Pressure Ulcers and Nursing Interventions, Exams of Advanced Education

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HONDROS NURSING NUR 150: EXAM 2 STUDY

EXAM NEW REVIEW UPDATE

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 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