Unit 3 Flashcards
(251 cards)
1
Q
infection
A
- invasion of a susceptible host by pathogens or micro-organisms that cause dz
- can be localized or systemic
2
Q
colonization
A
•micro-organim invades host, but doesn’t cause dz
3
Q
nonspecific innate immunity
A
- native immunity that restricts or immediately responds to antigens
- skin, phagocytic cells, complement, inflammation, etc
- temporary
4
Q
specific adaptive immunity
A
- allows body to make antibodies in response to specific antigens
- requires time
- provides permanent immunity
- B and T lymphocytes, immunoglobulins
5
Q
communicable dz
A
•transmitted from one person to another
6
Q
bacteriostasis
A
•prevention of growth and reproduction of bacteria
7
Q
nature of infection
A
- symptomatic if pathogens multiply and cause clinical signs/symptoms
- asymptomatic if no clinical signs
- communicable if can be transmitted
- hand hygiene is most important to prevent spread
8
Q
chain of infection
A
- ) causative agent- bac, vit, etc
- ) reservoir- host; tubing; food; flowers
- ) portal of exit- reap. tract, GI, GU, skin, blood
- ) mode of transmission- drop, air, contact
- ) portal of entry to host
- ) susceptible host
* organisms enter/exit thru same route
9
Q
incubation
A
- 1st stage of infection
* interval b/t pathogen entering body and presentation of first symptom
10
Q
prodromal stage
A
- 2nd stage of infection
- interval from onset of general symptoms to more distinct
- pathogen is multiplying
11
Q
illness stage
A
- 3rd stage of infection
* interval when symptoms specific to infection occur
12
Q
convalescence stage
A
- 4th stage of infection
- actue symptoms disappear
- total recovery may take days to months
13
Q
normal flora
A
- natural defense against infection
- release antimicrobial substances
- inhibit multiplication of pathogens
14
Q
inflammation
A
•natural defense against infection •vascular/cellular responses •exudates •tissue repair *histamine stimulates nerve endings and causes
15
Q
serous exudate
A
•contains serum (liquid)
16
Q
serum
A
•protein containing liquid part of blood that separates from platelets during coagulation
17
Q
serosanguineous exudate
A
- contains serum and blood
* pinkish color
18
Q
purulent exudate
A
•contains pus
19
Q
sanguineous exudate
A
•contains blood
20
Q
healthcare associated infection (HAI)
A
•infection acquired while receiving care in healthcare setting
•UTI/URI, wounds, and blood most common
•ICU most common source
*nosocomial infection
21
Q
iatrogenic infection
A
•HAI resulting from a diagnostic or therapeutic procedure
22
Q
exogenous HAI
A
- from microorganisms outside individual
- not normal flora
- Ex: salmonella
23
Q
endogenous HAI
A
- pt’s flora becomes altered and overgrowth results
- result of broad-spectrum abx
- Ex: strep
24
Q
developmental considerations of susceptibility to infection
A
- infant- immature immune response
- middle age- refined defenses
- older- cell-mediated immunity decline
25
nutrition and susceptibility to infection
•reduced macro-nutrient intake reduces defenses against infection and impairs wound healing
26
stress and susceptibility to infection
•increases cortisol levels, which results in decreased resistance to infection
27
asepsis
•absence of illness-producing micro-organisms
28
medical asepsis
* use of precise practices to REDUCE # of organisms and PREVENT transfer of those present
* "clean technique"
* used in oral care, NG tubes, providing personal hygiene, etc
29
surgical asepsis
* use of precise practices to PREVENT CONTAMINATION of open wound or ISOLATE operative area from unsterile
* "sterile technique"
* used in parenteral medication, urinary catheter, surgery, dressing changes, etc
30
standard precautions
* prevent and control infection and its spread
| * hand hygiene, gloves, gown, mask, etc
31
disinfection
* eliminates many or all micro-organisms (EXCEPT bacterial spores) from inanimate objects
* high level disinfection used for certain items, like endoscopes
32
wet pasteurization
•disinfection technique used for respiratory equiptment
33
sterilization
* COMPLETE elimination/destruction of all microorganism
| * includes spores
34
isolation
* separation/restriction of movement of ill pt w/ contagious dz
* precautions include: airborne, droplet, contact, and protective environment
35
sterile field
•area free of microorganisms and prepared to receive sterile items
36
principles of surgical asepsis (7)
1. ) object remains sterile only when touched by another sterile object
2. ) only sterile objects can be placed in sterile field
3. ) sterile object or field out of range of vision or an object held below waist is contaminated
4. ) sterile object or field becomes contaminated by prolonged exposure to air
5. ) when sterile surface comes in contact w/ wet, contaminated surface, the field/object becomes contaminated
6. ) fluid flows in direction of gravity
7. ) edges of sterile field/container are contaminated
37
opening sterile pkgs
* open on flat surface
* open while holding above waist
* open flaps furthest from you first
38
pressure ulcer
* localized injury to skin and underlying tissue
* usually over bony prominence
* results from combo of pressure & shear/friction
39
extended pressure
* occludes blood flow and nutrients
| * tissue ischemia/death if untreated
40
shear
•force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface
41
blanching
* normal red tones of skin are absent
| * doesn't occur in dark skinned
42
stage I pressure ulcer
•intact skin w/ nonblanchable redness
43
stage II pressure ulcer
•partial thickness skin loss involving epidermis, dermis, or both
44
stage III pressure ulcer
•full thickness tissue loss w/ visible fat
45
stage IV pressure ulcer
•full thickness tissue loss w/ exposed bone, muscle, or tendon
46
unstageable pressure ulcer
•no determination of stage b/c eschar or slough obscures wound
47
granulation tissue
* red, moist, and composed of new blood vessels
| * progression toward healing
48
slough
* stringy substance attached to wound bed
| * must be removed before wound can heal
49
eschar
* black/brown necrotic tissue
* needs to be removed before healing can proceed
* unstageable
50
primary intention wound healing
* wound edges are brought together and sutured
* skin edges approximated
* dressings removed as soon as bleeding stops
* Ex: surgical incision healing
51
secondary intention wound healing
* wound left open until filled w/ scar tissue
* healing of wounds involving loss of tissue
* dressing remains b/c provides moisture and assists in debridement
* requires packing
* Ex: burn, pressure ulcer, laceration
52
hemorrhage
* bleeding from wound site
* normal immediately after trauma
* complication if long after trauma
53
hematoma
* localized collection of blood underneath tissues
| * complication of wound healing
54
wound infection
* 2nd most common HAI
* edges of wound appear inflamed
* if drainage, odorous/purulent and yellow/green/brown color
55
dehiscence
* wound healing complication characterized by partial or total separate of wound layers
* occurs most often in obese pts
56
evisceration
* wound healing complication characterized by total separation of wound layers
* visceral organs protrude through wound opening
* requires immediate action
57
tissue perfusion
* tissue oxygenation fuels cellular fxn
* pts in shock or w/ DM have poor perfusion
* adequate amnt necessary for proper healing
58
abrasion
* superficial wound w/ little bleeding
| * partial thickness wound
59
laceration
•bleeds more profusely than a abrasion
60
puncture wound
* bleeding based on depth/size
* potential risk for internal bleeding
* allow to bleed to get rid of contaminants
61
Jackson-pratt drainage device
•exerts constant low pressure at wound site to drain large amounts of fluid
•drain with the bladder in wound
•empty at least 1x/shift
*make sure it's not left open- should be compressed
62
Penrose drain
* drain lies under dressing in the wound itself
| * pin on it so it doesn't go into wound
63
hyperemia
•increase of blood flow to specific area
64
mechanical debridement
* removing nonviable, necrotic tissue
| * wound irrigation w/ high pressure
65
autolytic debridement
•use of synthetic dressings over a wound to allow eschar to be self-digested by action of NZ in wound fluids
66
chemical debridement
* use of topical NZ to dissolve/remove nonviable, necrotic tissue
* preferred method and least damaging
67
surgical debridement
•removal of devitalized tissue using scalpel, scissors, or other sharp instruments
68
when wound caused by penetrating object...
•don't remove object b/c provides pressure and controls some bleeding
69
moist dressing technique
* used to maintain moist environment for clean granulating wound
* don't want the dressing to dry and stick
70
wet-to-dry dressing technique
* goal is to mechanically debride wound
* moist contact dressing is placed on wound and allowed to dry
* dressing sticks to necrotic tissue and debridement occurs during removal
71
hydrocolloid dressing
* combo of colloid, elastomeric, and adhesive components
* protects wound surface from contamination
* autolytically debride
* wound contact layer forms a gels as fluid is absorbed and maintains moist environment
72
hydrogel dressing
* gauze impregnated w/ water or glycerin gel
* maintains moist surface to support healing
* autolycically debrides
73
wound vacuum assisted closure (V.A.C.)
* drain evacuator that uses negative pressure to remove fluid from around the wound and draw edges of wound together
* sponge cut in shape of wound and vacuum attached
* reduces edema and improves circulation to the area
74
film dressing
•secondary dressing used for debridement of small wounds
75
montgomery ties
* Adhesive straps affixed to the skin so as to provide a method of securing a bandage and subsequently changing it without having to replace the tape each time
* Most often used for abdominal incisions
76
principles of cleaning skin (6)
1. ) clean in direction from least contaminated to most
2. ) use gentle friction when cleansing/applying sol.
3. ) allow irrigation fluid to flow from clean to contaminate
4. ) isotonic agents (NS) preferred
5. ) don't use cotton balls
6. ) don't use same gauze across wound twice
77
drainage evacuators
* portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage
* looks like a yoga ball pump
* when puffed up, it's filled
78
intermittent suturing
•surgeon ties each suture made into the skin
79
continuous suturing
•series of sutures w/ only two knots (at beginning and tend of line)
80
retention sutures
•placed more deeply than skin sutures
81
removal of intermittent suture
•cut suture as close to skin as possible
•remove suture
*never pull contaminated stitch through suture
82
bandages
* used when gauze isn't enough to create pressure, immobilize/support wound, and reduce/prevent edema
* also used to secure splint/dressing
83
binders
* designed for support/pressure exertion on an entire body part
* Ex: abdominal binder; sling
84
when to not use cold therapy
* edema
* neuropathy
* impaired circulation
* shivering
85
when to not use heat therapy
* active bleeding
* local inflammation
* CV issues
86
QSEN
* quality & safety education for nurses program
* developed to meet challenge of preparing future nurses w/ knowledge, skills, and attitudes needed to improve quality/safety of health care
* minimizes risk of harm to pts and providers through system effectiveness and individual performance
87
safety in health care setting
* reduces incidence of illness/injury
* prevents extended stay/treament
* improves/maintains fxnl status
* increases pt sense of well being
88
basic human needs
* oxygen
* nutrition
* temperature
89
hypoxia
* inadequate tissue perfusion caused by low blood O2
* early signs- tachycardia/pnea, restlessness, pallor, hypertension,i ncreased WOB
* later signs- cyanosis, bradypnea/cardia, hypotension, dysrhythmias
90
hyperoxia
* high [O2] reaching tissues
| * death w/in 1-3 min
91
hypothermia
•body temp below normal
92
hyperthermia
* core body temp exceeds that of normal
| * risk of heat stroke (>104°F)
93
< 5 y/o safety risks
•home accidents
94
school-aged safety risks
•travel injury
95
adolescent safety risks
* MVA
* suicide
* substance abuse
96
adult safety risks
* lifestyle habits- drugs, alcohol, etc
| * working environment
97
elderly safety risks
•related to physiological changes of aging
98
sentinel event
•unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
99
never events
* adverse events that should never occur in health care setting
* if hospital experiences, CMS denies higher payment
100
nurse-sensitive events
* those that a nurse can directly impact their development
| * Ex: fall; stage III pressure ulcer
101
Material Safety Data Sheets (MSDSs)
* info on the potential health effects of exposure to chemicals/dangerous substances
* and info on safe working procedures when handling chemical products
102
6 rights of medication administration
1. ) right drug
2. ) right dose
3. ) right route
4. ) right time
5. ) right pt
6. ) right documentation
* key to avoiding medication error
103
components of medication error report
1. ) patient information
2. ) location and time of the incident
3. ) description of what happened and what was done about it
4. ) condition of the patient
5. ) nurse’s signature
* don't document in records
104
patient-inherent accidents
* self induced by pt
| * Ex: climbing over bed rails
105
procedure-related accidents
•occur during therapy, med administration, IV, improper device sue, improper procedure performance
106
equipment related accidents
•result from malfunction, disrepair, or misuse of equipment
107
fall risk pts
•yellow bracelet
•restraints are LAST RESORT
•side rails used unless causes more hazard
*if fall once, more likely to fall again
108
ambularm
•safety device that straps to a pt's extremity alerts when pt is trying to get out of bed
109
Posey stay safe bed
* soft-sided, self-contained enclosed bed
| * less restrictive than chemical/physical restraints
110
RACE
* Rescue pts
* Activate alarm
* Confine fire
* Extinguish
111
sensory deficit
* change in reception and/or perception
| * body often compensates w/ other functioning senses
112
sensory deprivation
* reduced sensory input from internal/external environment
| * can be result of trauma, illness or isolation
113
sensory overload
* excessive, sustained, and unmanageable multi sensory stimulation
* tolerance to overload varies w/ pts
* symptoms of fatigue, irritability, etc
114
kinesthetic senses
* position and motion
| * measured during assessment, not history
115
aphasia
* inability to speak, interpret, or understand language
| * most common lang. disorder following stroke
116
expressive aphasia
* motor type
| * inability to name common objects or express simple ideas in words or writing
117
receptive aphasia
•inability to understand written/spoken language
118
global aphasia
•inability to understand language or to communicate orally
119
hyperesthesia
•sensitive to tactile stimuli
120
enhancing self-esteem of sensory impaired
* promote self-care
* Ex: food in clock formation on plate allows pt to feed themselves
* Ex: use of incandescent lighting for glaucoma pt
121
enteral nutrition (EN)
* tube feeding directly into stomach, duodenum, or jejunum
* naso gastric/intestinal- short term
* gastrostomy/jejunostomy- long term
* orogastric tube- ICU, trauma, ventilator, etc
122
polymetric EN formula
* milk based
| * for pts that can absorb whole nutrients
123
modular EN formula
* single macronutrients
| * used to supplement nutritional needs
124
elemental EN formula
* predigested nutrients
| * used if have GI dysfunction
125
specialty EN formula
•designed to meet specific nutritional needs related to illness
126
total parenteral nutrition (TPN)
•IV feeding
127
basal metabolic rate
•energy needed to maintain life-sustaining activities for a specific period of time at rest
128
carbohydrates
* provide most of energy and fiber
| * 4 kcal/g
129
fats
* provide energy and vitamins
* should be < 30% of intake
* 9 kcal/g
130
proteins
* contribute to growth and tissue repair
* necessary for nitrogen balance
* 4 kcal/g
131
vitamins
* organic substances necessary for metabolism
* fat soluble: A, D, E, K
* water soluble: C and Bs
132
minerals
* inorganic substances that complete biochemical rxns in body
* Ca++, Fe++, K+, Na+
133
metabolism
* all biochemica rxns w/in cells of the body
| * glycogenolysis, glyocgensis, gluconeogenesis
134
anabolism
•building of more complex biochemical substances thru synthesis of nutrients
135
catabolism
* breakdown of biochemical substances into simpler ones
| * occurs during states of negative nitrogen balance
136
dietary reference intakes (DRIs)
•acceptable range of quantities of nutrients/vit/minerals based on gender/age
137
infant nutrition
* high energy requirements
* breast milk (or formula)
* solid food @ 6 months
* no cow's milk/honey for first yr
138
ovolactovegetarian
* avoid meat, fish, poultry
| * eat eggs/milk
139
lactovegetarian
•drinks milk, but avoids eggs
140
vegan
•consumes only plant based foods
141
frutarian
•consume fruit, nuts, honey, and olive oil
142
zen macrobiotic diet
•brown rice, grains, teas
143
food security
•all household members have access to sufficient, safe, and nutrition food to maintain a healthy lifestyle
144
factors that affect serum albumin levels
* hydration
* hemorrhage
* renal or hepatic disease
* large amounts of drainage
* burns
* steroid administration
145
normal albumin level
* 3.5-5.5 g/dL
| * needs to be at least 3.5 for proper wound healing
146
medical nutrition therapy (MNT)
* nutritional therapy usage for treating illness/injury
| * utilized for nutrient metabolism, correcting deficiencies, eliminating food that worsen dz states
147
valsalva maneuver
•assists in stool passage by exerting pressure to expel feces through voluntary ctx of abdominal muscles, while maintaining forced expiration against closed airway
148
paralytic ileus
* following anesthesia, there is a temporary stop of peristalsis
* sometimes occurs b/c of blockage, so have to insert NG tube to decompress
149
constipation
* symptom, NOT a dz
* infrequent stool and/or hard, dry, small stools
* caused by improper diet, reduced fld intake, lack of exercise, and certain meds
150
impaction
* collection of hardened feces in rectum that person can't expel
* unrelieved constipation
* can cause obstruction if not removed
151
stoma
•temporary or permanent artificial opening in abdominal wall
152
ileostomy/colostomy
* surgical openings created in ileum or colon
| * ends of intestine brought through abdominal wall to create stoma
153
loop colostomy
* loop of colon is exteriorized and sutured to abdomen (still have connection holding together)
* results in 2 openings in 1 stoma
* proximal end drains stool
* distal end drain mucus
* used in medical emergency when bowel obstruction is anticipated
154
end colostomy
* terminal end of descending colon is brought through peritoneum/muscle and is sutured to skin
* one stoma formed from proximal end of bowel
* distal end is removed or sewn closed (Hartmann's patch)
155
double barrel colostomy
* intestine completely transected and both ends are sutured to abdominal wall
* results in 2 stomas
* proximal stoma drains stool
* distal stoma just chills
* after injury healed, divided ends anastomosed
156
Ileoanal pouch
* removal of the colon and creation of a pouch from the end of the small intestine
* pouch attached anus and provides for the collection of waste material
* pt continent b/c stool is evacuated via the anus
157
kock continent ileostomy
•small intestine forms pouch, which is emptied several times a day
158
fecal occult blood test (FOBT)
* aka guaiac test
* measures microscopic amounts of blood in feces
* accurate results require testing 3 times from 3 different defecations
159
GI post-op
•good to pass gas and have sounds b/c during surgery the bowels are packed and their movement is disrupted
160
caring for stoma
* NS, gentle
* pat dry
* assess color (want it to be beefy red)
* purple indicates necrotic tissue
* document what's in pouch
161
I/O sheet
* document what goes in/out
* in- fluids/food
* out- urine/bowel (including contents of bags)
162
enema
* instillation of sol. into rectum and sigmoid colon
* stimulates peristalsis
* also vehicle for meds aimed at rectal mucosa
163
cleansing enema
* simulate peristalsis thru infusion of large vol. of sol.
* tap water used in adults
* NS used in infants/children
* hypertonic sol. and soapsuds used to help draw stool out
164
oil retention enema
* lubricate rectum/colon
| * feces absorb oil and become softer/easier to pass
165
return flow (carminative) enema
•provides relief from gaseous distention
166
medicated enema
* contains drugs such as Kayexalate, which is used for high K+ levels
* another is neomycin- abx
167
digital removal of stool
•last resort to manage severe constipation when all other methods have failed
•break up fecal mass w/ fingers and remove in sections
•need dr. order
**double glove
168
laxative
* softens stool
* lube and place above rectal sphincter
* given if taking opiates b/c they block bowel receptors
169
cathartics
•promote peristalsis
170
NG tube
•pliable hollow tube that is inserted through nasopharynx into stomach
•used for decompression, enternal feeding, and lavage
*administration doesn't require sterile field
171
decompression
* removing secretions and gaseous products from GI draft
| * reduces nausea and decreases risk of vomiting/aspiration
172
lavage
* washing out body cavity w/ water, NS, or medication
| * Ex: used to flush overdose
173
renal colic
* obstruction within a ureter, such as a renal calculus (stone), causes peristaltic waves that attempt to move the obstruction to the bladder
* associated pain is referred to as renal colic
174
kidney fxns
* filtration of blood
* erythropoietin production (for RBC)
* renin, prostaglandin, and prostacyclin production (affect BP)
* converts vit. D to active form
175
control of bladder fxn
* stretch on bladder wall sends involuntary signal to brain
* higher brain centers respond/ignore urge
* detrusor muscle ctx in response to parasympathetic stimulation
176
diuresis
•increased urine formation
177
fever and urination
* increase in body metabolism and accumulation of body waste
* urine vol. reduced and highly concentrated
* body sweat out fluid in attempt to reduce fever, so reduced urine output
178
prerenal dzs
•cause decreased blood flow to/thru kidney
179
renal dzs
•involve abnormal conditions of renal tissue
180
postrenal dzs
* involve conditions in lower urinary tract
* prevent urine flow from kidneys
* Ex: narrow urethra, altered innervation, weak muscles
181
neuromuscular dzs and urination
* changes in nerve fxn, resulting in loss of bladder tone, reduced bladder sensation, inability to inhibit bladder ctx
* Ex: diabetes; MS
182
peritoneal dialysis
* dialysate instilled into peritoneum via surgically placed catheter
* dialysate remains for time and then is drained out, taking accumulated wastes and excess fluid w/ it
183
hemodialysis
* machine w/ semi-permeable membrane
* dialysate fluid pumped thru one side, while pt blood throughout eh other
* diffusion/osmosis clean blood, which is returned to the body
184
cystitis
* inflamed bladder
* often associated w/UTI
* causes dysuria
185
stress incontinence
* loss of small amounts of urine when laughing, sneezing, or lifting
* due to weak pelvic muscles, urethra, or surrounding tissue
186
urge incontinence
* inability to stop urine flow long enough to reach bathroom
| * due to overactive detrusor muscle
187
overflow incontinence
•urge to urinate is diminished, which leads to overflow and involuntary leakage
188
reflex incontinence
•involuntary loss of moderate amount of urine w/o warning
189
total incontinence
* unpredictable, involuntary loss of urine that doesn't respond to tx
* NOT a normal process of aging
190
normal urinary output
* at least 30 cc/hr
* if less, indicates kidney failure
* if contains no filtrate indicates kidney failure
191
cholinergic medications
* increase ctx of bladder and improve emptying
| * anti-cholingergic given if continuous feeling to urinate w/ catheter in place
192
catheterization
* introducing a tube thru urethra into urinary bladder
* can cause UTI, blockage, trauma
* urine drains by gravity
193
intermittent urinary catheterization
* periodic catheterization
| * use straight single use catheter that is immediately withdrawn
194
indwelling/Foley catheterization
•temporary intervention when client is at risk fro skin breakdown or when all other options have failed
•remains in place until pt able to void voluntarily or until no longer needed
*sterile
195
condom catheter
•used for incontinent or comatose men who still have complete spontaneous bladder emptying
196
Crede maneuver
•manual pressure on abdomen forces voiding and expelling of placenta
197
Kegel exercises
* incontinence therapy that strengthens the pelvic floor muscles thru repetitive ctx
* try to stop mid flow urine
198
BUN test
* blood urea nitrogen levels
* measures amount of nitrogen in urine
* determines if kidneys are able to clear urea from blood adequately
199
pylonephritis
* kidney infection
| * puss in the kidneys
200
hypoxemia
* low blood O2
* if goes too far leads to hypoxia
* diagnosed by ABGs
201
work of breathing
* effort required to expand/contract lungs
| * increased in COPD b/c they lose elastic recoil of lungs/thorax
202
surfactant
•chemical produced in lungs to maintain the surface tension of the alveoli and keep them from collapsing
203
atelectasis
•collapse of the alveoli that prevents normal exchange of O2/CO2
204
compliance
* ability of lungs to distend/expand in response to increased intra-alveolar pressure
* decreases w/ pulmonary edema, interstitial/pleural fibrosis, and structural abnormalities (kyphosis/broken ribs)
205
airway resistance
* increase in pressure that occurs as the diameter of the airways decreases from upper to lower resp. tract
* increased in asthma and tracheal edema
* greater resistance -> less O2 to alveoli
206
ventilation
•moving gases into/out of lungs
207
diffusion
* exchange of respiratory gases in alveoli/capillaries
| * slower in pt w/ thickened membranes/pleural fluids
208
spirometry
* measures volume of air entering/leaving lungs
| * used to keep lungs clear, esp. if immobile
209
hyperventilation
•ventilation in excess of that required to eliminate CO2
| *CO2 increase
210
hypoventilation
•alveolar ventilation inadequate to meed body's O2 demand or to eliminate sufficient CO2
*CO2 decrease
211
ventricular tachycardia
* life-threatening dysrhythmia caused by decreased cardiac output
* symptom of hypoxia b/c low tissue O2 causes heart to beat faster attempting to get O2 rich blood out faster
* faster beat means less blood w/ each pump
212
most effective position for lung expansion
* 45° semi-Fowlers
| * gravity reduces pressure from abdomen/diaphragm
213
noninvasive ventilation
* administration of ventilatory support without using an invasive artificial airway
* Ex: CPAP
214
influences on oxygen carrying capacity
* amount of O2
* amount of Hgb (low in anemia)
* tendency of hgb to bing to O2
215
carbon monoxide poisoning
* competes w/ O2 binding on Hgb
| * cherry red in color b/c O2 stuck at tissues
216
central cyanosis
•blue around mouth
217
chest tube
* catheter placed through thorax to remove air/fluid from pleural space
* prevents air from reentering space and re-establishes pleural pressures
* used for pneumothorax/hemothorax
218
endotracheal airway
* tube thru mouth and connected directly to ventilator
| * SHORT-TERM use to ventilate, relieve upper airway obstruction, protect against aspiration, and clear secretions
219
tracheostomy
* LONG-TERM airway created by surgical incision and insertion into trachea
* may/may not be connected to vent
220
normal concentration of O2 in room air
•21%
221
SpO2 readings
* 95%-100%: expected
* 91%-100%: acceptable
* <90%: hypoxemia
222
nasal cannula
* O2 therapy via tubing w/ two small prongs for insertion into nares
* lowest flow
223
face masks
* cover nose and mouth
* higher flow
* risk for CO2 accumulation
224
Venturi Mask
* covers mouth and nose
* delievers precise O2 concentration (based on colored nozzle)
* used for pt w/chronic lung dz
225
partial rebreather
* covers nose and mouth
| * has reservoir bag, which allows pt to rebreathe ⅓ of CO2 exhaled w/ room air
226
pursed lip breathing
* deep inspiration and prolonged expiration thru pursed lips
| * prevents alveolar collapse
227
suctioning
•used when clients have early signs of hypoxia, decreased SpO2, adventitious breath sounds, audible/visible secretions
•oropharyngeal, nasopharyngeal, orotracheal, nasotrachial, tracheal
*apply neg. pressure when withdrawing catheter, NOT on insertion
228
O2 above 4 L
•needs to be humidified
229
normal Hgb
* male: 14-18 g/dL
| * female: 12-16 g/dL
230
normal hematocrit
* males: 42-52%
| * females: 37-47%
231
purpose of patient education
•maintenance and promotion of health/wellness
•trying to prevent return to hospital
*teaching patient and family
232
ready to learn
* teaching is useless unless patient is ready to learn
| * teaching has to be innovative to get patient ready to learn
233
cognitive learning
* Includes all intellectual behaviors and requires thinking
* discussion (one-on-one or group), lecture, question-and-answer session, role play, discovery, independent project, field experience
234
affective learning
* Deals with expression of feelings and acceptance of attitudes, opinions, or values
* role play, discussion (one-on-one or group)
235
psychomotor learning
* Involves acquiring skills that require integration of mental and muscular activity
* demonstration, practice, return demonstration, independent projects, games
236
motivation to learn
•patient’s desire or willingness to learn
237
ability to learn
* Depends on physical and cognitive abilities, developmental level, physical wellness, thought processes
* best if patient not fatigued, anxious, or in pain
238
learning environment
* Allows a person to attend to instruction
| * well lit, good ventilation, comfortable temp, quiet, private
239
attentional set
•the mental state that allows the learner to focus on and comprehend a learning activity
240
self-efficacy
•person’s perceived ability to successfully complete a task
241
health literacy
* cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health
* reading, math, comprehension, and decision making skills
242
functionally illiterate
•inability to read above 5th grade level
243
calculate BMI
•weight in lbs/inches squared, then multiply by 703
•or weight in kg/meters squared
*17.9
244
pyrexia
* fever
* may have unknown origin or caused by pyrogens
* leads to increase in O2, CV, and respiratory demands
245
pyrogen
•a substance, typically produced by a bacterium, that produces fever when introduced or released into the blood
246
febrile
•showing symptoms of fever
247
nursing diagnosis related to activity intolerance
* impaired gas exchange
* ineffective airway clearance
* risk for aspiration
248
priority for trauma/burn pt
•intubate b/c at risk for airway swelling
249
A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac—rather than respiratory or gastrointestinal—when it
Does not occur with respiratory variations
250
A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes
Tracheal suctioning
251
When evaluating a post-thoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to
Place the device below the patient’s chest
