Exam #2

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stephrigu
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74705
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Exam #2
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2011-03-23 22:57:38
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Surg pt elimination med asepsis surg asepsis sexuality
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Surg pt.,elimination, med.asepsis, surg. asepsis, and sexuality
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  1. Sx Classifications: Seriousness
    • Major
    • Minor
  2. Sx Classifications: Urgency
    • Elective
    • Urgent
    • Emergency
  3. Sx Classifications: Purpose
    • Ablative
    • Pallitative
    • Diagnostic
    • Constructive
    • Reconstructive
    • Cosmetic
    • Restorative
    • Procurement of Organs
  4. Surgical Risks
    • Bleeding disorders
    • Diabetes mellitus
    • Heart disease
    • Liver disease
    • Fever
    • Heavy smoker
    • Chronic respiratory disease
    • Immunological conditions
    • Abuse of street drugs
    • Chronic pain
  5. Symptoms of Shock
    • Low BP
    • Rapid HR
    • Restlessness
    • Moist skin (cold and pale)
  6. Types of shock
    • Hypovolemic
    • Cardiogenic
    • Septic
    • Neurogenic
  7. Types of anesthesia
    • Regional (spinal, epidural, peripheral block)
    • General
    • Local
    • Conscious sedation
  8. Immediate Post-op
    • Flat or to side (unless contraindicated)
    • Administer antiemetic w/ persistent N/V
    • Keep pt. warm
    • Maintain airway. (SPIRO-CARE HOURLY )
  9. Possible Post-op Nursing Diagnosis
    • Alteration in comfort
    • Impaired skin integrity
    • Risk of ineffective airway clearance
    • Risk for volume deficit
    • Anxiety
    • SCD: bathing and groomin
  10. What is early ambulation helpful for?
    • abd. distention
    • depression
    • anxiety
    • thrombophlebitis
    • generalized muscle weakness
  11. Some early post-op complications
    • Abd. distention
    • Atelectasis
    • Hyperstatic pneumonia
    • Hypoxia
    • Nausea
    • Shock
    • Urinary retention
    • Wound hemorrhage
  12. Some later post-op complications
    • Thrombophlebitis
    • Wound infection
    • Wound dehiscence
    • Wound evisceration
    • Pulmonary embolus
    • Malignant hyperthermia
  13. Overall possible Surg pt. Nursing diagnosis
    • Airway clearance, ineffective
    • Breathing patterns, ineffective
    • Constipation, risk for
    • Coping, family, ineffective
    • Fear or Anxiety
    • Fluid volume deficit or excess, risk for
    • Infection, risk for
    • Mobility impaired, risk for
    • Skin integrity impaired
    • Knowledge deficit
  14. Discharge Planning?
    • Planning starts early-starts at admission
    • Plan on continuity of care
    • Discharge instruction sheet
    • Document how pt. went home
    • Follow up
  15. Causes of abdominal distention?
    Surgical manipulation of bowel, swallowed air
  16. Symptom of atelectasis?
    Shallow breathing
  17. Symptoms of hypostatic pneumonia?
    Shallow resp. and fluid accumulation
  18. Reasons for hypoxia?
    • respiratory depressants
    • mucus
    • pain
    • poor positioning
  19. Reasons for nausea?
    • medications
    • eating or drinking before peristalsis returns
  20. Reasons for shock?
    • loss of fluids and electrolytes
    • VS instability
    • trauma
    • medications
    • sepsis
  21. Reasons for urinary retention?
    • medications
    • local edema
    • positioning
  22. Reasons for wound hemorrhage?
    • slipping of suture
    • dislodged clot
    • wound evisceration
  23. Reasons for thrombophlebitis?
    • venous stasis
    • irritation from IV needles
    • blood clot
  24. Causes of wound infection?
    • poor technique
    • "dirty" wound
    • decreased immune system
  25. Causes of wound dehiscence?
    • (seperation of wound edges)
    • old age
    • malnutrtion
    • unusual strain
  26. What is wound evisceration?
    protrusion of abd. viscera through incision
  27. Symptoms of pulmonary embolus?
    • dyspnea
    • tachycardia
    • cough
    • hemoptysis
    • pleuetic pain
  28. NPSG #16?
    • Improve recognition and response to changes in pt's condition
    • Hold a "Time out" before any procedure in the hospital
    • A pre-op verification checklist is requires
  29. What is a core measure?
    • A specific item that can easily be measured in many hospitals.
    • JCAHO uses this method in order to make valid comparisons between hospitals.
    • Uses standardized sets of valid, reliable, evidence-based "core" measures that can be used to track progress in making hospitals safer for everyone.
  30. What is SCIP?
    • Surgical Care Improvement Project
    • This project is a national quality partnership of organizations focused on improving surgical care.
  31. Diprivan?
    • AKA- Propofol
    • General anesthesia
    • short-acting
  32. Atropine?
    • antiarrhythmics
    • anticholinergic
    • antimuscanarics
    • Given pre-op to decrease oral/respiratory secretions
    • Might increase HR
  33. Versed?
    • antianxiety agent
    • sedative/hypnotic
    • benzodiazepines
    • pre-op sedation, conscious-sedation, post-op amnesia
    • short-term
  34. Valium?
    • AKA- diazepam
    • relief of anxiety
    • sedation
    • amnesia
    • skeletal muscle relaxation
    • decreased seizure activity
  35. What do antiemetics generally do?
    to manage nausea and vomiting
  36. What do opiod analgesics generally do?
    Management of moderate to severe pain
  37. What do non-opiod analgesics generally do?
    Used to control mild to moderate pain and/or fever
  38. General use of anti-infectives?
    treatment and prophylaxis of various bacterial infections
  39. What are cephalosporins?
    • chemical modifications of the penicillin stucture.
    • bactericidal
  40. 1st generation cephalosporin?
    1st gen - used for skin/soft tissue infections. primarily active against gram-positive bacteria.
  41. 2nd generation cephalosporin?
    2nd gen - have increased activity against gram-negative micro-organisms and few cover anaerobes
  42. 3rd generation cephalosporin?
    More active against gram-negative bacteria. However, the 3rd gen is less effective against gram-positive cocci.
  43. 4th generation cephalosporin?
    Has antimicrobial effects comparable to the 3rd gen. It has the advantage of coverage against many Pseudomonas species and activity against gram-positive pathogens.
  44. Fluoroquinolones?
    • Are synthetic, broad-spectrum agents with bactericidal activity.
    • The antimicrobial spectrum for fluoroquinolones includes gram-negative and positive aerobes.
  45. What do opioid antagonists do?
    They bind to opiod receptors and competively displace the opiod analgesics from their receptor sites.
  46. Anzemet
    • AKA - dolasetron
    • Antiemetic
  47. Compazine
    • AKA - prochlorperazine
    • Antiemetic
  48. Reglan
    • AKA - metoclopramide
    • Antiemetic
  49. Vistaril
    • AKA - hydroxyzine
    • Antiemetic
  50. Tigan
    • AKA - trimethobenzamide
    • Antiemetic
  51. Zofran
    • AKA - ondansetrom
    • Antiemetic
  52. Narcan
    • AKA - naloxone
    • Opioid antagonist
  53. Morphine Sulfate
    Analgesic
  54. Tylenol & codeine (#3 & #4)
    Analgesics
  55. Demerol
    • AKA - Meperidine
    • Analgesic
  56. Dilaudid
    • AKA - hydromorphone
    • Analgesic
  57. Vicodin
    • AKA - hydrocodone and acetaminophen
    • Analgesic
  58. Percodan
    • AKA - oxycodone and aspirin
    • analgesic
  59. Percocet
    • AKA - Oxycodone and acetaminophen
    • Analgesic
  60. Phenergan
    • AKA - promethazine
    • Analgesic
  61. Nubain
    • AKA - nalbuphine
    • Analgesic
  62. Torodol
    • AKA - ketorolac
    • Analgesic
  63. Ancef
    • AKA - cefazolin
    • 1st generation cephlosporins - antibiotic
  64. Keflex
    • AKA - cephalexin
    • 1st generation cephlosporins - antibiotic
  65. Rocephin
    • AKA - ceftriaxone
    • 3rd generation cephlosporins - antibiotic
  66. Levaquin
    • AKA - levofloxacin
    • fluoroquinolones
  67. Cipro
    • AKA - ciprofloxacin
    • fluoroquinolones
  68. Infancy
    • 0-18 months
    • Gender is assigned, genitals sensitive
    • males may have erections
    • females vaginal lubrication
  69. Preschool
    • 1-5 years
    • Identifies gender
    • labels body parts correctly
    • parent of opposite sex is focus of love
  70. Childhood
    • 6-12 years
    • Becomes curious about sex roles and reproduction
    • friends are usually same sex
  71. Adolescence
    • 12-18 years
    • sex characteristics develop
    • friendships may include the opposite sex
    • may engage in masturbation and sexual activity
  72. Adulthood
    • 18-65 years
    • Establishes family to include sexual activity, values and family roles
    • Between 40-65 hormone production decreased leading to climacteric in both sexes
  73. Older adult
    • 65-death
    • frequency of sexual activity decreases
    • men and women experience altered sexual functioning
  74. Sexuality key concepts
    • acceptance of one's body image
    • sexual identity
    • self-concept
  75. WHO definition: Sexual Health
    • "a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity"
    • sexual intercourse
    • refers to the physical part of a relationship, genital sexual activity
    • gender/all developmental stages in life
  76. Male hormones
    FSH and LH stimulate the testes to release the male sex hormone, testosterone.
  77. Female hormones
    FSH and LH result in the production and release of mature egg cell and in the production of female sex hormones, estrogen and progesterone.
  78. Factors affecting sexual behavior
    • environment
    • illness
    • medications
    • surgery
  79. Primary dysfunction
    the problem has existed most of the individuals adult life
  80. Secondary dysfunction
    • sexual problem is recent in origin
    • HTN
    • Painful intercourse due to vaginal lubrication
  81. Manifestations of altered sexuality
    • sexual abuse
    • inhibited sexual drive
    • impotence
    • ejaculatory dysfunction
    • orgasmic dysfunction
    • dyspareunia
    • vaginismus
  82. How does sexual dysfunction impact activities of daily living?
    • Decrease in self esteem and in self confidence
    • interpersonal relationships may be affected
    • less emotional energy to concentrate on important aspects of daily living
  83. What is asepsis?
    The absence of germs or microorganisms
  84. What is medical asepsis?
    • Those actions designed to reduce the number of pathogens in an area and decrease the likelihood of their transfer.
    • Use of technique of clean to dirty (hand washing, changing pt's bed, cleaning thermometer, ect)
  85. What is surgical asepsis?
    • Actions to make or keep an object or person free of all microorganisms.
    • Sterilization destroys all microorganisms and their spores.
  86. What are nosocomial infections?
    • Hospital acquired
    • Higher in critical care areas (sicker pts and more invasive procedures)
  87. Some normal self-care prevention of biological hazards.
    • Storage and handling of food
    • Hand washing
    • individual tooth brush, ect.
    • immunizations
    • covering cough or sneeze
    • Precautions regarding sexuality
    • keeping newborns out of crowds
    • cleaning, dishwasher, laundry
    • liquid soap, paper cups in bath room
    • keeping contagious disesae people at home
  88. The normal defense mechanisms against infection
    • skin
    • mouth
    • eye
    • respiratory tract
    • urinary tract gastrointestinal tract
    • vagina
  89. What are the steps to the infection chain?
    • Infectious agent
    • Reservoirs
    • Portal of exit
    • Means of transmission
    • Portal of entry
    • susceptible host
  90. Breaking the chain: Use of infectious agents
    • disinfection
    • sterilization
    • disinfectant
  91. Breaking the chain: Reservoir
    • Good dressing techniques
    • non contaminated water pitchers
  92. Breaking the chain: Means of transmission
    • good hand washing
    • good asepsis with dressings
    • isolation techniques
    • proper disposal of urine
  93. Breaking the chain: Portal of entry
    • good care of skin and mucous membranes
    • no contaminated food or food serving utensils
  94. Breaking the chain: Susceptible host
    • identification of high risk pts
    • assessment and maintenance of nutrition and fluid balance
    • promoting therapeutic health habits
    • admin meds and assessment of effects of medicaiton on pt's defense mechanisms
    • supporting body's defenses
  95. The course of infection by stage
    • Incubation - entering to 1st symptoms
    • Prodromal - nonspecific to more specific
    • Illness - specific to type of infection
    • Convalescence - acute symptoms to good health
  96. VRE
    • vancomycin resistant enterococcus
    • enterococcus bacterium that is resistant to the antibiotic vancomycin
    • infected pts show clinical s/s
    • colonized pts do not show s/s
    • category - contact (and mask for respiratory tract symptoms
  97. C. Diff
    • causes pseudomembronous colitis
    • may be due to antibiotic use
    • primary symptom - diarrhea (stool sent to lab)
  98. Why can antibiotic use lead to c.diff?
    Antibiotics diminish normal colon flora and may result in overgrowth and release of toxins which injure mucosa
  99. Treatment of c.diff?
    • Contact precautions
    • May treat with oral flagyl or vancomycin
    • Must wash hands with soap and water
  100. What is MRSA?
    • Methicillin Resistant Staphylococcus Aureus
    • Staph bacteria have become resistant to various antibiotics including penicillin-related antibiotics
  101. What precautions are to be taken with MRSA?
    Precautions may be droplet, contact. ect. depending on where infection is
  102. Colonization?
    • indicates presence of bacteria but absence of signs and symptoms of infection
    • once initial infection for MRSA and VRE is treated, patient can remain colonized for indefinite period of time
  103. What to do with airborne precautions?
    • The door must be closed at all times
    • N95 particulate respirator mask (orange duckbill) MUST BE WORN BY ALL WHO ENTER
  104. What to do with droplet precautions?
    mask must be worn when working within 3 feet of the patient
  105. What to do with contact precautions?
    • gloves upon entry to the room
    • gown when you will be working directly with the patient
  106. 3 things to breaking cycle of infection
    • cleansing
    • disinfection
    • sterilization
  107. Definition of medical asepsis?
    procedures used to reduce the number of microorganisms and prevent their spread
  108. Definition of surgical asepsis?
    procedures used to eliminate all microorganisms including pathogens and spores
  109. Definition of disinfection?
    elimination of pathogenic organisms, with the exception of spores, on inanimate objects.
  110. Definition of sterilization?
    process of destroying all microorganisms, including spores
  111. The 7 principles of surgical asepsis?
    • 1. sterile object to sterile object
    • 2. sterile object on sterile field
    • 3. sterile object or field out of range of vision or an object held below person's waist is considered contaminated
    • 4. contamination by prolonged exposure
    • 5. wet = contaminated
    • 6. fluid flows in the direction of gravity
    • 7. edges of sterile field or container = contaminated
  112. Moist heat
    • autoclave (moist heat under pressure)
    • used for surgical instruments
  113. Radiation
    used in sterilizing drugs, plastics and food
  114. Boiling water
    • requires object to be in boiling water for at least 15 minutes
    • bacterial spores and some viruses resist
  115. Ethylene Oxide gas
    used to sterilize rubber, paper, plastic items
  116. Chemical solutions
    used for instruments and equipment
  117. Which procedures at bedside require sterile aseptic technique?
    • sterile dressing changes
    • urinary catheter insertions
    • preparing and administering injectable medications
  118. Describe an acute wound?
    • orderly and timely reparative process
    • sustained restoration of anatomical and functional integrity
    • caused by trauma from sharp object
    • wound edges clean and intact
  119. Describe a chronic wound?
    • not orderly and timely reparative process
    • unsustained restoration of anatomical and functional integrity
    • caused by friction, secretions, pressures
    • wound edges may be necrotic, drainage maybe present
  120. Primary Intention?
    • skin edges approximated
    • little loss of tissue
    • low risk of infection
    • healing is rapid and primarily by collagen synthesis
  121. Secondary Intention?
    • Wound edges not approximated
    • large and irregular
    • involves loss of tissue
    • takes longer to heal and has greater risk of infection
    • (burns, pressure ulcers, severe lacerations)
  122. Tertiary Intention?
    Wound is initially left open and later closed
  123. When does does hemorrhage occur?
    usually occurs within 24 to 48 hours
  124. When does does infection occur?
    commonly occurs on 4th or 5th day with post-operative wound
  125. When do you get a culture and sensitvity specimen of a wound?
    before starting antibiotics
  126. When does does dehiscence occur?
    commonly 3 to 11 days
  127. When does does evisceration occur?
    • medical emergency
    • IMMEDIATE ACTION
  128. What are the complications of a fistula?
    • increases risk of infection
    • fluid/electrolyte imbalance
  129. Definition of inflammation?
    protective response of body tissues to irritation or injury
  130. Definition of infection?
    infectious agent is living and growing in the tissues and overcomes the body's normal defenses
  131. S&S of an infection?
    • fever
    • tenderness
    • pain
    • elevated WBC
    • purulent and odorous drainage
  132. Factors influencing healing
    • age
    • nutrition
    • general health
    • weight
    • smoking
    • oxygen availability
    • drugs
    • wound stress
  133. When assessing the appearance of a wound what 7 things should you note?
    • 1. size
    • 2. appearance of tissue
    • 3. edges appoximated
    • 4.signs of inflammation or infection
    • 5. amount of discharge with color and odor
    • 6. discomfort
    • 7. drains (hemovac, jackson-Pratt (JP), penrose)
  134. What are the 5 purposes of wound dressing?
    • to protect wound from microorganism contamination
    • promote healing
    • support or splint the wound site
    • promote thermal insulation of the wound surface
    • provide maintenance of high humidity between wound and dressing
  135. What are the main surgical dressing layers?
    • Contact or primary layer
    • Absorbent layer
    • Outer protective layer
  136. Types of dressings?
    • Woven guaze sponges
    • non-woven sponges
    • non-adherent guaze
    • self-adhesive
    • transparent
    • hydrocolloid
    • hydrogel
    • alginate
  137. Mode of application?
    • dry
    • wet to dry
  138. Goals for wound treatment
    • keep the ulcer bed continuously moist
    • debridement
    • type, size and depth of wound
    • controlling exudate
    • caregiver time
    • area where wound is located
    • hospital protocol
  139. What is important to teach with meds going home
    • Take meds exactly as prescribed
    • evenly spaced intervals of dosing
    • take medication for the full length of time prescribed or until all the drug is gone
    • infection may return if the full course of therapy is not completed
    • any leftover medication should be appropriately discarded
    • provide list of adverse reactions, drug & food interactions

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