| Asepsis and Mobility | Pain and Vital Signs | Personal Hygiene and Wounds | Urinary and Bowel |
|---|---|---|---|
|
Gown, mask, goggles, gloves
What is the correct sequence of applying ppe?
|
distraction, medication, hot or cold pressure
What are three things that can relieve pain?
|
- friction and shear
- not repositioning - poor nutrition
What are 3 main causes of pressure wounds?
|
painful urination, sensation, burning, frequency
What are 3 signs of a UTI?
|
|
Gloves, gown, eyes, mask
What is the correct sequence of removing ppe?
|
Diaphoresis - Sweating
What is one main pain indicator that someone is in pain?
|
Clean the urethral meatus first, (if foreskin, retract it) then clean down the shaft and then the scrotum
What is correct sequence of providing peri care to a male?
|
dietary changes, fluids, and activity
Constipation is prevented by...?
|
|
Involvement of moving joints through their complete ROM.
active- done by the client passive- assistance provided
Define ROM exercise and define each type.
|
Blood pressure is the amount of force exerted against the walls of an artery by the blood.
baseline is around-120/60 controlled by- heart contractions, amount of blood pumped with each heartbeat, how it easily flows through blood vessels
Define blood pressure and what is the baseline for an adult? What is blood pressure controlled by?
|
four stages and 5th one is unstageable
2nd stage is- skin is severed (epidermis and dermis) and some drainage present 5th stage- full thickness loss, eschar and slough present
How many stages are there to wounds and what is stage 2 and stage 5?
|
to gain control or bowel movements
to develop a regular pattern of elimination
Bowel training has two goals. What are they?
|
|
Trochanter roll
To reduce hip rotation in a weak fragile patient, the
nurse should implement the use of which following device? |
Increase pulse, resp and bp
What vital sign(s) increases when you have pain and explain why.
|
Hemostasis phase- begins within minutes of injury, reaction to wound healing
Inflammatory- destroys bacteria and removes debris Proliferative- new blood vessels appear, fill and cover the wound Maturation- remodeling stage, final stage
Name all wound stage healing processes in order and describe.
|
Surgically created opening between iluem and abd wall.
A colostomy is opening between the colon and abd wall
What is an ileostomy and what is difference from colostomy?
|
|
Foot board
Which of the following device can reduce planter flexion in weak fragile patients?
|
5th intercostal space
opening and closing of valves of the heart, listening to the apex of the heart
In what intercostal space do you place a stethoscope to take apical pulse and what is apical pulse?
|
Phase 3, the Proliferative Phase, where the focus is to fill and cover the wound.
The Proliferative phase features three distinct stages: 1) filling the wound; 2) contraction of the wound margins; and 3) covering the wound (epithelialization).
Define in depth what proliferative phase is in wound healing.
|
odour, colour, amount, clarity and sediments
burning, frequency, pain, confusion and increase temp
What are 5 characteristics for urine and what are 5 things you look for in a uti?
|
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