nurs 202 exam 2 prep
Cranial Nerve X: Vagus
Assessed with cranial nerve IX; assess client's speech for hoarseness.
spiral reverse turns
Used to bandage cylindrical parts of body that aren't uniform in appearance like lower leg or forearm.
recurrent turns
Used to cover distal parts of body like end of finger, skul, stump of amputation. See page 948 for application
circular tunrs
used to anchor bandages and to terminate them. they usually are not applied directly over a wound because of the discomfort the bandage would cause
spiral turns
used to bandage parts of the body that are faily uniform in circumference (upper arm/leg)
Risk for impaired skin integrity
vulnerable to alteration in epidermis and/or dermis which may compromise health.
Risk for pressure ulcers
vulnerable to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear.
tertiary intention
wounds that are left open for 3-5 days to allow edema or infection to resolve or exudate to drain and then are closed. (also called delayed primary intention)
sensory deprivation clinical manifestations
yawning, drowsiness, sleeping, decreased attention span, difficulty concentrating, decreased problem solving, impaired memory, disorientation or confusion, crying, depression, apathy, hallucinations or delusions, preoccupation with somatic complaints
purulent exudate
Thicker than serous exudate because of the presence of pus, which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. This exudate varies in color, some acquiring tinges of blue, green, or yellow. The color may depend on the causative organism.
A nurse is providing teaching to the partner of a client who has conversion disorder. Which of the following statements by the partner shows an understanding of the teaching? 1. "My partner is pretending to be ill to get attention" 2. "My partner is purposefully making our child sick" 3. "The stress of losing our child caused my partner to go blind" 4. "My partner is worried that he has cancer, even though his tests are normal"
"The stress of losing our child caused my partner to go blind" Explanation: The nurse should explain to the partner that conversion disorder manifests as deficits in motor or sensory functions. Emotional conflict or stress is reflected in physical manifestations that can include paralysis, blindness, movement disorder, numbness, paresthesia, loss of hearing, or episodes resembling epilepsy
Delirium
- acute, fluctuating change in mental status - sudden, acute onset - temporary; may last hours to days - worsens at night - disturbed sleep and wake cycels; cycles often reversed - alterness fluctuates; may be alert and oriented during the day but become confused and disoriented at night - disorganized, distorted thinking; impaired attention; alterations in memory - may have visual, auditory, and tactile hallucinations; misinterpretations of real sensory experiences
causes of dementia
- alzheimer's disease - multiple infarct dementia
inflammatory phase
- begins immediately after injury and last 3-6 days. - two major processes: hemostasis and phagocytosis
sensory overload clinical menifestations
- complains of fatigue, sleeplessnes - irritability, anxiety, restlessness - periodic or general disorientation - reduced problem-solving ability and task performace - increased muscle tension - scattered attention and racing thoughts
When assisting clients who have a sensory impairment, a nurse needs to...
- encourage the use of sensory aids to support residual sensory function - promote the use of other senses - communicate effectively - ensure client safety
Norton's scale categories
- general physical condition - mental state - activity - mobility - incontinence - sometimes medications is added
Dementia
- memory impairment - slow insidious onset - chronic, gradual irreversible - no change with time of day - disturbed, fragmented sleep cycle; awakens often during the night - generally normal alertness - judgment impaired; difficulty with abstraction and word finding - delusions; usually no hallucinations
preventing pressure ulcers
- providing nutrition - maintaining skin hygiene - avoiding skin trauma - providing supportive devices
Braden scale for predicting pressure sore risk subscales
- sensory perception - moisture - activity - mobility - nutrition - friction and shear
risk factors for pressure ulcers
-friction and shearing -immobility -inadequate nutrition -fecal and urinary incontinence -decreased mental status -diminished sensation -excessive body heat -advanced age -presence of certain chronic conditions
difference between secondary and primary intention healing
1. the repair time is longer for secondary 2. the scarring is greater for secondary 3. the susceptibility to infection is greater in secondary
total points for braden scale
A total of 23 points is possible and an adult who scores below 18 points is considered at risk
Cranial Nerve III: Oculomotor
Assess six ocular movements and pupil reaction
Cranial Nerve V: Maxillary branch
Assess skin sensation as for ophthalmic branch above
Cranial Nerve IX: Glossopharyngeal
Apply tastes on posterior tongue for identification. Ask client to move tongue from side to side and up and down.
Cranial Nerve II: Optic
As client to read Snellen-type chart; check visual fields by confrontation; and conduct an ophthalmoscopic examination
Cranial Nerve V: Mandibular branch
Ask client to clench teeth
Cranial Nerve I: Olfactory
Ask client to close eyes and identify different mild aromas
Cranial Nerve XII: Hypoglossal
Ask client to protrude tongue at midline, the move it side to side
Cranial Nerve XI: Accessory
Ask client to shrug shoulders against resistance from your hands and turn head to side against resistance from your hand (repeat for other side)
Cranial Nerve VII: Facial
Ask client to smile, raise the eyebrows, frown, puff out cheeks, close eyes tightly. Ask client to identify various tastes placed on tip and side of tongue: sugar, salt, lemon juice, and quinine; identify areas of taste.
Cranial Nerve VIII: Cochlear branch
Assess client's ability to hear spoken word and vibrations of tuning fork.
Cranial Nerve IV: Trochlear
Assess six ocular movements
why do you crush the barrier to the inner compartment containing the transport medium at the bottom of the tube when getting a wound culture?
This ensures that the swab with the specimen is surrounded by medium, which prevents the specimen from drying out or any microorganisms from continuing to multiply.
A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? 1. Sugar 2. Coffee 3. Cotton wisps 4. Snellen chart
Cotton wisps Explanation: The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess to assess for recognition of pain and a cotton wisp to evaluate recognition to touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth
hydrocolloids purpose
To absorb exudate, to produce a moist environment that facilitates healing but doesn't cause maceration of surrounding skin, to protect wound from bacterial contamination, foreign debris and urine or feces and to prevent shearing.
hydrogels purpose
To liquefy necrotic tissue or slough, rehydrate wound bed & fill in dead space.
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? 1. Assign an assistive personnel to feed the child 2. Explain the sounds the child is hearing 3. Have the child use a cane when ambulating 4. Rotate nurses caring for the child
Explain the sounds the child is hearing Explanation: The noises in a facility can be frightening to a child who is experiencing a sensory loss. Explaining these noises can allay the child's fears.
A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? 1. 3+ Achilles reflex 2. Faint pedal pulses 3. Feet warm to the touch bilaterally 4. Capillary refill of <2 sec
Faint pedal pulses Explanation: Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity.
A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? 1. Have the client open his mouth and say, "aah" 2. Ask the client to identify the scent of coffee 3. Use a tongue blade to provoke a gag reflex 4. Have the client smile and raise his eyebrows
Have the client open his mouth and say, "aah" Explanation: The vagus or X nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth and say, "aah." The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness.
transparent film indications
IV dressing, central line dressing, superficial wounds, pressure ulcers stage I
clear absorbent acrylic purpose
Maintains a transparent membrane for easy wound bed assessment, provides bacterial and shearing protection. Maintains moist wound healing. Can be used with alginates to provide packing to deeper wound beds.
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? 1. Incontinence 2. Mental state 3. Nutrition 4. General physical condition
Nutrition Explanation: Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers.
alginates (exudate absorbers) purpose
To provide a moist wound surface by interacting with exudate to form a gelatinous mass; to absorb exudate; to eliminate dead space or pack wounds; and to support debridement
total points in Norton's scale
Total possible score of 24. Scores of 15 or 16 should be viewed as indicators, not predictors, of risk
Cranial Nerve V: Trigeminal Ophthalmic branch
While client looks upward, lightly touch the lateral sclera of the eye with sterile gauze to elicit blink reflex. To test light sensation, have client close eyes, wipe a wisp of cotton over client's forehead and paranasal sinuses. To test deep sensation, use alternating blunt and sharp ends of a safety pin over same areas.
Mixed hearing loss
a combination of conduction and sensoineural loss.
Glaucoma
a disturbance in the circulation of aqueous flid, which causes an increase in intraocular pressure.
receptor
a nerve cell acts as a ____ by converting the stimulus to a nerve impulse.
secondary intention healing
a wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated, heals by ___ Ex: pressure ulcer
polyurethane foams purpose
absorb up to heavy amounts of exudate, provide and maintain moist healing, provide thermal insulation
Anyone taking several medications concurrently may show ____ in sensory function
alterations in sensory function
impaired skin integrity
altered epidermis and/or dermis
ototoxic medication examples
asprin, furosemide (lasix), the aminoglycosides and certain drugs given for cancer chemotherapy
Cranial Nerve VI: Abducens
assess directions of gaze
collagen purpose
assists with stopping bleeding, helps recruit cells into the wound and stimulates their proliferation to facilitate healing
perception
awareness and interpretation of stimuli
maturation phase
begins on about day 21 and can extend 1 or 2 years after the injury. Fibroblasts continue to synthesize collage. The collagen fibers themselves, which were initially laid in a haphazard fashion, reorganize into a more orderly structure. The scar becomes stronger but is never as strong as the orignial tissue.
Danger signs of glaucoma
blurred or foggy vision, loss of peripheral vision, difficulty focusing on close objects, difficulty adjusting to dark rooms, and seeing rainbow-colored rings around lights.
transparent film purpose
to provide protection against contamination & friction, to maintain a clean moist surface that facilitates cellular migration, to provide insulation by preventing fluid evaporation, to facilitate wound assessment.
causes for delirium
cerebral and cardiovascular disease, infections, reduced hearing and vision, environmental change, stress, sleep deprivation, polypharmacy and dehydration
collagen indications
clean, moist wounds
serosanguineous exudate
consisting of both clear and blood-tinged drainage
purosanguineous discharge
consisting of pus and blood, is often seen in a new wound that is infected
serous exudate
consists chiefly of serum derived from blood and the serous membranes of the body. It looks water and has few cells. An example is the fluid in a blister from a burn
snaguineous exudate
consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. This is frequently seen in open wounds.
impaired tissue integrity
damage to mucous membrane, cornea, integumentary system, muscular fasica, muscle, tendon, bone, cartilage, joint capusle, and/or ligament.
Narcotics, antiepileptic agents, and sedatives ____ awareness of stimuli
decrease awareness of stimuli
suppuration
formation of pus
stage III pressure ulcer
full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia
stage IV pressure ulcer
full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures
Unstageable pressure ulcer
full-thickness skin or tissue loss - depth unknown: Acutual depth of the ulcer is completely obscured by slough and/or eschar in the sound bed
Sensory overload
generally occurs when a person is unable to process or manage the amount or intensity of sensory stimuli
risk for infection
if the skin impairment is severe, the client is immunosuppressed, or the wound is caused by trauma
sensory deprivation
impaired reception, perception or both
difference between impaired skin integrity and impaired tissue integrity
impaired skin integrity commonly applies to pressure ulcers and to wounds extending through the epidermis but not through the dermis. impaired tissue integrity applies to pressure ulcers and to wounds extending into the subcutaneious tissue, muscle, or bone.
polyurethane foams indications
light to highly exudating wounds, pressure ulcers, skins tears, venous stasis ulcers, surgical wounds, wounds undergoing chemical debridement agents
exudate
material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces
ototoxic medications
medications injuring the auditory nerve and causing hearing loss that may be irreversible.
why should you rotate the swab back and forth over clean areas of granulation tissue from the sides or base of the wound when getting a wound culture?
microorganisms most likely to be responsible for a wound infection reside in viable tissue
stage I pressure ulcer
nonblanchable erythema signaling potential ulceration
Primary intention healing
occurs when the tissue surfaces have been approximated and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring - ex: closed surgical incision
____ are at greatest risk for sensory alterations because they may have conditions that alter perception and spatial orientation.
older adults
stage II pressure ulcer
partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis
impregnated nonadherent indications
postoperative dressing over staples/sutures, superficial burns
hydrogels indications
pressure ulcers skin tears partial thickness wounds
hydrocolloids indications
pressure ulcers stage II-IV, autolytic debridement of eschar, partial-thickness wounds
alginates (exudate absorbers) indications
pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, wounds undergoing chemical debridement agents
clear absorbent acrylic indications
pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, wounds undergoing chemical debridement agents
acute pain
related to nerve involvement within the tissue impairment or as a consequence of procedures use to treat the wound.
Cranial Nerve VIII: Vestibular branch
romberg test
hemostasis
the cessation of bleeding results from vasoconstriction of the larger blood vessels in the affected area, retraction of injured blood vessels, the deposition of fibrin, and the formation of blood clots in the area.
impulse conduction
the impulse travels along nerve pathways either to the spinal cord or directly to the brain
Sensorineural hearing loss
the result of damage to the inner ear, the auditory nerve, or the hearing center in the brain
Conductive hearing loss
the result of interrupted transmission of sound waves through the outer and middle ear structures.
proliferative phase
the second phase in healing, extends from day 3-4 to about day 21 postinjury. Fibroblasts begin to synthesize collagen.
stimulus
this is an agent or act that stimulates a nerve receptor
granulation tissue
tissues become a translucent red color as the capillary network develops and is fragile and bleeds easily.
impregnated nonadherent purpose
to cover, soothe, and protect partial and full-thickness wounds without exudate
