exam 1 quick review

Overflow

-due to retention

Stage 1

1 layer of damage(epidermis) red skin that is NON blanchable and not broken.

Nasogastric tubes (ng tube) large bore

12-french, for gastric decompression or removal of gastric secretions (suction).

Stage 2

2 layers of damage (epi and derm) wound bed is red/pink,shiny,dry.

Stage 3

3 layers of damage(epi,derm,sub) full thickness skin loss into subcutaneous fat wound may tunnel under the edges of the wound bed.

What is normal hourly urinary output for a child

3-5 wet diapers a day,

What is normal hourly urinary output for an adult

30 mL an hour

Stage 4

4 layers of damage that extends all the way down into the muscle,bone,or tendon.

Hypoventilation

Alveolar ventilation decreases>the body retains CO2.

Systemic circulation

Arteries deliver nutrients and O2,Veins remove waste from tissues.

The nurse is providing patient teaching about prevention of pressure injuries. Which statement by the patient would indicate that the teaching was successful?

Because I have dry skin, I need to moisturize.

Regulation of ventilation

CNS controls respiratory rate,depth,rhythm.

Hyperventilation

Can be caused by severe anxiety, infection, drugs, and/or acid base imbalances.

Large intestines

Cecum,Ascending colon,Transverse colon,Descending colon,Sigmoid colon,Rectum

Hypovolemia

Conditions such as shock, severe dehydration, fluid loss and reduction in circulating volume.

Tertiary intention

Delayed primary intention closure.Planned period where superficial layers are left open (closed later by primary intention (surgically)

Small intestine (3 sections)

Duodenum,Jejunum,Ileum

The nurse recognizes that the pts limited mobility can have adverse effects on the skin. What other information would the nurse need to gather to establish priorities for the plan of care? (Select all that apply.)

Fall risk, nutritional status, smoking history, hygiene status/practices,circulation status.

Induration

Formation of thickened or hardened edges around the wound.

Hypoxia

Inadequate tissue oxygenation at the cellular level.

Medicated enemas

Kayexalate: used to treat dangerously high serum potassium levels

Stomach

Produces and secretes hydrochloric acid, mucous, pepsin (an ezyme), and intrinsic factor (essential in the absorption of vitamin B12).

Ostomy pouches

SenSura® one-piece pouch with Velcro closure,

Ostomy pouch

SenSura® two-piece pouching system with separate skin barrier and attachable pouch.

Coronary artery circulation

Supplies the myocardium with O2, nutrients, and removes waste.Coronary arteries fill during diastole.Left coronary artery get the most blood supply.

Primary intention

Surgical closure of a wound with sutures, staples, tapes, surgical glue. Low risk for infection

GI tract alimentary canal and it's accessory organs

Teeth,Tongue,Salivary glands,Liver,Pancreas,Gallbladder.

Blood flow regulation

The amount of blood ejected from the left ventricle each minute Is the cardiac output.Normal is 4-8 L/min at rest.Cardiac output increases in times of greater oxygen and metabolic needs (exercise)

The nurse is inspecting pts skin. To which areas should the nurse pay close attention while performing a physical assessment? (Select all that apply.)

Under breast, groin, arms and legs,sacrum.

Myocardial blood flow

Valves ensure blood flow is one way.,In ventricular diastole the atrioventricular valves (mitral and tricuspid) open.Systolic phase- semilunar valves (aortic and pulmonic) open.

Myocardial pump

Ventricles fill with blood during diastole and empty during systole,

Fatal dysrhythmias caused by conduction disturbances

Ventricular tachycardia,Ventricular fibrillation.

The nurse is providing education to Josephine Morrow on how to prevent additional venous stasis ulcers from developing. Which statement(s) would be appropriate to include in the teaching plan? (Select all that apply.)

Wear support stockings to help prevent ulcers and heal existing ones.', 'Watch for signs and symptoms of new ulcers.'

Diagnostic tests for bowel

X-ray, ct, fecal specimen , barium swallow, enema, endoscopy, occult stool sample occult=hidden.H & H, liver profile.

Dehiscence

a surgical incision fails to heal properly, the layers of skin and tissue separate.

Pelvic floor muscles

a thick layer of muscles stabilize the urethra and contribute to urinary continence.

Secondary intention

a wound involving loss of tissue, such as a burn, Stage 2 PI, severe laceration.Not closed surgically due to unable to bring the tissues together safely from tissue loss.

Factors that can influence normal bowel elimination

age,diet,fluids,activity/mobility,pain,pregnancy,surgery,meds,bashful bowels,impaction,hemorrhoids.

Urinary retention

an accumulation of urine due to the inability of the bladder to empty.

Eschar(esCHARCOAL)

black/brown dead necrotic tissue.

Lower urinary tract

bladder, urethra.

Diarrhea

can lead to dehydration, electrolyte and acid-based imbalance

Ureters

carry waste from the kidneys to the bladder. Urine draining from the ureters to the bladder is sterile.

Angina

chest pain from imbalance between O2 supply and demand.Transient (impermanent)

Atelectasis

collapse of alveoli causes less of the lung to be ventilated leading to hypoventilation.

Peristalsis

contractions of the esophagus that move food through the GI tract

External urethral sphincters

control the flow of urine.

Common signs/symptoms seen w/ UTI

delirium, confusion, fatigue, loss of appetite, decline in function, incontinence, falls, temperature.

Nasal cannula

delivers o2 from 1-6 liters.

Non-rebreather

delivers o2 from 10-15liters. Used in medical emergencies, such as co2 poisining.

Venturi mask

delivers o2 from 4-10 fio2. Most precise oxygen delivery device. Very accurate o2.

Simple face mask

delivers o2 from 6-10 liters.

Partial rebreather

delivers o2 from 6-10 liters. Flutter valves on the sides.

Hemorrhoids

dilated, engorged veins in the lining of the rectum.External or internal

Unstageable

eschar(black/brown)dead necrotic tissue, slough(yellow,stringy).

what might you see or hear when listening to an abdomen

extended, swollen, no sounds at all, or a lot of sounds.

DEEP TISSUE INJURY

fatty tissue is injured below the skin (dark purple,sometimes open wound.

Positioning-frequent repositioning

for a patient who is immobile reduces stasis of pulmonary secretions and the reduction of pneumonia risk.

Nasogastric tubes (ng tube) fine or small bore

for medication administration and enteral feedings.

BIPAP

forcefully pushes air deep into lungs delivering o2 while expelling co2. Last line before intubation.

The parasympathetic nervous system

governs the GI tract—(rest and digest).

Functional incontinence

have some problem with getting to the bathroom

Cathartic

have stronger and more rapid effect on the intestines than laxatives.

Oxygen transport

hemoglobin transports 97% of o2.

Non-blanchable erythema

if skin does not blanch when pressure is applied to skin and possible tissue damage is probable.

Wound VAC therapy

improves the possibility of primary closure of wounds and reduces the need for reconstructive procedures.

Myocardial infarction (MI)

inadequate coronary perfusion>cellular death after 20 minutes

UTIS can be caused by

indwelling catheters, instrumentation of the urinary tract, urinary retention, urinary and fecal incontinence, poor perineal hygiene. CAUTI, E. Coli.

Ambulation-immobility

is a major factor in developing atelectasis, ventilator-associated pneumonia (VAP).

Electrocardiogram (ECG)

is a measurement of electrical activity of the conduction system.

45-degree, semi fowlers position

is best for lung expansion.

Stroke volume

is the volume of blood ejected from the ventricles during systole.

Upper urinary tract

kidneys

When performing enema the patient needs to lay on the

left side lying position.

Kidneys

lie on each side of the spine against the muscles of the back. Normally the left kidney is higher than the right because of the position of the liver.

Most common areas for pressure injuries

lower back,buttocks (sacrum &coccyx), heels,ankles,hip bones,shoulders,elbows.

Bladder

muscular organ that holds urine.

Is the GI tract sterile

no it is dirty.

Constipation

patients taking pain medications may require a stool softener or laxative to prevent constipation.

Blanchable hyperemia

placing finger over affected area, if the skin turns lighter in color and erythema returns.

Process of wound healing

primary intention,secondary intention,tertiary intention.

Nutrition for wound healing

protein,vitamin C,trace minerals,zinc,copper. Chicken breast,Orange,Broccoli,Milk

Evisceration

protrusion of visceral organs through a wound opening.The condition is an emergency that requires surgical repair .

Carminative enemas

relief from gaseous distention

Exudate

should describe the amount, color, consistency, and odor of wound drainage.

The nurse is assessing a shallow, open ulcer with a red-pink wound bed that is located on a patient's sacrum. How would the nurse document this wound?

stage II.

Fecal impaction

stool that is too dry and hard to pass. Can lead to bowel obstruction.

C-diff

the most common health care related infection in America.

Colostomy

the surgeon pulls a portion of intestines through the abdomen and creates a stoma.

Left-sided heart failure

think L for Lung, decreased left ventricular function leading to decreased cardiac output>pulmonary congestion>crackles in lung bases, hypoxia, cough, SOB on exertion.

Right-sided heart failure

think R for rest of body. systemic back up in the systemic circulation>weight gain, distended neck veins, peripheral edema.

Face tent

typically used for facial trauma such as burns to face. Humidified o2.

Urethra

urine travels from the bladder to the outside of the body through the urethra.

Ileoanal pouch anastomosis

used in treatment of ulcerative colitis or familial adenoma polyposis (FAP).The end of the small intestines creates a pouch for fecal retainment which stimulates the rectum and then stool it exits the anus.

Incentive spirometry

used to prevent atelectasis in patients who had surgery, or prolonged bed rest.

Manipulation of the rectal tissue stimulates the

vagas nerve and causes low hr.

Carbon dioxide transport

venous blood transports co2 back into the lungs to be exhaled.

Slough

yellow stringy, think skin of cicken.