Exam 2 Flashcards
Reduces risk of transmission of microorganisms from known or unknown substances. Includes hand hygiene, gloves any other PPE for task, safe injection practices, safe handling of body fluids, and safe handling of contaminated equipment or surfaces.
Standard Precautions
Prevention of transfer of microorganisms and pathogens.
Asepsis`
MRSA, Vanomycin-Resistant Enterobacteria (VRE), Clostridium difficile (C. diff)
Gloves and gown
Client requires private room
Remove gloves and gown before leaving room
Contact Precautions
Varicella Viruses, TB
Respirator mask approved by OSHA :N95, PAPR
Negative airflow room: closed door, seal, HEPA filter
Airborne Precautions
*Particles less than 5 microns
Covid-19
Mix of multiple isolation
N95 or PAPR, gown, gloves, face shields, hair coverings
Enhanced Respiratory Precautions
Diphtheria, Rubella, Streptococcal pharyngitis, Influenza, Pneumonia/Scarlet Fever (infants), Pertussis, Mumps, Meningitis
Surgical Mask
Private room or cohort
Client needs mask if leaving room
Droplet Precautions
*Particles greater than 5 microns
For immunocompromised clients
Private room with positive airflow
Surgical mask
No fresh fruit, vegetables, flowers (anything that can harbor bacteria)
Protective Precautions
Sterile Technique
Procedures used to eliminate all microorganisms - used any time we break skin.
*Sterile objects only touch other sterile objects.
*Sterile surface should not come in contact with another surface.
*Hold sterile objects above the waist.
*Keep sterile objects in view.
*Use sterile objects in timely manner.
*Border of sterile field is contaminated.
Factors affecting urinary elimination:
*Medications
*Anesthesia and surgery
*Psychosocial and Personal Issues
Diseases that affect urinary elimination:
*Renal disease
*Diabetes
*Neuromuscular diseases: Affects nerves that innervate bladder
*Benign Prostatic Hyperplasia: due to constriction of urethra
*Cognitive disease
*Mobility-limiting diseases
Anuria
No urination (<100 mL in 24 hours)
Diuresis
Increased urine formation
Dribbling
Leakage of urine despite voluntary control
Dysuria
Painful or difficult urination
Frequency
Voiding small amounts at frequent intervals
Hesitancy
Difficulty initiating urination
Hematuria
Blood in urine
Incontinence
Involuntary loss of urine
Oliguria
Diminished urinary output
Polyuria
Large amounts of urine voided
Residual
Volume of urine remaining in the bladder after voiding
Retention
Accumulation of urine in the bladder without the ability to empty fully
Urgency
Feeling of needing to void immediately
Signs: Bladder distention, absence of urine output, pressure or tenderness, restlessness, and diaphoresis
Urinary Retention - could be caused by obstruction or medication
Hemodialysis
*Blood removed from body, goes through dialysis machine which pulls wastes and fluids from the blood, then returns filtered blood back to client
- Client must have access device that can withstand very high pressure with two sites to access - one to remove blood and one to return blood
*3 x week, 3-4 hrs per session
Arteriovenous (AV) Fistula
Hole made between an artery and vein in arm
Graft
Small tube placed between artery and vein in arm
Bruit
Whooshing or swishing sound head with stethoscope that indicates fistula or graft are functioning properly
Peritoneal Dialysis
*Peritoneal catheter placed in abdomen
*Client instills dialysate into peritoneal cavity which sits for prescribed amount of time
*Peritoneum acts as semipermeable membrane and allows for filtering of fluids and wastes - drained from abdomen
Incontinence that occurs when there’s an increase in abdominal pressure:
Stress Incontinence
A factor outside the urinary system is causing incontinence:
Functional Incontinence
Occurs when there’s a strong sense of needing to void and then almost an immediate void:
Urge Incontinence
Urinary Tract Infection
Causes: Indwelling urinary catheters, poor hygiene, women’s shorter urethra, urinary retention
Symptoms: Pain, burning with urination, frequent urination, urgency, cloudy urine, confused mental status, nausea and vomit in more severe infection, hematuria
Cystitis
Bladder infection
Pyelonephritis
UTI travels to kidneys causing more serious infection - monitor for worsening fever, flank pain, costovertebral tenderness
Non-invasive Tests for Urinary Alterations:
*X-ray
*CT scan
*Ultrasound
*Intravenous Pyelogram (IVP): X-ray used with contrast dye to highlight kidneys, ureters, and bladder
Invasive Tests for Urinary Alterations:
*Cystoscopy: Introduction of a scope into urethra to get visual of bladder
*Renal Arteriogram: Accessing the renal arteries through catheterization and use of contrast dye
Urinalysis
Most common urinary tests - screens for many issues and indicates problems in urinary system
Specific Gravity
Indicates how dilute or concentrated urine
*Lower more dilute
*Higher more concentrated
Indwelling Catheters
*Temporary or long-term - bladder is continually draining upon - upon insertion a balloons inflated to keep catheter in place in base of bladder - attached to bag the urine drains into - increased risk of infection due to continual access to urethra and bacteria can crawl in bladder
Intermittent Catheters
“Straight” catheters - place catheter, let all urine drain out then remove catheter - doesn’t stay in place - used to relieve retention, get specimen
External Catheter
Alternative to indwelling catheter - condom catheters: end attached to suction which sucks urine away to canister and keeps the client dry
PureWicks
For women - looks like banana with absorbent pad that is placed by labia - end attached to suction which sucks urine away and keeps client dry - not for ambulatory clients
CAUTI
Catheter Associated Urinary Tract Infection
CAUTI Prevention Measures
- Fluid Intake
*Frequent perineal care
*Catheter kept below bladder level
*Avoid dependent loops
*Empty bag prior to moving client
*Secure catheter to client’s leg
*Avoid prolonged cramping of tubing
Redness when there’s ischemia
Erythema
Redness that blanches when pushed on and returns to red when pressure is removed
Blanchable Erythema
When pressure is applied an area remains red - Stage 1 Pressure Ulcer
Non-blanchable Erythema
Pus that is yellow or green and thick
Exudate
Clear or yellow drainage
Serous
Pink drainage - mix of serous and sanguineous drainage
Serosanguineous
Blood drainage
Sanguineous
Gray, white, or yellow tissue that can be stringy - dead tissue
Slough
Black dead tissue in a would - indicative of infarction
Eschar
Granulation - new pink tissue that appears in wounds during healing
Vascular Tissue
Localized injury to skin and underlying tissue. Common over bony prominence
Pressure Ulcers
Pressure Ulcer Interventions
*Turning
*Positioning
*Placement of prophylactic dressings
Pressure Ulcer Risk Factors
*Decreased mobility
*Decreased sensory perceptions
*Moisture
*Incontinence
*Poor nutrition
*Altered LOC
*Shear and friction
*Age
3 Factors that Determine the Likelihood of Developing Pressure Ulcers
- Intensity
- Duration
- Tissue tolerance
Pressure Ulcer Intensity
Capillary closing pressure greater than 32 mmHg
Skin reddened and may be warm to touch and either feel firmer or softer than surrounding skin
Stage 1 Wound
Skin breaks open exposing the epidermis or dermis - lesion will be superficial and often resembles an abrasion/popped blister
Stage 2 Wound
Lesion extends into dermis and begins to enter the subcutaneous layer - lesion will form small crater and fat may begin to show in open sore
Stage 3 Wound
Subcutaneous layer and underlying fascia are breached exposing muscle and bone
Stage 4 Wound
Wounds that have so much eschar and slough that they can’t be staged - must deride wound first
Unstageable Wound
Occurs when epidermis is intact but there’s some injury deep down in tissue - will appear like severe bruise
Deep Tissue Injuries
Tool used to assess skin breakdown - was score of 23 and the lower the score the higher the risk for skin breakdown
Braden Scale
Primary intention wound
Wound that is closed (sutured or stapled)
Secondary intention wound
Wound is left open to heal from inside out
Tertiary intention wound
Would is left open for a while because of infection or drainage and is closed at a later time
Stages of Wound Healing:
*Hemostasis: wound stops bleeding
*Inflammatory: body reacts to injury - WBC’s and histamine go to site
*Proliferative: Healing begins - granulation tissue forms and wound will start to get smaller
*Remodeling: Final scar forms
Wound Complications:
*Hemorrhage or bleeding
*Infection
*Dehiscence: Layers of skin and tissue separate - primary intention - not uncommon
*Evisceration: Layers of skin, tissue, or muscle separate and organs are exposed - emergency - not common
Debridement
If wound has excess eschar or slough it will need to be removed so granulation tissue can come in
Mechanical Debridement
Packing wounds with progressively wet to dry dressings - as dressing dries it pulls some of the dead tissue then when we remove it
Autolytic Debridment
WBC’s eat any necrotic tissue - when dressings are removed they’re very wet and full of exudate
Chemical Debridement
Prescription creams can be put into wounds to chemically remove necrotic tissue (eschar) - might be used in addition to wet to dry dressings
Sharp or Surgical Debridement
Wound and ostomy nurses can do this bedside but if there’s a lot of dead tissue the client may have go into surgery - nurse cuts away eschar, slough, or any dead tissue with a scalpel or scissors
Plain, Simple Dressing
Never use non-adherent dressing these can stick to the wound and when removed further damage the skin or cause new tissue to tear especially in older clients
Wet to Dry dressing
Often used in sterile technique - moist gauze is placed at base of wound and packed in to fill wound which is then covered with a dry dressing
Wound Vacs
Wound is stuffed with sterile foam, covered with a clear Tegaderm dressing and then attached to suction canister. The suction continually derides the wound and collects any drainage
Dressing Changes:
*Make client comfortable
*Remove old dressing
*Assess and clean
*Secure dressing
*Pack wound
Musculoskeletal Effect of Immobility:
*Increased weakness
*Decreased muscle mass
*Increased instability
*Higher likelihood of falls
*Impair calcium metabolism
*Joint abnormalities
Integumentary Effect of Immobility:
*Pressure ulcers that can lead to ischemia
*Skin trauma from moving client
Metabolic Effect of Immobility:
*Decreased metabolic rate
*Affects how body metabolizes nutrients
*Fluid and electrolyte imbalances
*GI disturbance
*Decreased appetite
Urinary Effect of Immobility:
*Urinary stasis due to leaving renal pelvis unaided by gravity
*Increased risk of UTI’s
*Increased risk of renal calculi
Respiratory Effect of Immobility:
*Reduced lung expansion due to positioning
*Increasing weakness of respiratory muscles
*Increased risk of atelectasis (collapse of alveoli)
*Increased risk of hypostatic pneumonia
Cardiovascular Effect of Immobility:
*Orthostatic Hypotension (drop in systolic BP by 15mmHg)
*Increased Heart rate
*Decreased cardiac output
*Increased risk for thrombus formation
Psychosocial Interventions:
Involve clients in care
Respiratory Interventions:
Incentive Spirometer, turn cough, breathe, chest physiotherapy
Urinary Interventions:
Increase fluid intake, monitor I/O, watch for signs of urinary retention and renal calculi
Cardiovascular Interventions:
Use of SCD’s (sequential compression devices), anti embolic stockings, medications, change positioning slowly with orthostatic hypotension
Integumentary Interventions:
Turn and reposition every 2 hours
Musculoskeletal Interventions:
Encourage client to perform ROM, may consult PT/OT
Metabolic Interventions:
Monitor I/O, stool softeners
Types of Restraints:
*Physical
*Chemical
*Belt
*Extremity
*Mitten
*Elbow
*Enclosure Beds
T/F Client in restraints must be checked on every 15 minutes
True
Alternatives To Restraints:
*Reorientation and Diversion
*Relocate
*Evaluate Medications and Labs
*Camouflage Lines and Tubing
*Self-Releasing Seat Belts
*One-on-One Observation
*Bed and Chair Alarms
Fall Risk Factors:
*History
*Age
*Mobility
*Medications
*Elimination
*Cognition
*Equipment
*Vision
Client lies flat on back -HOB is flat
Supine - good if there’s risk of bleeding in groin or for decreased BP
Client lies flat on back with feet higher than the head by 15-30 degrees - no bend in knee
Trendelenberg - used in some surgeries and for decreased BP
Client lies flat on back with head higher than feet by 15-30 degrees - no bend in knee
Reverse Trendelenberg - used for some surgeries and when there’s a need for HOB to be up but client can’t flex knees
Client lies on stomach with their head to the side and HOB flat
Prone - used for client’s with acute respiratory distress syndrome (COVID-19 patients)
HOB is 60-90 degrees
High Fowlers - used when client is short on air, when placing nasogastric tubes, or when they have trouble swallowing
HOB is 15-30 degrees and client is in semi-sitting position
Semi-Fowlers - used when client must be at least 30 degrees with continuous feeding tube
Client lays on side with their knees and arms flexed
Lateral - used when needing to manually reposition clients
Halfway between lateral and prone
Sim’s - used when administering enemas or after seizures to keep airway open and help with drainage of any oral secretions
Client sits at the side of bed with their arms out and leans over the bedside table
Orthopneic - Used for client’s with respiratory distress or chronic lung issues or when performing thoracentesis
Client lies on back with HOB slightly elevated and knees flexed
Dorsal Recumbent - used for hospitalized client’s for comfort and to precent sliding down bed
Morse Fall Risk Tool:
*History of falling
*Secondary diagnosis
*Ambulatory aid
*IV therapy/heparin lock
*Gait
*Mental status
Act of moving gases in and out of lungs - breathing
Ventilation
Ability to get oxygenated blood to tissues
Diffusion
How well the heart ejects blood and the vessels get it to where it needs to go
Perfusion
Factors Affecting Oxygenation
Decreased Inspired O2 Concentration:
Airway obstruction (less ventilation so less O2 inspired), hypoventilation, decrease in O2 at high altitudes
Factors Affecting Oxygenation
Increased Metabolic Rate Increases Oxygen Demands
Metabolic rate can increase during pregnancy, exercise or infection
Factors Affecting Oxygenation
Decreased Ventilation
May decrease from musculoskeletal abnormalities, during pregnancy, from obesity, or from trauma. Can impair ability of lungs to fully expand. Sedation can affect frequency of ventilation.
Factors Affecting Oxygenation
Decreased Oxygen Carrying Capacity
*Anemia: decreases hemoglobin and therefore decreases amount of O2 being carried around.
*Carbon Monoxide poisoning: Carbon monoxide binds to hemoglobin so there’s less to carry O2.
*Hypovolemia (shock, severe dehydration): decreases blood volume which decreases body’s ability to move O2 to tissues.
Signs of Acute Respiratory Distress:
*Accessory Muscle Use - Chest Retractions
*Increased Rate of Breathing
*Cyanosis
*Nasal Flaring (Pediatric)
*Stridor (Inhalation noise)
*Grunting (Exhalation noise)
Life threatening condition related to inadequate tissue oxygenation - deficiency in O2 delivery or O2 use at a cellular level
Hypoxia
Early Signs of Hypoxia:
*Restless, confused, anxiety
*Trouble breathing
* ^ BP
* ^ HR
* ^ RR
*Dyspnea
Late Signs of Hypoxia:
*Decreased LOC
*Decreased activity
*Decreased RR
*Hypotension
*Bradycardia
*Acidosis - related to increase in CO2
Very Late Signs of Hypoxia:
*Peripheral Cyanosis: extremities, nail beds, ear lobes
*Central Cyanosis: tongue, soft palate, conjunctiva of eyes
Hypoventilation
Pathology: Occurs when alveolar ventilation is inadequate to meet O2 demands or sufficiently eliminate CO2 - not enough O2/not exchanging it well
Cause: Sedation from meds or after procedures, neuromuscular diseases, chronic lung disease
Signs/Symptoms:
*Mental status change
*Dysrhythmias
*Possible seizures
*Atelectasis (complete or partial collapse of lung) - due to collapse of alveoli
Hyperventilation
Pathology: State in ventilation in which lungs remove CO2 faster than it’s produced - client breathing so fast that they are getting rid of too much CO2
Cause: Anxiety, infection, pain, acid-base imbalance
Signs:
*Rapid respiration
*Lightheadedness
*Tingling
*Numbness
Treatment: Clients need to rebreathe their CO2 - breath in paper bag
Percentage of O2 that we’re breathing - room air is 21% - when using Venturi mask at 40% we’re breathing in 30% more concentrated than room air
Fraction of Inspired Oxygen (FiO2)
Nasal Cannula
*Flow Rates: 1-6 liters per nasal cannula (up to 15 for high flow)
*Nasal prongs are curved, they curve down and go around top of ears and adjusted under chin
*Check points of contact: tops of ears and cheeks
Flowmeter
Measures how much gas or oxygen moves through a pipeline in a given period of time
Simple Mask
*Flow Rate: 5-8 liters
*Not good for clients who may be retaining CO2 because they can rebreathe their exhaled air
*For very short term use
Non-Rebreather Mask
*Flow Rate: 10-15 liters
*Low flow because you can’t dial in specific FiO2 on device. Delivers a lot of O2.
*Used to give as much O2 as possible without moving to advanced tubing.
*Check fit of mask around nose and mouth
*Reservoir bag should be at least 2/3 full
One-way valve on top: Client gets air from bag but prevents air from entering reservoir bag
Venturi Mask
*Flow rate: 4-12 liters - FiO2 24%-60%
*High flow because specific FiO2 can be dialed in using Venturi barrel
*What flow rate you need for each FiO2 is listed on barrel
Airvo
*Humidifier with adjustable flow setting for delivery of gasses
*Can be used with nasal cannula or face mask or attached to tracheostomies
*Used for COVID-19 and clients that need really high levels of O2 and pressure to keep airways open
OxyMask
*New face mask for O2 delivery with small “diffuser” to concentrate and direct O2 toward mouth and face - large holes for exhalation
Pulse Oximetry
Gives SpO2 and client’s pulse
Placed on finger, earlobe, or forehead
SpO2
*Percentage of saturation of hemoglobin
*Normal value is 95%-100%
Incentive Spirometer
*Visual tool to encourage deep breathing
*They inhale slowly, hold breath 3-5 seconds, then exhale slowly
*They work towards reaching goal set on device
Precautions with Oxygen:
*10 feet away from flame
*Store cylinder upright and secure
*Toxicity can be problem for clients on high levels of oxygen over extended period of time
Airway and Secretion Management:
*Positioned at least 45 degrees or higher to facilitate lung expansion
*Movement mobilizes secretions clients should get up and out of bed as much as possible
Involves catheter advanced through the nares into oropharynx and then into trachea - invasive and uncomfortable for clients - only used when they can’t cough or get secretions up
Nasotracheal Suctioning
When client has tracheostomy and endotracheal tube and we are able to suction without having to go through nares and pharynx
Tracheal Suctioning
Used if client can cough up secretions into mouth but needs help expectorating
Oral Suctioning
Bronchodilators
Relax smooth muscles around airways and help keep them more open
Steroids
Anti-inflammatories that can help decrease inflammation in airway
Pursed-lip Breathing
*Purse lips and blow like blowing out a candle
*Help chronic lung disease clients when they have hard time exhaling
Abdominal or Diaphragmatic Breathing
Instruct client to push out abdomen when breathing in 9 diaphragm moves up) and then abdomen sinks when breathing out (diaphragm moves up)
The noxious stimulus is received
Transduction
The pain impulse moves through the nerves
Transmission
The pain impulse reaches the person’s brain and they become aware of their pain
Perception
Acute Pain (Categorized by duration)
Protective, easier to treat, identifiable cause, short duration, limited tissue damage, limited emotional response
The pain impulse is inhibited via the release of endorphins, serotonin, and GABA
Modulation
Chronic/Persistent Pain (Categorized by duration)
Lasts longer than 6 months, doesn’t always have identifiable cause, can lead to great personal suffering
Neuropathic Pain (Categorized by inferred pathological process)
Abnormal processing of sensory input by PNS and CNS, abnormal transmission along nerve pathways, quality of pain is typically different (burning, shooting)
Nociceptive Pain (Categorized by inferred pathological process)
What you think of when you think of pain.
Normal stimulation of special peripheral nerve endings called nociceptors.
*Somatic Pain: Bones, joints, muscles, skin, or connective tissue
*Visceral Pain: Arises from visceral organs like Gi tract or pancreas
Types of Chronic Pain:
*Chronic Episodic
*Idiopathic Pain
*Cancer Pain
Chronic Episodic Pain:
Pain that occurs over extended duration
Idiopathic Pain:
Chronic paining absence of identifiable physical or psychological cause or pain perceived as excessive for extent of an organic pathological condition
Cancer Pain:
Can be result of tumor pressing on nerves or referred pain
ABCDE
*Ask about pain
*Believe clients report of pain
*Choose and plan pain management
*Deliver interventions
*Empower the client
Factors Influencing Pain in Older Adults:
*Metabolize drugs slower due to declining liver function
*Excrete drugs slower due to declining kidney function
*Drugs absorbed differently due to decreases in muscle mass and increases in adipose tissue
*Lower levels of albumin can lead to active meds in system
*More sensitive to neurological effects of medication
FLACC Pain Scale:
Faces, legs, activity, crying, consolability
CNPI
Checklist of Non-verbal Pain Indicators
Non-Pharmacological Pain Interventions:
*Distraction
*Relaxation
*Biofeedback
*Cutaneous Stimulation (Massage and TENs)
*Ice and Heat
Analgesic Medications can be Administered:
*Oral
*Intramuscular
*Intravenous
*Sublingual
*Buccal
Most common are acetaminophen, aspirin, NSAIDS (Non-steroidal anti-inflammatories) like ibuprofen, naproxen, and ketorolac
Non-opioid Drugs
Derived from poppy plant - “narcotics” - highly regulated with many side effects such as respiratory depression, sedation, addiction, severe constipation - morphine, hydrocodone, hydromorphone
Opioid Drugs
Primary use not pain control but found to help with specific types of pain - can also treat conditions associated with pain (anxiety) - neuropathic pain is dysfunction of nerve pathway so it’s treated differently - gabapentin and antidepressants like amitryptyline
Adjuvants or Co-Analgesics
Control other symptoms associated with pain (benzodiazepines treat anxiety) - when administering opioids remember they’re sedating and can increase extant sedation which can decrease respiratory drive - must monitor patients
Non-Analgesics
Includes perineurial local anesthetic infusions and local anesthetics - nerve blocks injected into nerve innervating certain area - one time or continuous
Local Anestehtics
Applied directly to skin - most common are lidocaine creams or patches - meant to numb area of pain and should be placed where pain is localized - patch taken off for period of time after 24 hours - some creams over the counter and used for arthritic type pain
Topical Analgesics
Infusion pump that allows client to self-administer a small preset dose of opioids with minimal risk of overdose - can administer every 15 minutes - safety lock prevents tampering - only the client should administer this medication.
Patient Controlled Analgesia (PCA)
When client is undertreated for pain because it’s believed they aren’t in pain
Pseudo-Addiction
State of adaptation that is manifested by drug class-specific withdrawal syndrome - produced by abrupt cessation, rapid dose decrease, decreasing blood levels of the drug, and/or administration of an antagonist.
Physical Dependence
Symptoms: Shaking, chills, abdominal cramps, excessive yawning, joint pain
An increase in need for pain medication due to factors other than a tolerance such as disease progression, new disease, complication, or drug interaction
Pseudo-Tolerance
Primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.
Addiction
Sings: Impaired control over drug use, compulsive use, continued use despite harm and craving
A state of adaptation in which exposure to a drug induces changes that result in diminution of one or more effects of the drug over time - common with chronic pain
Drug Tolerance
Pain Assessment:
*Onset and Duration
*Location
*Intensity: Pain Scale
*Quality
*Pattern
*Relief Measures
*Contributing Symptoms
*Effects on client and their ADL’s
Behavioral Effects
