Midterm Flashcards
What are the 6 components of the chain of infection?
- Infection Agent
- Reservoir
- Portal of Exit from Reservoir
- Mode of Transmission
- Portal of entry to host
- Susceptible host
What are the 4 phases of wound healing? (page 1303)
Inflammatory phase, proliferative phase, remodeling, primary or secondary intention.
What are signs/symptoms of Hypergycemia
Thirst, headache, lethargy, increased urination
What are signs/symptoms of hypoglycemia?
Diaphoresis, shakiness, confusion, loss of conciousness
What are the normal lab ranges for blood glucose monitoring?
4-8 is normal below 4 is hypoglycemic and above 8 is hyperglycemic
What is the normal hourly output for an adult?
125ml or 500ml/4 hours
What are the 3 types of catheters and what are they used for?
Straight-cross intermittent is single use.
In-Dwelling double lumen (foley) for long-term
Triple Lumen-Irrigation long term w/balloon
What would be an indictation that intermittent bladder irrigation is necessary?
Decreased urine output blockage, distended suprapubic and abdominal discomfort.
What is the nursing assessment when observing urine output collecting in a straight drainage bag?
COCA color odor consistency amount
What are the components of a complete blood count?
RBCs, WBCs, Hematocrit, Hemoglobin, Platelet
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
What should the nurse assess prior to giving an enteral feed?
Allergies, order, tube placement, patency, intake & output
What are the 10 medication rights?
Patient, documentation, medication, dosage, time, route, reason, patient education, evaluation, refuse
What are 5 things a nurse needs to know before it is safe to give a medication?
Indication for medication, patients other medications, allergies
How often should you monitor a patient for Gastric Residual?
Every 4-5 hours.May be reflected if 200-500 mL or more remains in adult patients’ stomach; if >150 mL, check within hour
What position should a patient be in prior to initiating a feed or medication?
High Fowlers to prevent aspiration
What are the 3 types of enteral tube feeding?
Intermittent, Continuous and Open vs Closed
What would you assess for post-feed?
Respiratory status
Patency
Blood sugars
Intake & Output
Skin condition
Nausea/cramping
How do you prevent clogging of feeding tubes?
Flush before, in-between, and after medication(s)/feeds
Flush Q4-6H or as per agency policy/MD orders
What are 4 ways to troubleshoot a tube feeding?
Try clamping tube and allow warm water to “soak”
Try repositioning patient (potential kinks)
Try pushing and pulling back on syringe plunger (gently)
Enzymes (need MD order)
What should you document for tube feedings?
Type & amount of formula, patency of tube, stoma sties/skin integrity, response to feeding and side effects
What are the 3 distribution systems? Page 742
Stock Supply System- meds available in quantity, in large, multidose containers. Time consuming and costly. Eeach med must be dispensed seperatly for each patient- high rate of med errors.
Unit Dose System-portable carts containg a drawer with a 24-hr supply of meds for each patient.
Automated Dispensing System - AMDS are computerized to dispense narcotics and unit-dose medication. Nurse uses security code. Connected to a computer system.
What does a low score on the braeden scale mean?
The lower the score the higher the risk. Score ranges from 6 to 23
Define Primary intention
Surgical wound. Edges are approximate or closed and risen of infection is low.
What is granulation tissue?
Red moist tissue composed of new blood vessels which indicates progression toward healing.
What is Slough
Soft white or yellow tissue that needs to be removed before a wound can heal
What is Eschar
Black necrotic tissue which needs to be removed before a wound can heal
Define Secondary Intention
Wound healing involving loss of tissue such as burn, pressure injury or laceration. Wound is left open until it becomes filled by scar tissue. Takes longer to heal this chance if infection increases
What happens during the inflammatory phase?
Last approx 3 days
During hemostasis injured blood vessels constrict and platelets gather to stop bleeding.
Clots form fibrin which provides framework for repair.
Damage tissue and mast cells secrete histamine which results in vasodilation resulting in localized redness warmth and throbbing. White blood cells arrive to ingest bacteria and debris. This phase is done to clean the wound bed.
What happens during proliferative phase??
New vessels appear as reconstruction progresses this lasts 3 to 24 days. Wound fills with granulation tissue. Collagen provides strength and structure. Wound contracts to reduce area of healing.
What happens during the remodeling phase of wound healing
Takes up to 2 years.
Collagen scar continues to gain strength. Healed wounds are at risk for pressure injury. Fewer pigmented cells is why scars appear lighter.
What type of fluid is serous
Clear watery plasma
What type of fluid is purulent
Thick yellow green tan or brown
What type of fluid is serosanguineous
Pale red watery mixture of clear and red fluid
What type of fluid is sanguineous
Bright red indicating active bleeding
Define eviseration
Total separation of wound layers
Define dishiscence
When a wound fails to heal properly the layers of skin and tissue separate
Define intermittent catheterization
A single-use straight catheter is introduced urethra Lee for 5 to 10 minutes just long enough to drain the bladder the straight catheter has a single Lumen with a small opening urine drains from the tip through the Lumen into a receptacle intermittent catheterization is performed in patients who have incomplete bladder emptying do two neurogenic conditions. In hospitals this is a sterile technique in community patients clean their catheters and reuse them many times.
What is a Coude catheter?
Has a curved tip for male patients who have an enlarged prostate that partially blocks the urethra.
How much urine can a urinary drainage bag hold
1000ml-1500ml
What size of catheter for children
8 to 10 Fr
What size of catheter for female
10 to 12 Fr
What type of catheter for males
12 to 16 Fr
What balloon size to be used for a child with a catheter ?
3ml is considered pediatric
What size of balloon to be used in adult with catheter
10ml allows for optimal drainage however 30ml would be used after prostatectomy
Why would there be urine leakage around the catheter
Bladder spasms secondary to constipation or fecal impaction, the use of a large catheter balloon or a large catheter that causes irritation the presence of a UTI kinking of the catheter or trauma at the bladder neck from traction on the balloon. A change in Lumen size the use of anticholinergic drugs where referral to urologist maybe warranted
How many fluids should be in taken for a patient with a catheter
2000 to 2500ml.
What is orthopnea
An abnormal condition in which the person must use multiple pillows when lying down or sit with their arms elevated and leaning forward to breathe
What is Hemoptysis
Bloody sputum. Normally associated with coughing and bleeding from the upper respiratory tract, sinus drainage or the GI tract. Chest Xray, bronchoscopy, and other xray test to be performed.
What is Wheezing
Characterized by a high pitched musical sound caused by High Velocity movement of air through a narrowed Airway can occur during inspiration expiration or both.
