Final review 2 Flashcards
Pain tolerance
amount of pain one is willing to endure. need to take pain before it gets really bad - harder to get down when it’s so high.
lower respiratory infections
*Pneumonia is RESPIRATION (increases secretion in airways, affects respiration and gas exchange in alveoli), Respiratory Syncytial Virus (RSV),
tuberculosis
respiratory assessment
- BODY POSITIONING
Tripod breathing (leaning forward) – sign of respiratory distress - CONVERSATIONAL DYSPNEA
Inability or difficulty to speak complete sentences
without stopping to breath, pausing for breath
**7. STRIDOR
High-pitched whistling sound (hear a lot in babies, if in adult, very serious. ALWAYS go to stridor patient first, everything else can wait)
Caused by partial obstruction of larynx or trachea - WHEEZE
Musical sound produced by air passing through
narrow airways
Characteristics of stoma - pale = ? and purple = ?
pink/red normal (pale-anemia, maroon/purple-ischemia)
Hypercapnia/hypercarbia
(extra CO2)
COPD - Avoid high levels of
Avoid high levels of O2 (keep between 85-90% O2 sat if no
overt respiratory distress or COPD exacerbation)
COPD - cause of what?
Cor Pulmonale (cause of right side heart failure pulmonary disease. constant increased pressure in right heart, heart has to pump harder, chronic edema)
* Thin appearance
sputum colors
SPUTUM COLORS
COLOR/APPEARANCE SIGNIFICANCE
WHITE OR CLEAR Viral infection; common cold, viral bronchitis – supportive care
YELLOW OR GREEN Sign of infection
HEMOPTYSIS Lung damage, lung injury, TB
PINK AND FROTHY Pulmonary edema
causes of hypoxia (think - shutting off the pathway)
-Altered internal respiration: severe sepsis
-Shunting: septum foramen ovale (baby)
-Circulatory compromise: severe heart failure, cardiogenic shock
***lactic acid - excess in aerobic respiration
Airway inflammation
COPD
airway restiction
asthma
ventilation is movement of____respiration is exchange of____
air, gases (O2 and CO2) in the lungs
in ER, if a patient is tripoding, should you see them first, or last?
first, they are in disress - trying to bend over to expand lung volume
good O2 % level for ppl with COPD
90 - 92%
Intrapersonal:
self talk. Communication that occurs within
an individual.
Interpersonal:
Between 2 or more people. Assessment, teaching, providing
comfort and support
Transpersonal:
spiritual
Pre-interaction Phase:
reviewing chart, patient handoff
Orientation Phase: hi, how are you?
Goal – establish rapport and trust using verbal and non-
verbal communication;
Working Phase: (just the majority)
Bulk of therapeutic relationship occurs in this phase – active part, active listening
Termination Phase:
Prepares for future interaction
Share Observations (share questions and silence)
“You seem quiet today. What’s in your mind?
Connotative Meaning -
implied
denote
literal
when does orientation phase end? (I’m oriented to the role)
Once relationship/ role is defined, orientation phase ends
joint commission is
teaching
SMART
Specific
Measurable
Attainable
Relevant
Time Frame
observation or assessment - HELP acronym
H = Help: Observe the first signs patient may need help. Signs of distress? e.g. pain,
labored breathing
E = Environmental equipment: Safety hazards? Is equipment working?
L = Look: Examine patient - quick survey of patient - USE This for critical thinking worksheet
P = People: Who is in the room and what are they doing?
diagnostic reasoning (Mina can diagnose)
higher level skills and experience.
relevance of critical thinking (I’m critically thinking about the what ifs)
the what ifs
6 steps in critical thinking
1.recognize and define the problem or situation
2. assess all options
3. weigh each option
4. test possible options
5. consider the consequences of the decision
6. make the final decision
ex. temp is 38.3 - assess temp in 1 hour.
clinical judgement (the judge decides the outcome)
“the observed outcome of critical thinking and decision-making.”
clinical reasoning (reasoning and applying are verbs)
the process of applying (this is the application part) critical thinking to a clinical scenario
Epidermis and dermis - which immune cells
Epidermis: Langerhan cells
Dermis: macrophages and mast cell
acute wounds heal within
Heal within days to week
chronic wounds heal
> 30 days
phases of wound healing (BIPR wound)
bleeding, inflammatory, proliferative, remodeling
phases of wound healing - hemostasis (hemo = blood)
Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation
Inflammation (followed by what?) The flame became white and macros attracted the growth
(main point - redness, heat, pain)
Followed by vasodilation (heat and redness) → ↑capillary permeability leaking of plasma→ exudate→ swelling→ loss of function
Chemicals on tissues attract WBCs
WBC and macrophages migrate to injured site
Macrophages also attract growth factors for regeneration of epithelial cells and fibroblasts to fill in wound
Systemic Response during inflammation
fever
5 cardinal signs of inflammation***(flaming cardinals swap roles - SWP RL)
Redness, warmth, swelling, pain, loss of function
Proliferation - how long does it last? (prolif several weeks)
several weeks
Restoration/Maturation (the restoration took about 3 weeks)
Begins 3 weeks after injury
Initial collagen broken down and remodeled into scar tissue
signs of infection - when do they start? (
Usually occurs 2-7 days after injury or surgery
stages of a pressure injury
STAGE 1
STAGE 2
STAGE 3
STAGE 4
SUSPECTED DEEP TISSUE INJURY
UNSTAGEABLE PRESSURE INJURY
Devices Related PI That Can Be Staged (my ears, nose and throat on stage)
Behind ears from nasal cannula
Nasogastric tubes
Endotracheal tubes
mucosal membrane - PI - can or can’t be staged?
Found on mucous membranes with a history of medical device at location of injury
Due to the anatomy of the tissue these injuries cannot be stage
pressure injury stage I
skin is intact
Non-blanchable erythema
Not maroon or purple (Deep tissue injury)
Skin intact
Over bony prominence or device related
Area may be painful
Warmth or firmness compared to adjacent area
Difficult or assess in patients with dark skin tone or areas of hyperpigmentation
PI stage 2 (color and what level of skin is exposed?) (a blister is on stage 2)
Partial thickness skin loss with exposed dermis
Wound bed viable, shallow, pink or red and moist
Intact serum filled or ruptured blister
No adipose tissue, granulation tissue, slough or eschar
May be mistakenly used to describe skin tears, burns, maceration, excoriation, incontinence associated dermatitis or, abrasions
PI stage 3 (there are 3 stages for a fat granny, but fascists, muscle, and bone tend to be elsewhere)
Full thickness skin loss
Adipose and granulation tissue visible in the ulcer
Fascia, muscle, tendon, bone not visible
PI stage 4 (everyone is on stage at 4, even ebola - BUT one isn’t completely covering)
Full thickness tissue loss
Exposed bone, tendon, muscle, tendons, ligaments
Epibole (rolled around edges) undermining and/or tunneling common
Slough or eschar may be present but does not completely obscure wound bed
May cause osteomyelitis if bone exposed
PI unstageable**
UNSTAGEABLE PRESSURE INJURY
Obscured full-thickness tissue loss
Extent of tissue damage cannot be terminated d/t obscurity from slough or eschar
If slough or eschar removed (black stuff) from unstageable, it always reveals stage 3 or 4 PI
pressure injury - deep tissue***(deep tissue deep purple)
Persistent nonblanchable deep red, maroon, or purple discoloration
Result of intense, prolonged pressure and shearing at bony prominence
May rapidly reveal the actual extent of tissue injury or resolve without tissue loss
Difficult to detect in dark skin tones (compared to adjacent tissue, may be painful and firm)
Peripheral arterial disease (perry art is thin and dead)
Limits activity d/t pain and leads to muscle atrophy
Thin tissue that is prone to ischemia and necrosis
Need to restore arterial blood perfusion for wound healing
Chronic venous disease (veins get edema)
Results in engorged tissue with high levels of waste products resulting in edema, ulceration, and breakdown
critically colonized
(>100K per gram of tissue)
wound assessment - what to measure and the q-tip
Measure dimensions
L X W X D
wound assessment undermining (it’s literally just a mine)
Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions
tunneling
usually just in 1 direction
Primary Intention - wound healing
just bringing the edges together) Wound involves minimal or no tissue loss
Edges approximated (sutures, staples, or surgical glue touching/closed)
Secondary Intention - wound healing (the second you can’t close it)
Extensive tissue loss that prevents edges from approximating or because wound intentionally left open d/t contaminated/infected tissue/blood clot
Wound debrided or infection resolved then allowed to heal from inner layer to surface with beefy red granulation tissue (a type of connective tissue)
Tertiary Intention - wound healing (tersh needs to wait)
Tertiary Intention (Delayed primary closure):
Initially wound healed by secondary intention
When there is no evidence of edema or infection, granulation tissue pulled together and wound edges sutured
Requires strict aseptic technique to prevent infection
Scarring (my adhesions are to keloid and hypertrophy)
Hypertrophic scar -
Scar stays within boundaries of wound
Keloid-scar - outgrows border of injury; acts like a tumor
Adhesions: bands of scar tissue that form between or around organs e.g intestinal adhesions may lead to bowel obstructions
MEASURE - wounds
MEASURE
M=Measure size of wound
E=Exudate amount
A=Appearance of base: necrotic (black), fibrin (firm yellow), slough (soft yellow – viscous and opaque), granulation tissue (beefy and healthy or red and friable-unhealthy), biofilm
S=Suffering (Pain)
U=Undermining
R=Re-evaluate treatment
E=Edges
Exudate/drainage:
Serous (you’re seriously a straw)
typical of clean wounds, clear watery with little cells=straw colored serum
Exudate/drainage:
Sanguineous-bloody (and what colors?) (I sang w/ bloody capillaries)
Sanguineous-bloody; if bright red blood =bleeding active; if red-brown and darker probably indicates capillary damage
Exudate/drainage:
Purulence
thick, often malodorous (Pus-WBC’s, bacteria, and cellular debris
Clean (GU tract not clean)
Uninfected wound with minimal inflammation
Respiratory, GI, GU tracts not involved
Clean-contaminated (still clean, but…)
Surgical incisions that enter the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection
Contaminated
Open, traumatic wounds or surgical incision in which there is a bridge in asepsis
High risk of infection
Reposition chair or wheelchair bound patients how often? (The reposition is every hour. and how often to shift weight?)
every hour. If they are able, teach them to shift their weight every 15 minutes.
ppearance of base - colors - necrotic
black
appearance of base - colors - fibrin (fibrin is firm)
firm yellow
appearance of base - colors - slough (S for slough and soft)
soft yellow – viscous and opaque
appearance of base - colors - granulation tissue (granny loves mixing white and red to make pink)
most commonly seen in new wounds lighter pink, combination of serous and sanguineous drainage-
what is epibole and what stage would you see it? (the ebola rolled in at 3)
rolled wound edges common - stage 3
what might occur during stage 3? (mining the tunnels at 3 p.m.)
Undermining and tunneling may occur
stage 3 - Slough and or eschar (slough and eschar might not be seen on stage 3)
may be visible but if they obscure the extent of tissue loss, PI wound be considered unstageable
would assessment - Periwound skin (just the skin around the wound) (BI MEN periwound)
indurated (hard), erythematous, macerated (moisture), bruised, normal
what to do if evisceration occurs? (evisceration is a looooowww blow)
place patient in low fowler and immediately cover exposed organ with moistened sterile saline gauze**
*Contact provider immediately and stay with patient
place patient in low fowler and immediately cover exposed organ with moistened sterile saline gauze**
*Contact provider immediately and stay with patient
biofilm
Purosanguineous - (one step beyond)
thick red-tinged pus indicating blood in infected wound
arterial ulcers are what color?
pale bc blood can’t get to it
diabetic ulcers are venous or artery?
venous ulcers
would you see slough or eschar with arterial vascular disease? (art has a black heart)
black eschar
where are the sores located with venous ulcers?
the ankles
how long to monitor surgical wound and drains? (wounds in the first 48)
48 hours
3 Ds of confusion
delirium (hours to days), depression (weeks to months), dementia (months to years)
geriatric syndrome assessment (SPICES)
sleep disorders
problems eating or feeding
incontinence
confusion
evidence of falls
skin breakdown
living will
not legally binding. directive to physicians.
advanced directive
legally binding - lasts one year. directs another person to voice healthcare decisions, even if incapacitated.
unhealthy fats - (unhealthy saturated and trans don’t have friends) solid or liquid?
Saturated fat and trans fat Lacks double bonds between carbons leading to solid form at room temp
Animal source
Raises serum cholesterol
healthy fats (unsaturated/unfat have bonds)
Unsaturated fat: Mono-and poly-unsaturated fats
Contains at least one double bond between carbons; liquid at room temp
Olive oil, salmon, avocado
Lowers serum cholesterol
micro and macro minerals - numbers
macro - over 100 mg/day
micro - under 100 mg/day
cardiac diet
2 gm Na+ diets (Cardiac diet - aka low sodium)
better for nutrition - prealbumin or albumin?
prealbumin - half life 2-3 days
oral feeding - how to sit, and how long after meals to sit up?
When patient has normal swallowing reflexes (+ cough and gag)
Completely awake, alert, follows commands
Sit up at 90 degree; preferably in chair
Follow ordered diet
Sit up for at least 30 min after meals
indications (who should get it) for enteral (enter the anorexic…)
Anorexia
Frequent aspirations
Orofacial fractures
Head/neck cancer
PEG (stomach wall) - when to use? and how often is it changed? (I only see Peg every few months for a long time)
When longer term enteral feeding is anticipated
More comfortable
Tube replaced every few months
Laparoscopically placed in interventional radiology
Percutaneous Endoscopic Jejunostomy (GAG Juno)
A J-tube is considered in the following circumstances:
Gastroparesis
GERD
High risk aspiration
If surgery is needed on stomach/esophagus at later point
enteral feeding complications - aspirational pneumonia (HOB?)
Aspiration pneumonia (most serious)
Insert post pyloric
HOB>30-45°, maintain upright for at least 30 min- 1° after
bolus feed
Check tube placement and residual
Nursing Responsibilities: Enteral Nutrition - assess how often?
how often to assess length of tube?
how often to change tape?
Assess for residual per hospital policy (generally every 4-8hrs)
Insertion length verified and documented every shift
Securement tape should also be changed every day to assess skin
Eyeball for same marking before administration of feeding/meds
Nursing Responsibilities: Enteral Nutrition - check for…(enteral needs WD10-40)
Check for protocols such as hanging D10 when tube feed nutrition interrupted to prevent hypoglycemia
Will need MD order to restart tube feeding
Nursing Responsibilities Enteral Nutrition - tube patency (openness) - flushing -flush with what?
Flush with sterile water before/after each feeding, drug administration and after residual checks
Flush with 5mL of sterile water between meds
If residual is less than hold order, simply document feeding and refeed residual
enteral nursing considerations - glucose (label bag with what?)
Initial glucose checks
Label enteral bag with patient name, formula type, date and time started
