Skin and Wound Care: Understanding Trauma, Ulcers, and Pressure Injuries, Exams of Nursing

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Ventura College CNA Exam 2 | 100% Correct

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What does the skin do? - ✔✔Skin provides protection to the body. Also helps regulate temperature, pain receptors, synthesizes Vit D. What is trauma? - ✔✔Trauma is when the skin usually tears on impact where it overlies a relatively firm surface such as a bony prominence. The wound edges may be ragged, abraded, bruised, inverted. There may be tissue strands bridging the wound What causes skin tears? - ✔✔Slight pressure can cause a skin tear, skin tears are also caused by friction, shearing, fall or bumps, holding on to person to tight, removing tape or adhesives, bathing, dressing, pulling buttons or zippers across, jewelry, and long or jagged fingernails. What are circulatory ulcers? - ✔✔Circulatory ulcers are open sores on the lower legs or feet. Caused by decreased blood flow through the arteries or veins. How can you help prevent ulcers? - ✔✔You can prevent ulcers by remining the person not to sit with feet crossed, re-positioning them every 2 hours, use non-tight clothes, provide/promote good skin care, do not scrub or rub the skin, provide clean linens, make sure shoes fit well, avoid injuries, check the persons daily, do not massage pressure points, apply stockings, and following the person's care plan. What is the difference between wound dehiscence and evisceration? - ✔✔Dehiscence is the separation of wound layers. Evisceration is the separation of the wound along with the protrusion of abdominal organs. Serous drainage - ✔✔clear, watery fluid Sanguineous drainage - ✔✔bloody (sanguis) drainage. Serosanguineous drainage - ✔✔thin, watery drainage that is blood-tinged.

Purulent drainage - ✔✔thick green, yellow, or brown drainage. What type of dressing changes can CNA's do? - ✔✔A dry non-sterilize, "simple dressings". No packing, no medication and no sterile technique can be done by a CNA. How do you apply and remove dressings? - ✔✔Remove the dressings away from the patient view. Change gloves and sanitize after removing the old dressing. Then apply the dressing by placing over wound and securing with 3 tapes one in the middle and one below and above. What is a pressure ulcer? - ✔✔A pressure ulcer is injury to the skin and underlying tissue resulting from prolonged pressure on the skin. The injury is usually over a bony prominence or related to a medical or other device. The injury results from pressure or pressure in combination with shear. What are other names of pressure ulcers? - ✔✔Bed sores, pressure injuries, pressure sores, or decubitus ulcers. Where are common areas of pressure ulcers? - ✔✔Heels, sacrum, elbows, shoulder blades, back of the head, ankles, leg, knees, thighs, hip, ears, genitalia, ribs, breasts, and toes. What are risk factors for pressure ulcers? - ✔✔Aging and age-related skin changes, skin breakdown and non-intact skin, dry skin, fragile and weak capillaries, general thinning of the skin, loss of the fatty layer under the skin, decreased sensation, decreased mobility, limited activity, chronic diseases, poor nutrition, poor hydration, incontinence, moisture, pressure on bony parts, friction, poor nail care, and edema. How can you prevent pressure ulcers? - ✔✔You can prevent pressure ulcers by following a re-position schedule, do not leave a bedpan under for longer than needed, prevent shearing and friction, use pillows and wedges, or other devices, do not move them onto a pressure injury site, and inspect the skin as you give care. What is the first stage of pressure ulcers? - ✔✔Non-blanchable erythema of intact skin.

Why do we use heat therapy? - ✔✔Relieves pain, relaxes muscles, promotes healing, reduces tissue swelling, and decreases joint stiffness. What does heat do to the blood vessels? - ✔✔Heat will dilate blood vessels (expand them and make them larger). Vasodilation. Can a CNA use a heating device? - ✔✔Yes, you may but you must know what application to apply, how to cover the application, what temperature to use, the application site, how long to leave the application in place, what observations to record and report, when to report observations, and what patient or resident concerns to report at once. How often do you leave heat on? And how often do you check to make sure the skin doesn't burn? - ✔✔Usually, you apply for 15-20 mins. Check the person every 5 minutes for observation. What is the purpose of cold therapy? - ✔✔Reduce pain, prevent swelling, decrease circulation and bleeding, and cool the body when fever is present. Does cold usually constrict or dilate blood vessels? - ✔✔Constrict blood vessels but if left for extended period of time it can do the opposite and dilate blood vessels. How is heat and cold therapy applied and how often do you need to check the person? - ✔✔Usually, you apply for 15-20 mins. Check the person every 5 minutes for observation. What is hyperthermia and hypothermia? - ✔✔Hyperthermia is a body temperature over 99.5⁰F Hypothermia is a body temperature below 95⁰F As a CNA what do you need to do for a person with hyperthermia or hypothermia? - ✔✔Hyperthermia can be treated by cooling the person with cool packs, ice pads, if needed cooling blankets can also be used. Hypothermia can be treated by warming them up for example an electric blanket may be used. What is a prothesis? - ✔✔Replacement of a missing body part by an artifical substitute.

How do you care for it? - ✔✔CNA's can encourage residents to keep their skin clean, dry, and lubricated, keep their bedding free of wrinkles, eat well, and drink plenty of liquids. What do you observe the skin under the prothesis for? - ✔✔You should check them daily for skin breakdown issues. Are you allowed to place a prosthetic device on? - ✔✔Yes, you are allowed to place a prosthetic device on. List 3 different ways that you can protect a person's hearing aids. - ✔✔Store them in a clean dry place, handle with care, clean them, and change batteries often. How do you clean hearing aids? - ✔✔You clean hearing aids according to the manufactures instructions. Usually, you can rinse the mold and tube with water and dish soap. Before reconnecting those parts you need to use an ear mold dryer. You also can change out the filter if you have an inner ear hearing aid. laryngeal mirror - ✔✔an instrument used to examine the mouth, teeth, and throat otoscope - ✔✔a lighted instrument used to examine the external ear and the eardrum. ophthalmoscope - ✔✔a lighted instrument used to examine the internal eye structures nasal speculum - ✔✔An instrument used to examine the inside of the nose vaginal speculum - ✔✔an instrument used to open the vagina to examine it and the cervix What are things you can do to help prepare the person for an exam? - ✔✔provide privacy, have the person empty their bladder, obtain a urine sample, measure, and record vital signs, weight, height, pulse oximetry, drape the person, and position the person for the exam.

What is the importance of the belongings list? - ✔✔To assure the person leaves with all the things they came into the facility with. What do you do if the resident wants to leave the facility against medical advice? - ✔✔Allow them to leave as you can not prevent them from doing to and report it to the nurse and note the patient as AWOL. What is the purpose of the urinary system? - ✔✔to regulate and maintain the composition of the blood and to remove waste products of metabolism by producing, transporting, storing, and excreting urine How much urine does an adult produce? - ✔✔1500ml What should you observe urine for? - ✔✔color, clarity, odor, amount, particles, and blood How do you put someone on a bedpan correctly? - ✔✔Ask them to lift their hips up as you place the bedpan underneath or have then roll to one side, place the pan and then have them roll back on the bedpan. How can you help a resident who has incontinence issues? - ✔✔Continue to check them every 2 hours to see if they are indeed incontinent. Hourly rounding, good skin care , Kegel exercises. How do you help with bladder training? - ✔✔Checking normal habits of the resident and creating a bathroom schedule. How do you calculate intake and output? - ✔✔You use a graduated cylinder to trace output of urine or else you can weight a brief. Note all liquids consumed in a day. What do you do when urine intake and output is different by 500 cc or more on your shift? - ✔✔Make a note on the person's chart, notify the nurse, and the next oncoming CNA just to be aware. UA - ✔✔urinalysis

UTI - ✔✔Urinary tract infection How often do people have bowel movements? - ✔✔Some people have a bowel movement every day others every 3 days it depends on the person. What should you observe a BM for? - ✔✔You should observe a BM for consistency, odor, and color. BM can notify you of health changes and sensitivity to food. What is constipation and how can you prevent it? - ✔✔Constipation is when you have trouble passing stool/having a bowel movement. You can prevent constipation by increasing a residents fiber intake, exercise, and liquid consumption. What is fecal impaction? - ✔✔Fecal impact is harden stool that is stuck in the rectum or lower colon due to chronic constipation. As a CNA how do you help someone with diarrhea? - ✔✔Notify the nurse, take the resident to the restroom promptly, and keep the resident hydrated/ encourage water consumption. How does bowel training work? - ✔✔Same as urine training, track habits and create a bathroom schedule. What is a colostomy and what would you expect stool consistency to be? - ✔✔Colostomy is an opening in the large intestine through the abdominal wall. Stool should be soft and paste like consistency as it has past most of the colon and yet still contains water. How does a random urine specimen differ from a clean catch urine? - ✔✔Random catch urine is without cleaning the labia's or tip or the penis when collecting a sample simple just collect a sample. Clean catch urine you must clean before collecting a sample and the person must first start to pee, stop, place the cup, then continue to pee in the container for the sample to be collected properly. How do you collect a 24 urine specimen? - ✔✔You collect all urine produced in 24 hours. Patient starts on an empty bladder this first urine is tossed out and not noted.

12:30 am military time - ✔✔ 0030 2:20 pm military time - ✔✔ 1420 What is the nursing process? - ✔✔The method nurses use to plan and deliver nursing care; its 5 steps are assessment, nursing diagnosis, planning, implementation, and evolution. How does the nursing diagnosis differ from a medical diagnosis? - ✔✔A nursing diagnosis is a health problem that can be treated by nursing measure. Whereas a medical diagnosis is the identification of a disease or condition by a doctor. What is the difference between subjective and objective data? - ✔✔Subjective data is things a person tells you about that you cannot observe through your senses, symptoms. Objective data is information that is seen, heard, felt, or smelled by an observer, signs. What is the difference between signs and symptoms? - ✔✔Signs are things that can be observed through the 5 senses. Symptoms are thing that cannot be observed through the 5 senses but are told to you by the patient. How do CNAs help in the nursing process? - ✔✔CNAs help in the nursing process by being the observer/reporter to changes in the person's care. What does ADPIE stand for in the nursing process? - ✔✔A - Assessment D - Diagnosis P - Planning I - Implementation E - Evaluation

When developing a nursing plan of care what must all goals be? - ✔✔The overall goal(s) for nursing plan of care is to be aware or the person's needs, set acceptable and measurable goals, and embrace interventions to achieve an overall goal. Tachypnea - ✔✔rapid breathing bradypnea - ✔✔abnormally slow breathing orthopnea - ✔✔ability to breathe only in an upright position Dyspnea - ✔✔difficulty breathing Apnea - ✔✔absence of breathing What is a normal oxygen concentration for an adult? - ✔✔ 95 - 100% How do you use a pulse oximeter and how do you know if it is working correctly? - ✔✔Squeeze end to open oximeter and place around pointer finger; It will give waveform to ensure it is working correctly What systems have to be working for respirations to take place? - ✔✔Respiratory system, nervous system, and circulatory system Where does oxygen and co2 exchange take place? - ✔✔At the alveoli level in the lungs. What is respiratory arrest and what do you do for it? - ✔✔Respiratory arrest is a medical event where the person stops breathing. You must breathe for the person by giving rescue breaths or starting CPR. What is respiratory depression? - ✔✔Rate and/or depth of respiration is insufficient to maintain adequate gas exchange in the lungs

What are some precautions to think about for patient safety when caring for a person with a tracheostomy? - ✔✔Infections and pneumonia are high risk for patients with tracheostomy tubes. Make sure you shave a person carefully and cover it when exposing the person to water such as showering or bathing the person. Oral care is another thing to be careful about. Always check to be sure the tubing is in place, keep it covered when outdoors, and be aware of signs of hypoxia. Note Tach care is done by a LVN, RN, or RT. If someone is on a mechanical ventilator what is your responsibility? - ✔✔Our responsibility for dealing with someone on a mechanical ventilator is if an alarm is sounding make sure it is connected and get the nurse if it is alarming. Things to remember communication issues, make sure call light is in reach, explain everything, comfort and reassurance is all met every time. What is suctioning, and can you suction someone? - ✔✔Suctioning involves removing excess secretions from the nasal cavity, mouth, throat, and trachea. A CNA cannot suction someone. When a nurse suctions, how long should it be for? - ✔✔A nurse should suction for no more than 10 secs. hemothorax effusion - ✔✔blood in the pleural cavity Pneumothorax effusion - ✔✔air around or outside the lung; in the pleural space pleural effusion - ✔✔abnormal accumulation of fluid in the pleural space, sometimes also known as "water on the lungs" When someone has chest tubes do you still need to C&DB, re-position and use an incentive spirometer with them? - ✔✔Yes. Walking someone with a chest tube must be a minimum of a 2-person job and 1 person must manage the chest tubes. SOB - ✔✔shortness of breath O2 - ✔✔Oxygen

SpO2 - ✔✔saturation of peripheral oxygen 95 - 100% COPD - ✔✔chronic obstructive pulmonary disease C&DB - ✔✔coughing and deep breathing