Test 3 Flashcards
(107 cards)
1
Q
Different IV gauges smallest to largest
A
24-smallest and shortest inch - used in kids and peds
22 used in elderly or kids
20-radiology patients
18-16-14: biggest for trauma patients
2
Q
What IV site is most commonly used
A
Most common is basilic and cephilic in arm
3
Q
Most commonly used in trauma patient IV size
A
16-18
4
Q
Most common IV site in trauma patients
A
Peripheral IV in the forearm/antecubital area
If not able then- central lines- femoral, subclavian, or jugular sites using large bore
5
Q
How to hang IV fluids
A
Always on a primary line (gravity tubing) (not a pump)
6
Q
How to hang antibiotics
A
Hung on a secondary line which connects to the primary tubing by the Y-port
Be sure primary and secondary line meds are compatible together
(Normal saline is ok to use with any med)
Program the pump, before accessing IV you flush the line- start secondary line (antibiotic) then start the primary line which will flush the secondary line
7
Q
Sodium normal lab value
A
135-145
8
Q
Potassium normal levels
A
3.5-5
9
Q
Calcium normal levels
A
9-10.5
10
Q
Magnesium normal levels
A
1.8-2.6
11
Q
S/s of hyponatremia
What is happening and what is being affected with each one, common causes
A
Hyponatremia causes: diuretic use, diarrhea, heart failure, liver disease, renal disease, and the syndrome of inappropriate ADH secretion (SIADH).
affects the brain Lethargy Headache Confusion Apprehension Seizures Coma
Too much sodium loss or too much water (dilution)
12
Q
S/s of hypernatremia
What is happening and what is being affected with each one, common causes
A
Affects the brain
Wherever sodium goes, water follows. (headache) *affects the brain
Caused by dehydration, vomiting, diarrhea, medications
(too much sodium in the blood)
FRIED - Fever/Flushed, Restless, Increased fluid retention/BP, Edema, Decreased urinary output
Or
SALT- Skin flushed, Agitation, Low-grade Fever, Thirst
Hypernatremia causes: Dehydration or a loss of body fluids from prolonged vomiting, diarrhea, sweating or high fevers. Dehydration from not drinking enough water.
13
Q
S/s of hyperkalemia
What is happening and what is being affected with each one, common causes
A
Affects the heart
MURDER
M uscle weakness U rine, oliguria, anuria R espiratory distress D ecreased cardiac contractility E CG changes R eflexes, hyperreflexia (twitching increased reflexes), areflexia (absent reflexes)
caused by kidney disease (check potassium drip continuously) can affect heart and numbness as well.
Kidney disease is the most common cause of hyperkalemia, Addison’s disease, can lead to hyperkalemia, and Too much potassium in the diet
14
Q
S/s of hypokalemia
What is happening and what is being affected with each one, common causes
A
Affects the heart - threads pulse, arrhythmias/bradycardia/tachycardia
Shallow respiration’s
Decreased intestinal mobility
Alkalosis
Confusion
Weakness ,lethargic, fatigue
The heart and sensory/numbness is affected
Can be caused by diuretics (main cause), or vomiting, diarrhea, dehydration
15
Q
Hypocalcemia s/s
What is happening and what is being affected with each one, common causes
A
Very awake and muscles are affected and twitching- may cause trousseaus sign or Chvostek’s sign
Hypoparathyroidism is a main cause of hypocalcemia
S/s: Muscle cramps Increased DTR Numbness/tingling Convulsions Arrhythmias Both signs Increased QT interval (increased risk of heart attack or abnormal rhythms)
16
Q
Hypercalcemia s/s
What is happening and what is being affected with each one, common causes
A
person is very SEDATED also affect muscles
S/s: muscle weakness Decreased DTR Polyuria Anorexia Nausea/vomiting Arrhythmias Heart block Hypertension
Shortened QT interval (increased risk of heart attack or abnormal rhythms)
Hypercalcemia: person is very SEDATED also affect muscles
Need Vitamin D to retain calcium
Hypercalcemia is usually a result of overactive parathyroid glands.
Other causes of hypercalcemia include cancer, certain other medical disorders, some medications, and taking too much of calcium and vitamin D supplements.
17
Q
Hypermagnesemia s/s
What is happening and what is being affected with each one, common causes
A
person is very SEDATED also affect muscles
Decreased DTR (deep tendon reflexes) Flushing Muscle weakness Lethargy Decreased respiration’s Bradycardia Hypotension
Hypermagnesemia causes- kidney disease and liver failure
Ventilator if R < 12
Dialysis if in kidney failure
Watch kidney function and seizure precautions
18
Q
Hypomagnesemia s/s
What is happening and what is being affected with each one, common causes
A
Causes:
hypomagnesemia are decreased gastrointestinal (GI) absorption and increased renal loss. Decreased GI absorption is frequently due to diarrhea, malabsorption, and inadequate dietary intake.
Watch kidney function and seizure precautions
s/s: Increased DTR Confusion Neuromuscular irritability Seizures Muscle cramps Tremors Insomnia Tachycardia
person is very alert and awake also affect muscle twitching
19
Q
Immunogens and the immune response (S/S)?
A
Immunogens-immune response from antigen
Immune response: redness, heat, swelling, pain ,Loss of function of immflamation.
20
Q
teaching points of Hypervolemia
A
Excessive fluid in the ECF
- Body tries to defend by urinating more, and edema formation
- Daily weight
- Ensure safety, restore normal fluid balance, provide supportive care, prevent future overloads
- Risk for skin breakdown: Turn and Repo Q2H
- May need O2
- Diuretics (If Kidney function is good)
- Fluid and Na+ restrictions
- Monitor I & O
21
Q
teaching points of Hypovolemia
A
a. Circulating blood volume is decreased = decreased perfusion
b. Body defends by vasoconstriction & peripheral resistance
c. Daily weight
d. Orthostatic BP (lying, sitting, standing), monitor HR
e. Prevent further fluid loss, increase fluid volume back to normal and provide safety
f. Mild-Mod deficit: PO Fluids
g. Severe deficit: IVF (monitor HR and output)
22
Q
S/s for Hypervolemia
A
Hypervolemia:
HPN, WT gain, crackles, frothy sputum, distended neck vein, edema, increased CVP, bounding pulse, subjective cues.
23
Q
S/s for Hypovolemia
A
Hypovolemia:
HTN, WT loss, tented dry skin, increased resp and pulse, cool skin, oliguria (little urine), flat neck veins, lethargy, subjective cues.
24
Q
Standard Precautions:
A
applies to the care of all patients
Transmission based precautions: outlines precautions to take based on the mode of transmission of the infection.
- Gloves • For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin
- Gown • During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated
- Mask, eye protection (goggles), face shield* • During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation
Remember that gloves are an essential part of infection control and should always be worn as part of Standard Precautions.
Either handwashing or use of alcohol-based hand rubs should be done before donning and after removing gloves.
25
Airborne Precautions
1. Private room required with monitored negative airflow (with appropriate number of air exchanges and air discharge to outside or through HEPA filter); keep door(s) closed
2. Special respiratory protection: • Wear PAPR for known or suspected TB • Susceptible people not to enter room of patient with known or suspected measles or varicella unless immune caregivers are not available • Susceptible people who must enter room must wear PAPR or N95 HEPA filter*
3. Transport: patient to leave room only for essential clinical reasons, wearing surgical mask Diseases that are known or suspected to be transmitted by air:
• Measles (rubeola) • Mycobacterium tuberculosis, including multidrug-resistant TB (MDRTB) • Varicella (chickenpox)†; disseminated zoster (shingles)†
26
Droplet Precautions
1. Private room preferred: if not available, may room patient with same active infection with same microorganisms if no other infection present; maintain distance of at least 3 feet from other patients if private room not available
2. Mask: required when working within 3 feet of patient
3. Transport: as for Airborne Precautions Diseases that are known or suspected to be transmitted by droplets:
• Diphtheria (pharyngeal) • Streptococcal pharyngitis • Pneumonia • Influenza • Rubella • Invasive disease (meningitis, pneumonia, sepsis) caused by Haemophilus influenzae type B or Neisseria meningitidis • Mumps • Pertussis
27
Contact Precautions
Contact Precautions
1. Private room preferred: if not available, may cohort with patient with same active infection with same microorganisms if no other infection present
2. Wear gloves when entering room
3. Wash hands with antimicrobial soap before leaving patient's room
4. Wear gown to prevent contact with patient or contaminated items or if patient has uncontrolled body fluids; remove gown before leaving room
5. Transport: patient to leave room only for essential clinical reasons; during transport, use needed precautions to prevent disease transmission
6. Dedicated equipment for this patient only (or disinfect after use before taking from room) Diseases that are known or suspected to be transmitted by direct contact: • Clostridium difficile • Colonization or infection caused by multidrug-resistant organisms (e.g., MRSA, VRE) • Pediculosis • Respiratory syncytial virus • Scabies
28
Tetanus (Tdap) Vaccination
What is it?
When is it necessary?
When to get a booster?
What to ask patient?
Nail through foot,
ask is your tetanus up to date
Tetanus prophylaxis is necessary for burns or any break in skin integrity. (active immunity)
booster q 10 years.
29
Extracellular fluids=
edema= sodium
Calcium?
30
intracellular fluids=
potassium and magnesium
31
Know aldosterone, NP, RAS and ADH and how they work to regulate fluid balance in the body.
ADH:(Antidiuretic hormone)
RAS: renin angiotensin system
NP??? natriuretic peptide
Antidiuretic hormone (ADH) is a hormone that helps your kidneys manage the amount of water in your body.
holds onto H2O. nonapeptide that is synthesized in the hypothalamus. regulate the amount of water excreted by the kidneys.
RAS- renin angiotensin system: a hormone system that regulates blood pressure and fluid and electrolyte balance, as well as systemic vascular resistance. When blood volume or sodium levels in the body are low, or blood potassium is high, cells in the kidney release the enzyme, renin. Renin converts angiotensinogen, which is produced in the liver, to the hormone angiotensin
NP: natriuretic peptide hormone secreted from the cardiac atria.
The main function of ANP is causing a reduction in expanded extracellular fluid (ECF) volume by increasing renal sodium excretion.
32
corticosteroid hormone which stimulates absorption of sodium by the kidneys and so regulates water and salt balance. helps maintain blood pressure (BP) and water and salt balance in the body by helping the kidneys retain sodium and excrete potassium.
Aldosterone
33
. Know how to take orthostatic BP and what else should you monitor when taking this? (HR)
Monitor the heart rate as well.
1. Have the patient lie supine for 10 minutes and obtain blood pressure and HR. ...
2. Take blood pressure and HR immediately after the patient arises and ask about dizziness
3. After the patient maintains an upright posture for 3 minutes, obtain blood pressure and HR again.
34
Know isotonic, hypotonic and hypertonic solutions. Know when to use them and some examples of each.
—————————-
same osmolality as blood
stays in vascular space)
When to use? Fluid and ltye replacement Is needed
Example? is diffusion, the movement of molecules from an area of high concentration to an area of low concentration.
Passive Transports:
| 1. Isotonic Solutions:
35
lower osmolality(chemistry)than blood
(moves from vascular space into cells)
When to use? When Cellular hydration is needed
Example? A hypotonic solution is any solution that has a lower osmotic pressure than another solution.
Hypotonic Solutions
36
: higher osmolality than blood
moves from the cells into the ECF
When to use?
To increase urine output post op, DKA, hypovolemia, vascular expansion , third spacing
Example? Corn syrup, gluose, Saline solution, or a solution that contains salts, is hypertonic. ...
A solution of 5% dextrose (sugar) and 0.45% sodium chloride is an example of a hypertonic solution - so is a solution of 5% dextrose and 0.9% sodium chloride.
Hypertonic Solutions
37
Chvostek's sign- How to test for it and which electrolyte imbalance is it tested for?
-twitching of facial muscles/nerve by ear (looks like smile) due to hypocalcemia
38
Trousseau’s sign- How to test for it and which electrolyte imbalance is it tested for?
when your taking BP and the hands spasms or flexes upward- caused by inflating BP cuff above systolic pressure for 3 minutes.
Hypocalcemia
39
ABGs Normal Lab values & How to determine which imbalance the patient has
PH
CO2
HCO3
pH: 7.35-7.45.
PaCO2): 35-45 mmHg.
HcO3: 22-26
Look back at webex at her explanation
Tic tac toe method
40
Respiratory/Kidney/Chemical regulatory mechanisms for acid/base imbalances? (How do they work together)
There are three mechanisms which diminish pH changes in body fluid:
The kidneys help maintain the acid–base balance by excreting hydrogen ions into the urine and reabsorbing bicarbonate from the urine.
There are three mechanisms which diminish pH changes in body fluid:
buffers; respiratory; renal. (a) Proteins are the most important buffers in the body. They are mainly intracellular and include haemoglobin.
41
Metabolic Acidosis-what causes it? S/S
occurs when the body produces too much acid.
Causes: It can also occur when the kidneys are not removing enough acid from the body.
Symptoms include nausea, vomiting, fast breathing, and lethargy.
42
Metabolic Alkalosis- what causes it? S/S
Metabolic alkalosis is a metabolic condition in which the pH of tissue is elevated beyond the normal range
Common causes: include prolonged vomiting, hypovolemia, diuretic use, and hypokalemia.
s/s:
• Confusion (can progress to stupor or coma)
• Hand tremor.
• Lightheadedness.
• Muscle twitching.
• Nausea, vomiting.
• Numbness or tingling in the face, hands, or feet.
• Prolonged muscle spasms (tetany)
43
Respiratory Acidosis- what causes it? S/S
is a condition that occurs when the lungs can't remove enough of the carbon dioxide (CO2) produced by the body.
Excess CO2 causes the pH of blood and other bodily fluids to decrease, making them too acidic.
Causes: impaired respiratory drive (eg, due to toxins, CNS disease), and airflow obstruction (eg, due to asthma, COPD, sleep apnea, airway edema).
Symptoms: headache, confusion, and drowsiness. Signs include tremor, myoclonic jerks, and asterixis
44
Respiratory Alkalosis- what causes it? S/S
a disturbance in acid and base balance due to alveolar hyperventilation. Alveolar hyperventilation leads to a decreased partial pressure of arterial carbon dioxide (PaCO2
Causes: occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to rise and become too alkaline. When the blood becomes too acidic, respiratory acidosis occurs.
* Symptoms:
* anxiety.
* chest pain.
* lightheadedness.
* muscle stiffness.
* numbness around the mouth.
* tremors.
45
Know the local complications of IV therapy
Infiltration
Extravasation
Phlebitis
Thrombosis
More???
46
Leakage of a nonvesicant IV solution or medication into the extravascular tissue
Intervention-
Infiltration
Stop infusion and remove short peripheral catheter immediately after identification of problem.
Apply sterile dressing if weeping from tissue occurs.
Elevate extremity.
Warm or cold compresses may be used according to the solution infiltrated and organizational policy.
Warm compresses increase circulation to the area and speed healing. Cool compresses may be used to relieve discomfort and reduce swelling. Insert a new catheter in the opposite extremity. For all central venous catheters, obtain a study to determine the cause of the problem. For implanted port, remove and insert a new port access needle. Rate the infiltration using the INS Infiltration Scale and document
47
- Leakage of a vesicant IV solution or medication into the extravascular tissue Can occur with both peripheral and central catheters
Intervention
Extravasation
Stop infusion and disconnect administration set.
Aspirate drug from short peripheral catheter or port access needle.
Leave short peripheral catheter or port access needle in place to deliver antidote, if indicated by established policy.
If possible, aspirate residual drug from the exit site of a central venous catheter.
Administer antidote according to established policy.
Apply cold compresses for all drugs EXCEPT vinca alkaloids and epipodophyllotoxins. Photograph site. Monitor at 24 hrs, 1 wk, 2 wks, and as needed.
Surgical interventions may be required. Provide written instructions to patient and family.
48
- Inflammation of the vein Post-infusion phlebitis presents within 48-96 hrs after the catheter has been removed
Intervention
Phlebitis
Remove short peripheral catheter at the first sign of phlebitis;
use warm compresses to relieve pain.
Monitor frequently.
Document using Phlebitis Scale.
Insert a new catheter using the opposite extremity. Mechanical phlebitis occurring in the first week after PICC insertion may be treated without catheter removal.
Apply continuous heat; rest and elevate the extremity. Significant improvement is seen in 24 hrs, and complete resolution is seen within 72 hrs. Remove catheter if treatment is unsuccessful.
49
Blood clot inside the vein (infusion)
Intervention
Thrombosis
Stop infusion and remove short peripheral catheter immediately.
Apply cold compresses to decrease blood flow and stabilize the clot.
Elevate extremity.
Surgical intervention may be required. For central venous catheters, notify the physician and obtain requests for a diagnostic study.
Low-dose thrombolytic agents can be used to lyse the clot.
50
Know what a PICC line is and common complications of them
An intravenous line embedded into skin to avoid being poked multiple times
can have same complications as peripheral IVs,
(injury to local structures, phlebitis at insertion site, air embolism, hematoma, arrhythmia, and catheter malposition.
```
Late complications include infection, thrombosis, and catheter malposition.)
dressing changes (wear mask),
```
sterile precautions, prevent infection, PICC can become dislodged or moved (measure site every time you change) 10ML flush minimum flush with PICC
51
Know what an implanted port is and how to care for one.
Port is under the skin, feel for lumps (2 dots) place needle to poke. (patients who need for a year or longer such as cancer patients) the line (catheter) is threaded through a vein until the end is near your heart.
Care: can get clogged, heparin flush with 10cc syringes to avoid clots, when changing it, wear a mask and do things with sterile precautions.
52
Know what an IO is, the most common site, and how long it can be used for
1. Used only in the immediate resuscitation period (when you need immediate access) drill (different needles for different ages) into bone marrow (trauma patients)
2. DO NOT use over 24 hours
3. Contraindication of IO use = fracture of the bone
Sites: Proximal Tibia (most common), distal femur, medial malleolus, proximal humerus and iliac crest
53
Know the immune functions of inflammation
AMI and CMI
54
immune functions of inflammation response that involves interaction of B lymphocytes with antigen and their differentiation into antibody-secreting plasma cells.
AMI
55
The immune function of inflammation that involves several subpopulations of T lymphocytes that recognize antigens on the surfaces of cells. TH cells respond to antigen with the production of lymphokines.
CMI
56
Know neutrophils- segs and bands
Segs are good, bands are bad… (immature neutrophils)
Segs shift to the left when you have too many neutrophils..thats when you start to see the bands..if too many bands then you may be worried that your body will not be able to fight off infection.
57
immunity which results from the production of antibodies by the immune system after responding to an antigen.
Example: fighting off a sickness on one’s own after being exposed to bacteria. Building up resistance sue to immunizations
Active immunity
58
transfer of ready-made antibodies.
Example:
protection against infections by drinking colostrum.
Passive immunity
59
Know the 4 types of hypersensitivity reactions and examples of each
Which is the worst?
Type I: Immediate Hypersensitivity (Anaphylactic Reaction) These allergic reactions are systemic or localized, as in allergic dermatitis (e.g., hives, wheal and erythema reactions).
* Type II: Cytotoxic Reaction (Antibody-dependent) (blood transfusion reaction, RH, autoimmune disease)
* Type III: Immune Complex Reaction.-inflammation
• Type IV: Cell-Mediated (Delayed Hypersensitivity)
rash from poison ivy or nikel
60
Know the 6 links of the chain of infection and what they stand for?
```
infectious agent,
reservoir,
portal of exit,
mode of transmission,
portal of entry,
and susceptible host.
```
61
something that infiltrates another living thing, like you. When an infectious agenthitches a ride, you have officially become an infected host.
There are four main classes of infectious agents: bacteria, viruses, fungi, and parasites.
Infectious agent
62
place where fluid collects, especially in rock strata or in the body. (like a pool)
Reservoir
63
- is the site from where micro-organisms leave the host to enter another host and cause disease/infection.
For example, a micro-organism may leave the reservoir through the nose or mouth when someone sneezes or coughs, or in faeces.
Portal of exit
64
the route or method of transfer by which the infectious microorganism moves or is carried from one place to another to.
Mode of Transmission
65
is the site through which micro-organisms enter the susceptible host and cause disease/infection. Infectious agents enter the body through various portals, including the mucous membranes, the skin, the respiratory and the gastrointestinal tracts.
Portal of entry
66
a member of a population who is at risk of becoming infected by a disease.
Example- elderly people. frail people. people with certain medical conditions, such as diabetes. people with low immunity – such as people with diseases that compromise their immune system or people who are being treated with chemotherapy or steroids.
Susceptible Host
67
occurs when a disease affects a greater number people than is usual for the locality or one that spreads to areas not usually associated with the disease.
Epidemic
68
is an epidemic of world-wide proportions.
Pandemic
69
Know examples of primary defense mechanisms of the body
skin, nose hair, mucosa
```
Skin
Normal Flora
Nares, trachea & Bronchi (Respiratory Tree)
Eyes
Mouth
GI Tract
GU Tract
```
70
. What is medical Asepsis
AKA Clean Technique
Hand Hygiene (#1)
Clean Environment
71
removal of visible soil from object and surfaces
Cleaning
72
removes virtually all pathogens on objects by physical or chemical means
Examples?
Disinfecting
73
elimination of all microorganisms (except prions) in or on an object.
Examples?
Sterilization
74
six examples of bioterrorism and which 3 have drugs available to treat them????
Intentional or threatened release of disease producing organisms or substances for the purpose of causing death, illness, harm, economic damage or fear.
```
Examples of Bioterrorism:
▪Anthrax -meds to treat*
▪Botulism
▪Pneumonic plague- meds to treat*
▪Smallpox
▪Viral hemorrhagic fevers
▪Tularemia- meds to treat*
```
75
layers of the skin
Epidermis: outer portion of skin, 4-5 layers
Stratum corneum: outermost layer, functions as a barrier
stratum germinativum: innermost layer
▪ Keratinocytes: give the skin strength & elasticity
▪Melanocytes: produce melanin, which gives the skin color and protects it from UV light
▪ Langerhans cells: move around and engulf foreign material and trigger an immune response.
Dermis: lies below epidermis and above the subcutaneous tissue.
Subcutaneous tissue: connective and adipose tissue that provides insulation, protection and a reserve of calories if severe malnutrition occurs.
76
Know how wounds are classified
Wounds are classified according to
the degree of skin integrity,
length of time the wound has been present, level of contamination,
and depth or severity of the wound.
Skin integrity: open or closed
Length of time for healing: acute or chronic
Level of contamination: clean, clean-contaminated, contaminated and infected
Depth of wound: Superficial (epidermis), partial-thickness, and full-thickness (through every layer)
77
Know how wounds heal
Wounds heal by regeneration, primary intention, secondary intention or tertiary intention.
Invloves epithelial, endothelial, and inflammatory cells, platelets, and fibroblasts that migrate into the wound to bring about tissue re- pair and regeneration.
Regenerative/Epithelial healing: wound affects only the epidermis and dermis, no scar forms, new skin cells can’t be distinguished from the intact skin.
78
Minimal to no tissue loss and edges are well approximated and little scarring occurs.
Primary intention
79
Wound involves extensive tissue loss that prevents the edges from approximating and it is open not closed.
Heals from the inside out. Heal slowly, prone to infection and develop more scar tissue
Secondary intention
80
AKA delayed primary closure
Occurs when two surfaces of granulation tissue are brought together.
Less scarring than secondary intention but more than primary intention.
Tertiary intention
81
Wound healing phases
Inflammatory phase - bleeding, clot/scab 2-5 days
Proliferative- 5 days to 3 weeks - granulation - contraction-epithialization, new tissue growth
Maturation - collagen forms
Scar tissue is 80% as strong as original tissue
3 weeks to 2 years
82
Know examples of how to close wounds
When to use adhesive strips?
Sutures?
Where not to use staples?
Surgical glue?
Sutures, staples, durabonds (glue)
Adhesive strips: skin tears, lacerations, support after staples or sutures are removed
Sutures (Stitches): absorbent (dissolve over time), nonabsorbent (need to be removed)
Staples: DO NOT use on hands, feet, neck or face
Surgical glue: skin tears (low-tension wounds)
Negative pressure wound therapy
83
Clear watery plasma wound drainage ?
Serous
84
Thick, yellow, green, tan or brown drainage
Purulent
85
Pale red watery drainage
Serosanguineous
86
Bring red drainage (bleeding)
Sanguineous
87
Know the complications of wound healing
```
Hemorrhage
Infection
Dehiscence
Evisceration
Fistulas
```
Hemorrhage-The release of blood from a broken blood vessel, either inside or outside the body.
Infection-fever, red, warm, yellow/green drainage, pain, swelling, malaise
Dehiscence - wound split open
Evisceration- protruding out of wound
Fistulas-abnormal, epithelialized connection between two body structures
88
Know nursing interventions for patients at risk for infection
Assess patients for risk for infections.
Monitor for signs and symptoms of infection.
Monitor laboratory tests results such as cultures and white blood cell (WBC) count and differential.
Screen all visitors for infections or infectious disease.
Inspect skin and mucous membranes for redness, heat, pain, swelling, and drainage.
Promote sufficient nutritional intake, especially protein for healing.
Encourage fluid intake to treat fever.
Teach the patient and family the signs and symptoms of infections and when to report them to the primary health care provider.
Teach the patient and family how to avoid infections in health care agencies and the community.
89
* Assess any patient with a problem of fluid and electrolyte balance for fall risk. QSEN: Safety
* Supervise the oral fluid therapy and intake and output measurement aspects of care delegated to unlicensed assistive personnel. QSEN: Safety
* Use a pump or controller to deliver IV fluids to patients with fluid overload. QSEN: Safety
* Do not give IV potassium at a rate greater than 20 mEq/hr (mmol/hr). QSEN: Safety
* Never give potassium supplements by the IM, subcutaneous, or IV push routes. QSEN: Safety
* Use a pump or controller when giving IV potassium-containing solutions. QSEN: Safety
* Assess the IV site hourly of an adult receiving IV solutions containing potassium and document its condition. QSEN: Safety
* Use a gait belt when assisting a patient with muscle weakness to walk or transfer. QSEN: Safety
* Use a lift sheet to move or reposition a patient with chronic hypocalcemia. QSEN: Safety
.
90
```
Lifestyle choices that affect skin integrity?
Secondary (came from first infection)
Know Renin-angiotensin 2 pathway
Know common causes of fluid imbalances
What to watch with hypovlemia- Weight, heart rate and orthostatic BP
Common causes of fluid imbalances?
Bicarb- kidneys control (HCO3)
carbonic acid- lungs control (H2CO3)
Precautions sheets??
```
.
91
VRE stands for?
Vancomycin-resistant Enterococcus
| bacteria’s strains that are resistant to vancomycin
92
infection from hospital
Exogenous
93
Infection- from patient
Endogenous
94
Secondary infection
An infection that resulted due to primary infection
95
Lifestyle choices that affect skin integrity?
```
Friction and shearing.
Immobility.
Inadequate nutrition.
decrease Fecal and urinary incontinence.
Decreased mental status.
Diminished sensation.
Excessive body heat.
Medications
No Exercise
Dry skin no Moisturizer
Improper Hydration
smoking
```
96
What to watch with hypovlemia-
- Weight, heart rate and orthostatic BP
97
Common causes for fluid imbalance?
```
The body may lose too much fluid due to
diarrhea,
vomiting,
severe blood loss,
high fever.
Lack of a hormone called antidiuretic hormone (ADH) can cause the kidneys to get rid of too much fluid.
```
98
Know Renin-angiotensin 2 pathway
Angiotensin, specifically angiotensin II, binds to many receptors in the body to affect several systems. It can increase blood pressure by constricting the blood vessels. ... In the adrenal glands, angiotensin stimulates aldosterone production. This hormone causes the body to retain sodium.
99
Bicarb- control what? (HCO3)
| carbonic acid- control what? (H2CO3)
Bicarbonate controls kidneys
Carbonate acid controls lungs
100
Precaution sheets??
??
101
What plays a big role in how cells respond to the body/immunity?
Cell maturity
102
For someone to have full immunity (immunicompitent) optimal immunity
Inflammation , Antibody-mediated immunity (AMI)
| And cell mediated immunity (CMI)
103
is an immune response that does not involve antibodies. Natural killer cell T-cells
Cell -mediated immunity
104
Uses B-cells
Becomes sensitized to foreign cells and proteins
Memory cell -learns how to fight off infection
AMI (antibody mediated immunity)
| Most important
105
Can you have inflammation with out infection?
Will you always have inflammation with an infection ?
Yes
Yes
106
Cardinal s/s of infection?
Warmth, redness, swelling, pain, decreased function
107
4 types of hypersensitivity reactions and examples of each
Type I: Immediate Hypersensitivity (Anaphylactic Reaction) These allergic reactions are systemic or localized, as in allergic dermatitis (e.g., hives, wheal and erythema reactions).
* Type II: Cytotoxic Reaction (Antibody-dependent) (blood transfusion reaction, RH, autoimmune disease)
* Type III: Immune Complex Reaction.-inflammation
• Type IV: Cell-Mediated (Delayed Hypersensitivity)
rash from poison ivy or nikel
