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149 Cards in this Set
- Front
- Back
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What is an infecton?
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Entry & multipication of infectious agent or pathogen in host tissues.
-Causes cell injury |
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What is colonization/
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Pathogen is present but does not cause cell injury.
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What is a symptomatic infection?
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Pathogens multiply and cause clinical signs& symptoms.
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Define Communicable?
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Can be transmitted from one person to another.
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What are the requirements for transmission of an infection?
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-source of microorganism
-susceptible host -means of transmission *Contact, droplets, airborne, common vehicle, vector |
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What is the Incubation Stage of an infection?
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Time of exposure to pathogen to the time of the first symptoms.
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What is the Prodromal Stage of an infection?
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Time of general symptoms (low-grade fever, fatigue) to more specific symptoms. During this time, microorganisms grow and multiply and pt maybe capable of spreading disease to others.
Example: Herpes simplix begins with itching and tingling at the site before the lesion appears. |
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What is the Illness Stage of an infection?
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Time when pt shows symptoms of specific disease
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What is the Convalescence Stage of an infection?
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Interval when acute symtoms disappear. Recovery phase.
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What are the body's defenses to protect against infection?
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Skin, Mouth, Eyes, Respiratory Tract, Urinary Tract, GI Tract, Vagina
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Why are older adults at greater risk for infection?
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They are less capable of producing lymphocytes/antibodies. Ther duration of response is shorter. They tend to attack the body itself istead of infections. Their structure and function of the skin, urinry tact and lungs become altered and less able to protect against infecton.
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What is an Iatrogenic HAI?
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An infection that results from a procedure.
Ex: Pt gets infection from Foley Catheter |
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What is an Endogenous HAI?
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When normal flora becomes altered and overgrowth occurs.
Ex: PT is placed on several antibiotics in the hospital setting and develops C. Dificile infection as a result. |
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What is an Exogenous HAI?
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Organism is present outside of the indivual
Ex: salmonella, aspergillus - these organisms do not exist in the body's normal flora. |
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What are the major sites and some examples of HAI?
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Urinary Tract -unsterile insertion of catheter, improper specimen collection technique
Surgical or Traumatic Wound -improper skin preperation before surgery, failure to clense skin properly. Respiratory Tract -contaminated respiratory therapy equipment, failure to use aseptic technique while suctioning airway Bloodstream -contamination of IIV fluids by tubing, Failure to change IV access site when inflammation first appears |
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Define asepsis
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the absense of pathogenic(disease-producing) microorganisms.
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What is the aseptc technique?
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procedures that assist in reducing the risk for infection or infection transmission.
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What is medical asepsis?
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aka clean techique is used to reduce the number of microorganisms prsent ad prevent transmission.
Ex: hand washing, personal hygiene |
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What is surgical asepsis?
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Maintain sterility of anything thats going toenter clients body (except thru GI tract).
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Which bloodborne pathogens can be found in blood or body fluids?
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Hepatitus A, B, & C. HIV
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What is a direct mode of transmission for bacteria? Give an example.
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Person to person (fecal, oral)
Physical contact Ex: Hep A, Shigella Staphylococcus |
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What is an indirect mode of transmission for bacteria? Give an example.
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Contact of suceptible host with contaminated object (needles, dressings, environment).
Ex: Hep B, HIV, MRSA |
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What is a droplet mode of transmission for bacteria? Give an example.
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Large particles that travel up o 3 feet and come in contact with susceptible host (coughing, sneezing, talking)
Ex: influenza virus, rubella virus |
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What is a airborne mode of transmission for bacteria? Give an example.
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microorganisms suspended in the air or carried on dust particles.
Ex: TB, Chickenpox, measles virus |
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What are vehicle modes of transmission for bacteria? Give an example.
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Contaminated tems, water, drgs, blood, food.
Ex: MRSA, Pseudomonas, Hep B & C |
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What are vector modes of transmission for bacteria? Give an example.
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flies, mosquito, flea, tick
Ex: malaria, West Nile Virus, Lyme Disease |
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What is the chain of infection?
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Infectious agent -> resevoir -> portal of exit ->mode of transmission -> portal of entry -> susceptible host
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How does the assessment phase of the NP relate to infection and safe practice?
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When assessing the patient you will want to..
*Review past diseases, travel hx *Immunizations & vaccinations *Status of defense mechanisms (skin, etc) *Susceptibility *Appearance *Lab results |
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What is an example of a diagnosis for a pt with the risk for infection?
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Risk for infection R/T impaired primarily/secondary defense machanisms.
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What are some examples that increase a pt's risk for infection?
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malnutrion
immuno suppresive drugs chronic disease invasive procedures |
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When is it necessary to use PPE?
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Whenever their is a risk of contact with
blood or bodily fluids secretions, excretions (except sweat non-intact skin, mucous membranes contaminated equipment |
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Treat all clients as if they were ___________?
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Infectious
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What is the single most important way to prevent the spread of microorganisms.
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Handwashing
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What are some airborne precautions?
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Private room, mask or respiratory protection device
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What are some examples of droplet precautions?
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Private room, mask or respirator
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What are some examples of contact precautions?
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Private room, gloves, gown
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What are some examples of protective precautions?
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Private room, respirator mask, gloves, and gowns
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How can you reduce reservoirs of infection?
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Bathing -remove drainage, secretions, perspiration
Change dressing if wet or soiled - keep drainage tubes patent Moisture resistant bags for contaminated articles -tissues, dressings, linens, (hold away from uniform) Needles or sharps -use safety features, dispose of directly in sharps container Keep table surfaces clean & dry Keep bottles solutions tightly capped, date when opened & discard per facility policy Drainage bags/bottles -empty every shift or dispose of entire bottle per facility policy Never raise drainage reservoir above site being drained nless it is clamped (e.g foley bags) Use good handwashing & standard precautions PPE prn. |
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How do you know if if your infection control worked?
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The pt will have decreased sweeling, s/sx will have improved.
***Documentation of the pt's response to therapy is crucial |
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If an infectious disease can be transmitted directly from one person to another, it is:
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communicable
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In infectious diseases such as hepatitis B and C, a reservoir for pathogens is:
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blood
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The most effective way to break the chain of infection is by:
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Practicing good hand hygiene
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A nurse is assigned to care for a client with a deep wound infection. Which of the following actions would result in the contamination of sterile gloves?
A) The nurse grasps a sterile cotton-tipped swab to clean wound edges. B) The nurse takes a gauze pad in hand and places it in the wound. C) The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound. D) The nurse pulls up the sheet over the client's perineum for better draping. |
D. If the nurse touches a sheet (nonsterile) with sterile gloves, the gloves are contaminated. The other actions do not contaminate sterile gloves.
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A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client seems angry but knows this is a normal response to isolation. The best intervention is to:
A) Provide a dark, quiet room to calm the client. B) Explain the isolation procedures and provide meaningful stimulation. C) Reduce the level of precautions to keep the client from becoming angry. D) Limit family and other caregiver visits to reduce the risk of spreading the infection. |
B) When a client is in isolation, the nurse should take measures to improve the client's stimulation and make sure to explain the isolation procedures. Darkening the room can increase the sense of isolation. The nurse should not change the isolation level but should provide plenty of emotional support and make time for the client to prevent a sense of isolation. As long as family and caregivers follow infection precautions, there is no reason to limit contact with these individuals.
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When a nurse is performing surgical hand hygiene, the nurse must keep the hands:
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Above the elbows
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To remove a glove that is contaminated, what should the nurse do first?
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Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or fingers.
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Which of the following statements reflects the current trend in the directives from the Centers for Disease Control and Prevention (CDC) for minimizing risks of infection?
A) Discard all dressings into red bags. B) Do not recap bottles of solutions to minimize risk of contamination. C) Recap syringes or break needles off before discarding into sharps containers. D) Keep all drainage tubing below the level of the waist and/or site of insertion. |
D) Keeping the solution in drainage tubes draining away from the drainage site on the body reduces the risk for bacteria growth.
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The nurse has just admitted a client to rule out active hepatitis B. The client is confused, spitting and scratching everyone who enters the room. The nurse should:
A) Wait an hour until the client calms down and then use gloves when touching the client. B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment. C) Administer a sedative and then perform the assessment after the client is asleep; no precautions would be needed. D) Realize that isolation equipment might further confuse the client and avoid using a face mask and shield but use gown and gloves. |
B) Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination by spitting (saliva can be a source of bacterial contamination) and scratching others, which can break the skin and become a source of risk. All of the barriers listed would minimize cross contamination from the client to the nurse. Even though gloves may be all that is needed because of limited contact with the client, after an hour the client will remain confused and may not understand. The client may become aggressive again and spit or scratch, and other barriers are needed to stop that source of possible risks. A sedative may be given if needed, but trying to perform an assessment when the client is asleep is not appropriate and will prevent the nurse from successfully establishing rapport with the client. Although masks and shields might be frightening to some confused clients, if the client is spitting and body fluids could be exchanged, a barrier should still be used.
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For which airborne disease(s) would the nurse be required to use gloves, respiratory devices, and gown when in close contact with the client?
A) Herpes simplex, scabies B) Viral pneumonia, atelectasis C) Chickenpox, pulmonary tuberculosis D) Multidrug-resistant respiratory syncytial virus |
C) Chickenpox & TB
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Before the nurse washes the hands when leaving an isolation room, what is the last thing that is removed?
A) Mask B) Gown C) Goggles D) Head cover |
Goggles are the least contaminated item and the last to be removed before hand washing. The gown and gloves have been removed first. Head covers are usually not worn in isolation rooms as a barrier. The mask is considered contaminated, and it should be untied and discarded after the gown is removed to minimize contamination from the gown or gloves.
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The nurse is setting up a sterile field for the physician. Which of the following statements concerning a sterile field is correct?
A) The sides of the drape over the table are still sterile until they are touched. B) Reaching over the field is not a source of contamination if the nurse has on a clean gown and gloves. C) One inch around the border should be considered to be the barrier between the sterile field and under the table. D) A liquid spill onto the sterile field is a source of contamination from the table below the drape, even if the barrier is waterproof. |
C
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When transferring a sterile item to a sterile field, the nurse should:
A) Open the outer package and let the sterile assistant take the item from the nurse to put on the edge of the drape. B) Use a sterile lifting tool (forceps) to pick up the inner package and transfer it to the middle of the field. C) Open the outer package and use a sterile glove to pick up the item and drop it on the sterile field in the middle of the drape. D) Open the package by peeling back the cover without touching the inner package and drop the item within the sterile field without touching the 1-inch border. |
D) The rule is "sterile to sterile" to prevent contamination.
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Which statement comparing a surgical scrub with a regular hand-washing session is correct?
A) Water and soap are turned on with the leg or foot pedal in both cases. B) A surgical scrub lasts the same length of time as a hand washing between clients. C) The hands are held in the same position after the scrub as after regular hand washing to prevent contamination from other sources of contact. D) The fingers are held down to rinse in routine hand-washing but are held upright when performing a surgical scrub. |
D) In hand washing, rinsing is from clean to dirty; the arms are considered cleaner than the fingers and therefore rinsing is away from the cleaner part of the arm. In the surgical scrub the arm is considered more contaminated because the hands and nails are more thoroughly scrubbed; therefore, in a surgical scrub the hands are held above the elbows. In hand washing the fingers are held downward to rinse and are dried in the same manner. Keeping hands in sight is important in both cases, but no special position is needed after hand washing. Although a foot or knee pedal is a preferred method of soap and water delivery, using a faucet can be just as safe if a paper towel is used to turn off the water after the hands have been washed.
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What part of a sterile glove is considered contaminated once the glove is applied by the open gloving method?
A) The inner cuff of each glove B) The back of the gloved hands C) Any surface that the powder from the gloves touches D) The outer part of the glove that touched the inner wrapper |
A) The cuff is folded and touched to apply the glove; thus, it becomes contaminated during application of the glove. Usually the cuff will fall down over the wrist, but if it does not, then it is considered unsterile and should not be touched during the procedure. All of the outer part of the glove is sterile unless it has been contaminated. The inner wrapper that held the sterile glove is not contaminated unless one touches it. Therefore, the outer part of the glove can touch it without contamination. The powder is sterile and will not contaminate anything it touches.
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How can a nurse do to reduce the risk of patient injury?
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Assess for actual and potential safety risks
Develop processes to reduce the risk of pt injury (as well as liability risk) |
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Falls account for _____% of reported incidents.
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90%
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What are some factors that increase the risk for falls?
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-Disoriented or confusedUse of assistive devices
-Chronic diseases leading to weakness, dizziness -Osteoporosis |
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How can a nurse reduce the risk of pt falls?
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bed alarm or call light w/in reach
room closer to nurses station non-skid shoes bedside commode, urinal w/in reach sitter |
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When should the physical restraints be used?
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Only as a last resort to ommobolize the pt or an extremity.
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How often does a pt need to be assessed for injury?
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every 15 mins
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What is Status Epilepticus?
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seizure lasting >15 mins or repeated seizures in a 30 minute period.
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How can you avoid aspiration when giving intermittent enteral feedings or meds?
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Check placement of feeding tube by aspirating a tiny amount of contents and check if contents has ph <4 = in stomach.
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When will you hold feedings?
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If residual is >100 or as physician orders. Also check if pt is tolerating feedings. Assess.
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What are some aspiration precautions?
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-Before giving meds or food determine pt's ability to gag or cough if neurological system or level of conciousness is impaired
-provide meds in a form that is easy to swallow -Allow pt to self administer meds of able & drink directly from a cup (no straws) -Asses for s/sx of aspiration (coughing, choking, trouble swallowing) -Check placement of fedding tube prior to giving meds or feedings -Hold feelind is >100mL or physisican orders -Elevated pt head (30-45*) |
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What are some seizure precautions?
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-Assess seizure history
-Have necessary equipment near pt w/hx of seizures -Inspect surrounding for an objects that could cause injury if pt has seizure |
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What should a nurse do if pt has bleeding wound?
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Apply direct pressure to wound with clean cloth or gauze.
Avoid tourniquet When bleeding is controlled, clean wound with saline or commercial wound cleanser, apply dressing or arrange for other treatment options (stitches, etc) |
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When should an incident report be filled out?
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Any time there si an event that causes or has potential to cause client/staff injury.
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True or False
An incident report gets documented in the clients medical record? |
False. The fact that an incident report was filed does not get documented in pt's MAR.
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True or False.
Even though you filled out an incident report you still need to inform your supervisor, physician, client & family as indicated? |
True. Safety risks cannot be reduced if administration is not aware of events occuring in the workplace.
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What is the purpose of the Joint Commission’s National client Safety Goals (NPSGs)?
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to promote specific improvements in client safety.
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How can a nurse improve the accuracy of client identification?
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Goal: Improve the accuracy of client identification.
Requirement: Use at least two client identifiers (neither to be the client's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. |
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How can a nurse improve the effectiveness of communication among caregivers?
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Requirement: For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result.
Requirement: Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. Requirement: Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. |
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How can a nurse improve the safety of using medications?
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Requirement: Standardize and limit the number of drug concentrations available in the organization.
Requirement: Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. Requirement: Label all medications, medication containers (e.g., syringes, medicine cups), or other solutions |
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How can a nurse reduce the risk of health care-associated infections?
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Requirement: Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines
Requirement: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection. |
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How can a nurse reduce the risk of client harm resulting from falls?
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Requirement: Implement a fall reduction program and evaluate the effectiveness of the program.
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How can a nurse reduce the risk of influenza and pneumococcal disease in institutionalized older adults?
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Requirement: Develop and implement a protocol for administration and documentation of the flu vaccine
Requirement: Develop and implement a protocol for administration and documentation of the pneumococcus vaccine. |
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Goal: Implementation of applicable National client Safety Goals and associated Requirements by components and practitioner sites?
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Goal: Encourage the active involvement of clients and their families in the client’s care as a client safety strategy.
Requirement: Define and communicate the means for clients to report concerns about safety and encourage them to do so. |
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How can a nurse prevent healthcare-associated pressure ulcers (decubitus ulcers)?
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Requirement: Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.
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While the nurse is administering flu immunizations in November to a group of older adults at a community senior citizens' center, one of the seniors expresses a fear of contracting the flu from the injection. The nurse reassures the senior that this is not possible because the vaccine contains a dead virus and explains that this injection will produce _________ immunity, in which the senior's body will make antibodies to the virus.
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Active
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As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing how an organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted via which route?
A) Airborne B) Ingestion C) Absorption D) Blood-borne |
A) Organisms with an airborne route of transmission can claim many victims and spread very quickly. Smallpox is not spread via blood. There is no such thing as an absorption or ingestion route of transmission.
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When providing health maintenance teaching to new employees in the food-handling department, the nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent:
A) Food poisoning B) Spread of hepatitis A C) Bacterial food infections D) Salmonella contamination |
B)The hepatitis A virus is spread via fecal contamination of food, water, or milk. It is essential that food handlers wash their hands anytime they use the bathroom. Food poisoning can be due to bacterial contamination of food from a variety of sources, but not usually feces. Salmonella contamination usually arises from uncooked eggs.
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A child for which the nurse is caring in the hospital starts to have a grand mal seizure while playing in the playroom. What is the most important intervention the nurse can do during this situation?
A) Begin cardiopulmonary resuscitation. B) Restrain the child to prevent injury. C) Place a tongue blade over the tongue to prevent aspiration. D) Clear the area around the child to protect the child from injury. |
D) An area around the child should be cleared to prevent injury. Restraining the child or placing a tongue blade in the child's mouth may actually be a cause of injury. Cardiopulmonary resuscitation is required only if heart function stops after the seizure.
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The family of the nurse's confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to handle this situation is to:
A) Ask them to stay with the client at all times. B) Inform them of the risks associated with side rail use. C) Thank them for being conscientious and put the four rails up. D) Provide the client with a one-to-one sitter while the side rails are up. |
B) The use of side rails when a client is disoriented will cause more confusion and further injury. A confused client who is determined to get out of bed may attempt to climb over the side rail or climb out at the foot of the bed, and may fall or experience other injury. After the nurse has this discussion with the family, then the nurse should perform a thorough nursing assessment and develop a plan to ensure the client's safety.
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A couple has brought in their adolescent daughter for a school physical. The parents tell the nurse that they are worried about all the safety risks for this age group. As the nurse plans to teach the parents about these risks, the nurse remembers that adolescents are at a greater risk for injury from:
A) Home accidents B) Poisoning and child abduction C) Physiological changes of aging D) Automobile accidents, suicide, and substance abuse |
D) Adolescents are more likely to be involved in automobile accidents, commit suicide, and engage in substance abuse than are those in other age groups. Children are more susceptible to poisoning and child abduction, and older adults are more susceptible to home accidents and the physiological changes of aging.
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A parent calls the pediatrician's office frantic because her 2-year-old son drank a bottle of cleaner. Which of the following is the most important instruction the nurse can give to this parent?
A) Give the child milk. B) Call the poison control center. C) Give the child syrup of ipecac. D) Take the child to the emergency department |
B) The poison control center will direct all care given to a child who has ingested a substance. Based on the description of the poison, poison control center staff will tell the parent whether the child needs to go to the emergency department and what substances should be given to the child.
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What is a health assessment?
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A systematic collection of data to determine clients current and past health history/status, functional status and coping patterns.
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When a nurse is gathering health history is she collecting subjective or objective data?
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Subjective.
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A student nurse is doing a head to toe assessment, what would be considered objective data?
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All of it because the nurse is doing it and s is observabe and meaurable.
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A nurse thinks a man continously being admitted to the ER may have a drinking problem, what would be a cue?
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Smells of alcohol
Beligerent |
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When collecting data where should you begin and what should you focus on?
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You should begin collecting general dadt the move tomore specific. Focus on problem areas by asking more specific questions.
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What are the guidlines for assessment?
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Clent Prep - explain purpose & establish rapport.
Environmental setting -Use Std precautions to proetect self, safet toprotect pt, ensue confidentiality & privacy, make the pt comfortable ommunication- consider age, culture, speak in understandable language & tone, use eye contact Accurate & complete documentation |
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A nurse walks into the room, introduces herself, explains why she is there and what the pt an expect while he is there, establishes a nurse-cleint relationship. What phase of the interview is this?
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Oritentation/Introductory phase
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The nurse asks several questions pertaining to the client past health problems, treatments, and what pts chief compaint is. This information is used to create a health care plan. What interview phase is this?
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Working phase. Nurse gathers information durng this time.
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The nurse reviews what they have discussed and asks if the pt has any questions, gives the call light and makes the pt comfortable. What phase of the interview is this?
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Termination phase.
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What kind of things should a nurse ask about during a nutritional assessment?
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-Diet
-Appetite, food intake -Food allergies, intolerance -Do 24 hr food recall or askpt to keep diary -Current height & weight *desired wt, any recent loss or gain |
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What kind of things should a nurse ask about during a functiona assessment?
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-Assess pts ability to perform ADLS & IADLS
-What was their level of fuctioning prior to their hospitalization? -Assess rehab needs, & level of care req'd after hospital DC |
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Why is a mental status assessment so important?
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Because it can often detect mental impairment durint the std health hx interview.
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What does ABCT stand for and what part of the assessment is it for?
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Mental Health Status
A-appearance B-behavior C-cognition (orientation, attention span, recent & remote memory, new learning) T-thought process -content & perceptions (do they make sense, canI follow train of thought, any suicidal tendencies? |
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What tools am I going to need to do a physical examination?
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Thermometer, stethoscope, BP cuff, Pulse ox, Penlight, Hands, eyes, ears, nose
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The general approach to PE is?
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Systematicall examine your cloent. Focus on the areas of concern, makesure pt is comfortabe, try to make feel a sense of closeness so they are not so nervous. D vital signs first, establish rapport.
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What are the fou examination techniques?
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Inspection- "looking" at the client. any data collected through smell is also considered to be a part of ispection
Palpation - "feeling" with the hands during aPE Percussion - "tapping" th body with the fingers, hands, or an instument during PE's. Ausculation - "Listen" to the sounds of the body during a PE ****These use your senses -vision, hearing, smell, touch |
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During inspection of your client, what are you going to want to be looking for?
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symmetry, skin lesions or breakdown, ecchymosis, odd odors, appearance
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What is palpation used for?
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determine pulse, skin temp, tenderness, masses, elevations, lymph node or organ enlargement, skin turgor.
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During a head to toe assessment when should you check vital signs?
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first.
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During the H2T, how should you check if the client is oriented x5?
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Ask questions about himself, place, time/date, situation. Also check ability to follow commands
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During the H2T you want to note te overall appearance like what?
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skin & mucous membranes for color, temp, moisture
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During the H2T, what should you chck the head and neck for?
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symmetry, expresson & LOC
PERRLA -pupils equal, round reactiveto light & accomodation conjuctiva & sclera EOM -extraocular movements in 6 fields Check scalp, lymph nodes prn Look in mouth, throat, neck f r sores, ask pt if has an s/sx of soreness check for JVD |
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During te H2T, what should you check he upper extremiies for?
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symmetry
Grips, pulls, pushes (muscle strength equal? Radial puse @ dame time (0-+4) Check cap refill <2-3sec Check for clubbing Check temp w/dorsum of hand Chc skin turgor (if elderly checkunder clavicle or oversternum Assess ROM prn |
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During H2T, what should you check the chest & back for (lungs & heart)
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Inspect chest symmetry, ease of breathing, use of accessory muscles
Any chest pain, pressure or trouble breathing? Auscultate lungs in back , front, sides Auscultate heart sounds (APETM) note rate rhythm |
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What is a normal chest compard to barrel chest?
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Normal chest is 1:2
Barrel chest is 1:1 |
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When is the diaphragm part of te stethscope used?
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high pitched sounds (breath & bowel)
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When is the bell part ofthe stethoscope used?
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To hear soft, low-pitched sounds (vascular sounds, extra heart sounds-murmur)
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Normal quiet respiration is known as?
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Eupnea
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Abnormally slow respiration is known as?
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Bradypnea
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Rapid, shollow respirations is known as?
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Tachypnea
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What is hyperventalaton?
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Rapid,deep respiratons.
Caused by exertion, fear, anxiety, compensation for acidosis |
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What is apnea?
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complete or intermittent cessation of breathing.
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What are symtoms of hypoxia?
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Restlessness, anxiety, acute distress, mental status change, progresses to lethargy, drowsiness
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How many lobes does the right lung have?
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3
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How many lobes oes left lund have?
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2
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Which lobe is shorter and why?
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Right lung is shorter bc of underlying liver
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Wht is the angle of louis?
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The boney ridge forming articulation of manubrium & body of strnum. Continuous of 2nd rib
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What are adventitious sounds?
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Abnormal sounds that are superimposed on underlying breah sounds
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What do crackles (rales) sound like?
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hair rubbing together
-fine, high pitched crackling & popping noise |
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What type of adventitious breath sound can be cleared by cough?
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Gurgles/rhonchi
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What are you hearing happen when you hear crackle in the lungs?
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Alveoli popping open
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When does wheezing occur?
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When airways narrow
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What do wheezes sound like
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high-pitched, musical sound similar to squeak
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When is wheezing most common, during inspiration or expiration?
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expiration
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What do gurgles/Rhonchi sound like?
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low-pitched, coarse, loud.
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When is Rhonchi primarily heard?
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during expiration
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When a nurse listens to breath sounds and has crackles at the bases, what might this indicate?
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CHF -fluid overload
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What side of the stethoscope would I use to hear low & medium pitched sounds & murmurs?
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Bell
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What sie ofth stethoscope would I use to detect S1 & S2, diastolic & 3rd heart sounds, & high pitched murmurs?
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Diaphragm
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Where would I auscultate the Aoritic area?
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2nd ICS, RSB
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Where would I auscultate the Pulmonic area?
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2nd ICS, LSB
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Where would I auscultate Erbs Point?
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3rd ICS, LSB
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Where would I auscultate the Tricuspid valve?
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5th ICS, LSB
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Where would I auscultate the Mitral valve (apical area)?
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5th ICS, Left midclavicular line
-children up to age 7 -4th ICS -apical or formerly point of maximum impulse (PMI) |
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Where can the tricuspid valve be found?
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BW the right atria and right ventricle
(Tri before you Bi) |
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Where can the bicuspid/Mitral valve be found?
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BW the left atria & left ventricle
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Where can the pulmonic valve be found?
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BW the RV & pulmonary artery
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Where can the aortic valve be found?
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BW LV & Aorta
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What could high pressure on the right side of the heart lead to?
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Edema Neck vein distension
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What is S1?
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the first heart sound
beginning of systole produced by closure of mitral and tricuspid valves heard best in mitral or apex of hear coincides with carotid artery |
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What is S2?
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second heart sound
end of systole produced by closure of aortic & pulmonic alves heard best at base of heart (2nd ICS bilateraly) |
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What are s/sx of fluid overload?
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Dyspnea to exertion, fatigue
Crackles in lung Dependent pitting edema Increased BP, bounding pulse initially progresses to weak pulse, Dec. BP, S3 gallop, tachycardia JVD Skin pale, gray or cyanotic Dilated pupils N & V Ascites |
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When assessing the Abdomen remember I Ate Pecan Pie, what does this stand for?
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I-Inspect
A-auscultation Pe-percussions P -palpate |
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When doing H2T what should you assess the abdomn for?
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Inspect for symmetry, hernias (have pt do crunch), contour, skin, umbelicus
Ask about bowel & bladder fxn Start in RLQ & auscultate bowel sounds Lightly palpate all 4 quadrants |
