Term
| Elements of pre-op assessment + rationale |
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Definition
* Determine the psychologic status of the pt. in order to reinforce the use of coping strategies during the surgical experience.
* Determine physiologic factors that are directly or indirectly related to the surgical procedure that may contribute to operative risk factors.
* Establish baseline data for comparison in th eintraoperative and post operative period. (BP, BG, TPR, etc).
* ID and document the surgical site/side of body on which sergical procedure will be performed.
* ID rx medications, otc meds, and herbal supplements taken by the pt. that may result in drug interactions affecting the surgical outcome.
* Document the results of all pre-op labs and diagnostic tests, and communnicate this info to the appropriate health care provider.
*ID cultural and ethnic factors that may affect the surgical experience (blood transfusion ok, e.g.)
*Determin if pt. was able to make informed consent (enough info provided, all questions/concerns addressed) consent forms signed/witnessed. Must be done BEFORE sedation. |
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Term
| 3 conditions necessary to fulfill requirements of informed consent |
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Definition
adequate disclosure of the diagnosis; the nature and purpose of the proposed treatment; the riskes and consequences of the proposed treatment; the probability of a successful outcome; the availability, benefits and risks of alternative treatments; and the prognosis if treatment isn't instituted.
the patient must demonstrate clear understanding and comprehension of the information being provided before receiving sedating preoperative meds.
The recipient of care must give consent vountarily. the patient must not be persuaded or coerced in any way by anyone to undergo the procedure. |
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Term
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Definition
something that contributes to the occurence/development of something else. (critical thinking aid)
Example: Severly limited mobility is a risk for pressure ulcer.
Pre op dehydration is a risk factor for post op constipation. |
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Term
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Definition
pices of data that help us determine something about a patient (critical thinking aid).
Example: Auscultation of lung sounds = an assessment for COPD or fluid overload.
BG assessment for diabetic patients. |
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Term
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Definition
specific nursing action related to the patient's problem. (critical thinking aid).
Example: Apply TED hose to post op patient to prevent venous stasis, which could lead to DVT.
NO MEDICATIONS AS PART OF THIS PROCESS!!! |
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Term
| Most important role of the nures in the intra-operative phase of surgery |
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Definition
| Patient advocate. The nurse speaks on behalf of the patient because the patient is unable to speak or care for themselves. |
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Term
| Much of post op nursing care involves |
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Definition
* protecting the patient, who has been placed at physiologic risk during surgery.
preventing complications while the body repairs itself during the recovery process. |
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Term
| CNS effects of inadequate oxygenation |
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Definition
| Restlessness, agitation, muscle twitching, seizures, coma |
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Term
| CV effects of inadequate oxygenation |
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Definition
| Hypertension (HTN), hypotension,tachycardia, bradycardia, sysrhythmias, delayed capillary refill, decreased oxygen saturation |
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Term
| integumentary system effects of inadequate oxygenation |
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Definition
| flushed/moist skin, cyanosis |
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Term
| respiratory system effects of inadequate oxygenation |
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Definition
| increased to absent respiratory effort (hypoventilation), use of accessory muscles to aid in breathing effort, abnormal breath sounds, abnormal ABG's |
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Term
| renal efects of inadequate oxygenation |
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Definition
| urine output less than 0.5 mL/kg/hr. |
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Term
| Elements of post anesthesia care assessment |
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Definition
Airway: assess for patency, oral or nasal airway, trach tube.
Breathing: resp rate and quality, auscultated breath sounds, pulse ox, supplemental oxygen.
Circulation: ECG monitoring-rate/rhythm, BP, Temperature, capillary refill, color of skin, peripheral pulses.
(ABC's)
Neurologic: levl of consciousness (LOC), orientation, sensory and motor status, pupil sized and reaction (PERRLA).
GU: Intake (fluids/irrigations) and output (urine/drains) (I&O)
Surgical site: dressings/drainage
Pain: Incision or other |
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Term
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Definition
aka "waking up wild", signs/sx include: restlessness, agitation, disorientation, thrashing and shouting.
possible causes: anesthesia reaction, hypoxia, bladder distention, pain, residual neuromuscular blockade, or prsence of an endotrachial tube.
FIRST SUSPECT HYPOXIA (and treat accordingly as oxygen deprivation is time sensitive). |
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Term
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Definition
| causes stress response, increased HR/BP, cognitive and visual disturbances, anorexia, nausea, impaired mobility |
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Term
| Management of SE of narcotics |
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Definition
nausea-manage with cool cloth, give a snack before administering meds. Balance activities around it.
Administering anti-emetics if indicated and ordered.
Itching: manage with lotions, cool or warm wash cloth, assess for allergic reaction, urticaria, swelling, etc.
Respiratory depression/sedation: assess respiratory rate, encourage deep breathing, coughing to promote gas exchange. |
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Term
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Definition
central visual acuity for distance of 20/200 or worse in the better eye WITH correction.
Visual field no greater than 20 degrees in its wides diameter or in the better eye. |
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Term
| non pharmacologic interventions for pain |
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Definition
distraction by talking, playing music.
Pt. can't focus on 2 separate stimuli, one dilutes the effect of the other.
heat (for some types of pain)
Repositioning.
TENS/PENS |
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Term
| Interventions for hard of hearing patients |
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Definition
close door, blocking out ambient noise, which can distract the patient and make it difficult for them to understand you.
Minimize hand gestures, as they can be distracting. Only use gestures if they are helpful (mime).
Make sure that the patient has access to his/her hearing aids, and has them in place when you are talking to them.
Face the patient directly when you speak, so they can read your lips. |
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Term
| age related macular degeneration (AMD) |
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Definition
the most common cause of irreversible central vision loss in persons over age 60 in the US.
2 types- wet/dry
Dry AMD most common type. 90% of cases)
wet AMD most severe type. accounts for 90% of AMD related blindness. More rapid onset and noted by development of abnormal blood vessels in or near the macula. Always a progression from dry to wet AMD (when wet AMD developed).
central visual field affected, but peripheral vision still present.
Nursing intervention: set up food tray with items at outer edges of visual field. (outer corners of tray). |
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Term
|
Definition
a group of disorders characterized by increased intraocular pressure (IOP) and the consequences of elevated optic pressure, optic nerve atriphy, and peripheral visual field loss.
2nd leading cause of blindess in the US and leading cause in African Americans.
Types: primary open-angle glaucoma (POAG).
Primary angle-closure glaucoma (PACG) secondary glaucoma.
Important assessment: psychosocial assessment, to assess feelings about condition and possible outcome (blindness) and the accompanying lifestyle changes. |
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Term
| nursing interventions for oral candida |
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Definition
thorough mouth care (to remove infection),
directing patient to wash mouth out after taking inhaled/nasal steroid medications. (preventive) |
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Term
| interventions for candida in folds |
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Definition
clean and towel dry the area thoroughly (preventive)
application of mystatin powder, evn distribution to prevent clumping (treatment intervention) |
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Term
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Definition
PATHO:
activation of the varicella zoster virus; incidence increases with age, potentially contageous to anyone who has not had varicella or who is immunosuppressed. Can also be contracted even with previous exposure to chicken pox.
SIGNS/SX: linear distribution along a dermatome of grouped vesicles and pustules on erythematous base resembling chekenpox; usually unilateral on trunk, face and lumbosacral area; burning, pain, and neuralgia preceding outbreak; midl to severe pain during outbreak.
NURSING INTERVENTIONS
application of wet compresses |
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Term
| Factors affecting wound healing |
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Definition
nutrition status- necessariy nutrients for wound healing are Vitamin C (and multi vitamins),protein,higher caloric intake.
Impaired blood supply r/t diabetes, microvascular problems, positioning (esp. extremities). |
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Term
| Why is the pre op psychosocial assessment so important? |
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Definition
| Surgery is a very stressful experience. Psychologic and physiologic reactions too the surgical procedure/anesthesia may elicit the stress response. If the stressors or responses to the stressors are excessive, this can magnify the stress response and recovery can be affected. |
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Term
| (patho review) What is the stress responsse? |
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Definition
| elevated BP & HR, increased respirations |
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Term
| factors affecting a patients susceptibility to stress |
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Definition
| age, past experiences with illness/pain/surgery/anesthesia, current health status, and socioeconomic status. |
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Term
| Why is it important to identify a patient's perceived or actual stressors? |
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Definition
| It allows you (the nurse) to provide support during the pre op period so that stress does not become DISTRESS |
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Term
| The most common psychologic factors affecting stress levels |
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Definition
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Term
| Elements of a pre-op psychosocial assessment (assessing for potiental reasons/causes of anxiety/fear) |
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Definition
**Situational changes- ID support systems, including family, other caregivers, group and institutional structure & religius/spiritual orientation.
Define current degree of personal control, decision making and independence.
Consiser the impact of surgery and hospitalization & possible effects on lifestyle.
Determine the presenc of hope & anticipation of positive results.
**Concerns with the unknown: ID specific areas and degree of anxiety and fears. ID expectations of surgery, changes in current health status, and effects on daily living.
**concerns with body image: ID current roles or relationships and view of self. Determine perceived or potential changes in roles or relationships and their impact on body image.
**Past Experiences: Review previous surgical experiences, hospitalizations & treatments. Determine responses to those experiences (positive & negative). ID current perceptions of surgical procedure in relation to the above and information from others (e.g., a neighbor's view of a personal surgical experience).
**Knowledge Deficit: ID the amount and type of preoperative informationthe patient requires. Assess understnding of the surgical procedure, including preparation, care, interventions preoperative activities, restrictions, and expected outcomes. ID the accuracy of of information the patient has received from others, including health care team, family, friends, and teh media. |
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Term
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Definition
| cognition, decision making, and coping abilities are diminished. |
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Term
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Definition
fear of death
fear of pain & discomfort
fear of mutilation or alteration in body image
fear of anesthesia. |
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Term
| Elements of Pre operative preparation (patient teaching points) |
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Definition
**Sensory Information: Pre op holding area may be noisy, Drugs and cleaning solutions (betadine, alcohole, etc) may be cold and odorous. OR can be cold (let them know they can request a blanket if they want one). Talking may be heard in the OR but may be distorted becasue of mask. (Advise them to ask questions if something is not understood). OR bed will be narrow. (advise patient that a safety strap will be put across their thighs). LIghts in the OR may be very bright. Monitoring machines may be heard (ticking/pinging/beeping sounds) when awake.
**Procedural Information: What to bring and what type of clothing to wear to the surgery center; any changes in time of surgery; fluid and food restrictions; physical preparation required (bowel or skin prep); purpose of frequent vital signs assessment; Pain control and other comfort measures; Why turning, coughing and deep breathing postoperatively are important; practice sessions should be done pre-op... Procedure for anesthesia administration, Expect surgical site and/or side to be marked withindelible ink/marker.
**Process Information (the flow of the procedure)
Admission area; Pre op holding area, OR, and recovery area (PACU; Caregivers can usually stay in the pre op holding area until surgery; Caregivers will be able to see the pt. after discharge from recovery area or possibly in the recovery aree once the patient is awake; ID any technology that may be present on awakening, such as monitos and central lines/IV's.
**Where caregivers wait during surgery: Pt. and caregivers need to be encouraged to ask questions and/or verbalize concerns; OR staff will notify caregiver when surgery is completed; surgeon will usually talk with caregiver following surgery. |
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Term
| Considerations for peri-operative positioning of the patient (with rationale) |
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Definition
PROTECT THE PATIENT'S AIRWAY
provide correct musculoskeletal alignment (prevent injury and post op discomfort)
prevent undue pressure on nerves, skin over bony prominences, earlobes and eyes (same rationale as above).
provide for adequate thoracic excursion. (allow adequate access to surgical site?)
prevent occlusion of arteries and veins (prevention of thrombus formation,injury to vascular tissue)
provide modesty in exposure (protecting patient's dignity)
recognize and respect individual nees such as previously assessed aches, pains or deformities. (prevention of injury and pain) |
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Term
| Causes of Airway Obstruction (post op complication) assessments and nursing interventions included where applicable |
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Definition
Tongue falling back (usually happens in supine position) Intervention- position client in "recovery position... on their side). signs/sx: use of accessory muscles, snoring respirations, decreased air movements.
Retained thick secretions- secretions stimulated by anesthetic agents, or dehydration of secretions. (nursing intervention: deep breathing/coughing exercises) Signs/sx: noisy resps/coarse crackles).
Laryngospasm: signs/sx: respiratory stridor (assess lung sounds), acute respiratory distress, sternal retractions.
Laryngeal edema similar signs/sx as laryngospasm. |
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Term
Causes of Hypoxemia
Assessments and Nursing interventions where indicated |
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Definition
Atelectasis secondary to/related to bronchial obstructions. Assess for decreased breath sounds, decreased O2 sats. Nursing interventions: Deep breathing, coughing, incentive spirometry.
Pulmonary edema: assess for fluid overload, decreased O2 sats, assess lung sounds for crackles. Nursing intervention: restrict fluids.
Pulmonary Embolism (PE): Assess for acute tachypnea, dyspnean, tachycardia, hypotension, decreased O2 saturation. (monitor vital signs closely for these signs/sx). Nursing intervention- cardiopulmonary support.
Aspiration: monitor vitals for signs/sx of atelectasis, decreased O2 sats, unexplained tachypnea, respiratory failure. Nursing interventions: cardiac support.
Bronchospasm: assess breath sounds for wheezing, dyspnea, tachypnea and decreased O2 sats. Nursing intervention: O2 therapy |
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Term
| Causes of Hypoventiliation-Assessments/Nursing interventions |
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Definition
Cause: Depression of central respiratory drive, Poor Respiratory muscle tone, Mechanical restriction, pain.
Assessments: pain level and location,guarding behavior.
breathsounds for shallow resps, decreased resp. rate/apnea..
assessment for pain related hypoventilation include: assessing for increased resp. rate, hypo/hypertension, c/o pain.
Nursing interventions: stimulation of of breathing by coughing/deep breathing exercises. Elevation of the head of the bed, repositioning of the patient, loosen dressings, distraction techniques, music, guided imagery, meditation). |
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Term
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Definition
Whatever the patient experiencing the pain says it is, existing wherever the patient says it does.
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. |
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Term
| causes of fluid volume deficit |
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Definition
**Increased insensible water loss or perspiration (high fever, heatstroke)
**Diabetes insipidus
**Osmotic diuresis
**Hemorrhage
**GI losses- vomiting, NG suction, diarrhea, fistula drainage
** Overuse of diuretics
**Inadequate fluid intake
** third space fluid shifts- burns, intestinal obstruction. |
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Term
| causes of fluid volume excess |
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Definition
**Excessive isotonic or hypotonic IV fluids
**Heart failure
**Renal failure
**Primary polydipsia
**SIADH
**Cushing syndrome
**Long-term use of corticosteroids |
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Term
| Clinical manifestations of fluid volume deficit |
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Definition
**restlessness, drowsiness, lethargy, confusion.
**Thirst, dry mucous membranes
**decreased skin turgor, decresed capillary refill
**postural hypotension, increased pulse,
**decreased CVP
**decreased skin turgor, decreased capillary refill (not the most reliable in geriatric patients, in terms of assessments)
**decreased urine output, concentrated urine
**increased resp. rate
**weakness, dizziness
**weight loss
**seizures, coma |
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Term
| clinical manifestations of fluid volume excess |
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Definition
*Headache (HA), confusion, lethargy.
*Peripheral edema
**jugular venous distention
*bounding pulse, increased BP,increased CVP
**polyuria (with normal renal function)
**dyspnea, crackles (rales)
**muscle spasms
**weigh gain
*seizures, coma |
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Term
| causes of hypernatremia (sodium excess) |
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Definition
**excessive sodium intake: via IVfluids, hypertonic NaCl, IV sodium bicarbonate.
Hypertonic tube feedings without water supplements.
Near drowning in salt water.
**Inadequate water intake: Unconscious or cognitively impaired individuals.
**excessive Water Loss: (increased sodium concentration) increased insinsible water loss (high fever, heatstroke, prolonged hyperventilation), osmotic diuretc therapy, diarrhea
**diseases states: Diabetes insipidus, primary hyperaldosteronism, Cushing syndrome, uncontrolled diabetes mellitus |
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Term
| causes of hyponatremia (sodium deficit) |
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Definition
**excessive sodium loss
GI losses: diahrrhea, vomiting, fistulas, NG suction
Renal losses: diuretics, adrenal insufficiency, Na+ wasting renal disease
Skin losses: burns, wound drainage
**Inadequate sodium intake- fasting diets
**Excessive water gain(decreased sodium concentration) Excessive hypotonic IV fluids, primary polydipsia
**Disease states: SIADH, heart failure, primary hypoaldosteronism |
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Term
| Clinical Manifestations of Hypernatremia with DECREASED ECF fluid volume |
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Definition
| Restlessness, agitation, twitching, seizures, coma, intense thirst, dry, swollen tongue, sticky mucous membranes, postural hypotension, decreased CVP, weight loss, weakness, lethargy. |
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Term
| Sx of hypernatremia with NORMAL/INCREASED ECF volume |
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Definition
| Restlessness, agitation, twitching, seizures, coma, intense thirst, flushed skin, wieght gain, peripheral an dpulmonary edema, increaded BP, and increased CVP |
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Term
| Sx of hyponatremia with DECREASED ECF volume |
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Definition
| irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma, dry mucous membranes, postural hypotension, decreased CVP, decreased jugular venous filling, tachycardia, thready puls, cold and clammy skin. |
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Term
| Sx of hyponatremia with NORMAL/INCREASED ECF volume |
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Definition
| HA, apathy, confusion, muscle spasms, seizures, coma. Nusea, vomiting, diarrhea, abdominal cramps, weight gain, increased BP and CVP |
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Term
Causes of hyperkalemia
(K+ excess) |
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Definition
Excessive K+ intake via:
excessive or rapid parenteral administration, K+ containing drugs (e.g. potassium penicillin), K+ containing salt substitute.
SHift of K+ out of cells : acidosis, tissue catabolism (e.g. fever, sepsis, burns), crush injury, tumor lysis syndrome
Failure to eliminate K+:
renal disease, K+ sparing diuretics, adrenal insufficiency, ACE inhibitors |
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Term
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Definition
General sx: irritability, anxiety, abdominal cramping, diarrhea, weakness of lower extremities, paresthesias, irregular pulse, cardiac arrest if hyperkalemia sudden or severe.
Electrocardiogram changes:
Tall, peaked T wave, prolongeed PR interval, ST segmant depression, loss of P wave, widening QRS, ventricular fibrillation, Ventricular standstill.
Interventions:
avoid eating/drinking high potassium foods/fluids such as potatoes, bananas, orange juice, tomato juice |
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Term
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Definition
Genral sx: Fatigue, muscle weakness, leg cramps, nausea, vomiting, paralytic ileus, soft, flabby muscles, paresthesias, decreased reflexes, weak, irregular pulse, polyuria, hyperglycemia
ELECTROCARDIOGRAM CHANGES
ST segment depression, Flattened T wave, Presence of U wave, Ventricular dysrhythmias, (e.g. PVC's) bradycardia, enhanced digitalis effect
Interventions: increase intake of potassium rich foods/fluids... bananas, potatoes, orange juice, tomato juice |
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Term
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Definition
Increased TOTAL calcium:
multiple myeloma, malignancies with bone metastasis, prolonged immobilization, Hyperparathyroidism, Vitamin D overdose, Thiazide diuretics, Milk-alkali syndrome.
INCREASED IODIZED CALCIUM
Acidosis |
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Term
| Clinical manifestations of hypercalcemia |
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Definition
Lethargy, weakness, depressed reflexes, decreased memory, confusion, personality changes, psychosis, anorexia, nausea, vomiting, bone pain, fractures, polyuria, dehydration, nephrolithiasis, stupor, coma
ELECTROCARDIOGRAM CHANGES
shortened ST segment, shortened QT interval, Ventricular dysrhyhmias, increased digitalis effect |
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Term
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Definition
Decreased Total Calcium
Chronic kidney disease, elevated phosphorous, primary hypoparathyroidism, Vitamin D deficiencey, magnesium deficiency, acute pancreatitis, loop diuretics (e.g. furosemide/Lasix), chronic alcoholism, diahrrhea, decreased serum albumin (patient is usually asymptomatic due to normal ionized calcium level).
Decreased Ionized Calcium
Alkalosis, excess administration of citrated blood. |
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Term
|
Definition
easy fatigability, depression, anxiety, confusion, numbness and tingling in extremities and region around mouth, hyperreflexia, muscle cramps, Chvostek's sign, Trousseau's sign, Laryngeal spasm,, tetany, seizures
ELECTROCARDIOGRAM CHANGES
Elongation of ST segment, prolonged QT interval, Ventricular tachycardia |
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Term
| Causes of hyperphosphatemia |
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Definition
| Renal failure, chemotherapeutic agents, enemas containing phosphorus (e.g. Fleet enema), excessive ingestion (e.g. milk, phosphate containing laxatives), large vitamin D intake, hypoparathyroidism |
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Term
| signs/sx of hyperphosphatemia |
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Definition
| hypocalcemia, muscle problems, tetany, deposition of calciu-phosphate precipitates in skin, soft tissue, cornea, viscera, blood vessels |
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Term
| causes of hypophosphatemia |
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Definition
| malabsorption syndrome, nutritional recovery syndrome (reversal or treatment of starvation), glucose administration, total parenteral nutrition (TPN), alcohol withdrawal, phosphate binding antacids, recovery from diabetic ketoacidosis, respiratory alkalosis |
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Term
| signs/sx of hypophosphatemia |
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Definition
| CNS dysfunction, (confusion, coma), muscle weakness, including respiratory muscle weakness & difficulty weaning, renal tubular wasting of Mg2+, Ca2+, HCO3-, Cardiac problems (dysrhythmias, decreased SV,) osteomalacia, rhabdomyolysis |
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Term
| Causes of Respiratory Acidosis |
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Definition
| COPD, barbiturate or sedative overdose, chest wall abnormailty (e.g. obesity) severe pneumonia, atelectasis, respiratory muscle weakness (e.g. Guillain-Barre syndrome), mechanical hypoventilation. |
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Term
| Causes of respiratory alkalosis |
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Definition
| HYPERventilation (caused by hypoxia, pulmonary emboli, anxiety, fear, paxn, exercise, fever). Stimulated respiratory center caused by septicemia, encephalitis, brain injury, salicylate poisoning, Mechanical HYPERventilation |
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Term
| causes of metabolic acidosis |
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Definition
| diabetic ketoacidosis, lactic acidosis, starvation, severe diarrhea, renal tubular acidosis, renal failure, GI fistulas, shock |
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Term
| causes of metabolic alkalosis |
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Definition
| severe vomiting, excess gastric suctioning, diuretic therapy, K+ deficit, excess NaHCO3- intake, excessive mineralocorticoids |
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Term
| signs/sx of metabolic acidosis |
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Definition
Neurologic sx:
drowsiness, confusion, HA, coma
CV sx: low BP,dysrhythmias, (r/t hyperkalemia from compensation), warm flushed skin (r/t peripheral vasodilation)
GI sx: nausea/vomiting (N/V), diarrhea, abdominal px.
Neuro: no significant findings
Resp sx: deep, rapid resps, (compensatory action by the lungs) |
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Term
| signs/sx of repiratory acidosis |
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Definition
Neurologic sx: drowsines, disorientation, dizziness, HA,coma
CV sx: decreased BP, Ventricular fibrillation r/t hyperkalemia, from compensation), warm flushed skin (r/t peripheral vasodilation)
GI sx: no significant findings
Neuromuscular sx: no significant findings
Respiratory sx: hypoventilation with hypoxia (lungs unable to compensate when there is a respiratory problem). |
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Term
| signs/sx of repiratory alkalosis |
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Definition
Neurologic sx: lethargy, hight headedness, confusion
CV sx: tachycardia, dysrhythmias (r/t hypokalemia from compensation)
GI sx: nausea, vomiting, epigastric px.
Neuromuscular sx: tetany, numbness, tingling of extremities, hyperreflexia, seizures
Respiratory sx: hyperventilation (lungs are unable to compensate when there is a respiratory problem). |
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Term
| signs/sx of metabolic alkalosis |
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Definition
Neurologic sx: dizziness, irritability, nervousness, confusion
CV sx: tachycardia, dysrhythmias r/t hypokalemia from compensation
GI sx: nausea, vomiting, anorexia
Neuromuscular sx: tetany, tremors, tingling of fingers and toes, muscle cramps, hypertonic muscles, seizures
Respiratory sx: hypoventilation (compensatory action by the lungs). |
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Term
| Common assessments for fluid/electrolyte imbalances |
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Definition
Skin:
assess for poor skin turgor (not always reliable in older adults due to decreased elasticity of skin), cold,clammy skin (Na+ deficit, shift of plasma to interstitial fluid, pitting edema (fluid voume excess) , flushed dry skin (Na+ excess)
Pulse:
Bounding pulse- fluid volume excess, shift of interstitial fluid to plasma.
Rapid, weak, thready pulse- shift of plasma to interstitial fluid, Na+ deficit, fluid volume deficit
Weak, irregular, rapid puls- severe K+ deficit
Weak, irregular slow pulse- severe K+ excess
BP:
HYPOtension- fluid volume deficit, shift of plasma to intestitial fluid, Na+ deficit,
HYPERtension- fluid volume excess, shift of interstitial fluid to plasma
RESPS:
deep, rapid breathing- compensation for metabolic acidosis.
shallow, slow, irregular breathing- coompensation for metabolic alkalosis
SOB- fluid volume excess
moist crackles- fluid volume excess, shift of interstitial fluid to plasma
restricted airway- Ca2+ deficit
SKELETAL MUSCLES
cramping of exercised muscle- Ca2+ deficit, Mg2+ deficit, alkalosis
carpal spasm (Trousseau's sign) Ca2+ deficit, Mg2+ deficit, alkalosis
flabby muscles- K+ deficit
Positive Chvostek's sign- Ca2+ deficit, Mg2+ deficit, alkalosis
BEHAVIOR/MENTAL STATE
picking at bedclothes- K+ deficit, Mg2+ deficit
Indifference0 fluid volume dificit, Na+ deficit
Apprehension- shift of plasma to interstitial fluid
Extreme restlessness-K+ excess, Na+ excess, fluid volume deficit
Confusion/irritability- K+ deficit, fluid volume excess, Ca2+ excess, Mg2+ excess, H2O excess, Na+ deficit
Decreased LOC- Na+ deficit, H2O excess. |
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Term
|
Definition
| High HCO3_values, low PaCO2 values, blood pH above normal range |
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Term
|
Definition
| Low HCO3-values and High PaCO2 values blood pH below normal range |
|
|
Term
| Lab values indicating respiratory acidosis |
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Definition
| ABG: pH < 7.35, paCO2 > 45 |
|
|
Term
| lab values indicating metabolic acidosis |
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Definition
|
|
Term
| lab values indicating respiratory alkalosis |
|
Definition
| ABG: pH >7.45, paCO2 < 35 |
|
|
Term
| lab values indicating metabolic alkalosis |
|
Definition
|
|
Term
| determining presence and extent of compensation |
|
Definition
ABSENT:
pH is not within normal range
The component that does not match the pH imbalance is still within its normal range
PARTIAL
Partial:
pH is not within normal range
The component that does not match the pH disorder is above or below the normal range; opposite of the component that matches the pH
COMPLETE
Complete:
pH is within the normal range and both components are either above or below normal range opposite of each other |
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Term
|
Definition
Stage I- no break in skin, redness (erythema) that does not blanch when pressure applied to it. Usually located over a bony prominence.
Stage II- partial thickness loss of dermis manifesting as a shallow open ulcer with red/pink wound bed, without slough. May also manifest as an intact or open/ruptured serum-filled blister.
Stage III- full thickness tissue loss. SubQ fat may be visible, but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage IV- Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
UNSTAGEABLE- Full thickness tissue loss in which the base of the ulcer is covered by slugh (yellow, tan, gray, green or brown) &/or eschar (tan, brown or black) in the wound bed. |
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Term
| assessment for pressure ulcer risk factors |
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Definition
Braden Risk Assessment tool
example available here:
http://www.tissueviabilityonline.com/view-tool?resid=251&from=/risk-assessment |
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Term
| Pressure ulcer prevention interventions/rationales |
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Definition
**use an established risk assessment tool to monitor individual's risk factors (e.g. Braden scale), to reduce or eliminate factors that contribute to development or progression of the pressure ulcer.
*Remove excess moisture on the skin resulting from perspiration, wound drainage, and fecal/urinary incontinence to PREVENT MACERATION
*avoid massaging over bony prominences to prevent further tissue damage.
*Turn q 1-2 hours to avoid prolonged pressure in one area.
*Turn with care (e.g. avoid shearing0 to preven injury to fragile skin.
*Position with pillows to elevate pressure points off the bed.
*Use specialty beds and mattresses as needed to provide pressure relief and increase circulation to the site.
*use devices on the bed (e.g. sheepskin) that protect the individual from pressure.
*apply elbow and heel protectors as appropriate to avoide pressure.
*assist individual in maintaining a healthy weight as the risk for pressure ulcers is increased in people who are obese or very thin. |
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Term
Pressure ulcer care
interventions/rationales |
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Definition
Describe the characteristics of the ulcer at regular intervals, including size (length x width x depth), stage (I-IV), location, exudate, granulation or necrotic tissue, and epithelialization to provide baseline and ongoing data for monitoring pressure ulcer.
*keep the ulcer moist to aid in healing
*Cleanse the ulcer with the appropriate nontoxic solution, working in a circular motion from the center.
*debride ulcer, as needed, to promote new tissue growth.
*Apply a permeable adhesive mebrane (tegaderm), saline soaks, ointments, &/or dressings, as appropriate, to promote healing.
*verify adequate caloric and high-quality protein intake to provied nutrients necessary for tissue repair.
*Teach individual or family member(s) wound care procedures, to enhance self-care.
*instruct family member/caregiver about signs of skin breakdown to prevent recurrence
*initiate consultation services of the enterostomal herapy nurse, as needed for specialized direction of ulcer care. |
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Term
| General pressure ulcer info |
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Definition
| Beyond stage 1-- healing is never complete. Skin is not the same as before the injury. |
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Term
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Definition
ETIOLOGY/PATHOPHYSIOLOGY:
inflammation of subQ tissues; possibly secondary complication or primary infection; often following break in skin: S. aureus and streptococci are usual causative agents; deep inflammation of suQ tissues from enzymes produced by bacteria.
SIGNS/SX:
hot tender, erythematous, and edematous area with diffuse borders; chills, malaise and fever.
TXMT, NURSING INTERVENTION:
moist heat, immobilization and elevation administration of antibiiotic therapy as/if ordered by MD. |
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Term
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Definition
PATHO:
caused by Candida albicans, aka moniliasis; 50% of adults asymptomatic carriers, presents in warm, moist areas such as the gron, oral mucosa and submammary folds; HIV infection, chemotherapy, radiation, and organ transplantation r/t depression of cell mediated immunity that allows yeast to become pathogenic.
SIGNS/SX:
Mouth- white, cheesy plaque, resembles milk curds.
Vagina- Vaginitis with red edematous, painful vaginal wall, white patches; vaginal dischare: pruritus, px on urination and intercourse.
SKIN:
diffuse papular erythematous rash with pinpoint satellite lesions around edges of affected area.
NURSING INTERVENTIONS:
skin/oral hygeine to keep area clean and dry (if possible), powder is effective on non mucosal skin surfaces to prevent recurrence, but BE SURE to spread evenly, no clumps that can cause pressure ulcers or other injury. |
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Term
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Definition
PATHO:
manifestation of delayed hypersensitivity, absorbed agent acting as antigen, sensitization after one or more exposures, appearance of lesions 2-7 days after contact with allergen.
SIGNS/SX:
red papules and plaques; sharply circumscribed with occasional vesicles; usually pruritic; area of dermatitis frequently take shape of causative agent (e.g. metal allergy and band like dermatitis on ring finger).
NURSING INTERVENTIONS
skin lubrication, elemination of contact allergen, avoidance of irritating affected area. |
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Term
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Definition
PATHO: genetically influenced, chrionic, relapsing disease associated with immunologic irregularity involving inflammatory mediators, exaggerated by cutaneous response to environmental allergens; associated with allergic rhinits and asthma; most severe in childhood.
SIGNS/SX:
multiple presentations include acute, subacute, and chronic stages: all are pruritic; acute stage with bright erythema, oozing esicles, with extreme pruritis; subacute phase with scaly, light red to red-broun plaques; chronic stage has thickened skin with accentuation of skin markings (lichenification), possible hypopigmentation/hyperpigmentation, dry skin; common in antecubital and popliteal space in adults.
NURSING INTERVENTIONS
lubricaiton ofdry skin, stress reduction interventions (music, talking, distraction, calm, low lighting, etc). |
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