Fundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of NursingFundamentals of Nursing...
Fundamentals of Nursing
`Closed wound - ANSWER-skin is intact but injury to skin
ex: bruise
4 assessments - ANSWER-focused
initial
emergency
ongoing
5 rights of deligation - ANSWER-1. Right task
2. Right circumstance
3.right person
4. Right direction/communication
5.right supervision
6 components of the infection chain - ANSWER-infectious agent
reservoir
portal of exit
means of transportation
portal of entry
susceptible host
6 factors on the Braden Scale - ANSWER-1. Mobility
2.nutrition
3.friction and shear
4.sensory perception
5.moisture
6.activity
ADPIE - ANSWER-A: assessment
D: diagnosis
P:plan goals/ outcomes
I: implementation
E:evaluate
, Fundamentals of Nursing
airborne - ANSWER-pathogen floats on air and suspended for a extended period of time
airborne precautions - ANSWER-TB, measles, eboli transmission via ventilation systems
Alginates - ANSWER-super absorbent holds 20-40x their weight. require a secondary dressing
Uses: mod-large amount of drainage, wounds with tunneling and infected.
asepsis - ANSWER-cleaning the area of microorganisms
BLACK - ANSWER-necrotic dead tissue, needs to be debrided
blanchable hyperemia - ANSWER-an area that appears red and warm will turn a lighter color with
palpation
clean - ANSWER-not infected
Clean - ANSWER-uninfected
clean contaminated - ANSWER-surgical when in Resp/GI/GU
clean contaminated - ANSWER-surgical wound entering GI/GU/Resp ( increase risj due to the bacteria
we have here)
clean in what order - ANSWER-least contaminated to most contaminated
close system drain - ANSWER-Jackson Pratt, hemovac
both work on negative pressure
cold - ANSWER-inflammation, swell
colonized - ANSWER-microorganisms do not impede healing.
contact precautions - ANSWER-for pathogen that can spread with direct contact
ex: C Diff, impetigo, VRE, MRSA
gowns, shoe covers, equipment for just that patient
contaminated - ANSWER-infected >100,000 bacteria
dehiscence - ANSWER-wound splits open
Diagnosis - ANSWER-analyze and interpret
identify patterns
draw conclusions
formulate diagnostic statement
prioritize problems
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