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DCCC 110 Test 2

Stress, adaptation, & cognition, immunity, perfusion, & oxygenation

Define Stress A real or perceived event or demand made on an individual/family that causes said person/family to appraise the event/demand for meaning and determine if resources meet or exceed the ability to overcome. These are all individual and dynamic.
What is neutral stress? An event or demand that causes little to no stress. This is easily managed and does not go through resources nor does it upset the equilibrium.
What is a Challenging stressor? This event or demand is manageable, but it does require the use of resources, but is not taxing on the individual.
What is a Threatening stressor? An even or demand that is taxing on the individual(s) and exceeds the resources available and is disrupting to the equilibrium.
What is a stressor? A set of responses, either cognitive,emotional, or behavioral, to single or multiple events/demands. These are dynamic and individualized.
What determines the outcome of the interaction of a stressor? The current level of functioning (antecedents), The information processing (scope and meaning), The physiological and psychological responses
What are examples of Physiological stressors? Chemical agents, physical agents, infectious agents, nutritional imbalance, genetic/immune defects, hypoxia
what are the effects of a physiological stressor? The specific effect: alteration of normal body functions/structure. The general effect: the stress response.
What are examples of psychological stressors? These can be real or perceived; accidents, dramatic experiences, fear, rapid changes in the world, coping with anxiety, guilt, frustration, loss, or fear.
Define adaptation It is the change that take place as a result of the response to a stressor. It is an ongoing process to maintain equilibrium in both internal & external environments.
How is adaptation indicative of health? The ability to change positively is directly related to health.
What does capacity show? The maximum amount of ability and functioning at an adequate level when under stress.
Define Cognition Cerebral functioning, including the ability to perceive and understand one's world.
How is cognition related to stress? Knowledge is acquired and gained through perception, reasoning, and intuition and needed during the appraisal of an event/demand.
Describe the characteristics of stress overload. One may display anger, impatience, feelings of pressure or tension, inability to function or make decisions, physical & psychological symptoms.
What are the interventions of stress overload? Mobilize any support system, reduce stress through relaxation, initiate cognitive behavioral therapy.
What is collaborative treatment focused on? Rehabilitation, either through medication or counseling. The nurse provides education for medication and provides support during counseling.
What is coping? Being action oriented toward a goal to change a situation, including stress management efforts.
What are the different coping mechanisms? Constructive mechanism is when an individual treats a stressor as a warning & elects to resolve the problem. Destructive mechanisms is when an individual addresses the stress or anxiety associated with the stressor without resolving the problem (evasion)
What are coping mechanisms effectiveness? The continuum of coping response is not always one or the other. Mechanisms can be Effective(adaptive) or Ineffective (maladaptive) or a bit of both.
How can one determine if the coping mechanism is maladaptive? There is an inability to assess the stressor and/or respond appropriately.
What is involved in problem-focused coping? The involves cognitive process of evaluating the situation and taking action to manage the situation. Can be carried out in aggressive or rational efforts to change the situation or stressor.
What is involved in emotional-focused coping? This is more indirect and emphasizes on the regulation of the emotional response that occurs due to a situation. This can include isolation or withdraw or seeking drugs and alcohol to escape.
How does one learn coping mechanisms? They can be learned by family practices, past experiences or sociocultural learnings.
List some examples of coping mechanisms. crying, laughing, sleeping, cursing, withdraw, lack of eye contact or physical activity, exercise, limiting relationships, smoking, or drinking. These behaviors help a person decrease stress and anxiety.
Define Anxiety. An uneasy feeling of discomfort or dread often from and unknown source. A feeling of apprehension caused by anticipating danger. A normal response to stress.
Explain Mild Anxiety. Stems from the stress of daily living. Can be effective in problem solving because of heightened senses, alertness, and increased questioning. Can cause restlessness until the perceived stressor is relieved.
Explain moderate anxiety. Narrows perceptual field. Can only concentrate on impending problem & "fixing-it", inattention to other communication and details. Physiological symptoms: slight increase in respirations & pulse, "butterflies" in stomach, tremors, muscle tension.
Explain severe anxiety. A clinical issue. Ones judgement is impaired & can be a crippling experience with inability to process stressors or cope. Physiological symptoms: nausea, headache, tachycardia, hyperventilation, trouble speaking, increased motor function. Maladaptive
Explain panic anxiety. Loss of control, with experience in dread, a disorganized state of increased physical activity & distorted perception, without rational thoughts. Physiological symptoms: chest pressure, choking, trembling, sweating. Can lead to exhaustion or death
How does stress effect physiologic needs? Can change appetite and activity level. May also increase respirations, blood pressure and pulse.
How does stress effect safety and security needs? Can cause the feeling of threat and nervousness. One can become inattentive. May use ineffective coping mechanisms.
Hoes does stress effect love and belonging? While under stress one may blame others, and become aggressive. One may withdraw or isolate themselves or even become overly dependent.
How does stress effect self esteem? When under stress and individual may become a workaholic, or use attention seeking behaviors.
How does stress effect self actualization? One can lack control, refuse to accept reality, or become self-centered.
What is homeostasis? Physiologic mechanisms within the body respond to internal changes to maintain equilibrium.
What is Allostasis? Achieving stability or homeostasis through physiologic or behavioral changes. Negative effects can lead to autoimmune diseases (Grave's Disease, Rheumatoid arthritis, Systematic Lupus Erythemal), GI (GERD, IBS), Respiratory (asthma), Cardio(Hypertension)
What is Local Adaptation Syndrome (LAS)? Localized responses to stressors, short term, specific to tissue/organ. The stress may be dramatic or pathologic. 2 most common responses are the reflex pain response & the inflammatory. LAS is a short-term, homeostatic adaptive process.
How does the pain reflex response work? The CNS response to pain. It is rapid and automatic serving as a protective mechanism to prevent injury. Reflect depends on the functioning of the neurologic relax arc. Pain = pull back; like setting your hand on a hot surface.
How does the inflammatory response work? It is a localized response to injury or infection, it localizes and prevents spread of infection and promotes wound healing. Symptoms: Pain, swelling, heat, redness, and changes in function.
How does the General Adaptation Syndrome (GAS) help one to overcome stress? A physiological response to stress, can be from physical or emotional stressors. The Stages: Alarm reaction, Stage of resistance, and stage or exhaustion vary greatly depending on severity and duration of stressor, health, and coping mechanisms.
What happens during the Alarm reaction stage? This is when a person perceives a stressor and defense mechanisms are activated. ANS initiates Flight or fight. Shock Phase: increases oxygen intake, cardiac output, BP, energy levels & alertness. Countershock: reversal of body changes
What does flight or fight involve? the response of hormones to prepare the body to either fight off a stressor or run away from it.
What happens during the stage of resistance? Body now try to adapt to the stressor. vitals, hormones, and energy levels return to normal. If LAS can control Homeostasis starts to return. If body is too damaged then adaptive mechanisms become exhausted.
When and why does the stage of exhaustion occur? Exhaustion is the result when adaptive mechanisms can no longer defend. Without defense against the stressor the body may rest & mobilize defenses to return to normal, or reach total exhaustion and die.
What is a crisis? A disturbance by a perceived event, such as perceived loss, a threat of loss or a challenge. Usual coping method are ineffective, resulting in higher anxiety. Can be Maturational, Situational, or Adventitious.
When can a maturational crisis occur? During developmental events that require a role change, such as when teenager transitions into adulthood.
When can a situational crisis occur? When life disrupts a person psychological equilibrium, such as a job loss, death of a family member or loved one.
When can a adventitious crisis occur? These are accidental and unexpected events, usually result in multiple losses or major environmental changes, for example an earthquake or hurricane or a fire.
What are examples of developmental stress? Progressing through normal stages of development: Infant learning to trust others, toddler learning to control elimination, school-age child socializing with peers, adolescent striving for independence, middle-age adult accepting signs of aging.
What are examples of situational stress? May occur at any time in life: illness or traumatic injury, marriage or divorce, loss (belongings, relationships, family member), new job, role change.
Communication competence involves what? Communication that is both effective and appropriate. Effective meaning the communication goals are met and appropriate meaning that the communication has been adapted to people and situation.
What is intrarpersonal communication? "Self talk". Internal thought process where thoughts are entwined with emotions and values.
What is interpersonal communication? Dynamic process of communication between people. Therapeutic: interacting with a patient. Interprofessional: interacting between professionals.
Describe an assertive communication style. Someone who is honest, direct and accurately expresses their feelings.
What are the goals of a helping relationship? Goals are determined cooperatively and are defined by the terms of te patients needs. It is a dynamic relationship that is purposeful and time limited.
What happens during the orientation phase of a helping relationship? Introductions are made and address the nurse by name. The roles of both parties are defined. Goals of the relationship are defined. Location, frequency, and length of relationship is determined.
What happens during the working phase of a helping relationship? The patient actively participates in the relationship. Patient cooperates while working towards achieving mutually acceptable goals. Patiet expressed feelings and concerns to the nurse.
What happens during the termination phase of a helping relationship? Patient identifies the goals accomplished or any progress made toward goals. Patient will verbalize any feelings or concerns about termination of relationship. Can happen at end of shift or at discharge.
What is therapeutic relationship? One that is patient centers, honoring psychological and spiritual aspects, as well as physiological.
When does an actual loss occur? This can be recognized by others as well as by the person sustaining the loss. Such as a limb, child, object, money or job.
When does a perceived loss occur? This is only experienced by the person suffering the loss, but is intangible to others, Such as loss or youth or independence.
When does an anticipatory loss occur? When a person displays loss and grief behaviors for a loss that has yet to occur. As in a serious illness.
What is grief? an internal emotional reaction to loss that is caused by separation or death.
When would one display mourning? These are actions and expressions of grief that include symbols and ceremonies.
When someone is bereaved what loss have they suffered? They are in a state of grieving from loss of a loved one.
If someone has dysfunctional grief what may they experience? With unresolved they may have trouble expressing their feelings of the loss or even deny them.It may also be a state of bereavement that extends for a lengthly period of time. With inhibited grief that may manifest their grief as somatic symptoms.
What is the first stage of grief and the common reactions? Denial causes a person to deny the reality if the death and may repress what is discussed. It is a coping mechanism for time to adjust. Often a short stage "I'm fine" syndrome. May even refuse treatment because they are "not sick".
What is the second stage of grief and the common reactions? Anger expresses rage & hostility. "WHY ME?". Anger stage can also equal pain. This stage will comply with most treatments, even if grudgingly. Anger is therapeutic "I HATE this cancer!" Nurse should respond calmly & with respect. Don't take it personal.
What is the third stage of grief and the common reactions? The bargaining stage seek ways to protect themselves from what is happening. Unconscious coping mechanism to fulfill goals & avoid bad things. Trying to regain control. This stage has no time limit, some stay here indefinitely.
What is the fourth stage of grief and the common reactions? Depression is grief before death. This is a natural response to loss of independence, control, self-esteem, and to some degree HOPE. Let the patient talk and just LISTEN.They must experience emotions before they can move to acceptance.
What is the final stage of grief and is't common reactions? Acceptance is reached and the patient feels tranquil. They have accepted the reality and are ready to move on. All loose ends are tied up.
Define palliative care. Involves taking care of the whole person, mind, body, and spirit, heart and soul. It views dying as natural and personal. To give those with life threatening illnesses the best quality of care.
What is hospice? Care provided for an individual with a limited life expectancy, often at home.
What is a Physician order for life-sustaining treatment? POLST Medical order indicating a patients wishes regarding treatments. Commonly used in a medical crisis. Completed and signed by the Health Care Provider, NOT the patient.
What factors affect grief and dying? Development:children don't understand the same as adults. Family roles and dynamics may require one to "be strong". Culture, Gender and religion cause individuals to react different. The cause of death: sudden may cause shock and guilt.
What is involved when providing post mortem care for the body? Body is to place in normal anatomical position to avoid pooling of blood. Soiled dressings replaced. Tubes removed, unless autopsy is to be performed then stay in place. Some cultures want to wash body, some it is forbidden. ID tag on shroud & ankle.
How does a nurse care for a family after a death? Support is provided, this involves listening to expressions of grief, loss and helplessness. Arranging the family to have time with deceased. Sometimes guiding the family to making plans for what to do next.
How is compensation used as a defense mechanism? The person attempts to overcome a perceived weakness by emphasizing a more desirable trait. Student difficult in academics may excel at sports.
How is denial used as a defense mechanism? A person refuses to acknowledge the presence of a condition that is disturbing. A woman who fins a lump on her breast, but does not seek medical treatment.
How is displacement used as a defense mechanism? Transferring of and emotional reaction from one object to another. An employee who is angry with a coworker kicks a chair.
How is introjection used as a defense mechanism? Incorporating qualities or values of another person into their own ego. This is healthy if the imprinted material is helpful advice, warnings, or other lessons from parents and respected others,unhealthy if the messages are negative.
How is projection used as a defense mechanism? Attempts to banish or "disown" unwanted & disliked thoughts, behaviors, even "parts of self" by projecting them to someone else. Blaming someone else - "He should have let me off on that ticket but that cop was trying to fill his monthly quota."
How is rationalization used as a defense mechanism? Subconscious justifications, excuses or reasonings given to make a behavior seem logical A student fails the final he didn't study for and says... "I couldn't have passed it anyway, that teacher has it in for me."
How is reaction formation used as a defense mechanism? Developing conscious attitudes and behaviors opposite to what one would like to do. A married woman attracted to husbands best friend and is rude to him.
How is regression used as a defense mechanism? Giving up current level of development and going back to a prior level. Older child under stress begins wetting the bed or sucking a thumb after a long period without that behavior.
How is repression used as a defense mechanism? Painful, frightening, or threatening emotions, memories, impulses or drives that are subconsciously pushed or "stuffed" deep inside. Someone not remembering shaking a crying baby.
How is sublimation used as a defense mechanism? Redirection of impulses into socially acceptable activities -- normal and healthy, such as when the sexual impulses of adolescence is channeled into sports and competition.
How is undoing used as a defense mechanism? Using an act or communication to negate a previous act or communication. Abusive husband may buy a wife an expensive gift after abusing her.
What is immunity? A normal physiological response that provides an individual with protection against disease.
What is innate immunity? Natural or passive immunity present at birth providing non-specific immunity.
When is acquired immunity attained? After birth and is specific to antigens.
What is the difference between active and passive immunity? Active develops after the intro of a foreign antigen, resulting in formation of antibodies & sensitized T-cells. Natural or Artificial (vaccination) Passive occurs from intro of preformed antibodies. Artificial transfusion of Ig or natural mother-fetus.
What is the body's optimal immune response? Protect the body from invasion of microorganism and antigens. Remove dead or damaged tissues and cells. Recognize and remove cell mutations that have demonstrated abnormal cell growth and development.
What is the body's First line of defense? Non-specific and aims to stop entry from into the body. Skin boundary, including mucous membranes, enzymes, natural microbial flora and complete proteins.
What is the body's second line of defense? Non-specific resistance. Phagocytes, Inflammation and Fevers.
What is the body's 3rd line of defense? The third line of defense is specific resistance. This system relies on antigens, which are specific substances found in foreign microbes and the antibodies our body acquires to ward them off.
What is a suppressed Immune Response? Hypo-immune individuals are at risk to infection due to Primary immunodeficiency, improperly developed or absent immune cells, or secondary immunodeficiency, total loss of immune functions like from illness or treatment.
What is an exaggerated immune response? Hyper-immune is an overreaction of the immune system. Allergic reaction, cytotoxic reaction, autoimmune reactions.
Why are newborns at risk for infections? Their immune system is immature. Placental blood transfer and Colostrum and then the fast maternal catabolism is faster than newborn Ig production.
Why are older adults at risk for infections? Shrinking of thymus leaving less ability for Tcells to mature. This causes fewer Tcells & Ig. B cell function diminishes due to lack of circulating memory cells.
What does the Major Histocompatibility Complex Protein do? They are surface proteins that differentiate from self and pathogen. Class I found on all cells. Class II found on specialized cells.
Where do immune cells originate? All immune system cells are derived from stem cells.
How many classes of immunoglobulins are there? 9: 4-IgG, 2-IgA, 1 IgE, IgM, IgD
What is the antibody IgG responsible for? The Primary Ig in the blood. 80-85% of the circulating Ig Coats antigen for more effective and efficient presentation. Binds to macrophages & neutrophils to increase phagocytosis.
What is the antibody IgA responsible for? Protects the entrances of the body. High concentration in bodily fluids. Tears, saliva, recreation of respiratory and GI track.
What is the antibody IgE responsible for? Responsible for allergy symptoms and increase in the presence of parasitic worms. Found in trace amounts.
What is the antibody IgM responsible for? Remains in the blood to kill bacteria. Largest of all the Ig. First antibody produced with an initial (primary) immune response.
What is the antibody IgD responsible for? With in cell membrane of B-cells. Involved in allergic reaction, but precise function is unknown.
What are phagocytes responsible for? Recognizing and ingesting foreign antigens. Macrophages and neutrophils primary in body. Responsible for first line of defense. Macrophages stored in spleen, liver, GI and respiratory track. Neutrophils circulate blood.
What is the Complement system made up of and what is it responsible for? Comprised for 25 major proteins, they enhance the immune system. Responsible for such actions as dilation and fluid leak from vascular system that leads to readiness and swelling during the inflammatory response.
What is the role of a dendritic cell? They are sentinel cells throughout the body that seek out foreign antigens and alert lymphocytes.
What is the role of cytotoxic Tcells? After antigen exposure they attack and kill antigens using enzymes. Prefer virus, mutated or cancerous cells.
What is the role of the Helper Tcells They make up 75% of all Tcells. They regulate the immune system function vis protein monitors names: Lymphokines. They encourage other Tcells to activate B cells.
What is the role of the suppressor Tcells? These turn off the actions of the Helper and cytotoxic Tcells.
B-cells differentiate into what? Plasma cells that live days to months & secret high levels of Ig. First wave of fight againts infection. Memory cells live years & undergo a somatic hypermutation to have a super affinity towards a targeted antigen. Making response faster next time.
Hypersensitivity Type 1 involves what? IgE-mediated or atopic. Systemic anaphylaxis. Allergic reaction or rhinitis.
Hypersensitivity Type 2 involves what? IgG, IgM, Tissue specific or cytotoxic. Graves disease, auto immune diseases, hemolytic anemia. Graft rejection.
Hypersensitivity Type 3 involves what? IgG, IgM, immune-complex mediated. Systemic Lupus erythematosus, rheumatoid arthritis.
Hypersensitivity Type 4 involves what? Cell-mediated or delayed hypersensitivity. Contact sensitive. Poison Ivy, jewelry allergy. Delayed transplant grant rejection.
Describe Autoimmune disorders. Destruction of 1 or more types of body tissues, abnormal growth, changes in organ function.
What are the possible clinical findings of a suppressed immune system? Vitals may/may not be in normal parameters. Appear malnourished Generalized malaise or fatigue. Impaired wound healing. Changes to cognitive functioning.
What are the possible clinical findings of an exaggerated immune system? Things associated with an allergic response. Sneezing, watery eyes, nasal congestion. Rashes, swelling, shock syndrome. Cardiovascular symptoms or anemia. Joint pain. Renal dysfunction.
What is the purpose of inflammation? It is a protective process that minimizes or removes a pathologic agent or stimuli that triggered the response and to promote healing. Always present with infection, but infection does not need to be present for inflammation.
What is the Primary outcome of inflammation? Period of acute, non-specific, inflammation focusing on eradicating dead tissue, promoting immune response, & protect against infection. Damaged tissue replaced by identical functioning tissue by removing pathogen, injurious agent & allow regeneration.
What is the secondary outcome to inflammation? Fibrous repair and formation of scar tissue because of in ability to replace tissue with identical functioning so it is replaced with nonspecific fibrous tissue.
What is the third outcome of inflammation? Pathogens remain present despite best efforts developing chronic inflammation.
What is the worst outcome of inflammation? Death of tissue and eventually death of the host.
Describe acute inflammation. Immediate response to tissue injury & is short in duration. Majority of inflammation takes places within the first 24-48 hrs & lasts up to 5 days. Increased blood flow, increased vascular permeability, & migration of leukocytes.
Describe chronic inflamation. Inflammation that continues for weeks-years. Tissue is repeatedly being destroyed and repaired, impairing healing. Chronic localized results in granuloma- Build up of macrophages, fibroblast & collagen. Systemic chronic inflammation-autoimmune diseases
What are the risk factors to inflammation? Young-immature immune system. Elderly-less able to respond to foreign pathogen, stronger inflame response. Under/uninsured- simple inflammatory state turns to chronic because lack of care. Autoimmune, allergies or genetic predisposition. Poor hygiene.
Explain primary prevention for inflammation. Reducing the risk for infection and injury by proper hygiene, keeping wounds covered and clean, and using designated safety equipment.
What is is second inflammation prevention? There is none, making the primary prevention even more important.
What is RICE? Rest, Ice, Compression, & Elevation. 1st 24-48 critical to minimize swelling & prevent tissue damage.
What is an infection? The invasion and multiplication of micro organisms in body tissues, which may be clinically unapparent or result in local cellular injury due to competitive metabolism, toxins, intracellular replication or antigen-antibody response.
What is a disseminated infection? A spread of infection from the initial site to other areas of the body.
What is a System infection? An infection that spreads throughout the whole body or one that affects the body as a whole.
What is an epidemic? A situation in which there are more cases of an infectious disease than is normal for the population or geographical area.
What is a pandemic? A world wide epidemic of a disease.
What is a bacterial infection? 1 celled organisms without a true nucleus or membrane bound organelles. Synthesize DNA, RNA, Protein, reproduce independently. REQUIRE a host of a suitable environment to multiply. Can release end/exo-toxins. MRSA, C-diff, E.Coli, VRE.
What is a viral infection? A pathogen with nucleic acid and a protein shell that requires a host for replication. May cause disease or lay dormant. Hepatitis, HIV, Ebola, SARS, HPV
What is a fungal infection? Belonging to Fungi Kingdom. Can be single celled (yeasts), multicellular filamentous colonies (molds and mushrooms). Do not affect the healthy because they are controlled by the body's flora. Tinea pedius (athletes foot), ring worm, candidiasis.
What is a protozoa or parasitic infection? These generally infect individuals with compromised immune systems. Found in dead material, in water or soil. Fecal to oral route. Toxoplasmosis, Malaria, Giardiasis.
What is the Cycle of infection? 1. Pathogen 2. Susceptible Host 3. Reservoir (anywhere a pathogen might live and multiply) 4. Portal of Exit (from reservoir, urine, feces, saliva, blood, skin) 5. Mode of transmission (reliable) 6. Portal of entry ( sexual contact, broken skin)
What is the best way to prevent infection? Hand hygiene and proper safety precautions are the best way to avoid the spread of infection.
What happens during the incubation stage of infection? It is the interval between invasion and appearance of symptoms of infection. Organism is growing and multiplying (replicating)
What happens during the prodromal stage of infection? Early signs and symptoms are vague and non-specfic. Fatigue, malaise, or even low grade fever. Can last hours-days. Most infectious during this stage.
What happens during the full stage of illness? During the time the signs and symptoms are specific. The length of lines and severity varies depending on the infection.
What happens during the convalescent stage of illness? This is the recovery period. Signs and symptoms start to disappear. Herpes is a constant repeat of the cycle.
What are standard precautions? These are used regardless of patient's diagnosis. Gloves anytime may come into contact with blood, bodily fluids, secretions or excretions(except sweat). Practices: cough etiquette, safe injection practices, masks during high risk prolonged procedures.
What is involved in airborne precautions? These are infections that spread through the air: Tuberculosis, Varicella, SARS, Rubeola. Negative pressure private room with door closed, Mask or respirator is patient has TB, If Varicella mask not needed if immune, transport patient must wear a mask.
What is involved in droplet precautions? Spread by large droplets, 3ft from patient is contaminated. Mumps, Rubella, Diphtheria, adenovirus. Private room, door may remain open.
What is involved in contact precautions? This is for individuals who are colonized or infected by multidrug resistant organisms (MDRO) Private room, or share with another infected the same. PPE upon entry. Wash hands before leaving room. No sharing of patient equipment, limit patient transfers.
Describe a suspected deep tissue injury. Purple or maroon localized discolored intact skin or blood blister due to damage of underlying soft tissue from pressure or shear. May be difficult to identify on those with dark skin tone.
What are the characteristics of a stage 1 pressure ulcer? Non-blanchable erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly skin may not visibly blanch; color may differ surrounding area. Area may be painful, firm/soft, warmer/cooler that surroundings.
What are the characteristics of a stage 2 pressure ulcer? Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Shiny or dry shallow ulcer. Intact or open/rupture serum-filled blister. Skin tears, tape burns, perineal dermatitis, maceration.
What are the characteristics of a stage 3 pressure ulcer? Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, & muscle are not. My include undermining or tunneling. Depth depends on the amount of adipose and subcutaneous tissue.
What are the characteristics of a stage 4 pressure ulcer? Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present I'm some parts of wound bed. May extend into supporting structure making osteomyelitis possible.
When is a pressure ulcer unstageable? Full thickness tissue loss in which the bas of the ulcer is covered by slough (green, tan, grey, brown) or eschar (tan, brown, or black). Until slough is removes staging can not occur. Stable eschar on heels should not be removed.
What is the wound color classification? R=red=protect: in proliferation stage of healing. Gentle cleansing and moist dressings. Y=yellow=cleanse: presence of drainage or slough and requires cleansing. B=black=debride: may indicate eschar/necrotic tissue, removal to promote healing.
What is perfusion? The flow of blood through arteries and capillaries, delivering nutrients and oxygen to cells and removing cellular waste. Requires sufficient cardiac output to maintain cardiovascular health.
What is Anoxia? In adequate oxygen at the cellular level.
What is ischemia? Blood supply is available, but is decreased. This causes insufficient oxygenated blood to the tissues. Myocardial ischemia produces angina pectoris. If it is prolonged myocardial infarction can occur leading to death of myocardial tissue.
What is necrosis? Death of tissue.
Describe Central perfusion. Generated by cardiac output(amount of blood pumped out each min). Requires good cardiac function, BP, and blood volume. Reduction can result in shock.
Describe tissue perfusion The volume of blood that flows through target tissue. Hydrostatic pressure(force of ventricular contractions) and capillary permeability. Different organs require different volumes for functioning. can be from poor central perfusion/organ failure.
What are the clinical manifestations of shock? Blood supply to tissues is impaired because of inadequate cardiac output, significant blood loss, or vasodilation throughout body. Resulting in low BP, weak pulse, pallor, cold extremities, cyanosis. Heart not pumping-cardiogenic Fluid loss-hypovelmic
What are the modifiable risk factors of perfusion? Hypertension, smoking, diet, exercise, diabetes
What are non-modifiable risk factors of perfusion? Genetics, age, gender. Highest risk middle age/older adults, african-american, male.
What are the consequences of impaired central perfusion? occurs when cardiac output is decreased, due to occlusion or constriction of coronary arteries, reducing flow to myocardium, altered impulses interrupt contractions, or stenosis or insufficiency of valves, impairing flow through heart.
What are the consequences of impaired tissue perfusion? This is associated with occlusion, constriction, or dilation of arterials/veins. Atherosclerosis or thrombi can occlude arteries/veins. Vasoconstriction from frostbite. Dilation-aneurysm in arteries(varicose veins) Ischemia & tissue death if prolonged.
Reduced oxygen to tissues can cause what? Not enough oxidative metabolism for aerobic metabolism. Lactic acid build up: cellular acidosis. Inability to maintain ATPase pumps, potassium deficit and sodium overload causing inflammation.
Why does anemia effect perfusion and oxygenation? The reduction of hemoglobin results in the the decreased availability of RBC to carry Oxygen.
What is the normal pulse rate for an adult? Between 60-100 beats per minute.
What is tachycardia? A rapid heart rate of 101-180 BPM This decreases cardiac filling=decreasing stroke volume and CO. Causes: pain, decreased BP, elevated temp, poor oxygen, exercise, emotions, meds, prolonged application of heat.
What is bradycardia? Heart rate below 60 bpm. Can be slower during sleep in men or thin individuals, aging, on certain medication or during hypothermia.
What is a Sinus bradycardia? the SA made generates a slower that normal rate. Occurs in times when metabolic needs are decreased. During sleep, hypothermia or athletes at res, vagal stimulation, increased intra cranial pressure.
What does amplitude describe? The quality of the pulse in terms of its fullness and reflects the strength of the Left Ventricle contractions.
What does Rhythm describe? The pattern of the beats and pauses between beats.
What is a dysrhythmia? An irregular pattern,rhythm, of heart beats. Caused by abnormal conduction, with disease, hypertension, damage to the heart, drugs, or decreased oxygenation of tissues. Symptoms: low BP, dizziness, palpitations, weakness, fainting.
When is myocardial ischemia seen? Commonly caused by atherosclerosis, creating blockages and narrow passages, reducing the flow to heart tissue.
What is stable angina Caused by increased demand for oxygen from the heart.
Proper central perfusion is noted by? Heart rate & BP within normal limits. Orientation to date, time, person, place and situation. Bilateral movement and sensation. Clear speech. Presence of corrupted pulses.
Proper central perfusion is noted by? Warm extremities with color appropriate to race, capillary refill <3seconds. Radial and dorsal pulses 60-100bpm, absence of continuous pain in fingers/toes or leg pain when walking.
What subjective data can help when assessing perfusion? diet, exercise, smoking, alcohol, and drug intake.
What are the symptoms of Angina Pectoris? Constricting or squeezing sensation in chest, relieved with rest and/or 1 or more nitroglycerin tabs.
What are the symptoms of acute coronary syndrome? non-relievable chest pain, with shortness of breath, radiating pain in jaw or arms and nausea, vomiting, or diaphoresis.
When is Pleuritic chest pain present? At the onset of a pulmonary embolus.
What can perfusion cause leg pain? Impaired perfusion to legs can cause peripheral arterial disease. Deep vein thrombus can cause pain from pressure in the vein. Intermittent claudication is when one has pain when walking but not during rest.
How does dyspnea relate to perfusion? inadequate circulation of blood interferes with oxygen transport to tissues causing difficulty breathing. May need to sleep upright or have lots of pillows. Infants with stop feeding to catch their breath.
How does edema relate to perfusion? This may be due to Right side heart failure causing fluid to back up. Look for sock marks, and swollen feet at the end of the day. Incompetent veins (varicose veins) can cause peripheral edema.
What can you expect to find during an exam if the patient has impaired central perfusion? Changes in vital signs-hypotension or tachycardia. Shortness of breath-innsufficent oxygenation in pulmonary capillaries. Changes in heart rhythm-altered electrical functioning. Peripheral edema. Sympathetic NS response-anxiety or diaphoresis.
What can you expect to find during an exam if the patient has impaired tissue perfusion? Dependent in tissues involved. Less hair on legs. Pale or cool skin (dark skin tones look at palms & bottom of feet) Diminished/absent doornails pedal pulse. Slow capillary refill. Increased BP. Brain perfusion-weakness on side, difficulty speaking.
What do you check for during a neuromuscular assessment? Pain Pallor Peripheral Pulses Parastheia Paralysis Pressure
When is the enzyme tropic released? After a myocardial injury.
When are natriuretic peptides released? When arterial pressure increases. Likely during heart failure.
When would creatinkinase be elevated? Enzyme CK-MB is elevated after a myocardial infarction.
What does homocysteine in the blood show? A precursor to coronary artery disease CAD, cerebrovascular incident, PAD, or venous thrombosis. Recommended for family predisposition.
What does a seem lipids test show? It can show risk factors and vessel diseases.
What does an electrocardiogram measure? The electrical impulses of the heart.
What is done during a coronary artery bypass graft? Implants patent blood vessel to transport blood between aorta and myocardium distal to the obstructed coronary artery. Normally use: mammary, radial, artery or saphenous vein. Requires Cardiopulmonary bypass.
What is done during a peripheral artery revascularization? autogenous vein or synthetic graft to bypass the lesion in artery that is imparting perfusion.
What is done during a stent or angioplasty? Stent inserted o hold artery open. Balloon angioplasty is inflated to crush the blockage.
What is done during an endarterectomy? Artery is opened to remove the obstructing plaque. Carotid artery common place to increase brain perfusion.
What does a capnography monitor? The ventilation and indirectly the blood flow to through the lungs by measuring the amount of carbon dioxide that is expelled.
What does a thoracentesis do? The chest wall is punctured and pleural fluid is aspirated that is causing the distress or discomfort.
What is the primary prevention to impaired perfusion? To promote and prevent diseases. Living a heart healthy lifestyle, with proper diet and exercises. Adults-150mins per week 12-19y- at least 60 mins per week.
What is secondary prevention of perfusion? Diagnosis and prompt treatment through screening or BP, Blood sugar and lips screenings.
Normal BP range Adults- <120/80mmHg 8-19y- <90th %
Normal cholesterol range. Adult- <200mg/dL 6-19y- <70mg/dL
Normal blood sugar range. Adult- <100mg/dL 12-19y- <200mg/dL
Normal weight range. Adults- 25 kg/m2 12-19y- <85th %
What do vasodilators do? increase the diameter of blood vessel. Useful during hypertension or angina.
What do Vasopressors do? Decrease the diameter of a blood vessel.
What do diuretics do? Reduce the blood volume by preventing sodium reabsorption in the kidneys.
What do antidysrhythmics do? Correct erratic electrical impulses.
What do snticoagulans? Prevent blood clots.
What do antiplatelets do? Prevent platelets from aggregating to form clots.
What are thrombolytics? These disrupt clots by lysing fibrin.
Gas exchange is the process of what? The process by which oxygen is transported to the cells and carbon dioxide is transported out of the cells. It relies on optimal Ventilation, Perfusion, and Transport
What is hypoxia? Deficiency in the amount of oxygen reaching the tissue cells.
What is hypoxemia? Reduced oxygenation of arterial blood.
What is hypoventilation? A decreased rate or depth of air movement in the lungs.
What happens during ventilation? The process of inhaling oxygen and exhaling carbon dioxide. Can be spontaneous or mechanical(use of a ventilator) Person works harder to breath or use muscles to help. Find impairment At higher altitudes. any disorder affecting nasopharynx & lungs.
What is the process of retraction? The use of accessory muscles in abdomen and back to aid in respiration. Trapezius or sternocleidomastoid help during obstruction or constriction. Useful during an asthma attack to help air move until bronchi dilate. Sinus edema cases one to use mouth
What happens during the process of transport? The availability and ability of hemoglobin to carry oxygen from alveoli to cells for metabolism and to cary the product of carbon dioxide from cells back to alveoli to be eliminated.
What can impair the process of transport? Anemia, decrease RBC production (nutrient deficiency or lack of erythropoietin in bone marrow), increase loss of RBC (hemorrhage), premature destruction of RBC, chronic inflammatory, autoimmune, infectious, or militant disorders affecting hemoglobin.
How is perfusion involved in gas exchange? The ability of the blood to transport the oxygen containing hemoglobin to cells and return the carbon dioxide for expiration. Dependent on Activity level, positioning and an adequate blood supply.
What can impair perfusion for gas exchange? When oxygen doesn't reach cells ischemia or necrosis is possible. When carbon dioxide doesn't exit respiratory acidosis possible. Decreased cardiac output. Thrombi, emboli, vessel narrowing, vasoconstriction, or blood loss.
How are infants at risk for impaired gas exchange? The fetal hemoglobin is lower than maternal iron as the infant ages cellular metabolism uses this up fasted than the infant can produce replacements.
How are young children at risk for impaired gas exchange? Impaired exchange because of less alveolar surface area. Narrow peripheral airways are easily obstructed by edema, mucus or foreign objects.
How are older adult at risk for impaired gas exchange? Anatomic and physiological changes as part of the aging process. Chest wall stiffens due to loss of elastic recoil. Respiratory muscles weaken causing weaker cough. Weaker immunity.. Dilation of alveoli, decreased surface area decreased capillary.
What lifestyle risk factors can impair gas exchange? Air pollution. smoking, chemical intoxication, or prolonged immobility.
What regulated respiration? Respiratory center in the medulla gets signals from chemoreceptors in the aortic arch and the carotid arteries, stretch and irritant receptors in lungs, receptors in joints and muscles. Increased Carbon Dioxide in the blood is the biggest stimulant.
What does ABGs measure? The arterial blood gasses which the measurement of blood pH (7.35-7.45 normal) and arterial O2 & CO2. <7.35 acidosis >7.45 alkalosis
What is eupnea? Normal respiration rate. Adults 12-20 breath/min-thoracic Infants 30-55 breaths/min-abdominal 1-5y- 20-40 breaths/min-abdominal 6-12y- 18-26 breaths/min-thoracic 65+ 16-24 breaths/mim-thoracic
How does acid base balance effect respiration? Acidosis increases rate and depth of respirations. Hyperventilation to blow off CO2.
How does altitude affect respirations? Increase altitude may experience Cheyne-Stokes, especially while sleeping. Increases rate and depth prior to adaptation by the hemoglobin.
How can medication affect respirations? Narcotics, sedatives, anesthetics, opioids slow rate and depth. Amphetamines, cocaine increase rate and depth.
How can pain affect respirations? It can increase rate and depth.
What is tachypnea? Increase respiration rate. During a fever due to increase metabolic rate.
What is hyperventilation? Increased rate and depth. Seen during respiratory disorders.
What is bradypnea? Decreased respiratory rate. Found during increase intracranial pressure or while on opioids.
What is apnea? Periods of no breathing.
What is dyspnea? Difficult or labored breathing.
What is orthopnea? Difficulty breathing while in prone or supine position.
How many lobes are found in each lung? The right lung has 3 and the left lung has only 2 lobes to make room for the heart.
What is the airway lined with mucus? It traps cells, particles and infectious debris. Helps to protect underlying tissue from irritation and infections.
What is surfactant? A detergent like phospholipid that reduces surface tension between moist membranes of alveoli and prevents them from collapsing.
What is the Pleura? A serous membrane that lines the lungs and thoracic cavity. Visceral pleura lines the lungs. Parietal pleura lines the thoracic cavity. Pleura fluid between the layers acts as a lubricant and adhesive holding the lungs in an expanded position.
What is lung compliance? The ease in which the lungs can be inflated. Emphysema is related to decreased elasticity of lungs so they do not inflate easily.
What is airway resistance? Any impediment or obstruction that air meets as it moves through the airways.
What is atelectasis? Incomplete lung expansion or collapsing of the alveoli. Prevents pressure changes & exchange of gas by diffusion. Inability to fulfill functions of respiration. Obstructed airways or diseases that thicken alveolar-capillary membrane. (pneumonia)
How much oxygen is in atmospheric air? 21% oxygen
How much oxygen is put out by nasal cannula? 24%-44% Low Flow COPD no higher than 3L/min because of body compensation to higher CO2 rates.
How much oxygen is put out by a simple mask? 35%-50% humidified oxygen. 6-12L/mim Used for short term therapy.
How much oxygen is put out by a partial or non-rebreather mask? 60%-90% humidified oxygen 10-15 L/min
How much oxygen is put out by a venturi? A High flow of humidified oxygen at 24,28,31,35,40,50% Delivers a low constant oxygen concentrations to those with COPD
What is tidal volume? TV The amount of air inhaled or exhaled during normal breathing.
What is minute volume? MV The total amount of air exhaled per minute.
What is vital capacity? VC The total volume of air that can be exhaled after the maximum inspiration.
What is functional residual capacity? FRC The amount of air remaining in the lungs after normal expiration.
What is total lung capacity? This is the total volum of lungs when maximally inflated.
What is forces vital capacity? FVC the amount of air exhaled forcefully and quickly after maximum inspiration.
What is forced expiratory volume? FEV The volume of air expired during the first, second, & third seconds of the FVC test.
What is forced expiratory flow? FEF The average rate of flow during the middle half of the FVC test.
What is peak expiratory flow rate? PEFR The maximum volume during forced expiration.
Created by: mamajewels