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Intro To Nursing Care > Exam 3 > Flashcards

Exam 3 Flashcards

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1
Q

Absence of germs or microorganisms

A

Asepsis

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2
Q

Prevents growth and reproduction of bacteria
Ex: cold temperatures

A

Bacteriostasis

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3
Q

Disease that can be transmitted from one person to another by direct or indirect contact or by vectors

A

Communicable disease

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4
Q

Process of destroying all pathogenic organisms except spores

A

Disinfection

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5
Q

Infections produced within a cell or organism

A

Endogenous infection

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6
Q

Infection originating outside an organ or part

A

Exogenous infection

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7
Q

Infection resulting from the delivery of health services in a health care agency

A

Health care associated infections

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8
Q

Ways health care associated infections can occur

A

As a result of an invasive procedure
Antibiotic administration
The presence of multi drug resistant organisms
Breaks in infection prevention and control activities

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9
Q

Type of HAI caused by invasive diagnostic or therapeutic procedure

A

Iatrogenic infection

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10
Q

Examples of procedures that could cause an iatrogenic infection

A

Bronchoscopy
Treatment with broad spectrum antibiotics

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11
Q

Procedures used to reduce the number of microorganisms and prevent their spread

A

Medical asepsis

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12
Q

Microorganisms capable of producing disease

A

Pathogens

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13
Q

Guidelines recommended by the CDC to reduce the risk of transmission of blood borne and other pathogens in hospitals

A

Standard precautions

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14
Q

Area free of microorganisms and prepared to receive sterile items

A

Sterile field

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15
Q

Eliminating or destroying all forms of microbial life, including spores

A

Sterilization

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16
Q

Secondary infection usually caused by an opportunistic pathogen

A

Suprainfection

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17
Q

Procedures used to eliminate any microorganism from an area

A

Surgical asepsis
(AKA sterile technique)

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18
Q

An individuals degree of resistance to pathogens

A

Susceptibility

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19
Q

External mechanical transfer through living things (bugs)

A

Vector

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20
Q

Ability of an organism to rapidly produce disease

A

Virulence

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21
Q

List the steps in the chain of infection

A

Infectious agent
Reservoir
Portal of exit
Modes of transmission
Portal of entry
Susceptible host

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22
Q

Examples of infectious agents

A

Bacteria (c diff)
Virus
Spore

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23
Q

What things do a reservoir need?

A

Right amount of food, oxygen, water, temperature, pH, light
Ex: stool

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24
Q

Types of portals of exit

A

Skin and mucous membranes
Respiratory tract
Urinary tract
GI tract (booty hole)
Reproductive tract
Blood

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25
Q

Examples of modes of transmission

A

Airborne, direct contact
Ex: unwashed hands or equipment, splatter from coughing

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26
Q

What is direct contact?

A

Person to person (fecal, oral) physical contact between the source and susceptible host

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27
Q

What is indirect contact?

A

Personal contact of susceptible host with contaminated inanimate object (ex: needles, soiled linen, dressings, etc)

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28
Q

Explain airborne transmission

A

Organisms are carried in droplet nuclei or residue or in air during coughing or sneezing
Or germs are aerosolized by medical equipment or dust from a construction site

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29
Q

What are vehicles?

A

Contaminated items

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30
Q

Examples of vehicles

A

Water
Drugs, solutions
Blood
Food (improperly handled or stored)

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31
Q

What is a vector?

A

External mechanical transfer (Ex: flies)
Or internal transmission such as parasitic conditions between vector and host (Ex: mosquito, louse, flea, tick)

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32
Q

List our defenses against infection

A

Normal flora
Body system defenses
Inflammation

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33
Q

Examples of body system defenses

A

Skin
Respiratory tract
GI tract

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34
Q

*Two types of health care-associated infections

A

Endogenous
Exogenous

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35
Q

*What is the difference between endogenous and exogenous HAIs?

A

Endogenous - part of the pt’s flora becomes altered and organism overgrowth occurs

Exogenous - originates outside of the body (ex: salmonella)

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36
Q

*Factors influencing infection prevention and control

A

Age
Sex
Nutritional status
Stress
Disease process

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37
Q

How does age influence infection prevention and control?

A

Immunity goes down as you get older
Ex: older people can’t take as deep of a breath = more susceptible to pneumonia

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38
Q

How does sex influence infection prevention and control?

A

Women tend to be more prone

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39
Q

How does nutritional factors influence infection prevention and control?

A

Poor diet = won’t heal well

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40
Q

How does stress influence infection prevention and control?

A

Suppresses immunity

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41
Q

How does the disease process influence infection prevention and control?

A

Pts with diseases of the immune system are at risk for infection

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42
Q

Systemic symptoms we should watch for while assessing a pt for infection

A

*Pallor/absence of color
*Fever
Nausea/vomiting
Malaise
Enlarged lymph nodes near infection

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43
Q

What is a normal range for WBCs?

A

5,000-10,000

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44
Q

One important question to ask pt when assessing for infection

A

Do you have or feel as if you have a fever?

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45
Q

Nursing diagnosis outcomes for risk for infection

A

Pt will remain free from symptoms of infection
Pt will describe ways to prevent infection before discharge

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46
Q

What are cancer patients more at risk for regarding infection?

A

Infection due to impaired oral mucous membrane

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47
Q

What is the difference between surgical asepsis and medical asepsis?

A

Medical asepsis is clean and surgical asepsis takes more steps to maintain sterility (especially spores)

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48
Q

Which type of transmission precaution for TB?

A

Airborne

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49
Q

Which type of transmission precaution for MERS?

A

Airborne

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50
Q

Which type of transmission precaution for SARS?

A

Airborne

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51
Q

Which type of transmission precaution for measles?

A

Airborne

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52
Q

Which type of transmission precaution for influenza?

A

Droplet

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53
Q

Which type of transmission precaution for mumps?

A

Droplet

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54
Q

Which type of transmission precaution for rubella?

A

Droplet

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55
Q

Which type of transmission precaution for Scarlett fever?

A

Droplet

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56
Q

Which type of transmission precaution for meningococcal meningitis?

A

Droplet

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57
Q

Which type of transmission precaution for diphtheria?

A

Droplet

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58
Q

Which type of transmission precaution for MRSA?

A

Contact

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59
Q

Which type of transmission precaution for VRE?

A

Contact

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60
Q

Which type of transmission precaution for CPE/CPO?

A

Contact

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61
Q

Which type of transmission precaution for ESBL?

A

Contact

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62
Q

Which type of transmission precaution for c. Diff?

A

Contact

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63
Q

Which type of transmission precaution for salmonella/food poisoning?

A

Contact

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64
Q

Which type of transmission precaution for scabies?

A

Contact

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65
Q

Which type of transmission precaution for burn patients?

A

Protective

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66
Q

Which type of transmission precaution for immunosuppressed patients?

A

Protective

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67
Q

PPEs for patient on airborne precautions

A

Mask or respiratory protection device, N95 respirator

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68
Q

PPEs for a patient on droplet precautions

A

Mask or respirator

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69
Q

PPEs for patient on contact precautions

A

Gloves
Gowns

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70
Q

PPEs for a patient on protective isolation

A

Mask
Gloves
Gowns

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71
Q

5 moments for hand hygiene

A

Before touching a patient
Before a clean/aseptic procedure
After body fluid exposure risk
After touching a patient
After touching patient surroundings

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72
Q

What should a nurse wear when there is a risk for splashing?

A

Gown
Mask
*Eye protection

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73
Q

Another name for a MI

A

Acute coronary syndrome

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74
Q

The resistance to the ejection of blood from the left ventricle

A

Afterload

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75
Q

Device that maintains a positive airway pressure and improves alveolar ventilation without the need for an artificial airway

A

Noninvasive positive-pressure ventilation (NPPV)

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76
Q

Device that works by providing assistance during inspiration and preventing alveolar closure during expiration

A

Bilevel positive airway pressure (BiPAP)

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77
Q

What are BiPAPs used for?

A

Reduced airway closure
Expansion of areas of atelectasis
For improved oxygenation

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78
Q

Procedure done to visualize the inside of airways

A

Bronchoscopy

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79
Q

Provides info on how effectively CO2 is being eliminated by the pulmonary system

A

Capnography

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80
Q

Amount of blood ejected from the left ventricle each minute

A

Cardiac output

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81
Q

Formula to find the cardiac output

A

CO = SV x HR

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82
Q

Helps patient achieve optimal level of health through controlled physical exercise, nutritional counseling, relaxation and stress management techniques, and prescribed medications and oxygen

A

Cardiopulmonary rehabilitation

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83
Q

External chest wall manipulation using percussion, vibration, or high frequency chest wall compression to mobilize pulmonary secretions

A

Chest physiotherapy (CPT)

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84
Q

Catheter inserted through the rib cage into the pleural space

A

Chest tube

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85
Q

Functions of a chest tube

A

Remove air, fluids, or blood
To prevent the air or fluid from reentering the pleural space
To reestablish normal intrapleural and intrapulmonic pressures after trauma or surgery

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86
Q

Abnormal respiratory pattern with periods of apnea, followed by periods of deep breathing and then shallow breathing, followed by more apnea

A

Cheyne-Stokes respiration

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87
Q

What causes Cheyne-Stokes respiration?

A

Decreased blood flow or injury to the brain stem

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88
Q

Device that maintains a steady stream of pressure throughout a patient’s breathing cycle

A

Continuous positive airway pressure (CPAP)

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89
Q

Who would use a CPAP?

A

Patients with obstructive sleep apnea, heart failure, and preterm infants with underdeveloped lungs

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90
Q

Type of breathing that increases tidal volume and decreases respiratory rate, which leads to overall improved breathing pattern and quality of life

A

Diaphragmatic breathing

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91
Q

Which patients should use diaphragmatic breathing?

A

With pulmonary disease and dyspnea secondary to heart failure

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92
Q

Short-term artificial airway

A

Endotracheal (ET) tube

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93
Q

What are ET tubes used for?

A

To administer invasive mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear secretions

94
Q

Where does an ET tube sit in a patient’s throat?

A

Goes through pt’s mouth, past the pharynx and into the trachea

95
Q

Bleeding from the GI tract

A

Hematamesis

96
Q

Bloody sputum

A

Hemoptysis

97
Q

Accumulation of blood and fluid in the pleural space, usually resulting from trauma

A

Hemothorax

98
Q

When would a patient need Humidification of their oxygen?

A

If it is at a flow rate greater than 4L/min or children

99
Q

Lungs remove carbon dioxide faster than it is produced by cellular metabolism

A

Hyperventilation

100
Q

Alveolar ventilation is inadequate to meet oxygen demand of the body or eliminate enough carbon dioxide

A

Hypoventilation

101
Q

Reduced circulating blood volume

A

Hypovolemia

102
Q

Inadequate tissue oxygenation

A

Hypoxia

103
Q

Increase in breathing rate, usually greater than 35 breaths per minute and increased depth of respirations

A

Kussmaul respiration

104
Q

What causes Kussmaul respiration?

A

Acidic pH stimulates the increase in breathing rate
Ex: metabolic acidosis

105
Q

Results from sudden decreases in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion and is not reversed

A

Myocardial infarction

106
Q

Adds moisture to inspired air by mixing particles of varying sizes in with the air

A

Nebulization

107
Q

When is noninvasive positive-pressure ventilation (NPPV) used?

A

Obstructive sleep apnea
Respiratory failure
Following extubation of an ET tube

108
Q

Difficulty breathing while laying down flat

A

Orthopnea

109
Q

Collection of air in the pleural space

A

Pneumothorax

110
Q

Amount of blood in the left ventricle at the end of diastole

A

Preload

111
Q

Volume of blood ejected from the ventricles during systole

A

Stroke volume

112
Q

Artificial airway for long-term assistance

A

Tracheostomy

113
Q

Life threatening dysrhythmia

A

Ventricular tachycardia

114
Q

What causes ventricular tachycardia?

A

Decreased cardiac output

115
Q

What does ventricular tachycardia have the potential to deteoriate to?

A

Ventricular fibrillation or sudden cardiac death

116
Q

Process of moving gases into and out of the lungs

A

Ventilation

117
Q

Ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

A

Perfusion

118
Q

Moving the respiratory gases from one area to another by concentration gradient

A

Diffusion

119
Q

What needs to occur for air to be able to flow into the lungs?

A

Negative intrapleural pressure

120
Q

Primary function of pulmonary circulation

A

To move blood to and from the alveolar capillary membrane for gas exchange

121
Q

What regulates respiratory gas exchange?

A

Oxygen transport - the lungs and cardiovascular system allow for ventilation, perfusion, rate of diffusion, and allow for oxygen to be carried on hemoglobin

122
Q

What is ventilation controlled by?

A

Neural and chemical regulators

123
Q

*What is the path of blood flow through the heart?

A

Right atrium
Tricuspid valve
Right ventricle
Pulmonary valve
Pulmonary artery
Lungs
Pulmonary vein
Left atrium
Mitral valve
Left ventricle
Aorta
Body

124
Q

What type of valves are the aortic and pulmonary valves?

A

Semilunar valves

125
Q

When do coronary arteries fill?

A

During ventricular diastole

126
Q

How much blood is normal for cardiac output?

A

4-8 L/min

127
Q

What is the conduction system of the heart?

A

Organized transmission of electrical impulses that the relaxation and contraction of the heart depend on

128
Q

What does decreased oxygen-carrying capacity affect?

A

Hemoglobin can’t carry oxygen to the tissues

129
Q

Symptoms of decreased oxygen-carrying capacity

A

Fatigue
Decreased activity tolerance
Increased breathlessness
Increased heart rate
Pallor

130
Q

What happens when someone has hypovolemia?

A

Body tries to adapt by peripheral vasoconstriction and increasing heart rate to increase volume of blood returned to the heart, thus increasing cardiac output
Can result in hypoxia

131
Q

How does decreased inspired oxygen concentration affect breathing?

A

Fast, shallow breaths cause a decrease in O2 because there is not enough time for CO2 to fall off

132
Q

How does increased metabolic rate affect breathing?

A

It increased oxygen demand. levels of oxygenation decline when the body cannot meet this demand

133
Q

Example that causes increased metabolic rate

A

Fever = increased oxygen need and increased CO2 production. When fever persists, metabolic rate remains high, body increases rate and depth of respiration.
Pt will eventually show s/s of hypoxemia

134
Q

How can age affect a person’s breathing?

A
  • School age children/adolescents experiment with smoking
  • Young/middle-age adults have unhealthy diet, lack of exercise
  • Older adults: calcification of heart valves, vascular stiffening, * osteoporosis leads to changes in size and shape of thorax, cant take as deep of a breath
135
Q

Very late sign of hypoxia

A

Cyanosis

136
Q

What causes disturbances in conduction (dysrhythmias)?

A

Electrical impulses do not originate from the SA node

137
Q

Examples of disorders that could cause dysrhythmias

A

Ischemia
Valvular abnormality
Anxiety
Drug toxicity
Caffeine, alcohol, or tobacco use
Complication of acid-base or electrolyte imbalance

138
Q

Failure of the myocardium to eject sufficient volume to the systemic and pulmonary circulations

A

Altered cardiac output

139
Q

What occurs during left-sided heart failure?

A

Left ventricle gets hypertrophied, chamber can’t fill all the way
Not enough blood goes out to body, fluid gets backed up and leaks into lungs over time

140
Q

Signs and symptoms of left sided heart failure

A

Crackles in lungs
Fatigue
Breathlessness
Confusion
Dizziness
Paroxysmal nocturnal dyspnea (late sign)

141
Q

What occurs during right sided heart failure?

A

Result of long term left ventricular failure
Starts to back up in entire systemic circulation
This is a very late sign of heart failure

142
Q

Signs and symptoms of right sided heart failure

A

Weight gain
Distended neck veins
Hepatomegaly
Splenomegaly
Dependent peripheral edema

143
Q

What is stenosis of valves?

A

Hardening of the valves

144
Q

What happens to the heart when there is stenosis?

A

Blood flow is obstructed and adjacent ventricles have to work harder to get blood through, causing ventricular hypertrophy

145
Q

What is regurgitation of heart valves?

A

Impaired closure

146
Q

What happens in the heart when there is regurgitation?

A

Backflow of blood into adjacent chamber, can cause a whooshing sound or murmur

147
Q

Types of myocardial ischemia

A

Angina
MI

148
Q

What causes angina?

A

When oxygen supply is less than demand
Usually lasts 3-5 mins and is relieved with rest and coronary vasodialtors

149
Q

What causes MI?

A

Occurs when ischemia is not reversed
Cellular death occurs after 20 mins

150
Q

What does a complete blood count show?

A

Determines number and type of red and white blood cells
White: infection
Red: presence of anemia and ability of the blood to carry oxygen to the tissues

151
Q

What do cardiac enzymes show?

A

This level plus troponin to diagnose acute myocardial infarcts

152
Q

What do cardiac troponins show?

A

Elevates as early as 3 hours after myocardial injury

153
Q

What do serum electrolytes show?

A

Good for monitoring potassium

154
Q

What do brain natriuretic peptides show?

A

Increases levels may help determine severity of congestive heart failure

155
Q

What does C-reactive protein show?

A

To detect inflammation if there is high suspicion of injury or infection
Can also be used to evaluate pt’s risk of developing CAD or stroke

156
Q

What do arterial blood gases show?

A

Assessment of a pt’s respiratory and metabolic acid/base balance and adequacy of oxygenation

157
Q

What do pulmonary function tests show?

A

Determines ability of lungs to efficiently exchange oxygen and carbon dioxide
Also used to differentiate pulmonary obstructive from restrictive disease

158
Q

What does peak expiratory flow rate (PEFR) show?

A

Reflects changes in large airway sizes
Predictor of overall airway resistance in a pt with asthma

159
Q

What does a bronchoscopy show?

A

Trachial tree
Used to obtain fluid, sputum, or biopsy samples
Or to remove mucous plugs or foreign bodies

160
Q

What do lung scans show?

A

Identify abnormal masses by size and location
Or to find blood clot preventing normal perfusion or ventilation

161
Q

What does a thoracentesis show?

A

Specimen of pleural fluid obtained for cytological exam
Can indicate infection or cancer

162
Q

Dyspnea and nasal flaring can be cues for which nursing diagnoses?

A

Impaired gas exchange
Impaired breathing

163
Q

Examples of nursing diagnoses for oxygenation

A

Impaired gas exchange
Impaired breathing
Impaired cardiac output
Acute pain
Activity intolerance
Risk for activity intolerance
Impaired airway clearance

164
Q

If a pt’s goal is to have an improved breathing pattern, what are three outcomes?

A

Pt’s respiratory rate is between 12-20 breaths per min
Pt achieves bilateral lung expansion
Pt breathes without the use of accessory muscles

165
Q

Who is the flu vaccine recommended for?

A

Everyone 6 months and older
Especially pts with chronic illnesses, infants, older adults, pregnant women, and those in frequent contact with these groups

166
Q

Who should get the pneumococcal vaccine?

A

Routinely given to children under 2 years
Recommended for pts with medical conditions that make them more susceptible to pneumonia (ex: heart disease)
Adults over 65
Smokers

167
Q

Two top priorities in acute care nursing interventions

A

Dyspnea management
Airway maintenance

168
Q

What is involved in airway maintenance?

A

Adequate hydration to prevent thick, tenacious secretions
Proper coughing techniques
Suctioning
Chest physiotherapy
Nebulizer therapy

169
Q

What should you teach patients when you’re trying to mobilize secretions in their airways?

A

TCDB (turn, cough, deep breathe)

170
Q

How often should patients who need them do deep breathing exercises?

A

Every 2 hours while awake
Pts with large amount of sputum should cough every hour while awake

171
Q

Which patients is chest wall percussion contraindicated in?

A

Pts with thoracic trauma or surgery

172
Q

How often should patients use incentive spirometers?

A

5-10 breaths per session, every hour

173
Q

What is incentive spirometry used for?

A

To prevent / treat atelectasis in post operative patients

174
Q

When should oropharynx and nasopharyngeal suctioning be used?

A

When a patient is able to cough effectively but is unable to clear secretions (apply suction after the pt has coughed)

175
Q

When should orotracheal and nasotracheal suctioning be used?

A

Pt with pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway present
Catheter is inserted into trachea

176
Q

When should you apply suction pressure when suctioning?

A

When removing the catheter, never while inserting

177
Q

What are oral airways used for?

A

Prevents obstruction of the trachea by displacement of the tongue into the oropharynx

178
Q

What are ET tubes used for?

A

Short term
To relieve upper airway obstruction
Protect against aspiration
To clear secretions

179
Q

What are tracheostomies used for?

A

Same as ET tube but for long term assistance

180
Q

What is invasive mechanical ventilation?

A

A lifesaving technique used with artificial airways
Can be used to fully or partially replace spontaneous breathing

181
Q

When a patient has a chest tube, what should you check for?

A

Should be minimal intermittent, but continuous bubbling in suction chamber
(Continuous bubbling during inhalation and exhalation means there is a leak in the system)
Drainage system needs to be positioned lower than the patient’s chest

182
Q

Amount of oxygen for a nasal cannula

A

1-6 L/min

183
Q

Amount of oxygen for an oxygen-conserving cannula

A

8L/min

184
Q

Amount of oxygen for a simple face mask

A

6-12 L/min

185
Q

Amount of oxygen for partial and nonrebreather masks

A

10-15 L/min (reservoir bag should always be partially inflated)

186
Q

Amount of oxygen for a Venturi mask

A

24-50%

187
Q

Amount of oxygen for a high-flow nasal cannula

A

60 L/min

188
Q

What is pursed-lip breathing?

A

Involved deep inspiration and prolonged expiration though pursed lips

189
Q

What is pursed-lip breathing used for?

A

To prevent alveolar collapse
Helps improve exercise intolerance, breathing pattern, and arterial oxygen saturation

190
Q

What is diaphragmatic breathing?

A

Increased tidal volume and decreased respiratory rate

191
Q

What is diaphragmatic breathing used for?

A

Improved breathing pattern and quality of life
For patients with pulmonary disease and dyspnea secondary to heart failure

192
Q

What is Leininger’s Transcultural Caring?

A

Even though caring is universal, the expressions, processes, and patterns of caring vary among people of different cultures

193
Q

What is Watson’s transpersonal caring?

A

Conversations between patients and their families and nurses should be meaningful and address their needs
Nurse should look for deeper sources of inner healing

194
Q

Swanson’s 5 caring processes

A

Knowing
Being with
Doing for
Enabling
Maintaining belief

195
Q

What does knowing mean?

A

Striving to understand an event as it has meaning in the life of the other

196
Q

What does being with mean?

A

Being emotionally present to the other

197
Q

What does doing for mean?

A

Doing for the other as they would do for themself if it were possible

198
Q

What does enabling mean?

A

Facilitating the other’s passage through life trasitions

199
Q

What does maintaining belief mean?

A

Sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning

200
Q

What does presence mean?

A

Person to person encounter conveying closeness and a sense of caring

201
Q

What is knowing the patient?

A

Learning about the patient by talking to them and spending time with them
This occurs over time
Knowing your patient’s idiosyncrasies
Linked to patient satisfaction and successful outcomes of care

202
Q

What is world view?

A

How people perceive others, how they interact with and relate to reality, and how they process informaiton

203
Q

What is an emic world view?

A

And insider perspective

204
Q

What is an etic world view?

A

And outsider perspective

205
Q

What should you do when you are using and interpreter?

A

Use a medical interpreter
Ask for clarification if unsure about what the pt is saying
Speak directly to pt
Look at pt, not interpreter
Speak in short sentences
Ask pt for feedback and clarification at regular intervals
Be observant of the pt’s nonverbal and verbal behaviors
At end of convo, thank pt and interpreter

206
Q

What is body alignment?

A

Positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying
Individuals center of gravity is stable

207
Q

How to perform passive range of potion

A

Carry out movements slowly and smoothly though prescribed range
Only move to point of resistance

208
Q

When would passive range of motion be used?

A

Paralyzed extremities
Healing fractures

209
Q

How should a patient use a cane?

A

Cane on stronger side of body
Top of cane at greater trochanter
Keep body weight on both legs
1- advance cane
2 - bring weaker leg to cane
3 - advance stronger leg past cane

210
Q

What should you consider before attempting to lift a patient?

A

Weight of patient
Should a lift be used?
Is pt cooperative?
Can pt reposition independently?

211
Q

When a patient is in bed for an extended period of time, what action should you take first?

A

Help pt to dangle position
Sit for 1-2 min
Assess for orthostatic hypotension
If dizziness lasts >60 sec, return pt to bed

212
Q

4 factors to consider when assessing for activity intolerance

A

Physiological
Emotional
Developmental
Pregnancy

213
Q

Exaggeration of anterior convex curve of lumbar spine

A

Lordosis

214
Q

Increased convexity in curvature of thoracic spine

A

Kyphosis

215
Q

Legs curved inward so knees come together as person walks

A

Knock-knee

216
Q

What is a patient at risk for when they have respiratory changes from immobility?

A

Developing atelectasis (collapse of alveoli)
Hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions)
Prolonged recovery
Decreased oxygen

217
Q

What is a patient at risk for regarding cardiovascular changes after being immobile?

A

Orthostatic hypotension
Increased cardiac workload
Thrombus formation

218
Q

What is a patient at risk for regarding urinary elimination after immobilization?

A

Urinary stasis (gravity can’t assist urine flow so it fills renal pelvis before entering ureters)
Renal calculi (immobile pts frequently have Hyperkalemia, a risk for dehydration)

219
Q

What is a patient at risk for regarding integumentary changes when they have been immobilized?

A

Pressure injuries
Changes in metabolism accompany immobility

220
Q

How to assess for DVTs

A

Palpate calves and under thighs
Note tenderness/cramping or redness
Palpate for edema
Compare findings in both legs** (Measure)
Unilateral symptoms could indicate DVT

221
Q

What are the pressure points of a patient placed in SIMs position?

A

Ileum
Humerus
Clavicle
Knees
Ankles

222
Q

Psychosocial nursing diagnosis for a pt dealing with immobility

A

Social isolation

223
Q

How would you assess for respiratory complications of a patient who is immobile?

A

Respiratory assessment every 2 hours
Inspect chest all movement
Auscultate entire lung region
Watch for s/s of pneumonia

224
Q

Psychosocial nursing diagnoses for patient experiencing hearing and visual impairments

A

Risk for anxiety, fear
Impaired verbal communication
Impaired socialization

225
Q

Factors that influence sensory functioning

A

Age
Meaningful stimuli
Amount of stimuli
Social interaction
Environmental factors
Cultural factors

226
Q

What is expressive aphasia

A

Motor
Inability to name common objects or express simple ideas into words or writing

227
Q

What is receptive aphasia?

A

Sensory
Inability to understand written or spoken language

228
Q

What is global aphasia?

A

Inability to understand language or communicate

229
Q

When assessing a patient who has right sided hemisphere stroke, which side do you dress first?

A

Left side

230
Q

In preventing hospital acquired pneumonia, especially in elderly patients, what should you do?

A

Turn, cough, and encourage deep breathing with them every 2 hours

Intro To Nursing Care (10 decks)

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