Exam # 2 Review

1. Know difference between growth & development

Development refers to the sequence of physical, psychosocial, and cognitive
developmental changes that take place over the human lifespan.
o Development is cognitive.
Growth is a quantitative change in which an increase in cell number and size
results in an increase in overall size or weight of the body or any of its parts.
o Growth is physical
Giddens p 2
2. Know role of play in children & what the expected outcome of play are
Through the universal medium of play, children learn what no one can teach
them. They learn about their world and how to deal with this environment of
objects, time, space, structure, and people. They learn about themselves operating
within that environmentwhat they can do, how to relate to things and situations,
and how to adapt themselves to the demands society makes on them. Play is the
work of children. In play, children continually practice the complicated, stressful
processes of living, communicating, and achieving satisfactory relationships with
other people.
Can experiment without punishment.
(Hockenberry 75)
Potter 134 , play is important to a childs development
3. Know what parallel play is
Parallel playDuring parallel activities, children play independently but among
other children. They play with toys similar to those the children around them are
using but as each child sees fit, neither influencing nor being influenced by the
other children. Each plays beside, but not with, other children .There is no group
association. Parallel play is the characteristic play of toddlers, but it may also
occur in other groups of any age. Individuals who are involved in a creative craft
with each person separately working on an individual project are engaged in
parallel play.
(Hockenberry 76)
Playing independently amongst other children, they also play with toys similar to
those the children around them are using but as each child sees fit, neither
influencing nor being influenced by the other children. Each plays besides but not
with other children. Usually in toddlers.
4. Know approaches to children related to surgery
For extended hospitalizations, children enjoy doing projects to occupy time.
(Hockenberry 622)
Have parents stay close during procedure within childs view. Use words and
sentence length appropriate to childs level of understanding
Time structuring is an effective strategy for normalizing the hospital environment
and increasing the child's sense of control

(Hockenberry 623)
What to do prior to surgery? Prepare the child to play with doll and toy medical
equipment ex: stethoscope
Talk about things in aspect of boo boos and ouchies
During hospital stay it is important for child to understand routines and participate
in active treatment ex: keeping track of input and output
5. 5 questions on experienced RN intervening on novice RN
Dont touch patient unless asking
No translating unless translator
Always ABC, safety and Maslows hierarchy of needs
Dont re-assess if they already assessed in question
6. What are the expected outcome and skin characteristics in older adults?
Changes related to the aging process increase the risk of impaired skin integrity.
These changes include a loss of lean muscle mass; decreases in skin thickness,
strength, moisture, and elasticity; decreased arterial and venous blood flow; and a
diminished perception of pain and pressure that may prevent early recognition of
tissue injury.8 Skin changes often associated with aging are a result of sun and
environmental damage over a long period of time, leading to a wrinkled and
leathery appearance. In addition, hair and nail growth slow with aging and a
decrease in sebaceous gland activity can result in rough, dry, and itchy skin
(Giddens 250)
Age-related changes such as reduced skin elasticity, decreased collagen, and
thinning of underlying muscle and tissues cause the older adult's skin to be easily
torn in response to mechanical trauma, especially shearing forces
Concomitant medical conditions and polypharmacy, which are common in the
older adult, are factors that interfere with wound healing.
The attachment between the epidermis and dermis becomes flattened in older
adults, allowing the skin to be easily torn in response to mechanical trauma (e.g.,
tape removal).
Aging causes a diminished inflammatory response, resulting in slow
epithelialization and wound healing
The hypodermis decreases in size with age. Older patients have little
subcutaneous padding over bony prominences; thus they are more prone to skin
breakdown.
An identified risk factor for the development of pressure ulcers is malnutrition
7. What are expected cognitive changes in older adults?
Peaget theory thinking of local and abstract ideas, reasoning deductive, and
future is oriented
Psychoanalytical/psychosocial theories focus on an individual's unconscious
thought and emotions; cognitive theories stress how people learn to think and
make sense of their world. As with personality development, cognitive theorists
have explored both childhood and adulthood. Some of the theories highlight
qualitative changes in thinking; others expand to include social, cultural, and
behavioral dimensions

Personal values change, Try to separate themselves from society

Not normal: being disoriented, loss of language, poor judgment, loss of able to
calculate
P 178 potter demonstrate in cognitive environment
3 conditions affecting cognition: delirium, dementia, depression
o Delirium, or acute confusional state, is potentially a reversible cognitive
impairment that often has a physiological cause. Physiological causes
include electrolyte imbalances; cerebral anoxia; hypoglycemia;
medication effects; tumors; subdural hematomas; and cerebrovascular
infection, infarction, or hemorrhage. Delirium in older adults sometimes
accompanies systemic infections and is often the presenting symptom for
pneumonia or urinary tract infection.
o Dementia is a generalized impairment of intellectual functioning that
interferes with social and occupational functioning. Cognitive function
deterioration leads to a decline in the ability to perform basic ADLs and
IADLs. (Potter 180)
o Approximately one third of older adults experience depressive symptoms.
Older adults sometimes experience late-life depression, but it is not a
normal part of aging. Depression is the most common, yet most
undetected and untreated, impairment in older adulthood.

8. What is poly-pharmacy?
Use of a number of different drugs by a patient who may have one or several
health problems. Takes multiple drugs from multiple doctors.
Increases adverse drug effects, multiple medications is often necessary when
older adult has multiple diseases
Use of a number of different drugs by a patient who may have one or several
health problems.
9. Know appropriate activities in children related to play
children derive pleasure from handling raw materials ,Enjoy playing with paint,
Social effective play- want to play with touching stuff, respond to behavior as
smiling and cooing
Sports, games, playing with other children allows them to accept other peoples
views
Age 1 more complex, 9 months peek a boo and patty cake
P 148 potter --Play of preschool kids becomes more social, shifts from parallel to
associative
By age 4, children play in groups of 2 or 3. 3 year olds, play roles such as mother
and child. By age 5, they are cooperative playing, having leaders.
10. Know Ericksons stages and what they represent.
Potter 132, hockenberry 71, 72, giddens page 5

Trust vs. mistrust (birth 1 year)- Establishing a basic sense of trust is essential
for the development of a healthy personality. The infant's successful resolution of
this stage requires a consistent caregiver who is available to meet his needs. From
this basic trust in parents, the infant is able to trust in himself, in others, and in the
world
Autonomy vs. shame ( 1- 3)- By this stage a growing child is more accomplished
in some basic self-care activities, including walking, feeding, and toileting. This
newfound independence is the result of maturation and imitation. The toddler
develops his or her autonomy by making choices. Choices typical for the toddler
age-group include activities related to relationships, desires, and playthings.
Initiative vs. guilt (3-6)- Children like to pretend and try out new roles. Fantasy
and imagination allow them to further explore their environment. Also at this time
they are developing their superego, or conscience. Conflicts often occur between
the child's desire to explore and the limits placed on his or her behavior. These
conflicts sometimes lead to feelings of frustration and guilt. Guilt also occurs if
the caregiver's responses are too harsh.
Industry vs. inferiority (6-11)- School-age children are eager to apply
themselves to learning socially productive skills and tools. They learn to work and
play with their peers. They thrive on their accomplishments and praise. Without
proper support for learning new skills or if skills are too difficult, they develop a
sense of inadequacy and inferiority. Children at this age need to be able to
experience real achievement to develop a sense of competency
Identity vs. role confusion (puberty)- Dramatic physiological changes
associated with sexual maturation mark this stage. There is a marked
preoccupation with appearance and body image. This stage, in which identity
development begins with the goal of achieving some perspective or direction,
answers the question, Who am I?
Intimacy vs. isolation (young adult)- Young adults, having developed a sense of
identity, deepen their capacity to love others and care for them. They search for
meaningful friendships and an intimate relationship with another person. Erikson
portrayed intimacy as finding the self and then losing the self in another
Generativity vs. self-absorption (middle aged)- Following the development of
an intimate relationship, the adult focuses on supporting future generations. The
ability to expand one's personal and social involvement is critical to this stage of
development. Middle-age adults achieve success in this stage by contributing to
future generations through parenthood, teaching, and community involvement
Integrity vs. despair (old age)- Many older adults review their lives with a sense
of satisfaction, even with their inevitable mistakes. Others see themselves as
failures, with their lives marked by despair and regret. Older adults often engage
in a retrospective appraisal of their lives. They interpret their lives as a
meaningful whole or experience regret because of goals not achieved
11. Know role of pain in promoting wellness.
When managing pain, goals of care promote a patient's optimal function.
Determine, along with the patient, what the pain has prevented the patient from
doing. Then decide on a mutually acceptable level of pain that allows return of

function. An indication of the success of the plan is determined through

attainment of goals and outcomes.
Effective pain management improved quality of life, reduces physical discomfort,
promotes earlier immobilization and return to previous activity levels, results in
fewer hospital and clinic visits, and decreases hospital length of stay, which
results in lower health care costs.
(Potter 977)

12. Know alternative & complementary therapies related to pain

Distraction, prayer, Music, relaxation, guided imagery, cutaneous stimulation ,
massages, biofeedback -- lewis 93-97
Alternative replaces all medication etc,
Complementary is if someone is taking meds but also doing yoga
13. 4 questions :Know difference between acute, chronic, and neuropathic pain
Acute pain is protective, has an identifiable cause, is of short duration, and has
limited tissue damage and emotional response. It eventually resolves, with or
without treatment, after an injured area heals. Because acute pain has a
predictable ending (healing) and an identifiable cause, health team members are
usually willing to treat it aggressively. Unrelieved acute pain can progress to
chronic pain. (Potter 965)
Chronic pain lasts longer than 6 months and is constant or recurring with a mildto-severe intensity. It does not always have an identifiable cause and leads to great
personal suffering. Examples of chronic noncancer pain include arthritis, low
back pain, myofascial pain, headache, and peripheral neuropathy. Chronic pain is
usually nonlife threatening. Sometimes an injured area healed long ago, yet the
pain is ongoing and does not respond to treatment. (Potter 965)
Neuropathic pain arises from abnormal or damaged pain nerves . Each of
these pathological processes has distinct pain characteristics. Malfunction in your
nervous system. (Potter 965-966)
14. 3 questions on osteoarthritis on pain
Chronic pain may result from underlying medical conditions, such as cancer pain
from tumor growth or osteoarthritis pain from joint degeneration, and can persist
throughout a person's lifespan. Patients may experience both acute and chronic
pain as part of their disease process.
(Giddens 270)
Lewis 1641- slowly progressive non inflammatory disorder of the synovial joint
Potter 651 - Chiropractic therapy improves acute pain and disability in some
patients. This therapy is also sometimes effective over longer periods to reduce
pain caused by acute and subacute low back pain and joint pain caused by
osteoarthritis
15. Understand holistic nursing related to pain

Because pain affects physical and mental functioning, holistic health approaches
are important interventions for maintaining wellness. Holistic health is an ongoing
state of wellness that involves taking care of the physical self, expressing
emotions appropriately and effectively, using the mind constructively, being
creatively involved with others, and becoming aware of higher levels of
consciousness. The concept of holistic health parallels the values of nursing in
maintaining the integrity of the whole person.
(Potter 977)
When a person develops pain, you can offer nonpharmacological and
pharmacological strategies.
(Potter 977)
Focus on mind, body & spirit

16. Know what the standardized tools are to assess pain

A variety of tools such as a pain flow sheet or diary help centralize information
about pain management. (Potter 990)
Observe behavioral signs (e.g., facial expressions, crying, restlessness, and
changes in activity). There are many behavioral pain assessment tools available
that will yield a pain behavior score and may help to determine if pain is present.
However, it is important to remember that a behavioral score is not the same as a
pain intensity score. Pain intensity is unknown if the patient is unable to provide
it. (Giddens 274)
Use behavioral pain assessment tools.
Use evidence-based tools to ensure appropriate pain assessment
Evidence supports use of the Behavioral Pain Scale and the Nonverbal Pain Scale
for patients who are mechanically ventilated (Potter 972)
The Oucher uses photographs of the face of a child (in increasing levels of
discomfort) to cue children into understanding pain and its severity. A child points
to a face on the tool, thus simplifying the task of describing the pain.
Faces scale 6 cartoon face from happy to sad tearful ( 6 of them)
(Potter 972)
Behavioral pain assessment tool
Numerical pain scale from0 to 10
Verbal descriptive: no pain, mild pain ,moderate pain, severe pain
Visual Analog: no pain, unbearable pain
17. Know gait control theory in relation to pain
According to this theory, gating mechanisms located along the central nervous
system regulate or even block pain impulses. Pain impulses pass through when a
gate is open and are blocked when a gate is closed. Closing the gate is the basis
for nonpharmacological pain-relief interventions. You gain a useful conceptual
framework for pain management by understanding the physiological, emotional,
and cognitive influences on the gates.
(Potter 964)

18. Know what the side effects are when taking narcotics
Common side effects of opioids include constipation, nausea and vomiting,
sedation, respiratory depression, and pruritus. With continued use, many side
effects diminish; the exception is constipation. Less common side effects include
urinary retention, myoclonus, dizziness, confusion, and hallucinations.
Constipation is the most common side effect of opioids.
(Lewis 126)
981 Potter
Abuse is respiratory depression, cyanosis, constricted pupils
Respiratory depression you give narcan
19. How is peripheral neuropathy related to pain?
Neuropathic pain results from the abnormal processing of sensory input by the
nervous system as a result of damage to the brain, spinal cord, or peripheral
nerves.4 Simply stated, neuropathic pain is pathologic. Examples of neuropathic
pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and
poststroke pain syndrome. Patients with neuropathic pain use very distinctive
words to describe their pain, such as burning, sharp, and shooting.
(Giddens 270)
Symptoms numbness, tingling of affected area, and stumbling gait.
Damage to peripheral system, can be one nerve or group of nerves
Affects patients awareness of and response to pain
20. 4 questions: Understand how a PCA pump works & its process
The concept of PCA recognizes that only the patient can feel the pain and only the
patient knows how much analgesic will relieve it. Patients who use PCA must be
able to understand the relationships between pain, pushing the PCA button, and
pain relief. They must also be able to cognitively and physically use the PCA
equipment. Some of the methods used to manage pain are accomplished via
catheter techniques such as intraspinal analgesia and continuous peripheral nerve
block infusions with or without PCA capability.
(Giddens 275)
It is a drug delivery system that allows patients to self-administer opioids
(morphine, hydromorphone, and fentanyl) with minimal risk of overdose. The
goal is to maintain a constant plasma level of analgesic to avoid the problems of
prn dosing. Systemic PCA traditionally involves IV or subcutaneous drug
administration; however, a controlled analgesia device for oral medications,
Medication on Demand (MOD), is now available. This device allows patients
access to their own oral prn mediations, including opioids and other analgesics,
antiemetics, and anxiolytics, at the bedside
(Potter 983)
To receive a demand dose, the patient pushes a button attached to the PCA device.
Systems are designed to deliver a specified number of doses every 1 to 4 hours
(depending on the pump settings) given every 5 to 15 minutes (programmable) to

avoid overdoses .Most pumps have locked safety systems that prevent tampering
by patients or family members and are generally safe to be managed in the home.
21. Know how to assess pain across the lifespan. What are the right tools for the right
ages?
Oucher and faces for children
o The wong baker FACES scale consists of six cartoon faces with word
descriptors, ranging from a smiling face on the left for no pain (or hurt)
to a frowning, tearful face on the right for worst pain (or hurt).
o Numeric Rating Scale (NRS): The NRS is most often presented as a
horizontal 0 to 10 point scale, with word anchors of no pain at one end
of the scale, moderate pain in the middle of the scale, and worst
possible pain at the end of the scale. Giddens 271- 272
Pain symptoms can be different in older adults from children
22. What are patient education methods for chronic pain?
Giddens 272
It is particularly important to ask questions
Keep living a normal life, have goals
23. 4 scenarios on which patient to medicate first related to tissue integrity
Always IV first, always highest first, acute pain gets treated first
24. Role of herbal remedies related to health maintenance?
Cranberry juice for uti, aloe accelerates wound healing, chamomile antiinflammatory,
Herbal remedies are prominent in healthcare
Most frequent used is cranberry, soy, garlic,
25. What things should a nurse take into consideration related to pre-op assessment?
History of medication, allergies, vital signs, medical history,
Mark the operative site with an ink
In most hospitals the patient enters a holding area, also known as the
preanesthesia care unit or presurgical care unit (PSCU), outside the OR. In the
PSCU the nurse explains the steps for preparing the patient for surgery, reviews
the preoperative checklist, assesses the patient's readiness both physically and
emotionally, and reinforces teaching. Nurses in the PSCU are members of the OR
staff and wear surgical scrub suits, hats, and footwear in accordance with
infection control policies. In some ambulatory surgical settings a perioperative
primary nurse admits the patient, circulates for the operative procedure, and
manages the patient's recovery and discharge.
(Potter 1271)
26. Role of herbal remedies(therapies) and antibiotics in tissue integrity
Aloe good for wound healing, accelerates wound healing
Pg 652 potter
Antibioticas are used for infection, and antiinflammatory
27. How does an RN assess for chronic pain?

For patients with chronic pain, a thorough pain assessment includes affective,
cognitive, behavioral, spiritual, and social dimensions. In the home care setting
family members assess pain. Using the ABCs of pain management is an effective
way to manage pain (Potter 970)
Inadequate pain assessment is the single greatest barrier to effective pain
management. Data such as vital signs and patient behaviors are not reliable
indicators of pain, especially long-standing, chronic pain. It is important to
distinguish between persistent and episodic, positional, or breakthrough pain.
Therefore it is essential that a comprehensive pain assessment include a detailed
history to elicit the following characteristics of pain: quality, location, intensity,
duration, and precipitating and alleviating factors. Differentiating between types
of pain (e.g., visceral, bone, neuropathic) is important in developing an effective
pain management plan. (Lewis 279)
Find a way to find the pain tolerable

28. What are some common meds prescribed for osteoarthritis?

1562drug therapy 1564,1565 lewis
Lewis 992
Drug therapy is based on the severity of the patient's symptoms (Table 65-3). The
patient with mild to moderate joint pain may get relief from acetaminophen
(Tylenol). The patient may receive up to 1000mg every 6 hours, with the daily
dose not to exceed 4g. A topical agent such as capsaicin cream (Zostrix) may also
be beneficial, either alone or in conjunction with acetaminophen. It blocks pain by
locally interfering with substance P, which is responsible for the transmission of
pain impulses.
Tramadol, & osteoarthritis may benefit from the use of misoprosol
29. Know the side effects of narcotics in osteoarthritis.

If you're taking a narcotic for arthritis pain, keep in mind that alcohol and drugs
containing acetaminophen or Tylenol don't mix. The combination can greatly
increase your risk of severe liver damage.

When you take narcotic drugs, you also run the risk of developing a tolerance to
the drugs. That means that you need more and more of the drugs in order to get
the same effect. You also run the risk of becoming dependent or even addicted.
Also, narcotic drugs can cause side effects constipation, drowsiness, dry mouth,
and difficulty urinating.

30. What are risk factors for pressure ulcer formation?

Any patient experiencing decreased mobility, decreased sensory perception, fecal
or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer
development. (Potter 1177)

Moisture, friction, shear, incontinence

Impaired sensory perception, impaired mobility, alterations in level of
consciousness, shear, friction, moisture
Additional factors include : nutrition, tissue profusion, infection, age, and
psychosocial impact of wounds
31. Know the four stages of pressure ulcers
Stage I: Nonblanchable Redness of Intact Skin
Intact skin presents with nonblanchable erythema of a localized area usually over
a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain
may also be present. Darkly pigmented skin may not have visible blanching.
Further description: The area may be painful, firm, soft, warmer, or cooler than
adjacent tissue. Stage I may be difficult to detect in individuals with dark skin
tones. It may indicate at-risk persons
Stage II: Partial-thickness Skin Loss or Blister
A partial-thickness loss of dermis presents as a shallow open ulcer with a red-pink
wound bed without slough. It may also present as an intact or open/ruptured
serum-filled or serosangineous filled blister. Further description: Stage II presents
as a shiny or dry shallow ulcer without slough or bruising. This stage should not
be used to describe skin tears, tape burns, incontinence-associated dermatitis,
maceration, or excoriation
Stage III: Full-thickness Skin Loss (Fat Visible)
A stage III ulcer is a full-thickness tissue loss. Subcutaneous fat may be visible;
but bone, tendon, or muscle is not exposed. Some slough may be present. It may
include undermining and tunneling. Further description: The depth of a stage III
pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput,
and malleolus do not have (adipose) subcutaneous tissue; and stage III ulcers can
be shallow. In contrast, areas of significant adiposity can develop extremely deep
stage III pressure ulcers. Bone/tendon is not visible or directly palpable
Stage IV: Full-thickness Tissue Loss (Muscle/Bone Visible)
A stage IV ulcer is a full-thickness tissue loss with exposed bone, tendon, or
muscle. Slough or eschar may be present. It often includes undermining and
tunneling. Further description: The depth of a stage IV pressure ulcer varies by
anatomical location. The bridge of the nose, ear, occiput, and malleolus do not
have (adipose) subcutaneous tissue; and these ulcers can be shallow. Stage IV
ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or
joint capsule), making osteomyelitis or osteitis likely to occur. (Potter 1179)
32. Know: Primary, secondary, and tertiary INTENTION & PREVENTION
Primary Intention: Wound that is closed, ex: surgical incision, wound that is
sutured or stapled, heals quickly with minimal scar
Secondary Intention: wound edges are approximated, ex: pressure ulcer, surgical
wounds that have tissue loss, heals by granulation tissue formation

Tertiary intention: wound left open for several days, then wound edges are
approximated, ex: wounds that are contaminated and require observation for signs
and inflammation
Primary Prevention : conservation of quality/ ex: safety program, health
education, healthy diet
Secondary Prevention: treat & resolve, maintain highest level of quality of life/
Ex: HIV screening/ early detection, prevention of diability
Tertiary Prevention: maximize recovery, get most functioning back/promote self
care as much as possible, find community resources
Potter 1181
33. What lab data is indicative in pressure ulcers?
1186 potter protein, calories, nutrients, vitamin C, Zinc, Vitamin E & A
Calories: fuel for cell energy
Protein: fibroplasia, angiogenesis, collagen formation, and wound remodeling
Vitamin A: epithelialization, wound closure ,inflammatory response
34. What assessment data is needed for wound healing?
You need to assess pressure ulcers at regular intervals using systematic parameters
to evaluate wound healing, plan appropriate interventions, and evaluate progress.
Assessment includes depth of tissue involvement (staging), type and approximate
percentage of tissue in wound bed, wound dimensions, exudate description, and
condition of surrounding skin.
(Potter 1179)
You need to assess the type of tissue in the wound base; this information is used
to plan appropriate interventions. The assessment of tissue type includes the
amount (percentage) and appearance (color) of viable and nonviable tissue.
Granulation tissue is red, moist tissue composed of new blood vessels, the
presence of which indicates progression toward healing. Soft yellow or white
tissue is characteristic of slough (stringy substance attached to wound bed), and it
must be removed by a skilled clinician before the wound is able to heal. Black or
brown necrotic tissue is eschar, which also needs to be removed before healing
can proceed. (Potter 1180)
One method for assessment of a pressure ulcer is the use of a staging system.
Staging systems for pressure ulcers are based on describing the depth of tissue
destroyed. Accurate staging requires knowledge of the skin layers. A major
drawback of a staging system is that you cannot stage an ulcer covered with
necrotic tissue because the necrotic tissue is covering the depth of the ulcer. The
necrotic tissue must be debrided or removed to expose the wound base to allow
for assessment. (Potter 1179)
35. Know the roles of drains in post-op patients
The health care provider inserts a drain into or near a surgical wound if there is a
large amount of drainage. Some drains are sutured in place. Exercise caution
when changing the dressing around drains that are not sutured in place to prevent
accidental removal. A Penrose drain lies under a dressing; at the time of
placement a pin or clip is placed through the drain to prevent it from slipping

farther into a wound (Fig. 48-10). It is usually the health care provider's
responsibility to pull or advance the drain as drainage decreases to permit healing
deep within the drain site
Promote healing, prevent infection
36. What things do you look for in skin integrity assessment?
The assessment of skin involves taking a history, conducting an examination of
the skin, and performing diagnostic testing.
o Inspection: Examination of the skin starts with inspection, which includes
color and presence of lesions. Normal adult skin is a consistent color,
ranging for individuals from light pink, to olive tones, to deep brown, with
relatively darker shades in areas of sun exposure.
o Palpitation: The skin should be smooth and intact with an even surface,
and minimal perspiration or oiliness except after exercise or heat
exposure. There should not be dryness, peeling, or cracking, although
there may be calluses over the hands, feet, elbows, and knees. Skin folds
should not be excessively moist or macerated. Turgor

Giddens 252, 253

Check boney prominence and orthopedic devices, check skin and exposure to
body fluids
37. What are some risk factors for skin impairment related to mobility?
Moisture, incontinence, poor nutrition, shear, circulation
38. What are some early interventions a RN does for skin impairment?
Turn patient every 2 hours, check for skin assessment every 2 hours,
Prevent : quickly identify all high risk pts
Three major areas of NI: skin care & manage incontinence, proper positioning,
and proper use of therapeutic devices, education
39. Know what the role of an abdominal binder is in post-op patients?
1209,1226 potter
An abdominal binder supports large abdominal incisions that are vulnerable to
tension or stress as the patient moves or coughs . Secure an abdominal binder with
safety pins, Velcro strips, or metal stays.
The skill of applying an abdominal binder can be delegated to nursing assistive
personnel (NAP). The nurse is responsible for wound assessment; the evaluation
of wound care interventions and assessment of the patient's ability to breathe
deeply, cough effectively, and move independently; and assessment of skin for
irritation/abrasion, of incision/wound and dressing, and of comfort level before a
binder or sling is applied for the first time. Direct the NAP to:
o Immediately notify the nurse of any change in patient's respiratory status.
o Report any increase in wound drainage to the nurse.
o Report any changes in skin integrity under or adjacent to the binder to the
nurse.
o Remove the binder at prescribed intervals