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Interventions
Exam 2
| Question | Answer |
|---|---|
| Maintaining Fluid Balance | -Deficit or Increase in osmolality is sensed by osmo-receptors in hypothalamus: Stimulates pituitary gland depending on high or low osmolality to either release ADH or suppress release of ADH |
| Increase in plasma osmolality stimulates: | -Thirst -Release of ADH Results in: increased free water in body, decrease in plasma osmolality |
| Stimulants of the release of ADH | -Increased plasma osmolality: dehydration, increased Na intake -Decreasing circ. blood vol: hemorrhage,anemias -Stressors: Nausea, Nicotine, Morphine |
| Anti-Diuretic Hormone: ADH | -Affects water reabsorption -Stops secretion of urine -Retains liquids in body -Secreted by adrenal cortex: help regulate water and electrolytes (glucocorticoids, mineralcorticoid) |
| Post-Op patient: Fluid Balance Issues | -Decreased serum osmolality after sx(loss of bld,stress,narcs): Results in low UO-stimulates release of ADH -Decrease in plasma osmolality (stimulates secretion of ADH, lead to H20 excess): Results in secretion of urine to gain fluid balance |
| Crystalloid | -Isotonic -Hypotonic OP <250,fluid shifts out of bld vessels into cells and interstitial space(cell dehydration) -Hypertonic-OP >375,> cell,pull fluid from cell into vascular space (intravascular dehydration, intracellular overload) |
| Colloid | -Hypertonic -I intravascular osmotic pressures -Remain w/ ivs and pull fluid into space like sponge -Bld products-vol expanders -Cryoprecipitate-clot factors -Platelets-aggregations&clot -Fresh Frozen Plts-clot -Albumin-restore intravascular vol |
| TPN | -Hyperalimentation -Supplied through vein -Hypertonic,proteins,vit,minerals -Supplement change daily according to lab work -May have lipids -Lab work daily:lytes,bs,tri,ldh,lipase,liver profile) -Infused through central line unless dextrose 10% or |
| Fluid Volume Deficit | -D UO -I urine concentration -Wt loss -I pulse,hypotension -D venous filling -D pul artery pressure -D cvp -Thirst -D skin turgor -D pulse vol -Changes in mental state -I temp -Dry skin -Dry mucous membranes |
| Fluid Volume Excess | -Edema -Wt gain -SOB -Orthopnea -Fluid intake > output -3rd heart sound -Pul congestion -Abnormal breath sounds/rales -Change in resp -Change in mental status -I cvp&pul artery pressure -JVD -Oliguria -D specific gravity of urine |
| Infiltration | -Swelling,coolness,discomfort@site, slowed infusion rate, absence of bld return -Discontinue IV and restart in another location; Apply warm soaks to decrease swelling |
| Phlebitis | -Pain,warmth,and redness at site, vein may feel hard and cordlike, slowed infusion rate -Discontinue IV and restart in another location; apply warm soaks to decrease comfort; do not irrigate -Change q72h, use large veins rather than catheters |
| Infection | -Local:redness,warmth and purulent drainage at IV site -Systemic: fever,chills, malaise, and elevated WBC -D/c IV and restart, Culture catheter tip and draw bld cultures, treat with appropriate antibiotics |
| Fluid Overload | -Elevated BP, increased pulse and respirations, dyspnea, crackles, neck vein distention, weight gain =Slow IV to "keep open" rate and notify physician; place clietn in high or semi-fowler's postion; adminster 02 as needed |
| Air embolism | -Central venous catheters,seldom seen with peripheral venous lines -Pain in chest,shoulder,orback, dyspnea,hypotension,thready pulse, cyanosis,loss of consciousness -Place on left side in trendelenburg position,notify physician, monitor vs closely |
| IV practice | -Achieve high bld levels -Quick admin of drug -Know drug,how fast to give and dilution -Always swab port -Flush b/f & after -Aspirate for bld return&to get any air bubbles in port out -Check back in 15 min -Technique=push,pinch,push,pinch |
| Modes of Transmission | -Direct:person to person-touching a pt -Indirect:needles,dressing -Droplet:large particles that travel 3 ft-influenza virus -Air-droplet,nuclei or residue or evaporated droplets suspended in air or carried on dust-coughing, sneezing ex:TB |
| Modes of Transmission | -Vehicles: contaminated items,water, drugs, blood, food, ex: pseudomonus -Vectors: external mechanical transfer-mosquito, flea, tick, ex: malaria |
| Nosocomial Infections | -Exogenous: arises from microorganism external to individual that do not exist as normal flora ex: salmonella -Endogenous: occur when part of the client's flora becomes altered ex: yeast |
| MRSA | -Most important factor of resistance is antimicrobial use -Once an organism is resistant to one antibiotic in a class it is usually resistant to all antibiotics in that class |
| Principles of Surgical Asepsis | -A sterile object remains sterile only when touched by another sterile object -Only sterile objects may be placed on a sterile field -A sterile object or field out of the range of vision or an object held below a patient’s waist is contaminated |
| Principles of Surgical Asepsis | -A sterile object or field becomes contaminated by prolonged exposure to air |
| Principles of Surgical Asepsis | -When a sterile surface comes in contact with a wet,contaminated surface,the sterile object or field becomes contaminated by capillary action -Fluid flows in the direction of gravity -The edges of a sterile field or container are considered contaminate |
| Types of PPE | -Gloves -Gowns/aprons–protect skin and/or clothing -Masks and respirators–protect mouth/nose -Respirators–protect respiratory tract from airborne infectious agents -Goggles – protect eyes -Face shields – protect face, mouth, nose, and eyes |
| Do's and Don't of Glove Use | -Work from clean to dirty -Limit “touch contamination” –Don’t touch face or adjust PPE w/ contaminated gloves –Don’t touch envir surfaces except as nec during pt care |
| Do's and Don'ts of Glove Use | -Change gloves:During use if torn&when heavily soiled, After use on each pt –Never wash or reuse disposable gloves |
| Key Points about PPE | -Don b/f contact w/pt, before entering room -Use carefully–don’t spread contamination -Remove and discard carefully,either at doorway or immediately outside pt room;remove respirator outside room -Immediately perform hand hygiene |
| Sequence for putting on PPE | -Gown first • Mask or respirator • Goggles or face shield • Gloves |
| Gown | • Select appropriate type and size • Opening is in the back • Secure at neck and waist • If gown is too small, use two gowns – Gown #1 ties in front – Gown #2 ties in back |
| Mask | • Place over nose, mouth and chin • Fit flexible nose piece over nose bridge • Secure on head with ties or elastic • Adjust to fit |
| Respirator | •Select a fit tested respirator •Place over nose,mouth&chin •Fit flexible nose piece over nose bridge •Secure on head with elastic •Adjust to fit •Perform a fit check – –Inhale – respirator should collapse –Exhale – check for leakage around face |
| Eye and Face | • Position goggles over eyes and secure to the head using the ear pieces or headband • Position face shield over face and secure on brow with headband |
| Gloves | • Don gloves last • Select correct type and size • Insert hands into gloves • Extend gloves over isolation gown cuffs |
| Contaminated | •Contaminated – outside front: areas of PPE that have been in contact w/ body,materials,or envir surfaces where the infectious organism may reside |
| Clean | •Clean–inside,outside back,ties on head and back • Areas of PPE that are not likely to have been in contact with the infectious organism |
| Removing PPE | • Gloves • Face shield or goggles • Gown • Mask or respirator |
| Where to Remove PPE | • At doorway, before leaving patient room or in anteroom* •Remove respirator outside room, after door has been closed* *Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub |
| How to Remove Gloves | • Grasp outside edge near wrist • Peel away from hand, turning glove inside-out • Hold in opposite gloved hand • Slide ungloved finger under the wrist of the remaining glove • Peel off from inside,creating a bag for both gloves • Discard |
| Remove Goggles | • Grasp ear or head pieces with ungloved hands • Lift away from face • Place in designated receptacle for reprocessing or disposal |
| Remove Isolation Gown | • Unfasten ties • Peel gown away from neck and shoulder • Turn contaminated outside toward the inside • Fold or roll into a bundle |
| Remove Mask | • Untie the bottom, then top, tie • Remove from face • Discard |
| Remove Respirator | • Lift the bottom elastic over your head first • Then lift off the top elastic • Discard |
| PPE for Standard Precautions | • Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin |
| PPE for Standard Precautions | • Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated |
| PPE for Standard Precautions | Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions |
| -Bed bath -Suction oral secretions -Transporting a patient in a wheel chair -Responding to an emergency where blood is spurting -Drawing blood from a vein -Cleaning an incontinent patient with diarrhea -Irrigating a wound -Taking vital signs | -Generally none -Gloves and mask/goggles or a face shield – sometimes gown -Generally none required -Gloves,fluid-resistant gown, mask/goggles or a face shield -Gloves -Gloves w/wo gown -Gloves,gown,mask/goggles or a face shield –Generally none |
| Contact Precautions | -Required when organism can be transmitted to others by contact w/infectious secretions: MRSA, VRE, Purulent wounds,Infectious diarrhea |
| Contact Precautions: Appropriate Barriers | –Standard Precautions –Gown and/or gloves –Private room or cohort patients –Dedicate patient care equipment to single patient when possible –Decontaminate equipment after use |
| Airborne Precautions | • When a patient coughs, AIRBORNE ORGANISMS can potentially stay suspended in the air for hours without proper ventilation. • Common diseases that require Airborne Precautions: – Tuberculosis – Measles – Chicken Pox – Zoster in immune compromised |
| Airborne Precautions: Appropriate Barriers | – Standard precautions – Negative airflow room – Special respirators - N95 (for TB) – Patient wears surgical mask for transport •Chicken pox – health care workers must be immune to care for patient – mask not necessary |
| Droplet Precautions | • Droplet – when the patient coughs, large droplets containing infectious organisms that are aerosolized, land within three feet of the patient • Common infections requiring Droplet Precautions: – Bacterial Meningitis – Influenza – Pertussis |
| Droplet Precautions: Appropriate Barriers | – A regular surgical mask worn within three feet of the patient. – Standard precautions. • NO SPECIAL AIRFLOW IS REQUIRED |
| Urinalysis:Expected Normals | -Color:pale yellow-amber -Clarity:clear-slightly hazy -PH:4.5-8 -Protein: - -Blood: - -Glc: - -Ketones: - -Specific Gravity: 1.005-1.030 -Vol:600-2500/24h |
| Urine: Outside the Norm | -Decreased output means dehydration or obstruction -Darker the urine the more concentrated which means the more dehydrated the patient -Cloudy usually means infection, sediments may mean filtration issues |
| Incontinence | -Stress:sudden involuntary loss of urine(<50ml) d/t sudden increase in ab pressure(cough/sneeze) -Urge:sudden loss after strong feeling of need to urinate (common in UTIs) -Reflex:occurs when bladder reaches specific vol (spinal pts,neuropathy) |
| Incontinence | -Functional: inability or unwillingness for person with normal sphincter control to reach bathroom (confusion,disorientation) -Total: continuous, involuntary, unpredictable loss of urine from non distended bladder |
| Urinalysis | -UA -Not a sterile specimen -Color, turbidity, pH, Sp Gr, protein, glc, ketones |
| 24 hour Urine | -Must collect (or account) for all urine in 24 hour period, must be on ice |
| Signs and Symptoms of UTI | -Fever -Flank pain -Dysuria -Frequency -Urgency -Pyuria -Hematuria |
| Client Teaching | -Importance of fluid intake (1500/2000 ml/day) -Void every 4 hours -Adequate perineal hygiene -Women wipe from front to back -Void after sex -Avoid tight fitting pant, harsh soap, bubble baths, and powder |
| Temperature Calculation | F= (1.8 x C) + 32 |
Created by:
prettyinpink7
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