Which stage of pressure ulcer involves full thickness skin loss involving necrosis of subcutaneous tissue? |
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Stage 3 |
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What is a stressor? |
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Anything that is perceived as challenging, threatening, or demanding. |
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What is your acid and where is it produced? |
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carbon dioxide in the lungs |
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Food sources for vitamin A |
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liver, carrots, egg yolk, fortified milk |
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What are hydrogel dressings used for? |
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partial and full-thickness wounds, necrotic wounds, burns |
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Nursing interventions for pressure ulcers in regards to infection. |
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proper handwashing, aseptic techniques, monitor wound, administer meds, vital signs |
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compensation |
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overcome a perceived weakness |
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signs and symptoms of fliud volume deficit |
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thirst,weight loss weakness fatigue anorexia dry mucous membranes poor skin/tongue turgor sunken eyes weak rapid pulse ^specific gravity hematocrit BUN |
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hypertonic solution |
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has a greater osmolarity than plasma. water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. 5-10% dextrose = treats hypovolemia |
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norm value range of sodium |
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135 - 145 |
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food sources of vitamin d |
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sunlight, fortified milk, fish liver oils |
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which stage pressure ulcer involves intact skin, have a boggy feel and redness in lightly pigmented skin? |
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Stage 1 |
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What are hydrocolloidal dressings used for and how long can they be left in place? |
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shallow to moderate-depth skin ulcers, wounds with drainage, in conjunction with packing for open, deep wounds. can be left in place for 3 days. |
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Nursing interventions for pressure ulcers involving tissue integrity. |
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avoid pressure,reposition,monitor site, sterile dressing,hydration(in&out), increase protein and carbs |
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denial |
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refuses to acknowledge the presence of a condition that is disturbing |
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Physiological stressors |
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chemical (drugs,poisons), physical (heat, cold,trauma) infectious (viruses,bacteria) nutritional imbalances,hypoxia & genetic or immune disorders |
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which division of the autonomic nervous system regulates fight or flight response? |
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sympathetic |
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What is your base and where is it produced? |
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bicarbonate in the kidneys |
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what are percussion and vibration used for? |
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to loosen respiratory secretions so they can be more easily expectorated |
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isontonic solution |
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a solution that has about the same concentration of particles or osmolarity as plasma. normal saline IV |
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what is the average insensible loss from the skin and how is it lost? |
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200 to 400 mL from evaporation |
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what is a proporationate deficit of bicarbonate in ECF called? |
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metabolic acidosis |
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what is the normal value range for potassium? |
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3.5 - 5 |
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What are some food sources for vitamin E? |
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vegetable oild, wheat germ, whole grain products |
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What stage of pressure ulcer involves partial thickness skin loss and presents as an abrasion, blister or shallow crater? |
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stage 2 |
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What are some nursing interventions for skin ulcers related to immobility? |
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turn every 2 hours, pad, reduce shearing force, ROM, assistive devices |
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displacement |
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transfers of emotional reaction form one object or person to another object or person |
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what are some physical illness stressors in regards to autoimmune disorders? |
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Graves' disease, rheumatoid arthritis, ulcerative colitis, psoriasis, myasthenia gravis |
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Whick branch of the autonomic nervous system functions under normal conditions and at res? |
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parasympathetic |
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Hypotonic solution |
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less osmolarity than plasma. moves out of the intravascular space and into intracellular fluid, causing cells to swell and possible burst |
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What is the average sensible loss and how is it lost? |
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300 to 400 mL lost through sweat, urine and feces |
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what is the only hypo/electrolyte state that does not occur in seizures? |
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hypokalemia |
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What is the normal value range for calcium? |
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8.5 - 10.5 |
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What are some food sources for vitamin K? |
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dark green leafy vegetables |
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what are some treatments for stage 1 pressure ulcers? |
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frequent turning, pressure-relieving devices, positioning |
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Nursing interventions for pressure ulcers in regards to nutrition. |
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increase protein and carbs, hydration, daily weight, skin turgor, food diary, small frequent meals and snacks |
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introjection |
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a person incorporates qualities or values of another person into his or her own ego sturcture |
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what is the normal value range for magnesium? |
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1.3 - 2.1 |
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what are some treatments for stage 2 pressure ulcers? |
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frequent turning, pressure relieving devices, positioning, saline, occlusive dressing that promotes natural healing but prevents formation |
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what stage pressure ulcer involves full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle or bone? |
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stage 4 |
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projection |
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a person's thoughts or impulses are attributed to someone else |
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What are some physical illness stressors related to GI disorders? |
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esophageal reflux, constipation, diarrhea ulcerative colitis |
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If you increase CO2 do you create more acid or base? |
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acid |
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What is the average insensible loss from the lungs? |
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400mL - moisture in exhaled breaths |
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What is the normal value range for chloride? |
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95 - 105 |
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What are some treatments for stage 3 pressure ulcers? |
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Wet to dry dressings, surgical intervention, proteolytic enzymes. same treatments as stage 1 and 2 |
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rationalization |
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a person tries to give a logical or socially acceptable explanation for questionable behavior |
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What is hypocalcemia and what are some of the signs and symptoms? |
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calcium |
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what are some treatments for stage 4 pressure ulcers? |
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cover with nonadherent dressing and change every 8 to 12 hours, may require skin grafts. same treatments as stage 1-3 |
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during fight or flight what effect does dilation of skeletal muscles have? |
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increases strength |
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what is normal hemoglobin range? |
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12 - 18 |
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What is hypokalemia and what are the signs? |
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potassium |
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What is the normal pH of urine? |
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6 |
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what is the specific gravity of urine? |
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1.015 - 1.025 |
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What is the normal value range for bicarbonate? |
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25 - 29 |
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What is the normal range for hematocrit? |
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40 - 50% |
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What is a dietary source of sodium? |
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bacon, ham, sausage, catsup, mustard, processed foods |
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reaction formation |
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a person develops conscious attitudes and behavior patterns that are opposit to what he or she would really like to do. |
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What would an increased hematocrit indicate? |
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dehydration |
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What is hyponatremia? |
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sodium |
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What is the normal value range for phosphate? |
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2.5 - 4.5 |
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regression |
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a person returns to an earlier method of behaving |
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What is hypercalcemia? what can it lead to? |
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calcium > 10.5. Often leads to cardiac arrest |
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what would a BUN of 20 indicate? |
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starvation, high protein intake, severe dehydration |
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What are some food sources for potassium? |
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bananas, peaches, kiwi, figs, prunes, broccoli, potatoes |
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In fight or flight what two stages can follow the stage of resistance? |
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recovery or state of exhaustion |
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What is hypophosphatemia and what are the causes? |
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phosphate < 2.5 hyperventilation, insulin release, absorption problems, diuretic |
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sublimation |
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a person substitutes a socially acceptable goal for one whose normal channel of expression is blocked |
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Undoing |
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an act or communication used to negate a previous act or communication |
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What are some of the neuroendocrine activities in the shock phase of fight or flight? |
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^heart rate ^BP ^peripheral vasoconstriction ^metabolism ^water retention ^glucose. dilated pupils & bronchi. ^ mental alertness |
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What is metabolic acidosis? |
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deficit of bicarbonate. results from increase in acid |
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What is hyperkalemia? |
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potassium over 5. nerve conduction and muscle contractility can be affected. cardiac irregularities may result including cardiac arrest |
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What are some food sources of calcium? |
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milk, cheese, dried beans |
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What are the causes of hypocalcemia? |
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inadequate calcium intake, impaired calcium absorption, excessive calcium loss |
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the stage of exhaustion in fight or flight will result in either.... |
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rest and recovery or death |
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what are some food sources for phosphate? |
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beef, pork, dried peas, dried beans |
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what is hypernatremia? and what can it result from |
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sodium >145 excess water loss, overall excess of sodium |
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what is hyperphosphatemia? what are some of the causes? |
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above normal phosposphorus. impaired kidney excretion, excessive intake of phosphate containg laxatives, large vitamin D intake, chemo, hyperthyroidism |
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