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54 unit1.1
Therapeutic Enviro, Vital Signs, Mobility, Safety, Activity & Excercise
| Question | Answer |
|---|---|
| Apical Pulse | Location: 4th-5th intercostal space at Left mid-clavicular line. Apical & radial locations are most common site for pulse rate assessment. When meds effect HR, apical pulse is more accurate assessment of heart function. Requires stethoscope. good 4infant |
| Antipyretics | drugs that reduce fever |
| BMR | Basal Metabolic Rate accounts for the heat produced by the body at absollute rest. Depends on surface area, thyroid hormones, testosterone. Increases 10% per 1degreeCelcius increase. |
| Bradycardia | pulse less than 60/minute |
| Cardiac Output | The volume of blood pumped by heart in 1 minute. HR X SV (stroke volume)=mL per min Cardiac Output. HR70/min X SV70mL = 4900mL per min Cardiac Output |
| Conduction | 505 transfer of heat from one object to another (direct contact). Ex. solids, liquids, gasses |
| Convection | 505 transfer of heat away by air movement. |
| Evaporation | 505 Transfer of heat energy when a liquid is changed to gas. Approx 600-900mL/day from skin/lungs= water/heat loss. |
| Diaphoresis | 505 Visible perspiration primarily on forehead/upper thorax. |
| Radiation | 505 Transfer of heat from one surace of one object to surface of another without direct contact between two. 85% body surface to environment. periferal vasodialation = heat from internal organs to skin for radiation heat loss. |
| Afebrile | 507 "pyrexia" Heat loss mechanism is unable to keep pace with excessive heat production = abnormal high in body temp. Usually not harmful if <39c or 102.2F (multiple temp readings). Hypothalamus controlled. |
| diffusion | 532-533 Measured by O2 in blood. Norm 95-100%. O2 diffuses from alveoli to pulmonary blood attaches to hemoglobin in RBCs to L side of heart out peripheral capillaries then O2 attaches to tissues. |
| Hypertension | 537-8 Systolic >140mmHg / Diastolic >90mmHG. Associated with thickening/loss of elasticity in arterial walls. Increased risk= family history, obesity, smoking, heavy alcohol consum, hi sodium, sedentary life, continued expos to stress,diabetic,age,AfriAme |
| Hypotension | 538 systolic <90mmHG Dilation blood vessels, lo blood vol., lo heart muscle pump (myocardial infarction), hi HR, pallor, skin mottling, clammy, confusion, lo urine output. Life threatening |
| orthostatic hypotension | 538 "Postural Hypotension" occurs when normotensive person develops symptoms/lo BP when rising to upright position, hi HR. dehydrated, anemic, recent blood loss, prolonged bed rest, beds. Measure supine, sitting, standing after 1-3 min. faint/dizzy/weak.. |
| postural hypotension | 538 "orthostatic hypotension" occurs when normotensive person develops symptoms/lo BP/hi HR when rising to upright position. dehyrdration, animic, blood loss, prolonged bedrest, meds. faint/dizzy/weak. measure supine,sit,stand 1-3min after position chnge |
| orthopnea | 920 Abnormal condition in which clients must use multiple pillows when lying down or must sit with arms elevated and leaning forward to breathe. Labeled by # pillows used: 3-pillow orthopnea. |
| radial pulse | 521-23 Radial/thumb side of wrist common site used to assess character of pulse peripherally and assess status of hand circulation. only > 80/p. *do not press too hard. Good for teaching clients "own" pulse. |
| Sphygmomanometer | 543 BP cuff. 2types: aneroid needs biomedical colabration every 6mo. Murcury always start/end at 0. Cuff width is <40% of circumfrance of midpoint of limb. Use forearm if arm too big. |
| tachycardia | 913-15 >100 pulse. higher in infants. |
| aerobic | 643 With O2. Needs O2 for survival/multiplication...) cause more infections in humans than anaerobic. Ex. Staphylococcus aureus, Streptococcus |
| anaerobic | 643-44 Without O2. Organisms thrive in lo/0 O2. Infections deep in pleural cavity/joint/deepsinus tract. Tetanus, gas gangrene, botulism. Clostridium difficile (C-diff). |
| asepsis | 654-660,668-671 Absence of pathogenic microorganisms |
| medical asepsis | 655 Clean technique, procedures to lower#/transfer organisms. Hand hygiene/clean gloves/clean environ. Standard precautions used. |
| standard precautions | 655 Certain principles/procedures to prevent/control infection/spread = basic medical asepsis techniques to break infection chain. Blood/ bodyfluids/nonintact skin/mucous membranes. OSHA |
| indurated | 569 Hardened |
| edema | 569 areas of skin swollen from buildup of fluid in tissues |
| exudate | 1283 part of would assessment describes amount, color, consistency and odor of wound drainage. Excessive=infection |
| granulation tissue | 648,1282 red moist tissue composed of new blood vessels that indicate progress toward ealing. From chhronic inflammation and is not as strong as collagen and forms scar tissue |
| eschar | 1282 black or brown necroti tissue needed to be removed before healing can proceed |
| slough | 1282 soft yellow or white tissue stringy substance attached to wound bed that needs to be removed before wound can heal |
| nosocomial infection | 648 Health Care-Associated Infections (HAIs) |
| iatrogenic infections | 648 Type of Health Care-Associated Infection that results from a diagnostic or therapeutic procedure |
| bacteriostasis | 644 No growth/reproduction of bacteria (cold temps) |
| inflammatory response | 646 protective reaction to neutralize pathogens and repair body cells. Defense mechanism to protect against infection |
| systemic | 645, 908, 1225-9 An infection that affects the entire body instead of just a single organ or part and an become fatal if undetected or untreated. |
| surgical asepsis | sterile. 7 principles:1)sterile to sterile=steril 2)only sterile objects in sterile field 3)no out of range below waist 4)no prolonged exposure to air 5)wet surfaces contaminated by capillary action 6)gravity 7)1" boarder |
| footboard | board placed on the end of bed for patients to push against to move up in bed |
| friction | a force that occurs in the direction to oppose movement |
| hemiplegia | "heimparesis" Paralysis of one side of the body, usually resulting from damage to the corticospinal tracts of the CNS. Mostly caused by stroke. |
| hemiparesis | "hemiplegia" Paralysis of one side of the body, usually from a stroke. |
| isometric contraction | involve tightening or tensing of muscles without moving body parts. |
| isotonic contraction | muscle contraction and change in muscle length. Actual movement to create change in muscle length. |
| proprioception | awareness of the position of the body and its parts. Proprioceptors located on nerve endings in muscles, tendons, and joints. |
| ROM | Range of Motion. mobility.movement of a joint through extent of limitations. Can be active, active assisted or passive. |
| trapeze bar | triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. Allows client to pull with the upper extremities to raise the trunk off the bed. |
| restraint | human, mechanical and/or physical device that is used with or without the client's permission to restrict his or her freedom of movement or normal access to a person's body. |
| seizure | hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic as in a seizure disorder or transient and acute (head injury) |
| seizure precaution | encompass all nursing interventions to protect the client from traumatic injury, positioning for adequate ventilation and drainage of oral secretions, and providing privacy and support followup. |
| status epilepticus | medical emergency. Continual seizures without interruption |
| atelectasis | collapse of alveoli. One of the most common respiratory complications. |
| hypostatic pneumonia | inflammation of the lung from stasis or pooling of secretions. One of the most common respiratory complications. |
| disuse osteoporosis | immoilization results in bone resorption so bone less dense or is atrophied. At risk for pathological fractures. |
| thrombus | Accumulation of platelets/fibrin/clotting factors & cellular elements of blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel. Caused by: damage to wall, altered blood flow, altered blood constituents |
| immobility | inability of person to move about freely |
| joint contracture | abnormal and possibly permanent condition characterized by fixation of the joint. Caused by disuse, atrophy and shortening of the muscle fibers. |
| embolus | a dislodged venous thrombus. Possibly travel through circulatory system to the lungs and impair circulation/O2. 90% begin in deep veins of lower extremities. |
| logroll | getting patient from supine to side who have suffered spinal cord injury or are recovering from neck/back/spinal cord surgery. Keeps spinal column straight alignment. |
| muscle atrophy | Loss of muscle tone and joint stiffness usually due to disuse. |
| pressure ulcer | impairment of skin as a result of prolonged ischemia in tissues. initial is inflammation usually over bony prominence. |
| exudate | describes the amount, color, consistency and odor of wound drainage and is part of the wound assessment. excessive indicates presence of infection. |
| hypoxemia | low levels of arterial O2 |
| leukocytosis | increased number of circulating WBCs |
| phagocytosis | process that involves the destruction/absorption of bacteria by WBCs (neutrophils/monocytes) |
| sanguineous | containing red blood cells. Bright red: indicates active bleeding. |
| serous | clear, like plasma |
| purulent | containing WBCs and bacteria |
| virulence | ability to survive in the host or outside the body |
| pathogen | infectious agent |
| necrotic | dead (tissue) |
| colonization | a microorganism is present or invades a host, grows and/or multiplies but does not cause infection |
| alopecia | hair loss. Hair becomes brittle and broken. Results from chemotherapy, hormonal changes, improper hair practice, head trauma, poor hygiene, genetics. |
| epidermis | outer layer of skin composing of several thin layers. Shields against water loss/injury/disease entry. Inner layer new cells. Outer layer normal bacteria flora. |
| gingivitis | gum inflammation |
| neuropathy | degeneration of the peripheral nerves characterized by a loss of sensation. |
| abrasion | scraping or rubbing away of epidermis that will result in localized bleeding and later weeping of serous fluid. superficial with little bleeding and considered partial-thickness wound. |
| cerumen | earwax |
| approximated | close together |
| blanching | turning white |
| debridement | removal of nonviable necrotic tissue. necessary to rid wound of source of infection/visualize wound/allow healing |
| dehiscence | partial or total separation of wound layers. (disease/obese are at risk) |
| evisceration | protrusion of visceral organs through a wound opening |
| fistula | abnormal passage between two organs or between an organ and the outside of the body. Increase risk of infection and fluid/electrolyte imbalances. Chronic drainage=skin breakdown |
| hemorrhage | excessive bleeding |
| hematoma | localized collection of blood underneath the tissues. swelling/change in color/ sensation/warmth/mass of bluish discoloration. dangerous if near major vessel due to constriction |
| hemostasis | an arrest of bleeding or of circulation. Stagnation of blood |
| induration | hardening |
| laceration | wound or irregular tear of the flesh |
| tissue ischemia | tissue death from pressure applied over a capillary that exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time. |
| shearing force | force exerted parallel to skin resulting from both gravity pushing down on the body and resistance between the client and surface (patient is slid over bed but skin stuck to sheets by friction) |
| serosanguineous | pale, red, watery: mixture of clear and red fluid |
| primary intentions | wound that has approximated edges. Healing by epithelialization is fast with minimal scar formation |
| secondary intention | wound edges are not approximated (pressure ulcers, tissue loss, burns) Wound heals by granulation tissue formation, wound contraction and epithelializtion. Scars usually form |
| tertiary intention | delayed primary closure to reduce infection then edges are approximated. |
| embolus | dislodged venous thrombus. Possibly travel through circulatory system to the lungs and impair circulation/oxygenation. 90% begin in deep veins of lower extremities. |
| stomatitis | Inflammation of the mouth, including the lips, tongue and mucous membranes. (chemo/radiation/nasogastric tube intubation/infection of mouth |
| propriocetion | awareness of the position of the body an its parts. monitored by proprioceptors located on nerve endings in muscles, tendons, and joints. |
| febrile | core temperature of 100.4 or greater. Having a fever. |
| hematocrit | percentage of red blood cells in the blood determines blood viscosity |
| center of gravity | balancing one's body over the center as to balance with gravity. |
| perineal care | pts most in need are those at greatest risk for getting infection (uncircumcised males, catheters, rectal/genital surgery/childbirth) |
| ADL | Activities of Daily Living. shopping, preparing meals, writing checks, taking meds, toilet, ablitory... |
| EBP | Evidence Based Practice. problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician's expertise and client preferences/values in decisions about client care |
| peer-reviewed | a panel of experts familiar with the article's topic or subject matter has reviewed the article |
| QI | Quality Improvement. defined by TJC The Joint Commission. approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others. (improve health care related processes.) |
Created by:
hopewolf
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