EXAM 1 Flashcards
1
Q
when should a pt’s vitals be monitored and why is it important
A
before, during and after treatment
it is an important parameter in progressing the pt
2
Q
what are the assessments for physiological stability
A
HR
oxygen saturation
respiratory rate
blood pressure
body temp
3
Q
what is HR
A
indirect measure of contraction of the left ventricle of the heart
4
Q
what are the normal HR values for adults
A
60-100 bpm
5
Q
what are the normal HR values for newborns
A
100-150 bpm
6
Q
what are the normal HR values for children from 1 to 10 yrs old
A
70-130 bpm
7
Q
what are some factors that can affect HR
A
meds
PA
medical conditions
stress
dehydration
8
Q
where can we asses HR
A
brachial
radial
carotid
temporal
femoral
popliteal
dorsal pedal
9
Q
what are the normal ranges for oxygen saturation
A
95-100%
10
Q
what is hypoxemia
A
SpO2 is less than 90
11
Q
what are some factors that affect oxygen saturation
A
emotional
medical conditions
PA
age
environment
12
Q
how do we assess oxygen saturation
A
pulse ox monitor
13
Q
how do you manually measure respiration
A
one respiration= one inspiration and one expiration
14
Q
what are the normal respiration values for adults
A
12-20 at rest
15
Q
what are the normal respiration values for infants
A
30-50 at rest
16
Q
what are the factors that can affect respiratory rates
A
emotional
PA
age
medical conditions
environment
17
Q
how do we assess respiratory rate
A
count manually
look at- rate, depth, rhythm, character
18
Q
what is systolic BP
A
contraction of left ventricle
19
Q
what is diastolic BP
A
rest period of the heart
20
Q
what are some factors that may affect BP
A
emotional
PA
age
medical conditions
meds
diet
21
Q
how do we assess BP
A
support pts arm at level of heart
pt can be standing, sitting, supine or exercising
22
Q
why take BP in different positions
A
treatment tolerance depending on situation
23
Q
What are the normal BP values
A
120/80 mmHg
24
Q
What is the range for BP that is considered high normal
A
130-139/85-89 mmHg
25
What are the ranges for prehypertension
120-139/85-89 mmHg
26
What is the range for stage 1 BP
140-159/90-99 mmHg
27
What is the range for stage 2 BP
160-179/100-109 mmHg
28
What is the range for hypertensive crisis
>180/>110 mmHg
29
What is orthostatic hypertension and the S&S
Form of low blood pressure that happens when you stand up from sitting, sit up from lying down
S&S- dizziness or lightheaded
30
What are the orthostatic hypotension values
Systolic decrease- drop of 20 mmHg
Diastolic decrease- drop of 10 mmHg
Within 3 minute of positional change
31
How do we objectify pain
Scales and non-verbals
32
What are the odds of healthcare associated infections
1 out of 25
Fourth leading cause of death
33
What is the difference between medical and surgical aseptic techniques
Medical keeps pathogens confined to a specific area, object, or person
Surgical excludes all microorganisms before entering a sterile field
34
What are standard precautions for prevention of infection
Group of infection prevention practices that apply to all patients regardless of diagnosis
Frequent hand washing or rubs
PPE
35
How does transmission based precautions relate to standard precautions
Goes on top of the standard precautions
36
What is transmission based precautions
Designed to protect caregiver from highly transmissible pathogens
37
What is the hand rubbing method
Alcohol based, waterless antiseptic
Most effective when hand washing is not required
Less time, more effective, more accessible, less damaged to skin
38
What is the hand washing method
Preferred method when hands are visibly dirty, soiled, or considered to be contaminated
Bacteria is removed through friction and scrubbing
39
When is the hand washing method required
Entering ICU or operating room
Adding an anti microbial agent makes it antiseptic
Decontamination after treating C diff
Potential contaminants
40
What is a better decontamination of C diff
Hand washing method
41
What are potential contaminants of hand washing
bar soap
sink rims
waterspout
basin
towel dispenser
faucet handle
42
what are isolation precautions
linked to the method by which pathogens are transmitted
specific PPE depending on type of transmission
43
What are the 4 rules of asepsis
Know which items are sterile
Know which items are not sterile
Separate the non sterile from the sterile
If sterile items become contaminated, remedy situation immediately
44
What are the DO NOTS of contaminated garments
DO NOT
touch any area of body with PPE
touch outer surface of gloves with unloved hands
Touch sleeves or front of gown with ungloved hands
wear PPE outside pts room
45
What do you do with contaminated refutable equipment
Place in the appropriate container and return for sterilization
46
What do you do with contaminated disposable equipment
Should be placed in the appropriate containers and discarded according to policies and procedures
47
What is targeted in high level disinfectants
Everything except high numbers of bacterial spores
48
What is targeted with an intermediate level of disinfectant
Most viruses, fungi, vegetative bacteria, TB
49
What is targeted with low level of disinfectant
Most bacteria, some viruses, some fungi
50
What is removed in decontamination
Destroy blood borne pathogens that are no longer capable of transmitting infectious particles
51
Which is stronger disinfectant or decontamination
Decontamination
52
what is the P wave
atrial depolarization
53
what is the QRS wave
ventricular depolarization
54
what is the T wave
ventricular repolarization
55
what is the pathway for the cardiac conduction
SA
AV
Bundle of His
Bundle Branches
Purkinje fibers
56
what do you look for to determine rhythm
look for ventricular (R) and atrial (P) depolarizations
distance between intervals are equal
regular, irregular, irregular regular??
57
what is sinus rhythm
equal distance between identical waves
60-100
58
how do you measure rate
from the start of a bold red line- 300, 150, 100, 75, 60, 50
59
what is atrial fibrillation
continuous rapid firing of multiple atrial follicles
no single impulse depolarizes the atria completely
60
what causes A Fib
MI
CABG surgery
Valvular disease
HTN
Chronic alcoholism
61
what do you see on an ECG for A Fib
no definite P waves
irregular rhythm
continuous chaotic atrial spikes
irregular ventricular rhythm
normal QRS complex
62
what does premature ventricular contraction look like on ECG
early QRS complex
wider bizarre QRS
no P wave
compensatory pause
63
what does 3 or more PVC in a run mean
ventricular tachycardia
64
what is ventricular tachycardia
continuous run of PVC
150-250 bpm
65
whats causes VT
acute MI or ischemia
electrolyte imbalance
medication toxicity
idiopathic
illicit drugs
66
what are the S&S of VT
hypotension
syncope- fainting
67
what does VT look like on an ECG
continuous run of PVC
each QRS is wide
68
what are common lab values
electrolyte panels
metabolic panels
kidney function
liver function
cardiac markers
lipid panel
69
what are the reference values for WBC
5-10 x 10^9/L
70
what is the up trend for WBC
>11 x 10^9/L
infection, leukemia, obesity, inflammation, stress
weakness, fatigue, fever, dizziness
consider therapy timing around early morning (low level) and late afternoon (high peak)
71
what is the down trend for WBC
<4 x 10^9/L leukopenia and neutropenia
viral or bacterial infection, radiation
symptoms based approach to determine appropriateness for PT
72
what are the reference values for platelets
140-400 x k/ul
73
what is the down trend for platelets
<150 k/ul - excessive bleeding can occur
infection, leukemia, radiation/chemo, liver disease
bruising, petechiae, fatigue, jaundice
74
what is the up trend for platelets
>450 k/ul - thrombocytosis
infection, cancer, stress, inflammation
weakness, headache, dizziness, chest pain
75
what are the PT implications for platelets
<10,000 and or 100.5 temp = hold therapy
symptom based when considering activities
is pt a fall risk? = increased risk of hemorrhage
76
what are hemoglobin reference and critical values
men = 14-17.4 g/dl
women = 12-16 g/dl
<5-6 g/dl or >20 g/dl
77
what is the up trend for hemoglobin
CHF, dehydration, COPD, severe burns
dizziness, arrhythmias, TIA symptoms, chest pain
78
what is the down trend for hemoglobin
anemia, blood loss, lupus, kidney disease, stress to bone marrow
decreased endurance, pallor, tachycardia
79
what are the therapy implications for hemoglobin
facility dependent
symptom based
80
what are the hematocrit reference and critical values
men= 42-52%
women = 37-47%
<15-20% or >60%
81
what is the up trend for hematocrit
COPD, burns, CHF, dehydration
fever, HA, dizziness, weakness, fatigue
82
what is the down trend for hematocrit
leukemia, multiple myeloma, pregnancy, cirrhosis, RA
pale skin, HA, dizziness, chest pain, arrhythmias, dyspnea
monitor SpO2
83
what are therapy implications for hematocrit
<25%= essential ADLs only, hold out of bed activities
symptoms based approach
84
what is prothrombin time
evaluates bloods ability to clot
normal 11-13 sec
85
what is partial thromboplastin time
used to determine if heparin/warfarin/etc. (blood thinner) therapy is effective
normal 21-35 sec
86
what is international normalized ratio (INR)
measure how long it takes the blood to clot when an oral anticoagulant is used
PT and PTT can differ depending on lab
normal .8-1.2
increase = risk for bleeding, decrease = risk of clot
87
What is the rate of the sinus rhythm and diagnosis
between 100-150
trachycardia
88
what is the rate of the sinus rhythm and diagnosis
less than 50 bpm
bradycardia
89
what is the rate of this sinus rhythm
75 bpm
90
what is the diagnosis of the following ECG
VT
91
what is the diagnosis of the following ECG
PVC
92
what is the rate for the following sinus rhythm
60 bpm
93
what is the rate for the following rhythm
between 100-75 bpm
94
what is the rate for the following rhythm
less than 50 bpm
95
what is the diagnosis of the ECG
A Fib
96
what is short term positioning
allowing for treatment of different areas
MT, modalities
97
what is long term positioning preventing and promoting
preventing pressure ulcers and contractures
promoting better breathing positions
98
for long term positioning how often do you reposition a pt
every 2 hours to maintain integrity of all 4 movement systems
99
for short term positioning how often do you need to reposition a pt
every 15 minutes
100
why would you need to reposition a pt
poor circulation, fragile skin, decreased sensation, difficulty breathing
101
what is wrong if a pt has prolonged redness of bony prominences
tissue damage
102
what are the general positioning guidelines
explain procedure to pt
maintain neutral spine
always provide a way for pt to have communication
103
what are the areas of greatest pressure in supine
head
sp
inferior angle scapula
elbows
PSIS
sacrum
heels
104
what are the greatest areas of pressure in prone
forehead/lateral ear
acromial process
anterior humeral head
sternum
ASIS
patella
dorsum of foot
105
what are the areas of greatest pressure in sidelying
lateral ear
lateral ribs
lateral acromial process
lateral humeral head
medial or lateral humerus
greater trochanter
medial or lateral knees
medial or lateral ankles
106
what are the greatest areas of pressure in sitting
ischial tuberosity
posterior thighs
sacrum
sp
elbow
107
what can make pts more susceptible to pressure injuries
decreased mobility
fragile skin
incontinence
impaired sensation/circulation
muscle atrophy
friction or shear
108
what is the skin blanching test
when pressed, healthy lighter skin will blanche and quickly return to healthy pink
109
who is more at risk for skin breakdown
people with increased pigmentation
110
if skin does not blanche, what does it indicate
compromised/damaged tissue
111
what do we NOT do with a pt that has a negative skin blanche test
position them on compromised area
112
what increases load
a decrease in surface area
decrease in cushioning
113
how does load relate to time with pressure injuries
increase load + decrease time = injury
decrease load + increase time = injury
114
how do we prevent pressure injuries
limit direct contact with bony landmarks
increase surface area
increase cushioning
decrease load
decrease time
115
what are the most common contractures
flexion contractures
116
who has a increased risk of cervical flexion contractures
pts with swallowing restrictions or breathing dysfunctions, cardiac condition, lung condition
117
what can cause hip/knee flexion contractures
gathched bed
certain neurological conditions
118
who has an increased risk for wrist flexion contractures
neurological diseases, injury, disuse
also accompanied by finger and thumb flexion
119
how do you position a pt with edma
extremities above heart
120
how are positioning devices beneficial
reduce or eliminate load on the tissue
help pt maintain static positioning
121
what pts would we do prone positioning
pulmonary issues
amputees
122
when should we reposition a sitting position
every 10-15 minutes
123
what should we avoid in sitting
sacral sitting
124
what is the risk in high fowlers position
sacral shearing
125
what reason could we use trendelenburg
BP management
pregnancy
126
what reason could we do reverse trendelenberg
spinal cord
127
what are the safety and comfort concerns for supine position
support under knees/lower legs and head
128
what are safety and comfort concerns for prone
support under abdomen/hips- decrease lordosis
pressure off toes
129
what are the safety and comfort concerns for sidelying
support under head
distribute pressure over greater trochanter
support top arm
130
what are the safety and comfort concerns for sitting
back supported
131
what safety and concern should be in all positioning
normal spinal curves
proper airway
132
what are the principles of draping
clean linens
expose areas only being worked on
remove folds/wrinkles
instruct pt
ensure comfort
protect pts clothing
133
what are cultural sensitvities
same gender
hospital gown exposure
can't remove certain clothing items
134
what should we implement for pts with trauma
good communication
informed consent
respect boundaries
active pt involvement
monitoring signs of discomfort
