Perfusion
What are some risk factors?
Smoking High Cholesterol
Diabetes Physical Inactivity
Hypertension
Obesity
What are some S/S of Local Infection?
Redness, warmth, pain, edema, decrease movement, and increase wound drainage.
(Think about cellulitis that you seen in clinical on the lower legs)
What are some good positions to support oxygenation?
Fowlers, Hi-Fowlers, Tri-Pod Position
What are some nursing interventions to promote Tissue Integrity?
Pressure reduction support ( air mattress, gel cushions), keep pt peri-area clean ( foley, pure-wic), Increase protein (carful with renal pt's), barrier cream and skin prep to heels.
Hand washing
PPE
Education
Monitor temp, WBC,
Coronary Artery Disease- CAD- Narrowing of the arteries by arteriosclerosis, spasms, or birth defects.
Heart Failure: Decrease contractility impairs systolic function, leads 2 dilation, decrease heart's ability to meet needs.
Myocardial Infraction: Heart Attack- Pain/ Discomfort in Neck/Navel, Dyspnea, PAIN IN SHOULDER FOR WOMEN
Fever Increase WBC and ESR
Tachycardia LOC Change
Tachypnea Lymph node Tenderness
Malaise
Anorexia
Assessment of Oxygenation
Pt interview- Smoke/Vape
Inspection- Shape (barrel chest=copd), symmetry
Patterns- Use of accessory muscles?
Palpation- Size, shape, movement
Tactile Fremitus: Vibration in chest wall
What are some risk factors for skin breakdown?
Skin pressure, friction/shearing, immobility, malnutrition, incontinence, decrease sensory perception
What is the NORMAL BP and P FOR adults and older?
Pulse: 60-100
SBP: 90-120
DBP: 60-80
What are some Nursing Interventions for Decrease Cardiac Output?
-Monitor VS, I&O, Wgt (report 3lbs gain in 1 day and 5 in 1 week), Rest, Small Meals, Fluid Restrictions, Decrease Sodium & Fatty Meals.
*****WHAT IS THE CHAIN OF INFECTION?
Infectious Agent
Source- Reservoir of Host
Portal of Exit- How did it escape
Mode of Transmission- How does travel
Portal of Entry- How did enter the new HOST
Susceptible Host- New sick person
What are some breathing exercises?
Cough- ( If you ever hear rhonchi have pt do forceful cough to help clear)
Deep Breathe
Incentive Spirometer
Pursed Lip Breathing ( COPD)
Stage 3- Full thickness into SQ. Slough may be present.
Stage 4- Full thickness w/exposed bone, tendon, or muscle.
When do you collect a sputum specimen?
1st thing in the AM
What diet is good for Perfusion?
High Fiber
Low Fat
Avoid meats high in fat
Eat lean meat- Chicken
Manage Weight
Wear: Standard precautions, Negative pressure room, n95, limit visitor's
Disease: TB, Measles, Chickenpox
Whare are some ways to clear secretion clearance?
- Cough and Deep Breathing
-Increase po intake ( Esp. h20)
-Mucolytic's ( Mucinex)
-Humidifiers
-Suction
How to complete a wound assessment?
Location
Size- use "CM" when measuring. Will measure Length x Width x Depth.
Undermining- Around the wound edges
Tunneling- Tunnels - Think of a mole tunnels.
(Undermining and Tunneling will use the clock to describe the location)
Drainage and what type (smell/color)
What is the NORMAL lab value for WBC?
5,000-10,000 ( some books may say 4.5) just know that its above 10 ish that it's HIGH and possible infection
What are you LOOKING for with a peripheral vascular assessment?
Edema- Pitting, Soft, Weeping, Dependent ( feet been down for a while)
Pulses- Weak
Skin Color- Pale, Redness,
Texture- Hair Loss, Bumpy, Smooth
What do you diff for a pt with CDIFF?
Use contact precautions ( gowns and gloves) BUT YOU SOAP AND WATER. ALCOHOL WILL NOT WORK TO KILL THE CDIFF.
What are some respiratory alterations?
Cynosis- Blue/Grayish fingertips or lips at times ( Dark complexion pt's look at the mucus membranes- will be pale)
Digital Clubbing- Smokers/COPD and will also present with Barrel/Piegon Chest
PNA- Respiratory Infection
COPD UMBRELLA- Emphysema and Chronic Bronchitis fall under COPD as well
Where are Diabetic, Arterial, and Venus ulcers located?
Diabetic- Soles of the feet w/callus around wound
Arterial- Pressure areas around ankles/toes- looks like punched out and normally more Dry looking.
Venus- Found btwn knee-toes- shallow or flat with lots of drainage.
What are the diseases associated with DROPLET Precautions?
Pertusis ( Whooping Cough)
RSV
FLU