Homeostasis - Chapter 6, Mosby Nclex Review

Front 1

Causes of IV Infiltration

Back 1

Dislodging of the IV needle by client movement or obstruction of fluid flow

Front 2

Signs/Symptoms of IV Infiltration

Back 2

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

Front 3

Preventive Nursing Measures for Infiltration

Back 3

1. Stabilize IV catheter w/ armboard
2. Frequently check skin around IV site for coolness
3. Avoid looping tubing below bed level

Front 4

Infiltration Nursing Interventions

Back 4

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

Front 5

Causes of Phlebitis

Back 5

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

Front 6

Infiltration

Back 6

Occurs when IV catheter gets dislodged through the vein and the IV fluids infusing pass into the tissues

Front 7

Signs/Symptoms of Phlebitis

Back 7

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

Front 8

Preventative Nursing Measures for Phlebitis

Back 8

1. Change IV site every 72 hours
2. Use large veins to infuse irritating solutions
3. Stabilize the cannula
4. Dilute medications being infused

Front 9

Phlebitis Nursing Interventions

Back 9

Apply warm compresses - to stimulate circulation and promote absorption

Front 10

Inflammation

Back 10

Tissue's response to localized injury or trauma. It is an expected response to tissue injury

Front 11

Systemic Response to Inflammation

Back 11

1. Fever
2. Leukocytosis (increased number of neutrophils)
3. Weight loss
4. Increased pulse and respirations

Front 12

Cardinal Signs of Inflammation

Back 12

1. Redness
2. Heat
3. Pain
4. Edema
5. Loss of Function

Front 13

Factors that Delay Wound Healing Process

Back 13

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

Front 14

Infection

Back 14

Process by which an organism invades the host and establishes a parasitic relationship

Front 15

Infection Incubation Period

Back 15

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

Front 16

Direct transmission

Back 16

Route of transmission when pathogen has immediate transfer from one host to another. E.g., STDs

Front 17

Indirect transmission

Back 17

Routh of transmission when transfer of pathogen occurs via an intermediate carrier. E.g., Mosquito, bed sheets, contaminated food/water

Front 18

Nursing Interventions to Promote Healing with Infection/Inflammation

Back 18

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

Front 19

Signs/Symptoms of General Infection

Back 19

1. Fever
2. Localized inflammation
3. Joint pain
4. Fatigue
5. Increased WBCs

Front 20

Signs/Symptoms of GI Tract Infection

Back 20

1. Diarrhea
2. Nausea
3. Vomiting

Front 21

Signs/Symptoms of Resp Tract Infection

Back 21

1. Purulent sputum
2. Sore throat
3. Chest pain
4. Congestion

Front 22

Signs/Symptoms of Urinary Tract Infection

Back 22

1. Urgency, frequency
2. Hematuria
3. Purulent discharge
4. Dysuria
5. Flank pain

Front 23

Nursing Interventions to Decrease Pain with Infection/Inflammation

Back 23

1. Apply cold packs after initial trauma
2. Later, apply heat - promotes healing
3. Elevate the injured area - decreases edema and promotes venous return

Front 24

Nursing Interventions to Prevent Infection

Back 24

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

Front 25

Nursing Interventions to Prevent Complications with Infection/Inflammation

Back 25

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

Front 26

Sepsis

Back 26

Systemic inflammatory response to infection. Characterized by an infection at the site of origin begins to increase and bacteria directly invades the bloodstream

Front 27

Signs/Symptoms of Sepsis

Back 27

1. Increased cardiac output
2. Hypotension, tachypnea
3. Poor regulation of body temp - either up or down

Front 28

Nursing Interventions for Sepsis

Back 28

1. Maintain hydration status
2. Monitor BP and tissue perfusion
3. Prevent hypoxia
4. Monitor for resp acidosis

Front 29

Airborne Precautions

Back 29

1. Private room that has monitored negative air pressure
2. Wear respiratory protection - N95 respirator mask
3. Clients w/ measles, varicella, TB

Front 30

Droplet Precautions

Back 30

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.

Front 31

Contact Precautions

Back 31

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