NR 351 Week 4 / NR351 Exam 4 Exam with answers - Wagner College (A grade) ( Download 100% Correct and Reliable Questions and Answer)

NR 351 Week 4 Exam with answers - Wagner College (A grade) NR 351 Exam 4 Chapter 30 Hygiene- measure of personal cleanliness Factors affecting it: culture, economic class, spiritual practice, health state Assessing the Skin • Head-to-toe sequence • Compare bilateral for symmetry • What to consider? • Cleanliness, color, temperature, turgor, moisture, sensation, vascularity, evidence of lesions (ABCDE) Assessment of Oral Cavity • Lips- color/moisture • Buccal mucosa- color/nodules/bleeding • Color and surface of gums • Teeth- loose/missing/dentures (if they fit well) • Hard & soft palate- intact/patches • Oropharynx- movement of uvula (grading of tonsils) • Halitosis/bad taste in mouth • BOHSE- brief oral health status exam • Observe for oral problems- dental caries (cavities), gingivitis, periodontal disease • Mouth breathers/comatose patients Oral Hygiene • Moistening/cleaning the mouth • Caring for dentures- remove when sleeping; wear gloves when cleaning • Using mouthwashes- for children must contain fluoride Early Morning Care • Assist patient with toileting • Provide comfort measures • Wash face and hands • Provide mouth care Morning Care (AM care) *after breakfast unless patient wants it done first • Toileting • Oral care • Bathing • Back massage/ special skin measures • Hair care/cosmetics/dressing • Position for comfort • Refresh or change bed linens/tidying up bedside Afternoon Care (PM care) *ensure patients comfort after lunch • Offer assistance with toileting, hand washing, oral care • Straighten bed linens • Help patient with mobility to reposition self Hours of Sleep Care (HS care) *before patient goes to bed • Offer assistance with toileting, washing and oral care • Offer back massage • Change any soiled linens • Position patient comfortably • Ensure call light or any other objects are in reach As Needed Care (PRN care) • Offer individual hygiene as needed • Change clothing and bed linens to diaphoretic patients • Provide oral care every 2 hours as needed Back Massages • Act as body conditioners to relieve tension and promote relaxation • Also allows nurse to observe skin for signs of breakdown • Improves circulation and sleep quality Bathing • Same as back massages • Musculoskeletal exercise • Helps improve self image • Strengthens nurse-patient relationship- give patient a level of participation (independence) Bed Bath • Provide articles needed on bed table/ provide privacy • Remove top linens and replace with bath blanket • Eye care • Clean from inner to outer with warm compress • Use artificial tear solution or saline every 4 hours if no blink reflex • Care for eyeglasses, contact lens, artificial eye • Ear and nose care • Wash external ear with washcloth; check hearing aid battery (whistling sound on HIGH) • Have patient blow nose; remove crust around nose with warm compress • Hair care • Groom and shampoo hair; care for beards and mustaches; remove unwanted hair • Treat any lice (pediculosis) and ticks • Nail and foot care • Assess color, shape, intactness and cleanliness • Massage feet, provide diabetic foot care • Avoid knee high socks/crossing knees; prop feet up several x a day • Perineal and vaginal care • Perform assessment of genitalia and perform care • Cleanse vaginal area with plain soap and water (pubic anal) • Sitz bath- soak perineal and anal areas • Piercings • Aftercare; avoid alcohol, peroxide, ointments • Oral piercings- avoid tobacco, use alcohol-free mouthwash Bedside Safety (medical asepsis) • Bed in its lowest position; safe for patient • Make sure bed controls are functioning (call light and other electrical equipment) • Walk space is uncluttered; side rails are raised if indicated; wheels locked Chapter 31 Functions of Skin (first line of defense) • Protection; body temperature regulation; vitamin D production; absorption • Epidermis, dermis, subcutaneous • Children younger than 2 thinner and weaker skin; mucous membranes are easily injured and subject to infection • Older children increasingly resistant to injury and infection • Aging people skin loses elasticity, folds and sags; thin, dry and wrinkled; circulation and collagen formation are impaired • Nourished and hydrated body cells are resistant to injury; adequate circulation is necessary • Very thin and very obese people are more susceptible to skin injury • Excessive perspiration predisposes skin to breakdown • Jaundice causes yellowish, itchy skin • Eczema and psoriasis may cause lesions that require special care Types of Wounds • Intentional/unintentional; open/closed; acute/chronic; 4 stages of ulcers • Primary- edges match up • Secondary- burns/stabbing; uneven edges • Tertiary- delayed primary closure; left open before fully closed • Wound Healing: • Hand hygiene; adequate blood supply; free of foreign material Phases of Wound Healing • Hemostasis • Occurs immediately after injury; involved blood vessels constrict and clotting begins • Exudate is formed, causing swelling and pain; results in heat and redness • Platelets stimulate other cells to migrate to injury to help heal • Inflammatory (sometimes includes hemostatis) • Lasts 4-6 days • WBC move to the wound; macrophages enter wound • They ingest debris and attract fibroblasts to fill wound • Patient has body response (fever, increase in wbc) • Proliferation • Begins within 2-3 days of injury; may last 2-3 weeks • New tissue is built to fill wound space from fibroblasts • Capillaries and thin layer of epithelial cells form across wound • Granulation tissue forms foundation for scar tissue • Secondary wounds take longer in this stage • Maturation • Final stage of healing; begins 3 weeks-6 months after injury • Collagen is remodeled; new collagen tissue is deposited • Scar becomes flat, white line Factors Affecting Wound Healing (causing delay) • Desiccation: (dehydration) crust • Maceration: (over hydration) occurs with incontinence • Trauma- repeated injury • Edema / Infection (bacteria in wound) • Necrosis: death of tissue • Presence of biofilm: thick grouping of microorganisms Wound Complications • Infection / Hemorrhage • Dehiscence- partial or total separation of skin; muscle or adipose showing • Evisceration- when wound completely separates and intestines come through; usually occurs within day 4-5; use saline and treat as an emergency • Purulent- pus discharge • Hematoma- internal hemorrhage Pressure Ulcers • Occurs because of aging skin, immobility, fecal/urinary incontinence • External pressure compressing blood vessels • Friction (2 forces rubbing together- no pressure) or shearing (sliding down- gravity causing problem) forces tearing or injuring blood vessels • Stages • 1: nonblanchable of intact skin • 2: partial thickness skin loss • 3: full thickness skin loss; involving subcutaneous • 4: full thickness skin loss involving underlying bone • Unstageable: base of ulcer covered by slough and/or eschar (black leathery cover that must be removed- possibly surgically) • DTI: deep tissue injuries: look purple/red; can turn into a stage 4 • Measurement • Size of wound: drawing shape; describe in own words • Depth of wound: used with cotton tip to measure • Presence of: • Undermining- skin surface may be open underneath; test around edges to see if skin protrudes; determine direction • Tunneling- underneath skin or advances under skin deeper than what you’re seeing • Sinus tract- similar to tunneling but more advanced • Assessment • Braden scale • PUSH tool for existing pressure ulcers Wound Assessment • Sight/smell • Infection: swollen, deep red in color, hot on palpation, drainage has increased or may be purulent, foul odor, wound edges may be separated • Drainage • Serous- clear, watery, portion of blood • Sanguineous- large amount of RBC; bright red • Serosanguineous- pink, mixture of sero/sang • Purulent- WBC, liquid dead tissue; foul odor; dark yellow or green Cleaning Pressure Ulcer • Clean with each dressing change; use gentle motions and use 0.9% saline solution • Purpose of Dressings: • Provide comfort and prevent or eliminate infection • Absorb drainage or necrotic tissue • Protect wound from further injury Debridement • Removal of devitalized tissue and foreign material • Autolytic- uses occlusive dressings and uses own body’s way of healing and liquefy necrotic tissue • Biosurgical- sterile fly larvae secrete an enzyme that liquefies dead tissue; ingest by larvae; cleaning the wound • Enzymatic- involves application of commercial enzymes speeding the body’s autolytic process • Mechanical- external force to dislodge and remove debris Types of Bandages • Roller bandages; circular turn, spiral turn, figure of eight turn, recurrent-stump bandage • Telfa, gauze dressings, transparent dressings (clear) Types of Binders (holds things in) • Straight: used for chest and abdomen • T-binder: used for rectum, perineum and groin area • Sling: used to support an arm Types of Drainage Systems • Open systems- greater to lesser pressure • Penrose Drain- safety pin holds it in to drain • Closed systems- sutured to skin and comes out • Jackson-Pratt drain- bulb giving suction • Hemovac drain Color Classification for Open Wounds • R: red protect • Y: yellow cleanse • B: black debride • Mixed wound: contains components of any of these; treat according to worst color Applying Heat • Dilates peripheral blood vessels; increases vasodilation • Helps relieve pain; promotes healing • Devices: • Hot water bags/bottles • Electric heating pads • Sitz bath- medical solution Applying Cold • Increases vasoconstriction; reduces muscle spasms; decreases edema • Promotes comfort; control of bleeding • Apply for 30 min; Remove 1 hour • Devices: • Ice bags • Hypothermia blankets- mat that adjusts temperature • Cold compresses- neck pain/headaches Chapter 32 • Hematopoeisis- essential function of skeletal system; produces blood cells • Long bone upper and lower extremities • Short bones wrist and ankle • Flat bones ribs and skull bones • Irregular bones spinal column and jaw; and other bones not listed Joint Movements • Abduction- away from body • Adduction- towards body • Circumduction- circular movement of limb • Flexion- bend • Extension- stretch; hyperextension-over stretching • Dorsiflexion- backward bending of foot • Plantar flexion- foot flexion • Rotation- turning on axis internal and external • Supination- laying on back, palms upward • Pronation- laying on abdomen, palms down • Inversion- inward foot sole • Eversion- outward foot sole Types of Joints • Ball-and-socket shoulder/hip; Condyloid shallow; Gliding flat/carpal bones; Hingeelbow, knee/ankle; Pivot radius, ulnar; Saddle thumb Muscles • Skeletal- tendon/bones • Cardiac- forms heart contractions of heartbeat • Smooth or visceral- walls of hollow organs; blood vessels and internal organs • Maintenance of posture • Immobility- inability to move Afferent nervous system conveys information to CNS Efferent nervous system conveys response from the CNS to skeletal muscles via the somatic nervous system Postural Reflexes • Labyrinthe sense- sensory organs in inner ear; position, orientating movement • Proprioceptor/kinesthetic sense- informs brain of location of a limb as a result of joint movement • Visual/optic reflex- posture alerting person of spatial relationships • Extensor/stretch reflex- reflex contraction that aids person with position when overstretching Isotonic- muscle shortening and active movement; jogging, swimming, walking Isometric- muscle contraction without shortening; plank, kegels Isokinetic- muscle contraction with resistance; lifting weights Benefits • Cardiovascular- improved efficiency of heart; increased fibrinolysin (breaks up clots) • Respiratory- decreased work of breathing; improved alveolar ventilation • Musculoskeletal- increased muscle efficiency and flexibility; reduced bone loss Positioning • Fowler’s position- 45-60 degrees; supports cardiac function; pressure ulcer risk (check heels and ears as well) • Supine or dorsal recumbent position- laying down • Side-lying or lateral position- or oblique could be used • Prone position- on abdomen, head turned to side; can be uncomfortable Chapter 33 • Reticular activating system (RAS)- controls brain activites related to state of alertness • Bulbar synchronizing region- located in pons; releases serotonin • Hypothalamus- control center for sleeping and waking • Non-rapid eye movement (NREM) 4 stages • 1 transitional stage between wakefulness and sleep • 2person falls into stage of sleep where they can be aroused with ease • ¾ depth of sleep increases; arousal becomes increasingly difficult • Rapid eye movement (REM) • Sleep apnea and dreaming in this period • 1, 2, 3, 4, 3, 2, REM; if awoken goes back to start at stage 1 • Infant- 14-20 hours a day • Growing children- 10-14 hours a day • Adult- 7-9 hours a day Sleep Disorders • Dyssomnias- insomnia or excessive sleeping • Insomnia, hyper insomnia, narcolepsy, sleep apnea, restless leg syndrome, sleep deprivation • Pharmacologic therapy sedatives and hypnotics • Non-pharmacologic therapy monitor and help without use of medicine • Parasomnias- patterns of waking behavior that appear during sleep • Somnambulism, REM behavior disorder, sleep terrors, nightmares, bruxism (teeth grinding), enuresis (bed wetting), sleep related eating disorder Chapter 34 **Pain is very subjective **Pain should be 5th vital sign Acute pain- rapid onset; varies in intensity and duration ex/ surgical pain Chronic pain- lasts beyond normal healing period; interferes with normal functioning; periods of remission and exacerbation; ex/ cancer pain and RA • Figure out location and cause (etiology) Sources of Pain • Cutaneous- skin • Somatic- tendons/ligaments/bones/nerves • Visceral- poorly localized/ originates in body organs Origin of Pain • Physical- cause of pain can be identified • Psychogenetic- cause of pain cannot be identified • Referred- pain is perceived in an area distant from its point of origin Pain Process • Transduction- activation of pain receptors • Transmission- conduction along pathways (A-delta and C-delta fibers) • Perception of pain- awareness of the characteristics of pain • Modulation- inhibition or modification of pain Stimulators/Nociceptors/Pain Receptors • Bradykinin- a powerful vasodilator that increases capillary permeability and constricts smooth muscle; ex/ inflammation/redness • Prostaglandins- important hormone-like substances that send additional pain stimuli to the CNS • Substance P- sensitizes receptors on nerves to feel pain and also increases the rate of firing of nerves Gate Control Theory of Pain • Recognizes relationship between pain and emotions • Gating mechanism determines the impulses that reach the brain Perception of Pain • Pain threshold • Modulation of pain- neuromodulators; endorphins, dynorphins, enkephalins (ways to inhibit effects of pain) • Physiologic- involuntary; ex/ increase in blood pressure, pupils dilated • Behavioral- “guarding” • Affective- psychological; ex/ anxiety, fatigue, anorexia Basic Methods of Assessing Pain (2011) • Patient self report; report of family members • Nonverbal behaviors: restlessness, grimacing, crying, clenching fists, guarding • Physiologic: increased blood pressure and pulse Pain Assessment Tools • Wong Baker FACES children • Beyer oucher pain scale 1-10 • CRIES pain scale newborns • FLACC pain scale • Faces, legs activity, cry, consolability • 2 months to 7 year olds; unresponsive elderly Pharmacologic Pain Relief • Start simple analgesic administration (PRN) • Nonopioid analgesics- Tylenol NSAIDS • Opioids or narcotic analgesics- controlled substances • Adjuvant dugs- nerve pain ex/ diabetics medicine The WHO 3-Step Analgesic Ladder- explains whether to give pain medications and what type to give Numeric Sedation Scale (NAN- no action necessary) S: sleep, easy to arouse; NAN 1: awake and alert, NAN 2: occasionally drowsy, but easy to arouse, NAN 3: frequently drowsy, drifts off to sleep during conversation; reduce dosage 4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone (NARCAN)