Wound Care and Skin Integrity Management, Exams of Nursing

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NSG2000 Exam 3

acute trauma - ANS accident, irregular borders; skin tear-mechanical course; the elderly acute surgical - ANS staples, sutures, skin adhesive; intact (wound is closed), well approximated edges surgical clean/clean contaminated - ANS no infection, intentional (appendicitis, fistulas) surgical contaminated/dirty - ANS high infection, lots of debris, left open to heal, large bacterial load (healing takes months to years to heal) Moisture associated skin damage (MASD) - ANS risk: excessive sweating, increased skin temp, change in skin pH, deep skin folds S&S: rash that may have pain, burning or itching; higher risk for pressure injuries chronic wounds - ANS acute wounds that encounter complications, long time to heal; alterations in blood flow to an area (venous sufficiency), peripheral artery disease & diabetes, fat has no blood flow Phases of wound healing - ANS inflammatory, proliferative, maturation inflammatory wound healing phase - ANS time of injuries up to 3-6 days afterwards, blood vessels constrict, phagocytosis (WBC), lots of neutrophils (for immunity) proliferative wound healing phase - ANS begins at day 3 and lasts up to 24 days;; loss of tissues replaced with granulation and collagen, new blood vessels begin to form, edges pull in to help close area; helps cover and resurface wound (scar tissue) maturation wound healing phase - ANS combination of inflammatory and proliferative, open for 5- days then closed with no signs of infection (C-Section); long time to heal and usually healed with a wound vac

factors that impact healing - ANS age, overall wellness, decreased leukocyte count, infection, medications, nutrition, tissue perfusion, low Hgb levels, obesity, chronic disease, smoking, wound stress, meds (NSAIDS + Steroids inhibit healing), wound stress (coughing) assessment appearance - ANS day 1-4 bright red day 5-14 bright pink day 15-1 yr.: pale unless dark pigmented skin how do you measure a wound? - ANS 3D; length, width, depth (if tunneling, then use a q-tip to detect how long, how deep and how far it goes in) when testing drainage, what do you assess? - ANS amount, color, consistency, odor Types of exudate - ANS serous, sanguineous, serosanguineous, purulent how do you close a wound? - ANS staples, sutures, surgical glue how does scarring appear on light and dark skin? - ANS light=silver, dark=pale pink when using drains and tubing what should you look for? - ANS what it looks like around/under the drain, what type of drainage, if you are able to give the patient a showering, notify provider with any concerns how long after a drain is removed should you change the gauze? - ANS 24 hrs. active - ANS closed passive - ANS open Penrose drain - ANS passive/open, lots of exudate, 24-48 hrs; if gauze saturated then change them using sterile

portable bulb suction device - ANS active/closed, JP: empty bulb every 8 hr; if half full empty sooner; always apply suction; amount should decrease by 30-100 then removed; use something to measure then throw it in the toilet large bottle drainage - ANS active/closed; hang it on bed, used after trauma or long surgery, change when half full and mark output Circular portable wound suction device - ANS active/closed, hemovac (circular, low pressure), w/ spring wound vac - ANS active/closed, multi-layer, clear dressing over top then allows it to be flat, high pressure. the wound vac must be exact size of wound NSG interventions for wound care - ANS -hydration and nutrition -wound care -wound dressing wound dressings - ANS occlusive, non-occlusive, semi-occlusive, hydrocolloid, wet-to-dry, open to air Occlusive wound dressing - ANS often used as an immediate wound hygiene control and also prevents blood loss until debridement is performed debridement - ANS removal of foreign material and dead or damaged tissue from a wound semi-occlusive dressing - ANS allows wound to breathe (air can penetrate in and out) but at the same time, protects the wound from outside liquids Non-occlusive dressing - ANS could allow contaminates to pass through the bandage and contact the wound (think permeable) Hydrocolloid wound dressing - ANS - provides moderate absorption- change every 3-7 days

• protects and cushions

Wet to dry wound care - ANS moisten gauze over wound until it dries Wound closure techniques - ANS staples, suture, stere-strips, tissue adhesive staples - ANS most often, go straight in with no bending and it is removed 7-14 days after. A complication includes rotation of staple suture - ANS left in longer on joints, removed 7-10 days after, more scarring b/c body sees these as foreign objects. complications may be bind tracts which are similar to tunneling deep suture - ANS dissolvable shallow suture - ANS non-dissolvable steri strips - ANS tape, used with glue, after 7-10 days they peel off on their own tissue adhesive (glue) - ANS best for cosmetic surgery, DO NOT USE OVER JOINTS, 24 hr dry time and 5 days no showering, straight edges bandages, binders, slings advantage - ANS provides support bandages, binders, slings disadvantages - ANS gas pockets bandages, binders, slings complications - ANS skin breakdown secure dressing tapes include: - ANS paper tape, transport tape, cloth tape, OP site, transport, tegaderm paper tape - ANS hypo-allergenic, gentlest, does not stick well to moist skin, elderly, sensitive skin transpore tape - ANS hypoallergenic, most often, wet surfaces, sticks to patients, without gloves, strong

cloth tape - ANS strapping/general use, flexible and has heavy strength, different sizes Op-site, transparent, tegaderm - ANS IV's, skin tear, great for a dry granulating wound with no exudate under. Helps maintain moisture in wound and you can still see wound. Heat Therapy - ANS arthritis, joint pain, muscle strain, menstrual cramps, back aches; increases blood flow to injury, decreases pain and stiffness, relaxing Cold Therapy - ANS alway put something in between; decreases inflammation and pain, decreases blood flow, 20 minutes on and 20 minutes off wound complications - ANS dehiscence and evisceration Dehiscence - ANS Bursting open of a wound, especially a surgical abdominal wound, entire or small poring, 7-10 days after surgery Evisceration - ANS The displacement of organs outside of the body, EMERGENCY, sneezing, coughing, vomiting; put something wet (like saline) down and cover organs Wound Risk Factors - ANS -patient characteristics -poor surgical technique -infection wound manifestations - ANS -increase serosangeuineous drainage -strain of incision -popping sensation wound intervention - ANS - stay with patient -low fowlers position -cover area w moist dressing -start IV for lots of fluid -prep for surgery -document

-continue taking vitals Hemmorrhage - ANS large amount of blood lost either externally or internally over short period of time; 24-48 hrs after injury or surgery due to clot sidlodged, suture breaks, blood vessel damaged hemorrhage assessment - ANS decrease O2, increased HR, tachypnea, clammy skin, monitor I&O, internal=swelling/distention, hematoma (red or blue) Hemorrhage interventions - ANS apply pressure, notify provider, monitor vitals, give O2, start IV, give blood, prep for surgery other complications - ANS adhesions, fistula, tunneling adhesions - ANS not meant to be together, skin or incision to whatever is underneath; first few days after surgery must cut and release it fistula - ANS abnormal tunneling between two areas (bladder and vaginal wall), usually with sutures tunneling - ANS passages under skin Cellulitis - ANS local, warm, pain dwelling, purulent exudate systemic infection - ANS fever, chills, N&V, hypotension, increase pule and RR, increased blood sugar, increased WBC, change in mental status SSI - ANS use nursing bundles; staph is most common SSI CDC Criteria - ANS infection near surgical site within 30 days must be reported; deep surgical incisions within days 30-90 must be reported wound culture - ANS -anticipate suspected infection -clean wound with saline

-used cotton tipped applicators, get drainage from wound bed; don't touch patients skin but only within wound epidermis - ANS outer layer, protects skin from water loss, pathogens, and injury; major source of vit. D dermis - ANS middle layer, supports epidermis, protects underlying structures form injury, helps w/ wound healing sub Q layer - ANS inner most layer, insulation (most fat), shock absorption/protects internal organs and helps sense change in temperature skin integrity risk factors - ANS age, congenital, immobility, chronic disease skin integrity risk factor: age - ANS children and elderly; less sweat, dry flaky skin, old=longest exposure to sun) skin integrity risk factor: congenital - ANS birth defects skin integrity risk factor: immobility - ANS pressure injury, skin breakdown, injury, neurological issues skin integrity risk factor: chronic disease - ANS comorbidities, diabetes, kidney disease, liver failure cancer Role as a nurse for Skin Integrity - ANS assessment: abrasions, scars rashes, temp, color analyze: potential risk or actual risk? plan: what change need to happen in order to heal? implementation evaluate assessment of dark skin people: - ANS cyanosis, jaundice, bleeding, inflammation

assessment of dark skin people: cyanosis - ANS check lips and tongue for grey color, nail beds, palms, sole of feet (eye whites for pallor) assessment of dark skin people: jaundice - ANS check oral mucous membrane and check sclera closest to iris assessment of dark skin people: bleeding - ANS look for swelling and skin darkening assessment of dark skin people: inflammation - ANS look for warmth, shiny or taunt/pitting skin pressure injury - ANS boney prominence (easiest to get PI), sharing, compression Shearing - ANS when skin moves against fixed surface (friction) compression - ANS restrict blood flow to skin, ischemia, inflammation and necrosis how often do you turn a patient? - ANS every 2 hours Pressure Injury Risk Factors - ANS immobility, decreased perfusion, friction, incontinence, skin pressure, decreased level of consciousness, malnutrition, altered sensation what aids in the healing process and if it is low the wound won't heal? - ANS albumin financial damage - ANS up to $500 daily physical damage - ANS pain, prolonged healing, risk of infection psychological damage - ANS altered body image, social isolation, depression observe these 4 things about wounds: - ANS location, drainage, odor, devices/drains do you massage reddened (erythema) areas? - ANS no

non-blanchable erythema - ANS areas of redness that do not become pale when pressure is applied (bad) Blanchable erythema - ANS visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved (good) warmth indicates - ANS inflammation cold indicates - ANS decreased perfusion and blood flow what leads to moisture associated skin damage (MASD)? - ANS obesity Braden Scale ranges from - ANS 6- if Braden score is 18 or less: - ANS at risk for skin breakdown how many stages are on the Braden scale? - ANS 4 stage 1 Braden scale - ANS skin intact, hyperemia (reddened), non blanching, maybe painful, firm/soft, difficult to detect on dark skin Stage 2 on Braden Scale - ANS superficial, skin not intact, partial thickness and loss of DERMIS (main layer in wound healing), shallow open ulceration, red/pink, ruptured serum filled blisters stage 3 on Braden scale - ANS full thickness skin loss through epidermis, adipose tissue showing, ROLLED EDGES, tunneling, may show dead tissue Stage 4 on Braden Scale - ANS full thickness skin loss, muscles/tendons/ligaments/cartilage visible, rolled edges, undermining and tunneling may be present, dead tissues and organs seen unstageable breakdown - ANS obscured full thickness skin/tissue loss, yellow stringy, eschear black and brown tissue; if stuff overtop is removed it tends to be stage 3/4.

medical devices related pressure injury (MDRPI) - ANS prolonged exposure to devices worn by patients (O2 mask, tubing, urinary Cath, cervical collars) mucosal membrane pressure injury - ANS prolonged exposure to devices used for care of client (mouth, nose) when do you document for a pressure injury? - ANS routine assessment and each dressing change what do you document for a pressure injury? - ANS location, size, wound edges, exudate type and mount, pain, stage, appearance of tissue in wound, surrounding tissue, tunneling NSG interventions for PI - ANS assess and prevent, skin care, manage of incontinence, hydration and nutrition, relieving pressure and avoiding shearing, wound management skin care for PI - ANS cleaning skin including between folds, use proper soap (don't rub), apply lotion. check circulation and for ischemia. what is the minimum amount of Hgb needed to prevent ischemia? - ANS 12 Management of incontinence - ANS keep skin dry, use toilet every 3-4 hours or prn, external device, incontinence pads, catheter (IF NEEDED), make rounds every 2 hours, moisture barriers hydration and nutritional status - ANS push fluids, malnutrition, create positive nitrogen balance, protein, nutrition assessment what supplements are important especially for prevention of malnutrition? - ANS A, C, Zink how do you create a positive nitrogen balance? - ANS increase calories by 30- how do you increase protein? - ANS 0.8/kg/day to 1.8/kg/day relieving pressure and avoiding shearing - ANS turn at least every 2 hours, elevate HOB, sit less than 2 hours, MAKE SURE BED IS WRINKLE FREE, use padding

wound management - ANS cleaning and removing exudate, deriding, dressings, vacuum sister closure system cleaning and removing exudate - ANS clean cleanest to dirtiest, gentle friction will not cause damage or bleeding, wipe one with non-fiber shedding supplies and NO COTTON BALLS, use saline and a 19 gauge needle, keep wound moist and covered debriding - ANS removing non-viable tissue debriding surgical - ANS removal by physician or specialty nurse; scalpel, scissors, other star item deriding biological - ANS enzymatic egents(dressings), larvae/maggots Semiocclusive dressings: - ANS films, hydrocolloid, alginate, hydro-fiber, foams, polymeric membranes, hydrogels films - ANS superficial wounds hydrocolloid - ANS small abrasion, superficial burns, PI, post-op effects or immobility - ANS physical, psychological, cognitive physical effects of immobility - ANS stroke, amputation, balance/falls psychological effects of immobility - ANS depressed, isolation body mechanics - ANS use musculoskeletal and nervous system 3 principles of body mechanics - ANS alignment, balance, body movement ergonomics - ANS lifting, sitting, computer work, slippery surfaces, sleeping

how do you prevent staff injury? - ANS proper body mechanics lift teams safe equipment how do you prevent injury for patients? - ANS staff using proper body mechanics gait belts non slip footwear get them moving!! effects of immobility on musculoskeletal - ANS atrophy, sarcopnea, loss of muscle mass, disuse osteoporosis, demineralization, think, weakness, foot drop musculoskeletal - ANS muscles, bones, joints, tendons, cartilage, ligaments; movement, posture, positioning, generate body heat immobility effects musculoskeletal: bone - ANS disuse osteoporosis (demineralization), thin/weak increases risk of fractures, longer to repair than muscle strength immobility effects musculoskeletal: muscle - ANS atrophy disuse and sarcopenia (loss of muscle mass); O2 and glucose required immobility effects musculoskeletal: joint - ANS contractures (permanent; foot drop) immobility effects neurological - ANS central, peripheral, proprioception, kinesthesia immobility effects neurological: central - ANS brain spinal cord, balance and fine tune body positioning and movement with help from PANS immobility effects neurological: peripheral - ANS attached to spinal cord, helps communicate with muscles and receptors

immobility effects neurological: proprioception - ANS know posture, movements, change in equilibrium, knowledge of position, weight, and resistance to objects in relation to body immobility effects neurological: kinesthesia - ANS ability to perceive extent direction, or weight of movement NSG Activities for effects of immobility - ANS check doctors orders and see possible activities move every two house assess hourly (pain, weakness, stiffness, movement, assessment tools) MAT (movement associated tool) & TUG (timed up and go) NSG Activities implementation for effects of immobility - ANS ambulation -increase activity as much as tolerated -encourage independence -help decrease length of stay -help prevent pneumonia and decrease blood clots,

• increase emotion -splint/boot for foot drop -delegate ROM -use assistive devices NSG Activities for effects of immobility: SAFETY - ANS call light within reach, bed low and locked, fall precautions, safety trumpets privacy effects of immobility: respiratory - ANS bedrest impart gas exchange, positioning is affected, dehydration leads to pneumonia, atelectasis effects of immobility: respiratory positioning - ANS unable to fully expand rib cage, organs press on diaphragm which decreases coughing and deep eating, raise bed if difficulty breathing respiratory effects that lead to pneumonia - ANS dehydration leads to increased viscosity of mucus, leukocytosis, productive cough, fever, SOB, chest pain, incentive spirometer

atelectasis - ANS partial or complete collapse of the lung NSG Activities for Effects of Immobility Respiratory - ANS assess (prevent atelectasis and pneumonia by auscultating all lobes + monitoring 02, labs and vitals. swelling (dysphagia.. aspiration pneumonia) implementation ( incentive spirometer, cough and deep breathe, elevate HOB, turn every 2 hours, push fluids, see if O2 is needed. SEE IF ORAL CARE IS NEEDED ESPECIALLY IF THEY ARE ON VENT Effects of Immobility: Cardiac - ANS orthostatic hypotension, virchows triad, hyper coagulability, endothelial damage, DVT, PE, CVA & MI orthostatic hypotension - ANS effect of cardiac; check in the morning, look for decrease in systolic of 20 mmHg or decrease in diastolic 10 mmHg or more within 3 minutes of positioning. High fall risk. Ensure someone else is with you when monitoring for orthostatic hypotension to prevent injury for patient and nurse virchows triad - ANS cardiac effect of immobility; increased risk due to increased viscosity and atrophy of heart stasis of venous circulation - ANS cardiac effect; blood flow slows down and causes the cells to cluster and thicken Hypercoagulability - ANS cardia effect; change in clotting factors or increased platelets endothelial damage - ANS cardiac effect; damage to vessel walls DVT (deep vein thrombosis) - ANS cardiac affect; seem most often in arms, pelvis, thigh or lower legs s&s: pain, warmth, erythema action: measure calves, notify provider elevate extremity, no rubbing or pressure, use anticoagulants Pulmonary embolism - ANS cardiac effect; S&S: SOB, chest pain, may feel like they are smothering, often anxious, hemoptysis, decreased BP with rapid pulse, STAT page provider actions: STAT page provider, anticipate anticoagulants, position at fowlers, check o2 and vitals frequently, anticipate blood gasses, give O

CVA + MI - ANS cardiac effect; action: call rapid response stroke team (if not breathing then call code and start compressing), STAT page provider, frequent vitals and o2, give o2 as needed effects of immobility: cardiac assess - ANS orthostatic hypotension peripheral pulses calf circumference heart sounds palpate applying anti embolism stockings - ANS full leg, to knee, waist high, what size, dorsal recumbent roll down and grasp bottom of stocking; pull heel up and ensure NO WRINKLES; assess circulation 30 mins after putting on knee high: 2" below back of knee thigh high: 2" below buttocks effects of immobility: GI - ANS decrease appetite (slows healing) , slowing of GI tract, GERD effects of immobility: slowing of GI tract - ANS peristalsis, reduces thickness of mucosal lining -constipation: 16x higher risk if bedrest or on opioids GERD - ANS back flow of stomach fluids damaging esophageal lining effects of immobility: GI Assess - ANS constipation, gerd, malnutrition, bowel sounds, frequency of bowel movement, abdominal pain, heartburn, I&O effects of immobility: GI Implementation - ANS push fluids, ambulation, GERD, diet effects of immobility: urinary - ANS bedrest -position ensures organs are laying on bladder

effects of immobility: urinary complications - ANS urinary retention, renal calculi, UTI urinary retention - ANS inability to empty the bladder renal calculi - ANS due to hypercalcemia UTI - ANS stones and retention increase bacterial load, promotes UTI NSG Activities Assessment: Urinary - ANS I&O, suprapubic pain or incontinence/retention, frequency and burning/UTI NSG Activities Implementation: Urinary - ANS push fluids, sit upright when voiding, frequent peri care effects of immobility: metabolic - ANS BMR, nitrogen, calcium basal metaboic rate (BMR) - ANS energy needed at rest to maintain life sustaining activities (maintained by thyroid hormone). body naturally raises this to help fight infection effects of immobility: Metabolic Normal Nitrogen - ANS rebuilds, repairs, replaces body tissues, nitrogen balance. positive nitrogen balance occurs with greater intake than output; required for growth, lean body mass, wound health, vital organ, pregnancy nitrogen immobility - ANS not enough protein and carbs/calories usually call of dietary consult breakdown of tissue resulting in weight loss, decreased muscle mass and weakness calcium - ANS resorption from bones risks: -hypercalcemia leads to osteoporosis -pathological fractures -lethargy

-calcitonin: calms down calcium; helps body keep calcium in bones

• PTH regulates calcium Effects of Immobility: Psychological - ANS self concept is interrupted, give choices whenever you can, social isolation and loneliness, increased depression, anxiety and frustration Effects of Immobility: Psychological (Depression) What should nurses do? - ANS encourage movement, focus of gratitude Effects of Immobility: Psychological (Anxiety) What should nurses do? - ANS ask questions to determine what is causing anxiety, discuss coping strategies; call social worker or nurse discharge planner to help situation if possible Psychological Immobility NSG Activities - ANS assess: depression, anxiety, loneliness, isolation, monitor emotional state, confusion (elderly), dependance vs self reliance implementation: use therapeutic communication, be supportive and empathetic, encourage self care, ask how they normally cope, encourage visitors, notify provider and chaplain developmental changes: infant, toddler, preschooler - ANS -learning to stand and walk -intellectual development -risk of regresssion -musculoskeletal -gross motor skills developmental changes: adolescents - ANS -hospitalization causes them to be more dependent -social isolation -musculoskeletal developmental changes: adults - ANS -self concept -loss of income -family obligations developmental changes: older adults - ANS -functional decline

-bone loss and balance issues -lack of activity leads to no appetite (anorexia/malnutrition) sensory alteration is caused by - ANS 12 cranial nerves (age, meds, injuries, Nero cognitive disorders, disease sensory deficit - ANS deficit of one or more of the senses sensory deprivation - ANS reduction/absence of stimulate to one or more senses sensory overload - ANS receiving stimuli are a rate greater than what the brain can process sensory processing disorder - ANS oversensitive to normal stimuli effects of sensory depravation: cognitive - ANS decreased learning ability inability to problem solve disorientation unusual thought increased need for attention effects of sensory depravation: affective - ANS bored restless increased anxiety emotionally liable panic increased need for physical stimulation effects of sensory depravation: perceptual - ANS changes in visual/motor coordination reduced color perception less tactile accuracy difficult perceiving shape and size

difficulty in time judgement nurse responsibility for all senses - ANS assess: routine health screening, wearing safety equipment, meds, environmental noise safety: walkways lighten, assistive devices, phone and call light education cognitive disorders - ANS dementia, delirium, or amnesia characterized by impairments in cognition (such as deficits in memory, language, or planning) and caused by a medical condition or by substance intoxication or withdrawal dementia - ANS general term describing problems with reasoning, planning, judgement, memory, and any other thought processes caused impaired blood flow to brain. IIREVERSIBLE manifestations for dementia are _____ and often ________ - ANS slow, overlooked delirium - ANS disturbance in mental ability resulting in confused thinking/reduced awareness of environment delirium manifestations are _____ and ______ - ANS sudden, vary delirium treatment - ANS airway provide fluids ambulation treat pain look at meds avoid using restraints and foleys address incontinence encourage family myopia - ANS nearsightedness hyperopia - ANS farsightedness

astigmatism - ANS a condition in which the eye does not focus properly because of uneven curvatures of the cornea presbyopia - ANS farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age. cataract - ANS clouding of the lens of the eye diabetic retinopathy - ANS damage to the retina as a complication of uncontrolled diabetes Glaucoma - ANS increased intraocular pressure results in damage to the retina and optic nerve with loss of vision (if worsens go to hospital) macular degeneration - ANS irreversible degeneration of macula=loss of central vision, #1 cause of blindness > eye exam=snellen - ANS sit/stand 20' away, cover 1 eyes and read the smallest line Refraction assessment - ANS look at light passing to back of eye, if fails then you need contacts/glasses/surgery slit lamp - ANS exam of lens and eye structures with bright light, often dilate eyes with meds (looking for cataract, glaucoma and diabetic neuropathy) fluorescein angiography - ANS inject dye in eye in peripheral vein and observe flow thru vessels in eye (looks for diabetic neuropathy) answer grid - ANS client identifies if lines are straight or wavy (detects muscular degeneration) nurse responsibility: sight - ANS assessment education promoting eye healthy and injury prevention (eye protection, use contact/magnifying glass, monitor and educate about blood sugar and bp, annual exams)

safety for those with moderate impairment (blindness) - ANS clutter free environment, can/service animal, orient to room and food tray, picture board braille, safe home) hearing loss is caused by: - ANS infection, injury, genetic child hearing loss is evidenced by - ANS different speech, speech issues, learning difficulties conductive hearing loss - ANS when sound waves are prevented from passing from the air to the fluid-filled inner ear history of patient with conductive hearing loss - ANS otis media (infection of middle ear) otosclerosis (abnormal bone growth) sensorineural hearing loss - ANS the most common form of hearing loss, also called nerve deafness; caused by damage to the cochlea's receptor cells or to the auditory nerves (CN8) sensorineural hearing loss: newborn - ANS infection, chromosomal abnormality, preterm birth sensorineural hearing loss: childhood - ANS infection, mumps, measles, meningitis sensorineural hearing loss: adolescents-adults - ANS noise induced tinnitus - ANS a jingling; a ringing or buzzing in the ear when no sounds are present ototoxicity - ANS damage to the organs of hearing by a toxic substance (meds), can cause SNHL, tinnitus, dizziness, impaired balance mixed hearing loss - ANS having conductive and SNHL simultaneously hearing MEDS - ANS NSAIDS, ABX, certain carcinogens, diuretics

Rinne test - ANS hearing test using a tuning fork; checks for differences in bone conduction and air conduction audiometer test - ANS different decibels; most common, in padded room w headphones bone oscillator test - ANS monitor response of auditory nerve to vibration Auditory Brainstem Response (ABR) - ANS monitor brain response to sounds (electrodes on scalp) otoacoustic emmissions (OAEs) - ANS assess response of inner ear to sound waves (probe in ear) Nurse Responsibility: Hearing - ANS determine if its hearing loss of confusion encourage cerumen removal interventions for improved communication education on ear protection/treatments communicate w hearing loss pts. -well lit room -minimize noise -face them -hearing aids in -educate Communiation - ANS combination of thinking, cognition, hearing, speech production, motor coordination speech is controlled by these nerves - ANS 5,10,11,12, phrenic, intercostal aphasia - ANS inability to speak expressive aphasia - ANS The inability to produce language ( despite being able to understand language)

comprehensive aphasia - ANS doesn't understand others, speaks in long sentences w made up words speech exams - ANS MRI, labs, neuro exam Nurse Responsibility: Speech - ANS education of safety encourage speech therapy use picture boards allow extra time 2 pathways to obtain smell - ANS through nose or through opening between roof of mouth and nose anosmia - ANS absence of the sense of smell Hyposmia - ANS impaired sense of smell parosmia - ANS distorted sense of smell Phantosmia - ANS "hallucinated smell", often unpleasant small issues caused by: - ANS age, men more than women, head trauma, smoking, meds, neurological disease, sinus diseases, UR infections smell tests - ANS PCP: exam, history, review meds, test assessment referal xray MRI nasal endoscopy what types of cells are gastatory - ANS taste buds

phantom taste perception - ANS persistent, foul taste when the mouth is empty Hypogeusia - ANS reduced ability to taste ageusia - ANS inability to taste Dysgeusia - ANS altered taste taste exams - ANS exam by primary provider ent diagnostic Nurse Responsibility: Taste - ANS encourage dental visits encourage elderly to chew thoroughly wear helmet tobacco cessation installation of smoke detectors decrease unpleasant odors Sensation - ANS occurs when information interacts with sensory receptors (eyes, ears, tongue, nostrils, and skin) Tactile Hypersensitivity - ANS over sensitive by CNS and PNS tactile defensiveness - ANS severe sensitivity to touch tactile hyposensitivity - ANS under responsive to tactile stimulation peripheral neuropathy - ANS disorder of the peripheral nerves that carry information to and from the brain and spinal cord

diabetic neuropathy - ANS nerve damage and damage to blood vessels supplying said nerves in diabetic pics because glucose level is too high idiopathic neuropathy - ANS nerve damage from unknown disease Exams: TOUCH - ANS neurologic xrays lab work MRI EMG Nurse Responsibility: Touch - ANS education on safety (seat belts, safety equipment for sports, shoes examining feet, diabetics (blood sugar and pressure), handrails and non skid mats in tubs showers, watch for spinal cord injuries, clear walkways and rugs, nightlight impacts ADLs and social interactions/relationships MEDICATIONS FOR TOUCH (still need to know how why impact sensation) - ANS NSAIDS ABX loop diuretics antihypertensives psychotropics antihistamines aspirin (ASA)