Module 7 Nu 144
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The older population is at greatest risk for immobility related to reduce rom, pain in joints, bone fx, and reduced muscle mass.
Pain is what?
What the patient says it is. It is a complex, multidimentional experience. For many people, it is a major problem that causes suffering and reduces quality of life. "unpleasant sensory and emotional experience associated with actual or potential damage"
Controlling pain is important to promoting wellness. Unrelieved pain has been associated with
a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction
Nociceptive pain—
often described as dull, aching, and throbbing, pain of a surgical incision. Usually responsive to nonopioids and/or opioids
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~Functional ability changes throughout the lifespan and is influenced by: developmental stage (achievement of developmental milestones), physical health, and psychosocial health, and cognitive ability, social and cultural factors.
Which of the following describes a hydrocolloid dressing?
A) A seaweed derivative that is highly absorptive B) Premoistened gauze placed over a granulating wound C) A debriding enzyme that is used to remove necrotic tissue D) A dressing that forms a gel that interacts with the wound surface Answer: D
The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take?
A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Narcan).
The nurse determines that a client has a Braden Scale score of 9. Which is the nurse's best intervention related to this assessment?
A) Increase the client's fluid intake. B) Consult with the health care provider. C) Reassess the client in 3 days. D) Document the finding per protocol.
In a patient admitted with cellulitis of the left foot, which of the following clinical manifestations would you expect to find on assessment of the left foot?
A. Redness and swelling B. Pallor and poor turgor C. Cyanosis and coolness D. Edema and brown skin discoloration
The nurse is assessing a patient's functional ability and asks the patient, "How would you rate your ability to prepare a balanced meal?"
"How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities?
Interventions for atopic dermatitis..responds to controlled phototherapy with UV light. Protection from excessive UV exposure is important to prevent tissue damage.
(Pg 123 assessment). A chronic superficial inflammation of the skin with an unknown cause; however, it is commonly associated with hay fever and asthma and is thought to be familial.
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- Calcium alginate—used with significant exudate; must cover with secondary dressing - Gauze—used with normal saline or other prescribed solution; must unfold to make contact with wound. -Growth factors—used with gauze per manufacturer instructions
A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing?
1) Phantom 2) Visceral 3) Deep somatic 4) Referred
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-Evaluate whether current treatment plan is effective.
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-Implement discharge teaching about pain management.
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-Teach patient and caregiver about treatment plan.
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-Wear long sleeves and long pants, tight woven fabric. -Wear a hat with a wide brim. -Wear sunglasses.
Roles of Rn (bx on pg. 134)
-assess pain characteristics; pattern and onset, area or location, intensity, quality, associated symptoms, and management strategies.
Answer... A...
.Older adults are highly susceptible to deconditioning, a process that can be slowed or prevented by regular physical activity. This consideration supersedes any possible effect on pharmacokinetics, prevention of cognitive deficits, or the patient's sense of purpose.
A transparent film dressing is indicated for all but which of the following types of applications?
1 A 2-cm deep wound with copious amounts of serous drainage 2 A newborn with a skin tear 3 A laparoscopic cholecystectomy wound 1 day after surgery 4 A protective cover for an intravenous catheter
What is the primary mechanism of action of a hydrocolloid dressing?
1 It covers the wound, preventing staff or patient from viewing the affected area. 2 It forms a gel over the wound to facilitate moist wound healing. 3 It forms a temporary membrane over the wound, allowing oxygen transport directly to the wound. 4 It delivers epithelial growth factors to the wound base.
When using gauze moistened in normal saline for a wound dressing, why is the gauze pad wrung out before application?
1 To prevent excessive delivery of the solution to the wound 2 To keep the healing wound moist and wick any excessive drainage 3 To prevent moistening the secondary dressing and causing maceration 4 To allow the wound to become slightly dry to facilitate healing
A nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription?
1. Obtain blood cultures. 2. Administer antibiotics. 3. Apply cold compresses to the affected area. 4. Administer acetaminophen (Tylenol) for fever. Answer: 3.Apply cold compresses to the affected area
An immobilized bed-bound patient is placed on a 2-hour turning and positioning program. The nurse explains to the family members that this is done primarily to:
1. Support comfort 2. Promote elimination 3. Maintain skin integrity 4. Facilitate respiratory function
A nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse would include on the poster instructions to avoid which of the following activities?
1. Wearing a hat, opaque clothing, and sunglasses when in the sun 2. Being in the sun for prolonged periods between 10:00 ᴀᴍ and 3:00 ᴘᴍ 3. Using sunscreen when spending time outdoors 4. Examining the skin monthly for any lesions that might be cancerous
During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of a:
1.Stage 1 pressure ulcer.. 2.Stage 2 pressure ulcer.. 3.Stage 3 pressure ulcer.. 4.Stage 4 pressure ulcer..
A nurse notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area of a client on bed-rest. The nurse documents these findings as a
1.Stage 1 pressure ulcer.. 2.Stage 2 pressure ulcer.. 3.Stage 3 pressure ulcer.. 4.Stage 4 pressure ulcer.. Answer: 2.Stage 2 pressure ulcer
A nurse is checking the skin on a client who is immobile and notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents this finding as a pressure ulcer of which stage?
1.Stage 1.. 2.Stage 2.. 3.Stage 3.. 4.Stage 4.. Answer: 2.Stage 2
A nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse categorizes the ulcer as:
1.Stage I.. 2.Stage II.. 3.Stage III.. 4. Stage IV.. Answer: 2. Stage II
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12 activities: maintaining a safe environment, breathing, communication, mobilizing, eating and drinking, eliminating, personal cleansing and dressing, maintaining body temp, working and playing, sleeping, expressing sexuality, dying
Answer:D
A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose.
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A number of musculoskeletal changes occur with aging. In the spinal column, a thinning of vertebral disks, shortening of the spinal column, and onset of kyphosis with spinal column compression occurs.
Answer: B
A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer development in terms of decreased sensory perception, exposure to moisture, decreased independent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to consult with the health care provider to relay this information and to obtain more aggressive skin protection measures than are currently provided.
Answer: C
A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of débridement of the necrotic tissue and a possible graft to promote healing.
Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting?
A) Cutaneous skin stimulation B) Imagery C) Radiofrequency ablation D) Hypnosis
A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action?
A) Document as a stage I pressure ulcer and apply a transparent dressing. B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments. C) Document as a stage IV pressure ulcer and prepare the client for débridement. D) Document as a stage III pressure ulcer and start antibiotic therapy.
The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability?
A) Healthy individual, college educated, travels frequently, can balance a checkbook B) Healthy individual, works out, reads well, cooks and cleans house C) Healthy individual, volunteers at church, works part time, takes care of family and house D) Healthy individual, works outside the home, uses a cane, well groomed
What does the Braden Scale evaluate?
A) Skin integrity at bony prominences, including any wounds B) Risk factors that place the patient at risk for skin breakdown C) The amount of repositioning that the patient can tolerate D) The factors that place the patient at risk for poor healing B
On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?
A) Stage II.. B) Stage IV.. C) Unstageable.. D) Suspected deep tissue damage Answer: C
The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to:
A) bathe and dry the skin vigorously to stimulate circulation. B) limit intake of fluid and offer frequent snacks. C) turn the patient at least every 2 hours. D) keep the head of the bed elevated 30 degrees.
Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of:
A) mixed pain syndrome. B) chronic pain. C) neuropathic pain. D) nociceptive pain.
Know the ABCD method for assessing skin for signs of cancer, and what can be done to prevent skin cancer.
A- Asymmetry—the shape of one half does not match the other half.
Which of the following patients would be more likely to have the highest risk of developing malignant melanoma?
A. A fair-skinned woman who uses a tanning booth regularly B. An African American patient with a family history of cancer C. A Hispanic male with a history of psoriasis and eczema that responded poorly to treatment D. An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia
Which of the following interventions would be most helpful in managing a patient newly admitted with cellulitis of the right foot?
A. Applying warm, moist heat B. Limiting ambulation to three times daily C. Keeping the foot at or below heart level D. Wrapping the foot snugly in warm blankets
Which of the following practices should the nurse teach a patient to follow when the patient is applying topical medication?
A. Avoid applying medications directly on to dressings B. Use a tongue blade whenever the patient's skin integrity allows C. Avoid covering skin regions that have topical medication in place D. Apply a layer of medication that is just thick enough to ensure coverage
The nurse is teaching the client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include?
A. Avoiding or reducing skin exposure to sunlight B. Avoiding tanning beds C. Being aware of skin markings and performing skin self-examination D. Wearing SPF 40 sunscreen
During Mr. Bass's skin assessment the nurse notes an ulcer at the sacral area. The base of the wound is covered with dark necrotic tissue, and, when she presses on the tissue, it feels soft. What stage is this ulcer? 1 Stage II.. 2 Stage III.. 3 Stage IV.. 4 Not stageable..
4; Rationale: The base of the wound must be visible to determine the true depth of the wound. Until the necrotic tissue is removed, the stage cannot be determined
Percentage of falls that result in hip fractures.
90%
2
; Rationale: A moist saline gauze dressing provides a moist environment to the wound and wicks away excessive drainage, facilitating healing.
Decline of normal anatomical and physiological function caused by disease, aging, or inactivity - generalized illness.
A. Conditioned B. Pathophysiology C. Illness D. Deconditioned Answer D
The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient?
A. Eating and drinking, personal cleansing and dressing, working and playing. B. Toileting, transferring, dressing and bathing activities. C. Sleeping, expressing sexuality, socializing with peers. D. Maintaining a safe environment, breathing, maintaining temperature.
An 85 year old patient is assessed to have a score of 16 in the braden scale. Based on this information, how should the nurse plan for this patients care?
A. Implement q2hr turning schedule with skin assessment. B. Place DuoDerm on the patients sacrum to prevent breakdown. C. Elevate the head of bed to 90 degrees when the patient is supine. D. Continue with weekly skin assessments with no special precautions. Answer: A
An 82 year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1x2x0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?
A. Stage I.. B. Stage II.. C. Stage III.. D. Stage IV.. Answer C
When assessing the activity-exercise pattern in relation to the skin, the RN questions the pt regarding:
A. protection against sun exposure B. the use of moisturizing shampoo C. self-care habits related to daily hygiene D. the presence of dark circles under the eyes
in teaching a pt who is using topical corticosteroids to treat acute dermatitis, the RN should tell the pt that: (select all that apply)
A. the cream form is the most efficient system of delivery B. short term use of topical corticoisteroids usually does not cause systemic side effects C. creams and ointments should be applied with a glove in small amounts to prevent further infection D. abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the dermatitis E. systemic side effects may be experienced from topical corticosteroids if the person is malnourished
in teaching a pt with malignant melanoma about this disorder, the RN recognizes that the prognosis of the pt is most dependent on:
A. the thickness of the lesion B. the degree of color change in the lesion C. how much the lesion has spread superficially D. the amount of ulceration present in the lesion
Unrelieved pain is associated what
Associated with unnecessary suffering, physical and psychosocial dysfunction, immunosuppression, sleep disturbances. (Slide 57) unrelieved pain is one of the reasons that pt's make requests for assisted suicide.
Box 24-4 national cancer institute recommendations for skin cancer prevention through protection from sun exposure.
Avoid outdoor activities during the middle of the day. 10am-4pm
Answer A.
Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing, including hats.
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B- Border that is irregular. The edges are often ragged, notched, or blurred in outline. The pigment may spread into the surrounding skin.
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BADL's which the basic activities of daily living are and related to personal care and mobility: eating, hygiene, grooming, bathing, mouth care, dressing, toileting.
Why would an immobilized pt be on a prescribed turning schedule? (p. 243 concepts)
Because they cannot move themselves and they are at risk for developing pressure ulcers. The patient should be re-positioned at least every 2 hours. The patient dependent on caregivers for positioning is at significant risk for skin breakdown because of prolonged pressure over bony prominence.
Use specialty beds, cleanse skin if incontinence occurs. Use pads or briefs that are absorbant
Caloric intake elevated to 30-35 cal/kg/day or 1.25 to 1.50 g protein/kg/day, supplements, enteral or parenteral feedings may be necessary.
Answer A.
The most important prognostic factor is tumor thickness at the time of diagnosis. Two methods are used to determine thickness. The Breslow measurement indicates the depth of the tumor in millimeters, and the Clark level indicates the depth of invasion of the tumor. The higher the number, the deeper the melanoma.
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The neurologic category involves the brain, spinal cord and peripheral nerves. The neuromuscular category involves a combination of both.
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Risk factors for impaired functional ability: developmental abnormalities, advanced age, cognitive function, mental health issues, depression, trauma ,physical or psychological, and illness ,acute or chronic.
Answer A.
Risk factors for malignant melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy and a family history of other cancers are less likely to be linked to malignant melanoma.
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The speech therapist or occupational therapist is usually responsible for designing this program. The patient should remain in a high Fowler's position, preferably in a chair with the head flexed forward, for the feeding and for 30 minutes following.
You are caring for a 72 year old patient with advanced cancer who complains of increased pain and tactile sensitivity over the last several weeks. Which non pharmacological alternative could be added to her plan of care to enhance her comfort?
Therapeutic Touch, Therapeutic touch is thought to realign aberrant energy fields through passing hands over the energy fields without actually touching the body and promoting comfort.
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There are also biologically-based therapies that involve the use of herbs and vitamins and energy therapies such as reiki and tai chi.
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Throughout infancy, childhood, and adolescence bones change in composition, grow in length and diameter, and undergo changes in rotation and alignment.
Continued...Encourage to participate in moderate exercise to aid in the maintenance of muscle strength and balance.
To reduce falls, assess living environments so that scatter rugs are removed, wear adequate footwear, maintain good lighting and clear paths to the bathroom for nighttime use. Also stress the importance of adequate calcium and vitamin d intake.
Biologically based therapies to help osteoarthritis pain
Use of herbs and vitamins, and energy therapies such as reiki and tai chi.
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Use sunscreen lotions with a spf of at least 15. Apply the product's recommended amount to uncovered skin 30 minutes before going outside, apply every 2 hours or after swimming or sweating.
Know what is meant by deconditioning. Loss due to no physical activity.
Used to describe a loss of physical fitness. This applies not only to an athlete who fails to maintain an optimal level of training but also to an individual who fails to maintain an optimal physical activity.
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Similarly, the size and composition of muscles undergo changes as a result of physical growth and development throughout childhood, and are a major factor in weight gain during adolescence.
Answer: 3) Deep somatic Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery.
Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site.
Ways to prevent fractures in elderly.(Concepts p.243)
Ways to prevent fractures in elderly fall prevention; participating in regular physical activity, to maintain muscle strength and balance, making the environment safer, avoiding hazards, using hand rails, wearing sturdy shoes with nonslip soles, having adequate lighting, and optimizing vision.
ANS: b Visceral pain originates from body organs, or viscera, and often includes pain caused by acute appendicitis, cholecystitis, inflammation of the biliary and hepatic tract, gastroduodenal disease, cardiovascular disease, pleurisy, and renal and ureteral colic.
Somatic pain is from ligaments, tendons, bones, blood vessels, and nerves. It is often poorly localized, may produce nausea, and may be associated with sweating and blood pressure changes. Cutaneous pain would arise from the skin structures. "Superficial" pain is not a defining designation.
Answer A.
When assessing the activity-exercise pattern, the nurse asks the following questions: Do your leisure or work activities involve the use of any chemicals that are irritating to your skin? Do you do anything to protect yourself from the sun?
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-Develop treatment plan for patient's pain; including drug and nondrug therapies.
Which of the following wound characteristics would be appropriately treated by a foam dressing?
1 A dry venous stasis ulcer 2 A heavily exudating stage III sacral ulcer 3 A small, open abdominal wound with tunneling and copious drainage 4 A skin abrasion with minimal drainage.
Know pt education for applying steroid cream
Steroids. Topical steroids are often used to treat allergic dermatitis and the irritating symptoms of pruitus (itching). (p.255 concepts) steroid cream is to apply a thin layer, enough to cover the area and wear gloves to prevent spreading.
Answer: A
Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems.
Answer D.
Patients should be directed to avoid applying topical medications too thickly. Medications may be applied directly on to dressings, and regions with medications may be covered. A tongue blade is not normally necessary for application.
Answer B, D.
Systemic corticosteroids often have undesirable systemic effects. Topical corticosteroids for short-term therapy have fewer systemic effects. Rebound dermatitis is common when therapy is stopped abruptly; this effect can be reduced by tapering the use of topical corticosteroids
Purpose of woods light
TO R/O FUNGUL INFECTION Use of a woods lamp (black light) or immunofluorescence is an enhanced method of inspection involving magnification and special lighting, It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.
Examples of distraction for pain management?
TV, movies, conversing, listening to music, playing a game.
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Pillows can be used to maintain the position and support the patient's back and extremities
Ways to prevent pressure ulcers
Position with pillows or elbow and heel protectors.
Pt's that are immobile are at increased risk for developing what?
Pressure ulcers. Skin breakdown because of prolonged pressure (p.243 Concepts) at risk for stasis pneumonia.
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Proper body alignment achieved through proper positioning and regular repositioning can help prevent or relieve pain.
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Protect yourself from the sun's reflective rays by sand, water, snow, ice, pavement
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The 3 categories are similar in that they all play a role in enabling movement of a single body part or of the total body. They are also similar in that dysfunction in any of the categories can impair movement either of a body part or of the total body.
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The appendicular skeleton,extremities, grows faster than the axial skeleton ,head, thorax, and spine,—partly because the appendicular skeleton is disproportionately shorter than the axial skeleton.
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The categories are interdependent in that optimal mobility requires functional innervation of a voluntary muscle; without innervation, muscles do not contract, and without muscle contraction, no joint can move.
Answer: 2. Being in the sun for prolonged periods between 10:00 ᴀᴍ and 3:00 ᴘᴍ
Rationale: The client should be instructed to avoid sun exposure between the hours of 10:00 ᴀᴍ and 3:00 ᴘᴍ. Sunscreen, a hat, opaque clothing, and sunglasses should be worn when spending time outdoors. The client should examine the body monthly for the appearance of any possible cancerous or precancerous lesions.
2;
Rationale: A hydrocolloid dressing interacts with the moist wound base and forms a gel over the wound to support moist wound healing.
1;
Rationale: A transparent dressing is a clear, adherent, nonabsorptive polyurethane moisture- and vapor-permeable dressing that can be used to manage superficial, minimally draining wounds. A transparent dressing would be inappropriate for a deep draining wound
Answer c.
Rationale: The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.
Answer A.
Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, and heat in the affected area. These changes accompany the processes of inflammation and infection.
Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting
Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.
Answer 3.
Compression of soft tissue greater than 32 mm Hg prevents capillary circulation and compromises tissue oxygenation in the compressed area. Turning the patient relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences
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D—diameter—there is a change in size, usually an increase. Melanomas can be tiny, but most are larger than the size of a pea,larger than 6mm or about ¼ in.
Answer: D; the most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature.
Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing and bathing activities are BADL's. Sleeping expressing sexuality, and socializing with peers are a part of Roper-Logan-Tierney Model; however, these are not the most critical.
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E—evolving—the mole has changed over the past few weeks or months.
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For example, loss of muscle mass occurring with age results in weakness and can impede the ability to clean the house, lift objects, carry groceries, chronic diseases such as arthritis, Parkinson, glaucoma, can make opening jars difficult, lifting pans, using phone, writing checks.
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Functional assessment components: vision, hearing, mobility, falls, continence, nutrition, cognition, affect, home environment, social participation, BADL, IADL. Functional assessment approaches: self-reporting and performance based, this is preferred.
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Functional assessment conclusion based on level of assistance or dependency: no assistance, partial or total, level of difficulty: no, some, unable to perform. Overall goal is to maintain optimal independent function and prevent functional decline for health related quality of life
Answer: C The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage
I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and over stimulation of skin may all stimulate, if not actually encourage, dermal decline.
Answer: B
Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli.
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Immobility primary prevention: regular exercise, protection against injury, optimal nutrition, fall prevention
The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease.
Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death.
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Individual risk factors: traumatic injury ,brain, spinal cord, bones, joints, muscles, neurologic conditions, chronic conditions
A nurse prepares to help a health care provider examine the client's skin with a Wood's light. Which of the following would be included in the plan for this procedure?
1. Prepare a local anesthetic. 2. Obtain an informed consent. 3. Darken the room for the examination. 4. Shave the skin and scrub it with a povidone-iodine (Betadine) solution. Answer: 3. Darken the room for the examination.
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It has a focus on health rather than illness and promotes care directed toward health promotion and wellness. Ongoing patient assessment and facilitation of independence in the patient's normal activities of living are central to the model.
Know Roper-Logan-Tierney model of nursing. (Pg 12 in concept book. Box 2-1)
It is a model of nursing with the concept of functional ability as a cornerstone. According to this model, 12 activities of daily living are central to human life. It is used to guide nursing education and practice by providing a framework to organize and individualize care.
Continued
It is best to use a broad spectrum sunscreen lotion that filters both uvb and uva radiation
The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth.
Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response.
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Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others
Concept of mobility.
Mobility is a state or quality of being mobile or movable. There are 3 mobility categories: musculoskeletal, neurologic, and neuromuscular.
Modifiable—
Modifiable—hypertension, heart disease, serum cholesterol, smoking, excess alcohol consumption, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, drug abuse.
Continued
Moist heat, immobilization and elevation, systemic antibiotic therapy, hospitalization if severe.
The Nurse is assessing a patient's functional activity. Which activities most closely match the definition of functional ability?
a. Healthy individual, works outside the home, uses a cane, well groomed. b. Healthy individual, college education, travels, can balance a checkbook.
When counseling an older patient about ways to prevent fractures, which information will the nurse include?
a. Tacking down scatter rugs in the home is recommended. b. Occasional weight-bearing exercise will improve muscle and bone strength. c. Most falls happen outside the home. d. Buying shoes that provide good support and are comfortable to wear is recommended.
4 days following a stroke, a pt is to start oral fluids and feedings. Before feeding the pt, the nurse should first:
a.. Check gag reflex.. b. Feed pt .. c. Order soft food.. d raise bed to 90 degrees.. Answer..a
Unstageable—
adherent film, gauze plus ordered solution, enzymes,
Appropriate pain management for acute pain
analgesics for symptom control and treatment of the underlying cause, splinting for a fracture, antibiotic therapy for infection.
The nurse caring for a client with suspected appendicitis knows that the pain associated with appendicitis is
a- cutaneous pain. b- visceral pain. c- superficial pain. d-somatic pain.
In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in
a. African Americans. b. women who smoke. c. individuals with hypertension and diabetes. d. those who are obese with high dietary-fat intake
Continued
c. Healthy individual, works out, reads well, cooks and cleans house. d. Healthy individual, volunteers at church, works part time, takes care of family and houe. Answer: D
Stage 4—
full thickness loss can extend to muscle, bone, or supporting structures., bone, tendon, or muscle may be visible or palpable. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling may also occur.
Nursing responsibilities related to pain
gather and document data, make collaborative decisions with the pt and other health care providers. Regularly screen all patient's for pain
treatment Stage 1—none ,allows visual assessment, transparent dressing to protect from shear but not to be used in the presence of excessive moisture,
hydrocolloid does not always allow for visual assessment. Use a turning schedule, support hydration, nutritional support, pressure redistribution surface or chair cushion.
Stage 3—
hydrocolloid—must change when seal of dressing breaks, max wear time 7 days -Hydrogel covered with foam dressing - applied over wound to protect and absorb moisture.
Stage 4—
hydrogel covered with foam dressing -Calcium alginate -Gauze, growth factors
Somatic -
comes from bone, joint, muscle, skin or connective tissue; usually aching or throbbing in quality and well localized.
Stage2—
composite film—limits shear, Hydrocolloid—change when seal of dressing breaks; max wear is 7 days. Hydrogel—provides a moist environment.
Stage 1—
intact skin with non blanchable redness, possible indicators are skin temp, may feel cool warm initially then become cooler tissue consistency, pain. May appear with red, blue, or purple hues in darker skin tones. Boggy or edematous tissue may indicate a stage 1 ulcer
Neuropathic pain—
is usually burning, shooting, or electric like Pg. 973 funds. Abnormal processing of sensory input by the peripheral or central nervous system, treatment usually includes adjuvant analgesics.
Where does melanoma most commonly occur
most commonly found in men on the head, neck, and torso. In women, it is more commonly found on the torso and lower legs. Although rare, in people with dark pigmented skin it is found under nails and on the palms and soles
Visceral—
pain resulting from stimulation of internal organs. Arises from visceral organs such as the gi tract and pancreas.
Stage 2—
partial thickness loss of dermis. Shallow open ulcer with red/pink wound bed. Presents as an intact or ruptured serum filled blister.
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ex. Phantom pain, diabetic neuropathy, alcohol nutritional neuropathy, guillain barre syndrome, nerve root compression, nerve entrapment, trigeminal neuralgia.
Know braden scale
put table in
Interventions to decrease the risk of melanoma.
Monthly self-skin assessment. See#13 above. Also. Skin cancer and sun screen. See #13.
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Muscle mass and tone reduce significantly in late adult years. Cumulatively, these changes result in mobility impairment attributable to reduced range of motion and pain in joints, reduced muscle strength, and increased risk for bone fracture.
Medications to treat cellulitis
ANTIPYRETIC DRUGS: ASPIRIN (SALICYLATES), TYLENOL (ACETAMINOPHEN), NSAIDS (IBUPROFEN, MOTRIN, ADVIL). ANTIINFLAMMATORY DRUGS: ASPIRIN, PREDNISONE, NSAIDS VITAMINS; A, B COMPLEX, C, D
The nurse identifies that a patient's pressure ulcer has just partial-thickness skin loss involving the epidermis and dermis. The nurse documents that the patient's pressure ulcer is: 1. Stage I .. 2. Stage II .. 3. Stage III .. 4. Stage IV..
Answer 2. In a Stage II pressure ulcer the partial-thickness skin loss presents clinically as an abrasion, blister, or shallow crater.
Diagnostic testing is recommended for skin lesions when: A. a health history cannot be obtained B. a more definitive diagnosis is needed C. percussion reveals an abnormal finding D. treatment with prescribed medication has failed
Answer B. Biopsy is one of the most common diagnostic tests used in the evaluation of a skin lesion. A biopsy is indicated in all conditions in which a malignancy is suspected or a specific diagnosis is questionable.
A common site for the lesions associated with atopic dermatitis is the: A. buttocks B. temporal area C. antecubital space D. plantar surfaces of the feet
Answer C. The most common location for atopic dermatitis in adults is the antecubital or popliteal space.
What is the best way for the nurse to prevent the client's stage I pressure ulcer from advancing to stage II? A. Massage the reddened areas. B. Pad the ulcer. C. Promote mobility and/or frequent repositioning. D. Suggest an egg crate mattress.
Answer C.. Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.
Which modifiable risk factors for stroke are most important for you to include when planning a community education program? a. Hypertension b. Hyperlipidemia c. Alcohol consumption d. Oral contraceptive use
Answer a. Hypertension! Rationale: HTN is the single most important modifiable risk factor, but it is still often undetected and inadequately treated.
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As an infant they can't move themselves. Children are at risk due to CP, MD, juvenile arthritis, and fractures. Adolescents- Huntington's disease, stroke, adults/older OA.
After a stroke what intervention needs to be performed before starting oral feedings?
Assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and exercises to stimulate swallowing should be started.
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Assessment indicated in children with delays in development. Milestones and adults who have loss of functional ability, change in mental status, or multiple health conditions, or in frail elderly living in community setting.
When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. inability to concentrate b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility
Answer: A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred.
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Answer: C Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.
A 28 year old quadriplegic complains of burning pain in his lower legs. What type of pain should the nurse suspect?
Answer: Neuropathic Pain, Nociceptive/neuropathic pain is due to damage to nerve cells or changes in the processing of pain
A. Functional Activities Questionnaire (FAQ) B. Mini Mental State Exam C. 24h FAQ D. Performance based functional measurement
Answer:.. A...Functional Activities Questionnaire (FAQ)
The nurse would assess a patient admitted with cellulitis for which of the following localized signs? A. pain B. fever C. chills D. malaise
Answer A. Pain, redness, heat, and swelling are all localized signs of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.
A client with a history of metastatic liver cancer is experiencing nausea, vomiting and aching pain in the abdomen. The nurse interprets these symptoms as:
Answer: visceral pain.
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Bone density decreases and becomes brittle, particularly in females, leaving older adults more susceptible to fracture. Cartilage becomes rigid and fragile and there is a loss of resilience and elasticity of ligaments.
Stage 3—full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Bone/tendon is not visibleor directly palpable. Use hydrocolloid, hydrogel and alginate dressings to absorb exudates while maintaining a therapeutically moist wound surface to promote healing.
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Early id of functional deficits is linked to health outcomes. A comprehensive functional assessment is time intensive and should be an interprofessional effort.
Pressure ulcers stages descriptions and treatment
For stage 4 use vacuum assisted closure systems. Use natural or halogen lights to assess.
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Functional ability is the physical, psychological, cognitive, and social abilities to carry out the normal activities of life. There are 2 categories of functional ability,
Know about functional ability.
Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being.
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IADL's which are instrumental activities of daily living are more complex skills that are essential to living in the community: managing money, grocery shopping, cooking, house cleaning, laundry, taking meds, using phone, accessing transportation.
Know s/s of opioid overdose and what to do
Respiratory depression... less than 12 breaths a minute, withhold meds...use Narcan
Correct Answer: D..Rationale: Comfortable shoes with good support will help to decrease the risk for falls.
Scatter rugs should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but occasional exercise is not helpful in improving strength. Falls inside the home are responsible for many injuries.
Know how to describe neuropathic pain, nociceptive pain, visceral pain, somatic pain.
Several questions on these.
Why does mobility for patients change throughout the life span? (See #10 about elderly.)
Significant changes to the musculoskeletal system occur throughout infancy and childhood as a function of growth and development.
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The 3 mobility categories differ in the anatomic structures involved. The musculoskeletal mobility category involves bones, joints and muscles.
Answer A.
The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris
Answer: D
Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing..
Know CVA risk factors
Non-modifiable—age,doubles each decade after 55, Gender, more common in men; more women die, Ethnicity/race—higher incidence in African Americans, Heredity/family hx
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Older adults are at the greatest risk for functional impairments because of age related changes and chronic diseases.
2; Rationale:
A foam dressing is appropriate for moderate-to-heavy amounts of exudate. It generally needs to be changed daily to prevent maceration of periwound skin once the foam has reached it absorption capacity. It is not appropriate for dry wounds or any wounds with tunneling.
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C—color that is uneven: shades of black, brown, and tan may be present. Areas of white, gray, red, pink or blue may also be seen.
Answer: 2.Stage 2 pressure ulcer Rationale: In a stage 1 pressure ulcer, the skin is intact; the area is red and does not blanch with external pressure. .
In a stage 2 pressure ulcer, the skin is not intact; the ulcer is superficial and may characterize as an abrasion, blister, or shallow crater. In stage 3, skin loss is full thickness and the skin has a deep crater-like appearance. In stage 4, skin loss is full thickness with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
Ways to strengthen bones including supplements.
In addition to adequate dietary intake, nutritional supplementation with Vitamin D and calcium is useful prevention and treatment measures for osteoporosis. (Concepts p.244) Exercise, vitamin d and calcium
Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest.
Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms.
Answer B -
Primary prevention refers to measures such as proper diet, suitable exercise, and timely immunizations that prevent the occurrence of a specific disease.
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Thermal measures such as the application of localized, superficial heat and cooling may relieve pain and provide comfort by decreasing sensitivity to pain and muscle spasms and alleviating joint and muscle aches. The two measures are often used interchangeably.
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These changes include onset of kyphosis with spinal column compression and thinning of the vertebral disks, decrease in bone density and increase in bone brittleness, loss of resilience and elasticity of ligaments, increased rigidity and fragility of cartilage, and decreased muscle mass and tone.
Non drug, mind-body therapies, self-management and alternative strategies to help with rheumatoid arthritis
These include the body-based (physical) modalities, such as massage acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing and medication. (p. 275 concepts)
Examples of primary prevention strategies include:
a. colonoscopy at age 50 b. avoidance of tobacco products c. intake of a diet low in saturated fat in a patient with high cholesterol d. teaching the importance of exercise to a patient with hypertension
A nurse who is providing care for an 81-year-old female patient recognizes the need to maximize the patient's mobility during her recovery from surgery. What accurately describes the best rationale for the nurse's actions?
a. continued activity prevents deconditioning. b. pharmacokinetics are improved by patient mobility. c. lack of stimulation contributes to the development of cognitive deficits in older adults. d. regularly scheduled physical rehabilitation provides an important sense of purpose for older patients.