating inward Dorsiflexion Lifting the front of the foot, so that the top of the foot moves toward the anterior leg (toes pointed up) plantar flexion- while lifting the heel of the foot from the ground or pointing the toes downward Complications of immobility Musculoskeletal Abnormalities Arthritis Kyphosis Scoliosis Transferring Patient ** assess weight bearing ability ** - Tighten abdominals and keep back, neck, pelvis and feet aligned - Avoid twisting - Bend at knees; keep feet wide apart - Use arms and legs not back to lift Transferring Nursing Interventions - Plan how to do it - Obtain equipment - Remove any obstacles - Explain to patient what you are doing Physiological Changes with Age 1. Decrease muscle mass 2. Decrease muscle strength 3. Bone density decreases = increase osteoporosis 4. Tendon/Joint break down 5. Postural changes 6. Gait and Mobility 7. Increase risk falls Mobility Considerations for Patients Medicate for pain Make sure they are wearing brace or sling Give walker or device Follow with a wheelchair Clear the area of obstacles Slipper socks or shoes Motivations- take outside if able, bribe with treat Make a plan to walk for later, check boxes on the board Involve family Interventions to prevent falls/during falls/ post fall Prevention: Assisted devices: - Walker - Cane - Wheelchair - Crutches During: Lower to the ground - Call for help. Press button in room - Call team to bedside - Assess patient. - If vitals are stable and no head strike then can proceed to help them off the floor - Incident report - Post Fall: Precautions Teach the client to use the call light. Keep the client’s bed in the lowest position and locked Place a fall-risk identification band on the client’s wrist. Assess the client every 2 hr for any needs (bathroom, food, personal items..) Bed alarm Slipper socks commode/ urinal/ personal items within reach