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What is the best method to stop the spread of infection?
What is the purpose of normal flora?
Normal flora are a primary line of defense for the body. They are micro-organisms that normally live within the body without causing disease.
What is the most common HCAI (Health Care Aquired Infection)? How do people get this specific infection?
- UTI - urinary tract infection
- causes: catherizaiton
If you have a sick person with a draining wound in the home, what would you do to prevent the spread of infection in the home?
Wear gloves, place dirty bandages in a zip lock bag, seal and dispose in trash can.
When administering pain meds, it is important to assess the effectiveness of the pain medication in a timely fashion. What is the definition of pain (by the patient) and (don’t even go there with subjective vs. quantitative)
Pain is whatever the patient says it is, wherever the patient says it is.
What is the definition of palliative care.
Unable to cure but can make more comfortable
May include: blood transfusions, surgery, antibiotics, ect.
Five stages of dying
Denial, Anger, Bargaining, Depression, Acceptance
What increases the chance of surviving cancer?
Know the difference between infiltration, infection, phlebitis and venous spasm when the patient states “something is wrong with my IV site”.
- Infiltration: skin, cool, and swollen over insertion site
- Plhebitis: vein hard, skin red and tender
- Systemic IV Response: this is about the blood, not the site
- Fluid Overload: Iv infused too quickly resppiratory respnse and or cardiac response
- Infection: red, swollen, pus - fever, chills, fatigue
- Sodium: 135 - 145
- Potassium: 3.5 - 5.0
- Calcium: 8.4 - 10.6
- Magnesium 1.2 - 2.1
- Phosphate 3.0 - 4.5
- PH 7.35 - 7.45
- partial or complete tearing of ligaments
- no bruising
- pullin or tearing of the muscle, a tendon or both
streaching and tearing of ligaments around a joint with complete displacement of the bone
- break in the continuity of the bone
- complete, incomplete, communuted closed (simple), open (compound)
Braden scale - staging of pressure ulcers
- Stage I: no blanching, redness over bony prominence
- Stage II: blister, abrasion, open
- Stage III: bacterial infection high subcutaneous tissue destroyed
- Stage IV: deep/muscle involved/estensively infected
- Unstageable: eschar/wet oozing exudate be be debrided before it can be staged
- Insulin defienciency due to high levels of blood sugar
- dry skin
- Condition where the body produces too much acid
- rapid breathing
- Decreased blood volume
- from bleeding, dehydration, burns
- Fluid overload, abnormally increased blood volume - expecially plasma vol.
- s/s acitis, crackles, edema, diff breathing, high blood pressure, dyspnea (short breath),
- Causes: blood transfusion, Liver diseaes, CHF, Kidney failure, liver failure,
Restrictive lung disorders
- Decrease size of chest cavity
- stiff lungs: Pneumothorax, Pneumonia, Atelectasis, Fibrosis
Obstructive lung disorders
- Prevent air movement in and out of lung
- Narrowing of resp tract
- Chronic bronchitis and tumors
- breathing in excess of what the body needs
- may result in swallowing air causing the following:
- bloating, burping, passing gas, abdominal pressure.
- Causes carbon dioxide in the blood to decrease which may cause:
- weakness, fainting, dizziness, confusion, agitation, feeling of being outside self, disphoria, feeling like you can't breath
- teletherapy - external radiation, particles alpha, gamma rays pass through the tissue: remove jewerly, check skin
- brachytherapy - internal radiation, implantation for short periods. Requires isolation of the patients, limit time spent less that 30 min. in 8 hrs, private rm no one next door, dosimeter must be worn at all times.
What do you monitor post op to be a good nurse?
- 1. assess LOC
- 2. ABC - airway (top priority), breathing, circulation
- 3. Pain
- 4. Wounds
- 5. IV fluides and site
How to measure pain
- Ask pt. "how would you rate your pain on a scale of 1-10?" 10 meaning you can not take anymore pain.
- FLACC - Face, Legs, Activity, Cry, Consolability
- (used for congnitively imaired or unresponsive pts.)
Restore, improve or maintain funciton of the joint.
Relieve chronic pain
Total Hip replacement: ball and socket replaced
Total Knee replacement: part or all of knee joint/cap replaced
skin condition that is red and irritated, thick, flacky, silvery white patches
What level is considered hyperkalemic?
Level above 5.0
What are two conditions that are treated with a chest tube?
Purpose: to allow air/blood out of pleural space, re-expand lung
- Pneumothorax - air in the upper space of pleura
- Hemothorax - blood filled in lower space
Which respiratory condition causes CO2 retention?
- Emphysema - pink puffer
- Chronic Bronchitis - blue bloater
- Data collection/assessment and teaching
- cultural expectations
- Risk factors
- ability to understand
- Lab values: clotting factores, platelets, ptt, pt
- infection, anemia, organ function, healing, electrolyte, blood donation
- Physical assessment: mobility, skin, respirator, circulation, GI factors
- Reasons for surgery: diagnostic, curative, Restorative, palliative, cosmetic
- urgency of surgery: elective, urgent, emergent
- Minor surgery vs. Major
- Simple vs. Radical
- Prevent contractures: begin 307 days after immobilization, complete in 6-8 weeks
- most common - foot drob, then knees, wrists, fingers and arms
- ankyloisis (fused joints) after 18 mo. no movement.
- Best Nursing Action:
- Gradual mobilization,
- position, turning PROM
- Degenerative joint disease
- Symtoms = after 50-60
- Usually overweight people due to non movement
- Some deformity/fingers
- Degenerative joint disease
- Abnormal immune response, Systemic problem
- Progressive, sometimes fast
- Symptoms 30-40 years old
- Usually underweight due to systemic issue
- Estreme deformity/ankylosis