Exam # 1 Flashcards
what are the two kinds of restraints?
physical and chemical restraints
what are some examples of physical restraints?
wrist, ankle, vest, having 4 side rails up, vest,
what are the two kinds of quick-release options used on wrist and ankle restraints?
quick-release buckle or quick-release knot
what kind of knot is used in a quick release knot?
slip knot
what are chemical restraints?
medications
what part of the bed do you attach restraints to?
unmovable part of the bed
how often should you assess the patient in restraints?
30-60 minutes
what are you assessing for a patient in restraints every 30 - 60 minutes?
behavior changes
how often should the patient be released from restraints?
every two hours
can you take a patient off restraints if the family is present in the room?
no
if the patient is sedated can you leave the restraints undone while you get something outside of the room?
no
how long is an order for restraints good for?
24 hours
can you put the patient in restraints without an order?
no
what does reason mean on a informed consent?
why the procedure is occuring and what the procedure is
what does “who will be present” on the informed consent mean?
it lets the patient know who all will be in the room….medical students, anesthesia, PA, MD/DO, residents, reps, nurses etc
what does “alternatives” on the informed consent mean?
the patient must be informed of all of the alternative treatments other than surgery
what does “procedure risks” mean on the informed consent?
the risks involed in the procedure such as death, infections, respiratory distress, damage to other organs, errors
what does “anesthesia risks” mean on the informed consent?
risk that may follow anesthesia….sore throat, respiratory distress, death, waking up during surgery
what does blood products consent mean?
seperate from the informed consent but asks for permission to give blood during surgery if needed
what is the role of the nurse in a informed content?
to make sure tha the client is AAO x 4 and that their judgment is not impaired when signing the consent
what is the role of the surgeon in a informed consent?
to explain the procedure and all of the risks involved
what is the anesthesiologist role in the consent?
making sure they know all of the risk involved in the administration of anesthesia…keep the patient asleep during the surgery
can illiterate clients sign an informed consent?
yes
how can you help a blind patient with understanding what is on the consent?
read it to them and xxxxxxx`
how can you help an illiterate client sign an informed consent?
read what is said on the paper
can blind patients sign the consent?
yes
who is a court-appointed person in regards to a informed consent?
XXXXX for parents found to be un fit to make decisions for their child???????
what happens during a life-threatening situation where a person/family member can not be identified?
a doctor must consult with another physician to make the decision on the patients behalf
can you use a family member instead of a translator when signing a legal document?
no
what is perfusion?
the flow of blood carrying nutrients to the body
what are the factors that affect perfusion quality?
heart and pulmonary function
what is the leading cause of death in the USA?
coronary artery disease
what is coronary artery disease?
the build-up of plaque in the arteries supplying blood to the heart
where are coronary arteries found?
on the heart
what happens if the coronary arteries are blocked?
the reduction in blood can lead to chest pain or heart attack
what is atherosclerosis?
build of plaque in vessels
where does atherosclerosis take place in coronary artery disease?
the heart arteries
what are risk factors for coronary artery disease?
genetics, age, sex, ethnicity, lipid levels, diabetes, obesity, sedentary life style, smoking, hypertension
what is ischemia?
lack of blood flow and oxygen to a certain tissue
what is myocardial ischemia?
lack of blood flow and oxygen to the heart
what is angina?
chest pain
what causes angina?
insufficient coronary blood flow
what are some symptoms of CAD?
angina, epigastric distress, gas, pain that radiates in the jar or arm, SOB, MI, HF, or sudden cardiac death
how can you prevent CAD?
having regular medical exams, low-fat foods, low cholesterol, exercise, losing weight, quitting smoking
what medications help with the treatment of CAD?
atorvastatin…simvastatin…lovastatin…
what cholesterol is considered bad?
LDL
what value is wanted for LDL?
less than 100 and 70 in high risk patients
what value is wanted for total cholesterol?
less than 200
what value is wanted for HDL
greater than 40 in males and greater than 50 in females
what value is wanted for triglycerides?
less than 150
what is considered good cholesterol?
HDL
what are triglycerides?
common type of fat used by the body to provide energy for cells
what happens if blood flow is restricted for too long in the heart?
can cause irreversible damage to the myocardium
what causes angina?
physical activity, stress, or random times depending on the angina the patient has
what is stable angina?
caused by exertion…relieved by rest… lasts less than 15 minutes…predictable
what is unstable angina?
pain at rest or exertion…causes activity limitations…can progress to MI…unpredictable
what are some symptoms of angina?
tightness…choking…heavy sensation in chest…pain in neck…jaw….shoulders…back…left arm…dyspnea…nausea.. vomiting…weakness…numbness
what are the interventions for angina?
nitro, morphine, oxygen, baby aspirin
what is myocardial infarction?
plaque ruptures and a thrombus forms resulting in the occlusion of an artery….the occlusion leads. ischemia and necrosis of myocardium
what are the symptoms of a MI?
constant chest pain….pain radiation…SOB…diaphoresis…COOL,PALE, MOIST SKIN…indigestion…anxiety
what is another term for MI?
heart attack
what labs will physicians look at when diagnosing MI?
troponin, cardiac enzymes, creatine kinase, myoglobin
what is the normal value for troponin?
less than 0.4
what vital sign changes will you see in a patient with MI?
increased BP, HR, RR
what diagnostic tests will physicians use to diagnose MI?
ECG/EKG and Stress tests
what will an ECG/EKG show for a patient having an MI?
ST elevation
what is the goal of MI intervention?
to restore adequate blood flow to the heart…. manage symptoms until surgery
what is a stroke?
interruption of perfusion to the brain
what makes symptoms vary in a stroke?
the location of the ischemic or hemorrhage
what are the two types of CVA/STROKE?
ischemic and hemorrhage
what is an ischemic stroke?
a stroke where a clot block off blood supply to the area
what is a hemorrhagic stroke?
a stroke where a blood vessel ruptures and blood rushes out of the vessel and into the brain
what are non modifiable risk factors for TIA or CVA?
heredity, ethnicity, age
what does TIA stand for?
transient ischaemic attack
what does CVA stand for?
cerbral vascular accident
what are modifiable risk factors for TIA or CVA?
hypertension….elevated lipid levels…diabetes…obesity…smoking…sedintary lifestyle…a fib….substance abuse…alcohol use
what are general signs that someone is having a stroke?
sensory changes…mobility changes…vision changes..speech changes…behavior
what does the B in the acronym be fast mean?
B. Balance…..loss of balance, headache, dizziness
what does the E in the acronym be fast mean?
E. Eyes..blurred vision
what does the F in the acronym be fast mean?
F. Face…one side of the face is drooping
what does the A in the acronym be fast mean?
A. Arms….arm or leg weakness
what does the S in the acronym be fast mean?
S. Speech….difficulty
what does the T in the acronym be fast mean?
T. Time to call for an ambulance
why are TIA not as severe as CVA?
because TIAs are temporary
how long do TIAs last?
between 30 to 60 minutes
Do TIA and CVA has the same symptoms?
yes
what happens to the brain if you have repeated episodes of TIA?
permanent damage
what is a CVA?
sudden loss of brain function from disruption of blood flow
what are some characteristics of right hemispheric stroke?
happy…paralysis of the left side of body…left visual deficit…spacial perceptual deficits…increased distractibility…impulsive behavior…poor judgment
what are some characteristics of left hemispheric stroke?
paralysis of the right side of body….right visual deficit…aphasia…altered intellectual ability..slow..cautious
what is expressive aphasia?
xx
what is receptive aphasia?
xxx
what is global aphasia?
xx
what side of stroke can have ADHD-like tendencies?
right sided
what type of stroke is caused by thrombosis or embolic?
ischemic
what type of stroke can have a cryptogenic cause?
ischemic
what does cryptogenic mean?
an unknown cause
what are some symptoms of a ischemic stroke?
numbness or weakness of the face, arm, leg…especially on one side of the body, aphasia, vision loss
what are some sypmtoms of a hemorrhagic stroke?
extreme headache, decreased LOC, seizure
what stroke is easier to recover from?
ischemic
when is the majority of recovery gained after an ischemic stroke?
3-6 months and smaller steps after one year
what stroke is harder/slower to recover from?
hemorrhagic
what stroke typically leaves the patient with more disability?
hemorrhagic
why are CTs and MRIs performed on stroke patients?
to see the size and location of the clot
is contrast used on CTs for stroke patients?`
no
what is the goal when treating an ischemic stroke?
restore perfusion in the brain
what is the goal when treating a hemorrhagic stroke?
stop the bleed
what type of assessment should you do on all stroke patients?
neuro
what are you looking for in terms of BP for in ischemic stroke patients?
prevent drop in BP because this could further the ischemia
prevent sudden rises in BP to prevent hemorrhage and increased ICP
what happens to the pressure in the brain if BP increases too much?
the intracranial pressure increases
what are you looking for in terms of BP for in hemorrhagic stroke patients?
preventing sudden rises in BP to prevent further hemorrhage and increased ICP
after a stroke occurs what complications should be watched out for?
aspiration, skin breakdown, preventing future strokes
what is the infection cycle?
infectious agent….reservoir…portal of exit…means of transmission….portal of entry…susceptible host
what is the infectious agent?
the actual virus, funguns, or bacteria
what is the reservoir?
where the agent goes and grows
what is the portal of exit?
where the agent exits to the body
what is the means of transmission?
how the disease is transported…direct..indirect…vector
what does direct transmission mean?
passing a disease through contact with someone
what does indirect transmission mean?
passing a disease to someone even though you did not come into direct contact
what are some examples of direct transmission?
sex, kissing, droplet diseases
what are some examples of indirect transmission?
fecal-oral transmission….not washing hands after the bathroom and spreading it on surfaces where people touch that surface and touch their mouth
Airborne disease
what are some examples of airborne diseases?
xx
what PPE is required for airborne diseases?
xx
what are some examples of droplet diseases?
xx
what PPE is required for droplet diseases?
xx
what PPE is required for contact precautions
xx
what diseases fall under contact precautions?
xxx
what is the portal of entry?
where the disease enters the body
what is the susceptible host?
a person who is at risk for contracting the disease….immunocompromised…open wounds…old age`
what are the stages of infection?
incubation….prodromal….full stage of illness…convalescent period
what is incubation?
the infection is growing in the body
what is the prodromal stage?
period of incubation when they do not have symptoms present
most infection state
what is the full stage illness?
when the patient has visible symptoms
what is the convalescent period?
the healing stage…symptoms can be present?
what factors put someone at risk for infection?
skin integrity…pH level of GI..number of WBC…age…sex…heridity… immunization status…stress.fatigue…indwelling devices
how does the body respond to infections?
immune and inflammatory
what are some examples of bacterial infections commonly found in the hospital?
MRSA and CAUITI
what are some examples of fungi infections?
athletes foot and ringworm
what are some examples of viruses?
flu, covid, HIV
what are the two reasons for the body to have an inflammatory response?
infection or injury
what are the two parts of the inflammatory response?
vascular and cellular
what happens during the cellular stage?
leukocytes/neutrophils consume debris; damaged cells are repaired
what happens during the vascular stage?
vasodilation increases blood and results in redness and heat
histamines are then released which makes protein rich blood come to the site
what is an antigen?
a foreign body
what is an antibody?
produced by the body to fight off the antigen
whose at risk for MRSA?
people who have had invasive procedures, repiratory therapy, wounds, immunocompromised, catheters, tubes
whose at risk for CAUTI?
women, older adults, debilitated patients, malnourished, chronically ill, immunocompromised, diabetes
what are the signs and symptoms of CAUTI?
fever, chill, hematuria, cloudy urine, malodorus urine, anorexia, malaise
what is hematuria?
blood in the urine
what is malaise?
fatigue
what s the best way to test for a cauti?
urine culture
what are hospital acquired infections/HAI?
Infections that were not present or incubating at the time of the client’s admission to the healthcare setting
what is another name for hospital-acquired infections/HAI?
nosocomial infection
what is HIV?
human immunodeficiency virus
how is HIV spread?
through sex or blood
what should be some goals for treating your HIV patient
education…reduce anxiety….help with complications…educate on prevention of spread HIV
how can you help reduce anxiety in HIV patients?
encourage discussion of feelings, provide education, plan with their partner, refer to social worker if needed
what is considered PPE?
gloves, gown, mask, protective eyewear
how should you don PPE?
gown, mask, goggles, gloves
how should you doff PPE?
Gloves, gown, goggles, mask
when are standard precautions used?
with every patient even if there are no infections present
what are transmission based precautions?
for patients with an infection present…could be contact, droplet or airborne
when are contact precautions used?
MRSA, cauti, c dif
what PPE is on contact precautions?
gown and gloves
when are droplet precautions used?
flu, strep, meningitis, pertussis
what is PPE is included in droplet precautions?
surgical face mask, goggles, gown, gloves
when are airborne precautions used?
TB, Varicelle, Measles,
what is PPE is included in airborne precautions?
N95 mask , goggles, gown, gloves
what precaution uses a negative pressure room?
airborne
Is COVID airborne or droplet?
droplet unless respiratory care is done then it is airborne
what is an open fracture?
when the bone has punctured the skin
what is a closed fracture?
when the bone is broken but the skin is intact
what is a complete fracture?
when the bone is broken into two parts
what is an incomplete fracture?
when the bone is not split into two or more parts
what are some causes of fractures?
MVA…falls…bone disease…trauma..malnutrition
what is a common bone for elderly to break?
their wrist when catching themselves in falls
what are the symptoms of a fracture?
pain…inability to use extremities…inflimmation…ecchymotic…poor pulse distal to fracture….parathesia…issue with other systems
what is ecchymotic mean?
bruising causes by bleeding under the skin
what is paresthesia?
numbness or tingling
how can a fracture lead to issues with other systems?
ribs can puncture lungs….hip can damage bladder
what labs will they run during a fracture?
H and H…ESR…WBC
why would physicians run a H and H during a fracture?
xxx to see how much blood has been lost and if you need a infusion xxx double check
why would physicians run an ESR during a fracture?
to check inflammation
why would physicians run a WBC during a fracture?
to monitor infection
what imaging is used for fractures?
x ray….CT….MRI
what color tattoo prevents you from getting a CT?
red
what is a closed reduction?
putting the bone back in place without opening the patient up
what is the immobilization of a fracture?
using splints, boots, casts
what are the non surgical interventions for a fracture?
closed reduction, immobilization, drug therapy, PT
what is on the pre op check list?
complete history…advance directives..baseline labs…baseline images…NPO status…consent…procedure
what are some post operation complications?
acute compartment syndrome…. hemorrhage…fat embolism…DVT…..infection….delirium….dislocation
what is acute compartment syndrome?
bleeding in a certain area that keeps expanding….pain med wont help pain….could be decreased to no pulse….
how can you prevent acute compartment syndrome?
perform assessments and check pulses
what are some symptoms of a non stroke hemorrhage?
bruising, swelling, pallor, fatigue, confusion, pain,…..BP goes down HR goes up, pulse ox goes down
what is a fat embolism?
a blood clot in your fatty tissue that goes off to the rest of your body
how can you prevent fat embolism?
monitor vitals
what happens to vitals during a fat embolism?
increase in BP, HR, RR
what is DVT?
a blood clot in the leg
what does DVT do to your vitals?
increase in BP, HR, RR
what will DVT look like?
red, hot, swollen,
how can you prevent DVT?
ambulation…SCD…TED
what is a aka
above the knee amputation
what is a bka?
below the knee amputation
is healthy tissue removed during an amputation?
yes because they want to make sure to not leave any infected or necrotic tissue behind
what do you do for amputee neurovascular checks?
pulse at the lowest point….check the color…check the ability to move…ability to feel
what do you do for amputee skin integrity checks?
make sure the site is clean… infection-free….observe the sutures or staples..temp…drainage
why can a amputee h and h be altered?
because they lost a limb that creates those things
what are some symptoms of hemorrhaging?
low bp, increased HR, difficulty breathing, decreased spoo2
what are some signs of an infection after surgery?
temp greater than 100.5, drainage, confusion
what is phantom limb pain?
the patient feels pain from the extremity…if patient states that they have pain from it administer the medication
what is a neuroma?
a benign tumor that grows on the nerves that are bundled together
what is a flexion contractor?
the joint becomes stiff after not moving it
what are nursing priorities for a new amputee?
mobility, perfusion, infection, comfort, self esteem
