Exam 2 essentials

tissue ischemia results when the support surface and the bony prominence are

"squeezed" at a pressure greater than the capillary pressure for a sufficient time; shearing can cause capillary occlusion; friction denudes the skin surface causing maceration that allows rapid breakdown.

standing

(written prescriptions: unit based such as use of oxygen) many practitioners who practices are limited to a particular clinical area have a specified set of written orders for all their hospitalized patients

s/s of shock due to blood loss

- progressive -very restless at first - thirst due to hypvolemia -skin pallid, cold, wet with perspiration -gradually feels lethargic and faint - air hunger - labored breathing - nail beds and lips become bluish color -BP falls - patient becomes comatose and eventually dies if untreated.

additional rights for drug admin

- right client education - right to refuse -right assessment -right evaluation -right response

primary intention wound

- wound edges well approximated - wound heals w/o infection -minimal scarring -inflammation subsides in less than 24 hours -wound is resurfaced btwen day 4 and 7

emergency interventions for dehiscence

-HOB low to eliminate gravity - knees bent to decrease pull on suture -notify surgeon -cover the wound with large sterile dressing soaked in normal saline -obtain vital signs q5-10 minutes

cardinal signs of infection

-edema -increased amount of drainage -erythema - local and/or systemic fever - foul odor - purulent drainage -elevated white blood cell count PLUS malaise

purposes for maintaining a wound undressed

-eliminate conditions that favor the growth of microorganism -allow for better observation and assessment of the wound -facilitate bathing and hygiene -avoid adhesive tape reaction -avoid the friction and irritation that destroy new epithelial cells

Proliferative Phase

-granulation -nutrition required -fibroblast - collagen -angiogenesis - contract by the myofibroblast -epithelialization Epithelial tissue is fragile

inflammatory phase of wound healing

-hemostasis -clean up -nutrition required -observation and assessment

Vastus lateralis IM landmark

-identify greater trochanter -place hand at lateral femoral condyle -inject medication in the middle third of anterior lateral aspect

heat applications used

-relaxes muscle spasm softens exudate hastens healing due to vasodilation localization of infection - increases blood flow to area -do not apply heat to abdomen with suspected appendicitis as it may precipitate rupture warms a body part reduces congestion of an underlying organ increases persistalis reduces pressure from accumulated fluids comforts and relaxes

NG Tube medication admin

-some solid medications can be crushed mix with 15-30ml of water; mix thoroughly document all water given to client bring liquid to room temp

secondary intention occurs when

-wound is extensive -edges of the wound cannot or should not be approximated -greater injury and more granulation tissue will needed to close the wound -healing time prolonged, deeper, more extensive scarring, greater risk for infection

normal wbc in urine

0-4 per low-power field

u/a needs to be done within ___ of collection

1 hr

IM length

1-2 in

five functions of the skin

1. protection 2.regulate temperature 3. excretes waste 4. sensory organ 5. forms vitamin D in presence of UV light

specific gravity of urine - normal

1.005-1.030

change ostomy pouches when they fill

1/3 to 1/2 full

intradermal length

1/4-1/2 inch

proteins are ___ percent of total daily diet

10-35%

women catheter size

14-16 Fr

1 lb = ____ oz

16 oz

men catheter size

16-18 Fr

whats the max ml in deltoid?

2 ml

1 qt (pt, cups, oz)

2 pt 4 cups 16 oz

contaminated or traumatic wounds may show signs of infection within

2 to 3 days

age of child when they are able to control defecation

2 to 3 years

intramuscular volume

2-5 ml no more than 1mL to small children and older infants; no more than 0.5 ml to smaller infants

IM gauge

21 to 23

anuria

24 hr output less than 50ml

urine culture can take up to __ for reporting

24 to 48 hours

cold is effective treatment ___ after trauma

24-48, frequently followed by heat

subq gauge

25 to 30

intradermal gauge

25-27

change ileostomy pouch every

3 to 5 days

change colostomy pouch

3 to 7

subq length

3/8 - 1 inch

closed catheter irrigation/closed bladder irrigation (CBI)

30 ml in balloon

syringe ml and gauge for irrigation of wound

35 ml and 19 gauge needle fluid should flow directly into the wound and not over a contaminated area before entering the wound

pH of skin

4.5-5.5 acidic

pH range of urine

4.6-8

carbs ___% in diet

45-65%

subq angle/degrees

45-90

risk of hemorrhage is greater within the first ___ hours

48

surgical wounds may show signs and symptoms of infection between

4th and 5th day post op

how long should patient hold head for ear drops?

5 minutes - rub the tragus to move medication into ear

how long after inserting vaginal cream does pt stay in supine position?

5 to 10 minutes

intradermal degrees

5 to 15 degrees

chronic pain lasts more than

6 months, can be intermittent or continuous does not alter vital signs often poorly localized

encourage pages to increase fluid intake to at least __ to ___ glasses a day

6 to 8

how long does a patient have to void once an indwelling catheter is removed?

6 to 8 hours

children catheter size

8-10 Fr

IM angle

90 degrees

ice collar

A bag or pack that is filled with ice that can be wrapped around a part of the body not left on longer than 1 hour

biofeedback

A mind-body technique that uses instruments to teach self-regulation and voluntary self-control over specific physiological responses instruments measure, process, and provide info about neuromuscular and autonomic nervous system activity immediate feedback is provided in physical, physiological, auditory and/or visual signs

bile

A substance produced by the liver that breaks up fat particles.

braden scale

A tool for predicting pressure ulcer risk

fat soluble vitamins

A,D, E, K

ABCDE Pain assessment

A- Ask about pain regularly & assess for it systematically B- Believe reports of pain and what relieves it C- Choose pain control individualized to the pt and setting D- Deliver interventions in a timely, logical and coordinated fashion E- Empower pts & their families. enable them to control as much as possible

Instruct the client to inhale deeply and then cough.

An infant with a respiratory rate of 16 bpm The infant's normal respiratory rate is 20 to 40 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 32 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

heparin

Anticoagulant

ginger

Antiemetic

parenteral

Any route other than the digestive tract

puncture wound

Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental

water soluble vitamins

C, B -complex and Vitamin C

Mixing of alcohol and many drugs causes increased

CNS depression

NG tube sterile or clean?

Clean

pressure ulcer

Compromised circulation secondary to pressure or pressure combined with friction

The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?

Crackles Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Rales are small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). Vesicular breath sounds are heard across the lung surface.

incision

Cutting or sharp instrument; wound edges in close approximation and aligned

purpose of NG tube

Decompression, enteral feeding, compression, and lavage

cold application systemic

Decreased metabolic needs and capillary permeability,

hemmorhage

Excessive or profuse bleeding

abrasion

Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

glucose transported from

GI tract --> portal vein --> liver --> stored as glycogen

types of cleansing enema

Hypertonic Solutions Hypotonic Solutions Isotonic Solutions Soapsuds Enemas High Enema Low Enema

Z track recommended for

IM

venous ulcers

Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction

diabetic ulcers

Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure

arterial ulcers

Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

chronic/persistent non cancer pain

Is not protective, has no purpose, may or may not have an identifiable cause

inferred pathological pain

Musculoskeletal, visceral, or neuropathic

chronic episode pain

Occurs sporadically over an extended duration

acute/transient pain

Protective, identifiable, short duration; limited emotional response

pressure ulcer stages

Stage 1: non-blanchable erythema Stage 2: partial thickness loss (involving epidermis and/or dermis Stage 3: full thickness loss involving damage or necrosis if subq tissue which may extend down to, but not through underlying fascia. presents clinically as a deep crater with or w/o undermining adjacent tissue. Stage 4: 3+ undermining, see tendon, muscle

top of kidneys

T12

avulsion

Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

laceration

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue

pharmacodynamics

The process by which drugs act on target cells resulting in alterations in cellular reactions and functions drugs acting at the cellular level to achieve the desired result

apocrine gland

This type of sweat gland is found mainly in the arm pits and groin area; odorous

Chemical wound

Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

Normal RBC in urine

UP TO 2LPF

alkaline urine may indicate

UTI, diet high in fruits and veggies

irradiation wound

Ultraviolet light or radiation exposure

nutritional status

When dietary factors are altered, drug therapy may produce different effects in the body than would normally occur. low protein levels decrease the effectiveness of drugs

fibroblast

a cell in connective tissue that produces collagen and other fibers.

shock

a life-threatening condition that occurs when the body is not getting enough blood flow

intestine is the primary area of

absorption

What drugs are well absorbed in the stomach?

acidic drugs, other drugs are absorbed in the small intestine

Subcutaneous

adipose tissue, provides support and blow flow to the dermis

single dose or one time orders

administer once at a specific time; common for preoperative or preprocedural medications

anaphylactic reaction

anaphylaxis, life-threatening, respiratory distress, sudden severe bronchospams, cardiovascular collapse

purposes of bandages

anchor dressing, provide support to body part, immobilize body part, or promote circulatory return

patient may become ____ with infection

anorexic, nauseous, febrile or have "chills"

chamomile

anti-inflammatory, calming

Focused skin assessment

appearance of skin recent changes in skin activity/mobility nutrition pain elimination

PRN

as needed specific dosages, what frequency, under what conditions

transition phase of wound healing

as the macrophage starves, the fibroblast is attracted to the wound and the proliferative phase begins

before documentation of administration of drug must

assess pt for reaction or adverse effects can only document after client has taken the drug

how does malnutrition contribute to pressure ulcers?

because of reduced nutrient stores including protein for tissue repair

encourage older adults to empty the bladder completely

before and after meals and at bedtime

the more lipid soluble a drug is, the ____ absoroption into the cell

better

voiding =

bladder contraction + urethral sphincter and pelvic floor relaxation

ecchymosis

blood underneath the skin; no swelling

peritoneal dialysis

blood vessels in the perioneum is used as the kidneys: Dialysate through osmosis moves the waste products

contusion

blunt instrument, overlying skin remain intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

water is 50 to 60% of

body weight

eschar and necrotic tissue cannot be staged unless

bone or tendon is visible

definition of wound

break in the skin or mucous membrane resulting from physical means; may be superficial (affecting only the surface of the skin) or deep (involving blood vessels, nerves, muscle, fascia, tendons, ligaments, and bones)

fats are ____dense

calorie

nutrients needed for fibroblast

calories, protein, zinc, iron

cancer pain

can be acute or chronic

main source of energy

carbs

Vitamin K

catalyst for blood clotting factors

teratogenic

cause developmental effects on the fetus cocaine, alcohol, phenytoin (anticonvulsant) some drugs can also be found in mother's breast milk

neuropathic pain

caused by lesion or disease of the peripheral or central nerves; may be chronic; burning, tingling, stabbing, electric

metabolism aka biotransformation

change of an active drug from its original form to an inactivated or new form

occult blood in urine

chemical test used to detect hidden blood in the urine resulting from red blood cell hemolysis - indicates bleeding in the kidneys

vitamin B3 (niacin)

cholesterol lowering properties; causes peripheral vasodilation

yellow

cleanse

Vitamin B6 (pyroxene)

coenzyme in amino acid, lipid, and protein metabolsim; erythrocyte function

vitamin b2 (riboflavin)

coenzyme in protein and energy metabolism

functional urinary incontinence

cognitive, mobility, environment factors loss of urine due to interference

abscess

collection of infected fluid that has not drained

therapeutic range

concentration of drug in the blood serum that produces the desired effect without causing toxicity

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

confusion Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis

low fiber high in animal fats can cause

constipation

"healed" skin

continuous and strength is sufficient to allow normal activities

shearing pressure causes injury by

contributing to tissue hypoxia particularly when the head of the bed is elevated (skin remains stationary while the underlying tissues shift with the pull of gravity)

local cold applications

controls bleeding by constriction of blood vessels reduces inflammation controls accumulation of fluid reduces cellular activity (bacteria growth)

24 hour urine specimen

creatinine clearance keep urine for 24 hours ask pt to empty bladder then we throw that out

toxic effects

cumulation of the drug, nephrotoxicty, hepatotoxicity, ototoxicity

black

debride - removal of eschar

wound vac

decreases swelling speeds tissue generation

depression ____ peristalsis

decreases; can lead to constipation

moist heat penetrates__ than dry and is usually ___ tolerated.

deeper, better

fat ___gastric emptying time

delays

disease conditions affected urination

diabetes and neuromuscular neuromuscular disease benign prostatic hyperplasia cognitive impairments (eg Alzheimer's) conditions that make it difficult to reach and use facilities end-stage renal disease spinal cord injuries above sacrum - hyperreflexia

with needs the smaller the number, the larger the

diameter

somatic pain

diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves ex: sprain

distraction is associated with

diminished pain response

pathology

disease state affects drug actions

bandage from ___ to ___ area to promote blood return

distal to proximal

urinary diversion

diversion of urine to external source

interventions to promote urinary continence

do not restrict fluids. ensure 2 -3 L intake bladder training kegel exercises intermittent cath AVOID indwelling

What not to use for preventing pressure injury

do not use foam rings, foam cut-outs, or donut-type devices can use cushions, heel elevation, foam positioning wedges

weight and how it affects drug actions

drugs can be given based on our weight or BSA (body surface are)

components of small intestine

duodenum, jejunum, ileum

Definition of pharmacokinetics

effect the body has on a drug once that drug enters the body

interventions to prevent UTIs

empty bladder q2-4 hrs maintain acidity in urine

echinacea

enhances immune system

minerals are catalysts for

enzymatic reactions

skin alterations related to aging

epidermis thins; lower water contnet elasticity is lost as well as some fatty cushion blood vessels become

epithelialization

epithelial cell migrate over the granulation tissue

intake and output should be

equal greater than 30ml/hr

granulation

evidence of active tissue growth; appears beefy-red, shine, and "cobblestone" surface

ketones in urine may indicate

excessive aspirin intake state of starvation uncontrolled DM

woven gauze absorbs

exudate from wound

most concentrated source of energy in the diet

fat (lipids)

FOBT

fecal occult blood test avoid eating red meats 3 days before testing NSAIDs may provide false positive reslts avoid vitamin c supples for 3 days may produce false neg do not use laxatives 3 days before test

penetrating wound

foregin object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues

eccrine gland

found in palms, soles of the feet, and forehead cools the body through evaporation

sebaceous gland

found in the dermis, secrete sebum to protect hair from drying; prevents excessive evaporation of water; inhibits growth of some bacteria

more acidic urine found

freshly voided found in starvation, with diarrhea, or with a diet high in protein and cranberries

flatulence

gas in the stomach or intestines

pancreas releases

glucagon when the concentration of insulin (or indirectly glucose) in the bloodstream falls to low. Glucagon causes the liver to convert stored glycogen into glucose, which is released into the blood stream.

if muscle or liver stores are low what happens with glucose?

glucose is in the bloodstream is converted to glycogen and stored

drug classifications

groups of drugs that share similar characteristics (pharmaceutical/ chemical class); therapeutic/functional class)

chronic wound

healing delayed > days wound edges not well-approximated increased risk of infection

what influences adherence?

health beliefs, personal motivations, socioeconomic factors, and habits influence adherence

pharmacotherapeutics

helps us to understand why we administer a specific drug (clinical indication) Therapeutic uses and effects of drugs The treatment of pathologic conditions through the use of drugs acetaminophen mild to moderate pain or fever etc

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high fowler's Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

thermal wound

high or low temperature; cellular necrosis as a possible result

peak level

highest serum blood concentration; blood drawn 1 hours after drug has been administered

erythropoitin

hormone produced by the kidneys and stimulates the body to produce more red blood cells

proteins aid in manufacturing of

hormones

dry heat

hot water bottle/bag/ electric heating pad, lamp or aquamatic pad

first pass effect

how much of the drug is destroyed in the liver; drugs have specific routes for this reason

stat

immediately

when is the best time to test for post void residual urine?

immediately after

ginkgo biloba

improves memory

placebo

inactive substance; may have pyschological effects on clients

nonadherance

inconsistent use as prescribed self-adjusted dosing or scheduling

ginseng

increased physical endurance

residual urine =

increased risk for UTI

increase blood flow does what to absorption of drugs?

increases absorption

all infected wounds are in the inflammatory phase, but not all inflamed wounds are____

infected

all wounds are contaminated with bacteria, but not all wounds are ___

infected

garlic

inhibits platelet aggregation

abdomen

inspect, auscultate, percussion, palpate

Subq common meds

insulin and heparin

parenteral routes

intradermal, subcutaneous, intramuscular, intravenous

urinary incontinence

involuntary leakage of urine

Vitamin B5 (pantothenic acid)

invovled in fat, cholesterol and heme formation and amino acid activation

what affects calcium and phosphate regulation?

kidneys

animal source of carbs

lactose/ milk sugars

primary organ of bowel elimination

large intestine

when irrigating allow the solution to flow from

least contaminated to most contaminated

pressure ulcer definition

lesions caused by unrelieved pressure; underlying tissue damage

purulent exudate consists of

leukocytes, liquefied dead tissue debris, and dead and living bacteria

Enteral administration

liquid medications may be administered enterally (to gastrointestinal tract) via specially placed tubes; NG, GT (gastrostomy), and PEG risk for aspiration

what is the primary site for drug metabolism?

liver

regulates the conversion of glycogen to glucose

liver releases glucose into the blood strem

Deltoid IM landmark

locate the lateral side of the humerus from 2-3 finger widths below acromion process

stress urinary incontinence

loss of small amounts of urine from increased abdominal wall pressure w/o bladder contractions

vitamin E

lowers bad cholesterol antioxidant properties protects cell membranes

hemodialysis

machine filters waste from the blood

anthropometry

measurement system of the size and makeup of the body

nitrogen balance

measures the breakdown of tissue negative balance = tissue breakdown (not getting enough amino acids, protein)

chyme

mixture of enzymes and partially-digested food

factors affecting drug actions - biological sex

most drug studies have been conducted on males

abdominal binders minimize

muscular tension on abdominal organs

asparagus cause a __ odor

musty

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

slough

necrotic tissue and cells separating from wound bed; may be yellow/beige, tan/white/gray; layer or mass of dead tissue separated from surrounding living tissue, as in wound, a sore, or an inflammation.

vitamin B12 (cobalamin)

needed for the synthesis of hemoglobin, RBCs and DNA

what to inspect and palpate for bandages

neurovascular status of the extremity (temp, blanching sensation, pain)

___never use the same piece of gauze to clean across an incision or wound twice

never

epistaxis

nosebleed

contributing factors of pressure ulcers

occur mainly in people who are chair-bound, bed-bound, or have altered level of consciousness that causes them to be immobile elderly are at greater risk for the development of pressure ulcers because of the fragility of the skin moisture on the skin from sweating or incontinence can lead to skin breakdown

distribution

occurs after a drug has been injected or absorbed into the bloodstream - the drug molecules are transported throughout the body to where they take action. what the drug goes through to get to the target site

What is dehiscence?

occurs when a suture line accidentally reopens Patient may state "I feel something giving away"

evisceration

occurs when the edges of a suture line separate and the internal organs protrude through the incision same emergency procedures as dehiscence

now

one time admin; up to 90 minutes

malingerer

one who feigns illness to escape duty

classification of wounds

open or closed, full or partial thickness, non-infected or infected, and surgical

why does contamination and infection of the wound slow down the process of healing?

organisms present in the wound will compete with the body cells for oxygen and nutrition

epidermis

outer layer

urge urinary incontinence

overactive destrusor muscle with increased bladder pressure inability to stop urine flow

5th vital sign

pain

dysuria

painful or difficult urination

pallid

pale

color of urine

pale straw to amber

sensory deprivation or overload

patient's environment may influence that individual's response to medications.

chyme is moved through ____and is changed into____.

peristalsis and feces

Acetaminophen pharmaceutical/ therapeutic class

pharmaceutical class: nonsalicyclate, paraaminophenol derivative therapeutic class - nonopioid analgesic, antipyretic

phenazopyridine (pyridum) amitriptyline (elavil) levodopa anticoagulants affect on urine

phenazopyridine (pyridum) - orange/rust amitriptyline (elavil)- green or blue levodopa -dark brown or black anticoagulants - hematuria

angiogenesis

physiological process through which new blood vessels form from pre-existing vessels

ventrogluteal site IM landmark

place palm of left hand on right greater trochanter so index finger points toward anterosuperior iliac spine -spread first and middle fingers to form a "V" -inject medication in the middle of the "V"

trough level

point at which the drug is at its lowest level; blood drawn 30 minutes before the next dose

drugs given orally travel to the liver via the

portal vein

smell of ammonia indicative of

possibly UTI

glycosuria

presence of glucose in the urine

surgical wounds heal as

primary intention

absorption definition

process by which a drug is transferred from its site of entry into the bloodstream

define execration of drugs

process of removing drugs from the body via kidney, lungs (inhaled meds), feces, skin -minimal

valerian

promotes sleep, reduces anxiety

Red =

protect

neutrophil nutrition requirements

protein, vitamin B6, folic acid

nutrients needed for angiogenesis

protein, vitamin E, and A

necessary for nitrogen balance

proteins

pancreatic enzymes break down dietary ____ into amino acids in the ____

proteins; small intestine

dermis

provides elasticity to the skin, blood vessels, nerve fibers, glands, hair follicles

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

pulmonary function tests

upper UTI

pyelonephritis

intractable pain

resistant to therapy and persists despite intervnetions

medication reconciliation

resolve any discrepancies, conducted at admission, transferring and dischargin

transient urinary incontinecnce

reversible caused by UTI, disease processes (hyperglycemia, diuretics etc)

rate of absorption depends on?

route of admininstration

most common drainage from a noncomplicated surgical wound

sanguineous

healing intention for burns, pressure ulcers, severe lacerations

secondary intention

ceruminous

secrete thick, oil substance; found in external ear

components of braden scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

discontinue cold applications if

shivering occurs (this raises body temp) cyanosis of lips or nails accelerated weak pulse do not use if site is edeamtous or neuropathy present

adverse drug reactions

side effects - mild, predictable tolerable adverse reaction - may be severe or life threatening

where to place ear drops?

side of canal not in the middle as this will hit the ear drug

intradermal purpose

slow absorption small qty of solution used for skin testing

how do anti-inflammatory drugs affect fibrous tissue?

slow down the formation

digestion occurs in

small intestine bile emulsifies fat and helps pancreatic lipase break down the fat

moist heat

soak, compresses, hot packs assess skin condition after 5 minutes for increased swelling, excessive redness, blistering, maceration, pronounced pallor, or if the patient reports pain or discomfort

visceral pain

splanchnic; originates in body organs, thorax, cranium, abdomen

normal flora of the skin include

staph aureus, staph epidermis and strep

urine in the bladder is ___

sterile may become contaminated by bacteria from the perineum during collection

hemostasis

stoppage of bleeding vasoconstriction; sticky vessel walls; platelet plug

ethnopharmacology

study of the effect of ethnicity on responses to prescribed medication, especially drug absorption, metabolism, distribution, and excretion

cutaneous pain

superficial pain usually involving the skin or subcutaneous tissue

fats help to

support and protect organs, temp control, help to transport digested nutrients into the circulation (absorption)

soporiferous gland

sweat glands; apocrine; eccrine

adherence

taking medication as prescribed improved through client understanding

Define bioavailability

the amount of drug that reaches systemic circulation and can act on the cells

basal metabolic rate

the energy needed to maintain life-sustaining activities for a specific period of time at rest

serum drug levels indicate

the onset, peak, duration of action

guarding

the protection of an area of injury or pain by the patient reflex contraction of muscles

how does aging effect UTI?

they dont show as many symptoms, temp regulator not as effective, could have a fever and not show it hygiene might not be as good

eschar

thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

do not use cold ear drops this could cause

tinnitus and pain

catabolism

tissue breakdown

wolfe's law

tissue grows in response to stresses that are placed on it

anabolism

tissue replacement

nonadherent material does not stick

to wound bed

clarity/turbidity of urine

transpartent unless pathology is present

TURP

transurethral resection of the prostate

problems in proliferative phase of wound healing

tunneling, glassy, edematous, granulation, and hypertrophic granulation

pull pin for otic drug

up and back for adults down for infant or child less than 3 years straight back for a child older than 3 years

lower UTI

urethritis, prostatitis, cystitis

cold compress

use sterile technique for open wounds check site 5 to 10 min after intolerance removed after prescribed treatment period usually 20 minutes

vitamin b1 (thiamin)

used in carb metabolism

folic acid or folate

used in synthesis of DNA

acute wound

usually heal within days to weeks low risk infection edges well approximated

clean up - inflammatory phase

vessel leaking; neutrophilic migration to the site, macrophage and phagocytosis occur

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

vesticular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx

splanchnic

visceral

A patient in pain will not always experience a change in

vital signs

nutrients needed for epithelization

vitamin A

needed vitamins for wound healing

vitamin A vitamin B complex vitamin C vitamin K

nutrients needed for collagen

vitamin C

clot formation nutritent requirements

vitamin K

BMI calculation

weight (kg) / height (m^2)

nitrogen balance +

when N intake is greater than excretion

nitrogen balance -

when more nitrogen is excreted than ingested

aloe

wound

tertiary healing intention

wounds left open for several days wounds are contaminated observed for signs of inflammation closure is delayed

can stress cause fluid retention?

yes

enema bag should be raised to a level 18 inches above patient's poisition?

yes

macrophage nutrition requirements

zinc for cell production

indicators of poor nutrition

•Cachectic appearance •Dry, brittle hair •Flaccid muscles •Dry, scaly lips •Brittle nails •Scarlet, beefy tongue •Bleeding, receding gums •Sagging posture

topical tips

•Wash the skin with soap and water before applying the medication •Do not shave off any hair on the skin •Do not use an alcohol swab on the skin site •Do not apply heat to the site. •Wear gloves. •Avoid placing patches on skin lesions or hairy parts of the body.