NSG 122 Fundamental Concepts HESI Final Exam
Evidence-based practice (EBP) in nursing is a problem-solving approach to
making clinical decisions, using the best evidence available (considered
Evidence Based Practice
"best" because it is collected from sources such as published research,
national standards and guidelines, and reviews of targeted literature).
Integrity vs. Despair
People in late adulthood reflect on their lives and feel either a sense of
Erikson's Psychosocial Theory Older
Adults satisfaction or a sense of failure. People who feel proud of their
accomplishments feel a sense of integrity, and they can look back on
their lives with few regrets.
Droplet Precautions:
Use a private room, if available. Door may remain open.
Wear PPE upon entry into the room for all interactions that may involve
Droplet Precautions contact with the patient and potentially contaminated areas in the
patient's environment.
Transport patient out of room only when necessary and place a surgical
mask on the patient if possible.
Keep visitors 3 ft from the infected person.
Masks help prevent the wearer from inhaling large-particle aerosols, which
usually travel short distances (about 3 ft), and small-particle droplet nuclei,
Why are masks beneficial with droplet which can remain suspended in the air and travel longer distances. Masks
precautions? also protect the patient from the respiratory secretions of the health care
worker. Masks discourage the wearer from touching the eyes, nose, and
mouth, thus limiting contact of organisms with mucous membranes.
, Any patients, family members, and visitors with undiagnosed, transmissible
respiratory infections require education to cover their mouth and nose with
a tissue when coughing and promptly dispose of the tissue. During
Cough Etiquette periods of increased occurrence of respiratory infections, offer a
surgical mask to coughing patients and other symptomatic people upon
entry to the health care facility or office. Encourage the coughing patient
to maintain more than a 3-ft separation from other people in the health
care facility or office.
Factors affecting the risk for infection include: integrity of mucous
membranes, pH levels of the gastrointestinal and genitourinary tracts,
Factors Affecting Risk for Infection
immune response, age, sex, race, heredity, level of fatigue, nutritional
status, stress level, use of invasive or indwelling medical devices and
immunizations (natural or acquired)
Purulent drainage is made up of white blood cells, liquefied dead tissue
debris, and both dead and live bacteria. Purulent drainage is thick, often
Abnormal Wound Drainage
has a musty or foul odor, and varies in color (such as dark yellow or
green), depending on the causative organism.
A stage 1 pressure injury is a defined, localized area of intact skin with
nonblanchable erythema (redness). Darkly pigmented skin may not have
Pressure Ulcer Stage 1
visible blanching; its color may differ from the surrounding skin. The area
may be painful, firm, soft, warmer, or cooler as compared to adjacent
tissue
A stage 2 pressure injury involves partial-thickness loss of dermis and
Pressure Ulcer Stage 2
presents as a shallow, open ulcer or a ruptured/intact serum-filled
blister
A stage 3 pressure injury presents with full-thickness tissue loss.
Subcutaneous fat may be visible and epibole (rolled wound edges)
Pressure Ulcer Stage 3
may occur, but bone, tendon, or muscle is not exposed. Slough and/or
eschar that may be present do not obscure the depth of tissue loss.
Ulcers
Stage 4 injuries involve full-thickness tissue loss with exposed or palpable
Pressure Ulcer Stage 4 bone, cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may
be present on some part of the wound bed; epibole, undermining, and/or
tunneling often occur
Symptoms of infection include purulent drainage; increased drainage, pain,
redness, and swelling in and around the wound; increased body
Wound Infection
temperature; and increased white blood cell count. Additional signs and
symptoms include delayed healing and discoloration of granulation
tissue in the wound
Braden Scale: mental status, continence, mobility, activity, and
nutrition Using the Braden scale (VHMMN)
Lower to 9 Very high
Braden Scale risk-V 10 to 12 High
risk-H
13 to 14 Moderate risk-M
15 to 18 Mild risk-M
19 to 23 indicate No risk-N
, The application of heat accelerates the inflammatory response to promote
healing. The application of local heat dilates peripheral blood vessels,
increases tissue metabolism, reduces blood viscosity and increases
Heat Application capillary permeability, reduces muscle tension, and helps relieve pain.
Vasodilation increases local blood flow. In turn, the supply of oxygen and
nutrients to the area is increased, and venous congestion is decreased
Careful on large parts of the body
High Fowler's Position because accessory muscles can easily be used to
Dysnpea Positioning
promote respirations
Low Flow 8-11L/min, set flow rate so the mask remains two thirds full during
Partial Rebreather Mask
inspiration, keep reservoir bag free of twists or kinks
Evidence-based practice (EBP) in nursing is a problem-solving approach to
making clinical decisions, using the best evidence available (considered
Evidence Based Practice
"best" because it is collected from sources such as published research,
national standards and guidelines, and reviews of targeted literature).
Integrity vs. Despair
People in late adulthood reflect on their lives and feel either a sense of
Erikson's Psychosocial Theory Older
Adults satisfaction or a sense of failure. People who feel proud of their
accomplishments feel a sense of integrity, and they can look back on
their lives with few regrets.
Droplet Precautions:
Use a private room, if available. Door may remain open.
Wear PPE upon entry into the room for all interactions that may involve
Droplet Precautions contact with the patient and potentially contaminated areas in the
patient's environment.
Transport patient out of room only when necessary and place a surgical
mask on the patient if possible.
Keep visitors 3 ft from the infected person.
Masks help prevent the wearer from inhaling large-particle aerosols, which
usually travel short distances (about 3 ft), and small-particle droplet nuclei,
Why are masks beneficial with droplet which can remain suspended in the air and travel longer distances. Masks
precautions? also protect the patient from the respiratory secretions of the health care
worker. Masks discourage the wearer from touching the eyes, nose, and
mouth, thus limiting contact of organisms with mucous membranes.
, Any patients, family members, and visitors with undiagnosed, transmissible
respiratory infections require education to cover their mouth and nose with
a tissue when coughing and promptly dispose of the tissue. During
Cough Etiquette periods of increased occurrence of respiratory infections, offer a
surgical mask to coughing patients and other symptomatic people upon
entry to the health care facility or office. Encourage the coughing patient
to maintain more than a 3-ft separation from other people in the health
care facility or office.
Factors affecting the risk for infection include: integrity of mucous
membranes, pH levels of the gastrointestinal and genitourinary tracts,
Factors Affecting Risk for Infection
immune response, age, sex, race, heredity, level of fatigue, nutritional
status, stress level, use of invasive or indwelling medical devices and
immunizations (natural or acquired)
Purulent drainage is made up of white blood cells, liquefied dead tissue
debris, and both dead and live bacteria. Purulent drainage is thick, often
Abnormal Wound Drainage
has a musty or foul odor, and varies in color (such as dark yellow or
green), depending on the causative organism.
A stage 1 pressure injury is a defined, localized area of intact skin with
nonblanchable erythema (redness). Darkly pigmented skin may not have
Pressure Ulcer Stage 1
visible blanching; its color may differ from the surrounding skin. The area
may be painful, firm, soft, warmer, or cooler as compared to adjacent
tissue
A stage 2 pressure injury involves partial-thickness loss of dermis and
Pressure Ulcer Stage 2
presents as a shallow, open ulcer or a ruptured/intact serum-filled
blister
A stage 3 pressure injury presents with full-thickness tissue loss.
Subcutaneous fat may be visible and epibole (rolled wound edges)
Pressure Ulcer Stage 3
may occur, but bone, tendon, or muscle is not exposed. Slough and/or
eschar that may be present do not obscure the depth of tissue loss.
Ulcers
Stage 4 injuries involve full-thickness tissue loss with exposed or palpable
Pressure Ulcer Stage 4 bone, cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may
be present on some part of the wound bed; epibole, undermining, and/or
tunneling often occur
Symptoms of infection include purulent drainage; increased drainage, pain,
redness, and swelling in and around the wound; increased body
Wound Infection
temperature; and increased white blood cell count. Additional signs and
symptoms include delayed healing and discoloration of granulation
tissue in the wound
Braden Scale: mental status, continence, mobility, activity, and
nutrition Using the Braden scale (VHMMN)
Lower to 9 Very high
Braden Scale risk-V 10 to 12 High
risk-H
13 to 14 Moderate risk-M
15 to 18 Mild risk-M
19 to 23 indicate No risk-N
, The application of heat accelerates the inflammatory response to promote
healing. The application of local heat dilates peripheral blood vessels,
increases tissue metabolism, reduces blood viscosity and increases
Heat Application capillary permeability, reduces muscle tension, and helps relieve pain.
Vasodilation increases local blood flow. In turn, the supply of oxygen and
nutrients to the area is increased, and venous congestion is decreased
Careful on large parts of the body
High Fowler's Position because accessory muscles can easily be used to
Dysnpea Positioning
promote respirations
Low Flow 8-11L/min, set flow rate so the mask remains two thirds full during
Partial Rebreather Mask
inspiration, keep reservoir bag free of twists or kinks
