Fundamentals Test 5

Front 1

hemorrhage

Back 1

bleeding internally or from a wound, can occur from a slipped suture, a dislodged clot from stress at the suture line or site, infection, or the erosion of a blood vessel by a foreign body (a drain)
s/s: restlessness, anxiety, bleeding, increase heart rate, falling BP, thirst, shock
tx: control the bleeding (pressure drsg.), monitor VS closely, restore blood volume, prevent shock or treat sx of shock (see shock), may need to return to OR to stop bleeding

Front 2

shock

Back 2

not enough blood in periphery to get enough O2 out to periphery; s/s: increased heart weak thready pulse, falling BP, thirst, restlessness, anxiety, cold clammy skin, cool mottled extremities, deep rapid respirations, decreased urine output, apprehension
tx: maintian airway, lay flat with legs elevated, administer oxygen, maintain body warmth with blankets, restore tissue perfusion with fluids and meds, restore blood volume

Front 3

postural hypotension (orthostatic hypotension)

Back 3

low BP associated with weakness or fainting when one rises to an erect position.
Prevention: implement leg exercises and turn Q 2 hrs/ROM
s/s: becomes light headed or faints when rising from a reclined position.
prevention/intervention: implement leg exercises and turn every 2 hours/ROM (prevents clots also), have pt move legs in bed prior to sitting on edge of bed, HOB up and allow pt. to adjust to new position, have pt dangle legs before standing, allow pt to stand for a period of time before walking, if becomes dizzy return to supin postion

Front 4

deep vein throbophlebitis (DVTs)

Back 4

inflammation of a vein associated with a thrombus formation (feels like a cramp that won't go away)
Prevention: leg exercise Q2H/ROM, ambulate at least 3-4 times a day, TED hose or sequential use, avoid leg massage, avoid position that impede circulation, maintain hydration (monitor I&O), administer anticoaglulants as ordered.
s/s: pain and cramping in the calf or thigh, redness and/ or swelling or warmth in the affected area
Tx: administer anticoagulants, maintain bed-rest (with limb elevated) as ordered, use exterman heat application as ordered, measure bilateral calf or thigh circumference daily.

Front 5

pulmonary embolism (PE)

Back 5

blood clot that is dislogded and travels through the bloodstream lodging into the pulmonary vessels.
Prevention: prevent DVTs
s/s: dyspnea, chest pain, cough, cyanosis, rapid respirations, tachycardia, anxiety.
tx: contact MD immedicately (this may be life threatening), maintain bed rest in a semi-fowlers postition, administer O2, maintain IV fluids, administer anticoagulants, avoid Valsalva's maneuver (bearing down on the big BM)

Front 6

Atelectasis

Back 6

is the incomplete expansion or collapse of alveoli with retained mucus, resulting in poor gas exchange
Prevention: C&DB and incentive spirometer Q2H, ambulate 3-4 times a day or more, avoid positions that decrease ventilation (supine), maintain hydration.
s/s: decreased lung sounds, dyspnea, cyanosis, crackles, restlessness, apprehension
tx: position in semi-fowlers/high fowlers position, administer O2 as ordered, maintain fluid and nutritional status, encourage C&DB exercises and incentive spirometry, ensure rest and comfort

Front 7

hypostatic pneumonia

Back 7

pooling of secretions in lungs d/t immobility, increases risk of infection
Prevention: C&DB, incentive spirometer Q2H, amulate 3-4 times per day, avoid positions that decrease ventilation, maintain hydration
s/s: elevated temperature, chills, productive cough (rust or purulent sputum), crackles and wheezes, dyspnea, chest pain
tx:position in sem to high fowlers, administer O2 as ordered, maintain fluid and nutritional status, administer antibiotics, administer expectorants, encourage C&DB exercises and incentive spirometry, provide oral care, teach proper disposal of tissues and sputum, ensure rest and comfort

Front 8

nutrition complications

Back 8

lack of adequate nutrition secondary to lack of appetite
s/s: limited intake of fluids and food, N/V
Prevention: maintain clean environment, encourage pt. to sit while eating, advance diet as tolerated, provide small attractive meals, encourage family to eat with pt., bring foods pt. is willing to eat
tx: monitor I & O, treat nausea, treat vomiting, continue prevention measures

Front 9

abdominal distension

Back 9

decreased peristalsis following general anesthesia causes gas and fecal material to be retained in the abdomen
s/s: pt may describe symptoms of bloating, abdomen is distended (soft or hard), may experience N/V.
Prevention: assess for return of peristalsis Q4H while awake, assess for the ability to pass flatus, monitor use of pain meds., ambulate 3-4 times per day
tx: walking is the most effective way to get peristalsis to return and pass gas, maintain privacy when toileting patient, admister antigas medications as ordered.

Front 10

urinary retention

Back 10

a state in which the individual experiences incomplete emptying of the bladder.
s/s: voiding small frequent amounts (<50 ml each void), bladder distention/discomfort, more fluid intake than output.
Prevention: porvide privacy for voiding, assume normal position when voiding, monitor I&O and frequency of urine, ambulate 3-4 times per day
tx: diagnostic ultrasound to measure residual urine after voiding, report s/s, get an order for catheterization if: pt. has symptoms of retention and uncomfortable, pt. has adequate intake but has not voided in 8 hrs, and if no void has happened in 12 hours pt. must be catheterized

Front 11

dehiscence

Back 11

partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.
s/s: increased flow of serosanguineous fluid from wound between postop days 4 and 5, pt states something has suddenly given way.
tx: coverr with sterile moist dressing and notify MD, wound will be managed like any open wound

Front 12

evisceration

(most at risk are obese or malnourished, smokers, use antioagulants, have infected wounds, excessive coughing, vomiting or straining)

Back 12

wound completely separates with protrusion of viscera through the incisional area (completely through the muscle)
s/s: increase flow of serosanguineous fluid from wound between postop days 4 and 5, pt states something has suddenly given way, protrusion of viscera through incision area
tx: this is an emergency, position in low fowlers, cover wound with sterile towels moistened with 0.9% NaCl solution, have a nurse STAY WITH PATIENT, notify MD, prepare pt to return to surgery

Front 13

wound infections

Back 13

wound become contaminated and infected
s/s: appear 2-7 days postop, pain, redness, swelling around incision, increased drainage, purulent drainage, increased body temp.
Prevention: hand washing, educate pt on s/s to report to MD, educate pt. on proper was to care for wound and dressing, replace dressing if it is soiled or wet, good nutrition for wound healing
tx: dressing changes, antibiotics, treatment of fever

Front 14

incision

Back 14

cutting or sharp instrument; wound edges in close approximation and aligned

Front 15

contusion

Back 15

bruise (skin is intact); blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

Front 16

abrasion

Back 16

skin break due to friction (shearing); friction; rubbing or scraping epidermal layer of skin; top layer of skin abraded

Front 17

laceration

Back 17

tearing of skin and tissue with blunt or irregular instruments; tissue not alighned, often with loose flaps of skin and tissue

Front 18

puncture

Back 18

blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental; a hole

Front 19

penetrating

Back 19

foreign object entering the skin or mucous membrane and lodges in underlying tissue; fragments possibly scattering throughout tissues

Front 20

avulsion

Back 20

tearing from normal anatomical position (flap or divet out of tissue); tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Front 21

microbial

Back 21

secretions of exotoxins or release of endotoxins by living organisms

Front 22

chemical

Back 22

toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

Front 23

thermal

Back 23

high or low temperatures; cellular necrosis as a possible result

Front 24

irradiation

Back 24

UV or radiation exposure

Front 25

primary intention wound healing

Back 25

wound edges are well approximated (are tightly together), have minimal tissue loss, usually made intentionally by a surgical incision with sutured edges

Front 26

secondary intention

Back 26

these wounds have edges that are not well approximated; large or open wounds (burns or major trauma) require more tissue replacement and are often contaminated; scar is usually large and pronounced and take longer to heal

Front 27

tertiary or third intention

Back 27

wound is left open intentionally to allow edema or infection to resolve or exudate to drain, then are closed; because of possible contamination or debris, scar varies with wound, edges not usually approximated and tissue does not come together easily

Front 28

local factors affecting wound healing

Back 28

pressure, desiccation (wound drying out), maceration (wound too moist), trauma, edema, infection, necrosis

Front 29

systemic factor affecting wound healing

Back 29

age (elderly), circulation and oxygenation, nutrition status, wound condition, medications and health status

Front 30

based on urgency
elective surgery

Back 30

the delay of surgery has no ill effect to allow to schedule in advance

surgery to remove or repair a body part (tonsillectomy), to restore function (hip prosthesis), to improve health (hemorrhoidectomy), to improve self-concept (facelift, breast augmentation)

Front 31

based on urgency
urgent surgery

Back 31

surgery is usually done within 24 - 48 hrs.

surgery to repair a body part (colon resection), to preserve or restore health (removal of malignant tumor), to restore function (coronary bypass), to prevent further tissue damage (amputation)

Front 32

based on urgency
emergency surgery

Back 32

surgery done immediately

surgery done to preserve life (control hemorrhage, repair trauma, intestinal obstruction)

Front 33

based on degree of risk
major or high risk surgery

Back 33

may be elective, urgent, or emergency surgery and is done to preserve life, remove or repair, restore function, or improve health

cholecystectomy, nephrectomy, colostomy, hysterectomy

Front 34

based on degree of risk
minor surgery

Back 34

primarily elective; done to restore function, remove skin lesions, correct deformities

teeth extraction, wart removal, skin biopsy, D & C, larproscopy

Front 35

based on purpose
diagnostic surgery

Back 35

to make or confirm a diagnosis; ex: breast biopsy, laproscopy, bronchoscopy, exploratory, laparotomy

Front 36

based on purpose
ablative surgery

Back 36

to remove a diseased body part; ex: appendectomy, thyroidectomy, gastrectomy, colon resection, or amputation

Front 37

based on purpose
palliative surgery

Back 37

to relieve or reduce intensity of an illness (it is not a cure); ex:colostomy, balloon angioplasties, arthroscopy

Front 38

based on purpose
reconstructive surgery

Back 38

to restore function to a traumatized, malfunctioning tissue, or to improve self-concept; ex: scar revision, plastic surgery, skin graft, internal fixation of a fracture, breast reconstruction

Front 39

based on purpose
transplantation surgery

Back 39

to replace organs or structures that are diseased or malfunctioning; ex: kidney, liver, cornea, heart, joints

Front 40

based on purpose
constructive surgery

Back 40

to restore function in congenital anomalies; ex: cleft palate repair, closure of atrial-septal defect

Front 41

paralytic ileus

Back 41

paralysis of the intesinal smooth muscle; may occur after abdominal surgery.
s/s: abdominal distention, N/V, abdominal pain, inability to pass stool or gas.
Prevention: asses for return of peristalsis Q 4 hrs while awake, assess for the ability to pass flatus, NPO until pass gas, introduce foods slowly, ambulate 3-4 times or more per day.
Tx: nasogastric tube placement to decompress abdomen, assess for the return of peristalsis and the ability to pass flatus.

Front 42

phases of wound healing

Back 42

hemostasis, inflammation, proliferation, and maturation

Front 43

hemostasis

Back 43

immediated wound healing phase; involved blood vessel constrict and blood clotting begins through platelet activation and clustering; after capillary permeabliity increased forming exudate which causes swelling and pain

Front 44

inflammatory phase

Back 44

follows hemostasis, lasts about 4 to 6 days, WBC (neutrophils and macrophages) migrate to wound, these clean up debris and release growth factor to stimulate fibroblast and the growth of new epithelial cells, blood vessels, and fill in the wound
Characterized by pain, heat, redness, and swelling
Pt may have slight elevation of temp., leukocytosis, and generalized malaise

Front 45

proliferation phase

Back 45

known as the fibroblastic, regenerative or connective tissue phase; last for several weeks because new tissue is built (done by fibroblasts), the new tissue is called granulation tissue and it is highly vascular, red and bleeds easily

Front 46

Maturation phase

Back 46

final stage of healing, begins about 3 weeks after injury (could take longer), collagen is made stronger and a scar is formed. Scars are avascular, does not sweat, grow hair, or tan. Scars can limit movement.

Front 47

fistula

Back 47

abnormal passage from an internal organ to the outside of the body or from one internal organ to another.
ex: arteriovenous fistula created surgically to provide circulatory acces for kidney dialysis, or an infection that has developed into an abscess leading to an unnatural passage
Risk of delayed healing, infection, fluid and electrolyte imbalances and skin breakdown.