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Fundies > Fundies Final > Flashcards

Fundies Final Flashcards

1
Q

First stage of pressure ulcer

A

Skin intact
Over bony prominence
Pressure related alteration

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2
Q

Second stage of pressure ulcer

A

Ulcer is superficial may be an abrasion or blister
Shallow crater
Skin not intact
Partial thickness skill loss of epidermis or dermis

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3
Q

Stage 3 of pressure ulcer

A

Full thickness akin loss

Bone, tendon, muscle not exposed

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4
Q

4th stage pressure ulcer

A

Full thickness skin loss
Damage shows tendon, bone
Slough and eschar often present

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5
Q

Unstageable

A

All stages are viable

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6
Q

What is a deep tissue injury

A

Bruise- spongy to touch

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7
Q

What is a wound evisceration

A

When the wound completely separates with with protrusion of viscera through the incision area

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8
Q

What is fistula

A

abnormal connection or passageway that connects two organs or vessels

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9
Q

What is a hemorrhage

A

Bleeding or flow of blood may be external and visible

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10
Q

What are the stages of healing

A

Inflammatory
Granulation
Maturation
Primary

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11
Q

Stage inflammatory for healing

A

3-5 days

New blood vessles and tissue are formed

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12
Q

granulation

A

5-21 days

new blood vessels and tissue are formed

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13
Q

maturation

A

lasts for months
collagen fiber is remodeled
scare formation and contraction occur

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14
Q

primary wound healing

A

wound margins are well approximated
low risk of infection
rapid healing

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15
Q

secondary wound healing

A

wound margins are not well approximated
longer period of time to heal
pressure injure left open to heal

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16
Q

tertiary

A

wound healing is delayed and occurs when a wound that is previously closed
process is usually associated with large infected wound
longest time to heal and close

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17
Q

how/ when do you use the rationale of the braden scale ?

A

predicting pressure ulcer sore risk
lower score = more at risk
higher score= less at risk

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18
Q

types of pain

A

acute and chronic

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19
Q

what is acute pain

A

heals fast
appendicitis
caused by injury or noxious stimuli
develops quickly or slowly

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20
Q

what is chronic pain

A

long lasting

arises from stimulation o

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21
Q

risk factors of diabetes

A

age, race, ethnic group, family history, lifestyle, medical risks factors

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22
Q

what would a complete assessment of the GI system include

A

inspection
auscultation
palpation
percussion

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23
Q

classification of pain

A

nociceptive and neuropathic

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24
Q

nociceptive pain

A

arises from stimulation of nerve endings
visceral (internal organs)
- deep, pressure like pain
somatic
- skin, bones, joints, connective tissue, aching or throbbing

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25
Q
  • neuropathic
A

damage or dysfunction of peripheral nerves or central nervous pathways
described as constant or urning, tingling,

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26
Q

What is colderr

A

characteristics, onset, location, duration, exacerbation, radiation, relief

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27
Q

alternative techniques of pain management

A

hypnosis
distraction
guided imagery

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28
Q

guided imagery

A

focuses on evoking pleasant images to replace negative or stressful feeling and to promote relaxation

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29
Q

meditation

A

involves patient participation and is appropriate for all levels of care

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30
Q

massage

A

improves blood flow,

manipulation of soft tissues of the body by stretching and lossening muscle and connective tissue

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31
Q

reiki

A

restore balance in a patients energy field
last about 1 hour
SE are temporary light headedness

32
Q

pain scales

A

comfort, cries scale

wong baker

33
Q

comfort scale

A

adults, infants, and children who cannot rate their pain

observe patient for at least one minute in order to assess behavior

34
Q

cries scale

A

neonates, birth to 6 months

based off crying bitch and vitals taken

35
Q

what are primary types of care

A

immunizations
vaccines
diet
farm safety

36
Q

secondary prevention care

A 
PAP 
testicular exams 
BP 
screenings 
HIV., AIDS testing
37
Q

tertiary prevention care

A

education
hip surgery
rehab

38
Q

SBAR/ ISBAR

A 
introduction 
situation 
background 
assessment 
recommendation 
good method for report from shift to shift
39
Q

what are nursing notes what to include, what type of notes are there

A

DAR, ADPIE, SOAP, charting by exception

40
Q

what is evidence based practice

A

based on scientific evidence

research

41
Q

what is QSEN

A

quality, safety, education, nursing

it is about the the knowledge skills and atitudes to improve quality and safety in healthcare

42
Q

what is client centered care

A 
10 components 
remember it includes family and friends 
patient is the focus 
patient makes their own dicisions 
nurse is to provide infor to referrals they need
43
Q

ericksons developmental theory

A 
trust vs. mistrust = b-12monts 
autonomy vs shame = 1-3 
initiative vs guilt 3-6 
industry vs inferiority 6-12 
identity vs role confusion = 12-18 
intimacy vs isolation = 20-40 
generativity vs stagnation 40- 60 
integrity vs despair = mid 60s - end of life
44
Q

maslows

A

triangle
physiologica - air food and water
safety - risk for falls

45
Q

primary roles of the nurse table 1-2

A 
8 of them 
caregiver 
coordinator 
researcher 
advocate 
educator 
counselor 
communicator 
leader
46
Q

PICO

A 
EBP 
patient/ population 
intervention / interest 
comparison of interest 
outcome of interest
47
Q

lewins theory of change

A

unfreezing - recognizing a need for change
moving- planning for change
refreezing- when change becomes operational, new change has been put into place

48
Q

how do nurses coordinating care

A

scedule appointments they need, may have meetings with them to explain labs and test, preop education for surgery

49
Q

appropriate/ innaproprate communication skills

A

asking open ended questions

clarifying and reflecting

50
Q

nontherapeutic communication

A

nonchalant
cliche
false reassurance

51
Q

stage 1 of illness

A

present with symptoms physically, cognitvely and emotionally

52
Q

stage 2 of illness

A

sick roll, when symptoms persist and confirmation of illness

53
Q

stage 3 of illness

A

dependent roll- this is when the person becomes dependent on a healthcare provider

54
Q

stage 4 of illness

A

recovery and rehab

55
Q

health measures

A 
healthy diet 
support groups 
*prayer 
*meditation 
*mindfulness
56
Q

cultural sensitivity

A

when discussing pain, remember each person has their own views of pain
patient decides how to respond to their pain
recommended to learn about primary cultures and their helath practices that you are going to be working with

57
Q

professional nursing values

A

autonomy
integrity
social justice
altruism

58
Q

normal respiratory rate

A

12-20

59
Q

normal temperature

A

98.6

60
Q

normal bp

A

120/80

61
Q

normal o2 stat

A

98 and above

62
Q

what is PROM

A

increases circulations

minimize friction to the skin

63
Q

what is AROM

A

done on the non affected side

64
Q

imbobility/ mobility

A

**know the effects on the body system

65
Q

patient safety/ injury prevention

A

place feet wide apart and one foot in front, rock pelvis out to the side of the patient, grasp the gate belt, put weight of patient as close to your body and slide them to the floor

66
Q

nursing process

A 
ADPIE 
assesment 
diagnosis 
planning 
implementation 
evaluation
67
Q

what is planing for nursing

A

goals:
outcomes:

68
Q

in order to create a nursing diagnosis what details do you need to reference,

A

medical diagnosis or nursing assessment

69
Q

when prioritizing the nursing diagnoses, what goes first your actual or potential

A

potential first then actual

70
Q

what specific conditions would you auscultate them

A

COPD
phneumonia
asthma
CHF

71
Q

review o2 delivery devices

A

nasal cannula

different types of masks

72
Q

risk factors for cardio/ pulmonary illness

A

know what is modifiable and what is not

73
Q

chain of infection

A 
infectious agent 
reservoir 
portal of exit 
portal of entry 
susceptible host 
mode of transmission
74
Q

stages of infection

A

incubation
prodromal
full stage
convalescent period

75
Q

types of nosocomial/ hospital acquired infections

A 
HAIs 
rational of proper hand hygiene 
signs and symptoms of infection 
hyperthermia 
hypothermia

Fundies (1 decks)

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