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NUR 101 > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

What is the purpose of health assessment?

A

first phase of nursing process, systemic gather of subjective and objective data, ID health problems, form nursing dx, PRIMARY FUNCTION OF A RN.

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2
Q

What is subjective data (health history)?

A

info that is stated/experienced, known by patient (or fam), time to focus on comm skills!

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3
Q

What is objective data (physical assessment)?

A

info that is directly observed, signs and symptoms/clinical manifestations (that support nursing dx), determined by examination techniques

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4
Q

What are the five types of data gathered w/ health assessment?

A

Physical (what can be seen), psychological (pt’s awareness, consciousness, behavior, appearance, memory, abstract reasoning, language), developmental (app. age milestones), social (interactions w/ others), spiritual (religious beliefs)

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5
Q

What are the three types of assessment?

A

comprehensive, focused, and emergency

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6
Q

What does a comprehensive assessment consist of?

A

health history and complete physical exam. done annually (outpatient basis), following admission to hospital, long term facility, (every 8 hours if in ICU). It provides BASELINE for comparing later assessments.

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7
Q

When and how is a focus assessment performed?

A

when there’s a specific problem, occurs in all settings, usually involves one or two body systems.

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8
Q

What is an emergency assessment?

A

done in ambulance, ER, rapid and conducted to determine potentially fatal situations. ABC=AIRWAY, BREATHING, CIRCULATION

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9
Q

What is a head-to-toe assessment and how do you perform them on children?

A

Collect data from body parts from head to toe. A head-to-toe assessment on children are performed from least invasive to most invasive.

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10
Q

How do you prepare the client for a head-to-toe assessment?

A

Explain, remain sensitive to needs, use general terminology understandable for patient.

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11
Q

How do you prepare the equipment for a head-to-toe assessment?

A

Room should be adequately lit, warm, quiet, comfortable, private. prep exam table. have gown and sheet ready for pt. ensure all equipment works properly.

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12
Q

What are the developmental considerations about assessing infants?

A

explain assessment to caregiver, perform most invasive last.

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13
Q

What are the developmental considerations about assessing toddlers?

A

explain most things to child and all to caregiver; allow child to handle instruments; least invasive to most.

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14
Q

What are the developmental considerations about assessing preschool-aged children?

A

allow child to decide order of exam; explain instruments and let child try them; speak to caregiver before and after exam.

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15
Q

What are the developmental considerations about assessing school-aged children?

A

include child in all parts of the exam; head to toe approach; speak to caregiver before and after exam

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16
Q

What are the developmental considerations about assessing teens?

A

use mature language, appeal to his/her desire for care; explain confidentiality; allow time for talking separate from parents.

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17
Q

What does a health history involve?

A

client is primary source for subjective data. nurses should practice therapeutic communication skills and interviewing techniques and be sensitive to cultural differences.

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18
Q

What are the components of the health history?

A

biographical data, reason for seeking healthcare, history of present health concern, medical history (surgeries, chronic illnesses), family med history, lifestyle. Peds includes assessment of developmental level/functional level.

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19
Q

What is a stethoscope used to auscultate and what are the differences in the diaphragms?

A

used for heart, lungs, abdomen. large diaphragm used for high pitched sounds (most bodily sounds), small diaphragm used for low pitched sounds (heart murmurs).

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20
Q

What are ophthalmoscopes and otoscopes?

A

Ophthalmoscopes=handheld system of lights, lenses and mirrors used for inspecting interior structures of the eye. otoscope=used for inspecting ear canal and tympanic membrane

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21
Q

When is a Snellen chart used?

A

screening for distant vision. (basic eye chart)

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22
Q

What are the four techniques used during assessment?

A

Inspection=looking, palpation=feeling, percussion=tapping, auscultation=listening.

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23
Q

How is inspection performed?

A

begins w/ initial patient contact and continues through the entire assessment using vision, hearing, smell on every body part and system. looking at size, color, shape, position symmetry.

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24
Q

What is palpation used to assess?

A

uses fingers and palms to palpate shape, size, consistency, surface, mobility, tenderness, pulse of areas on the body

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25
Q

When is percussion used during an assessment?

A

Not usually by RNs. used to assess location, shape, size, density of tissues (ex. tumor). quiet=dense tissue (bones). loud=air (lungs and stomach)

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26
Q

When is auscultations used during an assessment?

A

to listen to movements of organs and tissues. blood pressure, lungs, heart, abdomen.

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27
Q

What is a general survey of a patient during an assessment?

A

summary of nurse’s impression of the client’s overall state of health of organs and tissues by assessing physical appearance, body structure, mobility, behavior, vital signs.

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28
Q

How is the integumentary system assessed?

A

skin, nails, hair are inspected and palpated for color, temp, texture, turgor, skin lesions (bruises, scratches, cuts, insect bites, blisters, freckles, wounds)

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29
Q

What are the words used to describe skin conditions?

A

normal, erythema=redness, cyanosis=bluish, jaundice=yellow, pallor=paleness, ecchymosis=purplish (bruising), petechiae=red spots (broken tiny blood vessels)

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30
Q

How do you know if a patient has edema?

A

in extremities, measure circumference and compare, palpate w/ fingers, indentation may remain. noticeable swelling, taut and shiny skin over edema. graded 0=none; +1=trace, 2mm; +2=moderate, 4mm; +3=deep, 6mm; +4=very deep

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31
Q

What is a Braden Score used to measure?

A

pressure ulcer risk, level of RN/LPN responsibility, >23=no risk, 15-18=low risk, 13-14=moderate high risk, 10-12=high risk, <9=very high risk.

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32
Q

What areas are assessed for a Braden Score?

A

sensory perception, moisture, activity, mobility (self position change), nutrition, friction & shear (moving/sliding skin)

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33
Q

What are normal age-related variations found during integumentary assessments of infants?

A

jaundice, milia (whiteheads) in newborns, fine downy hair (lanugo) for the first 2 weeks of life, smooth, thin skin at birth.

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34
Q

What are normal age-related variations found during integumentary assessments of older adults?

A

dryness, scaling, decreased turgor, raised dark areas (senile keratosis), flat brown age spots (senile lentigines), small round red spots (cherry angioma), hair loss, decreased body hair, facial hair on women.

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35
Q

What is inspected on the head and neck?

A

color, symmtery. eyes for PERRLA= Pupils are Equal, Round, Reactive to Light and Accommodates (finger moving). mucous membranes of eyes, nose, mouth are pink and moist.

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36
Q

What are some age-related variations seen in older adults during a head and neck assessment?

A

impaired near vision (presbyopia), decreased color and peripheral vision, decreased adaptation to light and dark, a white ring around the cornea (arcs senilis), entropion (inward turning of lower eyelid), ectropion (outward turning of lower eyelid), hearing loss (presbycusis)

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37
Q

How is the respiratory system assessed?

A

respiratory effort=rate and pattern (12-20/min), character of breathing (diaphragmatic, abdominal, thoracic), use of accessory muscles, depth of respirations (unlabored quiet breathing)

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38
Q

How are lung sounds auscultated?

A

Detect airflow with respiratory tract, have pt breathe in slowly and deeply through the mouth. use stetho to listen to five areas anteriorly and nine areas posteriorly.

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39
Q

What are normal breath sounds?

A

Bronchial=loud, high-pitched, expiration heard longer than inspiration over trachea.
Bronchovesicular=medium pitch and intensity, equal inspiration and expiration, and heard over larger airways.
Vesicular=soft, low-pitched, base of lungs during inspiration, longer than expiration.

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40
Q

What are adventitious sounds?

A

wheezes= continuous high-pitched sound on expiration, cause by secretions, swelling, or tumors, musical in tone.
pleural friction rub= a continuous grating sound caused by an inflamed pleura rubbing against the chest wall.
crackles=fine to coarse crackling sounds made as air moves through wet secretions. bubbling, popping on inspiration, coarse crackles=rhonchi
stertorous breathing=noisy, strenuous respirations.

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41
Q

What are age-related variations found in infants/children during a thorax and lung assessment?

A

Louder breath sounds
more rapid RR=20-40 bpm (until 8-10)
use of abdominal muscles during respiration

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42
Q

What are age-related variations found in older adults during a thorax and lung assessment?

A

Increased anteroposterior chest diameter
increase in the dorsal spine curve (kyphosis)
decreased thoracic expansion
use of accessory muscles to exhale

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43
Q

How is the circulatory system assessed?

A

includes heart & extremities
IDs activities of daily living and health behaviors that may increase risk of disease: lack of exercise, high fats and salt diet, smoking.

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44
Q

What are the areas for palpating pulse?

A

Aortic=right of sternum at 2nd intercostal space
Pulmonic=just left of sternum at 2nd ICS
Erb’s Point =just left of sternum at 3rd ICS
Tricuspid=just left of the sternum at the 4th ICS
Apical/Mitral=left midclavicular line at 5th ICS

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45
Q

What are the heart sounds heard during assessment of neck and precordium?

A

S1 (lub)=closure of the mitral and tricuspid valves, beginning of ventricular systole (contraction)
S2 (dub)=closure of the aortic and pulmonic valves, beginning ventricular diastole (relaxation)

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46
Q

How is circulation of the extremities assessed?

A

inspection for color, temperature, continuity, lesions, venous patterns, edema. palpation for cap refill: normal=brisk return 2-4s. palpate pulses:carotid, radial, brachial, femoral, popliteal, dorsalis pedis, posterior tibial. check for symmetry.
Measure amplitude of pulse 0 (absent), 1+ (weak), 2 + (normal), 3+ (increased), 4+ (bounding)

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47
Q

What are age-related variations seen in infants/children during a circulatory assessment?

A

visible pulsation if chest wall is thin
sinus disrhytmia
presence of S3 (1/3 of children)
more rapid heart rate

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48
Q

What are age-related variations seen in older adults during a circulatory assessment?

A 
difficult-to-palpate apical pulse
difficult-to-palpate distal arteries
dilated proximal arteries
more tortuous blood vessels
increased blood pressure
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49
Q

How is the abdomen area assessed?

A

Includes stomach, small intestine, liver, gallbladder, pancreas, spleen, urinary bladder.
LUQ, RUQ, LLQ, RLQ
Inspect, auscultate, palpate.

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50
Q

What do you note from assessment of the abdomen area?

A

skin color, surface.
bowel sounds: Normal=clicks & gurgles every 5-34 sec
hyperactive, hypoactive, absent
soft, relaxed, free of tenderness

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51
Q

What are some age-related variations seen in infants and children during abdomen assessment?

A

“pot-belly”=<5yo
visible peristaltic waves
easily palpated liver and spleen

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52
Q

What are some age-related variations seen in older adults during abdomen assessment?

A

decreased bowel sounds
decreased abdominal tone
liver border palpated more easily

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53
Q

How is the musculoskeletal system assessed?

A

includes: bones, muscles, cartilage, ligaments, tendons, and joints
subjective data: pain, stiffness, ability to move
exercise patterns
posture, gait, bone size, structure, ROM, muscle strength
alignment, symmetry

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54
Q

What are age-related variations seen in infants and children during the musculoskeletal system assessment?

A

C-shaped curve of spine at birth
Lordosis (exaggerated lumbar curve)
Pronation of the feet between 12 and 18 months

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55
Q

What are age-related variations seen in older adults during the musculoskeletal system assessment?

A 
Loss of muscle mass and strength
decreased range of motion
kyphosis (an exaggerated thoracic curve)
decreased height
osteoarthritic changes in joints
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56
Q

What data is collected from a neurological assessment?

A

subjective data=dizziness, loss of sensation, headaches, ability to see, hear, taste and detect sensations
objective data=mental status, level of consciousness, cranial nerve function, muscle strength, coordination, reflexes

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57
Q

How is mental status determined?

A

awareness=orientation to time, place, and person
consciousness=degree of wakefulness (Glasgow Coma scale=eye opening, motor response, verbal response, <7=coma)
Memory, abstract reasoning, language (expressive aphasia=cannot write or speak, receptive aphasia=cannot understand written or spoken words

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58
Q

What is the Confusion Assessment Method?

A

Assesses delirium when there is an acute change in mental status from patient’s baseline, abnormal behavior fluctuating during the day, tends to come and go or increase or decrease in severity, difficulty focusing attention

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59
Q

What is a Fulmer SPICES assessment?

A

Usually given to elderly hospitalized patients to recognize marker conditions:
Sleep disorders
Problems w/ eating, feeding
Incontinence
Confusion (knows where they are? dementia?)
Evidence of falls
Skin breakdown (Braden pressure ulcer risk assessment)

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60
Q

What are the five vital signs? and why?

A 
Temperature
Pulse
Respirations
Blood Pressure
Pain
Reflects health status=indicators of body functions & regulation through homeostatic mechanisms
61
Q

How often should nurses assess vital signs?

A

Routinely; as ordered daily, at least BID to q4h. Upon admission to a facility, before & after any procedure, before, during, and after administration of meds that affect vital signs, when pt condition changes, per policy or physician orders

62
Q

What does body temperature reflect?

A

balance b/t the heat produced and the heat lost from the body in degrees. Two types=core, taken at tympanic, rectal, esophagus, pulmonary artery, or bladder (most accurate, 97-99.5) and surface, taken at oral, axilla, skin

63
Q

What is the body’s thermoregulatory center?

A

Hypothalamus, body’s thermostat, functions to maintain homeostasis

64
Q

What are factors that affect body temperature?

A

circadian rhythms, age, gender, stress, environment

65
Q

What are the causes of pyrexia?

A

pyrexia=fever, signals infection and increases immune function. febrile=client w/ fever, afebrile=client w/o fever

66
Q

What are nursing interventions for a fever?

A

monitor vital signs, assess skin, monitor lab values, increase fluid intake, measure intake and output, rest, antipyretics, keep client comfortable.

67
Q

What is hypothermia and what are the physiologic and physical causes?

A

Hypothermia=abnormally low body temperature <34C(93F).
physiologic=excessive heat loss, inadequate heat production, impaired hypothalamic thermoregulation.
Physical=exposure to cold environment, immersion in cold water, lack of adequate clothing, shelter, or heat.

68
Q

What are clinical signs and symptoms of hypothermia?

A 
severe shivering 
pale, cool, waxy skin
hypotension
decreased urinary output 
lack of muscle coordination
disorientation
drowsiness progressing to coma
69
Q

What are nursing interventions for hypothermia?

A

provide warm environment: warm blankets, warmed fluids (PO, IV), keep limbs close to body, friction to extremities

70
Q

How do you take a patient’s oral temperature?

A

wait 15-30 minutes if patient has had hot/cold fluids, smoking, or chewing gum.
apply cover to probe on electric thermometer and place probe under the client’s tongue in posterior
sublingual pocket
have client close mouth and seal lips on probe

71
Q

How do you take a patient’s rectal temperature?

A

place patient in a supported side-lying position and expose and retract buttocks; ask client to relax; lubricate thermometer; insert thermometer into anus approx. 1.5”=adult, 0.5”=infants, 1”=children;

72
Q

How are temporal artery thermometers the best for measuring temperature?

A

an infrared sensor scans across the forehead, capturing the heat emitted by the skin over the temporal artery
it is the only artery close enough to skin’s surface to provide access for accurate temp.

73
Q

How is a temporal artery thermometer used?

A

probe is positioned in the middle of the child’s forehead, button pressed and held as probe is moved horizontally across the child’s forehead, midway between the eyebrows, over temporal artery, and then touch skin behind earlobe, button is released and temp is read

74
Q

What is the vital sign used to measure heart rate and rhythm?

A

Pulse=regulated by the autonomous nervous system through SA node (pacemaker). parasympathetic - decreases HR. sympathetic - increases HR. average PR=60-100bpm (at rest).

75
Q

What is cardio output and how is it determined?

A

Cardiac output is the amount of blood pumped from the heart (left ventricle) to the arterial circulation in 1 minute. Average is 3.5-8.0 L/min. CO=heart rate X stroke volume
HR=number of contractions of the heart per minute
SV=amount of blood that pumped out of the heart with each contraction

76
Q

What is noted from pulse assessment?

A

rate=# of bpm, tachycardia (>100), bradycardia (<60)
rhythm=pattern of pulsations, irregular or regular
volume=amplitude & quality, forceful/bounding, weak, feeble, or thready
equality=symmetry of vascular system

77
Q

What is the scale for measuring pulse?

A

0=absent pulse
1+=Thready pulse, not easily felt, slight pressure makes it disappear
2+=Weak pulse, stronger than thready but light pressure causes it to disappear
3+=Normal pulse, easily felt, takes moderate pressure to disappear
4+=Bounding pulse, strong, does not disappear with moderate pressure

78
Q

When is a telemetry used?

A

Clients with or have a past medical history of abnormal pulse rate, rhythm or volume.
portable monitor, allows for monitoring at nurses station and central monitoring room

79
Q

What are the peripheral pulse sites?

A 
carotid=side of neck
temporal=head
brachial=inner aspect of biceps muscle of arm
radial=along radial bone, thumb side of inner wrist
femoral=leg, pelvis midline
popliteal=behind the knee
posterior tibial=inner ankle
pedal=dorsalis pedis artery, top of foot
80
Q

how do you perform a pulse assessment?

A 
do not use thumb
apply moderate pressure
assess rate, rhythm, amplitude, equality
regular HR=count for 30 seconds, X2
irregular=1 min, compare to apical
81
Q

What is an alternative method for assessing pulse?

A

doppler ultrasound, when patients have difficult to palpate pulses

82
Q

What are factors that contribute to tachycardia?

A 
Decrease in BP
Increase in temp
Poor oxygenation
Exercise
Prolonged application of heat
Pain
Strong emotions
Meds
83
Q

What are the factors that contribute to bradycardia?

A 
Decrease in metabolic needs (sleep, hypothermia, athletes at rest)
Medications
Vagal stimulation
Suctioning  of resp. secretions
Pain
Increased cranial pressure
MI=myocardial infection
84
Q

What are nursing interventions for tachycardia and bradycardia?

A

Assess/monitor for other signs/symptoms, potential medication side effects, prevent injury, notify physician

85
Q

What are lifespan considerations when taking a patient’s pulse?

A 
Most reliable is apical for infants and young children due to increased rate.
Newborn-1 mo.=120-160
Infant=80-150
Toddler=70-120
Preschool=65-110
School-age=60=100
Adolescent=55-95
86
Q

What is respiration and what are its physiological functions?

A

R=pulmonary ventilation (breathing), inpiration & expiration
Gas exchange=oxygen & carbon dioxide
Rate & depth of breathing changes in response to body demands
Inhibition/stimulation of respiratory muscles controlled by R centers in medulla & pons
Increases in CO2=increase in RR & depth

87
Q

How is RR assessed?

A

Rate=reg rate counted for 30 sec (x2), irreg. rate count for 1 min, normal rate=12-20 breaths per min
Eupnea=normal, 1 respiration:4 heartbeats
Tachypnea=increased RR
Bradypnea=decreased RR
Depth=amount of chest wall expansion w/ ea. breath, ex. shallow, deep, normal, sigh
Rhythm=breathing intervals, apnea=no breathing (4-6min), dyspnea=difficult, labored breathing, Orthopnea=breathes easier sitting upright

88
Q

What are some age-related variations seen when assessing RR of children?

A

Infants=25-55 brpm (abdominal pattern)
Toddlers=20-30 brpm (abdominal pattern)
Preschoolers=20-25 brpm (thoracic pattern)
School-age=14-22 brim (thoracic pattern)
Teens and older=12-18 brim (thoracic pattern)

89
Q

What are factors that affect respiration rate?

A 
Age
Exercise
Gender
Pain
Anxiety
Smoking
Meds
Health conditions
90
Q

What is normal in a pulse oximetry assessment? What requires nursing interventions?

A

Normal=95-100%; however, consider other assessment findings
Commonly found low values=older adult, dark skin, hypothermia, poor peripheral blood flow, too much light, low hemoglobin, edema, nail polish
Results less than 91% require nursing intervention

91
Q

What are some concerns when assessing pulse oximetry at Sa02 <90% (hypoxemia)?

A

confirm sensory probe is properly placed, oxygen delivery system is functioning and that client is receiving ordered oxygen levels
Place client in semi-Fowler’s position (mx ventilation)
Encourage deep breathing and provide emotional support to decrease anxiety

92
Q

What is blood pressure, systolic pressure, and diastolic pressure?

A 
blood pressure=reflects force exerted by the blood in the arteries during heart contraction and relaxation
Systolic pressure(numerator)=pressure of blood as a result of contraction of the ventricles of heart; greatest during contraction of heart
Diastolic(denominator)=POB when ventricles of heart are relaxed.
93
Q

What is pulse pressure?

A

difference b/t systolic and diastolic BP (120/80=40 PP)

94
Q

What are reasons for decreased blood volume (BP) and increased blood volume (BP)?

A

Decreased=Bleeding, dehydration, shock

Increased=Fluid overload, heart failure, kidney failure

95
Q

What are factors that affect BP?

A

age, circadian rhythms, stress, ethnicity, gender, meds, exercise, food intake, body position

96
Q

What are BP readings in adults?

A

Normal=160/>120

Dx of HTN if elevated on at least 3 separate occasions over several weeks

97
Q

What are the arterial sites BP can be assessed?

A

Brachial artery, radial artery, popliteal artery, posterior tibial artery

98
Q

What client conditions do you NOT ever use arm or leg to assess BP?

A

limb or any parts on limb is injured or diseased
lymph nodes removed on an affected side (mastectomy)
IV fluids in limb

99
Q

What are the five Korotkoff sounds?

A

1=clear thumping sound, indicates systolic pressure
2=swishing sound
3=softer thumping than first sound
4=blowing, muffled sound that indicates the first diastolic pressure
5=disappearance of all sounds, silence indicates second diastolic BP

100
Q

What is hypertension and its physiologic changes?

A 
BP above normal for sustained period
"silent killer"
Physiologic changes=CV disease, stroke
Primary HTN=w/o known cause
Secondary HTN=w/ known cause
101
Q

What are risk factors and treatment for hypertension?

A 
Family history
Sedentary lifestyle
Obesity
Stress (continual)
Diet (restrict salt, cholesterol & fat, consume adequate K, Ca, Mag)
Treatment=meds, lifestyle changes
102
Q

What is hypotension and its causes?

A

Below normal BP, systolic <90mmHg

Causes=vasodilation of arteries, heart failure, fluid depletion

103
Q

What is orthostatic hypotension?

A

“Postural hypotension”

BP falls when client changes position from lying to sitting or standing

104
Q

Nursing interventions for orthostatic hypotension?

A

assess/monitor BP
assist with rising out of bed
allow time to sit for a few minutes before standing
lightheadedness and dizziness=return to bed, supine position

105
Q

What are the categories and sources of pain?

A

duration=acute, chronic
location and mode of transmission
etiology
sources=cutaneous, somatic, visceral, neuropathic, radiating, referred, phantom

106
Q

How is pain classified as chronic?

A

Limited, intermittent, persistent but lasts beyond normal healing
may experience periods of remission or exacerbation
chronic malignant=assoc w/ cancer or other life
Intractable pain=chronic, highly resistant to therapy

107
Q

What are the physiologic responses to pain?

A

elevated BP, PR, RR, blood sugar
adrenaline output
pupil dilation, pallor, muscle tension/rigidity
parasympathetic system= fainting, decreased BP, PR, rapid, irregular breathing

108
Q

What are factors affecting the pain experience?

A

Personal experience and attitudes towards pain meds (fear of addiction, side effects)

109
Q

What are components of a pain assessment?

A

patient’s self report, duration, location, quantity, intensity, quality of pain, pattern of pain, aggravating and alleviating factors, associated symptoms, effect on ADLs, behavior, physiological and psychological

110
Q

What are the side effects of opioid analgesics?

A

constipation, orthostatic hypotension, urinary retention, nausea, vomiting, sedation, respiratory depression

111
Q

What are adjuvant analgesics?

A

meds to enhance effects of non-opioids, alleviates other symptoms that aggravate pain, ex. anticonvulsants, anti anxiety, antidepressants, antihistamine, antiemetics

112
Q

What is a PCA?

A

Patient controlled analgesia. allows client to self-administer safe doses of opioid narcotics, less lag time, morphine and dialudid.

113
Q

How do you handle a patient refusing pain meds?

A

educate; fewer than 1% become addicted, unrelieved pain is more harmful

114
Q

Why are some patients reluctant to report pain?

A

fear of injectabe route, difficulty expressing personal discomfort, fear of further tests and expenses, seen as part of aging process

115
Q

What is PQRST of a pain assessment?

A 
Provoked (what brought about the pain)
Quality
Region/radiation
Severity
Timing
116
Q

What are the local effects of heat application?

A

Vasodilation=local blood flow increases
Increases blood viscosity (improves delivery of oxygenated blood, prolongs clotting)
Increases tissue metabolism
increases capillary permeability (improves delivery of leukocytes and nutrients to facilitate healing, improves removal of waste products)
reduces muscle tension
pain relief

117
Q

What are systemic effects of extensive and prolonged heat exposure of large body surface area?

A

Increased cardiac output
Increased HR
Decreased BP
Diaphoresis (perspiring profusely)

118
Q

When do you NOT apply heat?

A 
Open wound
hemorrhage
noninflammatory edema
acutely inflamed area (appendicitis)
Malignant tumors
the testes
metal implants
abdomen of pregnant women
119
Q

What are local effects of cold application?

A

Vasoconstriction: reduced blood flow, decreased metabolic needs, decreased capillary permeability, decreased release of histamine, serotonin & bradykinin
Increased coagulation
reduced muscle spasm
reduced pain

120
Q

What are the systemic effects of cold?

A

Increases blood pressure
Decreases heart rate
Shivering
Piloerection

121
Q

When do you not apply cold?

A

Open wounds
Clients w/ impaired circulation
Allergy to cold

122
Q

What is the “Rebound Phenomenon”?

A

Heat produces max vasodilation in 20-30 min, then vasoconstriction occurs
Cold produces max vasoconstriction when skin temp reaches 15 degrees centigrade (60 degrees F), then vasodilation occurs

123
Q

What is used for dry heat application?

A 
Electric heating pad- constant, even heat
Aquathermia Pad (K-pad)- safer, commonly used in hospitals, warm water is circulated through pad
Commercial hot packs- specified amt of time for specified period
124
Q

What is used for moist heat application?

A

Sterile moist compresses=promote healing, circulation & reduces edema
Sitz bath=used for pelvic or rectal area, water temp 34-37 degrees C (93-99F)
Warm soaks=immersion of a body area into warm water or medicated solution for 15-10 min

125
Q

What is used for dry cold application?

A

Ice bags=on for 30, off for 60 min
Commerical cold packs=
Hypothermia blankets=requires continuous temp monitoring, risk for skin injury, cardiovascular instability

126
Q

What is used for moist cold application?

A

Cold compresses=sterile or washcloth, leave on for 20 min

127
Q

What is an infection?

A

A disease state that results from the presence of pathogens.
caused by bacteria (simple organisms characterized by shape, aerobic or anaerobic), virus (smallest, uses cell energy from other cells to reproduce), fungi (molds, yeast, toenail fungus)

128
Q

What are the six links in the chain of infection?

A

infectious agent
Reservoir=natural environment for microorganism
Portal of exit=respiratory, GU, GI tracts
Mode of transmission=indirect, direct contact
Portal of entry=enters next person
Susceptible host

129
Q

What are the modes of transmission of infection?

A 
Contact (direct, indirect)
Airborne
Droplet
Common vehicle
Vector borne
130
Q

What is the differences b/t colonization and infection?

A

colonization=presence of microorganisms, no clinical signs/symptoms, potential to transmit (carrier)
infection=microorganism enter & multiply, signs/symptoms present, host is infected w/pathogens

131
Q

When do we initiate transmission based precautions (place patient in isolation)?

A

at first suspicion that a person has a pathogen
do not wait for cultures
alert infection control department

132
Q

What is the purpose of using transmission based precautions?

A

They are used in addition to standard precautions when a client has or is suspected of having a highly transmissible organism
Hand hygiene+barrier=reduced transmission

133
Q

What are the barriers/PPEs of transmission -based precautions?

A 
Gloves
Goggles
Gowns
Mask
Isolation carts/drawers
134
Q

What are the types of transmission based precautions?

A

Contact (additional hand & environmental)
Droplet
Airborne
Protective (Neutropenic=low white blood cells)

135
Q

What are Contact Precautions?

A

Used for organism which can be transmitted via direct/indirect contact
Gloves required
Gown required

136
Q

What are common organisms that require contact precautions?

A

MRSA=tested by nasal swab, found in nares, urine, wounds
VRE (Vancomycin-resistant Enterococcus)=transmitted through direct or indirect contact via hands, equipment or surfaces, organism found in GI tract, female genitalia, stool, blood & urine; tested via rectal swab

137
Q

What are additional hand and environmental contact precautions?

A

Handwashing is a must, plus private room if available. Used for patients with C. Diff, Norovirus or diarrhea of an unknown origin

138
Q

What is C. Diff?

A

Spore forming bacteria
common in hospital or long term care
caused by use of antibiotics and commonly spread via health care workers hands.
Alcohol rubs ineffective, pt must stay in isolation for 48 hours after diarrhea stops before D/C

139
Q

What is norovirus?

A

Highly contagious, sudden acute onset of diarrhea w/ nausea, vomiting, abdominal cramps
precautions d/c when client symptom free for 72 hours, bowel continent, able to perform hand hygiene, restricted visitors

140
Q

What are Droplet precautions?

A

Involves larger-particle organisms, do not suspend in air but DROP onto surfaces.
Surgical mask to be worn by nurse when w/in 3 feet of the client or upon entering room & client must wear must when leaving room

141
Q

When are droplet precautions used?

A

For patients with: influenza, meningitis, pertussis (whooping cough), mumps, rubella (german measles), infections caused by H. Influenza type B (HIB), neisseria

142
Q

What is meningitis?

A

Inflammation of the membranes which surround the brain and spinal cord
gains entrance into the body via respiratory tract
caused by neisseria organism

143
Q

When & how are airborne precautions applied?

A

Involves transmission of small particles that remain in air
requires air pressure room; provides 6-12 air exchanges per hour
door must be kept shut
use of high filtration mask (N95)

144
Q

What type of infectious patients require airborne precautions?

A 
TB, suspected or confirmed 
varicella zoster (chicken pox)
herpes zoster (shingles)
measles
SARS (severe acute respiratory syndrome)
Smallpox
145
Q

What are protective precautions for neutropenic patients?

A

Utilized for clients who are immunosupressed
keep alone
no food or live plants in room
client must wear mask when leaving room

146
Q

What are precautions taken for collecting specimens?

A

must double bag

cuff first bag when placing specimen inside, then double bag

147
Q

What are the available disinfectants and what are they used specifically for?

A

germicidal wipes=MRSA, VRE

Bleach=C-diff, norovirus, the only effective disinfectant, must be left on for 10 min!

148
Q

What departments are in place at hospitals for infection control?

A

Infectious Disease Department (ID)=control, survey, intervene in ID w/in hospital, consulted
Occupational Health=Concerned w/ care providers, employee records, immunizations, needle stick injuries

NUR 101 (3 decks)

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