EXAM ONE Flashcards
(47 cards)
1
Q
clotting
A
complex & multi-step process by which blood forms a protein-based structure (CLOT)
2
Q
what are RISK FACTORS that can cause increased or excessive clotting?
A
- increased IMMOBILITY
- POLYCYTHEMIA; increased # of RBCs
- smoking
3
Q
what can cause DECREASED blood clotting?
A
- chemotherapeutic agents
- corticosteroids
- LIVER CIRRHOSIS
- rare genetic diseases (ex. hemophilia)
4
Q
what diseases can occur with INCREASED and DECREASED CLOTTING?
A
- INCREASED clotting; venous thrombosis
- DECREASED clotting; prolonged bleeding
5
Q
thromboembolism
A
The formation of BLOOD CLOTS within the venous system
- can develop into DVT (deep vein thrombosis) or a PE (pulmonary embolism) **clot breaks off and can travel - blocking blood flow
6
Q
risk factors for THROMBOEMBOLISM
A
- immobility
- surgery
- cancer
- pregnancy
- certain medications
7
Q
what are signs of VENOUS THROMBOSIS/THROMBOLISM?
A
- redness
- pain
- swelling
- warmth
8
Q
how to PREVENT THROMBOSIS?
A
- want to assess and teach patients with decreased clotting
*drink more FLUIDS!
*AMBULATE more often & don’t cross legs!
*stop SMOKING!
*report any signs of thrombosis
- can also use ANTICOAGULANT THERAPY or compression stockings
- DIRECT THROMBIN INHIBITORS
9
Q
definition of COGNITION
A
complex integration of MENTAL PROCESSES and intellectual functioning
- considers REASONING, MEMORY, and PERSONALITY
10
Q
what are the RISK FACTORS for IMPAIRED COGNITION? (9)
A
- ADVANCED age
- BRAIN TRAUMA at any age
- having DISEASE or DISORDER
- TOXIN EXPOSURE
- SUBSTANCE USE
- GENETIC DISORDERS
- DEPRESSION
- use of medications/drugs **OPIOIDS, STEROIDS, anesthesia
- FLUID/ELECTROLYTE IMBALANCES
11
Q
what are some CONSEQUENCES that can occur due to IMPAIRED COGNITION?
A
- loss of memory (either short or long term)
- impaired reasoning
- disorientation / delusions / hallucinations
- disorientation
12
Q
what are the MAIN POST-OP priorities?
A
- Reviewing baseline preoperative assessment
- identifying potential surgical complications
13
Q
respiratory sys - post-op
A
- assessing AIRWAY/proper gas exchange
- does the patient have OXYGEN?
- checking lungs every 4 HOURS for the first 24 HOURS
14
Q
cardiovascular sys - post-op
A
- checking HR & BP
- checking PERIPHERAL VASCULAR ASSESSMENT
15
Q
neurologic sys - post-op
A
- assess LOC and CEREBRAL FXN
- A & O?
- signs of DELIRIUM?
16
Q
GI system - post-op
A
- PONV (postoperative N & V)
- constipation related to anesthesia etc…
17
Q
integumentary sys - post-op
A
- assessing WOUND HEALING
- any DRAINAGE? *sanguineous, serosanguineous, purlent, serous
- impaired wound healing *dehiscence, evisceration
18
Q
what are signs a patient is in pain?
A
- potential VERBAL CUES (pt. is moaning, reporting pain/describing)
- potential NONVERBAL CUES (pt. is grimacing, restlessness, crying)
- potential PHYSIOLOGICAL CUES (increased BP, HR, RR, pupils dilated)
- potential BEHAVIORAL CUES (reduced mobility/appetite/sleep)
19
Q
How do we assess pain in OLDER ADULTS?
A
- assess for any POTENTIAL COGNITIVE IMPAIRMENTS or COMMUNICATION ISSUES
- usage of SELF-REPORT SCALES; making sure to educate and explain the process to the pt.
- giving adequate TIME to respond
- using various RESOURCES or METHODS; translators, pointing, writing
- observing NONVERBAL CUES
- involving FAMILY MEMBERS
20
Q
how to PREVENT PAIN in patients working with PT?
A
- ensuring proper BODY MECHANICS; is the patient using proper form during PT?
- gradual PROGRESSION & WARM-UPS & COOL-DOWNS; is the patient taking breaks and being gradual during PT exercises?
- proper COMMUNICATION; is the patient communicating their pain levels?
- proper REST & RECOVERY: is the patient taking breaks in between?
- using ALTERNATE METHODS; is the patient open to try other factors like heat/cold therapy? massages?
21
Q
tracheotomy
A
type of SURGICAL incision into the trachea to create an AIRWAY to maintain gas exchange
22
Q
tracheoSTOMY
A
type of STOMA that results from the TRACHEOTOMY
23
Q
what needs to be considered for a patient with a tracheostomy?
A
- preventing TISSUE INJURY
- ensuring proper NUTRITION
- ensuring proper WEANING and SUCTIONING
- maintaining proper COMMUNICATION; can be difficult to speak with a TRACH
24
Q
providing tracheostomy care
A
- assessing
- securing trach tubes in place
- preventing accidental decannulation
*ensuring extra cannula is at bedside
*ensuring other RN/RT is there during care
25
weaning
the GRADUAL decrease in tube size - the ULTIMATE REMOVAL of the tube
- patient can now manage secretions; does not need assisted vent
26
overall steps while SUCTIONING a trach
1. Checking orders/hand hygiene/explaing procedure + getting consent
2. PREOXYGENATING the patient & getting pulse ox
3. obtaining materials such as the SUCTION CATH; want to insert the CATH WITHOUT SUCTION YET
4. once inserted; begin suctioning / mix of withdrawing motion
5. limit suctioning for around 10 -15 seconds / 1-2 passes *ensure to give patient breaks
6. Can flush catheter with NS if there is excessive mucus to clear the line
7. continue assessing patient's RR/reoxygenate as needed
27
risk factors for PRESSURE INJURIES (5)
- patient is at BEDREST/IMMOBILE
- patient is INCONTINENT
- patient has PVD/DM
- patient is MALNOURISHED
- patient has COGNITIVE ISSUES/decreased SENSORY PERCEPTION
28
signs of RESPIRATORY DEPRESSION after narcotics
- considered to be the MOST SERIOUS ADVERSE EFFECT of narcotics
- decreased RR
- shallow/irregular breathing patterns
- HYPOXEMIA/CYANOSIS
- confusion or ALTERED MENTAL STATUS
- SLURRED SPEECH
- difficulty to arouse patient
29
how to avoid/prevent sedation side effects?
- assessing dosage calculations of sedatives
- starting with the LOWEST effective dose and being gradual with dosages
- monitoring RR
- encouraging proper AMBULATION and routine
- patient education on PCA etc...
30
importance of INFORMED CONSENT
- allows proper PATIENT AUTONOMY
- ensures that the patient understands all RISKS, BENEFITS, and ALTERNATIVES to the procedure
- protection of patients rights and proper safeguard for HCP
- builds trust
31
food options for LOW SODIUM DIET
- avoiding PROCESSED/CANNED/CURED FOODS
- fresh fruits & veggies
- fresh LEAN meat/eggs
- low-sodium dairy products; YOGURT, BEANS, LENTILS
32
what are the COMPLICATIONS that can occur with IV INFUSION THERAPY?
1. INFILTRATION
2. PHLEBITIS
3. THROMBOSIS
33
infiltration
- where IV fluids begin LEAKING into the SURROUNDING TISSUES vs. entering the actual vein
SIGNS;
- swelling
- redness
- coolness
- buldging
- pain
*can cause tissue damage/necrosis
PREVENTION;
- monitoring site closely
- ensuring proper placement
TREATMENT;
- STOP INFUSION
- ELEVATE AREA
- APPLY WARM COMPRESS
- notify HCP/guidelines
34
phlebitis
the INFLAMMATION of the VEIN due to irritation of the IV CATHETER or SOLUTIONS
SIGNS;
- palpable vein at site
- pain, swelling, redness, warmth
- can progress to THROMBOSIS if not treated
PREVENTION;
- change/rotate IV sites
- avoid irritant solutions
- assess site frequent;y
- proper IV insertion
TREATMENT;
- WARM COMPRESS
- ELEVATION
- restarting IV or removal
35
priority steps if a patient develops SEPSIS
1. NOTIFY HCP
2. FREQUENT monitoring of vital signs; temp, RR, BP etc...
3. Administering of oxygen
4. Administering supportive care - IV fluids/vasopressors
5. can have possible BLOOD CULTURES/antibiotic therapy/fluid resuscitation
36
what are HEMATOLOGIC CHANGES that are associated with AGING?
- decrease in BV
- bone marrow; decreased production of BLOOD CELLS
- total RBC lowers; reduced Hb / HC
37
signs/symptoms of HEMATOLOGIC DISORDERS
- fatigue/weakness
- easy bruising or bleeding
- petechiae
- fevers
- frequent infections
- pale skin
- weight loss
38
steps of hanging a blood transfusion
1. verify patient/check blood product with a SECOND RN
2. obtain baseline VS before starting
3. obtain proper tubing (Y-tubing) and gauge
4. prime tubing only with NS
5. start infusion rate SLOWLY/ monitor patient for the first 15 minutes for signs of a transfusion reaction
6. monitor vital signs every hour after and observe for cont. signs of rxn
7. document start/stop etc...
39
important reminders for BLOOD TRANSFUSION
- always need proper CONSENT from patient
- need a SECOND RN CHECK
- 18-20 gauge used
- starting rate from the book; 2 mL/min or 120 ml per hour
- have to infuse blood in 4 HOURS/have to start transfusion 30 MIN FROM RECIEVING
40
metabolic acidosis
HYDROGEN IONS;
- have an OVERPRODUCTION or UNDERELIMINATION
BICARBONATE IONS;
- have an UNDERPRODUCTION or OVERELIMINATION
results in a LOW BLOOD PH (<7.35) and LOW BICARB LEVELS (<21) / have a HIGH SERUM POTASSIUM
typical PaO2 is NORMAL
typical PaCO2 is NORMAL/DECREASED
41
signs & symptoms of METABOLIC ACIDOSIS
- diarrhea
- renal failure
- lactic acidosis/diabetic ketoacidosis
- nausea & vomiting
- fatigue
42
treatment of METABOLIC ACIDOSIS
- insulin for DKA
- proper REHYDRATION & ANTIDIARRHEALS - for prolonged diarrhea
- administration of SODIUM BICARB
43
contact precautions
- all staff must WASH & CLEAN HANDS B/A leaving the room
- proper GLOVING/GOWN
- proper DISPOSABLE EQUIPMENT
used for;
- infections suspected of DIRECT or INDIRECT CONTACT
- ex. C. diff, MRSA, VRE
44
droplet precautions
- all staff must WASH & CLEAN HANDS B/A leaving the room
- must wear proper FACE COVERING on EYES/NOSE/MOUTH
used for;
- infections spread via DROPLETS (resp, coughing, sneezing)
- ex. COVID, influenza, pertussis, meningitis
45
airborne precautions
- all staff must WASH & CLEAN HANDS B/A leaving the room
- need of a FIT-TESTED N95 RESPIRATOR
- door must remain closed
- NEGATIVE PRESSURE ROOM
used for;
- highly CONTAGIOUS infections
- ex. TB, COVID, measles, chickenpox
46
hand sanitizer vs. hand soap
HAND SANITIZER;
- when hands are not visibly soiled
- before eating
- before and after patient interaction
HAND SOAP
- visibly soiled
- after the restroom
- after touching contaminated surfaces/bodily fluids
- C. DIFF PATIENT
47
normal urine output over an hour
around 30 - 50 mL per hour
around 0.5 mL/kg/hr
can vary dependent on patient intake, activity, weight, age, medical conditions
