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