H&I E2 Quiz ?'s
List 4 common causes of spinal cord injuries. (There are 6, list 4)
Four common causes of spinal cord injuries are: car accidents, falls, sports injuries, and violence.
A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
37
A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
58.5%
1) Write the Definition of Buck's Traction 2) What does the nursing assessment consists of, for a patient in Buck's Traction
1) Buck's Traction is a common skin traction method that is used for fractured or dislocated hips and knee injuries. Buck's Traction is the most common skin traction method used, and it involves a rope and pulley system with the injured foot in a foam boot to keep proper alignment. 2) The nursing assessment for a patient in Bucks Traction consists of checking skin integrity, especially over bony prominence's, and ensuring that the patient is positioned properly. More specifically, in the center of the bed, with their knee or hip kept straight.
Multiple Sclerosis does not shorten the affected individual's life span, so client may require treatment for _____ years or more, following diagnosis.
20
A few nonmotor symptoms of Parkinson Disease include: Sleep problems, constipation, emotional changes, sexual dysfunction and ___________.
Anosmia
A patient has the following signs and symptoms: abdominal cramping which is mainly located in the right lower side, ulcers in the mouth, bleeding anal fissure, and diarrhea. Based on the patient's signs and symptoms, which disease does this describe?
Crohn's Disease
______ is most commonly found in the terminal ileum and beginning of the colon.
Crohn's Disease
Which type of bowel disease is most likely to cause severe malnourishment?
Crohn's Disease The answer is Crohn's Disease. Remember Crohn's is most likely to affect the small intestine which is responsible for absorbing the nutrients from food. If the small intestine is inflamed it can NOT work properly...therefore there is a major risk of malnourishment issues
A patient had a colonoscopy which showed a "cobble-stone" appearance of the GI lining. This is found in:
Crohn's Disease The answer is Crohn's Disease. The reason for the "cobble-stone" appearance is because with Crohn's Disease there will be healthy areas of lining with diseased lining. This will give it a cobble-stone appearance. In ulcerative colitis, the diseased areas are continuous and there are not areas of healthy lining with diseased.
The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record?
Diarrhea
6. Compare and contrast friction and shear (describe each/define)
Friction is defined as the rubbing of surfaces together, and shear is the pressure put on the patients body. An example of friction would be the body rubbing in the opposite direction of an opposing force such as a sheet (the skin and sheet rub against one another). Shear would be the pressure on the body/skin due to being on the sheet/bed.
The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? *Think of the person's age and percent burned as you begin to answer this question.
Refer the client to a burn center The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not a high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.
A patient has the following symptoms: urgent and frequent bowel movements of diarrhea that contains visible blood with pus and mucous, low hemoglobin/hematocrit, potassium level of 2.0. Based on the patient's signs and symptoms, which disease does this describe?
Ulcerative Colitis
Which bowel disease starts in the rectum and migrates in a continuous fashion throughout the colon?
Ulcerative Colitis
Closed or Simple
Skin over the fractured area remains intact
3. What major factors increase risk for the development of pressure-induced ulcers?
Some major factors that increase risk for the development of pressure-induced ulcers are the patients age, immobility, commodities such as diabetes/obesity/vascular disease, mental deterioration, and incontinence. Age is a huge risk factor due to all of the changes in the body that occur with again such as the thinning of the epidermis, diminished senses, and impaired mobility.
5. Describe specific measures you would implement in her care to prevent further skin breakdown.
Some specific measures that I would implement in her care to prevent further skin breakdown would be to use the Braden assessment tool upon admission, plan to re position her every two hours, monitor her sheets and clothes for moisture so that I can change them to keep them dry, and I would also plan to ensure that she is clean. More specifically I would ensure proper skin hygiene especially because she is weak and will need help cleaning herself after bowel movements. I would also ensure that proper care of dressings is occurring, and she is maintaining her nutrition
7. For each of the four stages of pressure ulcers, describe the tissues involved and what you would expect the skin to look like: (define) Stage I: Stage II: Stage III: Stage IV:
Stage I: The tissue that is involved in a stage one pressure ulcer is the epidermis. With a stage I pressure ulcer you would expect the skin to look red/discolored (darker). The skin would also still be intact at this stage. Stage II: The tissues that are involved in a stage II pressure ulcer are the epidermis and the dermis. More specifically the extent of the injury has pasted the epidermis, and is now affecting the dermis. Also the entire dermis has not yet been affected, it is only partially affected otherwise referred to as shallow. The entirety of the epidermis is gone. The skin would be expected to be red/pink, shiny or dry, and it may be a blister that has ruptured or is still intact. Stage III: The tissues involved in a stage II are the epidermis, dermis, and fat. Usually the epidermis and dermis are gone. The skin would be expected to look like a semi-deep wound (no longer shallow due to undermining or tunneling occurring), and you may be able to see fat. There may also be slough present at this stage. Stage IV: The tissues involved in a stage IV are the epidermis, dermis, fat, and bone/tendon/muscle. With this type of injury it is expected for there to be loss of the epidermis, dermis, and fat. The wound is past that and now bone, tendon, and muscle can be seen. There may be slough or eschar, and undermining/tunneling will usually be present.
Select-ALL-the complications associated with Crohn's Disease: Stricture Anal Fissures Hemorrhoids Fistulas
Stricture Anal Fissures Fistulas Hemorrhoids is not a common complication in either Crohn's or ulcerative colitis.
4. What are the advantages of using a validated risk assessment tool to document a patient's skin condition on admission? What is the Braden Scale? Explain
The advantage of using an assessment tool to document a patients skin condition on admission is that you will be able to see how at risk the patient is for skin impairment. More specifically you will know what risk factors for pressure ulcers/skin impairment are present within the patient such as decreased mobility. With information like this upon admission you can appropriately plan care around the patients needs to ensure that their skin stays intact. The Braden scale is an assessment tool that is used to identify how at risk a patient is for developing pressure sores. This scale includes major risk factor categories such as their sensory perception, nutrition, mobility, moisture, activity, and friction and shear. When you identify the score you can then see if the patient is at mild risk, moderate risk, high risk, or severe risk.
2. You conduct a skin assessment. What areas of R.L's body will you pay particular attention to?
The areas of R.L.'s body that I would pay particular attention to would be her bony prominences. These areas would include her hips, sacrum, scapula, elbow, ball of foot, heel, ischium, head, and between her knees.
open or compound
The bone is exposed to air through a break in the skin, and soft tissue injury and infection are common.
At about one-half hour before the daily whirlpool bath and dressing change, the nurse should:
administer an analgesic Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.
Clinical manifestations for a patient with a Spinal Cord Injury include: Pain, Changes in strength, Loss of sensation, Paralysis and loss of other body functions below the site of the injury.
True
The vertebral column and spinal cord are divided into five segments, and spinal nerves protrude from each segment to innervate the body: They are called: Cervical, Thoracic, Lumbar, Sacral and Coccygeal.
True
True or False: Crohn's disease and Ulcerative Colitis are two forms of inflammatory bowel syndrome.
True Inflammatory bowel disease (IBD) is a term for two conditions (Crohn's disease and ulcerative colitis) that are characterized by chronic inflammation of the gastrointestinal (GI) tract. Prolonged inflammation results in damage to the GI tract. Most Common types: Crohn's disease: A chronic inflammatory bowel disease that affects the lining of the digestive tract. Ulcerative colitis: A chronic, inflammatory bowel disease that causes inflammation in the digestive tract.
Which of the following important points would the nurse include in a teaching program for a young adult with multiple sclerosis?
Why it is important to avoid extremes of heat and cold
compression
a fractured bone is compressed by other bone
Impacted
a part of the fractured bone is driven into another bone
Greenstick
one side of the bone is broken and the other side is bent; most commonly occur in children
The nurse should plan to begin rehabilitation efforts for the burn client:
after the client's circulatory status has been stabilized Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.
Select ALL the options below that are similarities between ulcerative colitis and Crohn's Disease:
cause inflammation both increase risk for colon cancer Both cause inflammation and can increase the risk for colon cancer. Crohn's disease can be found from the mouth to the anus, not ulcerative colitis. There is no cure for Crohn's disease.
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
preventing infection The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There are a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.
complete fracture
the bone is separated completely by a break into two parts
The classic motor symptoms of Parkinson disease include:
tremor, rigidity, bradykinesia, lack of afecct and postura instability