NUR 309/409 Final Test Map PDF

# NUR 309/409 Final Test Map ## Skin integrity - Review how to describe wounds. Such as by type (abrasion, ulcer, laceration, incision, maceration), depth (superficial, partial or full thickness), duration (acute/chronic) * **Type** * **Abrasion** — scrape, superficial, caused by friction/scraping against a surface * **Ulcer** * **Venous Stasis Ulcers** * Location= lower leg, ankle * Color= red, brown * Fluids= can happen * Borders= irregular * Temp= warm * Edema= yes * Affected= history of leg swelling, blood clots and varicose veins * Treatment= elevate the legs, manage fluids, heal wounds * **Arterial (ischemic) Ulcers** * Location= on the feet, toes * Color= brown, grey, black * Fluids= no * Borders= punched out * Temp= cold * Edema= no * Leg elevated= pale yellow/white * Pain= lots (especially at night) * Affected= history of poor circulation * Treatment= dangle legs, warmth to other extremities, antibiotics, amputations * **Neurotrophic (diabetic) Ulcer** * Location= pressure points at bottom of foot * Color= variable, pink/red or brown/black(depending on circulation) * Borders= punched out, skin around calloused * Affected= diabetes * Treatment= soften/removed callus, identify to prevent * **Laceration** — cut or tear in the skin caused by sharp object * **Incision** — clean, straight cut * **Maceration** — thickening of outer layer of skin due to moisture buildup * **Depth** * **Superficial** — skin, topmost * **Partial** — affecting some layers * **Full thickness** — down to the bone * **Duration** * **Acute** — short term, heals itself * **Chronic** — anything beyond what is normal - Understand the basics of wound and incision care. How do we clean these areas? * Wash your hands * Gather sterile supplies * Do not massage red areas or bony areas * Keep moist * Do not soak * Remove any debris * Clean area around the wound * Dry and cover up - Types of wound drainage * Purulent — puss, infection * Serous — clear body fluid * Sanguineous — bloody * Serosanguinous — little blood and clear - Phases of wound healing 1. **Inflammatory Phase (Reaction)** * Starting — vasoconstriction, platelet clustering, clot formation * 1 – 5 days * Later — vasodilation and phagocytosis * Goal — clean wound to begin repair process 2. **Proliferative Phase (Regeneration)** * 5 – 21 days * Fibroblasts go to wound and form collagen * New blood and lymph vessels sprout from existing capillaries * Epithelization 3. **Maturation Phase (Remodeling)** * 2 – 3 weeks after injury, lasts 3 – 6 months * Breaking down collagen and making a scar - Use the nursing process to review skin integrity focusing on pressure injury prevention. What will you assess, what are some analyses, what are some outcomes and interventions? * **Stage 1 Pressure Injury** * Think normal apple * Intact skin with a localized area and non-blanchable erythema * NO purple or maroon * Interventions — relieve pressure, protection (barrier creams), good nutrition and hydration * **Stage 2 Pressure Injury** * Think peeling of apple * Partial thickness, exposed dermis * Wound bed is viable, pink, red, moist, blisters can be there * NO adipose or deeper tissues visible * Interventions: same as stage 1 with wound cleaning and care * **Stage 3 Pressure Injury** * Think bite of an apple * Full-thickness loss, can see adipose tissue, granulation of tissues present * No connective tissue or bone visible * Epibole * Interventions — same, adding antibiotics and wound cultures * **Stage 4 Pressure Injury** * Think apple eaten to the core * Full-thickness loss, connective tissue and bone visible * Epibole * Intervention — same, adding negative pressure wound care, and specialists * **Deep Tissue Pressure Injury** * Think apple with a bruise * Skin intact on top but tissue damage occurring * Interventions: same, do not debris * **Unstageable Pressure Injury** * Think rotten apple * Covered in eschar or slough so depth can’t be seen * Interventions: remove eschar or slough first to assess depth - What would you assess, and what interventions will you use for the post op patient? * Impaired skin and tissue integrity * Clean, irrigate and dress wounds * Always suction — on, 3 hr window * Apply heat and cold * Immobilize wound - Review wound healing: primary, secondary, tertiary intention * Primary — can put edges of wound together, can heal edge to edge * Secondary — wounds that need to heal from bottom up, can’t do edges cuz of skin loss, usually a chronic wound * Tertiary — wound left open and then closed later ## Urinary Elimination - Understand the pathophysiology of urinary incontinence (know the various types), the risks, diagnoses that are pertinent, outcomes and appropriate interventions * **Normal** * Bladder fills (200-450 mL of urine) * Activates stretch receptors * Signals void reflex center * Contraction of detrusor muscle * Conscious relaxation of external urethral sphincter * **Age Factors** * **Infants** * 15 to 60 mL per kg * No voluntary control * **Children** * Mature neuromuscular sys * Good communication * Enuresis — invol urination * Nocturnal enuresis * **Older adults** * Kidney function decrease * Loss of stuff * Nocteria * Incomplete emptying * **Urinary Incontinence Types** * **Urge** — sudden need to pee * Cause — overactivity of detrusor muscle * **Stress** * Cause — damage to nervous system * **Reflex** — damage to nervous system * **Overflow** — overfilled bladder * Cause — can't make it to the toilet * **Total** * Cause — physical or cognitive impairment * **Nocturnal Enuresis** - Review some of the physiology of the urinary tract, the urethra, the bladder, the ureters, the kidneys and understand the implications of blockages in any of these areas. What would be the cause of problems in each area, what can one do to prevent these problems? - Review the process of various specimen collection. * **Normal Urine** * Color — clear yellow, transparent * Odor — none or light * No microorganisms, protein, glucose, ketones - Review the infection methods in regard to foley catheters and perineal care. * **Catheter** * **CAUTI** * Aseptic technique * Daily cleaning * Keep it closed * Regularly empty * **Perineal** * Daily cleaning * Proper wiping * Avoid moisture and skin breakdown - Review UTI, the disease process, how to assess, analyze, and intervene. * **Urethritis** — inflammation of urethra * **Cystitis** — inflammation of bladder * **Pyelonephritis** — inflammation of kidneys * **Signs** * Foul smelling * Pyuria — puss in urine * Dysuria — diff w/urination * Hematuria * Bladder spasm * Edema * Back pain, chills, nausea, fever * Altered mental status in elders * **Treatment and Prevention** * Hydration * Proper wiping * Cotton clothing * No tight clothing ## Bowel Elimination - What are some screening options related to the bowel? * Ultrasounds * Direct visualization * ERCP * Stool studies * Swallow studies - Review specimen collection for bowel elimination like stool for occult blood, stool for c-diff. * Stool for occult blood * Stool for C-Diff. - Review factors that increase constipation and diarrhea. Review what to assess, nursing analyses related to this along with interventions to treat and prevent these problems. * **Diarrhea** * Increased motility, and lots of other stuff * **Managing:** * Proper dietary teachings * Clear liquid, BRAT * Medications * Not for acute * Diphenoxylate w/atropine, loperamide * **Constipation** * Decreased motility, and lots of other stuff * **Managing** * Increase high fiber, intake, activity * Positioning * Laxatives - Discuss the nursing process in regard to bowel elimination, what will you assess (what are some abnormal assessments, post op complications, analyses, outcomes, interventions and evaluation). * **Assessing** * Bristol Stool Scale * Unformed, liquid — increase motility * Hard, dry — decrease motility * Excessive amounts — high fiber * Small amount — low intake, GI obstruction, constipation * Pencil thin — inflamed mucosa * Ribbon shaped — obstruction * Pungent — infection, blood in stool ## Infection Control - Review the types of precautions: How do you prepare for Contact, Droplet, Airborne precautions, and standard precautions. * **Contact** pathogens spread by direct or indirect contact * Precautions: private room, PPE * **Droplet** = pathogens spread by moist droplets * Precautions: same as contact, mask and eye protection w/in 3 ft of person affected * **Airborne** = pathogens spread by air currents * Precautions: ventilation sys, same as contact, negative air pres rooms, N95 masks - Review the chain of infection. How do you break the chain at each link? What are those interventions? What teaching can you do to help patients to understand infection control and break the chain of infection. * **Infectious Agents** * Pathogens * Normal flora becomes pathogenic * *Breaking chain:* hand washing, meds, antibiotics * **Reservoir** * Where the pathogens are before infecting humans * *Breaking chain:* hygiene, counter cleaning, decontamination, keeping things clean, watching over food, animals, bugs * **Portal of Exit** * How the organism gets out * Body fluids * Cough * Sneezing * Wounds * IV, tubes, lines * *Breaking chain:* aseptic technique, cover wounds, hygiene, cough etiquette * **Mode of Transmission** * Now out of reservoir, how it will get to host * Contact * Direct or indirect * Droplet * Airborne * *Breaking chain:* ?? * **Portal of Entry** * How it gets into human * *Breaking chain:* clean covered wounds, skin barrier, aseptic technique * **Susceptible Host** * Person with poor defense * *Breaking chain:* immunization, vaccines ## Review handwashing - Review how you would prioritize patient care when dealing with a case load of patients with various diagnoses, who would you care for first? * ABCD * Maslow's * Acute/Chronic ## Safety - Review the concepts of fall safety. What factors increase fall risk? What are the interventions we can do to prevent falls in the acute setting and in the home. What are the intrinsic and extrinsic factors for falls. - Review fire safety: P.A.S.S., R.A.C.E. ## Pain - What are the effects of pain? Review the body symptoms for how pain can affect function? - Understand how to assess and manage chronic pain and intractable pain, pain among pt's with a history of dependency. How do these approaches and precautions vary? - Review the different types of pain and the underlying causes. * Cutaneous/superficial: surface level not deep * Deep somatic: muscle injury, ligaments, tendons, nerves, bones * Visceral: organ pain, not localized * Radiating/referred: moving from one location to another, pain in distant area not expected * Phantom: pain in nonexistent area * Psychogenic: pain created by brain - Use the nursing process to assess, analyze, create outcomes, interventions, and evaluations for a pt complaint of pain. * **Assessment** * Ask * Score it * Onset, location, duration, how often, timing, descriptions * **Analyzing/Planning** * Different for every person ## Nutrition/Fluid Status: - Understand the effects of substances like caffeine, fiber have on the body. * Caffeine — increases, acts as stimulant * Fiber — acts a regulator and aids - Understand how to calculate intake and output. * Intake — stuff going in * Output — stuff going out * Record * Fluid balance = Total intake — total output - Understand how to obtain a nutrition assessment, know the risks for malnutrition. * **Nutrition assessment** * Medical and dietary history * Height, Weight, BMI * VS, skin turgor, muscle mass * Labs * Blood in glucose — none = brain damage * Hemoglobin — iron and protein * Albumin — long term Nutritional status * Half-life 21 days * Pre-albumin — half-life 8 days * Transferrin — half-life 2 days * BUN and Creatine — kidneys * Nitrogen balance * + = enough proteins to build * - = breakdown for fuels * **Malnutrition** * Low weight and muscle mass * Fatigue * Slow, sluggish - Review ranges for acid/base & electrolytes and common sources * **Acidosis** * Serum pH < 7.35 * Resp cause: holding CO2 * COPD, pneumonia, not getting enough air * Metabolic cause: loss of bicarbonate * DKA, renal disease, pancreatic, aspirin tox, dehyd, diarrhea * **Alkalosis** * Serum pH > 7.45 * Resp cause: blowing off CO2 * Excersize, anxiety, stress, increase RR, hyperventilation * Metabolic cause: increase in bicarbonates/loss of acids * N/V, diarrhea, hypovolemia, hypokalemia * **Acid-Base Regulation** * **Buffer sys** * Fastest * **Respiratory mechanisms** * Longer * Resp rate + depth increase * **Renal mechanisms** * Longest * Regulation of carbonate lvls in blood * Takes hormones to trigger kidneys - Review diets, what is a renal diet, carb controlled, Cardiac. When would these be used? * **Cardiac** — D. Low NA, Low Fat, Low Caffeine, No Smoking * **GERD** — A. Avoids Large Meals, Eating Late, OH, Caffeine, and Smoking * **Renal DX** — E. Low Phosphorus, NA, K+, Fluid Restriction * **Diverticulosis** — C. High in Fiber to Prevent Re-occurrence * **Dysphagia†** — B. Modifies Texture of Foods and Consistency of Liquids ## Review basic vitamins and minerals & know common sources | Electrolyte | Normal | Sodium | Rda | Potassium | Critical | Calcium | Critical | Magnesium | Critical | |---|---|---|---|---|---|---|---|---|---| | Hypo lvl | *Meds *Lots of water and alcohol *Burns *Adrenal insuf * Heart, kidney, liver disease | *Critical <120* *Meds *Lots of water and alcohol *Burns *Adrenal insuf *Heart, kidney, liver disease | *2300 mg/day* | *3.5-5 2600 - W 3400 - M *Critical = <3 *Meds — furosemide *Metabolic alkalosis *Decrease oral intake *Lots of sweat *Lots of alcohol* *CKD, DKA* | * <3* | *9.5-10 600 800- older *Critical <4.5* *Low vit. D *Hormone *Low albumin lvl* | * <4.5 * | *1.3-2.1 *Critical = <0.5 *Decrease intake + absorb* *Malnutrition *T2DM *Alcohol* | * <0.5 * | ## Hypo S/S | *Dry *Decrease weight *Lethargy *Severe= headache, irritability *Severe= muscle twitching *Decrease LOC* | *Muscle weak *Constipation *Fatigue *Neuro- paralysis *Severe= paralytic ileus *Hypotn *Arrthymias* | *Acute Cardiac *Chronic Resp *Bones *Skin* | *Weakness *Dysrthy *Cramps *Seizures *Resp weak* | - Nursing Care | *Seizures + coma *Fluid restriction *Diuretics *Treat underlying cause* *Seizure precautions *IV Fluids = 0.9% NaCl or greater* | *Underlying cause *Supplements* | *Increase intake *Treat alcohol use* | ## Foods | Foods | | Potato | Bannan | | Cheese | Milk | Critical | Spinach | Beans | |---|---|---|---|---|---|---|---|---|---| | Hyper lvl | | | Leafy Avocado | | | | *Critical = > 160* *Loss of body fluid volume *Vomiting *Excessive sweating *CKD *Diabetes *Impaired thirst response* | *Critical = > 6.1* *Renal fail *Dehydrate *Acidosis *Sepsis *Diabetes* | *Critical = > 13* *Cancer *Hyperparathyr oidism* | Rare *Kidney disease *Lots of laxatives* *Li use* *Elderly* | ## Hyper S/S | *THRIST *Muscle weakness *Severe muscle twitching *Decrease LOC *Seizures *Fluid replacement — free water and IV low in Na* *Diuretics* | *N/V *Muscle ache *Decrease tendon reflexes *HF *Arrthy, dysrhy *Underlying cause *Diuresis *Insulin & dextrose *Dialysis* | *Constipation *N/V *Anorexia *Polyuria *Neuro *Muscle weak *Phosphates *IV, diuretics* | *Bradycardia -> heart block *Resp distress -> apena* | ## Documentation - Review SBAR and how to give hand off report, telephone and verbal orders. How would you document them? * **Verbal order** = during emergency, only during critical time or **Telephone order** = Write what you hear, repeat what you wrote, get confirmation, make sure you have date, text, provider, and your signature, needs to be signed by the provider within 24 hrs. - Be aware of the different types of documentation: focused, charting by exception, narrative note. ## Teaching - Review how to teach in each domain of learning, how do you write outcomes for each, how do you evaluate each? * **Cognitive** — storing and recalling information from the brain * Simple to complex processes * Writing instructions * Educating o Teach back * Effective = patient understands and knows info they need to know * **Psychomotor** — Brain to hands, hands on skill * Demonstrations * Effective = patient can show you * **Affective** — lifestyle choice * Role modeling * Support groups ## Sensory - Review how to meet the sensory needs of the pts. To improve safety. Focus on methods to decrease sensory overload, sensory deprivation, to meet the needs to visual, auditory and tactile deficits. * **Vision** * Assessment = vision tests, asking patient directly * Intervention = make sure lightening is good, stay in patients' visual field, provide visual stimulation * **Hearing** * Assessment = hearing tests, asking patient directly * Intervention = providing music, making room silent, taking away or adding any stimulation * **Smell** * Assessment = smell tests, ask patient directly, smell and see if there are any odors * Intervention = clean room, remove any odors, provide nice odors * **Sensory overload** * Cues = anger, short tempered, silent, etc. * Risks = can make disease worst * Intervention = take away extra stimulation * **Sensory deprivation** * Cues = silence, restlessness, depression, annoyance * Risks = depression, withdrawal * Intervention = add stimulation * **Altered mental status** * Redirection/reorientation * explain things simply * use your name * don't make them feel dumb * short direct sentence * respond to feelings * **Decreased levels of consciousness** * SAFETY * airways and oxygenation * maintain secretions * head position * IV fluids * nutrition * neuro-checks * **Seizure** * **Before** * SAFETY * Education * Know seizure plan * **During** * Note the time when it started and ended * Airway open * Lay on side * Watch O2 * Wait 5-6 minutes * Watch head * Give rescue meds * **After** * Neuro-checks * Oxygenation * Vital signs * Conscious * Look for risks and causes * Assess for injury ## Oxygenation - Review oxygen and how elevation can affect oxygenation and perfusion. * **Oxygenation** — oxygen is delivered into the blood from the lungs and then to the rest of the body * **Perfusion** — delivery of oxygenated blood to the tissues and removal of waste * **Elevation** * harder to breath * Less oxygen readily available - Review how to teach a pt to cough and deep breath, incentive spirometer, pursed lip breathing. * **Incentive spirometer** * Inhale into the device and then hold it at the level you were told * Repeat - Review the signs of early and late hypoxia. How do we manage the pt with dyspnea? * **Hypoxia** — not good oxygen levels in the tissue at the cellular level * Causes — crap ton * Cues — skin discoloration, cold, clubbing of fingers, dizzy, restless/anxiety * Treatments — oxygen * **Early signs** * Restlessness * Tachypnea, tacycardia * **Late** * Elevated BP * Adventious lung sounds * Confusion * Bradycardia, bradypnea * Hypotension * Cardia s/s - Using the nursing process, assess factors for oxygenation, diagnosis, outcomes, interventions, and evaluation. * **Assessment** * Breathing pattern * Respiratory effort * Pulse oxy * Positioning * **Interventions** * Oxygen therapy * Spirometry * Mobilize secretions - Review factors that affect perfusion and circulation. How do we assess tissue perfusion, what are the analyses, outcomes, interventions, etc? ## Sleep - Understand the mechanism of sleep, the sleep cycle, the emotional and physical benefits of sleep. The role of the brain stem in sleep. * **Mechanisms of sleep** * Circadian Rhythm * Bio clock * Sleep-Wake Homeostasis * Helps the body remember to sleep * Regulates level of sleep depending on sleep deprivation of person * **Sleep Cycle** 1. **Transitional** * a. Lightest * b. Mostly alpha and beta brain waves * c. Breathing normal, skeletal muscle tone pres. * d. 1–5 minutes, 5% of total cycle 2. **Light Sleep** * a. Deeper * b. K-complex waveforms trigger brain stem * c. Harder to wake up * d. HR and temp decrease * e. 25 minutes but gets longer with each cycle * f. 50% * g. Number of cycles increase with age 3. **Deep Sleep/Slow wave/Delta sleep** * a. Deepest * b. Delta waves * c. Waken now = confusion * d. Repairing occurring * e. Declines with aging * f. About 40 minutes 4. **REM** * a. Dreaming * b. Looks like awake cycle * c. Skeletal muscles atonic * d. Breathing irregular, erratic HR elevated * e. 90 mins after falling asleep * f. 10 minutes but gets longer with each cycle * g. Helps with a lot (i.e. emotion, memory, immune sys, etc.) - How do you perform a sleep assessment? What do you assess? ## Immobility and Exercise: - Review ROM, be aware of the terms for each and the motions that go along with terms. ## Nursing Process: - What can and can't be delegated? - Review the nursing process and understand the function and classification of each stage.

NUR 309/409 Final Test Map PDF

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