Overview of Fundamental Content - EAQ,

Descriptive Theories

theories help to explain client assessments. Grief or Caring.

Predictive Theories

theories identify conditions or factors that predict a phenomenon.

Grand Theories

theories provide the structural framework for broad, abstract ideas about nursing.

Gyrate

twisted, coiled, spiral, snakelike

gauze

used for drying

Wound vacuum assisted closure (V.A.C.)

uses negative pressure to support healing. Chronic ulcers. Pulls fluid.

fistula formation

"abnormal" passageway from internal organ to outside of body or from one internal organ to another | between bowel and bladder

stage 2 pressure injury:

*partial thickness skin loss with exposed dermis. *the wound bed is pink or red and moist, may appear as an intact or ruptured blister.

secondary prevention

-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health status -examples: communicable disease screening and case finding; early detection and treatment of diabetes; exercise programs for older adult clients who are frail

autonomy

A nurse who promotes freedom of choice for clients in decision-making best supports which principle?

skin turgor

A reflection of the skin's elasticity, measured by monitoring the time it takes for the skin on he back of the hand to return to position after it is lightly pinched between the examiner's thumb and forefinger. Normal turgor is a return to normal contour within a few seconds; if the skin remains elevated (tented) more than a few seconds, turgor is decreased.

phenomenon

A theory contains a set of components such as concepts, definitions, assumptions or propositions that explain a phenomenon.

cold

vasoconstriction, decreases pain and swelling Used for initial injury C/I: decrease circulation, 20-30 minutes for cold

heat

vasodilation, relaxation C/I: Bleeding, burns

masceration

white wound edges

secondary healing intention

wound contraction brings things closer together leaves a scar. Risk for infections, trauma, ulceration, large amounts of exudate. Leave as is: heals inside out. Edges cannot be approximated.

Wrapping

wrap from distal to proximal

hydrocolloids

Adhesive wafers that interact with fluid to form a gel. Protection for partial thickness wounds, mild exudate. Do not use on effected wounds.

sutures

removed 7-14 days after absorption

action stage of change

Begins to change behavior through practice, may experience relapse

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

Hemovac drain

CLOSED DRAIN SYSTEM, a surgical drain to prevent blood and lymphatic fluid buildup under your skin and encourage healing. drains fluid by passive suction.

Correlation research

research explores the interrelationships among variables of interest without any active intervention by the researcher

Streptococcus infection

Crusting is seen

capillary refill

slow reaction time may be a sign of shock and can also indicate dehydration and decreased peripheral perfusion.

burns around face

smoke inhalation airway

Effects of lots of drainage on a wound

soft, wrinkled pail skin around wound

Which of these databases should the nurse use to obtain a broad view on biomedical and pharmaceutical studies?

EMBASE The EMBASE database is a good source of biomedical and pharmaceutical studies. PubMed is the health science library at the National Library of Medicine; this database offers free access to many journal articles. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. PsycINFO is a good resource for psychology and psychology-related healthcare disciplines.

Secondary Acute Care

Emergency care, acute medical surgical care, radiological procedures

An African man presents to the emergency department to obtain pain medication. The nurse behaves judgmentally and labels the client a drug abuser. What is the nurse demonstrating?

Ethnocentrism is the tendency of a person to hold his or her own beliefs superior to those of other people. It causes biases and prejudices in regard to people from other groups. This practice is transmitted by cultural groups from one generation to another. In multiculturalism, two cultures coexist and are accepted by the individual. In a cultural encounter, part of cultural competence, a nurse engages in cross-cultural interactions for effective communication. Cultural imposition occurs when a nurse or health care provider ignores the differences between his or her own culture and others and imposes his or her beliefs on people of other cultures.

What is the primary focus of the nurse when providing evidence-based care to the client?

Evidence-based practice is first and foremost a problem-solving approach to care. This problem-solving approach incorporates application of current best practice along with knowledge from research studies and clinical expertise.

What are the elements of discovery of a lawsuit?

Experts, medical records, and the depositions of witnesses are elements of discovery of a lawsuit. Proof of negligence is a part of a trial. Petition and elements of the claim are a part of the pleadings phase.

External Factors that influence health beliefs

Family practices, cultural background, and socioeconomic factors

Unstageable Pressure Injury:

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

stage 4 pressure injury:

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.

primary intention healing

Healing over an injury that is evenly closed (incision). Edges are held in close approximation; little granulation tissue formed.

The Magnet Recognition Program for health care organizations is based on fourteen forces of magnetism related to five magnet model components. Which force of magnetism is assessed to review the structural empowerment of the organization?

Health care organizations that apply for Magnet status must demonstrate innovations in professional practice. One of the forces of magnetism that impacts the structural empowerment of the organization is its personnel policies and programs. Personnel policies of an organization should provide an innovative environment in which the staff are developed and empowered. Empirical quality outcomes are reviewed by assessing the quality of care. New knowledge, innovations, and improvements are reviewed by assessing the quality improvement of the health care organization. Interdisciplinary relationships are assessed to review exemplary professional practice.

A nursing student lists examples of health promotion activities that can help clients maintain or enhance their present levels of health. Which examples are accurate? Select all that apply.

Health promotion activities enable clients to enhance or maintain their current health levels. Good nutrition and regular exercise are examples of such activities. Immunization against measles is an example of an illness prevention activity. Education about stress management and physical awareness are examples of a wellness education activity.

A nursing student is recalling information about hospice care. What is hospice care?

Hospice care is a system of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness.

General Skin assessment questions

How would you describe your overall skin condition? • Have you ever had problems with your skin? What kind of problems? Location? When? • Describe your usual skin care regime. • Describe your usual diet. Have you experienced any recent unintended weight loss? • Are you ever incontinent of urine or stool? • Have you been told that you have diabetes or problems with your circulation? • Do you smoke? • Do you drink alcohol or use illicit drugs? • Have you noticed any numbness or tingling in your feet? • Has it seemed to take a long time for a wound to heal in the past?

hypertrophic scar vs keloid

Hypertrophic is just over injury Keloid extends far beyound scar

Deep Tissue Pressure Injury:

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.

Which type of theory is the Neuman systems model?

Neuman systems model is an example of a grand theory that provides a comprehensive foundation for scientific nursing practice, education, and research. Theories related to growth and development are descriptive theories. Prescriptive theories address nursing interventions for a phenomenon, describe the condition under which the prescription occurs, and predict the consequences. Mishel's theory of uncertainty is a prescriptive theory. Middle-range theories tend to focus on a specific field of nursing. Mishel's theory of uncertainty in illness is a middle-range theory.

Seroanguineous

Pale, pink, watery; mixture of clear and red fluid

vitamins for wound healing

Protein, Vitamin C, Zinc and Copper

Undermining/Tunneling

Take sterile q-tip and put it in the wound; the wound is extending underneath the opening and it will eventually become a much bigger wound. (Two wounds) *detached from subq, uses clock

A nurse is in the process of conducting research. What action indicates that the nurse is designing the study?

The nurse prepares questionnaires and selects the treatment plans necessary for the study.

What is the function of the Professional Standards Review Organizations (PSROs) set up by the federal government?

To review the quality, quantity, and cost of hospital care

Why should organizations promote transparency in health care?

Transparency allows continuous feedback for improving client outcomes.

transparent film (tegaderm)

Used as a secondary dressing and for autolytic debridement of small wounds Advantages -Adheres to undamaged skin -Serves as a barrier to external fluids and bacteria but still allows wound surface to "breathe" -Promotes a moist environment -Can be removed with damaging underlying tissues -Permits viewing a wound -Does not require a secondary dressing

fascia

a band or sheet of fibrous connective tissue that covers, supports, and separates muscle

actinic keratosis

a precancerous skin growth that occurs on sun-damaged skin

Six Sigma

a process for reducing costs, improving quality, and increasing customer satisfaction

Petechiae

a small red or purple spot caused by bleeding into the skin. Nonblanchable.

JP drain

abbreviation for Jackson-Pratt drain; suction drain with tubing inside the body and a bulb reservoir which, when squeezed empty, applies suction and pulls fluid out of the body; used in thoracic or abdominal surgery

sanguineous exudate

an exudate containing large amounts of red blood cells

maintenance stage

sustained change over time; begins 6 months after action has started and continues indefinitely

Preparation stage of change

the client has made the commitment to change and is preparing to begin the change process

cherry angiomas

benign small bright red spots.

annular

circular, begins in center and spreads periphery (tinea corporis (ringworm)

serous drainage

composed of clear, serous portion of the blood and from serous membranes

closed wound drainage system

consists of a drain connected to either an electric suction or a portable drainage suction

Contemplation stage of change

the client is aware and accepts responsibility for problems

Prescriptive Theory

theories detail nursing interventions for a specific phenomenon and the expected outcome of the care.

tertiary intention

delayed primary intention due to delayed suturing

discrete

distinct individual lesions that remain separate (acne)

Value Stream Analysis

focuses on the improvement of processes. It studies each step of a process to determine if that step adds value to that process. It also determines if the process reduces the organization's time, cost, and resources. The National Committee for Quality Assurance (NCQA) created HEDIS to collect various data to measure the quality of care and services provided by different health plans. It is the database of choice for the Centers for Medicare and Medicaid Services.

stage 3 pressure injury:

full thickness loss, looks like deep crater extend to fascia, subtaneous tissue damged/necrpticfat visable undermining/tunneling may be present damage to surrounding tissue

Knowledge, Educational background and past experiences

influence how a client thinks about health.

Tertiary Care

intensive care, subacute care

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles

Paradigm

is a pattern of thought that is useful in describing the domain of a discipline.

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

is a standardized survey developed to measure client perceptions of their hospital experience. The survey asks 27 questions about the client's hospital experience. The survey is taken by clients who were discharged from the hospital between 48 hours and six weeks ago

Intellectual background

is an internal factor that affects the client's health beliefs and practices.

Domain

is the perspective of a profession.

zosteriform

linear arrangement along a unilateral nerve route (herpes zoster)

A wound that is pale or dry

may be reflective of conditions that are not optimal for wound healing, such as anemia, poor vascular status, nutritional deficiencies, or dehydration.

Confluent

merging together urticara (hives)

hydrogel dressing used for

moisture needed for wound healing

Stage 1 Pressure Injury:

non-blanchable erythema of intact skin

pen rose drain

note location, drainage on dressing, placed into incision so fluid can come out, expect more drainage, soft rubber tube placed in wound site to prevent build up of fluid, small. Not sutured in.

block and parish nursing

nurses living within a neighborhood provide services to older patients or those unable to leave their homes

abnormal reactive hyperemia

occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than one hour and the surrounding tissue does not blanch.

principle of wound management for all open wound is to

protect new granulation and epithelial tissue

Focused wound Assessment Questions:

• How long has this wound been present? What do you think caused this wound? Have you ever had a wound like this before? • What are you doing for this wound at home? What are you using to clean the wound? What have you put on it? • Have you noticed any changes in the appearance of the wound or the skin around it? • How much wound drainage is there? Has the amount, color, or odor of the drainage changed? How often do you need to change the bandage at home? • Do you live alone? Do you have anyone who helps you at home? • Is the cost of caring for this wound difficult for you to manage?