Quiz #14
Know the type of data you can receive from your patient during pain.
-Characteristics and description of pain -Location and intensity of pain -Ask patient what relieves the pain -What actions cause the pain to be worse -Identify normal coping mechanisms used by the patient and close family members -If medications are taken for relief of pain, the name, the dosage, the frequency and the effort of the drugs must be determines
Know the types of drainage systems
-Closed drainage: 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 drainage: passes through an open-ended tube into a receptacle or out onto the dressing -Suction drainage: uses a pump or other mechanical device to help extract a fluid -T-tube drainage: inserts a drainage tube into the duct to maintain a free flow of bile until edema subsides; drains by gravity into a closed drainage system
What substances attach to opioid receptors sites. What is it called?
-Endorphins -They attach to opioid receptor sites in the brain to prevent the release of neurotransmitters, thereby inhibiting the transmission of pain impulses
How should infection be prevented?
-Hand hygiene -Standard precautions -Sterile(surgical) technique
Know the different types of compresses and why you should use them.
-Heat compresses (stimulate blood flow) -cold compresses (decrease inflammation)
Know the phases of wound healing.
-Hemostasis (termination of bleeding) -Inflammatory phase (erythema (redness), heat, edema (swelling), pain, and tissue dysfunction) -reconstruction/proliferation (collagen formation; wound fills with granulation tissue and takes on the appearance of an irregular, raised, purplish, immature scar) -maturation/remodeling (collagen formation/keloid formation can occur)
Know your pain assessment.
-How does your pain feel -Intensity (0-10) -Location -Duration -Aggravating and alleviating -Pain rating scales
What should be done when doing a dressing change?
-Identify the pt and explain the procedure -Perform hand hygiene and don clean gloves -Assemble equipment and make sure the equipment is not expired -Assess the patient's tolerance -Document findings on the wound and the dressing -Measure the amount of drainage, report the amount of I&O -Assess patients skin for abrasions
Know what to do during wound irrigation. (SATA)
-Irrigation is gentle washing of an area with a stream of solution delivered through an irrigating syringe -Most common wound irrigant is normal saline solution -Step 1: cleanse in a direction from the least contaminated area to the most contaminated -Step 2: When irrigation, be sure that all of the solution flows from the least contaminated to the most contaminated area
What is the advantage of a PCA pump?
-It addresses the significant variations in analgesic requirements between individuals -No delays in waiting for a nurse to administer analgesics -Achieve pain relief and prevent pain from reaching elevated levels that are difficult to control
Reinforcing teaching when a patient has a PCA device. What is a correct statement or incorrect statement?
-It is a drug delivery system that allows patients to self-administer analgesics whenever needed -To receive a dose, the patient pushes a button on a cord attached to the pump -Each dose may be as low as 1mL or 1 mg of morphine every 6-12 minutes -It has a locked safety system to prevent tampering -PCA is based on the idea that only the patient can feel the pain and only the patient knows how much analgesic will relieve it
Know what intervention is used with a closed-wound drainage system.
Better control and monitor the drainage from a wound
What is acute pain?
intense and of short duration, usually lasting less than 6 months
Know the percentage of drugs addictive.
Less than 1%
Know the types of drainage seen post operative cholecystectomy.
T-tube drainage system
Know the side effects of morphine.
-Cause depression of vital nervous system functions -Respiratory depression by depressing the respiratory center within the brainstem
Know what to do when applying a chest binder
-Assess the patient's ability to breathe deeply, cough effectively, and move independently before and after binder application -Assess the patient's skin for irritation or abrasion, the underlying wound, and the patient's level of comfort
Know the amount of drainage that should be seen post-surgery.
-Normal bile drainage (250-500 ml/24 hr) -300mL or below the first 24 hours
How do we determine pain in a patient?
-Pain is verbal and nonverbal communication -Pain is subjective data and objective data -Pain assessment
What are signs and symptoms of sleep deprivation? (SATA)
-Physiological signs: hand tremors, decreased reflexes, slowed response time, reduction in word memory, decreased reasoning and judgment, and cardiac dysrhythmias -Psychological signs: mood swings, disorientation, irritability, decreased motivation, fatigue, sleepiness, and hyperexcitability
Know nonverbal behaviors in your patient postoperative. (SATA)
-Places hands over the painful area -Reduced attention span -Impaired thought processes -Moaning, rocking, crying, pacing, restlessness -Facial expressions of pain -Alterations in muscle tone -Change in blood pressure, pulse rate, respiration, and pupillary dilation
Know the signs and symptoms of a surgical wound that is normal and what type of formation will be seen?
-Primary intention: minimal scarring, begins during the inflammatory phase of healing -Secondary intention: granulation tissue fills wound -Tertiary intention: large and deep scar
Know the types of wound healing.
-Primary intention: minimal scarring, begins during the inflammatory phase of healing -Secondary intention: granulation tissue fills wound -Tertiary intention: large and deep scar
Know what objective signs are. (SATA)
-Pulse, respirations, blood pressure, dilated pupils, muscle tensions, nausea/vomiting -Rigid body position, restlessness, frowning, grimacing, clenched teeth, clenched fists, crying, moaning
Know what is seen during wound healing.
-Redness, heat, edema, pain -purplish/immature scar -Collagen formation/ keloid formation -granulation
Know what intervention you should use when evisceration happens in a wound.
-Remain with the patient and notify the health provider -Place the patient into a low-fowler's position with the knees slightly flexed -Protruding organ is covered with a sterile dressing moistened with sterile normal saline solution -Monitor the patient and assess vital signs -Make sure the patient remains on NPO -Reassure the patient and family b/c the occurrence of a wound evisceration is often frightening
Know what to do when the wound healing is by secondary intention. What is the nurse's best recommendation?
-Some pus forms during secondary intention, which results in needing to release it through a drainage system or by packing the wound with gauze -Supplementation, foods rich in protein, Vitamins A and zinc, rest, fluids
Know what gate control is.
-Suggests that pain impulses are regulated and even blocked (when another stimuli is happening at the same time) by gating mechanisms located along the central nervous system -Proposed location of the gates is on the dorsal horn of the spinal cord
Know what alternative healing modalities are used on patients with chronic pain.
-TENS (transcutaneous electric nerve stimulation) -Relaxation exercises -Administer analgesics and apply cold/heat applications -acupuncture -Deep tissue massage -Floatation (water) therapy
Know what transcutaneous electric nerve stimulation TENS provide for the patients.
-The use of a pocket-sized, battery-operated device that provides a continuous, mild electric current to the skin via electrodes attached to a stimulator by flexible wires -Stimulating large nerve fibers to "close the gate" in the spinal cord, thus blocking transmission of pain impulses -TENS is hypothesized to stimulate endorphin production
Following a wound, how much fluids should be consumed a day?
2,000-2,400 mL in 24 hours
Know the types of pain a patient can experience following a procedure/coronary insufficiency.
Referred pain
Know the advantages of pain management. (SATA)
Results in quicker recoveries, shorter hospital stays, fewer readmissions, and improved quality of life
What is sanguineous wound drainage?
bright red; indicates active bleeding
What is chronic pain?
characterized as pain lasting longer than 6 months
What is referred pain?
felt at a site other than the injured or diseased organ or part of the body
What is serosanguineous wound drainage?
pale, red, watery: mixture of serous or sanguineous
What is purulent wound drainage?
thick, yellow, green, tan, or brown
What is serous wound drainage?
watery plasma that is mostly clear, but may have some pink or yellow tinge to it