Exam 1- learning objectives

Question 1

Review the anatomy and physiology of the skin and mucous membrane.

Answer 1

Epidermis -outer layer-protection

Dermis-,middle layer-support/protection

Subcutaneous layer- insulation, supports, energy storage

mM-lubricates and protects organ cavities from invasive pathogens

Question 2

Identify risk factors which contribute to impaired skin integrity.

Answer 2

Age
* Lifestyle variables
* Changes in health state
* Illness
* Diagnostic measures
* Therapeutic measures

Question 3

Describe the system for staging pressure ulcers.

Answer 3

1-looks/feels red and warm.might burn hurt/itch.Erythma

2-partial thickness skin loss-skin starts to peel off

3-crater like appearance due o damage below surface-full thickness skin loss into dermis but not muscle or bone

4-The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved

Question 4

Review phases of wound healing.

Answer 4

Homeostasis-Stop bleeding- vasoconrticiton to block drainage-

inflammation-veins dilate again, causing neutrophils to enter/destroy bacteria, brings wbc to area to kill off infection

proliferation-fill wound-granulation tissue is present, new bv are formed, rebuilding the old tissue

remodeling-the new tissue slowly gains strength and flexibility. Here, collagen fibers reorganize, the tissue remodels and matures and there is an overall increase in tensile strength

Question 5

Differentiate between the different types of wound drainage.

Answer 5

Serous-white serum

serosanguineous- serum and blood

Sanguineous-blood

purulent-pus

Question 6

Describe potential complications of wound healing.

Answer 6

Dehiscence-Partial or total
separation of wound
layers

Evisceration-Protrusion of viscera (internal
organs) through incision-organ protrudes out

Question 7

Indicate factors affecting wound healing.

Answer 7

• Desiccation
• Maceration
• Pressure
• Trauma
• Edema
• Infection
• Excessive bleeding
• Necrosis
• Biofilm
• Age
• Circulation / Oxygenation
• Nutritional Status
• Wound Etiology
• Medications
• Immunosuppression

Question 8

Summarize the factors that are components of the Braden Scale for Predicting Pressure Sore Risk.

Answer 8

Sensory Perception-LOC
* Moisture-skins exposure to moistue
* Activity-how often the move out of bed
* Mobility-ability to change position
* Nutrition
* Friction and Shear

Question 9

Describe nursing interventions that will prevent skin breakdown and support wound healing.

Answer 9

Drains

wound dressings-protect wound

removing debris

provide moist wound healing envirment

proper nutrition

Question 10

Identify risk factors for acquiring an infection.

Answer 10

Age

poor nutrition

stress

no sleep

disease

medical history

Question 11

Review the chain of infection.

Answer 11

Pathogen-bacteria

resevior-where the pathogen lives

portal of exit-where exits body

mode of transmission-direct/indirect contact/vector

portal of entry-where enters body

susceptible host- anyone who will harbor disease

Question 11

Outline nursing assessments for identifying an infectious process.

Answer 11

Fever

pain/tenderness

redness/swelling

tachycardia/penia

malaise-dsiconfort

WBC count

Question 12

List interventions that break the chain of infection.

Answer 12

hand hygeine

vaccinations

covering coughs/sneezes

standard precations

contact isolation

ppe

cleaning/disinfecting equipment

Question 13

Describe isolation precautions outlined by the CDC.

Answer 13

contact-gloves and gown-is contact with body secretions, make and eyewear

droplet-within 3-6feet,use standard precations and use mask

airborne-every time, gown gloves and n95 mask

blood borne-gloves,mask,eyewear,gown

Question 14

Identify physical and psychological effects of the infectious process.

Answer 14

fever, headache, dizziness, rash, inflammatory response

delirium, mood disorder ,generally a worsened mood is a result of an infection

Question 15

List pharmacological approaches to treat and/or prevent infections.

Answer 15

antibiotic
antiviral
antifungal
antipastic

vaccines

Question 16

Identify the components of the nursing process.

Answer 16

Assessment

diagnosis

planning

implementation

evaluation

Question 16

List resources needed to complete a patient database.

Answer 16

Subjective
past/current health
treatment history
genetic history
family history
what’s going wrong

objective
anything you can find that may be abnormal, any findings/readings that prove what’s wrong

Question 17

Differentiate between a medical and a nursing diagnosis.

Answer 17

A medical diagnosis describes a disease, illness, or injury, and the purpose is to find pathology

. A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently.

Question 18

Explain the process of goal setting and outcome identification.

Answer 18

SMART goals

Specific
measurable
attainable
relevant
time based

this will create a goal and a set time to reach the goal that will get the patent where they need to be in order to leave care

Question 19

Identify factors that are considered when prioritizing care needs.

Answer 19

ABC

self actualization
self esteem
love/belonging
safety/security
physiological needs

Question 20

Select nursing interventions to support goal achievement.

Answer 20

assessing health status, preventing and treating illness or disease, and promoting health.

Question 21

Describe the relationship between patient outcomes and evaluation.

Answer 21

Terminate plan of care when expected outcomes are achieved

• Modify the plan of care if there are difficulties achieving outcomes
• Continue the plan of care if more time is needed
• The nurse should re-examine and revise the plan of care based on patient
  progress. Always ASSESS for
  effectiveness!

Question 22

Identify PN versus RN roles when using the nursing process.

Answer 22

PNs can only provide care when they are supervised by an RN and are expected to report changes in the patient’s care to their superiors. Generally, PN duties include:

Taking medical histories
Checking vital signs
Administering medications
Comforting patients
Assisting with administrative tasks
Supervising Unlicensed Assistive Personnel

Question 23

Identify different frameworks used for organizing data.

Answer 23

mallows heiracht of needs

data collection in predetermined categories

gives specific way to think to get data to observe