FINAL EXAM Flashcards by Tammy Nguyen

Factors Affecting Skin Breakdown

Age: Elderly & infants have thinner, more fragile skin, ↑ risk of breakdown.

Nutrition: Poor nutrition = delayed wound healing & skin repair. Good nutrition = supports healthy skin cells.

Circulation: Poor circulation = inadequate oxygen & nutrient delivery to tissues, ↑ risk for skin damage and delayed healing.

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Who Is at Risk for Skin Breakdown?

Older adults & infants
Paralyzed individuals
Diabetics – poor circulation (atherosclerosis), ↓ sensation, poor nutrition/hygiene → risk for diabetic foot ulcers
Patients with diarrhea – must change promptly
Bedrest/decreased mobility
Casts or medical devices
Medications
Radiation therapy – can cause burns or skin damage

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Factors That Affect Wound Healing

Pressure
Moisture balance:
Too wet → maceration
Too dry → cells can’t migrate to heal
Edema: Excess fluid causes swelling, impairs oxygen/nutrient delivery
Infection
Necrosis

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Wound Assessment – What to Look For

Size: Measure length, width, depth (use Q-tip for depth)
Stitches/Staples: Count and document how many are present
Color:
Beefy red: Healthy, good healing
Yellow (slough): Dead tissue, needs cleaning
Black (necrosis): Dead tissue, needs debridement
Drainage Type:
Serous: Clear or slightly yellow = normal
Sanguineous: Bright red blood = fresh bleeding
Serosanguineous: Mixture of clear and red
Purulent: Yellow/green pus = infection
Documentation: Take a photo and chart for trend monitoring

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What is included in Braden Scale?

Braden Scale: Used for Predicting Pressure Sore Risk
Sensory Perception – ability to respond to pressure-related discomfort
Moisture – exposure of skin to moisture
Activity – level of physical activity
Mobility – ability to change and control body position
Nutrition – usual food intake pattern
Friction and Shear – risk during movement/transfers

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Preventing Pressure Injuries

-Frequent skin assessments

-Clean skin promptly after bowel movements

-Moisturize to maintain skin integrity

-Avoid massaging bony prominences (can damage fragile tissue)

-Keep wounds moist, not too wet or dry

-Prevent friction and shearing during repositioning or transfers

-Use appropriate support surfaces (special mattresses, cushions)

-Address nutrition: increase calories and protein to support healing

-Encourage mobility and activity

-Reposition frequently (e.g., every 2 hours in bed)

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Common Treatments for Pressure Sores

Critic-Aid: Barrier ointment to protect skin from moisture/stool incontinence
Mepilex Foam Dressing: Soft, absorbent dressing used for skin tears and fragile skin
Santyl: Enzymatic debrider that removes necrotic tissue/slough
Aquacel: Highly absorbent dressing that turns into a gel to maintain moist wound environment
Aquacel Ag (Silver): Same as Aquacel but silver fights infection
Wound VAC (Negative Pressure Wound Therapy): Uses suction to remove drainage, reduce edema, and promote healing in open wounds

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Urine Characteristics

Color: Clear, yellow, amber, tea-colored, pink, bloody

Cloudy: May indicate infection

Sediments: Inflammation of bladder

Green urine: Possible med side effect (e.g., propofol)

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Ins & Outs Monitoring

-Measured every 8 hours

-Input: Fluids, IV, food, meds

-Output: Urine, vomit, BM, drains

-Fluid balance = Intake – Output

-Report if less than30 mL/hr urine output

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GU Labs & Tools

BUN & Creatinine: ↑ = renal failure

Diuretics: ↑ urine output

Bladder scanner: Measures retention

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Dialysis & AV Fistula

For end-stage kidney failure

AV Fistula: Artery + vein surgically connected

Bruit = Hear “whoosh” with stethoscope

Thrill = Feel rumble with hand

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Types of GI Bleeds

Lower GI bleed: Bright red blood

Upper GI bleed: Black, tarry stools (digested blood)

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Bowel Movements

Ask about last BM

If no BM in 4 days, consider laxatives or stool softeners

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GI Labs & Imaging

Occult blood: from stool

H/H (Hemoglobin & Hematocrit): Check for blood loss

Lipase & Amylase: ↑ in pancreatitis

Nuclear RBC scan: Detect source of GI bleed

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Ways to Relieve Constipation

Enema

Digital removal

Rectal suppository

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Rectal Suppository Insertion

Remove foil, moisten

Insert while lying on left side

Push deep enough to stay in for 5+ mins

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Nursing Diagnosis Format (3-Part Statement):

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Problem (NANDA-approved diagnosis)

Related to (etiology or cause)

As evidenced by (signs/symptoms or defining characteristics)

Burkes Swallow evaluation

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Common for stroke patients. Drink 30 mL of water, then watch for signs of discomfort or aspiration.

NG Tube Placement Check

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X-ray (best)
Aspirate: pH & appearance

Types of NG Tubes

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Dobbhoff (KAO): 1 lumen, feeding only

SUMP NG: 2 lumens, feeding + suction

TPN vs PPN

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TPN: Central line, high concentration
PPN: Peripheral line, lower concentration
-Both often given with IV lipids

HbA1c Test

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Blood test to measure % of hemoglobin that has sugar attached to it.
Provides a long-term view. (2-3 months)

Signs of Hypoglycemia

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Low sugar
- sleepiness
- sweating
- pallor
- lack of coordination
- irritability
- hunger

Signs of Hyperglycemia

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High sugar
- dry mouth
- increased thirst
- blurred vision
- weakness
- headache
- frequent urination

IV Meds

- Most dangerous, immediate effect; no turning back. - Needleless system. - SCRUB THE HUB before accessing the needle system.

IV Bolus or Push

- One-time, large dose - Given rapidly over seconds to minutes - Ex: NS 500 mL IV bolus post-op, Solu-Medrol 60 mg IV push over 2 min - Can be given through IV line or saline lock

IV Line Administration

- Check for drug compatibility with other meds in line - Avoid interactions or precipitation in tubing

Saline Lock (Heplock)

- IV access without continuous fluids - Use for intermittent meds or IV push - Flush with saline before/after use - Often used in home health (e.g., for Heparin)

Intermittent IV Infusion (IVPB)

- Meds + fluids given at set intervals (e.g., vancomycin 1000 mg IV daily) - Use smart pump to control rate - Given via secondary line (IV piggyback), Hang piggyback higher than primary fluids — gravity helps infusion - Label tubing with date + expiration - Most: change every 96 hrs (4 days), TPN/propofol: change every 24 hrs - Use disinfectant caps on all ports; replace after each use

IVPB & Reality Tips

Common IVPB meds: antibiotics, potassium Normal issues: air bubbles, occlusions — use ITRACE - Prime line if needed - Always scrub the hub before access

Syringe Meds & Pumps

Syringe pump: used for small doses, common in pediatrics PCA pump: locked, for narcotics - Can be set to: continuous, demand, or both - Monitors with EtCO₂ alarm for respiratory depression - Common PCA meds: fentanyl, morphine, dilaudid - PRN Narcan often ordered with PCA

SASH PROTOCOL

S - Saline A - Administer med S - Saline H - Heparin (in homecare only, hospitals no longer use this.) - This SASH protocol is followed when giving medications; ex. Administer through in a saline lock=NOT connected to a pump.

Calculating drip rate (pump calculates)

Total volume (mL) / total time (hrs) = mL per hour Ex. 1000ml/8hrs = 125 ml/hr

Calculating manual drip rate – no pump

(Volume (mL) / Time (min) ) x drop factor (gtt/ml) = gtt/min Ex. 500 ml in 3 hours; drop factor = 10 (500ml/180 minutes) x 10 = 28gtts/min

Body Water Distribution

Body = ~60% water ⅔ = Intracellular fluid (ICF) ⅓ = Extracellular fluid (ECF)

Osmosis (Fluid Movement)

Water moves from low solute → high solute concentration Also: high water concentration → low water concentration Maintains fluid balance between cells and surroundings

Crystalloids vs. Colloids

Crystalloids: Small particles, cross membranes (e.g., NS, LR) Colloids: Large particles, stay in vessels (e.g., Albumin, Hespan) Colloids = volume expanders (blood loss, low albumin)

Isotonic Fluids

Examples: 0.9% NS, D5W, LR No fluid shift (equal concentration) Used for: dehydration, blood loss, surgery

Hypertonic Fluids

Examples: 3% saline, D10W, D5NS, D5½NS, D5LR Fluid moves out of cell → cell shrinks Used for: cerebral edema, hyponatremia

Hypotonic Fluids

Example: ½ NS (0.45%) Fluid moves into cells → cell swells Used for: DKA, dehydrated cells, hyperosmolar states Caution: Rapid infusion = cerebral edema/seizures

Saline Flush Technique

Use PUSH-STOP motion during saline flushes to prevent pressure spikes and maintain line patency

FINAL EXAM Flashcards

(41 cards)