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Adult Care 1 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

risk factors for sepsis

A

immunocompromised, CLABSI, open wounds, malnutrition, invasive procedures, cancer, older than 80, alcoholism, diabetes mellitus, transplants, hepatitis, HIV/AIDS, GI ischemia, Hepatitis, transplant recipient, CKD, infection with resistant oraganisms, mucous membrane fissures in prolonged contact with bloody/ drainage soaked packing

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2
Q

stages of sepsis

A

SIRS, Sepsis, Severe Sepsis, Septic Shock, MODS

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3
Q

s/s of infection and sepsis

A

SIRS and confirmed infection
SIRS=2/4 criteria
body temp >100.5 or <96.8
HR>90
RR>20/PaCO2<32
WBC >12,000 or <4,000 or >10% immature bands
Infection:
fever
tachycardia
pain
swelling
warmth
redness
inc WBC

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4
Q

labs to assess for sepsis

A

sepsis labs: increased WBC, Decreased PLTs and Clotting factors, increased lactate, increased procalcitonin, BUN/creatinine, ABG, H&H, blood cultures, ALT, AST

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5
Q

labs to assess for infection progress

A

CRP(C-reactive protein), ESR (erythrocyte sedimentation rate) to track inflammation(is there a downtrend?), blood cultures, and labs listed for sepsis

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6
Q

nursing interventions for sepsis

A

hour-1 bundle
observe for organ dysfunction/worsening of s/s (decreased output, low BP, cyanosis, jaundice, etc)
qSOFA
SOFA

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7
Q

prioritization of nursing interventions for sepsis

A

hour-1 bundle
1. measure Lactate level
2. obtain blood cultures before adminstering antibiotics
3. administer broad-spectrum antibiotics
4. begin rapid adminstration of 30mL/kg crystalloid for hypotension or lactate > 4mmol/L
5. apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure >65 mm Hg

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8
Q

tx of sepsis

A

treat infection/fungal (broad-spectrum first, specific after blood cultures result), treat hypotension with vasopressors, start fluids 30mL/kg

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9
Q

prioritization of tx for sepsis

A

obtain blood cultures and lactate level, begin broad-spectrum abx, start 30mL/kg crystalloid fluid, adjust abx as blood culture sample gets back, monitor for worsening of s/s, monitor VS, and for rxns to abx and fluids.

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10
Q

adrenal function related to sepsis

A

decreased kidney function= toxins not released->furthering inflammation and decreasing perfusion r/t edema–> can indicate/lead to MODS

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11
Q

blood glucose levels related to sepsis

A

high glucose levels released from liver due to stress response; the more severe the response, the higher the glucose level

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12
Q

expected outcomes to sepsis tx

A

improvement in BP, return of WBC counts, increased O2 sat, decreased lactate level, increased perfusion, lack of edema, decreased procalcitonin

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13
Q

what has the highest risk of death over sepsis alone?

A

septic shock

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14
Q

DIC

A

disseminated intravascular coagulation

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15
Q

Disseminated intravascular coagulation; patho

A

microthrombi formed where not needed widespread; this consumes AVAILABLE PLTs and clotting factors and leads to hypoxia–> metabolic acidosis and organ dysfunction(inc hypoxia= inc metabolites-toxic-which amplifies inflammation and repeats poor gas exchange and perfusion)

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16
Q

discharge teaching for a pt at risk for sepsis

A

s/s of sepsis:
s/s of infection:

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17
Q

identify pt at risk for CV disease

A

male, over 40/45,smoker, alcohol, family hx, obese, sedentary lifestyle, african american, high cholesterol diet, uncontrolled HTN, uncontrolled stress

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18
Q

Modifiable risk factors

A

lifestyle, diet, exercise, smoking, drinking alcohol

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19
Q

non-modifiable risk factors

A

age, gender, ethinicity, family hx

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20
Q

NSR

A

normal sinus rhythm

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21
Q

describe normal sinus rhythm

A

impulse intiated by SA node
reg rhythm
rate 60-100bpm
normal P wave in lead
P wave before each QRS
normal PR, QRS, and QT intervals

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22
Q

sinus bradycardia

A

impulse initiated in SA node
sinus rhythm w/ rate <60
normal p wave
p wave before each QRS

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23
Q

causes for sinus bradycardia

A

vagal, drugs, ischemia, disease of nodes, ICP, hypoxemia, athletes(normal)

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24
Q

s/s of sinus bradycardia

A

can be asymptomatic
OR
confusion, SOB, CP, diaphoresis, syncope, lightheadedness, hypotension

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25
Q

sinus tachycardia

A

sinus rhythm with rate 100-150
normal P wave
p wave before every QRS

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26
Q

what does P wave represent

A

atrial depolarization

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27
Q

what does QRS complex represent?

A

ventricular depolarization

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28
Q

what does QT interval represent?

A

measures the complete ventricular cucles (depolarization AND repolarization)

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29
Q

what does T wave represent?

A

ventricular repolarization

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30
Q

normal values for P wave

A

0.12-0.2

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31
Q

normal values for QRS complex

A

0.06-0.10 seconds (longer=slower)

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32
Q

normal values for PR interval

A

0.12-0.20 seconds

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33
Q

normal values for QT interval

A

<0.44 seconds

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34
Q

how do you determine HR on an ECG strip?

A

find the tick marks, make sure strip is 6 seconds long. count the QRS complexes and multiply it by 10 (or count QRS in 30 boxes and multiply by 10)

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35
Q

how may seconds is one single box on an ECG strip?

A

0.04 seconds per small box

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36
Q

how many seconds is 5 boxes on an ECG strip

A

0.2 seconds for 5 boxes

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37
Q

what does amplitude measure on an ECG?

A

force of contraction

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38
Q

how is Time measured on an ECG strip?

A

horizontally

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39
Q

nursing interventions for sinus bradycardia

A

-monitor VS, monitor for confusion, SOB, CP, diaphoresis, syncope, lightheadedness, hypotension
-give fluids for hypotension
-anticipate orders for atropine or external pacing

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40
Q

nursing interventions for sinus tachycardia

A

assess for s/s: confusion, hypotension, lightheadedness, delay cap-refill, anxiety
monitor VS
anticipate medications

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41
Q

impact on beta-blockers on the heart

A

lower HR and BP

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42
Q

Risk factors for DVT/PE

A

endothelial injury, stasis of blood flow, hypercoagulable state (virchow’s triad)

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43
Q

Virchow’s Triad

A

endothelial injury, stasis of blood flow, hypercoagulable state

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44
Q

what falls under “endothelial injury”

A

part of Virchow’s triad for VTE risk factores:
surgery- Hip, knee, prostate
trauma
athersclerosis
smoking
catheter

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45
Q

what falls under the “hypercoagulable state”?

A

part of Virchow’s triad for VTE risk factors:
-malignancy
-congenital coagulation defect
-thrombophilia
-oral contraceptives
-inflammatory bowel disease

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46
Q

what falls under the “stasis of blood flow”?

A

part of virchow’s triad for VTE risk factors:
-immobility
-atiral fibrillation
-venous insufficiency
-venous obstruction
-Heart failure

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47
Q

diagnostics for DVT/PE

A

D-Dimer lab- tells if there is a clot that is breaking and floating
Venous Duplex Ultrasound- preferred method to dx DVT

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48
Q

non-surgical interventions for DVT/PE

A

early ambulation is the most important!
-SCDs
-ROM exercises
-TEDs
-elevation
-adequate hydration
-IS use
-coughing
-deep breathing
-turning while in bed

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49
Q

pt education about tx and prevention of DVT/PE

A

-prevent by walking frequently after procedures, perform gas pedal pumps and ROM in bed, wear compression stockings, maintain adequate hydration.coughing and deep breathing
-Rx for clot busters and anticoagulants may be given- enoxaparin/lovenox injection instructions or NOAC (novel oral anticoagulants)
-surgical:thrombectomy-remove clot by catheter aspiration suction
mechanical thrombectomy- blood clot is broken up into small pieces and removed

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50
Q

warfarin pt education

A

-vitamin K is the antidote- keep diet consistent, do not increase or decrease vitamin K consumption once therapeutic level of warfarin prescribed (leafy greens)
-s/s bleeding and prevention
-takes 3-4 days to be effective
-must have INR monitored as ordered (1.5-2)
-avoid prolonged sitting and crossing legs
-avoid smoking
-report abd pain
-pregnancy category X
-s/s hepatitis: jaundice, abd pain, nausea,etc.

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51
Q

ABG interpretation

A

pH level: 7.35-7.45 (acidosis or alkalosis)
PaCO2(respiratory):45-35
HCO3(bicarb;metabolic):22-26

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52
Q

pt prep for Chest X-RAY

A

education, no prep

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53
Q

Pt prep for thoracentesis

A

explain procedure and informed consent
supplies
pt position upright leaning on table
educate to remain absolutely still
VS

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54
Q

pt prep for bronchoscopy

A

-consent
-complete labs and diagostics needed
-NPO 4-8 hrs before
-remove dentures and oral prosthetics
-admin meds and topical anesthetics

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55
Q

pt prep for pulmonary function test

A

explain why tests are given: assess lung capacity and volumes, screen for respiratory complications and compare baseline overtime to others
-no smoking 6-8 hrs before
-no bronchodilator 4-6 hrs before

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56
Q

pt education for chest x-ray

A

used to monitor chest tubes insertion/placement daily
assess pulmonary issues, tubes,lines, evaluate condition of pneumothorax, pneumonia, abcess

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57
Q

pt prep for thoracentesis

A

local anesthetic, positioning, education, support, stay still, sterile procedure, collect specimen for tests and biopsies

58
Q

pt education for bronchoscopy

A

used to assess lung cancer, gather culture and sensitivity (what is in lungs and how it can be treated), remove foreign bodies
-NPO 4-8 hrs begore
-local anesthetic
-level of monitoring

59
Q

pt education for pulmonaryfunction test

A

no smoking 6-8 hours before
NPO 4-8 hours before
used to screen for disease, lung dysfunction, potential complications for surgeries and anesthesia
instructions for performing test

60
Q

indications for chest x-ray

A

pulmonary issues, tubes, lines, pneumonia, TB, abcess,pneumothorax

61
Q

indications for thoracentesis

A

discomfort due to fluid in pleural space–>needs removal, air built up in pleural space, instill medications into pleural space, obtain biopsy/samples from pleural space

62
Q

indications for bronchoscopy

A

view airway structures and obtain tissue samples to DX and manage pulmonary diseases (lung cancer)
remove foreign bodies
culture and sensitivity

63
Q

indications for pulmonary function tests

A

need a baseline to compare to other tests to view progress in pulmonary disease; monitor lung function

64
Q

nursing implications and post-procedure care for chest x-ray

A

if pt has diminished or absent breath sounds->pneumo?
hx of pulm disease or untreated infection?
-make pt comfortable and advocate

65
Q

nursing implications and post procedure care for thoracentesis

A

client complains of SOB, CP, diaphoresis, labored breathing, asymmetrical chest expansion, CXR shows collapsed lung or excess fluid
-dressing apply, pt comfortable, monitor VS and resp status
assess and look for s/s pnemo
-chest XRAY/iamging after
-turn, cough, deep breathing

66
Q

nursing implications and post procedure care for bronchoscopy

A

s/s or hx of lung disease, removal of foreign bodies
vital signs q15 min for 2 hrs
monitor VS and sedation level
did gag reflex return?->meds after
pain control

67
Q

nursing implications and post procedure care for pulmonary function test

A

screen for surgical complications, assess lung function, compare results to evaluate interventions and manage chronic pulm disease
-answer questions
-monitor resp status
-turn, deep breath, cough
-IS
monitor VS

68
Q

assessment findings for pneumothorax

A

-decreased/absent breath sounds on affected side
-asymmetrical chest expansion
-anxiety
-diaphoresis
-tachycardia
-tachypnea
-resp distress
-Resp failure
-distended neck veins
-hemodynamic instability
tension pneumothorax: tracheal deviation towards unaffected side, cyanotic, resp distress, absent breath sounds on affected side
-hypotension
-CP
-hyperresonance on percussion

69
Q

assessment findings for hemothorax

A

decreased or absent breath sounds on affected side, hypotension, poor gas exchange, poor perfusion (slow cap refill), chest pain, SOB, possible asymmetrical chest expansion,possible trachea deviation, dullness on percussion

70
Q

assessment findings for pleural effusion

A

decreased/absent breath sounds on affected side, dullness on percussion, low SpO2, slow cap refill, SOB, tachypnea, tachycardia

71
Q

assessment findings of flail chest

A

chest pain, paradoxical movement, Dyspnea, tachycardia, tachypnea,hypotension, 2 or more adjacent rib fractures in a couple places

72
Q

assessment findings for pulmonary contusion

A

Crackles, decreased breath sounds, wheezes over affected area. Bruising over injury, dry cough, tachycardia, tachypnea, dullness to percussion

73
Q

diagnostics for pneumothorax

A

chest xray, ABG, resp assessment

74
Q

diagnostics for hemothorax

A

chest XRAY, chest CT, CBC, resp assessment

75
Q

diagnostics for pleural effusion

A

chest xray, resp assessment

76
Q

diagnostics for flail chest

A

chest Xray
resp assessment

77
Q

diagnostics for pulmonary contusion

A

chest CT, resp assessment

78
Q

treatment for pneumothorax

A

needle aspiration, thoracentesis (emergent for tension)
chest tube

79
Q

tx for hemothorax

A

thoracentesis, needle aspiration or chest tube

80
Q

tx for pleural effusion

A

chest tubes, needle aspiration

81
Q

tx for flail chest

A

pain management, promote lung expansion

82
Q

tx for pulmonary contusion

A

pain management, splinting chest with positioning, coughing and deep breathing exercises.

83
Q

nursing care for pneumothorax

A

Assess lung sounds, prepare for chest tube insertion, maintenance of water levels for water sealed CDU, keep dressing occlusive, care for dry suction CDU, assess for leaks and kinks, TCDB

84
Q

nursing care for hemothorax

A

Assess lung sounds, prepare for chest tube insertion, maintenance of water levels for water sealed CDU, keep dressing occlusive, care for dry suction CDU, assess for leaks and kinks, TCDB, monitor drainage and if more than expected per hour

85
Q

nursing care for pleural effusion

A

Blood cultures before abx, education about chest tube insertion and prepare, maintenance of chest tube, VS, education and prep for Thoracentesis

86
Q

nursing care of flail chest

A

Assess for dyspnea, paradoxical chest movement, cyanosis, tachycardia,and hypotension. Stabilize by positive pressure ventilation. Maintain airway, oxygen PRN, education/prep for x ray, pain control

87
Q

nursing care for pulmonary contusion

A

Teach how to splint, TCDB, how to use IS, ambulate

88
Q

pt education for pneumothorax

A

Hygiene and chest tube maintenance, things to report, complications, procedure for if chest tube dislodged/falls out, valsalva maneuver

89
Q

pt education for hemothorax

A

Hygiene and chest tube maintenance, things to report, complications, procedure for if chest tube dislodged/falls out, valsalva maneuver

90
Q

pt education for pleural effusion

A
91
Q

pt education for pulmonary contusion

A
92
Q

medications for pneumothorax

A
93
Q

medications for hemothorax

A
94
Q

medications for pleural effusion

A
95
Q

medications for flail chest

A
96
Q

medications for pulmonary contusion

A
97
Q

complications of pneumothorax

A
98
Q

complications of hemothorax

A
99
Q

complications for pleural effusion

A
100
Q

complications for flail chest

A
101
Q

complications for pulmonary contusion

A
102
Q

prioritization of care for pneumothorax

A
103
Q

prioritization of care for hemothorax

A
104
Q

prioritization of care for pleural effusion

A
105
Q

prioritization of care for flail chest

A
106
Q

prioritization of care for pulmonary contusion

A
107
Q

safety considerations for penumothorax

A
108
Q

safety considerations for tension pneumothorax

A
109
Q

safety considerations for hemothorax

A
110
Q

safety considerations for pleural effusions

A
111
Q

safety considerations for flail chest

A
112
Q

safety considerations for pulmonary contusion

A
113
Q

assessment findings for tension pneumothorax

A
114
Q

diagnostics for tension pneumothorax

A
115
Q

tx for tension pneumothorax

A
116
Q

nursing care for tension pneumothorax

A
117
Q

pt education for a tension pneumothorax

A
118
Q

medications for tension pneumothorax

A
119
Q

complications for tension pnuemothorax

A
120
Q

prioritization of care for tension pneumothorax

A
121
Q

safety considerations for tension pneumothorax

A
122
Q

prioritization of assessment and care following cheset trauma

A
123
Q

atelectasis

A

collapse of alveoli

124
Q

prevention of atelectasis

A

incentive spirometer use, coughing and deep breathing exercises

125
Q

tx for atelectasis

A

thoracentesis

126
Q

purpose for NIPPV

A

benefit of oxygenation and ventilation improvement without intubating

127
Q

NIPPV

A

non-invasive positive pressure airway

128
Q

purpose for CPAP

A

continuous pressure to keep airway open and patent- improve oxygenation

129
Q

purpose for BiPAP

A

bi-level intermittent inspiratory and expiratory pressures to keep airway open, patent, and improve ventilation

130
Q

Purpose of PEEP

A
131
Q

NIPPV devices are used for pts with….

A

obstructive sleep apnea

132
Q

CPAP devices are used for pts with

A

sleep apnea
HF

133
Q

BiPAP devices are used for pts with…

A

COPD
HF

134
Q

PEEP devices are used for pts with…

A
135
Q

prep for chest tube insertion

A

clean room, OR preop checklist, VS (baseline), pt education, supplies, premedicate as ordered

136
Q

indications for chest tube insertion

A

pneumothorax, hemothorax, pleural effusion

137
Q

assessment of a pt with a chest tube

A

-insertion site: s/s infection?
-appropriate dressings
-pain level?
-kinks/occulsions of tubing?
-suction control chamber water level appropriate?
-water seal tidaling?
-water seal bubbling gently or aggressively(leak?)(on?)
-collection chamber full?
-CDU need to be changed?
-collection chamber marked hourly?
-dry/wet suction?
-suction levels appropriate?

138
Q

troubleshooting a chest tube

A

cannot clamp for long, clamp and unclap briefly to check for leaks
kinks/occlusions in tube effect suction and pressures
suction control at marked line?
tidaling present in water seal chamber?
is there gentle or aggressive bubbling (on vs leak in system)

139
Q

proper function of chambers of chest drainage system

A

collection chamber: collects fluid/air from pt pleural space
water seal chamber: prevents air from traveling back into pt pleural space
suction control chamber: controls suction based on level water (wet suction) or dial (dry suction), keep water at ordered level

140
Q

complications of chest tubes

A

Adult Care 1 (6 decks)

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