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Nursing Fundamentals ch 18
Terms in this set (69)
Term refers to the narrowing of veins and capillaries?
This may be caused by the application of ice to a site?
Term refers to an increase in capillary permeability and cellular metabolism?
This can be caused by the application of heat to a site?
Term for swelling due to excess fluid in interstitial space?
Term refers to irregular blotch in or purplish coloring on the skin?
Term for pale or smooth skin tone?
Term refers to inflammation of a vein due to IV therapy?
What are the 4 main conditions related to the application of heat and cold?
Vasodilation of vessels in underlying sites, Increase in nutrient rich blood flow to site, Increase in permeability of pores in capillary wall, increased plasma red and white blood cells and nutrients travel from capillaries into cells and the interstatial space between the cells.
The application of heat results in the decrease of what 3 thimgs?
Decreased blood flow to site results in decreased bleeding, Decreased inflammatory response slowing bacterial growth, Decreased capillary refill and cellular metabolism
What 2 other things does the application of heat result in?
Prevention. Of edema, Relaxation of muscles decreasing pain
On of the effects of cold and heat application is the
Of Blood Flow To site, Which. Bleeding
Decrease of blood flow to site which decreases bleeding
One of the effects of the application of ice is the relaxation of. .
One of the effects of the application of cold is. Relief.
The application of cold supports what process?
The Healing process
Once Edema stabilizes it can be further reduced with what?
Application of cold
The application of cold can be used to elevate what?
This is the mechanism that delivers extra phagocytes, oxygen, and the nutrients that are needed to prevent infection and build new tissue to heal the wound.
Increased Blood flow
Term refers to these which engulf and digest offending microorganism and debris in cells to prevent infection.
Without. This THE Tissue Will Not HEALTH PROPERLY IN A timely manner.
What are the 4 contraindications for heat therapy?
Newly injured joints, Large areas of the body in certain cardiac patients, Bleeding wound or injury, or a Suspected Appendicitis
When delivering heat therapy using a water bottle the nurse should fill it. Of the way with water. The remaining air place. Between the bottle and the patients skin.
Fill it 2/3rd full with warm water expel remaining air place cloth between bottle and patients skin
When delivering heat therapy using commercial heat packs how does the nurse activate them?
By squeezing, striking, or twisting
When using heating pads what should a nurse take care to remember?
Keep pad on medium to low temperature
This heat delivery device can be used continuously as it maintains a constant temperature?
The use of this heat delivery device depends on the design and can be placed either over or under patient or both.
This heat delivery device comes as a piece of gauze or cloth soaked in hot water, wrung out, and applied to inflamed area
When using this heat delivery technique a nurse should ensure the water temperature is between 105 and 110 degrees F
When soaking an inflamed site how hot should the water be?
105 to 110 degrees F
This heat delivery technique involves filling a basin with warm water (105 to 110 F) and set on toilet , unclaimed tubing to allow water to flow over perineum.
When doing a Sitz bath where should the basin be positioned?
On the toilet
When doing a Sitz bath in which direction and area should the water flow?
Over THE perineum
This heat delivery device is typically administered using a tub and done for physical therapy.
When using a whirlpool to deliver heat therapy how high should the nurse fill the tub?
Until the water is above the level of the jets.
When applying heat therapy according to guidelines it should be applied for. To. Minutes every. To. Hours
Apply 20 to 30 min every 2 to 3 hours
A nurse applying heat packs to a site should remember not to leave tem in place longer than?
Leaving heat packs in place for longer than 45 minutes may result in what?
Applying heat for too long can do what to blood vessels?
Constrict vessels instead of dilation
Applying heat therapy for too long can also result in what?
Worsening of the condition
Patient assessments that should be made prior to the application of heat therapy include patient's , level of function, , , impairment, and possible impairment of .
Patient's age, Cognitive level of function, orientation, Sedation, Sensory impairment, and possible impairment of circulation
Prior to the application of heat on a patient with diabetes or peripheral vascular disease the nurse should do a sspecific assessment of the patient's ?
When assessing the skin of a patient with diabetes or peripheral vascular disease prior to the application of heat what 5 things should the nurse look for?
Temperature, Color, Sensation, Edema, and Skin Integrity
After the start of heat therapy how long should the nurse wait to reases the skin for blistering or redness?
During heat therapy how often should the nurse check the site until the therapy is complete?
Every 10 to 15 minutes
When delivering heat therapy using a continuous K-pad how often should the nurse assess it?
When delivering heat therapy what should the nurse do before leaving the room?
Place patient call light within reach
Following heat therapy the nurse will want to assess the for or .
Assess the skin for redness or blistering
Following heat therapy a nurse should be sure and ask te patient what?
If the therapy helped
Following heat therapy a nurse should evaluate what?
The Effectiveness of the treatment
The prevention of Edema, Homeostasis, Pain relief, Numbing sensation, Reduction of Muscle Spasms, and Fever reduction are the 6 indications for what?
The real danger with a Fever is that as it increases to dangerous levels the metabolism what?
Also increass to dangerous levels
A Fever can result in what?
When trying to reduce fevers cold therapy can do what?
Reduce body temperature
When using cold therapy to reduce fever where should a nurse place ice packs?
On the forehead, in Axillae, and Inguinal areas (groin)
When using cold therapy a nurse may use what kind of bath?
A tepid but not cold bath (90 F)
When using cold therapy to reduce the fever a nurse should not the patient and prevent .
Should not chill the patient and prevent shivering.
This cold therapy delivery device is refillable or comes as collars?
Refillable ice bags/ collars
This cold therapy device is commonly reused by just refreezing what is it?
Refreezable Comercial cold packs
When doing cold therapy sometimes cold packs are used.
Chemical cold packs
When doing cold therapy compresses an baths may also be used.
Cold Compressess and Tepid Baths
During cold therapy the nurse should maintain a between and .
Maintain a thi barrier between ice pack and skin
During cold therapy a cold ice pack should be left in place no longer than to minutes.
20 to 30 minutes
During cold therapy how often should the nurse assess the skin for pallor or mottling?
Every 10 to 15 minutes
During cold therapy the nurse may need to place what over the patient?
A Blanket if needed
When using a tepid bath to administer cold therapy how long should it last?
10 to 15 minutes
During the application of cold therapy the nurse should of cold therapy and assess the .
Ealuate the effects of cold therapy and assess the patients response
When making a cold compress a nurse should a washcloth, place in and for a short period.
Fold the washcloth, place in reclosable plastic bag and place in freezer for a short period.
When making a cold compress a nurse should then use a water and dip a into it, out, and to the site.
Use a bowl of ice water and dip a washcloth into it, wring it out, and apply to the site
When mking a cold compress to do cold therapy on a site where the skin is not intact a nurse should use what?
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