NUR 155

pressure ulcers first appear _____ then _______ pale red Stage 1 pressure ulcer intact skin with nonblanchable redness (erythema) Signs of hemorrhage hypotension tachycardia increased respirations stage 2 pressure ulcer (abrasion, blister, shallow crater) partial thickness skin loss involving epidermis, dermis, or both Abrasion scrape stage 3 pressure ulcer Full-thickness damage or necrosis to subQ stage 4 pressure ulcer Full-thickness tissue loss with ex...

When bathing a dementia patient what should you do. Keep covered, move slowly, time bath to patients tolerance. primary prevention Precedes disease. Example: immunizations, nutrition education, family planning secondary prevention Early detection, prompt intervention Example: screenings, any procedure, self exams, assessments. tertiary prevention Begins after illness. Examples: support groups, teaching client to prevent complications. helath promotion Not disease...

Afebrile Absence of fever Apnea absence of breathing apical pulse pulse taken with a stethoscope and near the apex of the heart arrhythmia irregular heart rhythm auscultatory gap temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and is gradually reduced, with the sounds again heard at a lower level of pressure (usually occurring in patients who have hypertension) Bradycardia slow heart rate ...

During the transduction phase of nociception which method of pain control is most effective? A. Tricyclic antidepressants B. Opiods C. Ibuprofen D. Distraction Ibuprofen When a client has arrived at the nursing unit from surgery the nurse is most likely to give priority to which of the following assessments? A. Pain tolerance B. Pain intensity C.Location of pain D.Pain history Pain intensity A client who describes his pain as 7 on a scale of 0 to 10 is classified as havin...

Critical Thinking Involves the application of knowledge and experience. Clinical Reasoning The ability to focus and filter critical data to recognize what is most and least important. Steps of the Nursing Process ADPIE 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation Assessment Collect data -subjective(health hx, symptoms) -objective(measurable, signs, labs, exams) Recognize cues Three ways -observation -interview (primary: patient-...

Define Culturally responsive care. Care that is centered on the clients cultural point of view and integrates the clients values and beliefs into the plan of care. Culture a set of values, beliefs, and attitudes shared among a group of people Subculture Composed of ppl who have a distinct identiy and are related to a larger cultural group Multiculture A person who has multiple patterns of identification or crosses several cultures , lifestyle, and sets of values. ...

Intradermal needle gauge 25-27 gauge Intradermal needle length 1/4-5/8 inch Intradermal volume of fluid 0.1 mL Intradermal aspiration Do not aspirate intradermal common sites Inner lower arm, upper chest, back beneath scapulae Intradermal common uses allergy testing and TB screening subcutaneous injection needle size 25 gauge or 30 gauge for insulin Subcutaneous needle length Adult of normal weight: 5/8 in needle inserted at 45 degree an...

tanners model of clinical judgement noticing interpreting responding reflecting nursing process assess planning implementation evaluation identifying signs and symptoms N to identify any abnormal signs and symptoms when assessing the patient gathering complete and accurate data N to collect relevant and accurate data before making a plan of action assessing systematically and comprehensively N to use a step by step approach to make sure no information is mi...

Types of wounds Intentional or unintentional Open or closed Acute or chronic Partial thickness, full thickness, complex transparent film autolytic debridement, semi-permeable allows skin to breathe. uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears how do you apply an abdominal binder? start at typhoid, fasten from the bottom up used for support to keep dressing intact remove every two hours to asses underlying skin and wound Risk factors for pressure ulce...

What is identifying signs and symptoms a subcategory of noticing What is gathering complete and accurate data a subcategory of noticing what is assessing systematically and comprehensively a subcategory of noticing what is predicting and managing potential complications a subcategory of noticing and interpreting what is identifying assumptions a subcategory of noticing what is clustering related information a subcategory of interpreting what is rec...