Test 2 Flashcards

Question

Ileostomy

Answer 1

A stoma placed in the last part of the small intestine called the ileum, which drains fecal effluent that is watery to thick and contains digestive enzymes

Answer 2

-Secure indwelling catheters -Maintaining closed drainage system -Maintaining free flow of urine -Perform routine perineal care daily, after soiling

Answer 3

I-Introduce self, 2 patient identifiers V-Void A-Allergies (latex or soap_ P-Pain and privacy S-Safety (bed rails, wheels locked)

Answer 4

-Encourage self care -Dorsal recumbent positon -Use bath sheet, upper thighs -Non-dominant hand, pull back labia majora -Expose urinary meatus and vaginal orifice -perineum to rectum (outer, outer, inner) -Assess for skin breakdown, discharge, pain -Always front to back

Answer 5

-Encourage self care -Supine or low fowlers -Provide privacy -Retract foreskin if uncircumcised -Meatus outward -Assess for redness and discharge -Penis shaft -Under penis and scrotum -Rinse and dry thoroughly -Return foreskin

Answer 6

Head of the bed raised to an angle of 45 degrees or more; semi sitting position, foot of bed may also be raises at knee Preferred while patient eats. Is used for nasogastric tube insertion and nasogastric tracheal suction. Promotes lung expansion

Answer 7

Head of bead raised approximately 30 degrees: inclination less than Fowler's position: foot of bed may also be raised at knee Promotes lung expansion. Is used when patient receives gastric feeding to reduce regurgitation and risk of aspiration

Answer 8

Entire bed frame tilted with head of bed down Is used for postural drainage. Facilitates venous return in patients with poor peripheral perfusion.

Answer 9

Entire bed frame tilted with foot of bed down. Used infrequently. Promotes gastric emptying. Prevens esophageal reflux

Answer 10

Entire bed frame horizontally parallel with floor Is used for patients with vertebral injuries and in cervical traction; Is used for patients who are hypotensive; Is generally preferred by patients for sleeping

Answer 11

Removes waste from the blood, maintains the body's water balance

Answer 12

Voiding, urination, micturition

Answer 13

-Incontinence is embarrassing -The client is uncomfortable -Skin irritation, infection and pressure ulcers are risks -Falling is a risk because the client may rush to the washroom -The client's pride, dignity, and self-esteem are affected -Good skin care and dry garments and linens are essential

Answer 14

-Before, during and after surgery to keep bladder empty -For clients who are too weak or disabled to use the bedpan, urinal, commode, or toilet -To protect wounds and pressure ulcers from contact with urine -To allow hourly urinary output measurements -As a last resort for incontinence -For certain diagnostic purposes -high infection risk

Answer 15

Refers to the skin being a complete structure, in unimpaired condition

Answer 16

Altered epidermis and/or dermis, destruction of skin layers (dermis), and disruption of skin surface (epidermis)

Answer 17

-Increases the chance of infection, impaired mobility, and decreased function and may result in loss of limb or sometimes life

Answer 18

Epidermis-provides a waterproof barrier and creates our skin tone Dermis-contains tough connective tissue, hair follicles, and sweat glands Subcutaneous layer or hypodermic-fat and connective tissue

Answer 19

-Age -Genetics -General health -Hygiene -Living conditions -Mechanical forces

Answer 20

-Skin diseases -Previous bruising -General skin condition -Skin lesions -Usual healing of sores -Inspection and palpation -Skin color -Temperature -Texture and turgor -Presence of edema -Vascularity -Characteristics of any lesion

Answer 21

Skin eruption that may result from overexposure to sun or moisture from an allergic reaction -If skin is continually scratched inflammation and infection may occur -Wash the area thoroughly and apply antiseptic lotion to prevent further itching and aid in the healing process. Apply warm or cold compresses to relieve inflammation, if indicated

Answer 22

-Flaky, rough texture on exposed areas such as hands, arms, legs or face -Skin may become infected if the epidermal layer is allowed to crack -Bathing should be less frequent, rinsed well -Increase and encourage fluid intake -Use nonallergenic moisturizing cream to perform a protective barrier and keep fluid in -Use creams to cleanse skin that is dry

Answer 23

Inflammatory, papulopustular skin eruptions, usually involving bacterial breakdown of sebum; appears on face, neck, shoulders and back -Infected material within the pustule can spread if the area is squeezed or picked. Permanent scaring can result -Wash hair and skin thoroughly each day with soap and water to remove excess oil and prevent secondary infections -Use cosmetics sparingly -Use prescribed topical or oral antibiotics

Answer 24

-Inflammation of skin characterized by abrupt onset with erythema, pruritus, pain, and appearance of scaly oozing lesions -Often difficult to eliminate because the person is usually in continual contact with the substance causing the skin reaction, and it may be hard to identify this substance -Avoid causative agents

Answer 25

A non contagious, chronic skin condition characterized by an abnormal growth or keratinocytes and an inflammatory reaction that results in the formation of thick, silvery, scaly, inflamed patches of skin; commonly seen on the scalp, knees, elbows and chest -The cause is unknown and there is no cure. It is often difficult to diagnose as it has similar symptoms to eczema and atopic dermatitis -Treatment options are aimed at reducing the extent and severity of the condition and improving quality of life. The patient should avoid trigger agents such as smoking, stress, excessive alcohol, and skin injury

Answer 26

A bacterial skin infection characterized by red sores that can break open, ooze fluid, and develop a yellow-brown crust. The sores can occur anywhere on the body. It is one of the most common skin infections in children. While it can occur in adults, it is more common in children. Impetigo is contagious and can be spread to others through close contact or by sharing linens and clothing. Scratching can also spread sores to other parts of the body -Is cause by one of two kinds of bacteria, strep or staph. It can occur in healthy intact skin, but more often bacteria enter the body when the skin has already been irritated through other skin conditions, such as eczema, poison ivy, insect bites, burns, or cuts Is treated with antibiotics. For mild cases a topical antibiotic is prescribed. For more serious cases oral antibiotics may be prescribed

Answer 27

An illness cause by the enterovirus; manifest as sores or blisters in or on the mouth and on the hands, feet, and sometimes the buttocks and legs. The sores can be painful, and the illness usually lasts approximately 1 week. It is most common in children and most often occurs in the summer or fall -Symptoms may begin with fatigue, a sore throat, or a fever. Within 1-2 days, blisters or sores can appear. The virus spreads easily through coughing and sneezing, or through contact with infected stool or blister fluid -Usually, medical treatment is not required, Interventions are focused on symptom management, which includes offering cool fluids, analgesics, and antipyretics

Answer 28

Scraping or rubbing away of the epidermis that may result in localized bleeding and later weeping of serous fluid -Infection occurs easily because of the loss of this protective skin layer -Caregivers should trim their fingernails and not wear jewelry -clean the area and dry thoroughly and gently -Observe for retained moisture in dressings and bandages, excess moisture can increase the risk of infection -Lift-do not pull-When transferring or repositioning a patient -Consider the use of a lift, as needed, for immobile or heavy patients

Answer 29

A pressure injury develops when blood supply to the skin is cut off for more than 2 to 3 hours. As the skin dies, the bedsore first starts as a red, painful area, which eventually turns purple. Left untreated, the skin can break open and the area can become infected A bedsore can become deep. It can extend into muscle and bone. Once a pressure injury develops, it is often very slow to heal. Depending on the severity of the pressure injury, the person's physical condition, and the presence of other diseases (such as diabetes), pressure injuries can take days, months, or even years to heal. They may need surgery to help the healing process

Answer 30

Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discolouration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discolouration may appear differently in darkly pigmented skin. This injury results from intense or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or it may resolve without tissue loss

Answer 31

Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanch able erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discolouration; these may indicate deep tissue pressure injury

Answer 32

Parital thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum, filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds

Answer 33

Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough, eschar, or both may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are not exposed

Answer 34

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough, eschar, or both may be visible. Epibole, undermining, tunnelling, or a combination of these often occur. Depth varies by anatomical location

Answer 35

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar on th wheel or ischemic limb should not be softened or removed

Answer 36

Assessment tool used to recognize clients at risk for skin breakdown/pressure ulcers Widely used in adult population Based on a number scoring system 6 categories are assessed Total score ranges from 6-23 Lower Braden score indicates higher risk for pressure ulcer development

Answer 37

Sensory perception Moisture Activity Mobility Nutrition Friction and Shear

Answer 38

1-Completely Limited, or limited ability to feel over most of the body 2-Very limited-responds to painful stimuli only, or limited ability to feel over 1/2 of the body 3-Slightly limited-responds to verbal commands but cannot always communicate discomfort or need to be turned, or limited ability to feel pain or discomfort in 1 or 2 extremities 4-No impairment-responds to verbal commands, no limit to feel or voice pain

Answer 39

1-Constantly moist-Skin moist most of the time, dampness detected every time patient is moved 2-Very moist-Skin of often moist (not always), requires linen change-once per shift 3-Occasionally moist-Skin occasionally moist, requires linen change once per day 4-Rarely Moist-Skin usually dry, requires linen change at routine intervals

Answer 40

1-Bedfast-Confined to bed 2-Chairfast-Cannot bear own weight, requires assistance. Ability to walk limited or non-existent 3-Walks occasionally-Spends majority of time in bed/chair. Walks occasionally for short distances with or without assistance 4-Walks frequently-Walks outside room at least 2 times per day, walks in room at least q 2 hours

Answer 41

1-Completely Immobile-No independent changes in position 2-Very limited-Occasional slight changes independently, but requires assistance for frequency significant changes 3-Slightly limited-frequent, slight changes without assist 4-No limitation-Able to make major and frequent position changes without assist

Answer 42

1-Very Poor-Never eats complete meal/rarely more then 1/3, 2 or less proteins per day. NPO, clear liquids, IVs for more then 5 days 2-Probably inadequate-Rarely eats complete meal, approximately 1/2, 3 proteins. Occasionally take dietary supplements. Receives less than optimum liquid diet or tube feeding 3-Adequate-Eats over 1/2 of meals, 4 proteins. Usually takes a supplement, tube feeding or TPN probably meets nutritional needs 4-Excellent-Eats most of every meal, never refuses, 4 or more proteins. Occasionally eats between meals. Does not require supplements

Answer 43

1-Problem-Moderate to maximum asset with moving. Freq likes down in bed/chair. Spasticity, contractures or agitation leads to almost constant friction 2-Potential Problem-Maintains relatively good position in bed/chair most of the time, but occasionally slides down. Moves feebly, requires min assist. Skin probably slides against sheets 3-No apparent problem-Maintains good position in bed/chair/ Moves independently in bed/chair. Sufficient muscle strength to lift completely during move

Answer 44

6-9 Very high risk 10-12 High risk 13-14-Moderate risk 15-18 Low risk 19-23 Not at risk

Answer 45

-Assess client skin at least once per shift -Regular turning/repositioning schedule, reposition frequently -Offload client heels -Use pillows or foam wedges to keep bony prominences from direct contact with each other -Encourage activity when possible -Use pressure redistribution surfaces, ie air mattress -Manage moisture, friction and shear -change briefs ASAP -Use sliding sheets when moving client in bed -Encourage proper nutrition -Position clients in bed at 30 degrees to prevent sliding down in the bed

Answer 46

Redness of the skin due to dilation of the superficial capillaries. When pressure it applied to the skin, the area blanches or turns a lighter color

Answer 47

Redness of the skin due to dilation of the superficial capillaries. The redness persist when pressure is applied to the area, indication tissue damage

Answer 48

Rolled would edges

Answer 49

Redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries. Examples of erythema are nervous blushes and mild sunburn

Answer 50

A scab or dry crust that results from trauma, such as a thermal or chemical burn, infection, or excoriating skin disease

Test 2 Flashcards

(75 cards)