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Adult Care 1 > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

risk factors for sepsis

A

immunocompromised, CLABSI, open wounds, malnutrition, invasive procedures, cancer, older than 80, alcoholism, diabetes mellitus, transplants, hepatitis, HIV/AIDS, GI ischemia, Hepatitis, transplant recipient, CKD, infection with resistant oraganisms, mucous membrane fissures in prolonged contact with bloody/ drainage soaked packing

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2
Q

stages of sepsis

A

SIRS, Sepsis, Severe Sepsis, Septic Shock, MODS

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3
Q

s/s of infection and sepsis

A

SIRS and confirmed infection
SIRS=2/4 criteria
body temp >100.5 or <96.8
HR>90
RR>20/PaCO2<32
WBC >12,000 or <4,000 or >10% immature bands
Infection:
fever
tachycardia
pain
swelling
warmth
redness
inc WBC

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4
Q

labs to assess for sepsis

A

sepsis labs: increased WBC, Decreased PLTs and Clotting factors, increased lactate, increased procalcitonin, BUN/creatinine, ABG, H&H, blood cultures, ALT, AST

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5
Q

labs to assess for infection progress

A

CRP(C-reactive protein), ESR (erythrocyte sedimentation rate) to track inflammation(is there a downtrend?), blood cultures, and labs listed for sepsis

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6
Q

nursing interventions for sepsis

A

hour-1 bundle
observe for organ dysfunction/worsening of s/s (decreased output, low BP, cyanosis, jaundice, etc)
qSOFA
SOFA

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7
Q

prioritization of nursing interventions for sepsis

A

hour-1 bundle
1. measure Lactate level
2. obtain blood cultures before adminstering antibiotics
3. administer broad-spectrum antibiotics
4. begin rapid adminstration of 30mL/kg crystalloid for hypotension or lactate > 4mmol/L
5. apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure >65 mm Hg

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8
Q

tx of sepsis

A

treat infection/fungal (broad-spectrum first, specific after blood cultures result), treat hypotension with vasopressors, start fluids 30mL/kg

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9
Q

prioritization of tx for sepsis

A

obtain blood cultures and lactate level, begin broad-spectrum abx, start 30mL/kg crystalloid fluid, adjust abx as blood culture sample gets back, monitor for worsening of s/s, monitor VS, and for rxns to abx and fluids.

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10
Q

adrenal function related to sepsis

A

decreased kidney function= toxins not released->furthering inflammation and decreasing perfusion r/t edema–> can indicate/lead to MODS

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11
Q

blood glucose levels related to sepsis

A

high glucose levels released from liver due to stress response; the more severe the response, the higher the glucose level

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12
Q

expected outcomes to sepsis tx

A

improvement in BP, return of WBC counts, increased O2 sat, decreased lactate level, increased perfusion, lack of edema, decreased procalcitonin

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13
Q

what has the highest risk of death over sepsis alone?

A

septic shock

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14
Q

DIC

A

disseminated intravascular coagulation

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15
Q

Disseminated intravascular coagulation; patho

A

microthrombi formed where not needed widespread; this consumes AVAILABLE PLTs and clotting factors and leads to hypoxia–> metabolic acidosis and organ dysfunction(inc hypoxia= inc metabolites-toxic-which amplifies inflammation and repeats poor gas exchange and perfusion)

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16
Q

discharge teaching for a pt at risk for sepsis

A

s/s of sepsis:
s/s of infection:

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17
Q

identify pt at risk for CV disease

A

male, over 40/45,smoker, alcohol, family hx, obese, sedentary lifestyle, african american, high cholesterol diet, uncontrolled HTN, uncontrolled stress

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18
Q

Modifiable risk factors

A

lifestyle, diet, exercise, smoking, drinking alcohol

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19
Q

non-modifiable risk factors

A

age, gender, ethinicity, family hx

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20
Q

NSR

A

normal sinus rhythm

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21
Q

describe normal sinus rhythm

A

impulse intiated by SA node
reg rhythm
rate 60-100bpm
normal P wave in lead
P wave before each QRS
normal PR, QRS, and QT intervals

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22
Q

sinus bradycardia

A

impulse initiated in SA node
sinus rhythm w/ rate <60
normal p wave
p wave before each QRS

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23
Q

causes for sinus bradycardia

A

vagal, drugs, ischemia, disease of nodes, ICP, hypoxemia, athletes(normal)

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24
Q

s/s of sinus bradycardia

A

can be asymptomatic
OR
confusion, SOB, CP, diaphoresis, syncope, lightheadedness, hypotension

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25
sinus tachycardia
sinus rhythm with rate 100-150 normal P wave p wave before every QRS
26
what does P wave represent
atrial depolarization
27
what does QRS complex represent?
ventricular depolarization
28
what does QT interval represent?
measures the complete ventricular cucles (depolarization AND repolarization)
29
what does T wave represent?
ventricular repolarization
30
normal values for P wave
0.12-0.2
31
normal values for QRS complex
0.06-0.10 seconds (longer=slower)
32
normal values for PR interval
0.12-0.20 seconds
33
normal values for QT interval
<0.44 seconds
34
how do you determine HR on an ECG strip?
find the tick marks, make sure strip is 6 seconds long. count the QRS complexes and multiply it by 10 (or count QRS in 30 boxes and multiply by 10)
35
how may seconds is one single box on an ECG strip?
0.04 seconds per small box
36
how many seconds is 5 boxes on an ECG strip
0.2 seconds for 5 boxes
37
what does amplitude measure on an ECG?
force of contraction
38
how is Time measured on an ECG strip?
horizontally
39
nursing interventions for sinus bradycardia
-monitor VS, monitor for confusion, SOB, CP, diaphoresis, syncope, lightheadedness, hypotension -give fluids for hypotension -anticipate orders for atropine or external pacing
40
nursing interventions for sinus tachycardia
assess for s/s: confusion, hypotension, lightheadedness, delay cap-refill, anxiety monitor VS anticipate medications
41
impact on beta-blockers on the heart
lower HR and BP
42
Risk factors for DVT/PE
endothelial injury, stasis of blood flow, hypercoagulable state (virchow's triad)
43
Virchow's Triad
endothelial injury, stasis of blood flow, hypercoagulable state
44
what falls under "endothelial injury"
part of Virchow's triad for VTE risk factores: surgery- Hip, knee, prostate trauma athersclerosis smoking catheter
45
what falls under the "hypercoagulable state"?
part of Virchow's triad for VTE risk factors: -malignancy -congenital coagulation defect -thrombophilia -oral contraceptives -inflammatory bowel disease
46
what falls under the "stasis of blood flow"?
part of virchow's triad for VTE risk factors: -immobility -atiral fibrillation -venous insufficiency -venous obstruction -Heart failure
47
diagnostics for DVT/PE
D-Dimer lab- tells if there is a clot that is breaking and floating Venous Duplex Ultrasound- preferred method to dx DVT
48
non-surgical interventions for DVT/PE
early ambulation is the most important! -SCDs -ROM exercises -TEDs -elevation -adequate hydration -IS use -coughing -deep breathing -turning while in bed
49
pt education about tx and prevention of DVT/PE
-prevent by walking frequently after procedures, perform gas pedal pumps and ROM in bed, wear compression stockings, maintain adequate hydration.coughing and deep breathing -Rx for clot busters and anticoagulants may be given- enoxaparin/lovenox injection instructions or NOAC (novel oral anticoagulants) -surgical:thrombectomy-remove clot by catheter aspiration suction mechanical thrombectomy- blood clot is broken up into small pieces and removed
50
warfarin pt education
-vitamin K is the antidote- keep diet consistent, do not increase or decrease vitamin K consumption once therapeutic level of warfarin prescribed (leafy greens) -s/s bleeding and prevention -takes 3-4 days to be effective -must have INR monitored as ordered (1.5-2) -avoid prolonged sitting and crossing legs -avoid smoking -report abd pain -pregnancy category X -s/s hepatitis: jaundice, abd pain, nausea,etc.
51
ABG interpretation
pH level: 7.35-7.45 (acidosis or alkalosis) PaCO2(respiratory):45-35 HCO3(bicarb;metabolic):22-26
52
pt prep for Chest X-RAY
education, no prep
53
Pt prep for thoracentesis
explain procedure and informed consent supplies pt position upright leaning on table educate to remain absolutely still VS
54
pt prep for bronchoscopy
-consent -complete labs and diagostics needed -NPO 4-8 hrs before -remove dentures and oral prosthetics -admin meds and topical anesthetics
55
pt prep for pulmonary function test
explain why tests are given: assess lung capacity and volumes, screen for respiratory complications and compare baseline overtime to others -no smoking 6-8 hrs before -no bronchodilator 4-6 hrs before
56
pt education for chest x-ray
used to monitor chest tubes insertion/placement daily assess pulmonary issues, tubes,lines, evaluate condition of pneumothorax, pneumonia, abcess
57
pt prep for thoracentesis
local anesthetic, positioning, education, support, stay still, sterile procedure, collect specimen for tests and biopsies
58
pt education for bronchoscopy
used to assess lung cancer, gather culture and sensitivity (what is in lungs and how it can be treated), remove foreign bodies -NPO 4-8 hrs begore -local anesthetic -level of monitoring
59
pt education for pulmonaryfunction test
no smoking 6-8 hours before NPO 4-8 hours before used to screen for disease, lung dysfunction, potential complications for surgeries and anesthesia instructions for performing test
60
indications for chest x-ray
pulmonary issues, tubes, lines, pneumonia, TB, abcess,pneumothorax
61
indications for thoracentesis
discomfort due to fluid in pleural space-->needs removal, air built up in pleural space, instill medications into pleural space, obtain biopsy/samples from pleural space
62
indications for bronchoscopy
view airway structures and obtain tissue samples to DX and manage pulmonary diseases (lung cancer) remove foreign bodies culture and sensitivity
63
indications for pulmonary function tests
need a baseline to compare to other tests to view progress in pulmonary disease; monitor lung function
64
nursing implications and post-procedure care for chest x-ray
if pt has diminished or absent breath sounds->pneumo? hx of pulm disease or untreated infection? -make pt comfortable and advocate
65
nursing implications and post procedure care for thoracentesis
client complains of SOB, CP, diaphoresis, labored breathing, asymmetrical chest expansion, CXR shows collapsed lung or excess fluid -dressing apply, pt comfortable, monitor VS and resp status assess and look for s/s pnemo -chest XRAY/iamging after -turn, cough, deep breathing
66
nursing implications and post procedure care for bronchoscopy
s/s or hx of lung disease, removal of foreign bodies vital signs q15 min for 2 hrs monitor VS and sedation level did gag reflex return?->meds after pain control
67
nursing implications and post procedure care for pulmonary function test
screen for surgical complications, assess lung function, compare results to evaluate interventions and manage chronic pulm disease -answer questions -monitor resp status -turn, deep breath, cough -IS monitor VS
68
assessment findings for pneumothorax
-decreased/absent breath sounds on affected side -asymmetrical chest expansion -anxiety -diaphoresis -tachycardia -tachypnea -resp distress -Resp failure -distended neck veins -hemodynamic instability tension pneumothorax: tracheal deviation towards unaffected side, cyanotic, resp distress, absent breath sounds on affected side -hypotension -CP -hyperresonance on percussion
69
assessment findings for hemothorax
decreased or absent breath sounds on affected side, hypotension, poor gas exchange, poor perfusion (slow cap refill), chest pain, SOB, possible asymmetrical chest expansion,possible trachea deviation, dullness on percussion
70
assessment findings for pleural effusion
decreased/absent breath sounds on affected side, dullness on percussion, low SpO2, slow cap refill, SOB, tachypnea, tachycardia
71
assessment findings of flail chest
chest pain, paradoxical movement, Dyspnea, tachycardia, tachypnea,hypotension, 2 or more adjacent rib fractures in a couple places
72
assessment findings for pulmonary contusion
Crackles, decreased breath sounds, wheezes over affected area. Bruising over injury, dry cough, tachycardia, tachypnea, dullness to percussion
73
diagnostics for pneumothorax
chest xray, ABG, resp assessment
74
diagnostics for hemothorax
chest XRAY, chest CT, CBC, resp assessment
75
diagnostics for pleural effusion
chest xray, resp assessment
76
diagnostics for flail chest
chest Xray resp assessment
77
diagnostics for pulmonary contusion
chest CT, resp assessment
78
treatment for pneumothorax
needle aspiration, thoracentesis (emergent for tension) chest tube
79
tx for hemothorax
thoracentesis, needle aspiration or chest tube
80
tx for pleural effusion
chest tubes, needle aspiration
81
tx for flail chest
pain management, promote lung expansion
82
tx for pulmonary contusion
pain management, splinting chest with positioning, coughing and deep breathing exercises.
83
nursing care for pneumothorax
Assess lung sounds, prepare for chest tube insertion, maintenance of water levels for water sealed CDU, keep dressing occlusive, care for dry suction CDU, assess for leaks and kinks, TCDB
84
nursing care for hemothorax
Assess lung sounds, prepare for chest tube insertion, maintenance of water levels for water sealed CDU, keep dressing occlusive, care for dry suction CDU, assess for leaks and kinks, TCDB, monitor drainage and if more than expected per hour
85
nursing care for pleural effusion
Blood cultures before abx, education about chest tube insertion and prepare, maintenance of chest tube, VS, education and prep for Thoracentesis
86
nursing care of flail chest
Assess for dyspnea, paradoxical chest movement, cyanosis, tachycardia,and hypotension. Stabilize by positive pressure ventilation. Maintain airway, oxygen PRN, education/prep for x ray, pain control
87
nursing care for pulmonary contusion
Teach how to splint, TCDB, how to use IS, ambulate
88
pt education for pneumothorax
Hygiene and chest tube maintenance, things to report, complications, procedure for if chest tube dislodged/falls out, valsalva maneuver
89
pt education for hemothorax
Hygiene and chest tube maintenance, things to report, complications, procedure for if chest tube dislodged/falls out, valsalva maneuver
90
pt education for pleural effusion
91
pt education for pulmonary contusion
92
medications for pneumothorax
93
medications for hemothorax
94
medications for pleural effusion
95
medications for flail chest
96
medications for pulmonary contusion
97
complications of pneumothorax
98
complications of hemothorax
99
complications for pleural effusion
100
complications for flail chest
101
complications for pulmonary contusion
102
prioritization of care for pneumothorax
103
prioritization of care for hemothorax
104
prioritization of care for pleural effusion
105
prioritization of care for flail chest
106
prioritization of care for pulmonary contusion
107
safety considerations for penumothorax
108
safety considerations for tension pneumothorax
109
safety considerations for hemothorax
110
safety considerations for pleural effusions
111
safety considerations for flail chest
112
safety considerations for pulmonary contusion
113
assessment findings for tension pneumothorax
114
diagnostics for tension pneumothorax
115
tx for tension pneumothorax
116
nursing care for tension pneumothorax
117
pt education for a tension pneumothorax
118
medications for tension pneumothorax
119
complications for tension pnuemothorax
120
prioritization of care for tension pneumothorax
121
safety considerations for tension pneumothorax
122
prioritization of assessment and care following cheset trauma
123
atelectasis
collapse of alveoli
124
prevention of atelectasis
incentive spirometer use, coughing and deep breathing exercises
125
tx for atelectasis
thoracentesis
126
purpose for NIPPV
benefit of oxygenation and ventilation improvement without intubating
127
NIPPV
non-invasive positive pressure airway
128
purpose for CPAP
continuous pressure to keep airway open and patent- improve oxygenation
129
purpose for BiPAP
bi-level intermittent inspiratory and expiratory pressures to keep airway open, patent, and improve ventilation
130
Purpose of PEEP
131
NIPPV devices are used for pts with....
obstructive sleep apnea
132
CPAP devices are used for pts with
sleep apnea HF
133
BiPAP devices are used for pts with...
COPD HF
134
PEEP devices are used for pts with...
135
prep for chest tube insertion
clean room, OR preop checklist, VS (baseline), pt education, supplies, premedicate as ordered
136
indications for chest tube insertion
pneumothorax, hemothorax, pleural effusion
137
assessment of a pt with a chest tube
-insertion site: s/s infection? -appropriate dressings -pain level? -kinks/occulsions of tubing? -suction control chamber water level appropriate? -water seal tidaling? -water seal bubbling gently or aggressively(leak?)(on?) -collection chamber full? -CDU need to be changed? -collection chamber marked hourly? -dry/wet suction? -suction levels appropriate?
138
troubleshooting a chest tube
cannot clamp for long, clamp and unclap briefly to check for leaks kinks/occlusions in tube effect suction and pressures suction control at marked line? tidaling present in water seal chamber? is there gentle or aggressive bubbling (on vs leak in system)
139
proper function of chambers of chest drainage system
collection chamber: collects fluid/air from pt pleural space water seal chamber: prevents air from traveling back into pt pleural space suction control chamber: controls suction based on level water (wet suction) or dial (dry suction), keep water at ordered level
140
complications of chest tubes

Adult Care 1 (6 decks)

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