Final Exam Flashcards
Fluid output
2200-2700 mL/day
GI feces output
100-200 mL/ day
Kidneys Urine output
1500 mL/day
Insensible Skin output
300-600 mL/day
Fluid distribution
intacellular- inside the cell. 2/3 of body fluids
extracellular- outside the cell. 1/3 of body fluids
interstitial-around the cells
intravascular- in arteries, capillaries, & veins
isotonic- equal balance
hypertonic- cells shrink
hypotonic- cells swell
Goals for prevention and controlling of infections
Prevent exposure
Early detection
Eliminate or reduce the infection
Educate in infection prevention and control
Primary defense mechanisms
Skin Respiratory Tract Eye Mouth Gastrointestinal Genitourinary
Medical Asepsis:
Reducing number and preventing transfer of organisms
AKA “Clean technique”
Hand hygiene
Clean environment
Barrier techniques
Standard Precautions
Prevent contact with blood, body fluids, secretions, non-intact skin, and mucous membranes with ALL clients.
PPE
Gown
Gloves
Mask
Goggles
Droplet illnesses
Influenza (flu)
Mumps
Pertussis (whooping cough)
Droplet Barrier protection
Private or cohort room
Surgical mask w/in 3 feet
Patient leaves the room only if necessary
Mask on patient when transporting
Airborne illnesses
Measles
Chickenpox
Disseminated herpes zoster
Tuberculosis
Airborne barrier precautions
Private room Negative airflow pressure Door closed except entering and exiting Ultraviolet irradiation or air filter Mask (N95) Patient leaves the room only if necessary Mask on patient when transporting
Contact indications
MDROs- c. diff, MRSA, VCEs
Wound infections
Skin infections
Eye infections
Contact barrier precautions
Private room or cohort patient
Gloves and gown
Protective indications
Transplant
Chemotherapy
Immunocompromised
Burns
Protective enviroment
Private room
Positive airflow
No plants or fresh fruits
Full PPE
Surgical Asepsis
Eliminating microorganisms
Sterile technique
Sterile equipment and supplies
Sterile environments
Principles of Surgical Asepsis
- A sterile object remains sterile only when touched by another sterile object.
- Only sterile objects may be placed on a sterile field.
- A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated.
- A sterile object or field becomes contaminated by prolonged exposure to air.
Factors that increase susceptibility (Risk Factors)
- Break in primary defenses
- Acute illness and chronic disease
- Some medications
- Invasive procedures
- Tobacco use
- Substance abuse
- Multiple sex partners
- Environmental conditions
Local infection
Specific to the location Examples Wound Respiratory Urinary Gastrointestinal Eyes/Ear/Throat
Systemic Infections
Fever, chills, diaphoresis Increased HR and RR Malaise Anorexia Enlarged lymph nodes Organ failure
Healthcare Associated Infections (HAIs)
“Infection not present on admission” Results in increased: Patient stay Discomfort Cost
Peripheral placement iV
Short term use
Ease of insertion
Central placement IV
Purpose Long term use Large amounts Irritating substances Poor peripheral sites
Types PICCs Tunneled Nontunneled Implanted ports
Isotonic Solution
0.9% Sodium Chloride (NS)
Lactated Ringer’s (LR)
Dextrose 5% in Water (D5W)
Expands ECV (vascular and interstitial); does not enter cells
Hypotonic solution
- 45 % Sodium Chloride (1/2 NS)
- 225% Sodium Chloride (1/4 NS)
Expands ECV and rehydrates cells
Hypertonic Solutions
3% or 5% Sodium Chloride
Dextrose 5% in 0.45% NaCl (D5 ½NS)
Dextrose 5% in 0.9% NaCl (D5NS)
Dextrose 5% in LR (D5LR)
Sodium replacement
Draws water from cells
Isotonic fluid is used for
Hypotension, hypovolemia
Hypotonic fluid is used for
Hyperglycemic, conditions (diabetes ketoacidosis)
Hypertonic fluid is used for
Stabilize BP,
^ urine output, and reduce edema
Usually after loss or blood or plasma such as burns or hemorrhaging pts
16g to 18g is used for ?
rapid infusion, thick fluids, surgical or trauma pts
20g
adult blood transfusions
20g to 22g
adult peripheral transfusion
How many times should you attempt to initiate an IV?
No more than two tries, if you miss the first, go above the initial site or opposite extremity
Primary and secondary IV administration sets should be changed how often?
No more frequently than 96 hours, at least every 7 days
Intermittent administration sets should be changed how often?
Every 24 hours
What is the preferred type of dressing for an IV site? AND WHY?
Transparent semipermeable so you can see the site and permits evaporation or moisture and provide a secure anchor
How will you select a site for a peripheral IV?
age (adults = veins in hand or arm, child = scalp or foot)
- solution type (use large veins for < irritation when using hypertonic, viscous or irritating substances)
- infusion speed (the faster = larger vein and Iv cath
- duration (change peripheral IV 72-96 hours)
- presence of disease or previous surgery (avoid scarring or impaired circulation)
Infiltration
inadvertent administration of a nonvesicant (non tissue damaging) solution or medication into
Infiltration CMs
swelling, tenderness, pallor, hardness, and coolness at site, and burning sensation.
Nursing response: stop infusion Immediately, restart infusion in different vein, elevate affected arm on a pillow to promote absorption of excess fluid.
Extravasation
inadvertent infiltration of vesicant solution or medication into surrounding tissue
*if these happen don’t pull out catheter, stop infusion first, talk to pharmacist bc there might be an antidote to put through the catheter.
Extravasation CMs
pain, burning, swelling, and coolness of surrounding skin, blistering is a late sign.
treatment depends on severity, stop infusion immediately, administer an antidote, apply cold compresses, and elevate the extremity.
Phlebitis
inflammation of the vein, can result from the chemical part of fluid going into it or mechanical meaning the inside of catheter is damaging the vein.
Phlebitis CMs
redness, warmth, tender, may be palpable.
Nursing Response: discontinue iv infusion and restart in new location, apply cold compresses, assess for circulatory impairment, consult HCP.
Thrombophlebitis
clot forming in addition of the phlebitis that happened. Discontinue infusion and take out catheter, elevate extremity, apply warm compresses 3-4x a day, restart infuse in a different extremity.
Thrombophlebitis nursing response
discontinue iv infusion, and restart in opposite extremity apply warm compresses, consult HCP.
