Unit III

Medical and surgical asepsis

- Medical Asepsis means those practices that confine or reduce numbers of microorganisms. Also called clean technique, that involves measures that interfere with the chain of infection - Surgical Asepsis - Refers to those measures that render supplies and equipment totally free of microorganisms. Sterile.

Respiratory Assessment Questions

-How far can you walk on level ground? -How many stairs are you able to climb without becoming short of breath? -Do you have a cough? If so, when did it start? -Do you have pain with breathing? -Have you been exposed to dust, fumes, or smoke in the environment at work or home?

Respiratory Collaborative interventions

-Improved nutrition -Medications (bronchodilators, anticholinergics, corticosteroids, antibiotics, mucolytic therapy, leukotriene modifiers) -Oxygen therapy (refer to nursing skills lab: respiratory modalities)

Inhalations (med admin)

-Nebulizers deliver most medications through inhaled route (mask) -Metered-dose inhalers (MDI) with or without spacers -B before C

Eye Drop instillation

-one drop/application at a time into the lower lid -have client bling several times -maintain pressure to inner canthus

Topical (Percutaneous) Med Admin

-remove any prior applications (unless otherwise specified) -appropriately remove medication from the container (do not double dip) -apply to clean skin with a gloved hand, tongue blade, or cotton tipped applicator

Pursed-lip breathing and diaphragmatic breathing are

... for pt that is retaining CO2

Reservoir nasal cannula (Oxymizer) delivery rate

1-15 L/min FiO2 24-60%

Administering medications

1. locate and identify client 2. use 2 identifiers 3. explain each medication 4. conduct any necessary client assessments prior to admin 5. give client med 6. stay with the client until he/she takes med 7. correctly dispose of used supplies and wash hands

Potassium (mEq/L)

3.5-5 mEq/L

Potassium (K)

3.5-5.0 mEq/L

Respiration: Infants

30-80 breaths per minute

The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. How would the edema be documented?

4+ Rationale: Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse would assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8-mm depression. A grade of 1+ indicates a 2-mm depression. A grade of 2+ indicates a 4-mm depression. A grade of 3+ indicates a 6-mm depression.

Venturi mask flow rate

4-12 L/min FiO2 24-60%

WBC count

5,000-10,000/mm3

face tent flow rate

8-12 L/min FiO2 28-100%

Calcium levels

8.5-10.5 mg/dL

Cholesterol (mg/dL)

<200

clubbing and barrel chest

A *chronic* sign of hypoxia

Factors affecting blood pressure

Age (with age... loss of elasticity, PVR increases leading to a higher BP) Gender (typically women have lower BP) Race (hypertension is more prevalent in African Americans and women) Medications (example: oral contraceptives can increase BP) Weight Time of day (circadian rhythm) Diseases (hyper/hypovolemia... head injuries etc) Emotions (anger, stress, fear) Pain

When a client presents for vaccines, what type of immunity is the client achieving?

Artificially acquired active immunity

Otic medication

Child: < 3 years of age: Pull down and back on pinna Adult: > or = 3 years of age pull up and back on pinna

Exemplar 1: Wound healing complications

Dehiscence (partial or complete separation of the tissue layers during the healing process) Evisceration (total separation of tissue layers allowing the protrusion of visceral organs through the incision) Fistula formation (*abnormal connections* between two internal organs or between an internal organ and through the skin/outside of the body)

Blood borne pathogens

Disease-causing organisms transferred through contact with blood or other body fluids example HIV

What tablets must NEVER be crushed?

Enteric coated, time released/slow released, buccal, or sublingual medications

Normal structure of the skin

Epidermis, dermis, subcutaneous layer

innate immunity

Immunity that is present before exposure and effective from birth. Responds to a broad range of pathogens.

Resistant Organisms

MRSA (methicillin/vancomycin-resistant Staphylococcus aureus) VRE (vancomycin-resistant Enterococcus) ORSA (oxacillin-resistant Staphylococcus aureus)

Hemoglobin (HGB)

Male: 14-18 g/dL Female: 12-16 g/dL

RBC count

Male: 4.7-6.1 Female: 4.2-5.4

Hematocrit (HCT)

Male: 42-52% Female: 37-47%

Cardiovascular Health Promotion

Minimize modifiable risk factors such as smoking, hypertension, high blood cholesterol, obesity, physical activity, diabetes mellitus, recommended screening and patient education

How might a susceptible host be exposed to an infection?

Older age, chronic disease, immunocompromised, eating/drinking

Neurovascular Assessment (5 P's)

Pain Pulse Pallor Paresthesia Paralysis

Only what type of tablets can be cut?

Scored tablets

Inflammatory response

Second line of defense. A local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. Produces redness, heat, pain, and swelling.

Exemplar 2: Pressure Injury

Stage 1 (Unbroken skin, does not blanch or turn white) Stage 2 (partial thickness injury that looks like a blister...) Stage 3 (Full thickness that extends to the underlying tissue) Stage 4 (Full thickness into the muscle/bone/tendon) Unstageable Pressure ulcer (unable to assess the depth of the wound or the involvement of underlying structures Deep pressure injury: persistent non-blanchable, deep red, maroon or purple discoloration

Vaginal medication admin

Suppository: insert (lubricated) down and backward about 3-4 in Cream: via applicator insert about 2 in pt to remain sitting in supine position for 5-10 min after insertion

Regulation of tissue perfusion & cardiac output

The flow of blood through the arteries and capillaries delivering nutrients and oxygen to cells and removing cellular wastes.

UTI clinical manifestations

Urgency, frequency, burning, difficulty urinating, foul smelling, elevated WBC, inability to empty bladder, urinary retention

ECG/EKG

a graphic representation of the electrical activity that occurs in the heart

Respiratory Health Promotion

active lifestyle, environmental air quality, tobacco cessation, vaccinations, management of comorbidities

Factors affecting tissue integrity

age, comorbid conditions (vascular disease, diabetes, etc) medications, activity (clients that cannot turn are at risk for impaired tissue integrity) injury

Factors that influence respiratory function

age, exercise, health status, medications, pain, emotions

echocardiogram

an ultrasound examination of the heart that examines the movement of blood through the heart and output

UTI clinical therapy

antibiotics, increase PO intake

Instillations and irrigations

applied into body cavities and orifices

Blood pressure sites

arm: most common using the brachial artery thigh: auscultate over the popliteal surface leg: auscultate over posterior tibial/dorsalis pedis forearm: auscultate over brachial artery

What is an example of a non-disease carrying micro-organism?

bacteria

Perform hand hygiene

before and after pt contact as you enter the room before performing an aseptic task after body fluid exposure after contact with pt surroundings

b before c

bronchodilators before corticosteroids

PO (medication administration)

by mouth, oral

Which are important components of a neurovascular assessment performed by the nurse? Select all that apply. One, some, or all responses may be correct. Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation

capillary refill, pulse and skin temperature, movement and sensation Rationale: A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

CBC/ CBC diff

complete blood count and differential

The inflammatory process

fighting infection, bringing nutrients and blood to the site, serves as a signaling factor, promotes healing

The best time for sputum assessment

first thing in the morning can be obtained with suction if pt is unable to cough up secretions

Infection control and aseptic interventions

hand hygiene, precautions and isolation, PPE, medical and surgical asepsis, disinfection and sterilization

CO equation

heart rate (HR) x stroke volume (SV)

Chain of infection

infectious agent, source of infection, portal of exit, mode of transmission, portal of entry susceptible host

erythrocyte sedimentation rate (ESR)

measures the degree of inflammation in the body and the result can be an indicator of infection.

Anticoagulant therapy

medications that prevent the blood from clotting or prevent existing clots from getting larger. Usually anticoagulant studies use the light blue topped tube. Usually patient is on coumadin

eupnea

normal respiratory rate and rhythm

upper respiratory tract

nose, nasal cavity, sinuses, and pharynx

Chest X-Ray (CXR)

performed to examine the lungs, heart, and bones of the chest

adaptive immunity

the ability to recognize and remember specific antigens and mount an attack on them

immune response

the body's attempt to protect itself from foreign and harmful substances initiated by recognition of antigens

the nasal cavity is divided by

the nasal septum

Nasal Cannula delivery rate

1-6 L/min FiO2 24-44%

Preparing medications for administration

1. wash hands 2. gather equipment 3. locate clients drugs 4. select the appropriate medications needed for admin 5. calculate dosages if necessary 6. prepare the medications for admin 7. check prepared medications three times to assure accuracy

*Sputum Assessment*

1.) Provide oral care 2.) Breathe deeply 3.) Expectorate into container 4.) Obtain 2-10 mL of sputum 5.) Provide oral care again 6.) Label and send to lab

Respiratory assessment

1.) Vital signs: respirations, rate, depth, quality and O2 sat 2.) Interview Questions 3.) Inspection - shape, symmetry, accessory muscle use? Patterns p. 287 4.) Palpation - size, shape, tactile fremitus, movement, excursion 5.) Auscultation - normal breath sounds (CTA: tracheal, bronchial, bronchovesicular, vesicular) adventitious breath sounds (crackles, rhonchi, wheezing, stridor, pleural friction rub)

UTI risk factors

Age, gender, catheters, chronic illnesses, poor hygiene, hydration, urinary stasis

precautions and isolation

Airborne (transmitted through droplets/particles in the air... may have to wear N95 mask or negative pressure room) Droplet (transmitted through droplets, doesn't travel further than 3ft... wear a mask and gloves) Contact/Enteric (could be transmitted through direct contact or indirect contact... example HSV and C. Diff)

Diversity Considerations: Perfusion

Cardiopulmonary function changes with age. O2 uptake declines after age 25. Cardiovascular performance declines in the 40s-50s Emphysema typically begins in the 30's when present but become more severe in the 50s During pregnancy, cardiac output and blood volume increases and the growing uterus puts pressure on the diaphragm making it more difficult to breathe The heart mass of males increases about 15-30 percent more than that of females after puberty emphysema occurs more often in men than women CHD is higher in men than women through the age of 84 and after 85 the incidence of CHD is higher in women than men African American med have a higher chance of heart attack or heart disease compared to white men/women or black women from age 35-84 obesity contributes to diabetes and high cholesterol levels increasing the risk of CAD. It also contributes to hypertension and heart failure.

Common Errors in Blood Pressure Measurements:

Improper cuff size The arm is not at heart level Cuff is not completely deflated before use Deflation of the cuff is faster than 2-3 mmHg per second Improper cuff placement Defective equipment

Decreased Levels of Potassium

Loss of this vitamin due to vomiting, gastric suction, diarrhea, laxative abuse, frequent enemas use of K-wasting diuretics inadequate intake seen in anorexia alcoholism debilitated patients hyperaldosteronism

What determines blood pressure?

Pumping of the heart Peripheral vascular resistance Blood volume Blood viscosity Elasticity

oxygen therapy

The administration of supplemental oxygen at concentrations greater than room air to treat or prevent hypoxemia.

sequential compression device (SCD)

What type of equipment is used to prevent the formation of blood clots

Wounds

Wound Classification (closed or open?) Wound depth (superficial- abrasion, paper cut, partial thickness , full thickness) Amount of contamination

Troponin

used to determine if there is damage to the heart. levels increase 4 to 6 hours after an MI peak 10 to 2 hours after an MI return to baseline several days after an MI

partial nonrebreather mask flow rate

10-12 L/min FiO2 80-90% do not let the bag deflate

Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. Fatigue Orthopnea Pitting edema Dry hacking cough 4-pound weight gain

All of the above Rationale: Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.

Mode of transmission: Vector-borne

Insect or animal is an intermediate host example: a tick

Steroids

Reduce inflammation If our client is taking a steroid (oral or IV), it reduces the inflammatory response thus putting the client at risk for infection

Basic Metabolic Panel (BMP)

a test that measures electrolytes, carbon dioxide, glucose, and renal function

Electrolyte Imbalances in the body can cause

cardiac arrhythmias

Exemplar 2: Pressure injury

damage to the skin in an area that may include soft tissue damage found over bony prominences (also called pressure ulcers, bedsores, decubitus ulcers) Etiology - Pressure -intensity -duration -medical devices (MDR pressure injury) -friction and shear (p. 598) -sensory loss -immobility -moisture (maceration) -nutrition

Lower respiratory tract

larynx, trachea, bronchi, bronchioles, alveoli

Lipid Profile

lipoprotein is used to diagnose hyperlipidemia which is a risk factor for CHD Cholesterol is the primary lipid associated with the development of atherosclerosis (higher than 200 mg/dL)

bradypnea

slower respiratory rate

Physiology of Oxygenation

the movement of air into (inspiration) and out (expiration) of the lungs

Ineffective breathing pattern

(Inspiration and/or expiration that does not provide adequate ventilation) r/t: anxiety, body position structural deformity, hyperventilation, hypoventilation, obesity, pain As manifested by: alterations in depth of breathing, altered chest excursion, bradypnea, dyspnea, nasal flaring, orthopnea, tachypnea, use of accessory muscles Expected outcomes: "the client will report ability to breathe comfortably during my shift... the client will demonstrate the ability to perform appropriate breathing exercises during my shift..." Interventions: positioning (frequent repositioning, *Q 2hr*), TCDB, huff coughing, pursed lip breathing, diaphragmatic breathing, incentive spirometer Evaluation: nurse collects data to evaluate the effectiveness of the interventions

ineffective airway clearance

(inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway) r/t: airway spasm, excessive mucus, foreign body in airway, infection, second hand smoke, smoke inhalation as manifested by: absent cough, adventitious breath sounds, diminished breath sounds, dyspnea, excessive sputum, restlessness (early sign), cyanosis (late sign), changes in respiratory rate/rhythm. Expected outcomes: (remember SMART outcomes) "the client will maintain patent airway during my shift... client will demonstrate effective coughing and clear breath sounds by the end of my shift... client will identify and avoid specific factors that inhibit effective airway clearance after my teaching session...) Interventions: Positioning (high fowlers...) Frequent repositioning (Q2hr), TCDB, huff coughing, pursed-lip breathing, diaphragmatic breathing, incentive spirometer (IS), promoting secretion clearance (cough and deep breathe), encourage PO fluids as tolerated, humidifiers, suctioning Evaluation: nurse collects data to evaluate the effectiveness of the interventions

Preparing for medication administration

1. obtain client MAR 2. determine what drugs are to be given at current time 3. check mar for accurate info 4. be knowledgeable about all drugs being administered 5. collect client data

Respiration: Adults

12-20 breaths per minute

Respiration: Older adults

15-20 breaths per minute

Respiration: Children

15-25 breaths per minute

While assessing a client, the nurse notes an oxygen saturation of 92% and the client reports mild dyspnea. Which of the following nursing interventions should be *immediately* implemented? (Select all that apply.) a. Instruct client to deep breathe and cough b. Encourage huff coughing c. Initiate oxygen administration d. Reposition client to high fowlers e. Contact provider

A, D TCDB can improve O2 sat and mild dyspnea quickly, pt did not complain of cough so this intervention is not appropriate for this pt, initiating O2... you never want to administer O2 if the pt does not need it repositioning is always the initial step contacting the provider is not necessary in this situation

Exemplar 3: Contact dermatitis

An inflammation of the skin caused by direct contact with an allergen or irritant Apply topical corticosteroids for 2-3 weeks Prevent pruritus -use mild detergents; avoid fabric softener -avoid lotions and perfumes with alcohol -cleanse skin with tepid water (lukewarm), mild soap, rinse well -apply lotion while skin is still damp -humidifier -increase fluid intake -keep nails trimmed short -wear loose clothing, keep environment cool -apply pressure or cold for relief of symptoms

Impaired tissue integrity (p. 924)

Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament. r/t: Chemical injury agent, excessive fluid volume, humidity, imbalanced nutritional state, insufficient fluid volume, insufficient knowledge about maintaining tissue integrity, insufficient knowledge about protecting tissue integrity As manifested by: Acute pain, bleeding, destroyed tissue, hematoma, localized area hot to touch, redness, tissue damage Outcomes: Client Will (Specify Time Frame) • Report any altered sensation or pain at site of tissue impairment • Demonstrate understanding of plan to heal tissue and prevent reinjury • Describe measures to protect and heal the tissue, including wound care • Experience a wound that decreases in size and has increased granulation tissue Interventions: Incision Site Care; Pain Management; Pressure Ulcer Care; Risk Identification; Skin Care: Topical Treatments; Skin Surveillance; Wound Care; Wound Irrigation Evaluation:

Normal flora

a group of non-disease-causing microorganisms that live in or on the body found on the skin, eyes, nose, mouth, upper throat, lower urethra, small intestine, and large intestine.

Impaired skin integrity (p. 836)

altered epidermis and/or dermis r/t: chemical injury, excretions, humidity, hyperthermia, hypothermia, moisture, pressure over bony prominence, secretions, alteration in fluid volume, inadequate nutrition, psychogenic factor As manifested by: acute pain, alteration in skin integrity, bleeding, foreign matter piercing skin, hematoma, localized area hot to touch, redness Outcomes: (specify time frame) Client will regain integrity of skin surface.. Report any altered sensation or pain at site of skin impairment... Demonstrate understanding of plan to heal skin and prevent reinjury or complications... Describe measures to protect and heal the skin and to care for any skin lesion... Interventions: Incision Site Care; Pain Management; Pressure Ulcer Care Evaluation:

Risk for Impaired skin integrity (p. 840)

at risk for skin being adversely altered r/t: chemical injury agent, excretions, humidity, hyperthermia, hypothermia, moisture, secretions, alteration in fluid volume, inadequate nutrition, pressure over bony prominence, psychogenetic factor, alteration in metabolism, alteration in pigmentation, alteration in sensation, alteration in skin turgor, arterial puncture, hormonal change, arterial puncture As manifested by: Outcomes: Client will report sensation or pain at risk areas as soon as noted ... client will demonstrate understanding of personal risk factors for impaired skin integrity by the end of my shift... client will verbalize a personal plan for preventing impaired skin integrity before discharge... Interventions: Positioning (Q 2 turns), Pressure management, pressure ulcer care, skin surveillance, keep skin clean and dry, Evaluation:

dyspnea

difficult or labored breathing, SOB

Transdermal medication patches

do not cut remove prior to MRI remove previous patch, cleanse skin and always wear gloves rotate application sites

which is the best intervention for a client with Ineffective Airway Clearance related to thick secretions? being on O2 via NC encourage PO intake contact the provider incentive spirometer

encourage PO intake

Signs and symptoms of infection: Systemic

fever, increased heart rate, increase respiratory rate, lethargy, enlarged lymph nodes

Healthcare associated infections (HAIs)

infections that patients acquire within healthcare settings that result from treatment for other conditions CAUTIs, C. Diff, MRSA, VRE

Assessment: Tissue Integrity

inspect the skin palpate (turgor assessment, edeme assessment) Inspect scalp and hair distribution Inspect nails and color and curvature

Eye ointment instillation

instill an eye ointment (1/2 in. ribbon) into the lower lid moving from the INNER to OUTER canthus. close eyelids and move eyes for ointment

urinary tract infection (UTI)

invasion of pathogenic organisms (commonly bacteria) in the urinary tract, especially the urethra and bladder; symptoms include dysuria, urinary frequency, and malaise

cardiac catheterization (CC)

invasive (sterile) procedure that uses contract and a long flexible catheter to visualize the heart chambers, coronary arteries, and great vessels. Used to evaluate chest pain, locate the region of coronary artery occlusion and determine the effects of valvular heart disease

Exemplar 1: Wound healing process

primary -acute wounds -edges approximated (they can be drawn together easily) secondary -usually chronic wounds -new tissue fills in from the bottom and sides tertiary -delay between injury and closure of wound

Cardiac Enzymes

proteins that are released when there is cardiac damage

respiratory alterations impact on activities of daily living

quality of life is diminished... dyspnea worsens over time which reduces exercise tolerance...

What should be done with the first bead of eye ointment/drops?

the first bead is considered contaminated and should be wasted

transdermal application sites

trunk, lower abdomen, side, lower back, or buttocks

nonrebreather mask flow rate

use a flow rate of 15 L/min FiO2 60-90% do not let the bag deflate

For liquids less than 5mL

use a syringe or a dropper

Irritability/restlessness

*Early* sign of hypoxia; the client's brain is not receiving enough oxygen

Cyanosis

*Late* sign of hypoxia

Inspiration

-impulses from the respiratory center in the brain travel through phrenic and intercostal nerves, stimulating the diaphragm to move downward and the chest cavity to expand. -expanded lung volume decreases intraalveolar pressure causing air to move into the respiratory tract and the lungs to fill with air.

Respiratory laboratory diagnostic tests

-pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow, residual volume, functional residual capacity) -complete blood counts (altered red blood cell count impacts oxygenation) -ABGs -Chest X Ray -Bronchoscopy (another invasive test to assess airway) -sputum assessment

Exemplar 1: Wound healing

1. *Inflammatory* Phase -Exudate (serous, serosanguineous, sanguineous, purulent which indicated infection) 2. *Proliferative* Phase - Tissue repair, granulation tissue (new tissue) fills the wound bed with new tissue 3. Maturation -Scar formation

Exemplar 1: Factors affecting wound healing p. 595

1. Oxygenation/perfusion *biggest factor* 2. Diabetes 3. Nutrition (what are good things for someone with a wound to eat? Protein, vitamin D, C, A, Zinc, Copper... low sugar diet) 4. Age (slower collagen production, etc) 5. Infection

The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct. Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds

All of the above Rationale: Daily weight at the same time, on the same scale, and in the same clothing is important as it is an indication of fluid gains or losses. The nurse would also record daily intake and output and report intake exceeding output. The nurse would monitor for peripheral edema and document the findings. It is important to obtain and record vital signs and daily pulse oximetry as improving results relate to effectiveness of furosemide. The nurse would also auscultate breath sounds, look for jugular venous distension, and report abnormal data.

A client complains of chronically recurring ulcers on the lower leg. Upon assessment, the nurse finds the absence of hair growth on the legs and asks the client to consult the primary health care provider immediately. Which condition would the nurse suspect?

Circulatory insufficiency Rationale: Chronically recurring ulcers in the lower legs or the feet accompanied by an absence of leg hair growth are serious signs of circulatory insufficiency. This finding requires a primary health care provider's intervention. The symptoms of phlebitis include localized redness, tenderness, and swelling over the vein sites of the calves. Clubbing is caused by insufficient oxygenation at the periphery. This can result from chronic emphysema and congenital heart disease. Occlusion is characterized by pain, pallor, pulselessness, paresthesia, and paralysis.

What determines cardiac output?

Heart Rate (bpm) Preload (amount of blood and pressure in the ventricle at the end of diastole) Afterload (the resistance the ventricle must overcome to eject blood volume) Contractility (the capacity of the cardiac muscle fibers to shorten)

Which landmark is correct for the nurse to use when auscultating the mitral valve?

Left fifth intercostal space, midclavicular line Rationale: The correct landmark for auscultating the mitral valve (apical pulse) is found at the left fifth intercostal space (ICS) in the midclavicular line. Auscultation at the fifth ICS in the midaxillary line would yield breath sounds of the lateral lung field. Auscultation at the left second ICS at the sternal border is best to hear the pulmonic valve, and at the left fifth ICS at the sternal border for the tricuspid valve.

Wound assessment

Location Size (LxWxD) Presence of Undermining or tunneling Drainage Condition of the wound bed Condition of wound edges and peri-wound Pain Staging if pressure injury

Risk for Infection

Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health r/t: inadequate primary defenses, compromised host defenses, compromised circulation, contact with contagious agents, lack of immunization As manifested by: Expected outcomes: Client Will (Specify Time Frame) Remain free from symptoms of infection during contact with health care providers... State symptoms of infection before initiating a health care-related procedure... Demonstrate appropriate care of infection-prone sites within 48 hours of instruction... Maintain white blood cell count and differential within normal limits within 48 hours of treatment initiation... Demonstrate appropriate hygienic measures such as handwashing, oral care, and perineal care within 24 hours of instruction Interventions: Immunization/Vaccination Management; Infection Control; Infection Protection Evaluation: nurse collects data to evaluate the effectiveness of the interventions

The nurse assesses the vital signs of a 50-year-old female client and documents the results. Which are considered within normal range for this client? Select all that apply. One, some, or all responses may be correct. Oral temperature of 98.2°F (36.8°C) Apical pulse of 88 beats/min and regular Respiratory rate of 30 breaths/min Blood pressure of 116/78 mm Hg while in a sitting position Oxygen saturation of 92%

Temperature, Apical pulse, Blood Pressure Rationale: The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated, and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age group would be 12 to 20 breaths/min, and oxygen saturation level should be 95%.

CBC (complete blood count)

Test designed to provide information about O2 and CO2 transport capabilities and the status of immune response Components: RBC count, HGB, HCT, RBC indices, WBC count, and differential WBC count.

respiratory alterations

alterations in the cardiovascular and respiratory system may decrease the ability to deliver oxygen to alveoli, absorb oxygen, expect carbon dioxide, and deliver oxygen to tissue throughout the body. COPD- general term used for a group of disorders characterized by impaired airflow. Emphysema- enlargement of gas exchange airways/damage to alveolar walls in the lungs. due to loss of elasticity, expiration is difficult and air becomes trapped in the lungs. Exposure to pollution, family history of the disease, or childhood respiratory tract infections are other risk factors.

ineffective peripheral tissue perfusion

decrease in blood circulation to the periphery which may compromise health r/t: interruption of arterial blood flow, excessive sodium intake, smoking, sedentary lifestyle As manifested by: absent/diminished pulses in periphery, pain in lower extremities, paresthesia (numbness), changes in skin color, cool extremities, uneven hair distribution, delayed would healing Expected outcomes: client will have adequate peripheral person as evidenced by (AEB) warm and BLE with 2+ pulses and capillary refill < 3 sec... client will demonstrate adequate tissue perfusion AEB urinary output greater than 30 mL/hr during my shift... Client will identify changes in lifestyle needed to increase tissue perfusion prior to d/c. Interventions: Assess skin color, temp, texture, wounds, and hair distribution, neurovascular assessment, assess for pain in extremities, check cap refill, monitor peripheral pulses, keep pt warm, encourage ambulation, calf and ankle exercises, SCDs, meticulous foot care, medications, lifestyle changes (smoking cessation, occulation, etc) Evaluation: nurse collects data to evaluate the effectiveness of the interventions

orthopnea

difficulty breathing when lying down

antiembolism stockings (TED hose)

elastic stockings that compress superficial leg veins and promote venous return

tachypnea

elevated respiratory rate

Decreased cardiac output

inadequate blood pumped by the heart to meet metabolic demands of the body r/t: alteration in afterload, impaired contractility, altered heart rate, altered heart rhythm, cardiac muscle disease, fluid overload, electrolyte imbalance As manifested by: chest pain, bradycardia/tachycardia, arrhythmias, S3 and S4 sounds, nausea, anxiety, fatigue, edema, JVD, weight gain, diaphoresis, decreased peripheral pulses, prolonged cap refill, skin color changes, SOB, olguria, crackles, cough, orthopnea Expected outcomes: client will demonstrate adequate cardiac output AEB blood pressure, pulse rate and rhythm within normal parameters for client... Interventions: monitor VS, I&O (include IVF), telemetry monitoring, monitor lab values, monitor daily weight, O2, medications (diuretics- the body voids more frequently causing lower potassium) bed rest if indicated, reduce anxiety, fluid restriction, small, frequent, low sodium, low fat meals, provide care with rest periods, patient education Evaluation: nurse collects data to evaluate the effectiveness of the interventions

Signs and symptoms of infection: Localized

redness, swelling, warmth, tenderness, drainage, numbness

Increased levels of potassium

renal failure massive trauma, crushing injuries, burns hemolysis IV potassium Potassium-sparing diuretics Acidosis, especially diabetic ketoacidosis

humoral immunity

specific immunity produced by B cells (WBCs) that produce antibodies that circulate in body fluids

Cardiac Output (CO)

the amount of blood pumped by the ventricles into the pulmonary and systemic circulations in one min (4-8 L/min)