Nursing Skills 1 Exam #3 (Chapter 29,31,48)

If a patient comes into the ED with a fresh laceration, what would the nurse assess for?

-Anatomic location. -Type of wound (if known). -Degree of tissue damage. -Wound bed. -Wound size. -Wound edges and periwound skin. -Signs of infection. -Pain.

Why is the older adult population at risk for medication toxicity?

-As the body ages, changes can decrease the body's ability to break down or remove certain medications from the system. This may mean that medications will stay in their body longer. -They are also at risk of medication toxicity due to being on many different medications as a part of older age. -They may also not be taking medication properly due to cognitive decline.

What is a possible cause of bradycardia?

-Beta blockers (slow electrical impulses).

How is a tuberculin test administered?

-0.1 ml of tuberculin purified protein derivative (PPD) is injected into the inner surface of the forearm. -Is a intradermal injection administered at a 5-15 degree angle. -Medication is administered bevel up. -Site is circled to interpret results of Tb test.

Antibiotics must be administered within what?

-30 minutes of scheduled time. -Example: Due at 1200. Can be administered from 1130 to 1230.

Define Dehiscence:

-A surgery complication where the incision (cut made during a surgical procedure) reopens.

How does the nurse ensure safety when administering medications?

-Always ask patient about allergies, types of reactions, and severity of reactions. -Use at least two patient identifiers before administration and compare against the MAR. Six Rights of Medication Administration: -Right medication -Right dose -Right patient -Right route -Right time -Right indication (check six rights 3 times before giving medication)

Define Splinting:

-An external device employed to immobilize an injury or joint.

How can we prevent needlestick injuries in the workplace?

-Follow safety guidelines. -Avoiding the use of needles where safe and effective alternatives are available. -Helping your employer select and evaluate devices with safety features that reduce the risk of needlestick injury. -Using devices with safety features provided by your employer. -Avoiding recapping needles.

What are the benefits of encouraging clients to take their blood pressure at home?

-Helps with early diagnosis. -Helps track treatment. -Encourages better control. -Cuts health care costs. -Check if blood pressure differs outside a medical office.

Hypertension (high blood pressure):

-Hypertension: (higher than 130/80) Signs and symptoms: -Headache -Nosebleeds Risk factors: -Prevalence is > in African American and Hispanic -Diabetes Mellitus -Obesity -High cholesterol -Sedentary lifestyle Can lead to: -MI -Stroke -Kidney damage Treatments: -Lifestyle changes -Low fat/salt -Exercise -Limit alcohol -Diuretics (decrease fluid volume) -Beta blockers (decrease cardiac output) -Vasodilators (decrease peripheral vascular resistance) -Calcium channel blockers (decrease peripheral vascular resistance) -ACE inhibitors (decrease circulatory fluid volume)

Hypotension (low blood pressure):

-Hypotension: (lower than 90/60 mm Hg) Signs and symptoms: -Dizziness -Tachycardia -Pallor -Blurred vision -Nausea -Confusion Risk factors: -Blood/fluid loss (ex. hemorrhage, vomiting, diarrhea). -Vasodilation of blood vessels (ex. anaphylaxis reaction). -Heart failure (lack of effective pump). Orthostatic hypotension: -Decrease in systolic BP of 20 mm Hg and/or decrease in diastolic BP of 10 mm Hg within 3 minutes of changing position. -Educate patient to change positions slowly -Return to supine position if patient feels dizzy or faint.

What factors put a client at increased risk for skin breakdown?

-Impaired sensory perception -Impaired mobility -Alteration in LOC -Shear -Friction -Moisture

What steps should the nurse take if a medication error occurs?

-Own up to your mistake. -Inform the patient's doctor of the mistake so that action can be taken as soon as possible to counteract the effects of the incorrect medication. -Report / document medication error.

What is the role of protein in wound healing?

-Proteins significantly affect the entire process of wound healing through their roles in RNA and DNA synthesis, collagen and elastic tissue formation, immune system function, epidermal growth, and keratinization.

Define pyrexia. How do we assess this?

-Raised body temp (fever). Ways to assess: -Oral (sublingual pocket) -Rectal (considered most accurate "core temp") -Axillary -Temporal artery -Tympanic membrane

What is the purpose of splinting a wound with a pillow or abdominal binder?

-Reducing incision site pain.

Define and differentiate between the following stages of pressure ulcers:

-Stage I: (non-blanchable erythema of intact skin). -Stage II: (partial-thickness skin loss with exposed dermis). -Stage III: (full-thickness skin loss). -Stage IV: (full-thickness skin and tissue loss). -Unstageable pressure injury: (full-thickness skin and tissue loss obscured by slough or eschar). -Deep tissue pressure injury: (localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister).

Systolic Vs. Diastolic pressure:

-Systolic blood pressure is the top number and refers to the amount of pressure experienced by the arteries while the heart is beating. -Diastolic blood pressure is the bottom number and refers to the amount of pressure in the arteries while the heart is resting in between heartbeats.

Normal ranges in adults for each vital sign:

-Temp (96.7 - 100.5 F) -Heart rate (60-100 bpm) -Respiratory Rate (12-20 bpm) -Blood Pressure (<120 / <80 mmHg) -Pulse Ox (95-100%)

What is included in a vital sign assessment?

-Temperature (T) -Heart rate (Pulse) -Respiratory Rate (RR) -Blood Pressure (BP) -Pulse Oximetry (SpO2)

What is the Point of Maximal Impulse (PMI)? Where is it located?

-The location at which the cardiac impulse can be best palpated on the chest wall. -This is at the fifth intercostal space at the midclavicular line. -PMI is also known as the "Apical Pulse".

Define Evisceration:

-The surgical incision opens and the abdominal organs then protrude or come out of the incision.

When should the nurse assess the Point of Maximal Impulse (PMI)?

-When trying to determine the intensity / rate of the patient's pulse.

What medical interventions are performed for a wound that is unstageable or mostly covered with eschar/slough?

-Wound debridement -Wound cleaning -Reposition patient -Keep the site clean and dry -Provide adequate intake of protein and calories

Know and define the three intentions of healing:

Primary: -Uncomplicated healing of a noninfected, well-approximated wound. -Surgical wounds are the best example for primary healing. Secondary: -Occurs when a wound that cannot be stitched causes a large amount of tissue loss. -Doctors will leave the wound to heal naturally in these cases. Tertiary: -Delayed primary wound healing after 4-6 days. -This occurs when the process of secondary intention is intentionally interrupted and the wound is mechanically closed. -This usually occurs after granulation tissue has formed.

Subcutaneous Injection:

Sites: -Belly area -Thighs -Upper back -Lower back -Upper arm Needle length: (5/8 inch) Angle of insertion: -45 degrees -90 degrees

Intramuscular Injection:

Sites: -Ventrogluteal -Vastus lateralis -Deltoid Needle length: (1-1.5 inch) Angle of insertion: -90 degrees