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Nursing-Sem 1 > Foundations Exam 1 > Flashcards

Foundations Exam 1 Flashcards

1
Q

infection

A

invasion of a susceptible host by pathogens or microorganisms, resulting in disease

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2
Q

colonization

A

occurs when microorganism invades host but does not cause infection

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3
Q

patients in healthcare settings are at increased risk for acquiring infection because…

A

lower resistance to pathogens, increased exposure, invasive procedures, resistance

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4
Q

symptomatic

A

infection accompanied by clinical symptoms

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5
Q

asymptomatic

A

infection without clinical signs/symptoms

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6
Q

most important technique used in preventing and controlling the transmission of infection

A

hand hygiene

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7
Q

the CDC now recommends what as an alternative to hand washing?

A

alcohol-based waterless antiseptics (unless hands are visibly soiled)

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8
Q

Explain the chain of infection.

A

Host > Infectious agent > Reservoir > Portal of exit > mode of transmission > portal of entry > repeat.

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9
Q

Susceptibility to an infectious agent depends on…

A

An individual’s degree of resistance to pathogens

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10
Q

Reservoir

A

A place where microorganisms survive, multiply, and await transfer to a susceptible host

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11
Q

Exit portal

A

a source of exit from the reservoir

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12
Q

examples of exit portals

A

skin wounds, respiratory tract, urinary tract, blood, GI tract

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13
Q

immunocompromised

A

having an impaired immune system

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14
Q

virulence

A

the ability to produce disease

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15
Q

aerobic bacteria

A

require oxygen for survival and for enough multiplication to cause disease

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16
Q

anaerobic bacteria

A

thrive on little or no free oxygen

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17
Q

bacteriostasis

A

prevention of growth and reproduction of bacteria

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18
Q

bactericidal

A

destructive to bacteria

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19
Q

Four stages of the infectious process

A

incubation period, prodromal stage, illness stage, convalescence stage

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20
Q

incubation period

A

time between pathogen entry and first symptoms. patient contagious, but don’t know it (dangerous stage).

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21
Q

prodromal stage

A

time from development of nonspecific signs and symptoms to development of more specific signs and symptoms

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22
Q

illness stage

A

time when patient manifests signs and symptoms specific to the type of infection

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23
Q

convalescence

A

time when acute symptoms disappear

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24
Q

what precautions do you take when an infection becomes localized?

A

standard precautions, PPE, and hand hygiene to prevent spread to other body areas

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25
Q

what does PPE consist of?

A

gown, mask, goggle, gloves

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26
Q

Explain difference between localized and systemic infection.

A

Localized affects one body area, systemic affects entire body and can be fatal if undetected/untreated

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27
Q

normal flora

A

microorganisms that reside in the body

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28
Q

where are normal flora located?

A

skin, saliva, oral mucosa, intestinal walls

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29
Q

body organ defense mechanisms

A

A number of body organ systems have unique defenses against infection. For example, the airways are lined with moist mucous membranes and cilia, which rhythmically beat to move mucus or cellular debris up to the pharynx to be expelled through swallowing

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30
Q

how do normal flora help the body resist infections?

A

it helps by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganism

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31
Q

body defenses against infection

A

normal flora, body system defenses, inflammation

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32
Q

inflammatory response

A

protective cellular and vascular reaction that helps neutralize pathogens and repair body cells

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33
Q

how does inflammation help the cells in response to injury or infection?

A

it delivers fluid, blood products (i.e. platelets, WBCs), and nutrients to injured areas. neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues

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34
Q

the accumulation of fluid appears as…

A

edema (localized swelling)

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35
Q

signs and symptoms of infection

A

usually include fever, leukocytosis, malaise, anorexia, nausea, vomiting, and lymph node enlargement

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36
Q

leukocytosis

A

increase in circulating WBCs in response to WBCs leaving the blood stream.

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37
Q

phagocytosis

A

the process of destroying and absorbing bacteria

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38
Q

inflammatory exudate

A

the accumulation of fluid, dead cells, and WBCs that forms at the site of infection

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39
Q

what carries inflammatory exudate away (usually)?

A

lymph system

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40
Q

serous exudate (color)

A

yellowish clear color

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41
Q

serosanguinous exudate (color)

A

pink, thinner consistency than sanguinous

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42
Q

sanguinous exudate (color)

A

red, bloody, thicker than serosanguinouso

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43
Q

purulent exudate (describe)

A

thick, white-yellow-green-tan colors, odorous. contains WBCs and bacteria

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44
Q

if inflammation is chronic, normal tissue will be replaced by what?

A

granulation tissue, which is not as strong and may leave a scar

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45
Q

signs of inflammation?

A

redness, heat, swelling, sometimes pain.

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46
Q

signs of inflammation and localized infection are…

A

identical

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47
Q

HAIs (healthcare associated/acquired infections)

A

result from the delivery of healthcare in a healthcare setting. occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities

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48
Q

What increases risk for HAIs?

A

HANDS!, elderly, multiple illnesses, poor nourishment, low resistance to infection, invasive procedures, medical therapies, long hospitalizations, and increased contact with HC personnel.

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49
Q

ways to prevent HAIs

A

Meticulous hand hygiene practices, use of chlorhexidine washes, and other advances in intensive care unit (ICU) infection prevention

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50
Q

HAIs and cost

A

HAIs sig. increase costs. Insurance won’t cover cost of treating certain HAIs like UTIs with Foley catheters (hospital responsible for infection, so responsible for $ for tx)

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51
Q

biggest risk factor for HAIs

A

contact with hc personnel hands

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52
Q

major sites for HAI infections

A

traumatic or surgical wounds, respiratory and urinary tracts

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53
Q

asepsis

A

absence of pathogenic microorganisms

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54
Q

aseptic technique

A

practices/procedures that help reduce the risk for infection

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55
Q

medical asepsis

A

aka clean technique. includes procedures for reducing number of organisms present and preventing transfer of organisms

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56
Q

surgical asepsis

A

aka sterile technique. isolates the operative area from unsterile environment to prevent contamination of open wounds or maintain sterile field for surgery.

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57
Q

when do you use soap and water versus hand sani/chlorohexidine?

A

soap and water when hands are visibly soiled or patient has c.diff.

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58
Q

when do you wash hands?

A

when enter/exit room or before/after patient contact, after removing gloves, after using restroom, before eating, throughout day, no artificial nails or nail polish.

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59
Q

standard precautions

A

prevent and control the spread of infection; apply to all blood, body fluids, non intact skin, and mucous membranes. use generic barrier techniques for all patients.

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60
Q

hand hygiene

A

instant alcohol hand sanitizer when providing patient care, washing hands when soiled, performing surgical scrub.

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61
Q

hand washing

A

washing hands with soap and water for 15-20 sec, rinsing under stream of water

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62
Q

when to wear gloves

A

when touching body fluids, membranes

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63
Q

when to wear gowns

A

isolation, incontinence, risk for splashing/coughing fluids

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64
Q

when to wear mask

A

isolation (droplet), risk for splashing/coughing fluids

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65
Q

when to wear eye protection

A

risk for splashing/coughing fluids

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66
Q

disinfection versus sterilization

A

disinfection: eliminates many or all microorganisms from inanimate objects (except bacterial spores)
sterilization: elimination or destruction of all microorganisms including bacterial spores

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67
Q

cough etiquette

A

cover nose/mouth with tissue–promptly dispose of it. place surgical mask on pt if they can tolerate it. hand hygiene when in contact with resp. infection pts. separate >3ft with resp. infection pts. cough into gloved hands unless soiled, then cough into elbow away from pt.

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68
Q

if cough over sterile field

A

not sterile anymore

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69
Q

isolation

A

separation and restriction of movement of patients with contagious infections/diseases

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70
Q

implications of isolation (for patient and staff)

A 
psychological implications: loneliness
isolation environment (neg. pressure rooms, etc), PPE, specimen collection, bagging trash/linen, patient must wear mask for transport (transport limited to essentials)
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71
Q

types of isolation

A

airborne, droplet, contact, protective

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72
Q

airborne precautions

A

protect against:

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73
Q

droplet precautions

A

protect against: bigger droplet (>5 microns) transmitted infections within 3-6 ft. of pt.
require: private room, surgical mask, dedicated equipment

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74
Q

contact isolation

A

protects against: direct contact-transmitted infections

requires: gloves/gowns, special disposal of trash/linen (biohazard), dedicated equipment

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75
Q

protective isolation

A

protects: immunocompromised pts. from outside infections
requires: + airflow room, no fresh/dried flowers or fruit, respiratory mask, gown, gloves

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76
Q

PPE proper sequence for donning and doffing

A

donning: gown, mask, goggles, gloves
doffing: gloves, goggles, gown, mask

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77
Q

who monitors infection rates?

A

Joint Commission, CDC, Center for Medicare reimbursement

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78
Q

What does patient safety in healthcare settings do?

A

reduces incidence of illness/injury, prevents extended LOS, improves functional status, increases patients sense of well-being

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79
Q

a safe environment

A

meets patients physical, psychosocial needs; applies to all places pts receive care, includes pt and provider well-being, reduces risk of injury and transmission of pathogens, maintains sanitation, reduces pollution

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80
Q

largest safety issue for patients

A

medication errors

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81
Q

sentinel events

A

unexpected occurrence involving death or serious physical injury (loss of limb/functions)

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82
Q

nurse’s role in patient safety

A

assessing factors, maintain safe environment, provide patient teaching

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83
Q

factors influencing patient safety

A

age, lifestyle, occupation (exposure), social behavior (risk taking), environment (safety, exposures)

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84
Q

greatest age group @ risk of home accidents that result in severe injury

A

children

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85
Q

risks for school aged children

A

@ risk at home, school, and traveling to/from school

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86
Q

risks to adolescents safety

A

car accidents, suicide, drug/alcohol abuse

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87
Q

adult safety risks

A

mostly lifestyle (drinking, drugs, exercise, diet, work stress/env, domestic violence, car accidents

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88
Q

elderly safety risks

A

falls, car accidents, elder abuse, sensorimotor changes, fire

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89
Q

major cause of injury for those >64 years…

A

falls

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90
Q

risk factors for falls

A

age, hx of falls, impaired balance, altered gait/posture, weakness, medication, walking aids, orthostatic hypotension, slow run time, unfamiliar environment

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91
Q

how do you perform a controlled fall?

A

stand feet apart for support base, extend one leg and let patient slide against it to floor (“break fall” with leg), bend knees and lower patient to floor as they fall

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92
Q

types of restraints

A

physical (wrist ties, vests) and chemical (alters behavior)

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93
Q

negative outcomes of restraints

A

lowers cognitive ability, skin breakdown, contractures, incontinence, depression, delirium, anxiety, aspiration, breathing difficulties

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94
Q

where do you tie restraints?

A

to bed frame, NOT RAILS. always use quick release knot

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95
Q

cardiac effects of immobility

A

increased workload @ heart, orthostatic hypotension, venous stasis, thrombus formation (clotting)

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96
Q

respiratory effects of immobility

A

decreased respiration rate and depth, impaired gas exchange, pooling of secretions

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97
Q

musculoskeletal effects of immobility

A

atrophy, weakness, disuse osteoporosis (increased bone reabsorption), joint contractures

98
Q

metabolic effects of immobility

A

negative nitrogen balance (impedes wound healing), electrolyte/fluid imbalances, altered nutrients/gas exchange

99
Q

GI effects of immobility

A

constipation, decreased appetite

100
Q

GUT effects of immobility

A

urinary stasis, urinary retention, bladder infections, kidney stones, incontinence

101
Q

skin effects of immobility

A

decubitus ulcers (pressure ulcer)

102
Q

psychosocial effects of immobility

A

isolation, depression, negative effects on mood/behavior

103
Q

when not to use gait belts

A

in patients with abdominal or thoracic incisions

104
Q

how often do you change pt positions

A

q2h

105
Q

how do you maintain functional positions for paralyzed/unconscious patients

A

use rolls under hands (towels, etc)

106
Q

how do you prevent foot drop?

A

use foot supports to keep at 90 deg angle

107
Q

safe patient transfer practices

A

elevate or lower bed to appropriate height, LOCK WHEELS, avoid friction on pt skin, smooth motions (yours and pts), use mechanical devices or other personnel when needed

108
Q

moving patients…body mechanics?

A

DONT USE BACK OR TWIST

109
Q

purpose of bathing patient

A

clean and assess skin, stimulate circulation, improve self-image, reduce body odors, promote range of motion

110
Q

risk factors for skin impairment

A

immobility, reduced sensation (Can’t feel pain), nutrition & hydration, excretions/secretions, vascular insufficiency, external devices, altered cognition

111
Q

guidelines for bathing

A

privacy, safety, warmth, independence

112
Q

types of baths

A

complete bed baths, partial bed baths, tub or shower

113
Q

assessment points for oral hygiene

A

frequency, amount of assistance required

114
Q

brushing teeth: precautions for aspiration

A

positioning (lateral with head turned to side), use suction equipment, never put hand in mouth

115
Q

denture care

A

clean as often as natural teeth, personal property–careful!, remove before bed, store in labelled container with cleaner, when cleaning use washcloth in sink to prevent dropping/breaking.

116
Q

concept map

A

visual plan of care, diagram of pt problems, links important ideas together

117
Q

why make concept map?

A

organize data, visualize links/connections between issues, establish priorities, analyze, enable holistic view

118
Q

critical thinking

A

ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care

119
Q

nursing process

A

assessment, diagnosis, planning, implementation, evaluation (cyclical)

120
Q

center of care map

A

patient (age, c/c, mdx/surgical procedure, identifying info, allergies, code status)

121
Q

assessment: 2 steps

A
  1. collection of data

2. interpretation and validation of data

122
Q

assessment

A

deliberate and systematic collection of information

123
Q

how to cluster assessment data

A

patterns, i.e. Gordon’s Functional Health Patterns (11 common patterns of behavior that contribute to health)

124
Q

SBAR stands for…

A

situation, background, assessment, recommendations

125
Q

Gordon’s functional health patterns (11)

A

self-perception, role-relationship, sexuality-reproduction, coping-stress tolerance, value-belief, health perception-health management, nutritional-metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual

126
Q

care map boxes include

A

functional health pattern(s), problem/ndx, supporting data

127
Q

diagnosis phase

A

interpret and validate data, analyze data, organize in to patterns, name them/ndx, prioritize, connect the dots

128
Q

nursing diagnosis (definition)

A

statements that describe a patient’s actual or potential human response to life processes that nurses are qualified and competent to treat
NOT MED DX

129
Q

parts of a ndx

A

problem (human response) and etiology (related to) and mdx (secondary to–don’t have to have this necessarily)

130
Q

nursing dxs describe…

A

deviations from health, presence of risk, enhanced personal growth

131
Q

guidelines for writing ndxs

A

legally advisable terms, no value judgements, not circular (two parts mean same thing), etiology must be stated in terms that are changeable/fixable

132
Q

When prioritizing, what is generally most important?

A

ABCs

133
Q

planning

A

set priorities, identify outcomes, select interventions, write nursing orders, set evaluation criteria

134
Q

goals vs outcomes

A

goals = broad, outcomes = specific and MEASURABLE

135
Q

format for goals/outcomes

A

the patient will (goal) by (time frame) as evidenced by (outcome)

136
Q

components of an outcome statement

A

behavior, measurement, condition, time

137
Q

skin layers

A

(superficial) epidermis > junction > dermis (deeper)

138
Q

functions of skin

A

barrier/protection, sensory input for pain/touch/temp, synthesizes vitamin D, triggers healing response w/ injury

139
Q

basal layer of epidermis

A

stem cells divide and migrate to surface (constant cellular turnover)

140
Q

vascularity of skin layers

A 
epidermis = avascular
dermis = vascular (collagen, nerves, too)
141
Q

pathogenesis of pressure ulcers

A

pressure intensity, tissue ischemia, blanching, pressure duration, skin breakdown, tissue tolerance

142
Q

risk factors for pressure ulcer development

A

impaired sensory perception, impaired mobility, altered LOC, shear, friction, moisture

143
Q

shear

A

force exerted parallel to skin (gravity + resistance)

144
Q

friction

A

two surfaces sliding across one another

145
Q

stage 1 pressure ulcer

A

intact skin with nonblanchable redness

146
Q

stage 2 pressure ulcer

A

partial-thickness tissue loss involving the epidermis, dermis, or both

147
Q

stage 3 pressure ulcer

A

full tissue thickness loss with fat visible (involves subcutaneous tissues)

148
Q

stage 4 pressure ulcer

A

full-thickness tissue loss with bone, muscle, or tendon visible

149
Q

purple

A

deep tissue injury, can’t classify

150
Q

red area, but blanch-able

A

pre-ulcer area, @ risk area, move pt off pressure area to relieve.

151
Q

wound classification

A

by thickness (partial or full)

152
Q

wound color classifications:

A

black: eschar, necrotic tissue
white/yellow/tan: slough, required MD to remove
red: granulation tissue (new vessels, indicative of healing)
mixed-color: more than one of the above

153
Q

primary intention

A

wound healing with approximated edges (surgical incision, closed for healing)

154
Q

secondary intention

A

open edges and heals from the inside out. takes longer to heal. edges not together. scars.

155
Q

wound repair

A

partial thickness: inflammation, epithelial proliferation, migration to surface/ reestablishment
full thickness: hemostasis (clotting), inflammatory, proliferation, maturation

156
Q

complications of wound healing

A

hemorrhage, hematoma, infection, dehiscence, evisceration

157
Q

osteomyelitis

A

when bone becomes infected. requires 6 mo. of abx to treat.

158
Q

most common HAIs

A

wound infections

159
Q

dehiscence

A

wound comes back open

160
Q

evisceration

A

organs protrude through wound

161
Q

how to predict pressure ulcers?

A

Braden scale assessment

162
Q

how to prevent pressure ulcers?

A

turn patient, risk assessment, thorough skin assessments, nutrition, hygiene, specialty beds/equipment

163
Q

reimbursement related to pressure ulcers

A

CMS won’t reimburse for care related to Stage 3 or 4 pressure ulcers obtained in care facilities

164
Q

most common sites for pressure ulcers/breakdown

A

bony prominences, areas that get most pressure

165
Q

prevention of pressure ulcers

A

mobility, predictive measures (braden scale, ID risk), nutrition, hydration/fluids/weight, pain

166
Q

what to chart about wound?

A

location, size, shape, type (partial/full), color, drainage & exudate characteristics, if has drain, type of closure, etc.

167
Q

wound assessment includes…

A

predictive measures, mobility level, major risk areas/ pressure points, nutritional status, fluids, setting (Emergency v. stable), appearance, character of drainage, presence of drains, type of closure, palpation findings (temp, texture, etc.), cultures/labs

168
Q

ndx related to impaired skin integrity/wounds

A

risk for infection, impaired nutrition, actor/chronic pain, impaired mobility, impaired skin integrity (or @ risk for), etc.

169
Q

first aid for wounds includes…

A

hemostasis (control bleeding), clean, protect

170
Q

purpose of wound dressings…

A

protect from microorganisms, aid in clotting, promotes healing (absorb drainage), derides wound (healing), supports wound site, insulates wound, keeps moist

171
Q

types of wound dressings…

A

gauze, transparent film, hydrocolloid, hydrogel, foam, composite

172
Q

packing wound is what type of therapy?

A

negative pressure therapy (pulls wound edges closer together)

173
Q

way to clean contaminated sites…

A

from least to most contaminated (i.e. center of wound towards the edges) in circular motion. when irrigating, let flow from least to most contaminated areas.

174
Q

what helps with drainage evacuation of wounds?

A

hemovac (accordion) or woundvacs (sponge). Helps remove and collect drainage.

175
Q

when to use heat vs. ice

A

ice: usually for acute problems (not surgery though bc increases blood flow)
heat: for chronic problems

176
Q

sitz bath

A

container that goes in toilet with warm/cold water depending. Often for hernia patients. facilitates cleaning of wounds in perineal area.

177
Q

safety with wound care

A

positioning to prevent ulcers, falling off bed; plastic bag within reach for dressing disposal, extra gloves in case soiled, use PPE with irrigation, if using elastic bandage, check SCTM/CSMs below bandage.

178
Q

ECF

A

extracellular fluid. 1/3 body fluid. made up of intravascular (plasma), interstitial fluid, and transcellular fluid (sec by epithelial cells-pleural spaces).

179
Q

ICF

A

intracellular fluid. 2/3 body fluid.

180
Q

cations in body fluids

A

K+, Na+, Mg 2+, Ca 2+

181
Q

anions in body fluids

A

Cl-, HCO3-

182
Q

osmolality

A

particles of solute per kg of water. used to measure fluid concentration.

183
Q

effective concentration is determined by…

A

particles that cannot easily cross the cell membrane

184
Q

isotonic

A

same tonicity as normal blood

185
Q

hypotonic

A

more dilute than normal blood

186
Q

hypertonic

A

more concentrated than normal blood

187
Q

cells in hypotonic, hypertonic solutions do what?

A 
hypotonic = swell
hypertonic = shrink
188
Q

osmosis

A

movement of fluids between extracellular and intracellular

189
Q

filtration

A

movement of fluids between vascular and interstitial

190
Q

osmotic pressure

A

pressure solutes exert in bloodstream

191
Q

oncotic pressure

A

pressure albumin exerts

192
Q

hydrostatic pressure

A

pressure water exerts. responsible for keeping vessels open, filtration.

193
Q

average fluid intake for an adult/day

A

2300 ml

194
Q

fluid homeostasis controlled @

A

hypothalamus

195
Q

3 components of fluid homeostasis

A

fluid intake/absorption, distribution, and excretion

196
Q

fluid output occurs @

A

skin, lungs, GI tract, kidneys

197
Q

ADH functions

A

retain water, constrict blood vessels, increase BP

198
Q

RAAS

A

detect low BP > kidneys release renin > stimulates release of angiotensin I (lung) > converted to angiotensin II (vasoconstrictor) > stimulates adrenal cortex to release aldosterone > stimulates reabsorption of water and sodium @ kidneys > inc. BP

199
Q

osmoreceptor-mediated thirst

A

detect osmolality increase (more solutes concentrated in blood) and stimulates you to drink

200
Q

baroreceptor-mediated thirst

A

detects low BP and stimulates you to drink

201
Q

ANP

A

atrial natiuretic peptide. when excess fluid, cells @ atria stretch, release ANP which inhibits ADH and counters the effects of aldosterone (increases loss of sodium and water @ urine). Weak hormone.

202
Q

ECV deficit

A

present when there is too little isotonic fluid in the extracellular compartment.

203
Q

ECV excess

A

too much isotonic fluid in extracellular compartment

204
Q

osmolality imbalances

A

hypernatremia (too much salt) and hyponatremia (too little salt)

205
Q

s/s hypernatremia

A

cognitive dysfunction as brain cells shrivel

206
Q

s/s hypernatremia

A

cognitive dysfunction as brain cells swell. cerebral edema. Increase ICP. Dysfunction and damage.

207
Q

clinical dehydration

A

ECV deficit and hypernatremia at the same time (loss of extracellular fluid and too much salt/body fluids too concentrated).

208
Q

common causes of dehydration

A

fluid loss, fever, not enough fluid intake

209
Q

plasma vs cell concentrations of K+, Ca2+, Mg2+, and phosphate

A

higher concentrations in the cell, lower concentrations in plasma. need different concentrations to polarize/depolarize for nerve function.

210
Q

electrolyte output via…

A

sweat, urine, feces (normal) or vomiting, draining, fistulas

211
Q

fluid volume deficit causes

A

hemorrhage, vomiting, diarrhea, burns, diuretics, fever, impaired thirst

212
Q

clinical manifestations of fluid volume deficits

A

weight loss, thirst, orthostatic changes in BP/pulse, weak/rapid pulse, decreased urine output, dry membranes, tenting @ skin.

213
Q

fluid volume deficit tx/interventions

A

diet therapy, oral rehydration therapy, IV therapy, electrolyte replacement

214
Q

causes of fluid volume excess

A

CHF, renal failure, inc. sodium intake, IV therapy, corticosteroids

215
Q

clinical manifestations of excess fluid volume

A

inc. BP, bounding pulse, venous distension, pulmonary edema (SOB, crackles)

216
Q

tx excess fluid volume

A

diuretics (if no renal failure), dec./restrict sodium intake, I/O mgmt, weight

217
Q

hypokalemia

A

not enough potassium. cells don’t polarize/depolarize well (excitability), nerve stimuli don’t work as well

218
Q

hypokalemia causes

A

diuretics, shift into cells, digitalis (med), water intoxication, steroids, diarrhea, vomiting

219
Q

hypokalemia s/s

A

Peak Q waves, alkalosis, shallow respirations, confusion, weakness, arrhythmias, lethargy, dec. interstitial motility, thready pulse

220
Q

hypokalemia tx/intv.

A

encourage potassium-rich foods, K+ replacement, stop diuretics, monitor labs, treat underlying cause

221
Q

hyperkalemia

A

too much K+ causes increased excitability of cells

222
Q

hyperkalemia causes

A

too much K+ intake, renal failure, shift of K+ out of cell, K+ sparing diuretics

223
Q

hyperkalemia s/s

A

peak T waves, cramps, weakness, paralysis, drowsiness, dec. BP, EKG changes, abdominal cramping, diarrhea, oliguria (v. concentrated urine)

224
Q

hyperkalemia tx/intv.

A

need to restore balance, stop K+ administration, increase K+ excretion (Lasix, Kayexalate), infuse glucose and insulin, monitor cardiac function

225
Q

hyponatremia

A

too little salt

226
Q

hyponatremia causes

A

excessive sweating, wound drainage, NPO, CHF, low salt diet, renal disease, diuretics

227
Q

hyponatremia s/s

A

skeletal muscle weakness, personality changes, shallow respirations, cardiac changes, explosive diarrhea, inc. urine output

228
Q

hyponatremia tx/interv.

A

IV therapy saline (2-3% if severe), mannitol (osmotic diuretic), increase sodium intake, restrict fluid intake

229
Q

hypernatremia

A

too much salt

230
Q

hypernatremia causes

A

too much intake, diarrhea, dehydration, fever, hyperventilation, renal failure

231
Q

hypernatremia s/s

A

muscle twitches, contractions, poor deep tendon reflexes, pulmonary edema, low cardiac output/pulse/BP, dry/flaky skin, edema, low urine output

232
Q

hypernatremia tx/interv.

A

administer IV fluids (NSS or NaCl) and diet therapy (ensure water intake)

233
Q

hypocalcemia s/s

A

muscle spasms/twitches (chvostek & trousseau’s signs), resp failure/tetany, diarrhea,

234
Q

hypercalcemia s/s

A

disorientation, constipation, inc cardiac (HR, BP, bounding), inc. urine output

235
Q

how do you monitor acid-base balance?

A

arterial blood gasses

236
Q

normal blood pH

A

7.35-7.45

237
Q

acid base imbalances include…

A

respiratory and metabolic acidosis/alkalosis

238
Q

blood transfusion reactions

A

allergic (itching, swelling, rash/hives), febrile (fever, chills, anxiety), hemolytic (tachycardia, dec. BP, headache, chills, fever)

239
Q

what to do with blood reaction?

A

STOP.

240
Q

intervention for acid-base and electrolyte imbalances…

A

ABGs, support medical therapies to reduce imbalance, patient safety.

Nursing-Sem 1 (13 decks)

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