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31 Cards in this Set

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Causes of IV Infiltration
Dislodging of the IV needle by client movement or obstruction of fluid flow
Signs/Symptoms of IV Infiltration
1. Edema
2. Blanching of skin
3. Discomfort at IV site
4. IV fluid that is flowing slowly or has stopped
5. Skin around IV site feels cool than rest of skin
Preventive Nursing Measures for Infiltration
1. Stabilize IV catheter w/ armboard
2. Frequently check skin around IV site for coolness
3. Avoid looping tubing below bed level
Infiltration Nursing Interventions
1. Discontinue IV solution & remove catheter
2. Apply cold compress if within the first 30 minutes
3. Next, apply warm moist heat - to increase fluid absorption
Causes of Phlebitis
1. Overuse of a vein for IV infusion
2. Irritating IV infusion solutions or medications
3. Catheter in vein for too long a period of time
4. Use of large-gauge IV catheters
Infiltration
Occurs when IV catheter gets dislodged through the vein and the IV fluids infusing pass into the tissues
Signs/Symptoms of Phlebitis
1. Tenderness and pain along the course of the vein
2. Edema
3. Redness at IV insertion site
4. Red streak along the course of the vein
5. Extremity with IV feels warmer than other extremity
Preventative Nursing Measures for Phlebitis
1. Change IV site every 72 hours
2. Use large veins to infuse irritating solutions
3. Stabilize the cannula
4. Dilute medications being infused
Phlebitis Nursing Interventions
Apply warm compresses - to stimulate circulation and promote absorption
Inflammation
Tissue's response to localized injury or trauma. It is an expected response to tissue injury
Systemic Response to Inflammation
1. Fever
2. Leukocytosis (increased number of neutrophils)
3. Weight loss
4. Increased pulse and respirations
Cardinal Signs of Inflammation
1. Redness
2. Heat
3. Pain
4. Edema
5. Loss of Function
Factors that Delay Wound Healing Process
1. Nutritional deficiency - specifically protein and vitamin C
2. Decreased blood supply - e.g., edema, PVD
3. Antiinflammatory Drugs
4. Infection
5. Advanced age, obesity
Infection
Process by which an organism invades the host and establishes a parasitic relationship
Infection Incubation Period
Period of time from exposure to a pathogen until symptoms of infection occur in the host. Infection can still be transmitted to produce an infection in someone else
Direct transmission
Route of transmission when pathogen has immediate transfer from one host to another. E.g., STDs
Indirect transmission
Routh of transmission when transfer of pathogen occurs via an intermediate carrier. E.g., Mosquito, bed sheets, contaminated food/water
Nursing Interventions to Promote Healing with Infection/Inflammation
1. Increase fluid intake
2. Diet high in protein, carbs, and vitamins A, C, and B complex
3. Immobilize an injured extremity with a cast, splint, bandage
4. Administer antipyretic medications
5. Identify early signs of infection
Signs/Symptoms of General Infection
1. Fever
2. Localized inflammation
3. Joint pain
4. Fatigue
5. Increased WBCs
Signs/Symptoms of GI Tract Infection
1. Diarrhea
2. Nausea
3. Vomiting
Signs/Symptoms of Resp Tract Infection
1. Purulent sputum
2. Sore throat
3. Chest pain
4. Congestion
Signs/Symptoms of Urinary Tract Infection
1. Urgency, frequency
2. Hematuria
3. Purulent discharge
4. Dysuria
5. Flank pain
Nursing Interventions to Decrease Pain with Infection/Inflammation
1. Apply cold packs after initial trauma
2. Later, apply heat - promotes healing
3. Elevate the injured area - decreases edema and promotes venous return
Nursing Interventions to Prevent Infection
1. Use correct hand washing
2. Monitor vital signs - Increase in pulse, resp, and temp occuring 4 to 5 days post-op may indicate infection
3. Maintain aseptic technique in dressing changes and wound irrigations
4. Admin antibiotics
Nursing Interventions to Prevent Complications with Infection/Inflammation
1. Determine presence of leukopenia or impaired circulation if client is receiving steriods or drugs that depress bone marrow - Impairs inflammatory response
2. Protect healing wounds from injury - i.e., pulling, stretching
3. Protect immunocompromised clients
Sepsis
Systemic inflammatory response to infection. Characterized by an infection at the site of origin begins to increase and bacteria directly invades the bloodstream
Signs/Symptoms of Sepsis
1. Increased cardiac output
2. Hypotension, tachypnea
3. Poor regulation of body temp - either up or down
Nursing Interventions for Sepsis
1. Maintain hydration status
2. Monitor BP and tissue perfusion
3. Prevent hypoxia
4. Monitor for resp acidosis
Airborne Precautions
1. Private room that has monitored negative air pressure
2. Wear respiratory protection - N95 respirator mask
3. Clients w/ measles, varicella, TB
Droplet Precautions
1. Private room
2. Wear mask (surgical) when working within 3 feet of client
3. Keep client door closed
4. Clients w/ meningitis, flu
3.
Contact Precautions
1. Private room
2. Wear gloves - Always change gloves after contact w/ infected material and remove gloves before leaving room
3. Wear gown if clothing will have contact with client or environmental surfaces or if client has diarrhea or is incontinent - Remove before leaving room