Term
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Definition
Be orderly in data collection.
Look for patterns to clarify data.
Clarify any uncertainty. |
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Definition
Be open-minded
Do not make assumptions
Does the data reveal what you believe is true? |
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Definition
Look at the meaning and significance of findings.
Are there any relationships. |
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Definition
Look at all situations objectively
Use criteria to determine results |
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Term
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Definition
Support your findings and conclusions
Knowledge and experience |
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Term
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Definition
Reflect on your own experiences.
Find ways to improve your performance. |
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Term
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Definition
Seek the truth
Be couragous
Ask questions |
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Term
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Definition
Be tolerant of different views
Be sensitive |
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Term
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Definition
Analyze potentially problematic situations
Anticipate results or consequences |
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Term
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Definition
| Be organized, focused, and work hard |
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Definition
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Term
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Definition
Be eager to acquire knowledge
Learn explanations |
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Definition
Multiple solutions are acceptable.
Reflect upon your own judgements. |
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Term
| What is the definition of critical thinking? |
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Definition
| Is an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others. |
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Term
| What are the steps involved in critical thinking? |
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Definition
| Recognizing an issue, analyzing information, evaluating, and making conclusions. |
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Term
| What critical thinking skills are vital? |
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Definition
Ask questions
Remain well informed
Be honest with personal bias
Always be willing to reconsider and think clearly about issues. |
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Term
| When first caring for a client what critical thinking questions should you be asking? |
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Definition
What do I really know about this client?
How do I know it?
What opinions are available to me? |
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Term
| What are some questions you could ask yourself to think ahead? |
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Definition
What is the PT's status now?
How might it change and why?
What do I know to improve Pt's condition? |
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Term
| What are the three levels of critical thinking? |
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Definition
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Term
| What is Basic critical thinking? |
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Definition
Trust that experts have the right answers to every problem.
You do not have enough experience to anticipate how to individualize a procedure.
Learn to accept the diverse opinions and values of experts. |
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Term
| What is Complex critical thinking? |
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Definition
Begin to seperate themselves from authorities.
More independent.
Learn that alternative and conflicting solutions exist.
Each solution has benefits and risks. |
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Term
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Definition
Person anticipates the need to make choices without assistance from others.
Accept accountability for your decisions.
Pay attention the results of the decision and determine whether it is appropriate. |
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Term
| What are critical thinking competencies? |
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Definition
Scientific Method
Problem Solving
Decision Making
Diagnostic Reasoning and Inference
Decision Making |
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Term
| What is the scientific method? |
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Definition
A way to solve problems using reasoning
Systematic approach to gathering data and solving problems.
Looking for the truth. |
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Term
| What is involved in problem solving? |
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Definition
We obtain information and use what we already know to find a solution.
Evaluate the solution over time and make sure it is effective. |
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Term
| What is involved with decision making? |
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Definition
When you need to decide a course of action from several options.
Focus on problem resolution.
Recognize and define the problem
Assess all options
Weigh each option
Consider the consequences
Make a final decision |
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Term
| What is involved with diagnostic reasoning and inference? |
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Definition
As soon as you recieve info, diagnostic reasoning begins.
Clear perspective of a person's health status.
Inference is the process of drawing conlcusions from related pieces of evidence. |
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Term
| What is involved with clinical decision making? |
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Definition
Requires careful reasoning so that you choose the options for the best client outcomes on the basis of the client's condition and priority of the problem.
Know your client
Pt is the center of focus
Determine priorities and select therapies. |
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Term
| What is the critical thinking model? |
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Definition
Knowledge base
Experience
Critical thinking competencies
Attitudes
Standards |
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Term
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Definition
Educational experience
Reading Nursing Literature
Broad Knowledge |
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Term
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Definition
| Learn from observing, sensing, talking with pt's and families, and reflect on experiences. |
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Term
| Critical Thinking Competencies |
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Definition
The nursing process
General thinking and specific thinking. |
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Term
| Attidudes for critical thinking |
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Definition
Confidence
Independence
Fairness
Responsibility
Risk taking
Discipline
Perseverance
Creativity
Curiosity
Integrity
Humility |
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Term
| What are the layers of the skin? |
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Definition
Epidermis-Top layer of skin
When the skin is injured, epidermis functions to resurface the wound and restore protective barrier of the skin
Dermis- Inner layer of the skin
Collagen, blood vessels, and nerves
Subcutaneous- Underlying connective tissue |
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Term
| What are the functions of the skin? |
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Definition
Protection-1st line of defense, protect integrity
Temp Regulation
Sensation-Nerve endings send signals to the body. Altered sensations=risk for impairment.
Excretion
Maintenance of water
Vitamin D production |
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Term
| What are skin associated issues with the older adult? |
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Definition
-Reduced skin elasticity, increases dryness, wrinkling, decreased collagen, thinning of underlying muscle and tissues.
Puts client @ risk for skin tears.
-Decreased inflammatory response which results in slower wound healing.
-Reduced nutritional intake increases risk for pressure ulcers and slower wound healing.
-Hypodermis decreases in size with age.
Little subcutaneous padding which means skin breakdown. |
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Term
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Definition
Localized injury to the skin and/or underlying tissue.
Usually over a bony prominence
Result of pressure or combination of pressure, shear, friction, and moisture. |
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Term
| Facts about pressure ulcers |
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Definition
Prevention is key
Prevent sheering by keeping head of bed at 30 degrees or less.
Prevent friction by using sheets to move the Pt.
Identify Pt's @ risk and initiate early prevention measures. |
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Term
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Definition
Head, Shoulders, Elbows, Sacrum, Hip, Heels, Bony Prominences.
Pay specific attention to these areas. |
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Term
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Definition
When pressure exceeds normal capillary pressure, vessels occlude and tissue ishcemia develops, tissues may be damaged or tissue death may result.
Vessel Occlusion=Less blood to area and less oxygen. |
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Term
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Definition
Low Pressure over prolonged period of time.
High pressure over low period of time. |
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Term
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Definition
The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structure.
Older pt's=higher risk for pressure ulcers. |
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Term
| Factors contributing to pressure ulcer development |
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Definition
Major cause is Pressure!
Obese PT's @ higher risk for ulcers.
Immobility
Poor nutrition
Aging skin
Chronic Illness |
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Term
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Definition
Force exerted parallel to the skin resulting from gravity pushing down the on the body and resistance (friction) between the client and a surface.
Ex: As you elevate the head of the bed, the skeleton slides down while the skin stays fixed. |
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Term
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Definition
| Force of two surfaces moving across one another. |
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Term
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Definition
| Pressure and moisture on the skin increases the risk of ulcer formation. |
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Term
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Definition
| Normal red tones of the light-skinned client are absent. |
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Term
| How to assess dark-skinned Pt's for pressure ulcers |
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Definition
Avoid flourescent lights
Skin appears darker than surrounding skin.
Has purplish/bluish hue
Initial warmth
Shiny, Scaly |
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Term
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Definition
Mobility - Frequency of position changes
Nutritional Status - Loss of 5% usual weight, decrease of 10 lbs in brief time.
Moisture - Continuous exposure to urine,bile, stool, fluid)
Pain - Willingness to move, If pt in pain, they don't want to move. |
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Term
| What two scales are used to assess for pressure ulcers |
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Definition
Braden Scale
Norton Scale
The lower the number the higher the risk for pressure ulcers.
Scales should not be modified. |
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Term
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Definition
6 subscales
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear |
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Term
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Definition
Lower score = high risk
1-9 = very high
10-12 = high risk
13-14 = moderate risk
15-18 = mild risk
19-23 = not at risk |
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Term
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Definition
5 risk factors
Physical
Condition
Mental
Activity
Continence
Low score = risk for ulcer |
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Term
| Assessment for pressure ulcers |
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Definition
Head to toe assess within 8 hrs
Braden Scale within 8 hrs and then again every 24 hrs.
Continually assess skin
Cannot delegate
When hyperemia is suspected, outline the affected area with a marker to reassess later. |
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Term
| Visual and Tactile assessment |
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Definition
Report any change's in skin
Keep skin dry and provide hygiene after incontinence
Use scale
Assess all devices or areas of the body that are in contact with devices.
Evaluate activity level
Assess food intake pattern
Use appopriate interventions such as turning, heels, pressure-redistribution surface, wedge.
Provide education
Reduce pressure ulcer development |
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Term
| Stages of pressure ulcers |
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Definition
Stage 1 - Intact skin with nonblanchable redness
Stage 2 - Partial-thickness loss involving epidermis, dermis, or both.
Stage 3 - Full-thickness tissue loss with visible fat
Stage 4 - Full thinkness tissue loss with exposed bone, muscle, or tendon.
Unstageable - Full thickness tissue loss in which base of ulcer is covered by slough or eschar. |
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Term
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Definition
Soft yellow or white tissue
(Stringy substance attached to wound bed, needs to be removed before the wound can heal. |
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Term
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Definition
| Black or brown necrotic tissue |
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Term
| Suspected deep tissue injury |
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Definition
| Purple or maroon localized area of discolored skin that may painful, firm, mushy, boggy, warm or cool. |
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Term
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Definition
| Stable eschar on the heals serve's as the body's natural cover and should not be removed. |
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Term
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Definition
| Red moist tissue composed of new blood vessels. |
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Term
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Definition
Use disposable-wound measuring devices to obtain measurement of width and length.
Measure depth by using cotton-tipped applicator into wound bed.
Presence of tunneling, undermining, or sinus tract. |
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Term
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Definition
| Describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. |
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Term
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Definition
Avoid harsh soap and hot water
Moisturize after bath while the skin is moist
Do not massage bony prominences
Try to correct incontinence, perspiration, or wound drainage. |
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Term
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Definition
Reduces pressure and shearing forces
HOB 30 degrees or less
Turn q2 when pt supine and q1 when HOB elevated.
Protective devices (foam, gel, or air cushion)
Reassess skin for hyperemia. |
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Term
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Definition
Assess need for pain medication
Allergies?
Review order, privacy, hand hygiene
Assess ulcer
Sterile gloves
Cleanse with saline or irrigating syringe for deep wounds.
Apply topical agent and cover.
Assess at later intervals. |
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Term
| Topical agents for pressure ulcers |
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Definition
Enzymes
Apply thin layer over necrotic areas only, not to surrounding skin.
Apply gause, tape securely
Hydrogel
Cover surface of ulcer and cover with gause or transparent film.
Calcium Alginate
Pack wound with alginate and apply dry gauze or foam over alginate and tape into place. |
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Term
| Dressings by pressure ulcer stage |
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Definition
Stage 1-Hydrocolloid, does not always allow physical assessment
Stage 2-Hydrocolloid or hydrogel(provides a moist environment)
Stage 3-Calcium alginate when there is significant exudate
Hydrogel covered with foam dressing to protect and absorb moisture
Stage 4-Hydrogel or calcium alginate
Unstagable-Enzymes to facilitate debridement. Eschar will soften. |
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Term
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Definition
| Removal of non-viable necrotic tissue. |
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Term
| WOCN dressing recommendations |
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Definition
Use dressing that provide moist environment.
USe topical dressings as determined by assessment.
Keep surronding skin intact and dry
Choose dressing that controls exudate
Eliminate wound dead space by loosely filling all cavities with dressing material. |
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Term
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Definition
Prevent and manage infections
Cleanse wound
Remove non-viable tissue (debridement)
Mechanical-whirlpool
Autolytic-synthetic dressings (transparent and hydrocolloid dressings)
Surgical-use scalpel, scissors
Manage exudates
Protect wound |
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Term
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Definition
Status of skin integrity
Cause-intentional or unintentional
Depth-partial thickness or full thickness
Severity-superficial, penetrating or perforating
Cleanliness-Clean, infected, colonized |
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Term
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Definition
Abrasion-superficial with little bleeding, considered partial thickness wound.
Laceration-Bleeds more profusely, depending on depth and location.
Puncture- Like a nail puncture, deep and bleeds more depending on size and location.
Hematoma-Bruised and swollen |
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Term
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Definition
Serous-Clear, watery plasma
Purulent-Thick, yellow, green, tan, or brown
Serosanguineous-Pale, red, watery: Mixture of clear and red fluid.
Sanguineous-Bright red, indicates active bleeding. |
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Term
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Definition
Surgeon does initial dressing change.
Critical to assess wound for healing and pay attention to order for dressing changes.
Wound appearance-edges may be inflamed for first 2-3 days but should appear normal within 7-10 days.
Skin discoloration from bruising. |
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Term
| Characters of wound drainage |
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Definition
Note amount, color, odor, and consistency.
Chart # of dressings and frequency changed
Color and consistency depends on components. |
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Term
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Definition
Wound is swollen
Wound or edges are deep red in color
Wound feels hot on palpation
Drainage is increased and purulent
Foul odor
Wound edges seperated with dehiscence |
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Term
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Definition
| Partial or total seperation of wound layers. |
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Term
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Definition
| Protrusion of visceral organs through a wound opening. |
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Term
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Definition
Abnormal passage between two organs or between an organ and the outside of the body.
Caused by improper wound healing or complication of disease. |
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Term
| Drains and drainage devices |
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Definition
Drains are not sutured in
Provide an exit for blood and fluids that accumulate during the inflammatory process.
Use caution when changing dressings
Assess # of drains, placement, and condition of collection apparatus.
Measure drainage volume
Sudden decrease means blockage. |
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