Hondros Nursing- Nur 150: Exam 2, STUDY GUIDE

Hondros Nursing- Nur 150: Exam 2, STUDY GUIDEHondros Nursing Nur 150: Exam 2, Hondros NUR150 Exam 2, Hondros Nu150 Exam 2, HONDROS NUR 150 - EXAM 2 Study online at Stage 1 pressure ulcer Intact skin with nonblanchable redness Stage 2 pressure ulcer Partial loss of dermis. Shallow open ulcer, usually shiny, or dry. Red-pink wound bed without sloughing or bruising. Stage 3 pressure ulcer Full thickness tissue loss, subcutaneous fat may be visible. Possible undermining and tunneling. Stage 4 pressure ulcer Full thickness tissue loss with exposed bone, tendon,or muscle. Slough or eschar may be present as well as undermining and tunneling. Unstageable pressure ulcer Full thickness tissue loss, wound base covered by slough and eschar therefor dull depth cannot be determined. Slough Fibrous tissue in wound bed that can be yellow, tan, gray, green, or brown. Nursing interventions to prevent pressure unlcers Reposition bed bound pt every two hours, instruct pt in wheelchair to shift their weight every hour. Use of cushions and barrier cream. Manage moisture, optimize nutrition and hydration. Cognition All the processes involved in human thought External nutrition Nutrition support via tube feedings Parenteral nutrition Nutrition supplied intravenously DRI Refers to a set of nutritional based values that serve for both assessing and planning diets Three ways to confirm proper NG placement Chest x-ray, PH test gastric contents, air bolus. With tube feeding what must be monitored daily I/O, daily weight, daily labs 1 / 33 Hondros Nursing Nur 150: Exam 2, Hondros NUR150 Exam 2, Hondros Nu150 Exam 2, HONDROS NUR 150 - EXAM 2 Study online at Fatal risk of dysphagia Aspiration pneumonia Nectar thickened A little slower of the spoon than water Honey thickened Very much slower off the spoon than water Spoon thickened Will not drop off spoon Puréed Pudding consistency such as mashed potatoes, vegetables, pasta in pudding consistency Mechanical soft All foods except hard, crunchy, or sticky Dysphagia advanced Includes moist and soft foods such as cooked cereal, canned fruit, noodles in sauce. Cold therapy NC Recommended for first 24-48 hours after injury. Do not apply to red or blue areas. Check condition of skin every 5 minutes when using electrical cooling device. What color should the contents be when aspirating an NG tube Green, brown, or tan Caution with digital impaction removal Cardiac patients How many enemas should you do in a row Until everything comes out clear, no more than 3 HILDA Pain assessment: how does pain feel? Intensity? Location? Duration? Aggregating or alleviating factors? The fifth vital sign Pain Organ that inacativates and metabolizes drugs Liver Organ that eliminates the metabolites of the drug from the body Kidneys AC Before meals PC After meals 2 / 33 Hondros Nursing Nur 150: Exam 2, Hondros NUR150 Exam 2, Hondros Nu150 Exam 2, HONDROS NUR 150 - EXAM 2 Study online at Used to treat inflammatory responses- decreases edema, muscle spasms, pain, and decreases blood flow to the area. Cold and Heat Therapy when is cold and heat therapy recommended for an injury first 24 to 48 hours whose responsibility is it to evaluate proper application, adverse signs and symptoms and is also responsible for the patient's safety LPN where should you not apply a cold pack to red or blue areas how often should you check the skin of a patient who is using an electrical cooling device or an electrical heating device every 5 minutes what are common symptoms when using an electrical cooling device numbness and tingling How long should you leave a cooling device in place 15 to 20 minutes what are some adverse skin reactions when using a cooling device mottling, redness, burning, blistering and numbness what should you record when using a cooling device or heating device what device you used, location, duration, patient response, patient teaching and patients response to teaching when should you immediately stop application of a cooling device areas become mottled, red or blue/purple, or if the patient Is complaining of pain/numbness when should you immediately stop application of a heating device skin becomes redd