Fund 53 54 58 59 77 86 87 Flashcards Preview

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Flashcards in Fund 53 54 58 59 77 86 87 Deck (172):
0

The term for evaluating the status of an extremity encased in a bandage and is done by RN

PNA
Peripheral Neurovascular assessment

1

Name the things you check for during PNA

Skin color
Finger or toe motion sensation
Distal pulses
Cap refill under 3 secs
Edema
Pain
Skin temp

2

Overlapping application, alternating with ascending and descending wrapping with each pass of the bandage crossing over previous wrapping as in a figure eight

Figure eight

3

Type of wrap that stabilizes joints such as wrist or ankle and helps maintain immobilization

Figure eight

4

Wrapping a limb in ascending path partially covering previous wrapping while moving up the limb

Spiral

5

Type of wrap that promotes venous return. Effective when a bandage needs to be applied around an arm leg or wrist. May be used to hold dressings in place

Spiral wrap

6

Similar to spiral wrap except the bandage is folded back halfway through each process. The appearance of basket weave

Spiral reverse wrap

7

Arms, legs, thighs
Used for extremities that are wider at one end than the other, cone shaped. Promotes venous return. Holds dressings in place.

Spiral reverse

8

Wrapping with continuous application in same place such as a wrist. Stabilizes ankle wrist fingers and toes

Circular wrap

9

Anchored at the top with several spiral wraps, then back and forth across the end of the extremity or head. Finish with spiral reverse or figure right

Recurrent wrap

10

Binds amputation stumps in preparation for prosthesis fitting an also holds dressing on heads

Recurrent wrap

11

basic bandage
Wrapped around limb to give support used to exert pressure over a bleeding point
All cotton elastic

ACE bandage

12

Type of gauze used to hold dressing in place or to apply pressure

Kerlix

13

Net or mesh type material
Finger sized to large body sized bandages.
Also called TUBE GAUZE

Stretch net bandages

14

Bandages used in practitioners office or school offices

Stretch net bandages
Tube gauze

15

anti embolism stockings are also known as

TEDS

16

TEDS
Anti embolism stockings
are used for people with what disease

Thromboembolic disease

17

The point of TEDs anti embolism stockings are to

Return venous circulation to the heart to prevent clotting

18

Before nurse can apply TEDS anti embolism socks the nurse first must receive

A doctors order

19

Before applying anti embolism socks on a pt the nurse must have pt____

Lay down for 15 minutes to prevent pooling of fluids in legs

20

Perform PNA on a pt with TEDS every

2 hours

21

Remove TEDs on a pt every

4-8 hours

22

another device that promotes venous return is

PCD machine

23

PCD names 3 types

PCD pneumatic compression device
SCD sequential compression device
ISCD intermittent sequential compression device

24

Clients immediately after surgery with circulatory disorders need application of

PCD machine

25

Wide flat fabric piece applied to support specific body part or hold a dressing in place usually ordered for women after child birth

Binders

26

Binder that holds perineal pads or bandages in place for incontinent or menstruating female
Fastened with Velcro or pinned

T binder

27

Wide flat piece of fabric that is secured around the trunk of clients body to support the abdomen or dressings on abdomen. Rarely used after child birth mostly after abdominal surgery

Abdominal binder

28

Skin softening and breakdown due to moisture accumulation and lack of circulation

Maceration

29

These straps allow dressings to be changed without having to remove tape with each change. Tie straps

Montgomery bandages

30

Anti embolism stockings should never be allowed to bunch or roll up bc

This could lead to constricting circulation

31

Anti embolism stocking are applied from toes or finger

Upward

32

Anti embolism stocking should be removed every 4-8 hours to check for

Redness, edema, skin discoloration

33

Enlargement of blood vessels is called

Vasodilation

34

Normothermia

Normal body temperature

35

SSI

Surgical site infections

36

WA

While awake

37

heat application causes

Vasodilation

38

Name a few things heat helps with

Vasodilation
Increasing O2
Aids in removal of wastes from tissues
Wound healing
Reduce inflammation
Promotes drainage

39

Types of dry heat

Heating blanket
Water filled heating pad
Aquathermia pad
Heat lamps and tx

40

Types of moist heat

Compresses
Paks
Soaks
Sits bath

41

Do not apply heat to abscess or infected appendix as this may cause

Rupture

42

Type of dry heating pad where distilled water flows through and used for muscle sprains and inflammation
Dry heat

Aqua K pad
Aquathermia pad

43

Can any nurse use lamp tx on PTs?

No only specially trained personnel with specific education can

44

IR infrared does what for a pt

Relaxes muscles
Stimulate circulation
Relieves pain

45

UV ultraviolet does what for a pt

Mild UV radiation
Not much affective as IR

46

US does what for pt

Deep penetrating heat to muscles and other tissues

47

To apply heat or cold first you must receive

Doctors order

48

steps in disassembling Aquathermia pad

1) clamp tubing until over sink
2) unplug unit
3) empty water and everything over sink
4) discard pad
5) return only heater pump to dept

49

Areas on the body too sensitive to heat

Eyelids
Neck
Inside arms

50

Less heat resistance PTs

Infants
Old
Fair thin skin
Pt with illnesses

51

Do not use heat application to PTs who are at risk for injury such as

Unresponsive
Anesthetized
Have dimentia or neurological issues or psychological disorders

52

PTs who are susceptible to burns

Impaired circulation
Metabolic diseases
Diabetic
Chemo pt
Paralysis

53

Temperature
C 26.6-35 F 80-95 is considered

Tepid

54

Lamp or special heater that is mounted inside bed candle to provide dry heat

The heat cradle

55

Covered network of wires that emits heat
Never use pins to clamp down

Electric heating pad

56

Type of moist heat
Used basin
Bath with tap water for only 15-20 minutes

Warm soaks

57

Prevents escape of heat from body by slowing circulation

Cold application

58

Slows or stops bleeding
Slows bacterial activity
Reduces swelling
Controls fluid loss and edema
Finishes muscle contractions and spasms

Cold applications

59

What type of application is used for pain in engorged breasts

Cold

60

What type of application is used in abdominal inflammation to prevent peristalsis

Cold

61

If client complains of numbness or if skin looks white or spotty during cold application

Stop

62

Reduces swelling and inflammation in soft tissues or after tooth extraction

Cold moist compresses

63

Dry cold application used for head

Ice cap

64

Dry cold application used for neck

Ice collar

65

Types of cold applications used by athletes

Single freeze
Refer exabyte ice packs

66

Cold moist bath includes a

Tepid sponge bath

67

athroom not use alcohol during sponge baths as it

drys and cools quickly

68

Tepid baths are not used for these type of PTs

I elastic arteries
Arthritis
Children

69

Blanket that slows body processes
And lowers temperature

Hypothermia blanket

70

cold moist treatment that is used for PTs with respiratory disorders

Cold humidity
Humidifier

71

PTs with tracheostomy use

Teach mask
Face tent

72

An abnormal opening or break in the skin

Wound

73

Stab wound is called

Puncture wound

74

Wound with turned edges

Laceration

75

Rubbing off skins surface

Abrasion

76

Sterile intentional and non self inflicted wound

Surgical incision

77

Do not massage any reddened or dis colored pressure points as this can add to

Skin breakdown

78

Type of wounds are DX by

MD

79

Avoid inspecting wounds under fluorescent lights as this can lead to incorrect wound

Diagnosis

80

Drainage loss of protein and cellular debris

Exudate

81

clear thin watery drainage

Serous

82

Composed of serous and blood type drainage

Serosanguineous

83

Bloody containing a lot of blood and serous

Sanguineous

84

DrainGe containing pus

Purulant

85

Presence of one or more channels within or underlying an open wound
Usually measured with sterile applicator

Tunneling

86

If tissue recedes beneath skin creating a shelf or free edge with a space underneath also measured with sterile applicator

Undermining

87

Type of wound edge
softened by moisture

Macerated

88

Type of wound edge
Very hard yellow or white

Calloused

89

Type of wound edge
Healthy with tissue growth

Open

90

Erythema

Redness

91

Excoriated peri wound area means

Scratched or abrasion

92

Measurements
Linear measurement uses

Ruler

93

Measurement
Planimetry uses

Graph paper for flat wounds

94

Measurement
Stereo photogrammetry uses

Non invasive video camera

95

Measurement
Wound photography uses

Photo camera

96

Wound tracing used for what type of wounds

Flat
Irregular wounds

97

Types of skin breakdown
Limited to damage of dermis and epidermis

IAD
Incontinence associated dermatitis

98

Type of skin breakdown
Cause by sheer friction
Bony prominences
Leads necrosis

Pressure ulcer decubitus

99

Type of skin breakdown
Developed in lower extremities
Hypoxia
Large WBC and no growth factors

Venous stasis ulcer
Venous insufficiency ulcer

100

Type of skin breakdown
Diabetes mellitus
Impaired circulation
Difficult to treat

Diabetic ulcer
Diabetic neuropathic ulcer

101

Types of scale used to predict pressure ulcer risk

Norton scale
Braden scale

102

What can you use for easy removal of regular tape

Saline solution

103

Deep wounds must heal from the inside out or else an abcess will occur this is called

Granulation

104

Ways to prevent pressure ulcers

Turning schedule
Pillows
Padding

105

Ways to prevent shear friction normally seen on coccyx

Logroll turns
Foot board
Head 30 degrees or less

106

Prevention of perspiration wounds

Keep areas dry anti fungal powder

107

Prevention of arterial insufficiency

Elevate Edema legs

108

Sage of pressure ulcer
Redness
Blue purple coloring

Stage 1

109

Stage 1 is reversible by

Turning schedule
Pressure relieving devices

110

Stage of pressure ulcer
Loss of epidermis and dermis
Blister no sloughing

Stage 2

111

This pressure ulcer is relieved in several weeks using special moisture saline dressings or occlusive dressings

Stage 2

112

Stage of pressure ulcer
Fat may be visible
Undermining or tunneling


Stage 3

113

Pressure ulcer healing in months with wet to dry dressings

Stage 3

114

Stage of pressure ulcers
Full thickness tissue loss
Exposed bones tendons or muscles
Slough or eschar

Stage 4

115

pressure ulcer taking years to heal and may require skin grafting

Stage 4

116

The base of a full thickness pressure ulcer covered by slough and eschar

Nonstageable ulcer

117

Deep tissue injury is called

Bruises

118

Healing
Occurs in tissues with minimal tissue loss
Seals rapidly minimal scarring

First intention healing

119

Types of first intention healing

Surgical incisions
Sutured wounds

120

healing
Tissue loss
Granulate inside out

2nd intension healing

121

Healing
Delay in timing between opening and closing of wound
Infected
Granulate inward causing heavy scarring

Third intension healing

122

Antibiotic and antiseptics are applied to wound

Center not edges

123

Who does the first dressing change

Surgeon or MD

124

Basic dressing
Gauze
Telfa pads
Abdominal pads surgical pads

Dry to dry dressing

125

Type of dressing technique for debridement and cleansing
Uses asking or sterile solution packing for infected wounds

Wet to dry dressing

126

Do not use saline to remove what type of dressing

Wet to dry

127

Type of dressing technique used on clean open wounds granulating in. Vaseline

Wet to wet dressing

128

Wound care product
Promotes debridement
Not used on heavy or infected wounds. Ex: tegasorb, duoderm,

Hydrocalloid

129

Wound care product
Exudate absorption
Does not stick
Helps keep shallow wound moist

Foam

130

Wound care product
Minimal to heavy absorption
Gels as it absorbs
Must be irrigated out of wound

Alginate or hydrofiber

131

Wound care product
Causes Maceration
Adds moisture to wounds
For necrotic or infected wounds

Hydrogel

132

Open drainage system

Penrose drain

133

Type of closed drainage system that allows to collect in a bulb

Jackson Pratt

134

Press on device drainage system

Hemovac

135

Drainage bottle with rubber bulb
Balloon creates suction as it deflates

Pavol

136

Applies localized negative pressure to wound site
Used for stage 3&4 ulcers
Removes fluids and reduces swelling

VAC vacuum assisted closure

137

Manual irrigation are done by

Hand held syringe

138

Name the 6 stages of dying

Denial and isolation
Anger and rage
Bargaining
Depression
Acceptance
Detachment

139

This type of breathing is a result of acidosis

Kiss mauls breathing

140

Over 20 RPM
Labored and deep breathing

Kussmauls breathing

141

Alternating periods of apnea and hyper apnea

Cheyne stokes Respirations

142

Irreversible cessation of heart and lung function

Biological death

143

Irreversible cessation of brain function

Brain death
Cerebral death

144

When both Respirations and heart beat stops

Clinical death

145

For Clients on DNR and DNI you must document

Time of when heart stops and time when Respirations stop

146

Biological death have two exceptions

Drowning victims
Overdoes victims

147

Continuous force on broken bones to keep them in natural position for fusion

Traction

148

Type of cast remains wet for 24-48 hours
Do not use intense heat to dry
Less expensive

Plaster cast

149

Type of cast
Drys I'm 15 minutes
Light
Able to wet a little
X-ray can see through material

Synthetic cast

150

If a client has to per while in cast use

Fracture bed pan

151

Types of skin traction
Only left on for 3 weeks or less
8-10lbs of pull

Bryant's or bucks

152

You of traction where physician inserts metal pins or wires into clients bones an traction is applied directly

Skeletal traction

153

Type of traction that is used to stabilize fractures in femur

Balanced suspension traction

154

Type of respiratory tx where the person is placed in a head downward position

Postural drainage

155

During auctioning through nasal passageway this entire procedure should not take more than

20 seconds

156

Oxygen simulating deep sea diving by increasing pressure

Hyperbaric

157

Transparent mask with simple nipple adapter that fits over Clients nose mouth and chin
Low flow delivery system

Simple mask

158

Low flow delivery system that uses a bag

Partial re breathing mask
PRM

159

A nonrebreathing mask with valves on the outside

NRM

160

Type of mask with consistent flow of specific oxygen used for clients with COPD

Venturi mask

161

Type of breathing tx used for children or adults with chronic lung conditions

IPPB
Intermittent positive pressure breathing

162

Aerosol mist tx is used to deliver

Anti inflammatory or anti asthma medications to lungs

163

Type of aerosol devices

Mini nebulizar

164

A more sanitary an more effective resuscitation than mouth to mouth

Ampu bag
Manual resuscitation bag

165

A flexible plastic tube used as a temporary device to maintain a patent airway during intubation

Endotracheal ET tube

166

When a client cannot maintain breathing this device can be used

Mechanical ventilator

167

Mechanical ventilator can also be a called a

Respirator

168

Assist a client on a ventilator to turn every

2 hours

169

Strategy of weaning off ventilator where mechanical breathing gradually lessens

SIMV
Synchronized intermittent mandatory ventilation

170

Type of weaning off ventilator where constant pressure is applied as person inspires

PSV
Pressure support ventilation

171

Allows inspiration and expiration pressure to stay above atmospheric pressure

CPAP
Continuous positive airway pressure