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fundamentals final
| Question | Answer |
|---|---|
| metabolic changes due to immobility | decreased appetite due to negative nitrogen balance (weight loss, decreased muscles mass and weakness) hypercalcemia decreased GI motility |
| psychosocial changes due to immobility | depression |
| respiratory changes due to immobility | atelectasis hypostatic pneumonia |
| cardiovascular changes due to immobility | orthostatic hypotension thrombus |
| musculoskeletal changes due to immobility | disuse osteoporosis joint contracture foot drop |
| urinary changes due to immobility | urinary status renal calculi |
| bowel changes due to immobility | constipation |
| integumentary changes due to immobility | pressure injuries |
| localized infection | swelling, redness, heat, pain or tenderness, and loss of function in affect body part |
| systemic infection | fever, leukocytosis, malaise, anorexia, N/V, lymph node enlargement, or organ failure |
| contact precaution | MRSA and VRE private room, gown and gloves, and wash hands |
| droplet precaution | meningococcal meningitis, rubella, influenza, pertussis, and RSV private room, mask or respirator, and wash hands |
| airborne precaution | TB, chickenpox, SARS, and measles private room with negative pressure room and closed door, respirator |
| shear | force is sliding movement of skin and subq tissue while underlying muscle and bone is stationary |
| friction | force of two surfaces moving across one another such as mechanical force exerted when skin is dragged across coarse surfaces |
| stage 1 pressure ulcer | contact skin with nonblanchable skin |
| stage 2 pressure ulcer | partial thickness skin loss involving epidermis, dermis, or both blister |
| stage 3 pressure ulcer | full thickness tissue loss with visible fat |
| stage 4 pressure ulcer | full thickness tissue loss with exposed bone, muscle, or tendon |
| deep tendon injury | purple or maroon localized area of discoloration intact skin or blood filled blister |
| undermining | an area of tissue injury beneath intact skin around the margins of wound |
| tunnelling | tract of injury occurring in any direction from surface or edge of wound |
| granulation tissue | soft, pink, fleshy projections of tissue that form during the healing process in a wound not healing by primary intention |
| slough | stringy substance attached to wound bed |
| eschar | thick layer of dead, dry tissue, that covers a pressure ulcer or thermal burn it mat be allowed to be sloughed off naturally, or it mat need to be surgically removed |
| exudate | fluid, cells, or other substance that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membrane |
| serous drainage | clear watery plasma |
| purulent drainage | thick yellow, green, tan, or brown |
| serosanguineous drainage | pale, pink, watery: mixture of clear and red fluids |
| sanguineous drainage | bright red: indicated active bleed |
| dehicence | partial or total separation of wound layers |
| evisceration | total separation of wound that visceral organ protrudes through wound opening |
| debridement | removal of nonviable, necrotic tissue |
| what organ in the GI system absorbed the most nutrients | duodenum |
| what is something the large intestines DOES NOT do | absorb nutrients |
| nutritional considerations for someone who has a new ostomy | consume low fiber diet for the first weeks eat slowly and chew throughly drink 10-12 glasses pt mat choose to avoid gassy foods |
| ventilation | process of moving gases into and out of the lungs |
| perfusion | ability of CV system to pump oxygenated blood to the tissue and return deoxygenated blood to lungs |
| how to calculate the cardiac output | stroke volume x HR |
| preload | amount of blood I the LV at the end of diastole |
| afterload | resistance to Lt ventricular ejection |
| cardiac output | amount of blood ejected from the LV each minute |
| stroke volume | amount of blood ejected from the LV with each contraction |
| hyperventilation | ventilation in excess of that required rate and depth of respirations increase |
| causes of hyperventilation | severe anxiety infection drugs acid-base imbalance fever |
| s/s of hyperventilation | rapid respiration sighing breaths numbness and tingling in hands/feet light headedness LOC |
| hypoventilation | alveolar ventilation inadequate to meet the body's oxygen demand RR and depth is low |
| causes of hypoventilation | atelectasis drugs- that cause respiratory depression |
| s/s of hypoventilation | mental status changes dysrhythmias convulsions unconscious death |
| hypoxia | inadequate tissue oxygenation at the cellular level cyanosis is late sign |
| causes of hypoxia | decrease in hemoglobin and lowered O2 carrying capacity diminished inspired O2 decreased diffusion of O2 |
| s/s of hypoxia | apprehensive and agitation restlessness and behavioral changes decreased LOC dizziness increased HR and RR LATE S/S: decreased RR and HR; cyanosis |
| normal pH | 7.35-7.45 |
| s/s of hypovolemia | increased HR weak thready pulses change in position may increase HR or decrease BP dizziness/light headedness UO less than 500 mL altered mental status restlessness lethargy |
| s/s of hypervolemia | increased pulse distended neck vein increased BP polyuria edema SOB most crackles headache |
| s/s hypernatremia | restlessness agitation confusion seizures thirst dry, swollen tongue hypotension flushed skin edema weight gain |
| s/s hyponatremia | irritability apprehension dizziness tremors, seizures, coma cold and clammy skin N/V/D weight gain increased BP |
| s/s hyperkalemia | irritability abdominal cramping and diarrhea weakness of lower extremities irregular pulses cardiac arrect EKG: Vfib or V standstill |
| s/s hypokalemia | fatigue muscle weakness and leg cramps N/V and paralytic ileum soft and flabby muscle paresthesia and decreased reflexes bradycardia and dysrhythmias |
| s/s hypercalcemia | lethargy and weakness depressed reflexes confusion, personality changes, and psychosis anorexis; N/V/C bone pain and fractures flank pain/renal calculi ventricular dysrhythmias |
| s/s hypocalcemia | numbness and tingling in extremities hyperreflexia and muscle cramps Chvostek and trousseau's sign laryngeal spasms tetant and seizures ventricular tachycardia |
| s/s hypermagnesemia | bradycardia and hyptension cardiac arrest lethargic coma deep tendon reflexes are absent or reduced skeletal muscle contractions become progressively weaker and finally stop |
| s/s hypomagnesemia | confusion neuromuscular changes tremors/seizures hyperactive deep tendon reflexes painful muscle contractions monitor for + chvostek's and trousseau's sign |
| signs of infiltration | cool, pallor skin, and can be painful and swollen |
| signs of phlebitis | inflammation of vein with red, painful, streaked up vein |
| signs of acute hemolytic reaction | chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, hemoglobinuria, sudden oliguria, and cardiac arrest |
| cognitive learning domain | metal learning |
| affective learning domain | self or feeling |
| psychomotor learning domain | manual or physical |
| palliative care | prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of illness goal: help pt and families achieve best possible quality of life perk: pt can still look for curative treatments |
| hospice care | usually less than 6 months to 12 months left in life can't be getting curative treatments; only think is comfort care |
| causes of respiratory acidosis | drug OD pulmonary edema chest trauma airway obstruction COPD hypoventilation |
| causes of metabolic acidosis | diabetic ketoacidosis shock sepsis diarrhea renal failure salicylate OD |
| causes of respiratory alkalosis | anxiety high altitude initial stage of pulmonary emboli hypoxia fever pregnancy hyperventilation |
| causes of metabolic alkalosis | loss of gastric juice overuse of antacids potassium wasting diuretics |
| s/s of metabolic acidosis | headache decreased BP hyperkalemia muscle twitching confused and drowsy kussmaul respirations N/V/D |
| s/s of metabolic alkalosis | restlessness lethargy tachycardia dizzy N/V/D tremors muscle cramps tingling sensation hypokalemia |
| s/s of respiratory acidosis | hypoventilation -> hypoxia decreased BP dyspnea headache drowsiness and disoriented muscle weakness |
| s/s of respiratory alkalosis | seizures hyperventilation tachycardia decreased or normal BP lethargy light headedness numbness and tingling N/V |
Created by:
molrando
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