EXAM 1 Flashcards
when should a pt’s vitals be monitored and why is it important
before, during and after treatment
it is an important parameter in progressing the pt
what are the assessments for physiological stability
HR
oxygen saturation
respiratory rate
blood pressure
body temp
what is HR
indirect measure of contraction of the left ventricle of the heart
what are the normal HR values for adults
60-100 bpm
what are the normal HR values for newborns
100-150 bpm
what are the normal HR values for children from 1 to 10 yrs old
70-130 bpm
what are some factors that can affect HR
meds
PA
medical conditions
stress
dehydration
where can we asses HR
brachial
radial
carotid
temporal
femoral
popliteal
dorsal pedal
what are the normal ranges for oxygen saturation
95-100%
what is hypoxemia
SpO2 is less than 90
what are some factors that affect oxygen saturation
emotional
medical conditions
PA
age
environment
how do we assess oxygen saturation
pulse ox monitor
how do you manually measure respiration
one respiration= one inspiration and one expiration
what are the normal respiration values for adults
12-20 at rest
what are the normal respiration values for infants
30-50 at rest
what are the factors that can affect respiratory rates
emotional
PA
age
medical conditions
environment
how do we assess respiratory rate
count manually
look at- rate, depth, rhythm, character
what is systolic BP
contraction of left ventricle
what is diastolic BP
rest period of the heart
what are some factors that may affect BP
emotional
PA
age
medical conditions
meds
diet
how do we assess BP
support pts arm at level of heart
pt can be standing, sitting, supine or exercising
why take BP in different positions
treatment tolerance depending on situation
What are the normal BP values
120/80 mmHg
What is the range for BP that is considered high normal
130-139/85-89 mmHg
What are the ranges for prehypertension
120-139/85-89 mmHg
What is the range for stage 1 BP
140-159/90-99 mmHg
What is the range for stage 2 BP
160-179/100-109 mmHg
What is the range for hypertensive crisis
> 180/>110 mmHg
What is orthostatic hypertension and the S&S
Form of low blood pressure that happens when you stand up from sitting, sit up from lying down
S&S- dizziness or lightheaded
What are the orthostatic hypotension values
Systolic decrease- drop of 20 mmHg
Diastolic decrease- drop of 10 mmHg
Within 3 minute of positional change
How do we objectify pain
Scales and non-verbals
What are the odds of healthcare associated infections
1 out of 25
Fourth leading cause of death
What is the difference between medical and surgical aseptic techniques
Medical keeps pathogens confined to a specific area, object, or person
Surgical excludes all microorganisms before entering a sterile field
What are standard precautions for prevention of infection
Group of infection prevention practices that apply to all patients regardless of diagnosis
Frequent hand washing or rubs
PPE
How does transmission based precautions relate to standard precautions
Goes on top of the standard precautions
What is transmission based precautions
Designed to protect caregiver from highly transmissible pathogens
What is the hand rubbing method
Alcohol based, waterless antiseptic
Most effective when hand washing is not required
Less time, more effective, more accessible, less damaged to skin
What is the hand washing method
Preferred method when hands are visibly dirty, soiled, or considered to be contaminated
Bacteria is removed through friction and scrubbing
When is the hand washing method required
Entering ICU or operating room
Adding an anti microbial agent makes it antiseptic
Decontamination after treating C diff
Potential contaminants
What is a better decontamination of C diff
Hand washing method
What are potential contaminants of hand washing
bar soap
sink rims
waterspout
basin
towel dispenser
faucet handle
what are isolation precautions
linked to the method by which pathogens are transmitted
specific PPE depending on type of transmission
What are the 4 rules of asepsis
Know which items are sterile
Know which items are not sterile
Separate the non sterile from the sterile
If sterile items become contaminated, remedy situation immediately
What are the DO NOTS of contaminated garments
DO NOT
touch any area of body with PPE
touch outer surface of gloves with unloved hands
Touch sleeves or front of gown with ungloved hands
wear PPE outside pts room
What do you do with contaminated refutable equipment
Place in the appropriate container and return for sterilization
What do you do with contaminated disposable equipment
Should be placed in the appropriate containers and discarded according to policies and procedures
What is targeted in high level disinfectants
Everything except high numbers of bacterial spores
What is targeted with an intermediate level of disinfectant
Most viruses, fungi, vegetative bacteria, TB
What is targeted with low level of disinfectant
Most bacteria, some viruses, some fungi
What is removed in decontamination
Destroy blood borne pathogens that are no longer capable of transmitting infectious particles
Which is stronger disinfectant or decontamination
Decontamination
what is the P wave
atrial depolarization
what is the QRS wave
ventricular depolarization
what is the T wave
ventricular repolarization
what is the pathway for the cardiac conduction
SA
AV
Bundle of His
Bundle Branches
Purkinje fibers
what do you look for to determine rhythm
look for ventricular (R) and atrial (P) depolarizations
distance between intervals are equal
regular, irregular, irregular regular??
what is sinus rhythm
equal distance between identical waves
60-100
how do you measure rate
from the start of a bold red line- 300, 150, 100, 75, 60, 50
what is atrial fibrillation
continuous rapid firing of multiple atrial follicles
no single impulse depolarizes the atria completely
what causes A Fib
MI
CABG surgery
Valvular disease
HTN
Chronic alcoholism
what do you see on an ECG for A Fib
no definite P waves
irregular rhythm
continuous chaotic atrial spikes
irregular ventricular rhythm
normal QRS complex
what does premature ventricular contraction look like on ECG
early QRS complex
wider bizarre QRS
no P wave
compensatory pause
what does 3 or more PVC in a run mean
ventricular tachycardia
what is ventricular tachycardia
continuous run of PVC
150-250 bpm
whats causes VT
acute MI or ischemia
electrolyte imbalance
medication toxicity
idiopathic
illicit drugs
what are the S&S of VT
hypotension
syncope- fainting
what does VT look like on an ECG
continuous run of PVC
each QRS is wide
what are common lab values
electrolyte panels
metabolic panels
kidney function
liver function
cardiac markers
lipid panel
what are the reference values for WBC
5-10 x 10^9/L
what is the up trend for WBC
> 11 x 10^9/L
infection, leukemia, obesity, inflammation, stress
weakness, fatigue, fever, dizziness
consider therapy timing around early morning (low level) and late afternoon (high peak)
what is the down trend for WBC
<4 x 10^9/L leukopenia and neutropenia
viral or bacterial infection, radiation
symptoms based approach to determine appropriateness for PT
what are the reference values for platelets
140-400 x k/ul
what is the down trend for platelets
<150 k/ul - excessive bleeding can occur
infection, leukemia, radiation/chemo, liver disease
bruising, petechiae, fatigue, jaundice
what is the up trend for platelets
> 450 k/ul - thrombocytosis
infection, cancer, stress, inflammation
weakness, headache, dizziness, chest pain
what are the PT implications for platelets
<10,000 and or 100.5 temp = hold therapy
symptom based when considering activities
is pt a fall risk? = increased risk of hemorrhage
what are hemoglobin reference and critical values
men = 14-17.4 g/dl
women = 12-16 g/dl
<5-6 g/dl or >20 g/dl
what is the up trend for hemoglobin
CHF, dehydration, COPD, severe burns
dizziness, arrhythmias, TIA symptoms, chest pain
what is the down trend for hemoglobin
anemia, blood loss, lupus, kidney disease, stress to bone marrow
decreased endurance, pallor, tachycardia
what are the therapy implications for hemoglobin
facility dependent
symptom based
what are the hematocrit reference and critical values
men= 42-52%
women = 37-47%
<15-20% or >60%
what is the up trend for hematocrit
COPD, burns, CHF, dehydration
fever, HA, dizziness, weakness, fatigue
what is the down trend for hematocrit
leukemia, multiple myeloma, pregnancy, cirrhosis, RA
pale skin, HA, dizziness, chest pain, arrhythmias, dyspnea
monitor SpO2
what are therapy implications for hematocrit
<25%= essential ADLs only, hold out of bed activities
symptoms based approach
what is prothrombin time
evaluates bloods ability to clot
normal 11-13 sec
what is partial thromboplastin time
used to determine if heparin/warfarin/etc. (blood thinner) therapy is effective
normal 21-35 sec
what is international normalized ratio (INR)
measure how long it takes the blood to clot when an oral anticoagulant is used
PT and PTT can differ depending on lab
normal .8-1.2
increase = risk for bleeding, decrease = risk of clot
What is the rate of the sinus rhythm and diagnosis
between 100-150
trachycardia
what is the rate of the sinus rhythm and diagnosis
less than 50 bpm
bradycardia
what is the rate of this sinus rhythm
75 bpm
what is the diagnosis of the following ECG
VT
what is the diagnosis of the following ECG
PVC
what is the rate for the following sinus rhythm
60 bpm
what is the rate for the following rhythm
between 100-75 bpm
what is the rate for the following rhythm
less than 50 bpm
what is the diagnosis of the ECG
A Fib
what is short term positioning
allowing for treatment of different areas
MT, modalities
what is long term positioning preventing and promoting
preventing pressure ulcers and contractures
promoting better breathing positions
for long term positioning how often do you reposition a pt
every 2 hours to maintain integrity of all 4 movement systems
for short term positioning how often do you need to reposition a pt
every 15 minutes
why would you need to reposition a pt
poor circulation, fragile skin, decreased sensation, difficulty breathing
what is wrong if a pt has prolonged redness of bony prominences
tissue damage
what are the general positioning guidelines
explain procedure to pt
maintain neutral spine
always provide a way for pt to have communication
what are the areas of greatest pressure in supine
head
sp
inferior angle scapula
elbows
PSIS
sacrum
heels
what are the greatest areas of pressure in prone
forehead/lateral ear
acromial process
anterior humeral head
sternum
ASIS
patella
dorsum of foot
what are the areas of greatest pressure in sidelying
lateral ear
lateral ribs
lateral acromial process
lateral humeral head
medial or lateral humerus
greater trochanter
medial or lateral knees
medial or lateral ankles
what are the greatest areas of pressure in sitting
ischial tuberosity
posterior thighs
sacrum
sp
elbow
what can make pts more susceptible to pressure injuries
decreased mobility
fragile skin
incontinence
impaired sensation/circulation
muscle atrophy
friction or shear
what is the skin blanching test
when pressed, healthy lighter skin will blanche and quickly return to healthy pink
who is more at risk for skin breakdown
people with increased pigmentation
if skin does not blanche, what does it indicate
compromised/damaged tissue
what do we NOT do with a pt that has a negative skin blanche test
position them on compromised area
what increases load
a decrease in surface area
decrease in cushioning
how does load relate to time with pressure injuries
increase load + decrease time = injury
decrease load + increase time = injury
how do we prevent pressure injuries
limit direct contact with bony landmarks
increase surface area
increase cushioning
decrease load
decrease time
what are the most common contractures
flexion contractures
who has a increased risk of cervical flexion contractures
pts with swallowing restrictions or breathing dysfunctions, cardiac condition, lung condition
what can cause hip/knee flexion contractures
gathched bed
certain neurological conditions
who has an increased risk for wrist flexion contractures
neurological diseases, injury, disuse
also accompanied by finger and thumb flexion
how do you position a pt with edma
extremities above heart
how are positioning devices beneficial
reduce or eliminate load on the tissue
help pt maintain static positioning
what pts would we do prone positioning
pulmonary issues
amputees
when should we reposition a sitting position
every 10-15 minutes
what should we avoid in sitting
sacral sitting
what is the risk in high fowlers position
sacral shearing
what reason could we use trendelenburg
BP management
pregnancy
what reason could we do reverse trendelenberg
spinal cord
what are the safety and comfort concerns for supine position
support under knees/lower legs and head
what are safety and comfort concerns for prone
support under abdomen/hips- decrease lordosis
pressure off toes
what are the safety and comfort concerns for sidelying
support under head
distribute pressure over greater trochanter
support top arm
what are the safety and comfort concerns for sitting
back supported
what safety and concern should be in all positioning
normal spinal curves
proper airway
what are the principles of draping
clean linens
expose areas only being worked on
remove folds/wrinkles
instruct pt
ensure comfort
protect pts clothing
what are cultural sensitvities
same gender
hospital gown exposure
can’t remove certain clothing items
what should we implement for pts with trauma
good communication
informed consent
respect boundaries
active pt involvement
monitoring signs of discomfort
