NURS 210 EXAM 3

keratinocytes

Cells formed in the basal layer of the skin that function to protect the skin from the external environment.

melanocytes

Cells that are produced in the epidermis and produce melanin. - melanin: A pigment that determines the color of the hair and skin.

ergonomics

- Study of body mechanics in relation to the demand and design of the work environment and the equipment used. - important role in prevention of injury

Gastroesophageal reflux

- backflow of gastric fluids into the esophagus that can result in irritation of the tissue - may occur due to supine position

line of gravity

ear, shoulder, hip, knee, ankle

The parent of an 8-year-old child tells the clinic nurse of a concern that the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse would plan to make which response?

"At this age, children are developing their own personalities."

During an exercise session with a client who had vascular surgery to the leg, the nurse flexes and then extends the knee. The client looks surprised and asks why the nurse is performing this activity. What should the nurse include in a response?

"Passive range of motion will help maintain muscle tone until you can participate more actively in the exercises."

removing or applying dry dressing changes

- Assess pain and administer pain medications 30-60 min prior if needed - measure wound - clean cleanest to dirtiest on wound, then second swab for one side and third for other side - apply dressing and label it (write on tape and then apply it)

proliferative phase

- begins 3 days after the injury and can last up to 24 days - blood supply to the wound continues to improve - granulation tissue also develops - presence of collagen allows wound to mature

large bottle drainage

- if large amount of fluid is expected - change when half-full to measure drainage, place at eye level and draw line next to fluid level on bottle - document amount, color, volume

Positive Family Dynamics

- Assistance with child care after birth of new infant - Respite care for a caregiver - Support after injury or death of a spouse - Presence during surgery - Family reunions - Celebrations of birthdays and other significant events - Praying together - Supportive in-laws - Sharing care of a dependent family member

skin frailty

- At-risk vulnerable skin. - impairments in mobility, congenital conditions i.e. spina bifida, cerebral palsy, liver failure, kidney disease and cancer

Langerhans cells

- Cells found in the epidermis that play a role in cutaneous immune system reactions. - ingest and package foreign antigens to be presented to lymphocytes, which then trigger an immune response in the epidermis.

Negative/Dysfunctional Family Dynamics

- Child abuse - Codependency (related to substance abuse by a family member) - Interfering in-laws - Intimate partner violence - Marital infidelity - Placing blame for birth of a preterm infant or for death of a young child by SIDS - Sibling rivalry - Adolescent pregnancy

Industry vs. Inferiority (Childhood)

- Children at this stage are becoming more aware of themselves as individuals and learning complex skills. - When children are encouraged to achieve while at the same time praised for their accomplishments, they learn industriousness, perseverance, and putting work before pleasure.

Sensorimotor (Piaget)

- 0-2 years - With increased mobility and awareness, infants explore the world through direct sensory and motor contact. Object permanence and separation anxiety emerge.

wound irrigation

- 0.9% sodium chloride solution - removes surface materials and decreases bacterial levels in the wound. - helps rid wound area of necrotic tissue, purulent drainage, or debris

formal operation (Piaget)

- 12 years to adult - Adolescents reason abstractly and think in hypothetical terms. They can test hypotheses, and can expand and refine their thinking and reasoning skills as they achieve cognitive maturity. - the child's basic abilities to think abstractly and problem-solve are similar to an adult's

adolescence

- 12- 20 years - puberty begins

infancy

- 2 days of age to toddlerhood - During the first 2 months, infants develop the ability to hold their head erect and steady when held in the upright position; roll side to side - 4 months: front to side, lift head when prone, sit with support - 5 months: double birth weight - 6 months: pick up objects, deciduous teeth - 10 months: wiggle and crawl, sit unsupported - by end of first year: stand while holding furniture

Preoperational (Piaget)

- 2-6 years - Children use symbols (words and images) to represent objects and learn to express themselves through language and symbolic gestures, but do not yet reason logically. - egocentric thinking

semi-open dressings

- 3 layers - bottom: knit gauze infused with therapeutic ointments - middle layer: padding and absorbent gauze - final layer: adhesive * DO NOT control drainage well and can result in poor wound healing and breakdown of tissue adjacent to wound

clean dressings

- 48 hours after sterile technique - at home

Concrete operational (Piaget)

- 6-12 years - Children can think logically about concrete objects and can add and subtract. They understand the concepts of reversibility and spatiality, and can classify, socialize, and apply rules. - child is able to see another's point of view and is able to classify, order, and sort facts and see a variety of solutions to a problem.

late adulthood

- 65 years and older - heart valves thicken and become more rigid - peristalsis decreases - external sphincters weaken - taste changes, vision diminished

myocardial infarction (MI)

- A condition in which arterial blood flow to the heart muscle is blocked resulting in death of cardiac muscle cells. - DVT could lead to blood clot traveling to heart

shearing

- A force parallel to the surface of the skin. - occurs client is sitting or lying in an incline - results in stretching and trauma to the blood and lymphatic vessels

tunneling

- A narrow channel or passage way extending in any direction from the base of the wound - measure by gently inserting a sterile premoistened cotton tip applicator under the wound edges until resistance is felt.

hematoma

- Accumulation of blood in the body. - early removal drains has been associated with this

seroma

- Accumulation of serous fluid - early removal drains has been associated with this

Identity vs. Role Confusion (Adolescence)

- Adolescents are concerned about their appearance, body image, achieving a sense of identity and independence, and finding a meaningful place in society. - Successful resolution of this stage requires experimentation with different roles and exploration of different identities.

cardiovascular system effects of immobility

- After only 24 hours of bed rest, body fluids normally present in the lower extremities will be redistributed to the head, abdomen, and chest areas due to the change in gravitational force. - increases blood volume and hormones released result in diuresis and potential dehydration

doing for

- An action, a performance of tasks or activities, or an attitude - can be comforting activities

damage into skin layer

- An area of skin that is lighter in color than the usual skin tone - Open or intact blister - Shallow wound with a pink or red bed

lacerations

- Any tearing of the skin, usually caused by blunt or sharp objects. - often irregular or jagged shape

Autonomy vs. Shame and Doubt (Toddlerhood)

- Children at this stage develop a sense of independence and autonomy as they gain control over their bodies and explore their environment. - If caregivers provide encouragement, patience, and a secure environment from which the child can venture out and explore, toddlers can develop self-reliance and autonomy.

body mechanics

- Combined effort from the musculoskeletal and nervous systems to maintain posture, alignment, and balance. - how a person uses their body to do things

risk-minimization interventions

- Correct position of the bed: keep head of bed lower than 30 degrees, flex knees and place pillows under armpits to keep from sliding down - supportive surfaces: special pressure-relieving beds - Protection of bony prominences, skin, and mucosa under drains and other medical device

cultural competency models for health care providers and facilities has five key elements

- Cultural awareness: self-assessment of one's own culture and biases about individuals of other cultures - Cultural knowledge: being willing to learn about another person's cultural values, beliefs, and activities - Cultural skill: ability to accurately assess clients' cultural beliefs, values, and lifestyles - Cultural encounters: interactions with clients from cultures different from one's own - Cultural desire: commitment to become connected with clients' cultures

Category 5: The Three Modes of Care Decisions and Actions

- Culture care preservation and maintenance: Supporting or assisting clients to maintain their personal beliefs and values related to their culture. - Culture care accommodation and/or negotiation: Supporting or assisting clients to adapt their current personal beliefs and values related to their culture with the goal of providing safety, health, and optimal wellness. - Culture care repatterning and restructuring: Supporting or assisting clients to restructure their personal beliefs and values related to their culture with the goal of allowing for improved health outcomes.

cerebrovascular accident

- Death of brain cells due to a blood clot or the rupture of a blood level within the brain. - DVT could lead to blood clot traveling to brain

hormonal changes occurring during puberty triggered by hypothalamus

- Follicle-stimulating hormone (FSH) stimulates the development of eggs in females and sperm in males - luteinizing hormone (LH) stimulates the testes to secrete testosterone and the ovaries to secrete estrogen - estosterone and estrogen stimulate the development of primary and secondary sex characteristics and influence growth

open dressings

- Gauze bandages, after being moistened with 0.9% sodium chloride - wet-to-dry: gauze dries and tissue clings so necrotic tissue is removed but healthy can be too ** RARELY USED IN PRACTICE TODAY**

eschar

- Hard nonviable black/brown tissue found in the wound bed. - once eschar removed, wound reveals stage 3 or 4

three phases of wound healing

- Hemostatic or Inflammatory - Proliferative - Remodeling

hypoperfusion

- Inadequate supply of blood circulation, which results in low oxygen levels in tissues.

surgical wound healing stages

- Incision appears red days 1-4 - changes to bright pink days 5-14 - pale pink day 15- 1 year

Category 3: The Central Core of the Sunrise Enabler

- Influencers - Care expressions, patterns, and practices - Holistic health, well-being, disability, illness, dying, and death

sarcopenia

- Loss of lean muscle caused by immobility - caused by deterioration of twitch fibers in voluntary muscles

skin tears

- Loss of the top skin layer caused by mechanical forces. The severity of a skin tear is defined by the depth of the skin layer loss. - decreased collagen nd elasticity can increase risk for skin tears

what's included in mobility assessment

- Normal mobility status - Ability to sit - Ability to stand - Ability to walk - Use or need for assistance - Degree of mobility and immobility - Condition of the skin - Presence of any manifestations during activity

damage with skin intact

- Persistent redness or discoloration - Temperature difference compared to the surrounding skin - Firmness in the area

Initiative vs. Guilt (Preschool)

- Preschoolers continue to explore their environment and try out different roles. - Parents and caregivers need to permit their toddlers to explore their environment within safe limits and boundaries. When parents and other caregivers encourage and support children's quest for independence while simultaneously helping them make prudent and acceptable choices, children develop a sense of direction and purpose.

childhood obesity

- Primary prevention of childhood obesity must begin early to promote healthy lifestyle habits and ensure optimal health in adolescence and adulthood - Obesity in childhood increases the risk for diabetes, hypertension, cardiac conditions, pulmonary complications, muscular skeletal problems, and psychological disorders

evisceration

- Protrusion of internal organs through a surgical wound that has dehisced or opened. - emergency situation - sterile saline-soaked dressing should be placed on organs and the client prepped for surgery

proper body mechanics

- Stand or move as close to the object as possible. - Keep the abdominal muscles contracted and the lower back in its normal position. - Maintain the head upright with shoulders raised up. - Bow the hips slightly and squat. - Do not twist the torso. - Always pivot or side-step. - Push up from the knees and use that momentum to lift the object.

Category 2: Rays of the Sun Within the Sunrise Enabler

- Technological factors - Religious, spiritual, and philosophical factors - Kinship and social factors - Cultural values, beliefs, and lifeways (way of living) - Biological factors - Political and legal factors - Economic factors - Educational factors

Unstageable Pressure Injury: Obscured Full-Thickness Skin and Tissue Loss

- The full damage in the wound bed cannot be determined - Obscured full-thickness skin and tissue loss injury - covered in slough and eschar

debridement

- The process of surgically removing dead tissue and other debris that can cause infection - decreases number of bacteria and stimulates wound closure and epithelization

telehealth

- The provision of both clinical and nonclinical aspects of health care delivery through the use of telecommunication devices such as the internet and telephone. -example of telehealth is a nurse who provides client education or a pharmacist who monitors medication compliance.

fetal period

- This is the last stage of prenatal development. It begins at the ninth week and ends at birth

Intimacy vs. Isolation (Early Adulthood)

- This stage centers on forming intimate relationships with others. - Successful resolution of this stage requires the ability to form close, meaningful relationships with others.

trust v.s. mistrust (infancy) Ericksons

- This stage centers on the infant's basic needs for caring and comfort being met through the interaction between the infant and the caregivers - when caregivers are reliable and consistent sources of food, comfort, and affection, the infant learns trust

Generativity vs. Stagnation (Middle Adulthood)

- This stage is characterized by a focus on contributing to society and future generations. - Successful resolution of this stage involves finding ways to make meaningful contributions to society and future generations.

Integrity vs. Despair (Late Adulthood)

- This stage is characterized by reflection on one's life and coming to terms with the inevitability of death. - Successful resolution of this stage involves acceptance of one's life and the ability to find meaning and satisfaction in one's accomplishments.

wound measurement

- Tracing the wound circumference and calculating the wound surface area using a see-through film - Measuring the length and width of the wound using a ruler - use same method throughout treatment

Apgar score

- Uses 5 indicators (Appearance, Pulse, Grimace, Activity, and Respirations) to quickly determine whether a newborn requires immediate medical care at 1 minute and 5 minutes after birth. - highest (best) 10, but 7 or higher is normal

applying anti-embolism stocking

- Using stockings that are not the correct size can create a reverse pressure gradient. This increases the risk of DVT. - measure leg - ensure room to move toes - smooth stockings avoid wrinkles - 2 inches below knee or 2 inches below buttocks - assess clients' circulation and comfort 30 min after

biological debridement

- Various enzymatic agents, such as collagenase, papain (papaya extract), and bromelain (pineapple extract), can be applied to wounds to clear dead tissue and debris - larvae therapy (green bottle fly and Australian sheep blowfly liquefy necrotic tissue

deep vein thrombosis (DVT)

- a blood clot inside a deep vein, usually within the extremities. - immobility increases blood viscosity and atrophy of muscles which assist in pumping blood - venous stasis occurs and increases chance of clot

fecal impaction

- a hardened mass of stool that creates a blockage in the intestines

dangling

- act of having a client sit on the edge of the bed before moving to a standing position

portable wound bulb suction device

- active closed system - bulb emptied at least every 8 hours or when more than half-full - assess fluid, document date, time, color, and volume - fluid discarded into toilet

Changes to the structure and function of tendons, ligaments, and cartilage begin to occur after as few as 4 days of bed rest

- alterations in collagen fibers - changes in tissue tension, elasticity, and shape, leading to joint stiffness and decreased ROM - Prolonged immobilization causes formation of abnormal tissue within and between the joint spaces, which restricts nourishment to the joint

pulmonary embolism

- an obstruction of blood flow in a pulmonary artery due to the movement of blood clot from an extremity to the lungs. - most serious complication of DVT

sterile dressings

- applied after surgery and are usually kept on the incision site for 24 to 48 hours

achieving surgical asepsis may include:

- applying a hair cover, mask, protective eyewear, and show covers - performing hand scrub - applying sterile gown and sterile gloves *only individuals who have performed a surgical hand scrub and donned sterile gown and gloves should touch the sterile field.

performing dressing change and sterile wound irrigation/packing

- assess pain - if dressing is dry and adhering (add saline to help remove) - measure and assess wound, and tunneling -face shield and mask used for irrigation - begin irrigation at upper end of wound and flow down. make sure to not wash from contaminated to decontaminated area, use pads to pad dry, dont pad same area twice - packing for deep wounds and with tunneling - use prescribed topical medication around wound after packing

hemostatic or inflammatory phase

- begins the moment injury occurs and lasts 3 to 6 days -blood vessels constrict, damaged tissues release proteins that trigger the activation of various clotting factors - histamines released -->vasodilation and increased capillary permeability - white blood cells flood the area and clean the wound (phagocytes) - neutrophils enhance release of cytokines, which in turn promote new blood vessel formation, increase fibroblast and keratinocyte production, and aid in tissue maturation.

zygote period

- begins with conception and lasts approximately 2 weeks - series of cell divisions and continues to divide and change as it moves down the fallopian tube to the uterus

enabling

- being a guide through situations and events - effective communication is crucial

jean Piaget: cognitive development

- believed that intelligence is an inborn, natural ability that develops as children grow and adapt to their environment - children go through four distinct stages of cognitive development: sensorimotor, preoperational, concrete operational, and formal operational thought

location of pressure injury formation

- bony prominences, including the heels, toes, sacrum, hips, elbows, shoulders, and back of the head

climacteric

- both males and females eventually experience a change of life - in females is referred to as menopause (hot flashes, night sweats, vaginal dryness, and heart palpitations) - In males gradual and less dramatic

mechanical debridement

- can be achieved with wound irrigation or wet-to-dry dressings - when dressings removed, necrotic tissue also removed - autolytic debridement uses wound's own fluids to self-digest nonviable tissue

staples

- can be placed more rapidly than sutures - healing is faster (7-14 days) and staples removed - complications: scarring

center of gravity

- central point of weight for an object or the body. While standing, the imaginary line for the center of gravity runs horizontally just below the umbilicus, intersecting with the line of gravity - creating wide base feet shoulder-width apart increases stability

Attention-Deficit/Hyperactivity Disorder

- characterized by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development - Symptoms can occur as early as 3 to 6 years old, and most children with ADHD receive a diagnosis during the elementary school years. - Nurses can offer education and support to children and families to help children focus and organize tasks and schoolwork, monitor their behavior, and improve social skills.

Chronic wounds

- chronic venous insufficiency - peripheral artery disease - diabetes mellitus - immunocompromised - acute wounds with disruption in healing

pastoral care

- client-focused service that provides support to clients, families, and staff with ethical, spiritual, and religious needs - Chaplains are individuals who provide spiritual care

slide or transfer board

- clients are usually immobile or acutely ill and unable to assist - minimum of three to four staff members should be used when performing this type of transfer

Young Adulthood

- complete their physical growth by age 20, all organs and body systems are fully developed and mature by this age - brain maturation continues beyond adolescence, extending until approximately age 25 years - quarterlife crisis

secondary sex characteristics

- darker, coarse pubic hair - larynx and coal cords increase in males - distribution of fat and increase width of hips/pelvic of females - sebaceous glands become larger and more active

wound drains

- decrease accumulation of fluid, reduce accumulation of air, collect wound drainage for testing and identification - active or passive - open or closed

Autism Spectrum Disorder

- developmental condition that affects communication, socialization, and behavior - symptoms generally appear in the first two years of life - Risk factors include having a family member with ASD, older parents, genetic conditions, and a very low birth weight

toddlerhood

- developmental period that typically occurs from 12 months of age until 36 months of age - walk and run, toilet trained

- factors influencing wound healing

- diabetes mellitus - infection - presence of foreign body in wound - medications (steroids prevent formation of collagen and fibroblasts) - malnutrition -tissue necrosis (death because of diminished blood flow) - hypoxia - multiple wounds

dry v.s. wet dressings

- dressings changed based on provider but often every 2 days - wounds with dressings heal faster

semi-occlusive dressings (hydrogelalginates)

- dry wounds for debridement of necrotized tissue and eschar - can provide moisture to or draw moisture away from the wound depending on the needs of the wound - soothing effect, but may require frequent dressing changes -used to maintain a moist environment for wound healing

walker

- elbows at 15 degree bend

electrical stimulation and pressure injuries

- electrical stimulation for stage 2, 3, 4 stimulates granulation of wound bed and decreases pain. - promotes blood vessel growth, granulation, and stimulates circulation

kyphosis

- excessive outward curvature of the upper area of the spine - common in older adult females

risk factors for negative family dynamics

- expansion, trust violations, loss of financial stability, abusive behaviors, substance use, severe injury or illness, and death of a family member.

other factors contributing to pressure injuries and wounds

- exposure to moisture - tearing - cuts - bruises - friction

Primary wound healing

- first intention - occurs in clean lacerations and surgical incisions closed with skin adhesives or sutures - fastest to heal Ex: a surgical incision, a clean suture line, and a minor puncture wound

fragility fractures

- fractures that occur following stress on a bone that would not typically result in a break.

Stage 3 Pressure Injury: Full-Thickness Skin Loss

- full-thickness skin loss and visible adipose tissue - granulation tissue often present, and wound edges may be rolled - undermining and tunneling may be present - fascia, muscles, tendons, bone, ligament, and cartilage are not visible

Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss

- full-thickness tissue loss - fascia, muscles, tendons, ligaments, cartilage, and/or bone are visible - edges rolled - undermining and tunneling may be present - dead tissue may also be seen

gastrointestinal system effects of immobility

- gastrointestinal tract uses gravity to optimize the movement of food - decreased appetite and overall food intake - absorption of protein from the gastrointestinal tract decreases --> risk of malnutrition - constipation

Genitourinary System Effects of immobility

- gravity enhances the drainage of urine from the kidneys - can increase risk of urinary retention

purulent

- green/yellow wound drainage - indicates infection and should be reported to provider

bones

- hard connective tissues that create the rigid structure and shape of the human body - constantly remodeling: process of bone breakdown and replacement that occurs throughout a lifespan

prolonged immobility

- has physiological, psychological, and cognitive effects - reduces mechanical load and stress on bones, contributing to loss of mass, density, strength

contaminated and dirty surgical wounds

- have higher bacterial loads and may interfere with healing. - may be left open and require long-term wound management for healing

adulthood health risks

- heart disease - cancer - Type 2 diabetes

complications of drains

- hematoma -seroma - clot formation at insertion site - small tissue fragments obstruct tubing - accidental removal of drainage tube

universal measures for prevention and treatment of tissue injuries

- hygiene - hydration - nutrition - circulation

promoting skin integrity

- identify clients at risk - implement interventions to reduce risk

Swanson's Theory of Caring

- includes five distinct categories: maintaining belief, knowing, being with, doing for, and enabling - the implementation of these five categories improves clients' well-being

braids worn tightly to scalp

- increase the risk of developing an occipital pressure injury, esp if client is immobile - can lead to scarring, alopecia, permanent hair loss

age-related changes affecting mobility in older clients

- increased thoracic spinal curvature with head protrusion - increased flexion in knees and hips - poor balance - slow movement - joint stiffness - ankle and foot weaknesss - less endurance/ decreased strength - lower vision acuity and reduced depth perception

pneumonia

- infection of lung tissue - in clients with limited mobility as a result of shallow breathing, thickened mucus, and decreased ability to cough

skin assessment info

- inspect underneath all medical devices - pain at site of pressure points is red flag and can be warning of pressure injury formation

interventions for minimizing risk

- kept dry, repositioned frequently - If on side tilt body to 20-30 degree angle and use pillows for support - early mobilization

remodeling or maturation phase

- last phase, begins around day 21 and can last more than a year - collagen formed in the granulation tissues of the wound during the proliferative phase is replaced with stronger collagen, aiding in wound maturation - Wound closure continues - myofibroblasts secrete proteins that produce a contractile force pulling the wound edges together.

culture

- learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guides their thinking, decisions, and actions in patterned ways. - can impact not only the way that clients live their lives, but also the way they perceive and receive health care

deep tissue pressure injury (DTPI)

- localized, persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color.

disuse osteoporosis

- loss of skeletal mass, density, and strength caused by immobility. - results in fragile bones

circular portable wound suction device

- low vacuum pressure - to empty, open plug, and empty into measuring cup, wipe with alcohol and replace plug.

maintenance of muscles

- maintenance of muscle mass requires a significant supply of oxygen and glucose. When muscles are not used, they atrophy

risk factors contributing to pressure injury development

- malnutrition - immobility - reduced perfusion - altered sensation - decreased level of consciousness

wound assessment

- manifestations of healing - presence of infection - changes in color - amount and odor of exudate - appearance, size, and healing

applying sequential compression devices

- measure legs - remove every 8 hours or according to the facility - should be removed if indication of DVT

homeopathy

- medical approach that believes a substance that can cause a disease can also cure it - is a component of naturopathy

semi-occlusive dressings (foams)

- mild to moderate exudate, but more frequent dressing changes - may produce malodorous discharge

semi-occlusive dressings (polymeric membranes)

- mildly exudative wounds - stimulate growth of new epithelium and do not stick to the wound bed - less trauma to the new granulation tissue

semi-occlusive dressings (hydrofiber)

- moderate and highly exudative wounds - high absorbency and can stay in the wound for several days, less maceration than alginate

recommended exercise

- moderate-intensity aerobic activities for at least 150 min per week (30 min per day, 5 days a week)

subcutaneous tissue

- mostly adipose tissue - absorbs shock, insulates body, pads internal organs and structures - contains blood vessels and nerves that assist in thermoregulation and sensation

functions of skeletal muscle

- movement - posture and positioning - generate body heat

passive range of motion

- movement of a joint by another individual - the muscles and joints are completely relaxed while external motion and forces move the body part - preserves the flexibility of the joint, but it does not prevent loss of muscle mass or bone demineralization

Maintaining belief

- nurse portrays a hopeful attitude and assists clients in achieving or maintaining a positive attitude and finding meaning in life - Can be recognition of faith, in others, in God, or in a higher power

knowing

- nurse's awareness of assessment data, factors influencing the situation, and knowledge of the client's perception of the situation

mobility assessment

- objective assessment to determine the amount of assistance required for ambulation and transfers based upon the client's ability to move

crutches

- often in younger clients - axilla crutches so pads rest 1-2 inches below axilla - hand grips level with hips - elbows have 15-30 degree bend when holding hand grips

embryo period

- once implanted into uterine wall - continued cell division and differentiation - Structures that support, nourish, and protect the developing organism are formed, including the placenta

late adulthood health risks

- osteoporosis - Alzheimer's disease

Most often pressure injuries occur:

- over bony prominences *can also develop by medical devices: urinary catheters, oxygen tubing, endotracheal tubing, surgical wounds/drains

atelectasis

- partial or complete collapse of airways and small sections of the lung as a result of shallow breathing. The collapsing of the lung during expansion. - this decreases number of alveoli available

Stage 2 Pressure Injury: Partial-Thickness Skin Loss

- partial-thickness skin loss, with pink or red viable tissue - The tissue is moist, and deeper tissues are not visible - may present as ruptured serum-filled blister

Penrose drain

- passive and open - gauze placed to collect fluid

puberty

- period of rapid growth and development resulting in emergence of sexual differences between females and males regarding adult body size, composition, and shape - development of secondary sex characteristics - ends with menarche (first menstrual period) and spermarche (sperm production)

using crutches

- place two crutches in unaffected side when sitting and stand up - crutch stance 6 inches in front and to side of feet - 4- point gait: tolerate partial weight bearing on both legs. opposite leg and crutch moves forward together - 3-point gait: cannot bear weight on one leg. move both crutches forward, and then move unaffected leg forward (using only one leg) - 2-point gait: can manage partial weight on both legs, require less support than 4 point gait. pretty much same as 4-point

middle childhood

- preschool years to adolescence 6-12 - children should get at least one hour of physical activity per day -immunizations - malocclusion

integumentary system effects of immobility

- pressure injuries

nutrition essential for wound healing

- protein - omega-3 and omega-6 fatty acids - vitamins A and C

semi-occlusive dressings (alginate)

- recommended for moderate to highly exudative wounds - provide hemostasis, high absorptive abilities, can remain in a wound for several days, so they require less frequent dressing changes - calcium alginate: is absorbent and is used in stage 4 wounds or those with deeper tissue injury - secondary dressing needed to cover

semi-occlusive dressings (films)

- reduced ability to absorb moisture, oxygen can enter wound + promote wound healing and decrease wound infection risk, provider can visual wound - dont use with wounds with lots of exudate

respiratory system effects of immobility

- reduces the amount of air exchanged and increases the risk of infection - supine positioning impairs the ability of the ribcage to freely expand due to the physical restriction caused by the bed - decreases depth of breaths

Failure to thrive (FTT)

- refers to children whose current weight or rate of weight gain is much lower than that of other children of similar age and gender

Lawrence Kohlberg: Moral Development

- refers to the changes in a person's thoughts, emotions, and behaviors that influence their beliefs about right and wrong - moral dilemma story of Heinz

passive drains

- rely on gravity to remove accumulated fluid - Penrose drains

mechanical lift

- required for clients who are unable to support their own weight - Inspect the sling for manifestations of wear and ensure the base of the lift is placed in the maximum open position before use

secondary healing

- second intention - when wound is left open and granulation tissue forms from bottom up - prolonged healing process, wound must be kept moist - higher risk of infection

closed drains

- sends fluid to closed containment system - reduces risk of infection and allows more accurate measurement of drainage

braden scale (6 categories)

- sensory perception, moisture, activity, mobility, nutrition, and friction and shear - lowest score 6 and max is 23 -lower the score the greater risk client has for alterations

cane

- single-point or four-point models - top of cane should be level with inside of wrist - when gripping cane, elbow should be bent at 15-30 degrees - use cane on good side - advance cane, then move weaker leg forward parallel with cane. then move strong leg forward past cane.

Stage 1 Pressure Injury: Non-blanchable Erythema

- skin is intact with a localized area of non-blanchable erythema

semi-occlusive dressings (hydrocolloid)

- small abrasions, superficial burns, pressure injuries, and postoperative wounds - maintain moist wound bed, bacteriostatic properties, stimulate growth of new granulation tissue + comfortable - can cause dermatitis, foul smelling gelatinous film (dont be confused with purulent drainage)

middle adulthood

- spans the period of life from the mid-forties through the early sixties - growth and progression, childbearing, economic stability, work responsibilities - but also empty nesters, become grandparents, care for elderly parents - fat deposits in trunk region

Negative pressure wound therapy (NPWT)

- speeds up wound-healing - Should NOT be used in area with skin cancer, anticoagulants, poor tissue health, or have exposed vessels, nerves or organs, or wounds with tracts/tunneling. - applies negative pressure to porous foam or gauze dressing - assists healing stage 3 and 4 pressure injuries

preschool age

- stage of early childhood development which generally refers to children from ages 3 to 6 years old. - screen time should be limited to no more than one hour per day

deciduous teeth

- starts to emerge at about 6 months - Commonly known as baby teeth. They are the first set of teeth and will be lost and replaced by permanent teeth.

wound culture collection

- sterile cotton applicator, needle aspiration or tissue biopsy - for sterile cotton applicator: clean wound with 0.9% sodium chloride, swab, place applicator in vial to keep swap moist -if wound large may need to take more than one culture - note if patient is on any recent antibiotic or anti-fungal therapy

renal calculi

- stones that develop in the kidney and usually related to dehydration or an increase of stone-forming substances. - incomplete drainage of kidneys can leads to stones

adolescence health risks

- substance abuse - eating disorders - depression

functions of skeletal system

- support -protect (internal organs) - produce: red bones marrow produces RBC, WBC, platelets, and macrophages - storage: calcium, phosphorous, magnesium, iron, lipids - movement

delayed primary closure

- tertiary intention - combination of primary and secondary - wound left open for 5-10 days before closed with sutures - decreases risk of infection in wounds not considered clean at time of injury

spina bifida

- the neural tube does not close properly - low folic acid (folate) intake is a chief contributor to spina bifida

epidermis

- the outermost layer of skin - squamous epithelial cells - barrier to external environment - contains keratinocytes (protect from water loss, pathogens and injury) - melanocytes - Merkel cells - Langerhans cells

drains removed when

- total wound drainage for a 24 hour period is between 30-100 mL - after removal gauze applied to drain site

acute wounds

- traumatic wounds: lacerations - surgical wounds - moisture-associated skin damage

fetal alcohol spectrum disorder (FASDs)

- triggered when alcohol in the mother's blood passes to the fetus through the umbilical cord - leading cause of developmental disabilities in the United States - often have a low birth weight, misshaped face, small head, thin upper lip, short nose, and widely spaced eyes - hyperactive behavior, attention and memory problems, learning disabilities, speech and language delays, poor judgment skills, and a variety of health problems.

Down syndrome

- trisomy 21, extra chromosome 21 - intellectual disabilities as well as congenital heart defects, gastrointestinal anomalies, weak neuromuscular tone, audio and visual impairment, characteristic facial and physical features, and early-onset Alzheimer's disease - incidence of Down syndrome increases with maternal age

foot drop

- type of joint contracture that results in a partial or total inability to pull the toes up toward the head (dorsiflexion) - results from nerve entrapment and shortening of the calf muscles and Achilles tendon in the lower leg

spiritual distress

- uncomfortable feeling related to a questioning of life's meaning, the client's belief system, and anger toward a higher power or the universe. It produces distressing manifestations such as despair, anger, uncertainty, and fear. -The nurse is well positioned to provide spiritual support to clients

active drains

- use negative pressure to suction drainage from wounds or body cavities - portable wound bulb suction devices

skin adhesives

- used as alternatives to sutures and staples - small minor wounds with straight edges - cosmetic look - liquid paste sets in few minutes, glue peels off in 5-7 days

mechanical sit-to-stand

- used to assist the client in rising from a seated to a standing position - appropriate for a client who possesses the lower extremity strength and balance required to maintain an upright position, once that position is achieved

embryonic period

- usually begins the third week after conception and lasts until the end of the eighth week during which body structures and internal organs develop -three cell layers form : - ectoderm, mesoderm, endoderm

three major categories of chronic lower extremity wounds with different etiologies

- venous disease wounds - arterial disease wounds - neuropathic disease wounds These wounds predispose clients to the development of pressure injuries.

active range of motion

- voluntary movement of a joint by client without any type of assistance

sutures

-made from synthetic materials such as nylon or polyester, or from natural fibers such as silk, linen, and dried animal intestines - absorbable or non-absorbable -Synthetic can dissolve within days to weeks - non-absorbable has been associated with prolonged pain and suture sinus at site

8. The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? 1. "Do you have any allergies?" 2. "Will you be able to wash your own hair?" 3. "Are there any areas you want us to spend more time bathing?" 4. "Do you have any preferences regarding how we help you bathe?"

1. "Do you have any allergies?"

The care plan for a client diagnosed with end-stage renal disease who just began hemodialysis identifies spiritual distress in the client problem list. Which comments by the client to the nurse would validate that diagnosis? Select all that apply. 1. "I can't see much point in going on like this." 2. "I really hate this place. I'll be glad to get out of here and back to my own bed." 3. "Can you find a priest to come and talk to me sometime?" 4. "What kind of a God would let this happen to me?" 5. "Being in the hospital is really depressing."

1. "I can't see much point in going on like this." 3. "Can you find a priest to come and talk to me sometime?" 4. "What kind of a God would let this happen to me?" Rationale: Not seeing "much point in going on" indicates the client is depressed and needs to discuss his options with someone. Asking for a priest is a valid request to help the client understand the effect his end-stage renal disease has on his spirituality and ultimate end-of-life care. Questioning God's will is indicative of spiritual distress.

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply.

1. "I should not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 4. I need to have spare crutches and tips available."

A 78-year-old client who is visually impaired is admitted to the nursing unit. Which intervention by the nurse would be most appropriate in reducing sensory deprivation? 1. Adjust window shades to reduce glare. 2. Keep doors open to provide indirect light in the room. 3. Avoid use of overhead lighting. 4. Keep lights in the room dimmed.

1. Adjust window shades to reduce glare. Rationale: Reducing glare can help improve vision for the older client. Indirect light may not be sufficient to maximize visual acuity in older clients. The quality of the light source is more important than its location (overhead). Dim lights reduce the client's perception of the environment.

In planning nursing care to prevent pressure injury in a client confined to bed, the nurse should include which interventions? Select all that apply. 1. Lift the client when turning or repositioning. 2. Assess the condition of the bed linens frequently, changing whenever damp or soiled. 3. Vigorously massage bony prominences. 4. Post a turning schedule at the client's bedside. 5. Use a bed sheet that has been folded into quarters for a turning sheet.

1. Lift the client when turning or repositioning. 2. Assess the condition of the bed linens frequently, changing whenever damp or soiled. 4. Post a turning schedule at the client's bedside. Rationale: Sliding the client may create shearing forces that can further damage the skin and lead to the development of pressure injury, so the client should be lifted to avoid skin shear. A single-thickness pad or sheet will create fewer wrinkles and reduce the risk for pressure injury.

7. Before acting upon the perceived nonverbal behavior of a client from Italy, the nurse should do which of the following? 1. Validate his or her perception. 2. Use a translator. 3. Get another nurse to assess the client. 4. Form a conclusion about nursing priorities.

1. Validate his or her perception. Rationale: Nonverbal behavior may have varied meaning among different cultures; therefore, the nurse must validate meaning. There is insufficient information to determine the need for a translator. Another nurse's assessment is not necessary.

A hospitalized client exhibits excessive yawning, drowsiness, impaired memory, crying, and depression. The nurse should suspect which problem? 1. Sensory deprivation 2. Sensory overload 3. Visual deficit 4. Auditory deficit

1. sensory deprivation

genital phase

12 years to adulthood - genitalia -reach sexual maturity individual seeks psychological detachment and independence from the parents and creates meaningful and lasting relationships. Failure to resolve the genital stage may result in an inability to develop meaningful, healthy relationships.

anal phase

18 months - 3 years - anus - elimination, toilet training

A nurse is caring for a client who will require a mechanical lift to transfer from the bed to a reclining chair. The nurse should follow the recommendation of asking how many personnel to assist with this task?

2 or more

8. An older adult client expresses difficulty sleeping because her spirit is disturbed due to "sin in my life." The nurse should select which nursing intervention as highest priority? 1. Call the chaplain and schedule a visit. 2. Ascertain if there is a religious practice preferred by the client. 3. Pray immediately with the client. 4. Administer sleep medications as prescribed.

2. Ascertain if there is a religious practice preferred by the client. Rationale: assessing the religious practice will enable the nurse to obtain spiritual care that is most appropriate for the client. The client may or may not want a visit from the chaplain, as the chaplain may or may not be of the same religious denomination as the client. Also, the nurse would not act without verifying that this is acceptable to the client.

3. A client reports a decrease in sexual desire and function. The nurse should examine the client's medication list for which type of medication? Select all that apply. 1. Macrolide antibiotic 2. Beta blocker 3. Ascorbic acid (Vitamin C) 4. Anabolic steroid 5. Antidepressant

2. Beta blocker 4. Anabolic steroid 5. Antidepressant Rationale: Beta blockers are known to have side effects that interfere with sexual function. Anabolic steroids can negatively affect sexual function. One side effect of antidepressants is a decrease in sexual desire

In an effort to provide culturally relevant care to an American male client of Chinese descent, the nurse should first determine whether which intervention would be helpful? 1. Arrange a visit from the hospital chaplain. 2. Encourage him to participate in choosing dietary selections. 3. Provide discharge instructions to female family members. 4. Provide healthcare education online.

2. Encourage him to participate in choosing dietary selections. Rationale: Dietary choices are important aspects of culturally competent care. The nurse should first assess the client's religious practices and preferences before arranging for visitation from a hospital chaplain. The Chinese culture tends to be male dominated, and discharge instructions are more likely to be given to the eldest son. A teaching video may or may not be effective, while verbal instructions allow for discussion and exchange of questions and answers.

The nurse is assessing an 83-year-old male adult with cellulitis in the lower extremity. Which age-related changes should the nurse expect to influence the client's wound healing? Select all that apply. 1. Collagen tissue becomes more flexible as a person ages. 2. Immune function decreases with age. 3. Cell renewal is slower in older adults. 4. Reduced blood flow leads to poor healing. 5. Older adults become incontinent.

2. Immune function decreases with age. 3. Cell renewal is slower in older adults. 4. Reduced blood flow leads to poor healing. Rationale:

The nurse educator is preparing to conduct a teaching session about school-age children regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information would the nurse include in the session? Select all that apply. 1.Individuals move through all six stages in a sequential fashion. 2.Moral development progresses in relationship to cognitive development. 3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5.In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6.In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

2.Moral development progresses in relationship to cognitive development. 3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 6.In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

phallic phase

3-6 years - genitalia - resolve oedpius or electra complex Children resolve the Oedipus and Electra complexes by taking on roles and characteristics of the same-sex parent, which forms the foundation for sex-role identification. disapproval can result in shame or confused sexual identity

When evaluating clients in a mental health clinic, one assessment made by the nurse is whether clients are working on psychosocial tasks as described by Erikson. Which statements by a 45-year-old client indicate that the client is working on meeting the appropriate developmental task? Select all that apply.

3. "I am now coaching a tee-ball team for our local baseball league." 5. "I've been helping my daughter plan her wedding, which is two months away." Mentoring the next generation is a psychosocial task of the middle adult.

In working with a group of assigned clients, which client wounds should the nurse expect will heal by secondary intention? Select all that apply. 1. A surgical incision that is closed with staples 2. A clean leg laceration that was closed with sutures 3. A large, open abdominal wound from a gunshot injury 4. A Stage 4 pressure injury 5. A puncture wound to the finger from a sewing needle

3. A large, open abdominal wound from a gunshot injury 4. A Stage 4 pressure injury Rationale: Healing by secondary intention occurs in large, open wounds that do not have closely approximated wound edges. Pressure injuries must heal by secondary intention since they cannot be closed.

The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply. 1.A client with leukocytosis 2.A client with thrombocytosis 3.A client with thrombocytopenia 4.A client receiving an antiplatelet medication 5.A client receiving acetaminophen as needed for mild pain

3.A client with thrombocytopenia (low platelet count) 4.A client receiving an antiplatelet medication

latency phase

6-12 years - no erogenous zone - development of defense mechanisms Failure to successfully resolve the latency stage can result in an inability to form healthy relationships as an adult.

A nurse is caring for an adolescent client who has recently shared that they are bisexual. Which of the following factors is the client at increased risk for?

A Being bullied at school B Depression C Sexually transmitted infections D Use of illicit drugs E Suicide

human genome project

A National Institutes of Health funded research that was able to identify how types of human behavior may be traced to certain strands of DNA located on specific chromosomes.

A nurse is providing education about pressure injury development to a newly licensed nurse. Which of the following points should the nurse include in the teaching?

A Shear forces occur when the skin and muscles are pulled in opposite directions. C Friction is a continuous force exerted on or against an object. D Factors contributing to pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss.

acculturation

process of sharing and learning cultural traits or social patterns of another group.

moisture-associated skin damage (MASD)

A form of dermatitis; a skin irritation that forms when the skin is exposed to irritants like feces, urine, stoma content, and wound exudates. - excessive sweating, increased skin temp and pH, and deep skin folds predispose to MASD

Watson's Theory of Human Caring i

A model in client care that has a holistic mind-body-spirit healing perspective characterized by caring moments in which the nurse and the client have a human-to-human connection; transpersonal caring and Caritas Processes.

palliative care

A multidisciplinary care approach that is focused on the management of symptoms for chronic or life-threatening illnesses while maintaining the highest level of quality of life possible for the client.

dermatitis

A red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates. This type of dermatitis is called an irritant dermatitis.

8. After a client was diagnosed with terminal liver cancer, the nurse observes that the client's family assists the client with all activities of daily living (ADL). The nurse should communicate which rationale for self-care to the family?

A sense of loss can be lessened by retaining control in certain areas of life. Rationale: Performing activities of daily living (ADL) enhances control of one's life after surgery and can enhance the client's ability to deal with a terminal diagnosis.

associative play

A small group of pre-school aged children who interact with each other in a similar or identical activity but there are no well- established rules.

maceration

An irritation of the epidermis caused by moisture.

When does a toddler demonstrate readiness for toilet training?

A toddler needs to be able to dress and undress self to participate successfully in self-toileting. A toddler needs to be able to walk in order to be able to get to the bathroom for self-toileting.

Leininger's Sunrise Enabler

A visual portrayal of elements within the theory to assist nurses and other health care providers to provide culturally congruent care that works together to enhance the health and well-being of all clients at all stages of life.

wound

A wound is a disruption in the normal composition and performance of the skin and it s underlying structures.

undermining

An open area extending under skin along the edge of the wound.

etic knowledge

An outsider's viewpoint of a culture.

A nurse is teaching a group of older adults at a community center about the functions of the skin. Which of the following statements should the nurse include in the teaching?

A. The skin plays an important role in the production of vitamin D. C The skin protects against bacteria and viruses. D The skin helps regulate the body temperature.

DVT interventions

ASSES: pulses and capillary refill Instruct the client to perform lower leg exercises to promote contraction of the lower-extremity muscles and venous return Apply antiembolism stockings to promote venous return. Use sequential compression devices as prescribed to promote venous return. Encourage fluid intake to prevent dehydration and decrease the risk of developing a clot. Ambulate the client frequently, if appropriate, to stimulate the action of muscles moving the venous blood along. Administer anticoagulant medications as prescribed to decrease the formation of blood clots.

Factors Related to Health Disparities That Affect Access to Care for Vulnerable Populations

Access to transportation Accessibility to health care Health insurance Religion Geographic location Sensory deficits Physical disabilities Mental health Cognitive disabilities Socioeconomic status Race Ethnicity

demographics

Age English language proficiency Household type Population density Race and ethnicity Sex

The nurse is preparing to provide instructions to new parents regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the parents to take which measure?

Allow the newborn infant to signal a need. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others.

prone position

Allows for full extension of the hip and knee joints to prevent contractures Promotes drainage of secretions

joint contractures

An abnormal fixation of a joint due to changes in muscles and connective tissue.

gait belt

An adjustable belt or strap that is secured around a patient's waist or hips and is used to protect and control the patient during gait activities or transfers.

blanchable erythema

An area of a reddened skin that temporarily turns white or pale when light pressure is applied. the skin then reddens when pressure is relieved.

cellulitis

An infection of the superficial layers of skin.

emic knowledge

An insider's viewpoint of a culture.

cultural health assessments

Assessments that can be conducted to gather information regarding the client's culture and how it can affect their health.

FICA

spiritual assessment tool

object permanence

Begins at 9 months of age and is fully developed in toddlerhood. It is the cognitive understanding that an object exists even when it can t be seen or heard.

cultural competence

Being able to incorporate effective nursing care with emic and etic knowledge including appreciating, accepting, and respecting all individual s cultural influences, beliefs, customs, and values.

being with

Being physically and emotionally present with another person, which provides comfort

viability

Between 22 and 28 weeks, most bodily systems function well and an infant born at this point is considered to be able to survive.

sanguineous

Bloody wound drainage.

marginalized sexual groups

Clients who identify as lesbian, gay, or bisexual, and can also include those clients who are questioning their sexual orientation or sex identity.

heath status

Chronic health conditions Disabilities Health insurance status

Info about cleaning wound

Cleaning the wound from the center out is correct wound care technique. It is important to assess the wound after cleaning, when the wound characteristics will be most visible. A catheter can be used for wound irrigation and it would be placed close to the open area. Sterile gloves are not required to remove contaminated dressings.

benchmarking

Comparing results and outcomes to other sources of similarly retrieved data.

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when providing discharge instructions to the client?

Consult the certified medical interpreter who speaks the client's language.

The nurse is changing a wet-to-damp dressing as prescribed for a pressure injury. A family member asks why the dressing is put on wet. The nurse should incorporate which purpose of this dressing when formulating a response?

Debride the wound A wet-to-damp dressing debrides the wound. As the dressing partially dries, necrotic debris will adhere to the dressing. When the dressing is removed, dead tissue will be removed also.

Deep damage through the skin and tissue layer

Deep wound with exposed muscle, ligaments, or bone, and dead tissue

psychological effects of immobility

Depression Anxiety Hostility Fear Isolation Restriction of self-image and independence Sensory deprivation Difficulty sleeping

medically futile

Doing treatments that are not helpful because they will not provide a cure or extend life.

Which assessment of the immobilized client should prompt the nurse to take further action? 1. Client report of fatigue 2. Urinary output of 50 mL/hour 3. White blood cell count of 9,500/mm3 4.vDiminished bowel sounds

Diminished bowel sounds is a complication of immobility. It could be followed by constipation and other gastrointestinal problems.

socioeconomic factors

Education level Employment status Household income Poverty status

supine or dorsal recumbent

Enables visualization of the client for examination (possibly with knees bent)

urinary retention interventions

Encourage fluid intake to increase bladder filling and stimulate the urge to void. Remind the client to remain in an upright position during urination to use gravity to promote adequate bladder emptying. Assist the client to use the toilet or bedside commode to promote complete emptying of the bladder.

sarcopenia interventions

Encourage the client to participate in self-care activities as able to use the muscles. Gradually increase activities to include dangling, sitting, and then standing to build strength. Assist with ambulation to decrease the risk of falls.

joint contractures interventions

Encourage the client to perform ADLs as able to promote flexion and extension. Ensure each joint is moved at least once every 8 hours, either by the client or by the health care team, to promote joint mobility. Use splints as prescribed to support and stretch contracted joints. Inspect the client's position and posture for proper body alignment every 2 hours.

atelectasis interventions

Encourage the use of an incentive spirometer to promote lung expansion. Instruct the client to perform deep breathing and cough exercises to expand the lungs fully and promote expectoration of secretions. Monitor oxygen saturation levels. Provide supplemental oxygen as prescribed. Elevate the head of the bed at least 30 to 45 degrees to encourage deep breathing. Turn and reposition the client every 2 hours to promote lung expansion. Refer to the

The nurse assesses a wound of a client and finds that a scab has formed. The nurse should conclude that the wound is at what point in the phases of wound healing?

End of the inflammatory phase Rationale: Near the end of the inflammatory phase of wound healing, protein dries out at the top of the wound, forming a scab. This scab provides safety for the wound because the first line of defense, the skin, is again covered.

pressure injury interventions

Ensure client is repositioned at least every 2 hours to promote adequate blood flow to bony prominences. Use pillows and cushions to support the client. Use assistive devices and proper technique when repositioning to minimize additional skin trauma. Use pressure redistribution devices on mattresses and chairs to decrease prolonged pressure on areas susceptible to breakdown. Moisturize dry skin to decrease the risk of skin breakdown. Ensure intake of adequate calories, protein, and micronutrients to promote healing of damaged areas. Keep skin free from moisture due to incontinence, wound drainage, or perspiration, all of which increase the risk of skin breakdown.

proprioception

Feedback from sensory receptors to coordinate, balance, and fine-tune body positioning and movement.

cartilage

Flexible connective tissue that coats bony areas, allowing them to glide over each other and absorbs shock. - reduces friction between bones

ligaments

Flexible fibrous connective tissue that attaches bone to bone.

synovial joints

Fluid-filled capsules that connect bones and enable movement.

musculoskeletal system

General term used when referring to the muscles and the skeleton.

vulnerable populations

Groups of people who are at higher risk for poor health outcomes resulting from barriers to social, economic, and environmental resources including limitations due to illness or disability.

The nurse is using the Braden scale to assess a client's risk for developing pressure injury and calculates a score of 7. The nurse should interpret that this client has which level of risk for development of pressure injury?

High risk Rationale: Low numbers indicate factors that are likely to contribute to the development of pressure injury. Overall scores above 19 indicate that the client has a low risk of pressure injury development.

Simple to complex

Human development evolves in an orderly fashion from simple to complex. Infants accomplish head control before they are able to crawl.

Cephalocaudal principle

Human development follows a head-to-toe progression. Infants gain control over their neck and head before they can control their extremities.

Continuous process

Human development is a continuous process characterized by periods of growth spurts and periods of slow and steady growth.

General to specific

Human development occurs from large muscle movement to more refined muscle movements.

Proximodorsal principle

Human development progresses from the center of the body in an outward direction. The spine develops first, followed by extremities, then fingers and toes

Individualized rates

Human development varies from individual to individual. Each person has their own growth timetable and rate of development.

activity intolerance

Inadequate amount of physical or psychological energy to undergo or complete a necessary activity

mucosal membrane pressure injury

Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement?

Injury to the brachial plexus nerves

malnutrition interventions

Instruct the client about the consumption of high-protein, nutrient-dense foods to promote optimal nutrition. Help the client select foods based on preferences and nutrients to promote intake of nutritious foods. Assist the client during meals, if needed, to promote adequate intake. Consult a dietitian to provide dietary guidance to address nutritional deficiencies.

pressure injuries

Localized damage to the skin and/or the soft underlying tissue, which can be caused by prolonged contact with a firm surface that interferes with circulation to the area.

teratogens

May cause physical malformations and abnormal prenatal development. The effect of teratogens on the unborn child depends on the duration of exposure, the amount of teratogenic substance, and the stage of embryonic or fetal development when exposure occurs.

peripheral nervous system

Nervous system outside of the brain and spinal cord, which regulates the responses of the body to external stimuli.

tendon

Nonflexible fibrous connective tissue that attaches muscle to bone.

disuse osteoporosis interventions

Notify the provider if a fragility fracture is suspected. Ambulate the client with assistance to protect from falls or injuries. Monitor for increased pain as weight-bearing activities increase. Perform hourly rounding to ensure the client's needs are met and to decrease the risk of falls.

foot drop interventions

Notify the provider of foot drop if present. Apply splints as prescribed to support and stretch the limb. Assist with ambulation to decrease the risk of falls.

damage beyond skin layer

Open wound, possibly with adipose tissue or granulation tissue visible

clients that are at high risk for pressure injury due to immobility?

Parkinson disease causes mobility issues due to rigidity and stiffness. Quadriplegia causes mobility issues due to spinal cord injury and associated problems. Patients with COPD and other cardiopulmonary diseases can have mobility issues due to poor oxygenation. Patients with feet wounds and/or neuropathy will have mobility issues due to pain with ambulation and movement.

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

Partial-thickness skin loss with exposed dermis

prenatal development

Period of development that occurs from conception to birth takes an average of 38-40 weeks and is divided into three periods: zygote, embryo, and fetus.

Merkel cells

Receptors cells in the epidermis that are specialized for detection of light touch.

health disparities

Preventable differences in incidence and prevalence of disease, injury, or violence among populations, based on race, ethnicity, gender, gender identity, LGBT, age, or socioeconomic status.

Fowler

Promotes lung expansion

lateral

Promotes spinal alignment Reduces pressure on the sacrum and heels

Trendelenburg

Promotes venous return Promotes drainage of the lower lobes of the lungs

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse would plan to tell the parent that which factor motivates good and bad actions for the child at the preconventional level?

Punishment and reward

erythema

Redness of the skin due to dilation of blood vessels.

nonblanchable erythema

Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues.

Lateral semi-prone recumbent

Reduces pressure on the sacrum and hips Promotes drainage of secretions

The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take?

Report the observation to the pediatrician.

spiritual well-being

Satisfaction and a feeling of contentment with who one is and their belonging in the universe.

The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse classify this pressure injury?

Stage 3 pressure injury

Conventional reasoning (10 to 13 years to adulthood) Kohlberg

Stage: - Good boy—nice girl - law and order Motivation: - Rules obeyed for acceptance and approval - Rules obeyed to maintain social order

Postconventional reasoning (adolescence to adulthood) Kohlberg

Stage: - social contract - universal ethical principles Motivation: - Rules challenged if they impinge on the rights of others - Individuals formulate and apply their own rules based on ethical principles

Preconventional reasoning (4 to 10 years) Kohlberg

Stage: -Punishment and obedience - Instrumental relativism Motivation: - Rules obeyed to avoid punishment - Rules obeyed for personal gain

The nurse is preparing to describe Piaget's cognitive developmental theory to pediatric nursing staff. The nurse would plan to tell the staff that which child behavior is characteristic of the formal operations stage?

The child's basic abilities to think abstractly and problem-solve are similar to an adult's. In the formal operations stage, the child's basic abilities to think abstractly and problem-solve are similar to an adult's.

Dermis

The layer under the epidermis that is composed mainly of connective tissue and provides strength and flexibility of the skin. - also has blood vessels and lymph vessels - collagen and elastin fibers (strength and elasticity and protect from alterations in tissue integrity)

dehiscence

The complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly. - This complication generally occurs 7 to 10 days after surgery, and often is preceded by a serosanguineous discharge - if occurs notify provider, administer pain medications, cover wound in moist sterile dressing, implement IV therapy, prepare client to go to OR

friction

The force created when two objects rub together. * not direct cause of pressure injuries but does cause trauma to skin and tissues increasing risk

quality of life

The fulfillment of a client's purpose and meaning of life

The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching?

The nursing student applies lotion in between the toes.

body alignment

The positioning held by the various parts of the body while performing activities or during rest.

Telemedicine

The provision of health care which includes diagnostic testing and monitoring through the use of telecommunication devices such as the internet. example, a provider in an urban location can obtain an electrocardiogram of a client who resides hundreds of miles away, diagnose illnesses, assess heart and lung sounds, and prescribe treatment.

serous exudate

Thin, watery wound drainage.

Category 4: Focus on the Individual, Families, Groups, Communities, or Institutions in Diverse Health Contexts

This category includes the client's folk (generic) care, integrative care practices, and professional care-cure practices.

Potentially inappropriate treatment

Treatment that is not appropriate for a client, meaning that it might not be futile, but it also might not be appropriate. treatment does what it is intended to do, but not appropriate for client

parallel play

type of play that occurs during the toddler years. Toddlers will play side by side but not interact with each other

pneumonia interventions

Use prone positioning to promote drainage of secretions (if appropriate) Elevate the head of the bed at least 30 to 45 degrees to encourage deep breathing. Encourage fluid intake to thin secretions. Provide supplemental oxygen as prescribed. Encourage deep breathing and coughing exercises to promote lung expansion and expectoration of secretions. Turn and reposition the client every 2 hours to promote lung expansion.

the nurse caring for this client has made the decision to use a medical interpreter. Which of the following reasons supports the need for a medical interpreter?

Using a family member to translate would be a violation of the client's confidentiality.

health equity

Valuing all individuals equally and removing obstacles to optimal health and health care across different populations.

slough

Yellow, stringy nonviable tissue found in the base of the wound.

he nurse aids both the client and the caregivers in determining the client's priority:

a life of quantity or of quality

Presbyopia

age-related farsightedness the inability to focus on close objects; this condition normally accompanies aging

Presbycusis

age-related hearing loss

human attachment

an enduring emotional bond that connects one person to another over time and space and infants need to develop a relationship with at least one primary caregiver for normal social and emotional development.

Culturally competent nursing practice

application of evidence-based nursing that is congruent to the preferred cultural values, beliefs, worldviews, and practices of the client.

biological factors

assessing the client for any personal or family history regarding physical and mental illnesses, hereditary and genetic conditions, and their impacts on the client's life

Level 4 No Assist (0 to 1 personnel)

assessment task: - Client can march in place - Client can step forward and backward equipment needed: none

Level 1 Maximum assist (2 or more personnel)

assessment tasks: - Client extends arm and reaches across midline to shake hands with nurse - Client moves self from semi-reclining position to sitting on edge of bed and maintains for at least 2 minutes equipment needed: - mechanical lift - slide boards

Level 2 Moderate Assist (2 or more personnel)

assessment tasks: - While seated at edge of bed, client places feet on floor - Client extends one leg out, flexes ankle and points toes; repeat with other leg equipment needed: - Mechanical sit-to-stand lifts - Ambulation assistive devices

Level 3 Minimal Assist (1 or 2 personnel)

assessment tasks: - Client can raise self from a seated position using assistive device (cane or bed rail) - Client can maintain standing position for at least 5 seconds equipment needed: - gait belt - ambulation assistive devices

cardiac deconditioning

atrophy of the heart muscle which results in a decreased amount of blood being ejected from the heart during contraction

ectoderm

becomes hair, outer layers of skin, and nervous system

Flexion

bend; reduce the angle between the bones

oral phase

birth to 18 months - mouth, lips, tongue - wean from breast Fixation at this stage is characterized by too much or too little gratification, which can lead to immature personality development and preoccupation with oral activities such as drinking alcohol, smoking, or overeating.

risk factors tissue integrity for clients who have decreased mobility/paralysis

contributing factors: Reduced blood circulation Alterations in thermoregulation Incontinence Loss of collagen Muscle atrophy Impaired sensation skin problems: Skin tears Pressure injuries Skin infection Incontinence-associated dermatitis

risk factors for tissue integrity for older adults

contributing factors: Thinning of the skin Decreased - Elasticity - Subcutaneous tissue - Blood supply - Hydration skin problems: Skin tears Pressure injuries Itchy, dry, flaky skin Skin infections

nerves

control contraction and relaxation of muscles; coordinate balance and movement

cultural awareness

cultural awareness encompasses the ability and willingness to investigate and understand the differences between perceptions, beliefs, traditions, and values within the nurse's own culture and those in other cultures understand bias

Mobility assessment tool (MAT)

determine client's mobility level

health equality

distribution of the same resources, including opportunities, to all individuals within a population. Equal distribution of resources (health equality) is not necessarily the same as a fair and nondiscriminatory distribution (health equity) of the same resources

wound care and sterile gloves

don sterile gloves when packing the wound don sterile gloves when irrigating and packing pressure injury

skin has three layers

epidermis, dermis, subcutaneous (adipose tissue)

edema and exudate should decrease by postoperative day 5

exudate: Fluid secreted by the body during the inflammatory stage of healing and is made of plasma.

endoderm

form lungs and digestive system

poor ergonomics in the workplace results in

frustration, stress, workarounds, and exposure to dangerous or hazardous situations

A nurse is caring for a client who can rise to a standing position from a chair with the use of a cane. The nurse should assist the client with ambulation using which of the following equipment?

gait belt

clean and clean-contaminated surgical wounds

have minimal bacterial loads and are closed at completion of procedure

Isometric exercises ------------------------------------------------ isotonic exercises

involve resistance --------------------------------- involve no resistance

Family dynamics

involve the interaction and communication among family members. The defining attributes of family dynamics include the involvement of the family as a group with relational obligations, fluid and changing interactions, and communication among family members.

A nurse is caring for a client who can move self from a semi-reclining position to sit on the edge of the bed but is unable to hold the position. The nurse should assign the client which of the following activity levels?

maximum assist

malocclusion

misalignment of the upper and lower teeth when the client bites down. Often referred to as an overbite or crossbite

rotation

moving lengthwise

conception

occurs when a single male sperm cell penetrates and successfully fertilizes the female egg

Freudian psychosexual development

oral, anal, phallic, latent, and genital

when to pack a wound

packing assists with secondary intention healing and is for wounds that are deep or have additional tunneling present use sterile tip applicator to assist with packing

when should a mobility test be performed?

prior to initially mobilizing a client and repeated every 24 hours

open drains

remove fluids to air

kinship and social factors

single, separated, married, divorced, or widowed

Sensory overload symptoms

sleeplessness, irritability, disorientation, and reduced problem-solving ability

muscles

soft tissues that provide the motor power or force for movement

extension

straightening arm

child maltreatment

the abuse or neglect of children younger than 18 years of age, including both physical and emotional ill-treatment, sexual abuse, neglect, and negligence

Clients who are immobile also frequently experience dehydration, which:

thickens the mucus secretions in the lungs, making it difficult for the client to expel the mucus when coughing

serosanguineous

thin, watery wound drainage mixed with blood

Borg Rating of Perceived Exertion (RPE) scale

tool to evaluate activity tolerance

The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound?

transparent dressings, hydrocolloid dressings, or no dressing and leaving the wound open to air.

Inversion

turn inward - turning sole of foot toward the midline

eversion

turn outward

fontanels "soft spots"

two open areas found in between the newborn infant s bones of the skull. Infants have an anterior fontanel, often known as the soft spot and a posterior fontanel

tinnitus

when you experience ringing or other noises in one or both of your ears, often associated with hearing loss.

technological factors

whether a client has access to technology including a phone, internet, or computer

vernix caseosa

white, cheese-like covering that is found in the skin creases of a newborns. It serves to protect the fetus' skin during pregnancy

mesoderm

will become muscles, bones, and circulatory system