Exam Flashcards
1
Q
pressure ulcers
A
a localized area of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear
2
Q
pressure injuries: principles for practice
A
- Occur from unrelieved prolonged soft tissue compression
- Most common site is over bony prominences (see next slide)
- Assess wounds on scheduled basis
- Thorough wound assessment:
- Identify type of wound healing (e.g., primary, secondary, tertiary intention)
- Identify type of tissues and characteristics of the wound base
- Identify condition of the wound edges and peri-wound skin
- Healing process phases
3
Q
wound healing: primary intention
A
wound edges of a clean surgical incision remain close together
4
Q
wound healing: secondary intention
A
wounds are left open and allowed to heal by scar formation
5
Q
wound healing: tertiary intention
A
(also known as delayed primary intention or closure): occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed
6
Q
viable tissue
A
granulation tissue - red to pink and moist
7
Q
factors that influence wound healing
A
- adequate blood perfusion and oxygenation
- nutrition and hydration
- chronic moisture
- pressure off loading
- wound infection
- advanced age
- corticosteroid therapy (decrease immune function)
- medical devices
8
Q
stages of wound healing:
Stage 1: Nonblanchable Erythema Skin Intact
A
Intact skin with darkened areas
Changes in sensation, temperature, or firmness
9
Q
stages of wound healing:
Stage 2: Partial Thickness Skin Loss with Exposed Dermis
A
Wound bed is pink and viable, may have serum blister
Adipose not visible, no slough or granulation
Often associated with moisture, skin tears, medical devices
10
Q
stages of wound healing:
Stage 3: Full Thickness Skin Loss
A
Adipose and granulation present, slough and eschar visible
Areas with adipose tissue are deeper
Undermining and tunneling may occur
Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed
11
Q
stages of wound healing:
Stage 4: Full Thickness Tissue Loss
A
Exposed fascia, muscle, tendons, etc
Slough and eschar present
Epibole - rolled/curled under wound edges
Undermining and tunneling often present
12
Q
deep tissue injury
A
Intact or not intact skin with unblanchable deep red or maroon discolouration revealing blood filled blister
Pain and temperature changes
13
Q
unstageable pressure injury
A
Full thickness skin and tissue loss where the loss cannot be determined due to obscure slough and eschar
Once those removed, may reveal Stage III or IV
14
Q
Risk Assessment, Skin Assessment, and Prevention Strategies
A
- Prevention of pressure ulcers requires
- Implement cost-effective strategies/plans that prevent/treat pressure ulcers
- Perform risk assessment on entry to the health care setting, and repeat on a scheduled basis or when a significant change in the patient’s condition is noted
- Use risk assessment tools
- Inspect the patient’s skin and bony prominences at least daily
15
Q
performing a wound assessment
A
- location
- type of wound
- extent of tissue involvement
- type and percentage of tissue in wound base
- wound size
- wound exudate
- presence of odour
- wound edge
- periwound area
- pain
- tunnelling/undermining
16
Q
sterile technique
A
- Purpose: to maintain an area free from pathogenic microorganisms
- Minimizes patient exposure to infection-causing agents
- Reduces infection risks of patients
- Majority of sterile technique practice are used in the OR
- Sterile technique includes:
- PPE (applying mask, protective eyewear, gown and cap)
- Performing surgical hand scrub
- Applying sterile gown and gloves
- Proper hand hygiene is required
- Used at bedside for procedures that require intentional puncture of skin, insertion of devices into a sterile part of the body, and when skin integrity is compromised
- Standard precautions are the minimum standard for infection control
- Must maintain sterile technique at all times throughout procedure
17
Q
principles of surgical asepsis
A
1) all items used in the sterile field must be sterile
2) a sterile barrier permeated by punctures, tears, moisture is contaminated
3) 1 inch (2.5cm) border around the edge of sterile package is unsterile
4) tables draped as apart of the sterile field is only sterile at the table level
5) any doubt about the sterility of an item - consider it unsterile
6) sterile touching sterile = sterile, sterile touching unsterile = unsterile
7) sterile field must stay in visual field or else it is unsterile
8) sterile field/object is only sterile above the waist
9) sterile field/object becomes contaminated by prolonged exposure to air (move quickly)
18
Q
donning pre order
A
apply cap (if necessary) apply mask apply eyewear apply sterile gown (if necessary) apply gloves (sterile or not)
19
Q
doffing pre order
A
Remove gloves first
Remove eyewear
Remove gown
Remove mask
20
Q
people at risk for latex allergy
A
- people who have had multiple surgeries
- workers with high latex exposure (HCP)
- rubber industry workers
- personal or family history
21
Q
levels of latex allergy
A
1) irritant dermatitis
2) type 4 delayed hypersensitivity
3) type 1 immediate hypersensitivity
22
Q
wound care
A
- Proper wound care is necessary to promote healing that results in an intact skin layer
- The skin defends the body in other ways by serving as a sensory organ for pain, touch, and temperature
- Plays a major role in thermoregulation, metabolism, immunity, and fluid balance regulation
23
Q
black/brown wound (eschar)
A
- full thickness tissue destruction
- necrotic tissue
24
Q
yellow wounds (slough)
A
- nonviable tissue
- infection
- slough
25
red wounds (granulation)
- granulation tissue
- increased amount of new blood vessels in wound
- healthy tissue
26
wound irrigation
- Wound irrigation cleanses and irrigates surgical or chronic wounds
- Proper wound cleaning solution does not harm tissue, uses adequate force to agitate and wash away surface debris and devitalize tissue that contain bacteria
- **do not irrigate a wound where you cannot see the wound bed (eg. tunneling)
27
irrigate a wound with wide opening
- Fill a 35-mL syringe with warmed irrigation solution.
- Attach 19-gauge angiocatheter.
- Hold syringe tip 2.5 cm (1 inch) above upper end of wound and over area being cleaned.
- Using continuous pressure, flush wound; repeat steps until solution draining into basin is clear.
28
irrigate a wound with a small opening
- Attach soft catheter to filled irrigation syringe.
- Gently insert tip of catheter into opening about 1.3 cm (0.5 inch).
- Do not force the catheter into the wound because this will cause tissue damage. Ensure that irrigant solution will be flushed out of the wound; avoid irrigating when the wound base will not permit effective flushing out of solution.
- Using slow, continuous pressure, flush wound.
- Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. - Pressure settings should be set per provider prescription, usually between 4 and 15 psi, and should not be used on skin grafts, exposed blood vessels, muscle, tendon, or bone. Use with caution if the patient has a coagulation disorder or is taking anticoagulants (Ramundo, 2016).
- While keeping catheter in place, pinch it off just below syringe.
- Remove and refill syringe. Reconnect to catheter and repeat until solution draining into basin is clear.
29
clean wound with handheld shower
- With patient seated comfortably in shower chair or standing if condition allows, adjust spray to gentle flow; make sure that water is warm.
- Shower for 5 to 10 minutes with shower head 30 cm (12 inches) from wound.
30
wound healing process
Hemostasis
Inflammation
Proliferation
Maturation
31
TIME framework for assessment
- Tissue management (remove non viable tissue) (more non viable tissue increases risk for infection)
- Inflammation/infection
- Moisture (moisture is good when unrelated to incontinence)
- Edge (want good edges)
32
outcome of wound dressings
- keeps wound bed moist and surrounded periwound tissue dry and intact
- reduces volume of exudate and amount of necrotic tissue
- resolves or prevents periwound erythema or maceration
- reduces wound dimensions or depth of sinus tract
- reduces pain intensity during dressing changes
33
gauze dressing
- cotton or synthetic material
| - used to protect surgical or minimally draining wound or wound packing
34
transparent film
- waterproof adhesive membrane
- securing IV tubing
- can visualize wound and skin underneath dressing
35
hydrocolloid
- gel forming agents
- create autolysis (debridement) of slough in wound bed
- maintain moist environment
- used for stage 2,3, unstageable
- allow 2-3cm of intact hydrocolloid dressing around the wound
36
hydrogel
- glycerin or water based polymer
- provides moisture to dry wound
- can be used for partial or full thickness wounds and pressure injuries
- dry to light exudate
- necrotic wounds
37
alginates and hydrofibre dressings
- when wet turns into a gel form that is atraumatic and easy to remove
- moderate to heavy drainage
- comes in sheets or ribbons so can be fluffed into a wound bed
38
foam dressing
- absorbent, non-adherent polyutherane or film coated layer used to protect wounds and maintain moist healing
- moderate to heavy exudate
- stage 3, 4
39
serous drainage
clear watery plasma
40
sanguineous drainage
fresh bleeding, bright red
41
serosanguineous drainage
pale, red, more watery drainage that sanguineous drainage
42
purulent drainage
thick, yellow, green, tan, or brown drainage
43
applying a dry dressing
- Dry non-woven gauze dressing used for wounds healing by primary intention (with little drainage)
- Protect wound from injury, reduce discomfort, and promote healing
- Commonly used for abrasions and non draining post op incisions
- Frequent dressing changes required (as they dry out as moisture evaporates quickly)
- Do not open a new surgical wound until the order says to (can only reinforce it)
- May come impregnated with substances (e.g., zinc oxide paste)
- Not appropriate for healing wounds where the dried gauze may stick to and damage healthy tissue
44
types of debridement
- autolytic - hydrocolloids
- enzymatic - agents applied directly to the wound bed and digest collagen in necrotic tissue
- surgical - gold standard but may not be readily available or appropriate
- maggot therapy - less common
45
types of debridement
- autolytic - hydrocolloids
- enzymatic - agents applied directly to the wound bed and digest collagen in necrotic tissue
- surgical - gold standard but may not be readily available or appropriate
- maggot therapy - less common
46
wound packing
- Some wounds require packing to promote healing
- Purpose: fill dead space and avoid potential abscess formation
- Gauze impregnated with hydrogel used for undermining or tunneling
- Ribbon gauze used to fill narrow areas
47
Applying Gauze and Elastic Bandages
- Gauze and elastic bandages secure or wrap hard-to-cover body areas
- Bandages are a secondary dressing
- Select type of bandage turn and width on the basis of size and shape of body part
- Place outer surface next to the skin and roll it around the surface to be covered
- Apply even tension during application
48
oxygen therapy
- Administration of supplemental oxygen
- Prevents or treats hypoxia
- Routes of administration:
Nasal cannula
Face masks
Noninvasive ventilation
Positive-pressure ventilators
49
oxygen therapy: principles for practice
- Aim: treat hypoxemia (insufficient oxygen to meet the metabolic demands of the tissues and cells)
- Decreased hemoglobin levels reduce amount of O2 transported to cells and CO2 transported away from cells
- Pain and anxiety affect oxygenation
- Assess for cyanosis (in conjunction with SpO2, RR, and other vitals)
- Treat O2 therapy as a medication à follow rights of medication administration (next week) – note you cannot apply oxygen in clinical until after medication safety lab
- Contraindications to O2 therapy are those with increased risk for respiratory failure (e.g., in COPD uncontrolled o2 increases risk of hypercapnia)
50
signs an symptoms of acute hypoxia
- apprehension, anxiety, behavioural changes
- decreased LOC, confusion, drowsiness, altered concentration
- increased pulse rate
- hyperventilation
- decreased lung sounds, adventitious lung sounds
- elevated bp (then decreased bp)
- SPO2 less than 90% and less than 88% in those with COPD
- dyspnea
- use of accessory muscle of inspiration
- cardiac dysrhythmias
- pallor, cyanosis
- fatigue
- dizziness
51
oxygen therapy safety guidelines
- Know a patient’s normal range of vital signs (in particular pulse oximetry (SpO2) values) and be mindful if they have COPD and what the order to maintain oxygen is!)
- Be aware of environmental conditions (e.g., polluted environments)
- If on home oxygen, complete an environmental assessment for respiratory hazards in the home.
- Document a patient’s smoking history (pack years = multiply “the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on” (National Cancer Institute, n.d., para 1)
- Know a patient’s most recent hemoglobin values and past and current arterial blood gas (ABG) values.
- Oxygen is a medication.
- Provide education to patient and family about home oxygen therapy.
- Have suction equipment available to assist in clearing airway secretions.
- Most facilities require a self-inflating resuscitation bag to be available in patient rooms, especially those requiring mechanical ventilation.
52
high flow oxygen devices
- used in more in critical care - ICU, emergency room
- Venturi-mask
- Large-volume nebulizer
- Blender masks
- High flow nasal cannula
53
low flow oxygen therapy devices
- more common
- Nasal cannula (low flow and oxygen conserving)
- Simple face masks
- Partial rebreather mask
- Non rebreather masks
54
venturi mask
specific amount of O2 with humidity
55
low flow nasal cannula
effective for low concentrations
56
partial rebreather
useful for short periods to acute hypoxia
57
oxygen therapy: humidity
- Humidity prevents drying of nasal and oral mucous membranes and airway secretions at high-flow rates or for long-term use
- If oxygen flow rate is less than 5 L/min, humidification provides no difference in nose/throat dryness. At rates greater than 5 L/min, nasal mucous membranes dry, and pain in frontal sinuses may develop
58
incentive spirometry
- Helps a patient deep-breathe by providing visual feedback and encourages patient to take long, deep and slow breaths
- Use in combination with deep breathing, coughing and early mobility
- Two types
- Flow-oriented (balls)
- Volume-oriented (pictured here)
- When encouraging a patient to use incentive spirometry, what position should they be in? → sitting up
- Instruct patient to take a slow, deep breath IN and maintain constant flow, like pulling through a straw. If flow-oriented is used, inhalation should raise the ball. If volume-oriented is used, inhalation should raise the piston. Remove mouthpiece at point of maximal inhalation; then have patient hold their breath for 3 seconds and exhale normally
59
oropharyngeal airway (OPA)
- Oropharyngeal airway (OPA)
- Allows for
- Suction
- Maintenance of airway patency in unconscious patient
- Select size based on patient age and anatomy (*Measure from the corner of the mouth to the angle of the jaw just below the ear for size estimation)
- In adults, hold OPA with curved end up and insert distal end until airway reaches back of throat; then turn airway over 180 degrees and follow natural curve of tongue.
60
ten rights of medication administration
```
Right medication
Right route
Right dose
Right patient
Right time
Right education
Right to refuse
Right assessment
Right evaluation
Right documentation
```
61
right medication
- A medication order is required for every medication that you administer to a patient
- Verbal and telephone prescriptions
- Compare the prescriber’s orders with the medication administration record (MAR) when the medication is initially ordered
- Common types of med prescriptions (orders) (Scheduled, Prn, One time (stat or now))
- Order must include patient's name, date prescribed, medication name, strength and dosage, route, dose frequency, and time(s) of administration
- Pre-printed and electric order sets/protocols
- As a nurse, once you determine that information on the patient's MAR is accurate, use the MAR to prepare and administer medications (more on this in Year 2)
62
right dose
Double-checking
Drawing up medications
Splitting and crushing pills
Wireless bar-code scanner
63
right route
- Order must specify the route
- If the route of administration is missing, or if the specified route is not the recommended route, consult the prescriber immediately
- Recent evidence shows that medication errors involving the wrong route are common
64
right time
- Prescribed dosage schedules (what time you give the medication)
- Time-sensitive medications (antibiotics, anticoagulants, insulin) within 30 minutes of scheduled time
- Non-time-sensitive medications within 1-2 hours of scheduled time
65
right patient
Always use at least two patient identifiers (e.g., name and DOB)
Ask patient to state their full name and DOB
Wireless bar-code scanners
66
right documentation
- First make sure that the information on the patient's MAR corresponds exactly with the health care provider's prescription and the label on the medication container
- If incomplete, illegible, vague etc. always contact HCP before giving
- Only document that you’ve given it once you’ve given it
- Document name of med, dose, time of admin, and route on patient’s MAR
67
medication preparation
- Interpreting medication labels
- Clinical calculation (medications are not always dispensed in the unit of measure in which they are ordered)
- Conversions within one system
- Conversions between systems
68
avoid distractions during medication administration by:
- Wearing a medication safety vest
- Use of visible medication preparation signs
- Medication administration checklists
- Staff and patient education
- Use of no interruption zones
69
Medication pre admin activities
- Ensure that the medication prescription has not expired
- Minimize distractions during medication preparation
- Do not interpret illegible handwriting; clarify with health care provider
- Read the label on the medication container and compare it with the MAR at least 3 times
- double check all calculations
- Administer only those medications that you personally prepare.
70
medication administration
- Follow the 10 rights of medication administration.
- Educate the patient
- Stay with the patient
- Respect the patient's right to refuse
71
medication post admin activities
- Record medications immediately after administration
- Document post assessment data pertinent to patient's response. This is especially important when giving prn medications
- If a patient refuses a medication, document that it was not given, the reason for refusal, patient education provided and when you notified the health care provider.
72
reporting medication errors
- A written incident or occurrence report must be filed (usually within 24 hours of an incident)
- The incident report is an internal audit tool and is not a permanent part of the medical record
- Report all medication errors, including mistakes that do not cause obvious or immediate harm or near misses
73
medication error disclosure
- Patient and family disclosure of med errors based on patient safety, openness, transparency, accountability and compassion
- Current literature all supports open and honest disclosure of patient safety incidents
- Disclosing a patient safety incident to the patient and family demonstrates respect and person-centred care and facilitates safe and appropriate clinical care
