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133 Cards in this Set
- Front
- Back
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Health (def)
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The state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.
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Wellness (def)
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State of optimal health wherein an individual maximizes human potential, moves toward integration of human functioning, has greater self-awareness and self-satisfaction, and takes responsibility for health.
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Health Maintenance includes (3) and uses a _____ approach:
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Prevention (of dz)
Early (detection and dx) Dz (tx) Holistic approach - mental, intellectual/vocational, spiritual. |
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Prevention (3 types)
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Primary: before dz begins
Secondary: early detection and intervention Tertiary: caring for a person with a health problem; focuses on maximizing recovery after an illness or injury and preventing long-term complications |
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The patient is the ________ of the health care team.
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center
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What effects health?
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genetics (only one pt cannot control)
human biology personal behavior environmental influences |
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Physical Exams (frequency)
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20-39: 1-3 yrs
40-49: 1-2 yrs >50: every 1 year |
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Immunizations (frequency)
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tetanus booster q10 yrs for adults
influenza q 1 yr pneumococcal pneumonia q 6 yrs |
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What tests should be done with every physical exam?
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CBC
BS cholesterol UA stool for blood Pap (for women) men: manual prostate exam q 1 yr if age >40 women: breast exam with every physical, baseline mammogram at 40 and yearly thereafter EKG at 20 and 40 and q 5 yrs after 40 (unless pt high risk, then yrly) |
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Dental/Eye exam frequency
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dental - starting at 6 mo then every 6-12 mo
eye - q 2-3 40-49/q 1-2 >50 or diabetic |
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Adaptive energy (def)
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the inner force an individual uses to respond or adapt to stress.
general stress - rxns affect entire body local stress - affects only involved body part |
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Stress
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universal experience - can be positive or negative (neutral)
Stress is a nonspecific response to any demand on the body. Individual perception of stressor determines effect of stress response. |
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General Adaptation Syndrome - stage one
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crisis or alarm
body readies itself to handle stressors cool, pale skin, shivering, sweating of palms when severe may cause dilated pupils, dry mouth, pounding heart, N/D |
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GAS (general adaptation syndrome) - stage two
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adaptation or resistance
body attempts to defend against stressor through fight/flight response body becomes physiologically ready to defend itself |
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GAS - stage three
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exhaustion
if adaptive energy can't deal with prolonged stress |
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Local Adaptation Syndrome
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physiologic response to a stressor on specific part of body
i.e. inflammation symptoms at site of injury usually temporary, but if does not resolve can trigger GAS |
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S/S of stress - physiological
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pulse rate/BP increase, resp rate increases and is shallow, blood thickens, dizziness, sweaty palms, HA, pupils dilated, nausea, appetite change, constipation, diarrhea, increase urination, twitching, trembling, increase in blood glucose, cortisol
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S/S of stress - psychological
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irritability, feelings easily hurt, sadness, depression, feelings of pleasure and accomplishment reduced
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S/S of stress - cognitive
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impaired memory and judgment, confusion, unable to concentrate, poor decision making, altered perceptions, delayed response
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S/S stress - behavioral
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pacing, rapid speech, insomnia, withdrawal, easily startled
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S/S stress - spiritual
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alienation, social isolation, feeling of emptiness
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Eustress
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type of stress resulting in positive outcomes
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Distress
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stressors evoking an ineffective response
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Adaptation
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ongoing process whereby individuals adjust to stressors and change
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Conditioning
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occurs when a person is taught a behavior until it becomes an automatic response
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Defense mechanisms
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unconscious functions protecting the mind from anxiety - only considered maladaptive when the only way individual responds to threat
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maladaptive measures
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used to avoid conflict and stress
may include somatic disorders, rituals, excessive use of alcohol or drugs, excessive eating, withdrawal from reality |
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crisis
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acute state of disorganization
occurs when stressors surpass ability to cope coping mechanisms are not longer adequate time limited |
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teaching
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active process wherein one individual shares information with another as a means to facilitate learning and thereby promote behavioral changes
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learning
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act or process of acquiring knowledge, skill, or both in a particular subject; process of assimilating knowledge resulting in behavioral changes
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Formal/Informal teaching
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Goal Directed
Formal - takes place at a specific time, in a specific place, and on a specific topic Informal - takes place any time, any place, whenever a learning need is identified |
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Learning Domains
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cognitive: acquisition of facts and data; used in decision-making and problem-solving
affective: attitude changing, emotion, and belief; used in making judgments psychomotor: gaining motor skills;used in physical application of knowledge |
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Children learn primarily through _____.
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play
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Teaching Children
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goals of education children are to improve cooperation, prevent excessive anxiety, and hasten the recovery process.
use play, imitation, and role play provide frequent repetition, reinforcement |
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teaching adolecents
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respect the adolescent
boost their confidence by seeking their input and opinions on health care matters |
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Effective teaching is based on nurse's ability to establish ______ with the client.
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rapport
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teaching and documentation
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Document the content, method used, and *outcome*
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CHF meds
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Lasix (loop diuretic) - monitor BP prior to adm, K level, I&O, daily weights
Lanoxin (+inotropic, -chronotropic) - assess apical HR 1 min prior to admin, must be 60 or above, if not re-ck in 1 hr (if still too low call dr). Assess dig level |
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Atrial Fib meds
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Coumadin (anticoagulant) - assiss INR, bleeding
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UTI meds
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incorporate F/E lecture r/t need for IV to administer IVPB antibiotics
determine if UTI - UA + for bacteria Antibiotics - how to determine effectiveness (WBC) |
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COPD meds
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updraft
inhaler admin - bronchodilator first, steroid next (rinse mouth after steroid inhaler) assess HR and BP prior to adrenergic bronchodilator, WBC, and BS prior to steroid |
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Classifications of Surgery
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Diagnostic - removing tissue for dx
Curative - i.e. removal of dz'd gallbladder, CABG, appendix Restorative - heriorrhaphy, knee replacement Palliative - for increased comfort and function but without curing illness such as resect bowel obstruction r/t CA mets Cosmetic - nose, lips, breast implants Emergent - gun shot wound Urgent - GI bleed Required - fractures Elective - Gastric Bypass |
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Surgical Consent
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Informed consent is signed by client and witnessed by another person granting permission to client's Dr to perform procedure described by physician (description must be in full words - no abbreviations)
Nurses obtain and witness client's signature, ensure client signs voluntarily and is alert |
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Intraoperative period
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time during the surgical experience that begins when the client is transferred to OR table and ends when client is admitted to PACU
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Asepsis
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absence of pathogenic microorganisms
aseptic technique is a collection of principles used to control and/or prevent the transfer of pathogenic microorganisms from sources within and outside client |
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preoperative phase
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begins with client's decision to have surgery and ends with transfer of client to OR table
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Postoperative phase
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begins with the end of surgical procedure and lasts until client is D/C'd from medical care
goal is to promote recovery from anesthesia and effects of surgery - airway, I&O, fluid volume, hypo/hyperthermia, blood sugar |
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PostOp V/S frequency
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every 15 min for 1 hr
every 1/2 hr for 2 hrs every hr for 4 hrs |
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Anesthesia (def)
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absence of normal sensation
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Sedation (def)
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reduction of stress, excitement, or irritability, and involves CNS depression
used to decrease awareness of events,s relieve anxiety, control physiologic changes often accompanying anxiety, ease the induction of general anesthesia |
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conscious sedation (def)
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minimally depressed level of consciousness during which the patient retains his ability to maintain a continuously patent airway and respond appropriately to physical stimulation or verbal commands produced by the administration of IV sedative, hypnotic, and opioid drugs.
- able to maintain patent airway - permits appropriate response by client to verbal command or physical stimulation |
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Levels of sedation
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light - respond to verbal stimuli, intact protective reflexes, normal resp and eye movement
deep - weak or absent protective reflexes, responds to painful stimuli, difficult to arouse |
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General anesthesia
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unresponsive to all stimuli, unconscious, absent protective reflexes
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Meds used for sedation
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valium, versed, ativan, morphine sulfate, demerol
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Equipment at bedside for sedation
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O2, crash cart, antagonists, pulse ox, telemetry, BP monitor
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Ongoing assessment of sedated pt - Goal
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relaxed, arousable, cooperative state with intact protective reflexes
assess for: resp depression or hypoventilation or apnea hypotension: 20-30% decrease of normal BP unarousable sleep that approaches general anesthesia hypovolemia |
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Nursing care for sedated pts
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BP, P, R, cardiac rhythm, O2 sat, LOC q 5 min
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Malignant Hyperthermia
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life threatening reaction to common inhalation anesthetics
1st sign: increased end tidal CO2 (ETCO2), hypercapnia (increased CO2) late sign: rhabdomyosis, dark urine MH is a hypermetabolic crisis caused by excessive Ca+ released by muscles TREATMENT: DANTROLINE 36 vials with sterile water |
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Level of Consciousness scale
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2 - Fully awake and alert
1 - Able to arouse to verbal or tactile stimuli 0 - unresponsive |
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Post-procedural care in PACU
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- activity, oxygenation, circulatory, LOC q15 min until sedation/analgesia score is 9 or greater
- monitored for 1 hr prior to discharge (if antagonist administered must be monitored for 2 hours minimum) - assess and document safety precautions - post-procedural documentation of pt's tolerance, LOC, v/s |
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antagonists
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benzodiazepine - Romazicon (flumazenil) - 0.2 mg over 30 sec within 1-2 min after med injected, may be repeated at 1 min intervals
opioid - Narcan (naloxone) - 0.1-0.2 mg IV titrated at 2-3 min - Repeat admin may be necessary if duration of action of opioid or benzo exceeds duration of reversal agent |
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Regional anesthesia
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a region of the body is temporarily rendered insensible to pain by injection:
local nerve blocks spinal and epidural blocks Lidocaine (with or or without epi) common, lasts about 1 hr |
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Nerve block
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a local anesthetic is injected more deeply into body and/or is directed at a specific nerve or nerves
may last 1-12 hours |
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A&P r/t epidural
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spinal cord within spinal canal covered with meninges:
- dura mater: outermost toughest layer, fibrous, dense - arachnoid mater: thin, separated by subdural space - pia mater: delicate connective tissue, clings tightly to cord and brain Subarachnoid space: between pia and arachnoid mater & contains CSF (normal level ~150mL) Spinal cord terminates at level of L1-L2 *site for intrathecal (spinal) is L3/4 or L4/5 |
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Epidural anesthesia or analgesia
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- potential space extending from skull to sacrococcygeal membrane between dura mater and vertebral arch
*contraindicated in pts with high INR, PT, PTT, bleeding pathologies - wait 2hr after epidural for lovenox admin |
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Epidural catheter may remain in place for ???
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47-72 hrs
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Epidural physiological effects
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*autonomic nervous system (ANS) can be blocked, relaxing blood vessels which lowers BP
-motor blockade 2 dermatones lower than sensory -bladder control at sacral segments 2-4 - requires Foley -adrenal medulla blocked reducing stress response |
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Contraindications for epidural
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infection at proposed puncture site
generalized systemic infection coagulopathy/anticoagulant therapy increased intracranial pressure allergic rxn prior laminectomy |
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Epidural Nrsg care
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routine post-op v/s then q 4hr
extremity movement q 4 hr appearance of drsg q 4 hr HOB elevated 30 degrees at all times Read infusion pump q 1 hr x 24 hrs then q 4 hr LOS and LOP assessment sensory/neruo assessment Epidural site/dressing I&O catheter may remain in place for 48-72 hr removed only by anesthesia personnel Pulse ox continuous and 4 hrs after d/c No IV/IM/PO narcotics/sedatives except as ordered by physician |
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Epidural complications
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dural puncture
pruritus urinary retention N/V delayed resp depression sympathetic blockade allergic rxn backache epidural hematoma infection direct damage to spinal cord or nerves indirect injury secondary to loss of sensation (i.e. fall, pressure ulcer) catheter migration |
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spinal anesthesia
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-procedures below diaphragm
beneficial for clients with cardiac or respiratory dz, clients with hx of airway problems r/t intubation or reactive airway dz |
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spinal contraindications
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coagulopathy - risk of developing hematomas that could compress nerve roots or spinal cord resulting in neuro deficit or permanent paralysis
uncorrected hypovolemia - leads to severe hypotension systemic or localized infection allergy to anesthetic increased ICP acute neurologic dz scoliosis neurologic abnormality |
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Dermatones
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T4 - nipple line
T6 - xiphoid process T10 - umbilicus L1 - hip L2/3 - thigh L4/5 - calf S1 - toes |
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return of motor and sensory function after spinal
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large nerve fibers before other functions
light touch and pressure before temp and pain motor function and sensation from hip to feet, with the higher dermatones recovering 1st Assess motor function: wiggle toes, flex/extend foot, ability to raise leg Assess sensory: cold (alcohol swab), paper clip One side may return faster than other side *assess bilaterally |
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Complications of spinal
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Hypotension - autonomic blockade
venous pooling - elevate legs assess v/s frequently bradycardia with high spinal block - admin atropine urinary retention - persistent sensory or autonomic blockade of bladder - insert urinary catheter |
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Postdural puncture HA
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position dependent: keep head flat, increase IV and PO fluids,
s/s - frontal/occipital HA, tinnitus, diplopia, n/v, photophobia analgesics autologous blood patch: 20 mL of pt's blood into epidural space to serve as hemostatic plug, closing the dural tear and prevental CSF leakage. |
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PQRST(U) method of pain assessment
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P - provokes
Q - quality R - radiates S - severity T - time (U - how is your pain affecting U) |
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4 stages of general anestesia
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Induction - going to sleep, includes inserting an oral airway
maintenance - anesthesia maintained with combination of IV and inhaled drugs Emergence - drugs allowed to wear off Recovery - may take days or weeks |
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Atelectasis (def)
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collapse of alveoli
may be diffuse, segmental, lobar, or entire lung causes: histamine rxn, mechanical ventilation, potential onset: first 48 hrs |
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Atelectasis s/s
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temp > 102 F, tachycardia, restlessness, tachypnea (24-30), altered breath sounds, dullness to percussion, absent/diminished breath sounds, crackles, decreased PaO2, cyanosis, pleural pain
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Atelectasis prevention/tx
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turn q 30 min - 1 hr, deep breathe and cough q 1 hr, ambulate ASAP, medicate to reduce pain, splinting, force fluids
Incentive spirometry, supplemental O2, elevate HOB, TCDB q 1-2 hr, force fluids , monitor response to tx, monitor for onset of pneumonia |
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Gastic Distension (def)
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accumulation of swallowed air and gastric juices in presence of ileus r/t decreased peristalsis and intestinal manipulation
potential onset 24-36 hr |
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Gastric Distension (s/s)
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increased circumference of abdomen
client c/o fullness/gas pain tympanic abdomen on percussion |
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Gastric Distension prevention/tx
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avoid swallowing air, position change q 2 hr, ambulation ASAP, warm fluids to stimulate peristalsis (ONLY IF BS PRESENT)
Frequent turning to move air and secretions, up in chair, ambulate, NG tube to low suction, assess abdominal circumference, assess bowel sounds, assess passage of flatus, rectal tube |
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Nausea/Vomiting risk, s/s
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clients at risk: general anesthesia, narcotic analgesics, presence of surgical airway, presence of NG tube
S/S: client c/o nausea, emesis |
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N/V prevention, tx
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avoid stimulating gag reflex, avoid rapid movements, remove airways ASAP
tx: NPO, side lying position or turn head to side, change positions slowly, oral care, antiemetics, cool cloth to throat or head, Narcan if r/t duramorph regional anesthesia, alcohol pad to nose |
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Ileus (def)
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failure of peristalsis
Potential onset: first 24-36 hr all surgical clients are risk |
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Ileus s/s, prevention, tx
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S/S: No bowel sounds or <5 per minute
no prevention tx: monitor for return of bowel sounds, offer only sips of water until they return, monitor for distention, monitor for passage of flatus |
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Intestinal Obstruction (def)
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inability of bolus to move through intestinal tract rt adhesions or intussusception or volvulus
potential onset day 3-5 risk: pts with abd surgery |
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Intestinal Obstruction s/s, prevention, tx
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s/s: no postop BM, abd distension, c/o periodic sharp, colicky pain, hyperactive bowel sounds, abd tenderness, NG drainage: dark brown/black
tx: identify condition early, report to Dr immediately, reduce client anxiety, maintain patent NG tube, never give laxative if obstruction is suspected |
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Paralytic Ileus (def)
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paralysis of intestinal peristalsis
risk: pt's with intraperitoneal surgery, pneumonia, peritonitis, hypokalemia, kidney surgery, wound infection, opioid analgesics |
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Paralytic Ileus s/s, tx
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s/s: no bowel sounds, abd distension, no flatus, NG drainage green to yellow 1-2 L/24hr, hiccoughs, tympany
tx: same as ileus - NG tube to low intermittent suction until peristalsis returns |
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Pneumonia (def)
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inflammatory process in which alveoli are filled with exudate
onset: first 36-48 hr risk: unresolved atelectasis, aspiration, smokers, elderly, debilitated, chronic bronchitis, heart failure, alcoholics, immobile, cough suppressant or respiratory depressing med |
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Pneumonia s/s, prevention, tx
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c/o dyspnea, fever, tachycardia, productive cough and increasing amounts of sputum becoming tenacious, rust, purulent, tactile fremitus, bronchial breath sounds, crackles, decreased PaO2
prevention: provide rigorous tx of atelectasis, prevent aspiration, early ambulation, TCDB, no smoking tx: TCDB q 1hr, sputum C&S, frequent mouth care, admin O2, increase fluid intake, admin antipyretic as ordered, elevate HOB, incentive spirometry |
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Pulmonary Embolism (def)
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foreign object migrated to pulmonary artery causing blood flow obstruction
onset: 7-10th day risk: presence of DVT, intraperitoneal surgery, introduction of air emboli, long bone fractures, orthopedic surgery, pelvic surgery |
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Pulmonary Embolism s/s, prevention, tx
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s/s: sharp, stabbing chest pain, effected by respirations, may be localized RLL, tachypnea, dyspnea, tachycardia, dysrhythmia, restlessness, diaphoresis, cough + hemoptysis, cyanosis, sense of impending doom
prevention: ROM, encourage early ambulations, prevent thrombophlebitis, DVT, do not massage legs, adequate hydration, leg exercises, TCDB, avoid Valsalva maneuver, TED hose TX: O2, reduce anxiety, position on left side with head dependent, IV fluids, analgesics, prepare for fibrinolysis and anticoagulation |
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Thrombophlebitis (def), onset, risk
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Inflammation of a vein with clot formation
onset: 7-14th day risk: varicose veins, previous thrombophlebitis, trauma to vein wall (including tight strap or bumping leg), surgery on hips or pelvis, age >60, immobility, casts, restrictive dressings, constant Fowler's position, prolonged dependent LE, knee gatch elevated, pillows under knees, obesity, postpartum, PVD, adb distension, hypovolemic shock, heart failure, surgical stress response, infection, anesthesia, oral contraceptives |
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Thrombophlebitis s/s
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s/s: superficial - redness, pain, tenderness, induration along vein, palpable cord, hx trauma including IV
deep small vein - increased muscle turgor and tenderness, deep muscle tenderness, warmth, positive Homan's sign, fever 101 F or >, c/o tightness/stiffness in leg Femoral vein thrombosis - pain/tenderness in distal thigh and popliteal region; swelling extends to level of knee |
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Thrombosis prevention/tx
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Prevention: avoid lower extremity IV, avoid restraints, early ambulation, leg exercises 10 min q 1-2 hr, prevent sitting with legs dependent, AROM/PROM, prevent restrictive dressings, antiembolic stockings, adequate hydration, prevent infections, maintain circulation
TX: treat symptoms, analgesics, local heat, anticoagulants |
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UTI
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onset 3-5th day
prevention: sterile technique during catheterization and removal, catheter care, early ambulation, force fluids tx: force fluids (cranberry juice), increase activity to enhance bladder emptying, encourage voiding q 2 hr, admin antibiotic as ordered, monitor for residual urine >100 mL |
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Wound infection
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onset: 5-7th day postop (if Strep 24-48 hrs after contamination)
s/s: tender, swollen, warm, red, increase HR, increase temp, increasing or recurring serous drainage, purulent drainage, if deep infection, may be no local sign prevention: adequate nutrition, good circulation, normal blood volume, prevent anemia, nonrestrictive dressings, frequent turning, maintain PaO2, increased attention for immunosuppressed clients, handwashing, aseptic technique tx: cleanse wound as ordered, antibiotics, keep following preventative nursing measures |
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Dehiscence/Evisceration
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onset: 7-14th day
s/s: incisional separation, viscera exposed, sudden profuse serosanguinous drainage Intervention: Low Fowler's with knees flexed, NPO, support opening, cover with moist sterile gauze |
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Surgical meds to hold
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anticoagulants
potassium (unless contraindicated) to be taken with food laxatives insulin, oral antihyperglycemics |
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Emergency Assessment
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ABCs
9 dx signs to observe: respiratory effort pupillary changes skin color reflexes v/s LOC posture skin temp/turgor deformities |
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Use ABCDE to assess in emergencies
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A - airway and cervical spine (immobilize)
B - breathing C - circulation and bleeding D - disability E - expose and examine |
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Circulation and Bleeding
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palpate pulse for 5-10 sec, note rate and regularity
weak, rapid - loss of blood, shock rapid, bounding - fear, anxiety slow, bounding - head trauma, heart block absent - death |
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Skin assessment in emergency
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ashen - shock, fright
red - fever, sunburn cherry red - carbon monoxide purple - respiratory distress |
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Assess for shock
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- use capillary refill to evaluate for shock: press finger into middle of forehead until white, remove finger, count seconds for color to return.
- If it takes > 3 seconds for color to return, shock is progressing. - Assess for hemorrhage: if pulse, heart is beating |
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Stop Bleeding
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must be done immediately
place sterile compress over wounds and apply pressure do not remove old dressings - place additional compress implement measures to stop bleeding: apply direct pressure, elevate a bleeding limb above heart, apply ice or cold pack, apply indirect pressure, if severe try to clamp bleeder with fingers, final option is to apply tourniquet |
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Disability: Neurologic Assessment
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A - alert (speaks and moves spontaneously, answers questions about name, place, date correctly)
V - responsive to verbal stimulus only (answers when directly addressed) P - responsive to painful stimulus only (rubbing sternum or pressure on nail beds) U - unresponsive |
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Assess Eye Signs
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pupillary response:
PERRLA: pupils equal, round, reactive to light and accommodation (C = coordinated) Failure to react r/t blindness, nerve damage, cataract, head injury, death |
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Expose and Examine
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check any site for possible injury - reexamine if pt still complains of it
after you have life-threatening under control obtain info from pt try to find out what happened V/S q 5 min - count pulse and resp for 30 seconds (records a baseline for future tx) |
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Shock
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Regardless of etiology, the primary pathophysiologic outcome in shock consists of hypoperfusion, which results in tissue hypoxia, acidosis, and end organ dysfunction.
Condition of profound hemodynamic and metabolic disturbance - inadequate tissue perfusion and body's inability to meet tissue demands for O2. Can develop rapidly. Every pt should receive preventative and precautionary tx for shock. Compensatory mechanisms can keep person responsive. |
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Hypovolemic Shock
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caused by: trauma, hemorrhage, severe burns, dehydration
tx: restore fluid volume (LR, Hispan, PRBC, Albumin - H&H, T&CM - NS only, get a warmer) |
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Cardiogenic Shock
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caused by: inefficiency of heart as a pump, MI, Cardiac tamponade, restrictive pericarditis, pulmonary embolus, arrhythmias. Systolic or diastolic dysfunction.
Adrenergic meds: dopamine, debutamine |
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Vasogenic Shock
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massive vasodilation
neurogenic: interferes with sympathetic nervous system anaphylactic: vasodilation secondary to massive histamine release, allergies septic: caused by severe infection |
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Metabolic shock
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often associated with diarrhea, vomiting, polyuria
alteration in pH, K+, and Na+ electrolytes |
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Obstructive shock
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obstruction to central arteries or veins
pulmonary emboli tension pneumothorax |
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Psychogenic shock (fainting)
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caused by nervous system reaction and is often result of fear.
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Effects of shock on the five vital organs
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Heart: decreased coronary artery perfusion causes decreased function of the heart muscle as a pump; stroke volume and blood pressure decrease.
Brain: If oxygen and nutrient supplies are inadequate, brain function diminishes and unconsciousness follows. Lungs: as the partial pressure of O2 decreases because of decreased blood volume or blood pressure, gas exchange does not take place at the capillary membrane level. Liver: glycogen stores are depleted by an excess of circulating epinephrine, metabolic acids that are normally detoxified in the liver cause acidosis. Kidneys: a drop in cardiac output causes a decrease in blood flow through the kidneys, decreased urinary output and renal failure result |
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Key signs of shock (stages)
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early: usually no clinical evidence, but there may be increased HR, restlessness, and the pt may have a sense of impending doom.
compensatory: resp and HR increase, pulses may be weak, urinary output decreases, skin is cold and clammy, mottled, and pale, pupils dilate, bowel sounds are hypoactive, hyperglycemia. progressive: pt's condition noticeably deteriorates; pulse may be too rapid to count, blood pressure falls below 80 mmHg, peripheral pulses disappear, there is metabolic acidosis, peripheral edema, pulmonary crackles and wheezes are heard, and the client may be unresponsive. refractory: there is too much cell death and tissue damage from inadequate oxygenation. The pt does not respond to tx. Multiple organ failure occurs, which generally results in death. |
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Tx of shock (types)
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Hypovolemic - restore volume
Cardiogenic - improve myocardial function Septic - IV antibiotics and fluids Neurogenic - medications for hypotension Anaphylactic - identify cause (allergen) Obstructive - identify and treat the cause |
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Nrsg care for shock
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keep pt lying and calm, have someone call for assistance
establish, maintain, and monitor airway administer high concentrations of O2 control bleeding maintain body temp NPO elevate lower extremities use position that is most comfortable for pt immobilize fractures monitor LOC, V/S q 5 min |
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subdural hematoma
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brain is bruised, lacerated, and punctured: blood from ruptured vessels flow between meninges, blood clot between dura mater and brain
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epidural hematoma
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when blood flows between the meninges and skull
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intracerebral hematoma
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blood pools in the brain
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lacerations (r/t brain injuries)
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penetrating or perforating wounds of cranium
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Degrees of frostbite
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first: (superficial) temp tenderness, reddened skin - probably no permanent damage
second: (partial thickness) blisters and some tissue and nerve damage - can result in permanent damage such as hypersensitivity to cold and increased risk of future frostbite. third: (full thickness) tissue death - requires skin grafting or amputation |
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Hypothermia
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when exposed to extreme cold or is cold long enough for core temp to drop below 95 degrees F
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Heat exhaustion
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diaphoresis with pale, moist, cool skin, HA, weakness, dizziness, muscle cramps, nausea, chills, tachypnea, confusion
tx: move to cool shady area, loosen/remove constrictive clothing, pour water over pt, place near fan, elevate feet |
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Heat stroke
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red, flushed, hot, dry skin, no diaphoresis
tx: loosen/remove constrictive clothing, pour water over client, place near fan, start 2 large bore IVs, elevate feet, check core temp often |
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Dressing vs Bandage
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dressing: any material applied to a wound in an effort to control bleeding and prevent further contamination. Prefer sterile.
bandage: any material used to hold a dressing in place. Need not be sterile |
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Intrusion vs Avulsion dental injury
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Intrusion: pushed up into socket
Avulsion: knocked out |
