fundamentals exam 2 study guide

what’re the 3 layers of the skin

1. epidermis

2. dermis

3. subcutaneous

what factors can affect skin integrity

• wounds

• vascular wounds

• vascular disease

• diabetes

• malnutrition

• cholesterol and fatty acids

• vitamins and minerals

• medications

• excessive moisture

• external forces (pressure, shear, friction)

• aging (skin elastic decreases)

what is an open wound

actual break in the skins surface

what is a closed wound

the skin is still intact

what are 3 terms used to describe wound depth

• superficial: involves only the dermis

• partial thickness: involves the epidermis and dermis but doesn’t extend through eh dermis to the subQ

• full thickness wound: extends through the dermis to the subQ layer and could extend farther to muscle or bone

what is the definition of a clean wound

no infection and the risk o one is low

what is the definition of a contaminated wound

results from a break in sterile technique during surgery

what is the definition of a clean contaminated wound

it is like a clean wound but because the surgery involves organ systems that are likely to contain bacteria the risk of infection is greater

what is the definition of an infected wound

shows clinical signs of infection (redness, warmth, increased drainage that may or may not be purulent (pus containing), and has bacterial counts in the tissue when sampled)

what is the definition of a colonized wound

1 or more organisms are present of the surface of the wound when a culture is obtained but theres no overt sign of an infection in the tissue below the surface

what is an acute wound (healing process term)

a wound that progresses through the phases of wound healing in rapid uncomplicated manner (healed by primary intention) → surgical incisions or traumatic wounds which the edges can be approximated (brought together) to heal

what is a chronic wound (healing process term)

commonly heals by secondary intention → when a wound heals this way new tissue must fill in from the bottom and sides of the wound nail the wound bed is filled with entirely new tissue (these wounds are associated with disease processes → diabetes/vascular disease or wounds that have inhibited proper wound healing)

what are the 3 phases of wound healing

1. inflammatory

2. proliferative

3. maturation

what’re the 3 types of healing intentions

• primary intention: wounds that tend to heal quickly and result in minor scar formation because the edges of the skin can be brought together

• secondary intention: new tissue fills in from the bottom and sides of the wound until the wound bed is filled

• tertiary intention: a delay in wound healing between injury and closure

what is an approximated wound

a wound that can be brought together by the edges

what is the inflammatory healing process

• the body initial inflame response happens and lasts about 3 days

• when the injury fort happens bleeding occurs triggering the coagulation cascade which forms a clot to prevent the bleeding

• there is an increased pain, warmth, and swelling in the injured area since the blood vessels are dilated and leak fluid into the tissue surrounding the injury

what is the proliferative phase

• when the wound is filled with new granulated tissue (theres development of new blood vessels that are needed to support the new tissue, wound contraction, and epithelialization)

• this lasts usually several weeks (can be shorter if its a surgical closed wound or longer if the wound is larger or left to heal via secondary intention)

• epithelial cells move laterally form the edges of the wound across the granulated moist tissue until the wound has been resurfaced with epithelial cells and normal skin layers are reestablished (THIS IS WHY WE USE MOIST WOUND DRESSINGS TO PROMOTE AND SUPPORT WOUND HEALING IN THIS WAY)

what is the maturation phase

• this is remodeling that can last up to a year

• collagen is deposited more cuasing scar tissue formation thats strengthened due to the collagen

• the strength of scar tissue only can reach 80% of its previous strength

what factors affect wound healing

• oxygenation and tissue perfusion

• diabetes

• nutrition

• age

• infection

what is dehiscence

a PARTIALof separation of the tissue layers during the healing process (usually deals with connection with surgical incisions) → if sutures break open because of something you possibly did

what is evisceration

TOTAL separation of the tissue layer allowing the protrusion of visceral organs through the incision

what is the best form of action for an eviscerate wound

splinting (if its not splinted it will create a FISTULA/hole)

what is a stage 1 pressure ulcer description

• an intact, non-blistered skin with non-blanchable erythema (persistent redness) → NO SKIN BREAK DOWN YET

what is a stage 2 pressure ulcer description

a PARTIAL THICKNESS skin loss that involves the EPIDERMIS and exposes some of the DERMIS → blistering skin

what is a stage 3 pressure ulcer description

a FULL THICKNESS tissue loss the extends to the SUBQ layer but doesn’t go to the muscles or bones → can have tunneling that must be measured and recorded

what is a stage 4 pressure ulcer description

a FULL THICKNESS tissue loss with exposed MUSCLE AND BONE → osteomyelitis is a risk for this stage since exposed bone is possible (this stage MAY need to have slough cleaned out to determine the true depth and levels of tunneling thats occurred)

what is an unstageable pressure ulcer description

an OBSCURED FULL THICKNESS tissue/skin loss where the amount of necrotic tissue and eschar (black/brown) /slough (white/cream/yellow) in the wound makes it impossible to determine the true depth of wound and tunneling → just can tell how bad it is

what increases the risk for pressure ulcers

• patients inability to feel pain

• unable to respond to pain appropriately

• limited to their ability to move/maintain position

what tools are used to assess pressure ulcers

braden scale → ranks the risk factor, sensory perception, moisture, activity, mobility, nutrition, and friction

Norton scale → ranks the physical condition, mental state, activity, mobility, continence of patient (low risk = 16-30 / moderate risk = 11-15 or below / high risk = 10 or below)

what are the score description for Braden scale

• 23 means theres NO RISK for developing ulcer

• high risk = 10-12

• VERY high risk = 9 or less

• the lowest possible score of SIX means there at the highest risk for an ulcer

what assessments need to be done if a patient has a wound

• location

• size

• presence of undermining or tunneling

• drainage (COCA)

• conditions of wound edges and surrounding tissue (white ring around wounds and fresh tissue growing right next to the wounds barrier → this is maceration (due to being exposed to excess moisture))

what is the difference between serous, serosanguineous, and sanguineous

• serous: clear watery fluid from plasma

• serosanguineous: pink to pale red and contain a MIX of serous fluid and red bloody fluid

• sanguineous: indicates bleeding and is BRIGHT red

what does COCA stand for

color

odor

consistency

amount

what does maceration mean

condition where excessive moisture causes a softening of the skin (white ring forms around a wound)

what’re ways to prevent a pressure ulcer

• frequent position changes: every 2 hours, elevate egad NO MORE than 30 degrees to reduce shear effects, when side lying position patient at 30 degrees rather than 90 to prevent pressure on bony prominences

• use cushions (waffle padded boots)

• skin hygiene

• spread out body weight over a greater surface area

what is a Jackson Pratt (JP) drain

a closed drainage system (usually sutured in place) where a soft drain is attached to a springlike suction device → these deal with orthopedic and abdominal surgery patients

• this promotes healing and reduces number of microorganism entering because its closed (no open ends)

what is a hemovac drain

a closed drainage system (usually sutured in place) where a soft drain is attached to a springlike suction device → these deal with orthopedic and abdominal surgery patients

• this promotes healing and reduces number of microorganism entering because its closed (no open ends)

what is a Penrose drain

an open drainage system thats a flexible piece of tubing not surgically sutured inplace

• *abdominal surgery* particularly after incision and drainage procedures, gallbladder surgery, or other operative procedures involving the common bile duct

• The system drains excess fluid to the outside of the body (the pressure inside the wound is greater than the pressure outside the body; therefore the drainage flows out of the tube onto the dressing)

• the drains typically are inserted through stab wounds a few centimeters away from the surgical incision line, to prevent any interference with healing of the main surgical site

what is a wound va drain

uses negative pressure to remove excess wound fluid, stabilize wound edges, and stimulate granulated tissues

what is an infection

a disease state caused by an infectious agent that occurs when a pathogen multiplies in a susceptible host

what is asepsis

freedom from and prevention of disease causing contamination

what is sepsis

a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body’s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death

what is a sterile body area vs a non sterile body area

sterile: any place a microorganism can’t reach (blood, urine, CSF)

unsterile: any place where microorganisms can reach (skin, mouth, organs)

what’re the lines fo defense of the body

1. normal flora

2. inflammatory

3. immune response (innate (immediate defense)/adaptive (long term immunity))

what normal flora may cause problems

• S. aureus

• C. Diff

signs and symptoms of inflammation

• fever

• chills

• malaise

• altered mental status

• redness

• heat

• pain and swelling at the site

what is an ANTIGEN

substance that provokes adaptive immune response (nonliving things: toxins chemicals, drugs, foreign particles)

what is an ANTIBODY

immunoglobulin molecules that recognizes foreign invaders

what is innate immunity

(nonspecific) provides immediate defense against foreign antigens, produces chemical mediators that fight infection, remove foreign substance (activate the adaptive immune system)

what is adaptive immunity

(specific/aquired) provides long-term immunity when the body is exposed to an antigen

• Humoral (antibody-mediated → WBC involvement, and happens within lamp and and blood)

• Cellular (cell-mediated → WBC involvement when body doesn’t know whats attacking it)

both are types of adaptive immunity

what is active immunity

immunity to a pathogen that occurs following exposure to said pathogen (vaccines)

what is passive immunity

immunity given from one person to another (breastfeeding or placenta)

what are the steps in chain of infection (with examples)

what is HAI

healthcare associated infections → formerly referred to as NOSOCOMIAL infections

• infections acquired while the patient is receiving treatment in a facility (hospital, long term care, nursing home)

• HAIs are associated with the use of medical devices such as catheters and ventilators, complications after a surgical procedure, contagious transmission between patients and health care workers, and the overuse of antibiotics

what is the most effective method to fighting infections

• hand washing/ alcohol based sanitizer

• precautions and isolation (airborne, droplet, contact precautions)

what is an acute infection

develop and run their coarse rapidly (coughs, colds, ear infections) → last 10-14 days

what is a chronic infection

may persist for months/years (wounds, bone infections, hepatitis, AIDS)

what’re are signs and symptoms of systemic infections

infections that infiltrate the bloodstream → can cause fever, increases in heart and respiratory rates, lethargy, anorexia, and tenderness or enlargement of lymph nodes

what patients are risk for infection

people with chronic diseases, alterations in the immune system, medications such as chemotherapeutic drugs, alterations in skin integrity, malnutrition, indwelling medical devices such as urinary catheters, lack of proper immunizations

what is the complete blood count (CBC) lab

• identifies and counts the 7 types of cells found in the blood, red blood cell, neutrophil, eosinophil, basophil, lymphocyte, monocyte, and platelet

• it can detect: Anemia, Autoimmune disorders, Bone marrow disorders, Dehydration, Infections, Inflammation, Hemoglobin abnormalities, Leukemia.

what is a differential white blood cell count (WBC) lab

• It helps determine whether the body is mounting an immune response to an infection

• a normal level is 4500-10500 → anything higher than this can indicate infection

what is an erythrocyte sedimentation rate (ESR) lab

• it measures the degree of inflammation in the body

• An ESR that remains elevated indicates a poor response to current therapy, whereas an ESR that decreases indicates a good response

what is a culture and sensitivity test (C&S)

• this is used to determine what kind of bacteria is in a possible infection → the presence of bacteria has a positive result

• there is a blood, urine, stool, or wound drainage

• the culture parts determine the pathogen and the sensitivity determines the nit biotic needed

who should we use standard precaution on and what is standard precaution

• everyone

• hand washing/sanitizing and gloving

what is contact isolation

• transmission of contagious disease may occur through several routes: direct and indirect

• disease requiring contact precaution: multi drug resistant organisms, scabies and herpes simplex virus, and draining wounds where they have been cultured (USE GLOVES AND GOWN)

what is airborne isolation

• this is used when known or suspected contagious diseases can be transmitted via small droplets or particles that’re suspended in the air

• this type requires negative pressure rooms with high efficiency particulate air (HEPA) filtration system

• people need to wear N95 mask (needs to be fitted)

• diseases that require this: varicella, rubella/measles, TB

what is droplet isolation

• this is used when known contagious disease can be transmitted through large droplet suspended in the air (coughing, sneezing, or talks)

• diseases that use this: pharyngeal diphtheria, mumps, rubella, pertussis, scarlet fever, meningococcal sepsis, and influenza

what is protective isolation

• this is used for patients who have a compromised immune systems (protects the patients from microorganisms)

• diseases that need this: ˜immunosuppression, including leukemia, myelodysplastic syndrome, aplastic anemia, systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), human immunodeficiency virus (HIV) infection, and severe sepsis

• patients rooms need positive pressure HEPA filtration, anyone entering needs a mask and wash hands, nothing alive in the room or fresh fruits/veggies in the room

what is medical asepsis

(often referred to as clean technique) procedures include handwashing, wearing gloves, gowning, and disinfecting

what is surgical asepsis

• (sterile technique) is used to prevent the introduction of microorganisms from the environment to the patient

• Surgical asepsis is used for: surgical procedures, invasive procedures such as catheterization, procedures that invade the bloodstream or break the skin, dressing changes, and wound care

what is the definition of pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such

what does nociception mean

process when the sensation of tissue injury is conducted from the peripheral to the central nervous system

what is pain threshold

lowest intensity at which the brain recognizes the stimulus as pain

what is pain tolerance

intensity/duration of pain that a patient is able or willing to endure

what is acute pain

• occurs abruptly after an injury or disease, persists until healing occurs, and often is intensified by anxiety or fear

• lasts LESS THAN 6 months

what is chronic pain

• may be malignant or nonmalignant but lasts for a prolonged period of time during prolonged tissue pathology or pain that persists beyond the normal healing period for an acute injury or disease

• lasts MORE THAN 6 months

what is nociceptive pain

Physiologic pain in response to trauma, injury, or inflammation

what is visceral pain

inner pain with the organs (appendix, pancreas, bowels)

what is somatic pain

outer pain with the body (skin, muscles, bones, and joints)

what is neuropathic pain

pain with the nerves

what is phantom pain

brain receives pain message from area of amputation

what is psychogenic pain

no physical cause but can be caused by mental, emotional, or behavioral factors

what are (physiologic) vital sign changes for acute pain

• increased blood pressure, heart rate, increased respirations

• diabetics have increased blood glucose due to stress or pain

what are the types of pain assessment tools to use

• 10cm visual analog scale (0-10)

• Wong-baker faces pain scale

• the nonverbal pain scale

• SOCRATES (site, onset, character, radiation, associations, time course, exacerbating relieving factors, severity)

what is the purpose for documenting and what is documenting

to describe facts clearly and concisely to improve communication

• ´the written, or electronically generated, information about a patient that describes the patient, the patient’s health, and a care and service provided, including the dates of care.

what’re the purposes of patient record

• Communication

• Reimbursement

• Care Planning

• Education

• Quality Review

• Decision Analysis

• Legal

• Documentation

• Research

• Historical Documentation

what’re important considerations for guidelines for documenting

• timing: needs the date and time of any recording

• confidentiality: keep this as a legal private record (access is restricted to health professionals)

• permanent: enteries made in dark colored black so its permanent and changes can be indicated

• signature: each recording is signed by the nurse doing the assessment/charting (needs name and title → O. Rose R.N.) → don’t walk away before logging off

• accuracy: all recordings must be accurate and correct → with facts and exact observations (quote directly, spell correctly, avoid general words, draw a line through errors needing corrected and blank spaces)

• sequence: recording events in the order they occurred (assessments, interventions, and patients response)

• appropriateness: only record info that pertains to patients health and care

• use of standard terminology: use only commonly accepted symbols, abbreviation, and terms specified by agency

what’re the formats for nursing documentation

• Initial Nursing Assessment

• Kardex Care Plan

• Plan of Nursing Care

• Critical/Collaborative Pathways

• Progress Notes

• Flow Sheets

• Discharge and Transfer Summary

• ´Home Healthcare Documentation

what’re components of Flow sheets

• Graphic Sheet

• 24-Hour Fluid Balance Record

• Medication Record

• 24-Hour Patient Care Record

what’re some problems with documentation

• 1 in 4 malpractice suits are determined on the basis of patient record

• documentation content that increases risk for legal problems (objective things)

• documentation mechanics that increases risk for legal problems

whats the difference between EMR and EHR

• EMR: record of one episode→ certain patients current chart

• EHR: record from different doctors and long term view

what is CPOE

computer physicians order entry → access via password and verification codes

• providers entering and sending treatment instructions (including medication, laboratory, and radiology orders) – via a computer application rather than paper, fax, or telephone

what is MAR

medication administration record: a drug chart that tells you the patients 6 rights of med administration (nurse must go over them 3 times prior to giving med)

whatre some issues of not giving good report

When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur

what is SBAR and what it used for

• s: situation

• B: background

• A: assessment

• R: recommendation

• its used for communication between health care professionals

what an incident report

When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed → falls, med errors, equipment malfunctions

• not apart of medical record

• factual only, objective, nonjudgemental

what the importance of using informatics in nursing

The use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research

• this is recognized as a specialty in nursing

what does DIKW stand for and what does it mean

D= data (facts)

I= information (organized data)

K= knowledge ( organized info thats meaningful)

W= wisdom (appropriate application of knowledge)

what is BCMA used for

bar-code medication administration is used as a part of the process of med administration (fewer errors made)