Quiz 14

Which data-collection activities should the nurse use to determine whether the treatment is effective for pain?

Ask for patient to rate their pain & compare to their pain rating before the intervention

Patients in pain what should we do first

Assess the patient's pain; accept patient report of pain

How long does acute pain last?

Lasts less than 6 months; intense & of short duration Warning to the individual of actual or potential tissue damage (fight or flight response) Chronic pain: longer than 6 months, continuous & intermittent

Primary intention advantage what happens with scarring

Minimal scarring: wounds in which skin edges are close together & little tissue is lost Low risk of infection, heals rapidly

Which vitamins help wound healing?

Vitamin A: dark, leafy vegetables and yellow or orange fruits and vegetables Vitamin C: strawberries, tomatoes, spinach, and cruciferous vegetables (broccoli, cauliflower, and cabbage are rich in Vitamin C)

Select all that apply: Wound irrigation?

Clean from least to most contaminated Cleanse area wound with antiseptic swab Instill solution into wound then insert syringe tip into wound Wound cleansing and irrigation is accomplished using sterile or clean technique Cleansing solution is introduced directly into the wound with a syringe, syringe and catheter, shower, and whirlpool Fluid retention is avoided by positioning the patient on his or her side to encourage the flow of the irrigant away from the wound Promote wound healing through removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar Cleanse in a direction from the least contaminated area to the most contaminated area

Types of drainage

Closed: system of tubing or other apparatus attached to the body to remove fluid in an airtight circuit that prevents environmental contaminants from entering the wound or cavity Open: passes through an open-ended tube into a receptacle or out onto the dressing Suction: uses a pump or other mechanical device to help extract a fluid

What type of precautions are needed for cleaning wound dressing

Don clean gloves when removing the dressing; doff gloves when going from dirty toclean surface or supplies; hand hygiene Aseptic technique

What's considered an abnormal amount of drainage within the first 24 hours post surgery

Drainage exceeding 300 mL

Postoperative has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Fully recollapse the reservoir after emptying it Closed drainage: system of tubing or other apparatus attached to the body to removefluid in an airtight circuit that prevents contaminants from entering wound

Acute lower back pain from moving heavy boxes. What should we reinforce for care?

Heat or cold application Cold application reduce acute pain associated with inflammation from arthritis or from acute injury

What's the major advantage of PCA pump

It is easier to prevent rather than treat severe pain Acknowledge the pt as an expert in his own experience of pain

Which types of drainage systems describe an open-ended tube that drains into a receptacle or out into the dressing?

Open drainage

Which method is the most reliable source when determining the intensity of the client's pain?

Patient self-report of their pain; pain scale

How do you keep patient comfortable during dressing change

Position patient comfortably and drape/cover with bath blanket exposing only the wound Close door or pull privacy curtain

How do we prevent post op incisional infections?

Practice hand hygiene before performing dressing change

How do we know a wound is healing with a wound vac?

Presence of granulation tissue over the surface of the wound; decrease in wound drainage; decreased swelling

Select all that apply: Signs and symptoms can a nurse assess in a client with sleep deprivation?

Psychological: mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, and hyperexcitability Physiological: hand tremors, decreased reflexes, slowed response time, reduction in memory, decreased reasoning & judgment, and cardiac dysrhythmias

Clinical infections of wound infection

Purulent drainage, pain, Redness, edema, fever, chills, odor, Increased Pulse, RR, WBC count

Select all that apply: advantages of a client receiving proper pain management during their hospital stay?

Quicker recovery, fewer readmissions, improved quality of life, shorter hospital stay

What's the major advantage of PCA pump

Quicker recovery; gives patient some control over pain

Reason for a client using cold compress

Reduce acute pain associated with inflammation/swelling from arthritis or from acute injury Vasoconstriction: reduced blood flow to injured area

What's a complication from morphine

Respiratory depression A child

Which nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply.)

Restlessness, grimacing, clenched fists, moaning, crying, frowning

Clinical manifestations of pain

Self-protective > guards the painful area, can't think of anything but the pain Withdrawal from social contact; grimacing, restlessness Increased pulse rate

Which term should the nurse document to describe red drainage?

Serosanguineous: pale, red, water, mix of serous & sanguineous Red (describes as pink) Sanguineous: bright red (indicates active bleeding)

Select all that apply: Objective signs of pain?

Signs & objective cues; observable & measurable data Tachycardia, increased rate and depth of respirations, diaphoresis, increase systolic or diastolic blood pressure, pallor, facial expression, increased muscle tension, possibly nausea or weakness, withdrawal, dilated pupils

Clinical manifestations of granulation tissues

Soft, pink/red, fleshy, projections that consist of capillaries surrounded by fibrous collagen Presence of granulation tissue (signs that wound is healing)

Teaching with a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device.

Teach the use of PCA before surgery so that patient will know how to use it after awakening from anesthesia Instruct patient of PCA, operating instructions, lockout intervals, expected pain relief, side effects, patient controls med delivery Explain that the pump prevents overdose; family cannot operate device Ask patient to demonstrate use of PCA delivery button The ability to obtain a dose when it is needed places the patient in control and eliminates the wait for medication administration A drug delivery system, allows patients to self administer analgesics whenever needed

What are endorphins?

The body produces morphine-like substances (potent polypeptides composed of amino acids, found in pituitary gland & other areas of CNS) Pain relief measures: transcutaneous electric nerve stimulates (TENS), acupuncture, and placebos (cause the release of endorphins)

Define the gate control theory

The gate control theory of pain suggests that pain impulses are regulated & even blocked by gating mechanisms located along CNS Stages that the brain does not have the capacity to acknowledge pain stimuli while it interprets another stimuli In the dorsal horn of the spinal cord (pain and other sensations of the skin and muscle travel same way in the spinal cord) Gates open: pain impulses flow freely Gates closed: pain impulses become blocked (caused by pressure of a back rub, the heat of a warm compress, or cold from ice applications) Alterations by thoughts, feelings, and memories

Care for eviscerations

The protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall Patient is to remain in bed, and the wound and contents should be covered with warm, sterile saline dressings The surgeon is notified immediately Considered a medical emergency, and the wound requires surgical repair The outer edges of a wound normally appear inflamed for the first 2-3 days then slowly disappears; 7-10 days healing wound fills with epithelial cells and edges close

What's the priority in administering analgesic

The safety of the patient