Terms and Knowledge Flashcards
0
Q
A state of being that people define in relation to their own values, personality, and lifestyle.
A
Health
1
Q
Provides science-based, 10-year national objectives for promoting health and preventing disease
A
Healthy People
2
Q
The actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others while adjustments are made as needed to maintain structural integrity and harmony with the environment.
A
Health (as defined by Pender, Murdaugh, and Parsons)
3
Q
A person’s ideas, convictions, and attitudes about health and illness.
A
Health Beliefs
5
Q
Four goals for Healthy People 2020
A
1- Attain high-quality, longer lives free of preventible disease
2- Achieve healthy equity, eliminate disparities, and improve the health of all groups
3- Create social and physical environments that promote good health for all
4- Promote quality of life, healthy development, and healthy behaviors across all life stages
6
Q
Health Model: Addresses the relationship between a person’s beliefs and behaviors.
A
Health Belief Model (Rosenstoch, Becker, and Maiman)
7
Q
Health Model: Directed at increasing a patient’s level of well-being, describes the multidimensional nature of persons as they interact within their environment to pursue health.
A
Health Promotion Model (Pender)
8
Q
Model of Health: Promotes optimal health by considering emotional and spiritual well-being and other dimensions of an individual as important aspects of physical wellness
A
Holistic Health Models
9
Q
Internal Variables Influencing Health, Health Beliefs, and Health Practices
A
Developmental Stage Intellectual Background Perception of Functioning Emotional Factors Spiritual Factors
10
Q
External Variables Influencing Health, Health Beliefs, and Health Practices
A
Family Practices
Socioeconomic Factors
Cultural Background
11
Q
Three components of the Health Belief Model
A
- Individual’s perception of susceptibility to an illness
- Individual’s perception of the seriousness of an illness
- Likelihood that an individual will take preventative action
12
Q
Teaches people how to care for themselves in a healthy way and includes topics such as physical awareness, stress management, and self-responsibility.
A
Wellness Education
13
Q
State of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
A
Health (as defined by WHO)
14
Q
Activities such as routine exercise and good nutrition that help patients maintain or enhance their present levels of health.
A
Health Promotion
15
Q
Immunization programs that protect patients from actual or potential threats to health.
A
Illness prevention
16
Q
When individuals gain from the healthful activities of others without acting themselves.
A
Passive strategies of health Promotion
17
Q
Flouridation of municipal drinking water is an example of:
A
Passive strategies of health promotion
18
Q
Health Model: Attempt to meet patient’s basic needs by prioritizing those needs.
A
Maslow’s Hierarchy of Needs
19
Q
Fortification of homogenized milk with vitamin D is an example of which type of health promotion strategy?
A
Passive strategies of health promotion
20
Q
Individuals motivated to adopt specific health programs
A
Active strategies of health promotion
21
Q
Weight-reduction is an example of which type of health promotion strategy?
A
Active strategy for health promotion
22
Q
Smoking-cessation is an example of which strategy of health promotion?
A
Active strategies of health promotion .
23
Q
True prevention before it precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy.
A
Primary Prevention
24
Q
Type of prevention that focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications of worsening conditions; focuses on prompt intervention to allow patient to return to a normal level of health.
A
Secondary Prevention
25
Smoking cessation to minimize health risks before they happen is an example of which LEVEL of prevention?
Secondary Prevention
26
A health behavior stage in which the patient is not interested in information about the behavior changes and may be defensive
Pre-contemplation
27
Receiving Immunizations is an example of which level of prevention?
Primary Prevention
28
Healthy eating and regular exercise by a healthy individual is an example of which level of prevention?
Primary
29
Risk Factors concerning Health
Genetic and Physiological Factors
Age
Environment
Lifestyle
30
A state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired.
Illness
31
A stage of health behavior change in which ambivalence may be present but patient may accept information as a result of a belief in the value of change.
Contemplation
32
A stage of health behavior change in which the patient has no intention of making a change in the next 6 months.
Pre-contemplation
33
A stage of health behavior change in which a patient believes that advantages outweigh disadvantages of behavior change, but may need assistance in planning to change.
Preparing
34
A stage of health behavior change in which a patient is making small changes in order to make a change in the next month.
Preparation
35
A stage of health behavior change in which previous habits may prevent taking action and the patient identifies barriers and facilitators of change.
Action
36
A stage of health behavior change in which the patient is actively engaged in strategies to change behavior.
Action
37
A stage of health behavior change in which the changes must be integrated into the patient's lifestyle
Maintainence
38
A stage of health behavior changes in which the patient has sustained change over 6 months after beginning and continues indefinitely
Maintenance
39
An illness that is usually reversible, has a short duration and is often severe
Acute illness
40
An illness that persists usually longer than 6 months and is irreversible and affects functioning in one or more systems.
Chronic illness
41
Losing weight to reduce health risks before they happen is an example of which level of prevention?
Secondary Prevention
42
Results from a patient being released from roles, social expectations, or responsibilities.
Illness Behavior
43
A patient's perception of illness and the nature of the illness are: internal or external variables?
Internal
44
A patient's visible symptoms, social group, culture or background related to an illness are: internal or external variables?
External
45
Impact of an illness on the patient and family includes which 5 things?
```
Impact on Body Image
Impact on Self-Concept
Behavioral and Emotional Changes
Impact on Family Roles
Impact on Family Dynamics
```
46
List Maslow's Hierarchy of Needs
- -Physiological (Oxygen, Fluids, Nutrition, Body Temp, Elimination, Shelter, Sex)
- -Safety and Security (Physical safety, Psychological safety)
- -Love and Belonging
- -Self-esteem
- -Self-actualization
47
Illnesses that guide behavioral responses
Illness Behaviors
48
Allopathic Medicine
Conventional western Medicine
49
Therapies used in addition to conventional treatment recommended by the person's health care provider.
Complementary Therapies
50
Five stages of Health Behavior Changes
```
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
```
51
Therapies that become the primary treatment instead of conventional western medicine.
Alternative Therapies
52
Prevention that occurs when a defect or disability is permanent or irreversible and focuses on preventing complications and deterioration.
Tertiary prevention
53
Health education programs is an example of which level of promotion?
Primary
54
A stage of health behavior change in which the patient is considering a change within the next 6 months.
Contemplation
55
A person who uses yoga to ease chronic pain instead of using opioid medications is demonstrating a use of...
Alternative therapy
56
A patient receives monthly massages to help back pain while using medication regularly as well. This is an example of....
Complementary therapy
57
Ayurveda and TCM (Total Chinese Medicine) that are based on different philosophies and whole life systems are examples of....
Whole Medical Systems
58
A free school lunch program is an example of:
Integrative health care program
59
The concept of holistic medicine integrate _____, ______, and ______.
Mind, Body, and Spirit
60
A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.
CAM- Complementary and Alternative Medicine
61
The three Nursing-accessible therapies are...
Relaxation Therapy
Meditation and breathing
Imagery
62
Dietary supplements, macrobiotic diets, and Herbal medicines are examples of....
Biologically Based Therapies (Natural Products)
63
Reiki therapy and Therapeutic Touch are examples of....
Energy Therapies (Use or manipulation of energy fields)
64
Respiratory therapy for a person with COPD is an example of which level of prevention?
Tertiary prevention
65
Massage, chiropractic medicine, and craniosacral therapy are examples of....
Manipulative and body-based methods (Involve movement of body with focus on body structures and systems)
66
Breathwork, biofeedback, and Guided imagery are examples of....
Mind-body interventions (Honor connections between thoughts and physiological functioning using emotion to influence health and well-being)
67
Some physical responses to the relaxation response are...
Arousal reduction
Elongating of Muscle fibers (decrease of muscle tension)
Reducing of neural impulses
Decrease of heart rate, respiratory rate, O2 consump.,& blood pressure
Increase of alpha brain activity
Increase in peripheral skin temperature
68
Limitations of Relaxation Therapy
May increase sensitivity
| Can cause increased fatigue in patients with AIDS or Cancer (Progressive Relaxation)
69
The four components of meditation
- A quiet space
- A comfortable position
- A receptive attitude
- A focus of attention
70
Any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus so the person is able to become more aware of self.
Meditation (Self directed and differs from relaxation because of MINDFULNESS)
71
Clinical application of Meditation
Reduction of hypertensive risk
Less depression, anxiety and distress
Patients with cancer, PTSD, chronic pain, stress
Increases productivity, mood, sense of identity
Lowers irritability
72
Emphasizes the importance of the relationship between practitioner and patient.
Integrative health care
73
Limitations of Meditation
Those who are afraid to lose control
| May become hypersensitive to drugs
74
Clinical applications of Imagery
Controls/Relieves pain in adults and children
Decreases Nightmares/Improves sleep
Helps treat certain chronic diseases
75
Limitations of Imagery
Increased anxiety and fear (PTSD)
| Increased airway constriction (COPD, asthma)
76
Training specific Therapies include:
```
Biofeedback
Therapeutic touch
TCM
Acupuncture
Chiropractic Therapy
Natural products/Herbal Therapies
```
77
Clinical applications of Biofeedback:
Helpful in: stoke recovery, smoking cessation, ADHD, epilepsy, headache disorders, and GI and Urinary disorders
78
Limitations of Biofeedback:
Precautions in psychological or neurological conditions
Repressed emotions/Difficulty coping surface
Sometimes lowers blood pressure and heart rate
79
Clinical Applications of Acupuncture:
Modifies the body's response to pain
Helpful for many types of pain (Lower back pain, myofacial pain, migraines and headaches, osteoarthritis, heel pain, chronic shoulder pain)
80
Limitations of Acupuncture
- Unsterile needles cause complications
- Puncture of internal organs, bleeding, fainting, seizures, and drowsiness
- Infection
81
Therapeutic Touch clinical applications
May help with pain in adults and children
| May help with dementia, trauma, and anxiety during illness
82
Limitations of Therapeutic touch
Sensitivity to human interaction (physically abused/psychiatric disorders)
Pregnant, neonates, cardiovascular, neurological instability, and older patients may be sensitive to re patterning
83
Mycotherapies, Orthomolecular medicine, Probiotics, and the "zone" are examples of....
Biologically Based Therapies (Natural products)
84
Healing touch and Magnet therapy are examples of....
Energy Therapies (Use or manipulation of energy fields)
85
Acupressure and Simple touch are examples of....
Manipulative and Body-based Methods (Involve movement of body with focus on body structures and systems)
86
Acupuncture, Art therapy, Healing intention (prayer), and meditation are examples of....
Mind-body interventions (Honor connections between thoughts and physiological functioning using emotion to influence health and well-being)
87
Music therapy, Psychotherapy, Tai chi, and yoga are examples of...
Mind-Body interventions
88
Dance therapy, Feldenkrais method, and Pilates are examples of....
Movement therapies
89
Ayurvedc medicine, Homeopathic medicine, and Naturopathic medicine are examples of....
Whole Medical systems
90
Use of conscious mind to create mental images to stimulate physical changes in the body
Imagery
91
Self-directed imagery based on the mind-body connection
Creative visualization
92
Use of instruments to self-regulate and voluntarily self-control specific physiological responses
Biofeedback
93
Vital energy flowing through the body in channels
Qi (pronounce chi)
94
System of pathways made up of channels of vital energy
Meridians
95
Specific areas along channels used for acupuncture
Acupoints
96
Therapeutic touch- The five phases
```
Centering
Assessing
Unruffling
Treating
Evaluating
```
97
Restoring structural and functional imbalances and realignment of the spine to allow energy to flow and innate healing of the body to begin.
Chiropractic Therapy
98
Clinical applications of Chiropractic therapy
Improves acute pain and disability in some patients
May reduce low back pain and joint pain (osteoarthritis)
May enhance the effects of conventional treatment in pediatric asthma
Treats headaches, dysmenorrhea, vertigo, tinnitus, and visual disorders
99
The most important concept of Chinese medicine is:
Yin (Cool)
| Yang (Hot)
100
A whole medicine system that includes moxibustion, cupping, tai chi, qi gong, and acupuncture.
TCM- Total Chinese medicine
101
Clinical applications of Chinese Medicine
Some evidence shoes helpfulness in treating fibromyalgia and reducing pain and spasticity in children with Cerebral Palsy
102
Limitations of Chinese Medicine
Not regulated in most states (acupuncture is)
Herbs, teas, remedies and supplements are not regulated by the FDA
Labels may be inconclusive and products may be potent causing complications- Always ask about use of ALL OTC medicines including herbs.
103
Clinical Applications of Herbal therapy
Cranberry supplements help prevent UTIs
Chamomile promotes sleep and relaxation and helps treat minor GI disturbances and pre-menstrual problems
Many herbs are safe and beneficial
104
Limitations of Herbal Therapy
Not regulated by FDA and no safe limits established
May contain toxic products linked to cancer
May be contraindicated with other medications
105
Which of these herbs are safe for use?
1. Life root
2. Comfrey
3. Ginger
4. Garlic
5. Saw palmetto
6. Licorice
3. Ginger
4. Garlic
5. Saw palmetto
6. Licorice
106
Which of these herbs are safe for use?
1. Aloe
2. Echinacea
3. Coltsfoot
4. Ginseng
5. Valerian
6. Pokeweed
1. Aloe
2. Echinacea
4. Ginseng
5. Valerian
107
Limitations of chiropractic therapy
Cannot treat bone and joint infections
Contraindicated in: acute myelopathy, fractures, dislocations, rheumatoid arthritis, and osteoporosis
Includes risk of injury
108
Top layer of the skin
Epidermis
109
A state of generalized decreased cognitive, physiological and behavioral arousal
Relaxation Response
110
Inner layer of the skin that provides tensile strength and mechanical support
Dermis
111
A tough, fibrous protein
Collagen
112
Localized injury to the skin and underlying tissue over a bony prominence.
Pressure Ulcer
113
Occurs when normal red tones of the light skinned patient is absent
Blanching
114
Three pressure-related factors that contribute to pressure ulcer development:
1. Pressure intensity
2. Pressure duration
3. Tissue tolerance
115
Hyperemia
Redness
116
Blanching hyperemia
Redness or erythema that blanches and then the redness returns
117
Sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary.
Shear
118
Which of these are Safe Herbs to use:
1. Chamomile
2. Feverfew
3. Calamus
4. Gingko biloba
5. Chaparral
6. Ephedra
1. Chamomile
2. Feverfew
4. Gingko biloba
119
A non-blanchable redness of intact skin
Stage 1 pressure ulcer
120
6 Risk factors that contribute to pressure ulcer development
```
Impaired Sensory Perception
Impaired Mobility
Alteration in Level of Consciousness
Shear
Friction
Moisture
```
121
Partial-thickness skin loss or blister
Stage 2 pressure ulcer
122
Full-thickness skin loss with visible fat
Stage 3 pressure ulcer
123
Full-thickness Tissue loss with muscle and/or bone visible
Stage 4 pressure ulcer
124
Full thickness skin or tissue loss with unknown depth
Unstageable/Unclassified pressure ulcer
125
A purple or maroon localized area of discolored intact skin OR blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear.
Suspected Deep Tissue Injury (sDTI)
126
Assessment of a pressure ulcer includes: ________ of ulcer, ______ involvement (staging), type and approximate _______ of tissue in wound bed, wound ________, _______ description, and _______ of surrounding skin.
Depth, Tissue, percentage, dimensions, exudate, condition
127
What is the correct intervention concerning a pressure ulcer covered with necrotic tissue?
Debride necrotic tissue in order to assess and stage the ulcer (will be stage 3 or 4)
128
A pressure ulcer presents as a red nonblanchable area on the patient's sacrum. The skin is discolored, intact, warm, with localized edema. What stage is this ulcer?
Stage 1
129
A patient has an intact serosangineous filled blister. What stage is this pressure ulcer?
Stage 2
130
The patient has a shallow ulcer with a red-pink wound bed. There is no slough preset and is only affecting the dermis. What stage is this ulcer?
Stage 2
131
A patient has an ulcer with no slough present. The wound is shallow and there is subcutaneous fat visible. What stage is this ulcer?
Stage 3
132
The patient has a deep pressure ulcer with subcutaneous fat visible. There is slough present. What stage is this ulcer?
Stage 3
133
The patient has a shallow ulcer on the bridge of the nose due to glasses wear. The bone is visible and there is slough present. What stage is this ulcer?
Stage 4
134
The patient has a large ulcer in the sacral area. Tendons are visible and eschar is present. There is deep tunneling and undermining present. What stage is this ulcer?
Stage 4
135
The patient has an open ulcer on the heel. It is completely black with no slough present. What stage is this ulcer?
Unstageable
136
A patient has a large ulcer on the sacral area. Although the area is covered with slough, you guess that the ulcer is probably deep with tunneling. Which stage is this ulcer?
Unstageable (until you remove the slough and assess more thoroughly)
137
A patient has an area of deep purple intact skin. The area is warmer than the adjacent skin. What stage is this ulcer?
sDTI
138
The patient has intact skin over a cool, dark-red area. What stage is this ulcer.
sDTI
139
Red, moist tissue composed of new blood vessels, presence indicates direction towards healing.
Granulation Tissue
140
Soft, yellow or white tissue that is stringy and attached to the wound bed.
Slough
141
Black or brown necrotic tissue
Eschar
142
Describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. May indicate presence of infection.
Exudate
143
Describe Primary Intention, its causes, and the healing process:
1. Wound that is closed- minimal tissue loss
2. Surgical incision- wound is sutured or stapled
3. Healed by epithelialization- heals quickly, minimal scarring
144
Describe Secondary Intention, its causes, and its healing process:
1. Wound edges not approximated
2. Pressure ulcers, burns, and surgical wounds with tissue loss
3. Wound heals by granulation, wound contraction, then epithelialization- Scarring present
145
Describe Tertiary Intention, its causes, and its healing process:
1. Wound left open for several days, then closed (approximated)
2. Wounds that are contaminated and require observation for infection
3. Closure of wound delayed until risk of infection is resolved.
146
Three stages of healing in Partial-Thickness wound repair:
Inflammatory Response
Epithelial Proliferation and Migration
Reestablishment of the Epidermal layers
147
Four phases to Full-thickness wound repair:
Hemostasis
Inflammatory
Proliferative
Remodeling
148
Healing Phase: A series of events designed to control blood loss, establish bacterial control, and seal the defect that occurs when there is an injury
Hemostasis
149
Healing Phase: Clots form a fibrin matrix, blood vessels constrict, and platelets gather to stop bleeding.
Hemostasis
150
Healing Stage: Involves WBCs that clean the wound and promote collagen formation.
Inflammatory Phase
151
Healing Phase: Vasodilation of capillaries causes redness, warmth, throbbing and edema as the body secretes histamine.
Inflammatory
152
Healing Phase: Begins with appearance of new blood vessels, the wound fills with granulation tissue and collagen, and the surface is repaired by epithelialization.
Proliferative stage
153
Healing Phase: Collagen scar continues to reorganize and gain strength. May last up to a year.
Remodeling
154
List the Four complications with wound healing:
Hemorrhage
Infection
Dehiscence
Evisceration
155
Bleeding from the wound site that occurs internally or externally occurring after hemostasis stage.
Hemorrhage
156
Hemorrhage may indicate....
Slipped surgical suture
Dislodged clot
Infection
Erosion of blood vessel by a foreign object (drain)
157
Localized collection of blood underneath the tissues.
Hematoma (very dangerous near major artery/vein)
158
A wound is infected if _________ __________is present.
Purulent Drainage
159
A patient has an infection of a surgical wound. What assessment data might you suspect to see?
- Fever
- Tenderness and pain of wound site
- Elevated WBC count
- Edges of wound inflamed
- Odorous, purulent drainage (yellow, green, or brown)
160
Serous drainage appearance:
Clear, water plasma
161
Purulent drainage appearance:
Thick, yellow, green, tan or brown
162
Serosanguineous drainage appearance:
Pale, pink, watery, mixture of clear and red fluid.
163
Sanguineous drainage appearance:
bright red, indicates active bleeding
164
A partial or total separation of wound layers.
Dehiscence
165
Identify patients at risk for Dehiscence
OBESITY
Poor nutrition
Infection
Recent abdominal wound
166
If a wound has a sudden increase in serosanguineous drainage, you should be alert for...
Dehiscence
167
A total separation of wound layers with protrusion of visceral organs through the wound opening.
Evisceration
168
What are the correct interventions for evisceration?
- Place sterile saline-soaked towels over protruding organs (to prevent bacterial infection and drying of tissues)
- Immediately contact the surgical team
- Do not allow the patient anything by mouth (NPO)
- Observe the patient for signs and symptoms of shock
- Prepare the patient for emergency surgery
169
What are the six assessment categories used on the Braden Scale?
1. Sensory perception (ability to respond to pressure)
2. Moisture (degree to which skin is exposed to moisture)
3. Activity (Amount of physical activity)
4. Mobility (Ability to change body position)
5. Nutrition (Quality of food intake)
6. Friction and Shear (amount of shear movement)
170
Briefly describe the Braden Scale:
An assessment tool used to determine a patient's risk for impaired skin integrity. Scores range from 6-23, Lower scores equal higher risk. (Score of 18 is considered cutoff for risk of pressure ulcer onset)
171
List the Five factors that influence pressure ulcer formation:
```
Nutrition
Tissue Perfusion
Infection
Age
Psychosocial impact of wounds
```
172
A patient who has undergone surgery and is well-nourished requires at least ______ calories/day
1500
173
What are the four most important nutritional factors for wound healing?
Calories
Protein
Vitamin C
Vitamin A
174
What are good sources of protein to promote wound healing?
Poultry
Fish
Eggs
Beef
175
What are good sources of Vitamin C to promote good wound healing?
Citrus Fruits
Tomatoes
Potatoes
Fortified Fruit Juices
176
What are good Sources of Vitamin A to promote optimal wound healing?
```
Green leafy veggies (spinach)
Broccoli
Carrots
Sweet Potatoes
Liver
```
177
Best measure for nutritional status is:
Prealbumin
178
What factors do you Assess when identifying a patient at risk for pressure ulcer formation? (5)
```
Using appropriate Predictive measures (ex. Braden Scale)
Mobility
Nutritional Status
Body Fluids
Pain
```
179
What patients are at risk for pressure ulcer formation?
- Neurologically impaired patients
- Chronically ill patients in long-term care
- Patients with diminished mental status
- Patients in ICU, oncology, hospice, or orthopedic patients
180
When you note hyperemia, what do you document (3 things)
Location
Size
Color
**Reassess in 1 hour
181
When you suspect abnormal reactive hyperemia, what do you do?
Outline the area with a marker to make reassessment easier.
182
Which of these bodily fluids carry the Highest risk for skin breakdown? Select all that apply:
1. Bile
2. Saliva
3. Urine
4. Gastric drainage
5. Ascitic fluid
6. Pancreatic drainage
4. gastric drainage
| 6. Pancreatic drainage
183
A superficial, partial-thickness wound with little bleeding.
Abrasion
184
A patient has a "weepy" shallow wound. You know this is...
An abrasion
185
A more serious wound that bleeds profusely (depending on depth and location)
Laceration
186
A wound in which the skin is pierced with an object- internal bleeding is a risk.
Puncture wound
187
A tetanus injection may be necessary for a patient with a dirty wound and who has not had one in ___ years.
5
188
If you anticipate the removal of a dressing to be painful, you should....
Consider giving analgesic at least 30 minutes prior
189
You should not the _____, _____, ______, and ________ of wound drainage.
Amount, Color, Odor, Consistency
190
___ g of drainage weighed is usually equal to ____ mL of volume.
1, 1
191
Four items to assess concerning Drains include:
Number of drains
Drain placement
Character of drainage
Condition of collecting equipment
192
A sudden decrease in drainage through the tubing may indicate...
A blocked drain- notify health care provider
193
Is a frequent skin closure and provides more strength than nylon or silk sutures.
Staple (stainless-steel)
194
Edema is normal around sutures for the first ___ to ___ days.
2-3
| *Continued swelling indicates too-tight sutures
195
A tissue adhesive that forms a strong bond across apposed wound edges, allowing normal healing to occur below.
Dermabond
196
Extreme tenderness upon palpating a wound edge indicates....
Infection
197
If drainage occurs when palpating a wound area, you should....
Note the character of the drainage
198
If you detect purulent or suspicious-looking drainage, you should...
Obtain a specimen of the drainage for culture.
199
When obtaining a wound specimen for a culture, you should...
Clean the wound first with normal saline
Use a method of specimen collection according to agency policy
Know that tissue biopsy is the best method.
200
When choosing a nursing diagnosis related to normal wound healing, you should choose diagnosis that...
relate to risk-factors that could impair healing
| impaired nutrition, ineffective tissue profusion, pain
201
In the event of an acute wound, what is the priority?
Immediate Intervention
202
In the event of a chronic wound, what is the priority?
Patient's hygeine.
203
In the even of a risk for pressure ulcer development, what are the nursing priorities?
-Preventative interventions (skin care, elimination of shear, and positioning)
204
Three major nursing interventions for prevention of pressure ulcers are:
1. Skin care and management of Incontinence
2. Mechanical loading and support devices (proper positioning and therapeutic surfaces)
3. Education
205
When cleaning the skin related to pressure ulcer prevention, you should...
- Avoid soap and hot water
- Use cleaners with nonionic surfactants
- Completely dry skin
- Apply moisturizer (do not oversaturate)
- Apply thick layer of barrier cream if needed
206
Positioning to prevent pressure ulcer formation includes...
- Raising the bed to 30degrees or LESS
- Repositioning at least every 2 hours (if allowed by condition)
- A 30-degree lateral position is optimal to avoid pressure on bony prominences
- Limit sitting time to 2 hours or less- instruct patient to shift position every 15 minutes
- Avoid donut and rigid cushions and use foam, gel, or air cushions instead.
207
List the principles to address to maintain a healthy wound environment: (6)
```
Prevent and manage infection
Clean the wound
Remove nonviable tissue
Manage exudate
Maintain the wound in a moist environment
Protect the wound
```
208
Acute wounds require monitoring every ___ hours.
8
209
Dakin's solution, acetic acid, hydrogen peroxide, and povidone-iodine are cytotoxic solutions and should....
NOT be used in clean, granulating wounds
210
Removal of nonviable, necrotic tissue
Debridement
211
When debriding a wound, normal observations include increase in ___, ___, and ___.
Exudate, odor, size
212
____ _____ may be necessary when you debride a wound.
Pain Management
213
Three purposes of debridement:
1. Rid the wound of infection
2. Enable visualization of wound bed
3. Provide a clean wound base- necessary for healing
214
Four methods of debridement:
Mechanical
Autolytic
Chemical
Surgical-removal
215
Wet to dry saline gauze dressing is an example of which type of debridement?
Mechanical
| *never use on wounds with granulation tissue
216
Placing synthetic dressings over a wound to allow the eschar to self-digest (due to enzymes present in the wound fluids) is an example of which type of debridement?
Autolytic
217
Use of Dakin's solution or sterile maggots to reduce necrotic tissue are examples of which type of debridement?
Chemical
218
Removal of devitalized tissue by scalpel, scissors, or other sharp instruments is an example of which type of debridement?
Surgical
* Quickest
* when patient has signs of cellulitis or sepsis
219
A patient can lose as much as ___ g of protein a day from an open, weeping pressure ulcer.
50
220
Recommended protein intake of ____ g/kg/day is necessary for wound healing.
1.8
221
Low hemoglobin levels decrease delivery of oxygen to tissues and lead to ischemia. It is therefore important to maintain hemoglobin levels at ____g/100mL
12
| *Can give iron supplement to help
222
First aid for Wounds includes: (4)
1. Stabilizing cardiopulmonary function
2. Promoting hemostasis
3. Cleaning the wound
4. Protect from further injury
223
When concerning a wound healing by primary intention, the dressing should be removed...
when drainage stops
224
Concerning a wound healing of secondary intention, the dressing should...
remain in place to promote a moist environment to the wound for healing.
225
List the 7 purposes of dressings:
Protect wound from microorganism contamination
Aids in hemostasis
Promotes healing by absorbing drainage and debriding
Supports or splints the wound site
Protects patients from seeing the wound
Promotes thermal insulation of the wound surface
Provides a moist environment
226
Factors that affect tissue tolerance:
Nutrition
Age
Hydration
Low BP
227
Factors that impair wound healing:
Age
Anemia
Low protein
Low zinc
228
You should allow a wound to bleed freely when....
There is a risk for infection (Dog bite, dirty wound)
229
What types of dressings are appropriate for a stage 1 ulcer?
None
Transparent
Hydrocolloid
230
What types of dressing are appropriate for a clean stage 2 ulcer?
Composite film
Hydrocolloid
Hydrogel
231
What types of dressings are appropriate for a clean stage 3 ulcer?
```
Hydrocolloid
Hydrogel (with foam)
Calcium Alginate
Gauze
Growth Factors (with gauze)
```
232
What types of dressings are appropriate for a clean stage 4 ulcer?
Hydrogen (with foam)
Calcium Alginate
Gauze
Growth factors (with gauze)
233
What types of dressings are appropriate for an eschar covered unstageable ulcer?
Adherent film
Gauze plus ordered solution
Enzymes
None (Heel ulcer w/ eschar)
234
List the 6 advantages of a Transparent film dressing:
1. Adheres to undamaged skin
2. Serves as a barrier to external fluids and bacteria while allowing wound surface to breath
3. Promotes a moist environment that speed epithelial cell growth
4. Can be removed without damaging underlying tissue
5. Permits viewing of t he wound
6. Does not require secondary derssing
235
What types of wounds are transparent dressings ideal for?
small superficial wounds (partial-thickness wounds) OR to protect high risk skin
236
What are the functions of a hydrocolloid dressing? (7)
1. Absorbs drainage through use of exudate absorbers in the dressing
2. Maintains moisture
3. Slowly liquifies necrotic debris
4. Is impermeable to bacteria and other contaminants
5. Is self-adhesive and molds well
6. Acts as a preventive dressing for high-risk friction areas
7. May be left in place for 3-5 days, minimizing trauma of skin healing
237
Hydrocolloid dressings are best on which types of wounds?
Granulating wounds
Autolytically debrided necrotic wounds
Shallow to moderately deep dermal ulcers
238
Hydrocolloid dressings are contraindicated in which types of wounds?
Heavily draining wounds
Full-thickness wounds
Infected wounds
239
List the four advantages of hydrogel dressings:
- Soothing, can reduce wound pain
- Provides a moist environment
- Debrides necrotic tissue (softens the tissue)
- Does not adhere to the wound base and is easy to remove
240
Hydrogel dressings are best for which types of wounds?
```
Partial-thickness or full-thickness wounds
Deep wounds with SOME exudate
Necrotic wounds
Burns
Radiation damage to skin
```
241
Alginate dressings are best for which types of wounds?
Wounds with large amounts of exudate
| **DO not use in dry wounds!
242
Foam dressings are best used in which type of wounds?
Wounds with large amounts of exudate
| Around drainage tubes to absorb drainage
243
Functions of bandage and binders (5):
1. Create pressure
2. Immobilize body part and/or support a wound
3. Reduce or prevent edema
4. Secure a splint
5. Secure dressings
244
List the guidelines to follow during a dressing change (4):
- Asses the skin beneath the tape
- Perform hand hygiene before and after care
- Wearing sterile gloves before directly touching a fresh or open wound
- Removing or changing dressings over closed wounds when they become wet, as ordered or if S/S of infection are present
245
Summarize the principles of packing a wound (4):
- Assess size and depth and shape: determines type of dressing used
- Entire wound must be in contact with part of the moist gauze dressing
- Don't pack too tightly- causes pressure
- Should not overlap wound edges
246
Activation of negative pressure of a wound through suction to facilitate healing and collect wound fluids. Worn 24hours- 5days
NPWT- Negative pressure wound therapy (Wound Vacuum-assisted closure device)
247
Heat applications cause which physiological responses?
- Reduces edema by vasodilation
- Reduces blood viscosity
- Reduced muscle tension
- Increased tissue metabolism
- Increased capillary permeability
248
Cold applications cause which physiological responses?
- Vasoconstriction
- Local anesthesia
- Reduced cell metabolism
- Increased blood viscosity
- Decreased muscle tension
249
Before applying hot or cold therapies....
Assess the patient's physical condition for signs of potential tolerance to heat and cold.
250
Cold therapies are contraindicated in....
```
Impaired skin integrity
Neuropathy
Edema
Impaired circulation
Shivering
```
251
Heat therapies are contraindicated in....
Impaired skin integrity
Neuropathy
Active areas of bleeding
Acute localized inflammation (Appendicitis)
Cardiovascular problems (do not put heat on large portions of the body)
252
True or False: A health care provider's order needs to be obtained before removing a bandage applied by a health care provider.
True
253
If a patient has peripheral disease, ensure you assess the __________ before applying heat or cold therapies
Extremities
254
If a patient has an order for a heat or cold therapy to the legs and has poor circulation to the area, you should...
Question the order
256
If a patient has a decreased Level of Consciousness and is receiving a hot or cold therapy, you should....
Assess skin integrity frequently during therapy
257
Pain occurs during heat and cold therapies when the temperature is less than ______*F or greater than _______*F
59, 113
258
Heat therapies should not be applied for longer than _______.
1 hour
259
True or False: The patient should adjust the temperature of the cold or heat therapy as needed.
False
260
A type of warm therapy that improves circulation, relieves edema, and promotes consolidation of purulent drainage.
Warm, moist compress
261
A type of warm therapy that promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution.
Warm soaks
262
A type of warm therapy for a patient who has recently had rectal surgery, episiotomy, painful hemorrhoids, or vaginal inflammation (such as pregnancy).
Sitz bath
263
A warm therapy that uses a prepared disposable pack to apply dry heat to an injured area
Commercial hot packs
264
A cold therapy that applies cold for 20 minutes to relieve inflammation and swelling.
Cold, moist, and dry compresses
265
A type of cold therapy which uses water at a temperature of 59*F
Cold soaks
266
A cold therapy used for patients who have a muscle sprain, localized hemorrhage, hematoma, or has undergone dental surgery. Prevents edema formation, controls bleeding, and anesthetizes the body part.
Ice bag or collar
267
When a patient has a binder applied, it is important to assess the skin every ___ hours.
2
