nursing fundamentals and clinical skills Flashcards
represents the balance between health produced and health lost by the body
body temperature
are relatively constant
core temps
fluctuate depending on blood flow to the skin and env conditions
surface temps
what are the temp measurement sites?
mouth, rectum, axilla, and tympanic
reflect fluctuations in the core temp. cannot be used in infants or sm children
oral temps
are the preferred method of measurement in young children who cannot use oral thermometers, should not be used for newborns due to the risk of anal perforations
rectal temps
is the safest site to measure temperatures in newborns
axillary temps
an easily accessible site that provides a core temperature quickly
tympanic membrane temp
site in easy to obtain without changing the clients position
temporal artery temp
bounding of arterial blood flow that is palpable at various points on the body
pulse
heart rate below 60bpm in an adult
bradycardia
heart rate above 100bpm in an adult
tachycardia
an irregular or abnormal rhythm
dysrhythmia
a normal increase in heart rate associated with inspiration
sinus arrhythmia
difference between apical and radial pusles
pulse deficit
the mechanism that the body uses to exchange gases between the atmosphere and the blood and between the blood and cells
respiration
regular but slow breathing at a rates of less than 12 breathes per min
bradypnea
regular but rapid breathing at a rate of greater than 20 breaths per min
tachypnea
laboured, deep respirations at a rate of greater than 20 breaths per min
hyperpnea
temporary cessation of breathing which then resumes
apnea
shortness of breath resulting in laboured or difficult breathing
dyspnea
an abnormal condition in which a person uses multiple pillows when lying down or must sit with their arms elevated and leaning forward to breathe deeply or comfortably
orthopnea
the indirect measure of arterial oxygen saturation and pulse rate
pulse oximetry
is the force of the blood under pressure pushing on the walls of an artery
BP
the peak of max pressure when the left ventricle contracts and ejects blood under high pressure into the aorta
systolic
is the min pressure exerted on the artrial walls when the ventricles relax
diastolic
the difference between systolic and diastolic pressures
pulse pressure
the temporary disappearance of korotoff sounds during auscultation of bp
auscultatory gap
persistently elevated BP and is often asymptomatic
hypertension
occurs when the systolic BP falls to 90 or below
hypotension
occurs when a person with bp within normal range develops symptoms and low bp when moving to an upright position
orthostatic hypotension
is the invasion of the body by pathogens and the rxn of the tissues to their presence and to the toxins generated by them
infection
cause more generalized symptoms, such as fever, fatigue, and malise
systemic infection
what are the elements of the chain of infection?
infecious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host
acquired after admission to a hospital or another HC agency that were not present or incubating at the time of admission
health care associated infections
procedures used to reduce and prevent the spread of microorganism
medical asepsis
includes all procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area
surgical asepsis
are infection control precaution designed for the care of all clients in any setting regardless of their dx or presumed infectiousness
routine practice
are designed to contain pathogens in one area, usually in a clients room
additional precautions
used for known or suspected infections caused by microbes transmitted by airborne droplets, measles, ckn pox, vericella
airborne precautions
used for known or suspected infections caused by microbes transmitted by droplets produced by coughing, sneezing, or talking
droplet precautions
used for known or suspected infections caused by direct or indirect contact
contact precautions
straight single lumen catheter is introduced to empty thr bladder and removed after the bladder is drained
intermittent catheterization
catheter with an inflatable balloon is inserted into the bladder on a short term or long term basis
in dwelling catheterization
irrigation or flushes used to maintain the patench of in dwelling catheters or to wash out the bladder and treat local infections
bladder irrigation
usually involves infrequent bowel movements, difficult defecation, inability to defecate at will, and hard feces
constipation
a condition in which a collection of hardened fleece cannot be expelled from the rectum
fecal impaction
the passage of liquid necessary and an increase in the number of stools
diarrhea
inability to control the passage of feces and gas
fecal incontinence
excessive gas in the stomach and intestine
flatulence
are dilated, engorged veins in the rectal area
hemorrhoids
divert the feces from the bowel directly to the abdomen surface
fecal diversions
are an installation of a solution into the rectum and sigmoid colon
enemas
include tap water, NS, low volume hypertonic and soap suds
cleansing enemas
lube the rectum and colon
oil retention enemas
used when the client has a fecal impaction. nurse breaks up the fecal mass with a finger and removed it in sections
digital removal of stool
follow the normal healing process in a predictable and timely fashion
acute wounds
do not heal easily, and the normal reparation process is interrupted
chronic wounds
have little or no tissue loss, have well approximated wound margins, and heal quickly
primary intention
have loss of tissue, such as second or third degree burns, or pressure injuries, and there is no approximation of wound edges
secondary intention
occurs when postponing suturing of a wound in which two layers of granulation tissue are sutures together
tertiary intention
partial or total separation of the wound layers
dehiscence
protrusion of the abdominal organs through wound opening
evisceration
abnormal passage between two organs or between an organ and the outside of the body
fistula
clear, watery
serous
thick green, yellow, or brown and containing pus cells
purulent
thin, watery, blood tinged
serosanguineous
localized damage to the skin and underlying soft tissue, usually over a body prominence or relates to a medical or other device
pressure injury
when two surfaces are rubbed against each other
friction
parallel force that happens when the skin and underlying subcutaneous tissue are pulled taut
shear
a deep red, purple or maroon localized area of discolored intact skin nonintact skin or blood filed blister
suspected deep tissue injury
intact skin with nonblanchable redness of a localized area, usually over a body prominence
stage 1 pressure injury
partial thickness of dermis presenting as a shallow open ulcer with a red pink wound bed
stage 2 pressure injury
full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle not exposed
stage 3 pressure injury
full thickness skin and tissue loss with exposed bone, tendon or muscle
stage 4 pressure injury
full thickness skin and tissue loss in which the bas of the injury is covered in slough, escherichia or both
unshakeable pressure injury
are losses in the normal function of sensory reception and perception, such as vision or hearing impairment
sensory deficits
is the result of inadequate sensory stimuli
sensory deprivation
occurs when clients recieve multiple sensory stimuli and cannot disregard or filter out some stimuli
sensory overload
