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NR224 / NR 224 Exam 2 (Latest 2021 / 2022) Fundamentals - Chamberlain College of Nursing, Study Guides, Projects, Research of Nursing

NR224 / NR 224 Exam 2 (Latest 2021 / 2022) Fundamentals - Chamberlain College of Nursing

Typology: Study Guides, Projects, Research

2020/2021

Available from 12/16/2021

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Download NR224 / NR 224 Exam 2 (Latest 2021 / 2022) Fundamentals - Chamberlain College of Nursing and more Study Guides, Projects, Research Nursing in PDF only on Docsity!

NR I224: IFundamentals IExam I 2

Chapter I 48 Roles Iof Iskin

  • Protective Ibarrier Iagainst Idisease-causing Iorganisms
  • Sensory Iorgan Ifor Ipain, Itemperature, Iand Itouch
  • Vitamin ID IsynthesisILayers Iof Ithe Iskin
  • Epidermis o Basal Ilayer: Icells Idivide, Iproliferate, Iand Imigrate Itoward Ithe IepidermalIsurface
  • Secondary Iintention: Ihealthy, Ipink, Igranulating Itissue Ihealing Ifrom Ibottom Iup; Ikeep moist. INeed Ito Ipack Iotherwise Itop Ilayer Iheals Ibefore Iand Iinfection Ican IoccurISkin Iintegrity
  • Patient Ieducation
  • Pressure Iulcers: Irelated Ito Ipressure Iintensity, Ipressure Iduration, Iand Itissue Itolerance; Iblanching Idoes Inot Ioccur Iwith Ipressure Iulcers; IAlso Iknown Ias IpressureIsore, Idecubitus Iulcer, Ior Ibed Isore o Risk Ifactors Ifor Idevelopment ▪ Impaired Isensory Iperception ▪ Impaired Imobility ▪ Alteration Iin ILOC ▪ Shear ▪ Friction ▪ Moisture o Staging ▪ 1: Iintact Iskin Iwith Inonblanchable Iredness ▪ 2: Ipartial-thickness Iskin Iloss Iinvolving Iepidermis, Idermis, Ior Iboth ▪ 3: Ifull-thickness Itissue Iloss Iwith Ivisible Ifat ▪ 4: Ifull-thickness Itissue Iloss Iwith Iexposed Ibone, Imuscle, Ior Itendon ▪ Unstageable/unclassified: Ifull-thickness Ior Itissue Iloss- IdepthIunknown. ICompletely Icovered Iby Islough Iand/or Ieschar. ▪ Suspected Ideep Itissue Iinjury: Idepth Iunknown; Ipurple Ior Imaroon localized Iarea Iof Idiscolored Iintact Iskin Ior Iblood-filled Iblister Idue Ito Idamage Iof Iunderlying Isoft Itissue Ifrom Ipressure Iand/or Ishear. IMay IbeIpainful, Ifirm, Imushy, Iboggy, Iwarmer/cooler. o Process Iof Iwound Ihealing ▪ Primary Iintention: Ii.e. Isurgical Iincision Iwith Ilittle Itissue Iloss; Ilow Irisk IofIinfection, Iedges Iare Iapproximated Ior Iclosed, Ihealing Ioccurs Iquickly Iwith Iminimal Iscar Iformation ▪ Secondary Iintention: Ii.e. Ipressure Iulcer; Iwound Iwith Iloss Iof Itissue, Ileft open Iuntil Ifilled Iwith Iscar Itissue; Itakes Ilonger Ito Iheal; Igreater IchanceIof Iinfection ▪ Stage I 3 Iis Iresolved Ior Iclosed Ibut Inever Ihealed ▪ Complications
  • Hemorrhage I(hematoma): Ilocalized Icollection Iof IbloodIunderneath Ithe Itissue
  • Infection
  • Dehiscence: Ithe Ipartial Ior Itotal Iseparation Iof Iwound Ilayers; Ipatient Iat Irisk Ifor Ipoor Iwound Ihealing Iis Iat Irisk Ifor Idehiscence
  • Evisceration: IProtrusion Iof Iorgans Ifrom Iwound; ITHIS IIS IAN EMERGENCY, I IMMEDIATELY IPLACE IDAMP ISTERILEIGAUZE IOVER ISITE IAND ICONTACT ISURGICAL ITEAM. o Prevention/ INursing Iinterventions ▪ No Iadditional Ireimbursement ▪ Good Inutrition ▪ Mechanical Iloading Iand Isupport Idevices
  • Repositioning Iproperly Iand Ifrequently o At Ileast Ievery I 2 Ihrs o 30 Idegree Ilateral Iposition
  • Use Iof Itherapeutic Isurfaces ▪ Skin Icare Iand Imanagement Iof Iincontinence
  • Keep Iskin Iclean Iand Idry ▪ Pain Icontrol ▪ Education o Factors Iinfluencing Ipressure Iulcer Iformation Iand Iwound Ihealing ▪ Nutrition ▪ Tissue Iperfusion ▪ Infection ▪ Age ▪ Psychosocial Iimpact Iof Iwounds o Important Inutrients Iand Ilab Ivalues ▪ Vitamins IAI& IC ▪ Calories: I 1500 Ikcal/day ▪ Proteins o Braden Iscale ▪ 6 Isubscales
  • Sensory Iperception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction/shear ▪ Higher Iscore I Ilower Irisk I(6 Ito I 23 Ipoint Iscale)
  • Goals Ifor Iskin Iintegrity o AIgood Igoal: Ipressure Iwill Ibe Ireduced Ito Isacral Iarea, Iand Ithe Iwound IwillIshow Imovement Itoward Ihealing Iin I 1 Iweek
  • Wounds o Wash Iwounds Iwith Inormal Isaline Ibefore Iculturing o Important Ito Iidentify Ithe Isupport Isurface Ithat Iwould Ibe Iappropriate ItoIdecrease Ipressure Ion Ipatient Iskin

Chapter I 41 o Debridement: Iremoval Ior Inonviable, Inecrotic Itissue; Imechanical, Iautolytic,Ichemical, Iand Isharp/surgical o Negative I pressure I wound I therapy I I suctioning o Types Iof Idrainage ▪ Purulent- Imilky; Igenerally Igray, Igreen, Ior Iyellow; Ithick Iconsistency;Imay Ibe Isign Iof Iinfection ▪ Serosanguinous- Ithin Iand Iwatery; Ipink ▪ Sanguineous- Ifresh Iblood Iprevalent Iamong Ideep Iwounds ▪ Serous- Ithin, Iclear, Iand Iwatery

- The Iairways Iof Ithe Ilung Itransfer Ioxygen Ifrom Ithe Iatmosphere Ito Ithe Ialveoli, Iwhere ItheIoxygen Iis Iexchanged Ifor Icarbon Idioxide - Structure Iand Ifunction o Ventilation: Ithe Iprocess Iof Imoving Igases Iinto Iand Iout Iof Ithe Ilungs o Perfusion: Ithe Iability Iof Ithe Icardiovascular Isystem Ito Ipump Ioxygenated Iblood ItoIthe Itissues Iand Ireturn Ideoxygenated Iblood Ito Ithe Ilungs o Diffusion: Iexchange Iof Irespiratory Igases Iin Ithe Ialveoli Iand Icapillaries

  • Lung Ivolumes o Tidal: Ithe Iamount Iof Iair Iexhaled Ifollowing Ia Inormal Iinspiration o Residual: Ithe Iamount Iof Iair Ileft Iin Ithe Ialveoli Iafter Ia Ifull Iexpiration o Forced Ivital Icapacity: Ithe Imaximum Iamount Iof Iair Ithat Ican Ibe Iremoved Ifrom ItheIlungs Iduring Iforced Iexpiration o Blood Iflow Iregulation ▪ Cardiac Ioutput: Iamount Iof Iblood Iejected Ifrom Ithe Ileft Iventricle IeachIminute ▪ Stroke Ivolume: Iamount Iof Iblood Iejected Ifrom Ithe Ileft Iventricle Iwith Ieach contraction ▪ Cardiac Ioutput I(CO) I= Istroke Ivolume I(SV) I* IHeart Irate I(HR) ▪ Preload: Iend-diastolic Ipressure; Iamount Iof Iblood Iin Ileft Iventricle Iat ItheIend Iof Idiastole ▪ Afterload: Iresistance Ito Ileft Iventricular Iejection
  • Alterations Iin IRespiratory IFunctioning o Hypoventilation: Ialveolar Iventilation Iinadequate Ito Imeet Ithe Ibody’s IoxygenIdemand Ior Ito Ieliminate Isufficient Icarbon Idioxide o Hyperventilation: Iventilation Iin Iexcess Iof Ithat Irequired Ito Ieliminate Icarbon Idioxide produced Iby Icellular Imetabolism o Hypoxia: Iinadequate Itissue Ioxygenation Iat Ithe Icellular Ilevel ▪ Signs Iand Isymptoms: Iapprehension, Irestlessness, Iinability Ito Iconcentrate, Idecrease ILOC, Idizziness, Iand Ibehavioral Ichanges ▪ Cannot Ilie Iflat Iand Iappears Iboth Ifatigued Iand Iagitated ▪ Increase Ipulse Irare Iand Irate Iand Idepth Iof Irespiration o Cyanosis: Iblue Idiscoloration Iof Ithe Iskin Iand Imucous Imembranes
  • Heart Ifailure o Left Isided ▪ If Isignificant, Ithe Iamount Iof Iblood Iejected Ifrom Ithe Ileft Iventricle IdropsIgreatly, Iresulting Iin Idecreased Icardiac Ioutput

▪ S/S: Ifatigue, Ibreathlessness, Idizziness, Iand Iconfusion ▪ Blood Ibegins Ito Ipool Iin Ithe Ipulmonary Icirculation, Icausing IpulmonaryIcongestions I( Ifrothy, Iblood Itinged Isputum) ▪ Clinical Ifindings: Icrackles Iin Ithe Ibase Iof Ithe Ilungs Ion Iauscultation, hypoxia, ISOB Ion Iexertion, Icough, Iand Iparoxysmal Inocturnal Idyspnea o Right Isided ▪ Results Iusually Ifrom Ichronic ILS Iheart Ifailure Ior Ipulmonary Idisease ▪ Elevated Ipulmonary Ivascular Iresistance I(PVR). IAs IPVR Irises Ithe Ir. Iventricle Iworks Iharder, Iand Ithe IO2 Idemand Iof Ithe Iheart Iincreases. IAs Ifailure Icontinues, Ithe Iamount Iof Iblood Iejected Ifrom Ithe Iright Iventricle Ideclines, Iand Iblood Ibegins Ito I“back Iup” Iin Ithe Isystemic Icirculation ▪ Clinical: Iweight Igain, Idistended Ineck Iveins, Ihepatomegaly Iand splenomegaly, Iand Idependent Iperipheral Iedema

  • Rales: IWheezes
  • Suctioning Itechniques o Oropharyngeal Iand Inasopharyngeal ▪ Patient Ican Icough Ieffectively Ibut Icannot Iclear Isecretions o Orotracheal Iand Inasotracheal ▪ Patient Iis Iunable Ito Imanage Isecretions Iby Icoughing Iand Ihoes Inot IhaveIartificial Iairway o Tracheal I(only Ifor Ithose Iwith Itrachs) ▪ Used Iwith Ian Iartificial Iairway
  • Methods Iof Ioxygen Idelivery o Nasal Icannula o Oxygen Imask
  • CPR o 30 Ichest Icompressions I: I 2 Ibreaths o First Ishock Iin Iless Ithan I 2 Imins Iof ICPR
  • Safety o Patients Iwith Isudden Ichanges Iin Itheir Ivital Isigns, Ilevel Iof Iconsciousness, IorIbehavior Iare Ipossibly Iexperiencing Iprofound Ihypoxia. I(especially Ianxiety) o Perform Itracheal Isuctioning Ibefore Ipharyngeal Isuctioning Iwhenever Ipossible. o Use Icaution Iwhen Isuctioning Ipatients Iwith Ia Ihead Iinjury. o The Iroutine Iuse Iof Inormal Isaline Iinstillation Iinto Ithe Iairway Ibefore IET IandItracheostomy Isuctioning Iis Inot Irecommended. o Check Iyour Iinstitutional Ipolicy Ibefore Istripping Ior Imilking Ichest Itubes. o The Imost Iserious Itracheostomy Icomplication Iis Iairway Iobstruction, Iwhich IcanIresult Iin Icardiac Iarrest. o I Patients Iwith ICOPD Iwho Iare Ibreathing Ispontaneously Ishould Inever Ireceive Ihigh levels Iof Ioxygen Itherapy. Chapter I 46
  • Micturition Ioccurs Iwhen Ithe Ibrain Igives Ithe Ibladder Ipermission Ito Iempty, Ithe IbladderIcontracts, Ithe Iurinary Isphincter Irelaxes Iand Iurine Ileaves Ithe Ibody Ithrough Ithe Iurethra
  • Patient Ieducation I/ IPrevention o Urine Iis Iproduced Iin Inephron

o Promote Inormal Imicturition ▪ Maintaining Ielimination Ihabits ▪ Maintaining Iadequate Ifluid Iintake

  • Avoid Inocturia Iby Iavoiding Ifluid Iintake I 2 Ihrs Ibefore Ibed o Promote Icomplete Ibladder Iemptying ▪ Time Ivoiding I Ivoiding Iaccording Ito Iclock Inot Iurge Ito Ivoid ▪ Crede Imethod I(manual Icompression) I Iplace Ihands Ion Ibladder IandIcompress Ito Iassist Iin Iemptying o Preventing Iinfection
  • Common Iurinary Ielimination Iproblems o Urinary Iretention: Iaccumulation Iof Iurine Idue Ito Ithe Iinability Iof Ithe Ibladder ItoIempty o UTI: Iresults Ifrom Icatheterization Ior Iprocedure o Urinary Iincontinence: Iinvoluntary Ileakage Iof Iurine
  • Signs Iand Isymptoms Iof Icystitis Iand IUTIs o UTI ▪ Burning Ior Ipain Iwith Iurination I(dysuria) ▪ Irritation Iof Ithe Ibladder I(cystitis) Icharacterized Iby Iurgency, Ifrequency,Iincontinence, Isuprapubic Itenderness, Iand Ifoul-smelling Icloudy Iurine
  • Getting Ispecimens o Label Iwith Ipatients Iname, Idate, Itime, Iand Itype Iof Icollection o Need Ito Ireach Ilaboratory Iwithin I 2 Ihours Iof Icollection o Mid-stream Iclean Icatch
  • Foley Icare Iand Iprocedures o Keep Ibag Ibelow Iwaste o Assess Ifor Ikinks Iin Itubing o Catheter Icare Ievery I 8 Ihours Iat Ileast Ito Iprevent ICAUTI o Empty Idrainage Ibag Iwhen Ihalf Ifull
  • Incontinence o Types ▪ Urge/urgency IUI Ihave Ito Igo Iextreme Ionset Iand Igoes ▪ Stress IUII Isneezing, Ilaughing, Irunning, Ior Icoughing Ileads Ito Ipeeing ▪ Functional IUI I Ilack Iof Ifunctional Iability ▪ Overflow IUII Iwhen Ibladder Ireaches Ioverflow Ibladder Ileaks o Signs Iand Isymptoms ▪ Urgency IUI
  • Overactive Ibladder; Iincreased Iurinary Ifrequency Iand Inocturia o Treatments
  • Renal Icalculi
  • Pyelogram Itesting o Assess Ipatient Ifor Iallergies; Iintravenous Ipyelogram I Ishellfish Ior Iiodine
  • Intake/output o Way Ito Ievaluate Ibladder Iemptying, Irenal Ifunction, Iand Ifluid I& IelectrolyteIbalance o Intake Iincludes: Iall Ioral Iliquids Iand Isemi-liquids, Ienteral Ifeedings, Iand Iany parenteral Ifluids

o Outtake Iincludes: Iurine, Iand Iany Imeasureable Ifluid Icoming Iout Iof IbodyI(vomitus, Igastric Idrainage Itubes, Iwound Idrains) o Dark Iamber I Ihigh Iconcentrations Iof Ibilirubin I(liver Idisease)

  • Nursing Iinterventions
  • Common Imedications I(ex. Iphenazopyridine) o Antimuscarinics: Itreat Iurgency, Ifrequency, Inocturia Iand Iurgency IUI o Bethanechol: Itreat Iurinary Iretention o Tamsulosin Iand Isilodosin: Irelax Ismooth Imuscle o Finasteride Iand Idutasteride: Ishrink Ithe Iprostate o Antibiotics: Itreat IUTIs o Patients Iwith Ipainful Iurination, Iare Isometimes Iprescribed Iurinary IanalgesicsIthat Iact Ion Ithe Iurethral Iand Ibladder Imucosa I(i.e. Iphenazopyridine) I Iturns Iurine Iorange Chapter I 45 - Patient Ieducation - BMR I(Basal Imetabolic Irate)- Ienergy Ineeded Iat Irest Ito Imaintain Ilife-sustaining Iactivities Ifor Ia Ispecific Iamount Iof Itime - Carbohydrates- I 4 Ikcal/g; Imain Isource Iof Ifuel o Monosaccharides Iand Idisaccharides Iare Isimple Icarbohydrates o Polysaccharides I(i.e. Iglycogen, Icomplex Icarbs, Istarches): Iinsoluble Iin Iwater IandIdigested Ito Ivarying Idegree Fiber: Inot Iable Ito Ibreak Idown, Idoes Inot Icontribute Ito Idiet - Proteins- I 4 Ikcal/g; Isource Iof Ienergy, Iessential Ifor Ithe Igrowth, Imaintenance, Iand Irepair IofIbody Itissue o Simplest Iform: Iamino Iacid I(hydrogen, Ioxygen, Icarbon, Iand Initrogen) Indispensable Iamino Iacids Inot Isynthesized Iby Ibody, Ineed Ito Iingest ▪ Dispensable Iamino Iacids Iproduced Iby Ibody: Ialanine, Iasparagine, IandIglutamic Iacid o I Albumin Iand Iinsulin Iare Isimple Iproteins Ibecause Ithey Icontain Ionly Iamino Iacids or Itheir Iderivatives
  • Fats- I 9 Ikcal/g; Imost Icalorie-dense Inutrient o Triglycerides Icirculate Iin Ithe Iblood Iand Ire Icomposed Iof I 3 Ifatty Iacids Iattached Ito IaIglycerol o Can Ibe Isaturate Ior Iunsaturated o Monounsaturated Ifatty Iacids Ihave Ione Idouble Ibond o Polyunsaturated Ifatty Iacids Ihave I 2 Ior Imore Idouble Icarbon Ibonds o Linoleic Iacid, Ian Iunsaturated Ifatty Iacid, Iis Ithe Ionly Iessential Ifatty Iacid Iin Ihumans
  • Nursing o Need Ito Ievaluate Ithe Ipatient’s Icurrent Iweight Iin Icomparison Iwith Itheir Ibaseline Iweight, Iserum Ialbumin Ior Iprealbumin, Iand Iprotein Iand Ikilocalorie Iintake Iroutinely
  • Vitamins I(Fat Isoluble) o A: Icarrots, Isweet Ipotatoes, Isquash; Iblood Iclotting o D: Idietary Iintake o E: Irelated Ito Iblood Ithinning o K: Iblood Iclotting, Iinfants Iinjected Iwhen Iborn Ito Iprevent Ifrom Ibleeding Iout IwhenIcord Iis Icut
  • Minerals o Macro Iminerals: Icalcium, Ipotassium, Iphosphorus, Imagnesium, Isodium, Ichloride,Isulfur o Trace Ielements Ior Imicro Iminerals: Iiron, Imanganese, Icopper, Iiodine, Izinc, Icobalt, fluoride, Iselenium
  • Absorption o The Ismall Iintestine, Ilined Iwith Ifingerlike Iprojections Icalled Ivilli, Iis Ithe IprimaryIabsorption Isite Ifor Inutrients o Diffusion, Iosmosis, Iactive Itransport, Iand Ipinocytosis I(ingestion Iof Iliquid Iinto Ia Icell by Ithe Ibudding Iof Ivesicles Ifrom Ithe Icell Imembrane) o Absorption Iof Icarbs, Iprotein, Iminerals, Iand Iwater-soluble Ivitamins Ioccurs Iin IsmallIintestine o Water Iabsorption Iin Ilarge Iintestine
  • Metabolism: Iall Ibiochemical Ireactions Iwithin Ithe Icells Iof Ithe Ibody
  • Anabolism: Ibuilding Iof Imore Icomplex Ibiochemical Isubstances Iby Isynthesis Iof Inutrients
  • Catabolism: Ibreakdown Iof Ibiochemical Isubstances Iinto Isimpler Isubstances IoccursIduring Iphysiological Istates Iof Inegative Initrogen Ibalance
  • Elimination o Chyme Imoves Iby Iperistaltic Iaction Ithrough Ithe Iileocecal Ivalve Iinto Ithe IlargeIintestine, Iwhere Iit Ibecomes Ifeces
  • Dietary Iguidelines o DRIs: Iacceptable Irange Iof Iquantities Iof Ivitamins Iand Iminerals Ifor Ieach IgenderIand Iage Igroup o myPlate ▪
  • Alternative Ifood Ipatterns o Ovolactovegetarian: Iavoids Imeat, Ifish, Iand Ipoultry; Ieats Ieggs Iand Imilk o Lactovegetarian: Idrinks Imilk Ibut Iavoids Ieggs o Vegan: Iconsumes Ionly Iplant Ifoods o Zen Imacrobiotic: Ibrown Irice, Iother Igrains, Iand Iherb Iteas o Fruitarian: Iconsumes Ifruit, Inuts, Ihoney, Iand Iolive Ioil
  • Parenteral Inutrition o Patients Iwho Icannot Itolerate Inutrition Ithrough IGI Itract o Consists Iof Iglucose, Iamino Iacids, Ilipids, Iminerals, Ielectrolytes, Itrace Ielements,Iand Ivitamins
  • Enteral ITube IFeeding o Provide Inutrients Iinto Ithe IGI Itract o Risk Iof Iaspiration
  • Signs Iand Isymptoms Iof Ihyperglycemia

o Increased Ithirst, Iheadaches, Itrouble Iconcentrating, Iblurred Ivision, IfrequentIpeeing, Ifatigue, Iweight Iloss, Iblood Isugar Imore Ithan I180mg/dL

  • Peptic IUlcer o Causes ▪ H. Ipylori ▪ Stress ▪ Acid Ioverproduction o Treatments ▪ Avoid Icaffeine ▪ Avoid Ispicy Ifoods ▪ Avoid Iaspirin, INSAIDs ▪ Consume Ismall Ifrequent Imeals
  • Inflammatory Ibowel Idisease o Crohn’s o Idiopathic Iulcerative Icolitis
  • Medical Inutrition Itherapy o Diabetes Imellitus: IType I 1 ▪ Insulin Iand Idietary Irestrictions o Diabetes Imellitus: IType I 2 ▪ Individualized Idiet ▪ Carb Iconsistency Iand Imonitoring ▪ Saturated Ifats Iless Ithan I7% ▪ Cholesterol Iintake Iless Ithan I 200 Img/dL ▪ Protein Iintake I 15 Ito I20% o Cancer ▪ Smell Iand Itaste Idistortions ▪ Decreased Isalivation ▪ Dysphagia ▪ Intake Iof Inutrients Iand Ifluids: Iencourage Ismall Ifrequent Imeals Iand IsnacksIthat Iare Inutritious Iand Ieasy Ito Idigest o AID/HIV ▪ Maximize Ikcals Iand Inutrients ▪ Encourage Ismall, Ifrequent, Inutrient-dense Imeals Iwith Ifluid Iin Ibetween Transferring Ipatients
  • Transfer/gait Ibelt
  • Transfer Iboard
  • Transfer Isheet
  • Mechanical Ilifts I(>200 Ilbs) Math 2.2 Ikg I= I1lb I 1 Ilb I= I 16 Ioz I 1 Ioz= I 30 ImL 1 Itbs I= I 15 ImL

1 Itsp I= I 5 ImL 1 IL I= I 1000 ImL 1 Ig I= I 1000 Img 1 Imicrodrip I= I 60 Igtts/mL