Module 1 Flashcards
Define infection
disease state that results from the presence of a pathogen
define pathogen
disease-producing microbe
These microbes are categorized by shape and size and classified as gram+ or gram-
bacteria
In the chain of infection, this is the place for growth and multiplication
reservoir
Portals of entry/ exit
Point at which organism enters or leaves reservoir
Examples: Respiratory tract, bodily excretions
Means of transmission
How the organism is transported from resevoir to new host (e.g. direct contact/touching)
Standard precautions
apply to ALL care activities regardless of suspected or confirmed infection status
Transmission-based precautions
added measures to prevent the spread of infection from patients with known or suspected disease
Donning order for PPE
Gown, mask, glasses, gloves
Doffing order for PPE
gloves, glasses, gown, mask
What are the signs of a localized infection?
Redness, swelling, warmth, pain or tenderness, loss of function
What are the signs of a systemic infection?
Fever, increased HR, increased RR, lethargic, swollen lymph nodes
Lab work: WBC, lactate, blood cultures
When is hand hygiene performed?
-Before and after every patient
-After touching contaminated surfaces or belongings
-Visible exposure to bodily fluids (wash with soap and water)
Hand hygiene, appropriate cleaning, early detection, adequate nutrition, vaccinations, education, and stress management are all examples of ways to _____
prevent and control infection
Asepsis
all interventions to prevent infection - break the chain of infection
(medical and surgical interventions are subtypes of asepsis)
The Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
In this step in the nursing process, you systematically collect patient data (observe, listen, examine)
assessment
In this step in the nursing process, you clearly identify patient strengths and actual and potential problems
diagnosis
In this step of the nursing process you develop a holistic plan of individualized care that specifies the desired patient goals and the related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (care plans, resources, interdisplinary team)
planning
In this step of the care plan, you execute the care plan
implementing
In this step of the nursing process, you evaluate the effectiveness of the care plan in terms of patient goals achievement
evaluation
what kind of room do you want for airborne precautions?
you want a negative air pressure room
what does VRE stand for?
vancomycin resistant enteroccocus
what are some airborne pathogens?
TB, chicken pox, smallpox, measles, meningitis, COVID
in what order do you don PPE for droplet precautions?
mask, eyewear
in what order do you doff PPE for droplet precautions?
eyewear, mask
in what order do you don PPE for airborne precautions?
mask, eyewear
in what order do you doff PPE for airborne precautions?
eyewear, mask
what is the difference between DRO and enteric precautions?
With both enteric and DRO, you wear the same PPE (gown and gloves), but for DRO you can use purple/top and hand sanitizer. For enteric, you have to use soap and water and bleach.
when is it necessary to wash with soap and water?
-when hands are visibly soiled
-after working with a patient with infectious diarrhea
-after potential contact with certain spores (e.g. C diff)
what are some ways to prevent falls?
-call bell within reach
-lower bed
-bed alarm
-non-slip socks
-assistive device
-room assignment r/t nurse’s station
never-event
iatrogenic event - limited reimbursement for hospital services (e.g. after a fall, the hospital is not going to be reimbursed)
sentinel event
unexpected occurence involving death or serious physical/psychological injury or risk of death - THAT COULD HAVE BEEN AVOIDED
what are examples of physical restraints?
-all 4 side rails are up
-four-point
-mitts
-hold
if a patient is in a 4-point restraints, you need to reassess them every _____
15 minutes
what are the four types of dementia?
-vascular
-lewy-body dementia
-mixed dementia
-Alzheimer’s Disease
Lewy-body dementia
protein deposits of the nerve cells
Amyloid plaques and tau tangles are features of _____ ______
Alzheimer’s disease is characterized by the presence of abnormal protein deposits in the brain. These deposits include beta-amyloid plaques, which accumulate between nerve cells, and tau tangles, which form inside neurons. These plaques and tangles disrupt the normal functioning of brain cells, leading to their deterioration and eventual cell death.
what are risk factors of delirium?
-sleep deprivation
-immobility
-visual impairment
-hearing impairment
-dehydration
-cognitive impairment
localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a device
pressure injury
how long does it take to form a pressure injury?
can form in as little as an hour
what are the populations at risk for pressure injuries?
-older adult (aging skin, chronic illness, immobility, malnutrition, incontinence, altered mental status)
-spinal cord injuries
-TBI/unconsciousness
-neuromuscular disorders (MS, ALS, Parkinson’s neuropathy)
-diabetic patients
what are risk factors for pressure injuries?
-immobility
-nutrition and hydration
-moisture
-mental status
-age
localized, intact skin, non-blanchable erythema
stage 1 pressure injury
partial thickness loss of dermis, open ulcer blister
stage 2 pressure injury
full thickness tissue loss, visual subcutaneous fat, slough, eschar
stage 3 pressures injury
full thickness tissue loss, tendon & bone exposure, epibole, slough, eschar
stage 4 pressure injury
what happens if a clot in DVT (deep vein thrombosis) becomes dislodged?
you are at risk for a pulmonary embolism
atelectasis
partial or complete collapse of the lung
what disorders of the respiratory system does decreased activity put you at risk for?
increased risk of atelectasis and pneumonia
How does the ANA define nursing?
“the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations”
what is included in the Nursing’s Social Policy Statement (2010) by the ANA?
the scope of nursing practice, standards of professional nursing practice, and the regulation of professional nursing
What are these?:
To promote health
To prevent illness
To restore health
To facilitate coping with disability or death
The four aims of nursing practice
The nurse uses four blended competencies: cognitive, technical, interpersonal, and ethical/legal. They are expanded as patient-centered care, teamwork and collaboration, quality improvement, safety, evidence-based practice, and informatics in the _____________
Quality and Safety Education for Nurses (QSEN) project competencies
The following are the leading indicators of healthy as outlined in ________:
Access to health services
Clinical preventive services
Environmental quality
Injury and violence
Maternal, infant, and child health
Mental health
Nutrition, physical activity and obesity
Oral health
Reproductive and sexual health
Social determinants
Substance abuse
Tobacco
Healthy People 2020 (document by the U.S. Department of Health and Human Services which outlines guidelines for health promotion)
immunoglobin produced by the body in response to a specific antigen
antibody
foreign material capable of inducing a specific immune response
antigen
smallest of all microorganisms; can be seen only by using an electron microscope
virus
nonhuman carriers—such as mosquitoes, ticks, and lice—that transmit organisms from one host to another
vector
practices that render and keep objects and areas free from microorganisms; synonym for sterile technique
surgical asepsis aka sterile technique
natural habitat for the growth and multiplication of microorganisms
reservoir
something originating or taking place in the hospital (i.e., infection)
nosocomial
process used to destroy microorganisms; destroys all pathogenic organisms except spores
disinfection
Infectious agent
Reservoir
Portal of exit
Means of transmission
Portals of entry
Susceptible host
Infection cycle / chain of infection
this kind of bacteria has a thick cell wall that resists decolorization (loss of color)
gram-positive bacteria
this kind of bacteria have chemically more complex cell walls and can be decolorized by alcohol
gram-negative bacteria
A person is most infectious during this stage. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever.
prodromal
Incubation period
Prodromal stage
Full (acute) stage of illness
Convalescent period
stages of infection
in this phase of the inflammatory response, small blood vessels constrict in the area, followed by vasodilatation of arterioles and venules that supply the area. This increase in blood flow results in redness and heat in the area. Histamine is released, leading to an increased permeability of vessels, which allows protein-rich fluid to pour into the area. At this point, swelling, pain, and loss of function can occur
vascular phase
During this stage of the inflammatory response, white blood cells (leukocytes) move quickly into the area. Neutrophils, the primary phagocytes, engulf the organism and consume cell debris and foreign material. Exudate composed of fluid, cells, and inflammatory byproducts is released from the wound. The exudate may be clear (serous), contain red blood cells (sanguineous), or contain pus (purulent).
the cellular stage
The following factors increase the risk of _______
-Integrity of skin and mucous membranes
-pH levels of skin and tracts
-white blood cell count and characteristics
-Age: neonates and older adults
-Immunizations, natural or acquired, which act to resist infection
-Level of fatigue, stress, nutritional and general health status, the presence of pre-existing illnesses, previous or current treatments
-Use of invasive or indwelling medical devices
Infection
Susceptibility of the host
This type of white blood cell may be increased in allergic reaction and parasitic infection
Eosinophil
This type of white blood cells is increased in chronic bacterial and viral infections
Lymphocytes
This type of white blood cell is increased in acute infections that produce pus; increased risk for acute bacterial infection if decreased; may also be increased in response to stress
Neutrophils
Increased in severe infections: function as a scavenger or phagocyte
Monocyte
What could you put as etiology (r/t) for the nursing diagnosis:
Risk for Infection
*Alteration in peristalsis
*Alteration in skin integrity
*Inadequate vaccination
*Insufficient knowledge to avoid exposure to pathogens
*Malnutrition
*Stasis of body fluid
How could you complete the following nursing diagnosis problem?
Deficient Fluid Volume
r/t
*Barrier to accessing fluid
*Insufficient fluid intake
*Insufficient knowledge about fluid needs
AEB (as evidenced by)
*Decrease in blood pressure, pulse pressure, and pulse volume
*Dry mucous membranes
*Increase in body temperature
*Sudden weight loss
*Weakness
_____ _______ or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Ex: performing hand hygiene and wearing glove
Medical asepsis
What are the five moments of hand hygiene?
Moment 1 – Before touching a patient
Moment 2 – Before a clean or aseptic procedure
Moment 3 – After a body fluid exposure risk
Moment 4 – After touching a patient
Moment 5 – After touching patient surroundings
preferred hand hygiene for C. difficile
soap and water
What is a CLABSI?
Central line–associated bloodstream infection
What is an HAI?
healthcare-associated infection
What is a CAUTI?
Catheter-Associated Urinary Tract Infection
what is CRE?
DRO:
carbapenem-resistant Enterobacteriaceae
disinfection vs sterilization
Disinfection destroys all pathogenic organisms except spores; sterilization destroys all microorganisms, including spores
do the following activities require gloves:
turning a patient, feeding a patient, taking vital signs, and changing IV fluid bags
not for standard precautions, unless you expect to come into contact with body fluids
________ Precautions
-Place patient in a private room that has monitored negative air pressure in relation to surrounding areas, air filtration or ventilation if possible
-Wear a respirator or N95 and eye protection
-Transport patient out of room only when necessary and place a surgical mask on the patient if possible.
Airborne
tuberculosis, varicella (chicken pox), and rubeola (measles) are all ______
airborne
rubella, mumps, diphtheria, and adenovirus are all _______
spread by droplets
slough
In the context of pressure injuries, slough refers to a type of tissue that can be found on the surface of a wound. It typically appears as a yellow or white substance that is moist, stringy, and often adherent to the wound bed. Slough is composed of dead or necrotic tissue, debris, and inflammatory cells. Effective wound management often involves removing or debriding the slough to promote healing.
effective wound management often involves removing or debriding the slough to promote healing.
debridement
separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound
dehiscence
dessication
dehydration; the process of being rendered free from moisture
thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur
eschar
fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells
exudate
localized mass of usually clotted blood
hematoma
new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
granulation tissue
deficiency of blood in a particular area
ischemia
activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid
negative pressure wound therapy (NPWT)
force created when layers of tissue move on one another
shear
This body system is made up of the skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including glands in the skin, hair, and nails, blood vessels, nerves, and sensory organs of the skin.
Integumentary System
The skin has two layers the ___ and the _____
the epidermis and the dermis
this layer of skin is composed of layers of stratified epithelial cells that form protective, waterproof layer of keratin material
epidermis
This layer of skin consists of a framework of elastic connective tissue comprised primarily of collagen. Also includes nerves, hair follicles, glands, immune cells
dermis
This layer is beneath the dermis and stores fat for energy, serves as a heat insulator for the body, and provides a cushioning effect for protection. This fatty tissue layer contains blood and lymph vessels, nerves, and fat cells.
subcutaneous tissue
_____ occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate.
Hemostasis
The _______ phase follows hemostasis and lasts about 2 to 3 days.
inflammatory
In this phase of wound healing, white blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing
inflammatory phase
The ____ phase of wound healing is also known as the fibroblastic, regenerative, or connective tissue phase. It lasts for several weeks.
proliferation
In this phase of wound healing, new tissue is built to fill the wound space, primarily through the action of fibroblasts. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. Fibroblasts form fibrin that stretches through the clot. A thin layer of epithelial cells forms across the wound, and blood flow across the wound is reinstituted. The new tissue, called granulation tissue, forms the foundation for scar tissue development. It is highly vascular, red, and bleeds easily. In wounds that heal by first intention, epidermal cells seal the wound within 24 to 48 hours, thus the granulation tissue is not visible.
proliferation
Wound ____ are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins.
biofilms
What do you do if dehiscence occurs?
Cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the health care provider. Place the patient in the low Fowler’s position. Do not leave the patient alone, and be sure to provide reassurance and intravenous pain medications as appropriate. Notify the primary care provider immediately. This situation is an emergency that requires prompt surgical repair, so the patient should be kept NPO
_____ is an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another
fistula
In this stage of a pressure injury, there is a defined, localized area of intact skin with nonblanchable erythema (redness). Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
stage 1
This stage of a pressure injury involves partial-thickness loss of dermis and presents as a shallow, open ulcer or a ruptured/intact serum-filled blister
stage 2
In this pressure injury presents with full-thickness tissue loss. Subcutaneous fat may be visible and epibole (rolled wound edges) may occur, but bone, tendon, or muscle is not exposed. Slough and/or eschar that may be present do not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling
A stage 3
This stage of pressure injury involve full-thickness tissue loss with exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle. Slough or eschar may be present on some part of the wound bed; epibole, undermining, and/or tunneling often occur
stage 4
_____ drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery.
serous drainage
____ drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.
serosanguineous drainage
This scale assesses mental status, continence, mobility, activity, and nutrition to determine risk for pressure injuries
Braden Scale
What is the cutoff point for a person become high risk on the Braden Scale?
19 to 23: no risk
15 to 18, mild risk
13 to 14, moderate risk
10 to 12, high risk
9 or lower, very high risk
The following are all ______:
Disturbed Body Image
Deficient Knowledge related to wound care
Impaired Tissue Integrity
Impaired Skin Integrity
Risk for Impaired Skin Integrity
Risk for Infection
Nursing diagnoses related to skin integrity and wound care
Impaired Skin Integrity
r/t _____________________
AEB ____________________
r/t
*External: chemical injury agent, moisture, pressure over bony prominences, hypothermia/hyperthermia
*Internal: alteration in fluid volume, inadequate nutrition, psychogenic factor
AEB
*Acute pain
*Bleeding, redness, hematoma
*Presence of a pressure injury; destruction of skin layers
*Presence of intentional or unintentional wound; disruption of skin surface
Readiness for Enhanced Health Management AEB ___________
*Expresses desire to enhance choices of daily living for meeting goals
*Expresses desire to enhance management of prescribed regimens (regarding wound care)
*Expresses desire to enhance management of risk factors (for pressure injuries)
Risk for Infection r/t ________
*Alteration in skin integrity
*Malnutrition
*Obesity
*Stasis of body fluid
*Associated with chronic illness, immunosuppression, and invasive procedure
The patient will:
Maintain skin integrity
Demonstrate self-care measures to prevent pressure injury development
Demonstrate self-care measures to promote wound healing
Demonstrate evidence of wound healing
Demonstrate increase in body weight and muscle size, if appropriate
Remain free of infection at the site of the wound or pressure injury
Remain free of signs and symptoms of infection
Experience no new areas of skin breakdown
Verbalize that the pain management regimen relieves pain to an acceptable level
Demonstrate appropriate wound care measures before discharge
Verbalize understanding of signs and symptoms to report and necessary follow-up care
Outcomes for skin integrity and wound care
Transparent films, such as:
3M Medipore
3M Tegaderm
BIOCLUSIVE
ClearSite
DermaView
OPSITE
Suresite
*Allow exchange of oxygen between wound and environment
*Are self-adhesive
*Protect against contamination; waterproof
*Prevent loss of wound fluid
*Maintain a moist wound environment
*Facilitate autolytic debridement
*No absorption of drainage
*Allow visualization of wound
*Wounds that are small; partial thickness
*May remain in place for 4–7 days, resulting in less interference with healing
*Stage 1 pressure injuries
*Wounds with minimal drainage
*Cover dressings for gels, foams, and gauze
*Secure intravenous catheters, nasal cannulas, chest tube dressing, central venous access devices
Hydrocolloid dressings, such as:
Comfeel
DuoDERM
Exuderm
PrimaCol
Ultec
*Are occlusive or semiocclusive, limiting exchange of oxygen between wound and environment
*Inner layer is self-adherent, gel forming, and composed of colloid particles
*Outer layer seals and protects the wound from contamination
*Minimal to moderate absorption of drainage
*Maintain a moist wound environment
*Thermal insulation
*Provide cushioning
*Facilitate autolytic debridement
*May remain in place for 3–7 days, depending on exudate
*Partial- and full-thickness wounds
*Stage 2 and stage 3 pressure injuries
*Prevention at high-risk friction areas
*Wounds with light to moderate drainage
*Wounds with necrosis or slough
*First- and second-degree burns
*Not for use with wounds that are infected
what are the benefits of exercise and the risks of immobility on the cardiovascular system?
Benefits:
↑Efficiency of heart
↓Resting heart rate and blood pressure
↑Blood flow and oxygenation of all body parts
Risks:
↑Risk for orthostatic hypotension
↑Risk for venous thrombosis
↑Cardiac workload
what are the benefits of exercise and the risks of immobility on the Respiratory System?
Benefits:
↑Depth of respiration
↑Respiratory rate
↑Gas exchange at alveolar level
↑Rate of carbon dioxide excretion
Risks:
↓Depth of respiration
↓Rate of respiration
Pooling of secretions
Impaired gas exchange
what are the benefits of exercise and the risks of immobility on the Gastrointestinal System?
Benefits:
↑Appetite
↑Intestinal tone
Risks:
Disturbance in appetite
Altered protein metabolism
Altered digestion and utilization of nutrients
↓Peristalsis
what are the benefits of exercise and the risks of immobility on the Urinary System?
Benefits:
↑Efficiency in excreting body wastes
↑Blood flow to kidneys
↑Efficiency in maintaining fluid and acid–base balance
Risks:
↓Bladder muscle tone
↑Urinary stasis
↑Risk for renal calculi
what are the benefits of exercise and the risks of immobility on Psychological Well-Being?
Benefits:
Energy, vitality, general well-being
Improved sleep
Improved appearance
Improved self-concept
Positive health behaviors
Risks:
↑Sense of powerlessness
↓Self-concept
↓Social interaction
Altered sleep–wake pattern
↑Risk for depression
↓Sensory stimulation
Risk for learned helplessness
Musculoskeletal System
Benefits:
↑Muscle efficiency
↑Efficiency of nerve impulse transmission
↑Coordination
Risks:
↓Muscle size, tone, and strength
↓Joint mobility, flexibility
Bone demineralization
↑Risk for contracture formation
↓Endurance, stability
Metabolic System
Benefits:
↑Efficiency of metabolic system
↑Efficiency of body temperature regulation
Risks:
↑Risk for electrolyte imbalance
Altered exchange of nutrients and gases
Describe the role of the skeletal, muscular, and nervous systems in the physiology of movement.
Identify variables that influence body alignment and mobility.
Differentiate isotonic, isometric, and isokinetic exercises.
Describe the effects of exercise and immobility on major body systems.
Assess body alignment, mobility, and activity tolerance, using appropriate interview and assessment skills.
Develop nursing diagnoses that correctly identify mobility problems amenable to nursing interventions.
Utilize principles of ergonomics when appropriate.
Use safe patient handling and movement techniques and equipment when positioning, moving, lifting, and ambulating patients.
Design exercise programs.
Plan, implement, and evaluate nursing care related to select nursing diagnoses involving mobility problems.
fill out later
a foam cushion placed alongside the hip and thigh to maintain proper alignment and prevent external rotation of the leg. It is primarily used to provide support and prevent pressure injuries in specific areas.
A trochanter roll
a metal or overhead frame with a triangular-shaped handle hanging above the bed. It is designed to assist clients in pulling themselves up, repositioning, or transferring within the bed. The client can grasp the trapeze handle and use their upper body strength to lift themselves or shift their position.
A bed trapeze
A frame that is placed over the bed to keep the covers or sheets from resting directly on the client’s body, particularly when there is sensitivity or pain in certain areas.
A bed cradle
A frame that is placed over the bed to keep the covers or sheets from resting directly on the client’s body, particularly when there is sensitivity or pain in certain areas.
A bed cradle
how do you apply graduated compression stockings for a client at risk for venous thromboembolis?
elevating the feet and having the client lie down for 15 minutes before applying the stockings helps to reduce any dependent swelling in the legs and improves venous return
how to use crutches
When climbing stairs, advance the unaffected leg past the crutches, place weight on the unaffected leg, and then advance the affected leg followed by the crutches.
Crutches should be at least 3 inches from the feet. When descending stairs, move crutches and the unaffected leg first, followed by the affected leg.
Support body weight with hands and arms.
Keep elbows close to sides.
how to use an incentive spirometer
-Sit upright or semi-upright in a comfortable position.
-Hold the incentive spirometer in an upright position.
-Place the mouthpiece in your mouth and create a tight seal around it with your lips.
-Breathe in slowly and deeply through the mouthpiece, trying to raise the indicator or ball inside the spirometer as high as possible.
-Hold your breath for a few seconds (as long as you can comfortably manage).
-Exhale slowly and remove the mouthpiece from your mouth.
Activities to decrease risk of _______ _________:
-deep breathing
-coughing
-incentive spirometry
-leg exercises
-repositioning
-early ambulation (within a few hours)
respiratory complications
Condition characterized by the inflammation of a vein accompanied by the formation of a blood clot within the vein
Thrombophlebitis
How do you reassess thrombophlebitis?
-Mark the area so you can assess improvement or worsening over time
What are some signs and symptoms of DVT?
-localized pain
-redness at the site
-unilateral edema
-increased temp at the site, decreased temp distally
-diminished pulse at popliteal artery
If you find a pt has a DVT, what do you do?
-Notify provider who will probably order an ultrasound and anticoagulant
-Do NOT ambulate
-Do NOT massage
What are preventative measures for DVT?
-Heparin
-Graduated compression stockings
-IPCD
-Increase mobility
-Venous foot pump
Venous foot pump is a medical device used to improve blood circulation in the lower extremities by applying intermittent pressure to the foot, aiding in the prevention of blood clots and venous stasis
incomplete expansion or collapse of alveoli with retained mucus
atelectasis
what are the signs/symptoms of atelectasis?
-decreased lung sounds
-dyspnea
-cyanosis
-crackles
-restlessness, apprehension
when is an automatic BP machine not accurate?
for a patient with a fib
difference between apical and radical pulse rates
pulse deficits
how does a hemorrhage affect VS?
-low BP
-high HR
what impacts heart rate?
-slows down with age
-goes up with activity
-athletes tend to have low resting HR
-fever and stress
-medications
-disease
what is the clinical term for an irregular pulse rhythm
dysrhythmia
how else can you check O2 sat for people with peripheral vascular disease or poor circulation?
earlobe probe
periods of not breathing, usually while sleeping
apnea
what is the most important risk factor for a stroke?
hypertension
what are the risk factors for hypertension?
family hx, race, age, sleep apnea, DM, obesity, HLD, alcohol, diet, sedentary lifestyle, oral contraceptives
what is the cutoff for hypertension?
> 130
OR
80
systolic BP is caused by ventricle _______
contraction
diastolic BP is caused by ventricle ________
relaxation
what are the long-term consequences of HTN?
-permanent remodeling
-increased peripheral resistance and pressure to organs
-heart failure
-kidney failure
hypotension results from _______
CHF
Hemorrhage
Dehydration (high dose of diuretics)
what are the signs and symptoms of hypotension?
dizziness, tachycardia, pallor, diaphoretic, visual changes
orthostatic hypotension
drop by 20/drop by 10 within 3 mins of supine > sitting > standing
how do you take an orthostatic hypotension?
lying down (5 mins), standing (1 min), standing (2 min)
do you use a sequential compression device for a pt with a known DVT?
NO - increases risk of the clot breaking loose
for an IVPB, if the manufacturer does not specify the drip rate, what is the standard?
50 mL / 30 mins
what is drip rate measured in?
gtt / min
admixture
a medication that comes premixed with IV fluid
Which activity as occurring during inspiration?
A Air flows out of the lungs.
B Thorax size reduces.
C Intercostal muscles contract.
D Chest pressure increases.
During inspiration, the diaphragm and the external intercostal muscles contract. The diaphragm, a dome-shaped muscle at the base of the lungs, contracts and moves downward, while the external intercostal muscles between the ribs contract and lift the ribcage upward and outward. These muscle contractions expand the thoracic cavity, increasing its volume.
As the thoracic cavity expands, it creates a negative pressure gradient within the lungs. This negative pressure allows air to flow into the lungs, filling the expanded space. Oxygen-rich air is drawn in through the airways, passing into the alveoli (air sacs) in the lungs for oxygenation.
A procedure in which a needle or catheter is inserted into the pleural space to drain the accumulated fluid. It is performed to relieve symptoms, diagnose the underlying cause of the pleural effusion, or both.
Thoracentesis
______ _________refers to the abnormal accumulation of fluid in the pleural space, which is the space between the layers of the pleura (the membranes that line the lungs and chest cavity). This fluid accumulation can be caused by various conditions, such as infections, heart failure, lung cancer, pneumonia, or trauma.
pleural effusion
A ______ refers to the sudden constriction or tightening of the smooth muscles surrounding the airways, leading to narrowing of the bronchioles. It can be triggered by various factors, including an allergic reaction to a bee sting.
bronchospasm
Catheter-associated urinary tract infection (CAUTI)
Surgical site infection (SSI)
Central line–associated bloodstream infection (CLABSI)
Ventilator-associated pneumonia (VAP)
These make up the majority of HAI
nursing __________ are actions performed by the nurse to:
-Monitor patient health status and response to treatment
-Reduce risks
-Resolve, prevent, or manage a problem
-Promote independence with activities of daily living
-Promote optimum sense of physical, psychological, and spiritual well-being
-Give patients the information they need to make informed decisions and be independent
interventions
Graduated compression stockings are often used for patients at risk for developing _________
deep vein thrombosis
pulmonary embolism
phlebitis
how do graduated compression stockings work?
By applying pressure, graduated compression stockings increase the velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs, promoting venous return to the heart. By preventing pooling of the blood, clot formation is less likely. An order is required from the patient’s health care provider for their use
heat-loss mechanisms of the body
sweating, vasodilation, increased respirations
physical effects of a fever
Patients with fever may experience loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. Respirations and pulse rate increase.
signs of hypothermia
poor coordination, slurred speech, poor judgment, amnesia, hallucinations, and stupor. Respirations decrease and the pulse becomes weak and irregular with lowering blood pressure.
Peripheral pulses result from a wave of blood being pumped into the arterial circulation by the contraction of the ____ _______
left ventricle
What does the pulse tell you about how the heart is working?
The pulse indicates the effectiveness of the heart as a pump, the volume of blood ejected with each heartbeat (stroke volume), and the adequacy of peripheral blood flow.
Tachycardia, a rapid heart rate, decreases cardiac filling time, which, in turn, _____ stroke volume and cardiac output.
decreases
Counting of the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical–radial pulse rate. A difference between the apical and radial pulse rates is called the ____ _____ and indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated
pulse deficit
The exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood
Diffusion
The exchange of oxygen and carbon dioxide between the circulating blood and tissue cells
Perfusion
An increase in _______ is the most powerful respiratory stimulant, causing an increase in respiratory depth and rate.
carbon dioxide
The relationship of one respiration to _____ heartbeats is fairly consistent in healthy people.
four
Stroke volume and heart rate determine ____ _____
cardiac output
Disorders resulting from hypertension
Thickening of the myocardium, enlargement of the ventricles, heart failure, myocardial infarction (MI), cerebrovascular accident (stroke), and kidney damage
Risk factors for hypertension
Family history of hypertension, race, aging, sleep apnea, and metabolic disorders such as type 2 diabetes mellitus, obesity, and high cholesterol. Lifestyle risk factors include a sedentary lifestyle; excessive alcohol consumption; high dietary intake of salt, fats, and calories; and use of oral contraceptives in women.
Signs of hypotension
Associated symptoms of dizziness, tachycardia, pallor, increased sweating, blurred vision, nausea, and confusion
causes of orthostatic hypotension
dehydration or blood loss; problems of the neurologic, cardiovascular or endocrine systems; and/or use of certain classes of medications
