Exam 3 Study guide Flashcards

Question

Conditions affecting chest wall movement

Answer 1

Previous smoker Other conditions Decrease mobility

Answer 2

``` Ineffective airway clearance Elevate head of bed during and after meals Encourage coughing and deep breathing Possible aspiration precautions Monitor sputum Assess and monitor respiratory status Perform chest physiotherapy if needed Provide exercise and activity Suction pt airway as needed Monitor ABG Ineffective breathing pattern Impaired gas exchange Assist ADLs Auscultate breath sounds Monitor respiratory status Monitor signs of respiratory problems Perform chest physiotherapy Limit agitation Encourage incentive spirometry Monitor ABG Maintain airway Afterload, Preload, Stroke Volume Afterload- resistance of blood from L. ventricle Preload- amount of blood at end of ventricular diastole Stroke volume- amount of blood pumped out ventricle w each beat/contraction Differentiate types of oxygen delivery systems Regular nasal cannula mustache/ pendant cannula Simple face mask Partial rebreather with reservoir bag Non rebreather with reservoir bag High flow nasal cannula Venturi mask Regular nasal cannula O2 1-6 L/min 24%-44% Mustache or Pendent cannula o2 3x-4x more than regular cannula with same flow rate No humidifier Simple face mask o2 5-8 L/min 40%-60% Partial rebreather with reservoir bag 02 8-11 L/min 50%-75% Non Rebreather with reservoir bag o2 10-15 L/min 80%-95% High flow nasal cannula o2 Max flow 60 L/min 10 L/min-65% 15 L/min-90% Humidifier Venturi mask o2 Deliver precise, high flow rates Masks available of 24%, 28%, 31%, 35%, 40%, 60% Which o2 methods are low flow? Regular cannula Mustache or pendant cannula Simple face mask Partial rebreather Non Rebreather Which o2 methods are high flow? High flow nasal cannula Venturi mask Which o2 methods are used with a humidifier? Regular nasal cannula Simple face mask High flow nasal cannula ```

Answer 3

``` Age Broken skin Dehydration Dry skin Poor circulation Reduced mobility Malnourished Medication Decreased sensation ```

Answer 4

``` subQ/dermal tissues are thin Increase risk of injury Decreased insulation Decrease elasticity Decreased sensation to pain Skin is dry and have itching Cell renewal is shorter/healing time is delayed Hair turns white/grey Decrease pigmentation Wrinkles ```

Answer 5

``` Status of skin integrity Cause of the wound Severity of tissue injury Partial involving epidermis Full thickness-both layers of skin Cleanliness of wound Car accident/ sitting in dirt Descriptive qualities ```

Answer 6

Injury occurs Hemostasis Blood flow stopped Platelet aggregation Inflammation Neutrophils secrete chemicals to kill bacteria Macrophages engulf debris Proliferation Fibroblasts secrete collagen Epidermal cells migrate from the wound edge Granulation tissue is formed Remodeling/ Maturation Wound contracts increasing tissue integrity Fibroblasts secrete collagen to strengthen wound Identify factors affecting wound healing Local: infections, trauma, necrosis, dehydration, edema Systemic: age, circulation, nutritional status, general health, immunosuppressant, adherence to drugs

Answer 7

``` Hemorrhage Infection Dehiscence Splitting or bursting open of a wound Evisceration Being cut further Primary intention: open wound, closed surgically with staples Secondary intention: kept clean, left alone to let tissue repair, inside heals first Tertiary Intention: wound left open for a period of time, make sure no infection then surgically close with staples. Identify factors involved in pressure injury Aging skin Chronic illness Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord injuries Brian injuries Neuromuscular disorders Can a stage be reversed? No What is slough? yellow/white material in the wound bed Eschar Dead tissue/dry Undermining Occurs when tissue under wound edges becomes eroded Tunneling A wound that has progressed to form passageways under the skin ```

Answer 8

Base of wound not visible Full thickness tissue loss Completely obscured by necrotic tissue

Answer 9

Skin is intact | Nonblanchable

Answer 10

Shallow, open ulcer Can be a blister with fluid Particle thickness loss of epidermis with exposed dermis red/ pink wound bed

Answer 11

``` Full thickness skin loss May see subcutaneous fat Sloughing may be present- yellow tissue Eschar may be present-dead tissue Possible undermining and tunneling ```

Answer 12

Full thickness skin and tissue loss Exposed bone, tendon or muscle Possible slough or eschar Often undermining and tunneling

Answer 13

``` Low risk 23-19 ? Moderate risk 18-15 ? High risk 14-10? Very high 9 or below (lower score is higher risk) ```

Answer 14

``` Etiology Nociceptive Normal pain process Occurs from actual injury Most common Neuropathic Caused by lesion or disease of nerves Exact cause unknown Burning Stabbing Intractable Persistent and resistant Phantom Occurs with amputations Absence of pain receptors and nerves Psychogenic No physical cause can be identified Feelings of pain are just as intense as psychical pain Duration Either acute or chronic Acute-quick onset, protective, ANS activation Chronic- lasts longer than expected, lasts at least 6 months, variable, stigmatizing Acute example broken bone, pulled muscle, a cut Chronic example nerve damage, lower back pain, arththiris Location Cutaneous Superficial Somatic Deep Tendons Bones Well localized Visceral Occurs in organs Referred Pain is perceived at a site other than the original location ```

Answer 15

- Patient Controlled Analgesia-drug (PCA): used after surgery/burns, administered IV. Patient is in control and can self administer by pushing a button - Anesthesia-Local infiltration of anesthetic medication to induce a loss of sensation. Brief surgical procedures-removing a mole/lesion, suturing a wound - Analgesics-creams, ointments, patches. Education important on placement - Regional Anesthesia-injection or infusion of local anesthetics to block a group of sensory nerve fibers. - also block motor and autonomic functions - Perineural Local Anesthetic-Type of regional anesthesia-infusion of local anesthetics infused through an unsutured catheter that is inserted near a nerve or group of nerves. Usually left in place for 48 hours. Continuous or intermittent infusion. On-Q pump. - Epidural Analgesia-Type of Regional Anesthesia-Opioids or combination of anesthetics are administered into epidural space. Inserted by anesthesiologist or Nurse Anesthetists. Patients can self administer demand doses.

Answer 16

``` Ethnic variables Family, sex, age Religious beliefs Environmental Support system Past pain experiences Anxiety and stressors Fatigue ```

Answer 17

The concentration of water soluble drugs (morphine) in the body is increased. The volume of distribution for fat soluble drugs also increases (fentanyl). This is because with aging, there is a decrease in muscle mass, body fat increases, and body water percentage decreases. Older adults often eat poorly, without an adequate protein intake, which can lower serum albumin level. Many drugs are highly protein bound. Low albumin can cause the active form of the drug to be more available, increasing side effects and toxicity. Liver and renal function naturally start to decline with age, which can reduce the metabolism and excretion of drugs. Can cause a greater peak and longer duration of analgesics. Age related skin changes, such as thinning of the skin and loss of elasticity can affect the absorption rate of topical medications.

Answer 18

``` Acute pain Give meds Educate pt and family about meds Express importance of pain reporting Establish acceptable pain level Assess for nonverbal pain cues Assess pain characteristics, severity, location, onset, type, factors and duration Chronic pain Give meds Promote nonpharmacologic relief Same as above Transduction Activate pain receptors Transmission Sent to brain Perception Realizing its hot/awareness characteristic Modulation How to fix pain ```

Exam 3 Study guide Flashcards

(43 cards)