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164 Cards in this Set
- Front
- Back
Nature of Infection |
invasion of a susceptible host by pathogens or microorganisms, resulting in disease
entry and multiplication of organisms result in disease |
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When does colonization occur |
when a microorganism invades the host but does not cause an infection |
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Communicable Disease |
infectious disease transmitted from one person to another |
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Symptomatic Infection |
when pathogens multiply and cause clinical signs and symptoms |
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Asymptomatic Illness |
when clinical signs and symptoms are not present |
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Hand Hygiene |
*most important technique in preventing and controlling the transmission of infection* |
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Chain of Infection |
Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal Entry, Host |
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Types of Contact Mode of Transmission |
Direct, Indirect, Droplet, Airborne, Vehicles, Vector |
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Direct Contact |
Person to Person / Person to Source |
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Indirect Contact |
Person to inanimate object |
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Droplet (contact) |
Coughing, Sneezing, Talking |
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Airborne (contact) |
Droplet nuclei or residue suspended in air or on dust particles |
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Vehicles (contact) |
Food, Water, Drugs & Solutions, blood, fomites |
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Vector (contact) |
External transfer, Internal transmission (parasitic), Mosquito, flea, tick, louse |
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Immunocompromised |
having an impaired immune system |
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Virulence |
the ability to produce disease |
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Aerobic Bacteria |
requires oxygen for survival and for multiplication sufficient to cause disease |
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Anaerobic Bacteria |
thrive where little or no free oxygen is available |
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Bacteriostasis |
Prevention of growth and reproduction of bacteria |
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Bactericidal |
destructive to bacteria |
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How to stop spread of infection from Infectious Agent to Reservoir |
hand hygiene, sterilization, antibiotics/antimicrobials |
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How to stop spread of infection from Reservoir to Portal of Exit |
Transmission-based precautions, sterilization or use of disposable supplies |
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How to stop spread of infection from Portal of Exit to Means of Transmission |
dry intact dressings, hand hygiene, wear gloves if in contact with body fluids, cover nose and mouth when sneezing |
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How to stop spread of infection from Means of Transmission to Portals of Entry |
hand hygiene, use of pesticides to eliminate vectors, adequate refrigeration |
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How to stop spread of infection from Portals of Entry to Susceptible Host |
hand hygiene, wear gloves, wear masks and appropriate protective gear, proper disposal of needles and sharps |
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How to stop spread of infection from Susceptible Host to Infectious Agent |
Immunizations & healthcare screenings |
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Four Stages of Infectious Process |
Incubation Period, Prodromal Stage, Illness Stage, Convalescence |
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Incubation Period |
the time interval between entrance of pathogen and appearance of first symptoms |
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Prodromal Stage |
the interval from the onset of of nonspecific signs and symptoms to more specific symptoms |
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Illness Stage |
interval when the patient manifests signs and symptoms specific to the type of infection |
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Convalescence |
interval when acute symptoms of infection disappear (takes about one week for antibiotics to work) |
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Localized Infection |
Client experiences symptoms in a specific area |
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Systemic Infection |
Affects the entire body, can be fatal if not treated or not detected |
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What does PPE consist of |
mask, face shield/protective eye equipment, gown & gloves |
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Normal Flora |
microorganisms, normal body fluid helps to resist infection by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganisms |
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Where are Normal Flora Found |
skin, saliva, intestines, oral mucosa |
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Defenses Against Infection |
Normal Flora, Body Defense Mechanisms, Inflammation, Vascular and Cellular Responses, Inflammatory Exudate, Tissue Repain |
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Body Defense Mechanisms |
the skin, mouth, eyes, respiratory tract, and vagina have natural defenses against infection |
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Vascular and Cellular Responses |
it delivers fluid, blood products, and nutrients to an injured area. the accumulation of fluid appears as localized swelling (fluid) |
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Inflammatory Exudate |
accumulation of fluid, dead tissues, and WBC's that form at the site of infection. something that leaves your body - serous, sanguineous, purulent |
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Serous Fluid |
clear, like plasma |
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Sanguineous Fluid |
containing red blood cells |
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Purulent Fluid |
containing WBC's and bacteria |
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Tissue Repair |
Occurs when tissue cells undergo an injury. damaged cells are replaced with healthy cells. *If inflammation in chronic, tissues will be replaced with granulation tissues, which is not as strong as strong as normal tissue and will leave a scar |
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HAI |
Healthcare Acquired Infection - Results from delivery of health services in a healthcare facility - nosocomial |
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Types of Patients at a Greater Risk for HAI |
multiple illnesses, older adults, poorly nourished, lowered resistance to infection, critical illness, invasive treatment devices |
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Risk Factors for HAI's |
number of health care employees with direct contact to the patient, types and numbers of invasive procedures, therapy received, length of hospitalization |
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Major Site for HAI's |
surgical or traumatic wounds, urinary and respiratory tracts & bloodstream |
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Iatrogenic |
from a diagnostic/therapeutic procedure |
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Exogenous |
from microorganisms found outside the individual |
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Endogenous |
Occurs when part of the client's flora becomes altered and an overgrowth occurs |
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Factors influencing infection prevention and control |
age, nutritional status, stress, disease process, treatments or conditions that compromise the immune response |
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Medical Asepsis |
controlling pathogens, hand hygiene, "clean procedure", common on home/ECF/assisted living, standard precautions (CDC) |
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Sterile Asepsis |
killing or eliminating pathogen, scrub (surgical), PPE sterile handling, common in hospital |
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Principles of Surgical Asepsis |
sterile equipment may touch sterile equipment, sterile objects can only touch sterile field, when object it out of reach/vision or under the waist it is considered contaminated, if sterile equipment is wet it is then considered contaminated, fluid flows in direction of gravity, edges of sterile field are considered contaminated |
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Disinfection |
a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects |
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Sterilization |
the complete elimination or destruction of all microorganisms, including spores |
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Infection Control and Prevention |
hand washing, bathing, dressing changes, contaminated needles/sharps, bedside table clean, surgical wounds, preventing backwash of drains/tubes |
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Patient Safety with Infection Control and Prevention |
separate personal care items, handling solid and liquid waste appropriately, wound cleaning, pt education, cough etiquette, isolation precautions, surgical asepsis |
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Cough Etiquette |
cover your mouth when coughing or sneezing, promptly dispose of used tissue, wear mask, practice hand hygiene, keep 3 feet between you and the person who is contaminated |
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Steps for putting on PPE |
wash hands, put on gown, mask, eye protection, gloves |
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Steps for taking off PPE |
gloves, eye protection, gown, mask, wash hands |
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Isolation Considerations |
psychological considerations (loneliness), environment (negative pressure), PPE equipment, specimen collection (clean), patient transport (pt must wear mask if airborne), linen (tie bag to prevent spread of infection) |
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Nursing Process |
Assessment, Diagnosis, Plan, Implementation, Evaluation |
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Assessment |
review past diseases, travel history, immunizations/vaccines, status of defense mechanisms, pt susceptibility, medications/therapy, clinical appearance, signs and symptoms of infection, Lab tests (CBC & WBC) |
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Neutrophils |
pus forming, bacteria |
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Lymphocytes |
chronic bacteria or viral infection |
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Monocytes |
protozoan, TB infection |
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Eosophils |
parasitic infection |
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Basophils |
normal during infection, anaphylaxis |
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Diagnosis |
risk for infection, imbalanced nutrition (less than body requirements), impaired oral mucous membranes, risk for impaired skin integrity, social isolation, impaired tissue integrity, readiness for enhanced immunization status |
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Plan |
Goals and outcomes: preventing exposure to infectious organism, controlling/reducing extent of infection, maintain resistance to infection, explain infection prevention and control techniques |
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Setting Priorities (Plan Stage) |
establish priorities for each diagnoses and for related goals of care |
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Teamwork and Collaboration (Plan Stage) |
remember to plan care and include other disciplines as necessary |
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Implementation |
*Health promotion - prevention is key* Consider: medical/surgical asepsis, control of infectious agents, control reservoirs, control portals of entry, control transmission, hand hygiene, isolation precautions |
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Acute Care |
treating an infectious process includes eliminating the infectious organisms and supporting the patients defenses |
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Asepsis |
absence of pathogenic (disease producing) microorganisms |
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Aseptic Technique |
practices/procedures that assist in reducing the risk for infection |
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Medical Asepsis |
*AKA clean technique* includes procedures for reducing the number of organisms present and preventing the transfer of organisms |
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Surgical Asepsis |
*AKA Sterile Technique* prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery |
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Evaluation |
see through the patients eyes, patient outcomes, exposure issues |
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Patient Outcomes |
measure the success of the infection control techniques, compare pts response to expected outcomes, if goals are not achieved - create new steps to complete goals |
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Exposure Issues |
pts and healthcare workers are at risk for acquiring, infection from accidental needle sticks - report immediately, follow-up for risk of acquiring infection begins with patient testing |
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Teaching for Asepsis Prevention at Home |
prepare foods at high enough temp, use care with cutting boards/utensils, keep food refrigerated, wash raw fruits and vegetables, use pasteurized milk and fruit juices, wash hands after bathroom/before cooking, use individual care items, cough/sneeze into inner arm (not hands) |
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Immobility |
Can be defined as the inability to engage in activity - NANDA International |
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NANDA International definition of Immobility |
Impaired Physical Mobility as a limitation in independent, purposeful physical movement of the body or one or more of its extremities |
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Activity Tolerance |
the kind and amount of exercise or activity a person is able to perform |
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Factors influencing Activity Tolerance |
Physiological Factors, Emotional Factors, Developmental Factors, Pregnancy |
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Pathological Abnormalities |
congenital defects (acquired), disorders of bones/joints/muscles, CNS damage, MS trauma |
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Body Mechanics |
Can be defined as using alignment, posture, and balance in a purposeful and coordinated effort during activity |
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General Rules of Body Mechanics |
1. Assess the situation carefully before acting 2. Use the large muscle groups whenever possible 3. Work at appropriate height 4. Use mechanical lifts or assistance as indicated |
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Safety Alert! |
Any doubt, ask for assistance, if you're working with someone - always communicate... 1 2 3 lift |
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Benefits of using mechanical devices |
decreased number of falls/injuries, increased comfort for pt, decrease skin tears, decrease anxiety, decrease risk of injury to nurse, easiest for full-lift patients |
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Scientific Principles of Body Mechanics |
great base of support = more stable body, face direction of work, use less energy if body is balanced, pelvic tilt, less energy to keep object moving, reducing friction = less energy required, hold object close to body, use strong leg muscles when pushing/pulling, smooth and continuous movements, rhythmic movements at normal speed = less energy |
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Applied Principles of Transfer and Positioning |
adjust height of work area, correct alignment, widen base of support, pelvic tilt, center of gravity, objects close to body, push/pull/roll item instead of lifting, face direction of movement, avoid twisting/stretching/reaching, use arms and legs for power, smooth motions, reduce friction, bend knees/hips |
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Effects of Immobility |
No body system is immune to effects of immobility - influenced by the client's general health status and developmental status |
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Metabolic Changes |
decreased metabolic rate, altered metabolism of carbohydrates/fats/proteins, fluid/electrolyte/calcium imbalances, decreased appetite and slowing of peristalsis, calcium resorption (release of calcium into circulation, leads to hypercalcium with increase chance of renal calculi), negative nitrogen balance |
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Effects of Metabolic Changes |
fluid/electrolyte imbalances, bone demineralization, alters exchange of nutrients, altered GI fuctioning |
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Altered GI Functioning |
constipation, nausea/vomiting, indigestion, decreased appetite |
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Metabolic Assessment and Interventions |
Assessment: Anthropometric measurements, fluid intake and output measurements, lab tests
Interventions: high-protein/calorie diet, supplemental vitamin C, vitamin B complex, TPN/Enteral Feedings |
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Respiratory Changes |
-Decreases lung expansion, promotes retained secretions, impairs gas exchange, atelectasis (collapse of aveoli), hypostatic pneumonia |
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Respiratory Assessment and Intervention |
Assessment: assess respiratory status, assess breath sounds, check O2 saturations
Interventions: Incentive Spirometer (q1-2h when awake), TCDB (q1-2h when awake) |
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TCDB |
Turn, Cough, Deep Breath |
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Cardiovascular Changes |
increases cardiac workload, causes orthostatic hypotension, increases risk from thrombus formation |
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Cardiovascular Assessment |
Monitor vital signs, orthostatic vital signs, monitor for edema and signs and symptoms of DVT |
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Cardiovascular Interventions |
avoid sudden changes in position (HOB, dangle, standing), mobilize client/activity schedule, dangle client, discourage use of valsalva maneuver (exhale rather than hold breath when moving), assess for DVT risk, initiate DVT prophylaxis, TED hose/SCD's |
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DVT Prophylaxis |
Reduce DVT risk, leg/foot/ankle exercises, fluids, position changes, meds, SCD's/TED hose, *DO NOT MASSAGE LEGS* |
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Urinary Elimination Changes |
Urinary stasis, renal calculi, increased risk for UTI |
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GU Assessment and Intervention |
Assessment: I&O's, Signs and symptoms of UTI
Intervention: Encourage fluids, record I&O's |
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GU Effects/Constipation |
Abdominal/perineal muscles can weaken, in supine position - rectal filling is slowed, client may fail to respond to urge when immobile - intestines absorb more water - dehydration can worsen the problem, client may develop impaction |
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Integumentary Changes |
Significant risk for pressure ulcer |
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Skin Assessment and Interventions |
1.Conduct a pressure ulcer admission risk assessment for all patients 2. Reassess skin daily 3. Manage Moisture 4. Optimize Nutrition 5. Optimize Hydration 6. Minimize pressure - turn and reposition at least every 2 hours |
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Psychosocial Effects of Immobility |
hostility/fear/anxiety, confusion, powerless with decreased self-esteem, altered coping, sleep-wake alterations, depression |
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Musculoskeletal Changes |
Decrease muscle strength/tone, contractures and joint pain, lack of coordination, altered gait, activity intolerance, may lead to permanent or temporary impairment or permanent disability |
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Muscle Effects |
Reduced muscle mass/strength, disuse atrophy, puts clients at risk for falls
Intervention: maintain strength muscles must contract, without contractions muscle strength may decrease by 5% per day |
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Skeletal Effects |
Impaired calcium metabolism, bone resorption (leads to osteoporosis), joint abnormalities (joint contracture - foot drop)
Intervention: Mobilize patient, without stress of weight bearing activity *bone demineralize* |
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Positions for Patients |
Supported Fowler's, Othopneic, Sims', Prone, Knee-Chest, Lithotomy, Trendelenburg |
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Supported Fowler's |
Head of bed raised approximately 45-60 degrees |
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Orthopneic |
Sitting up in bed at 90 degree angle, sometimes resting forward supported by pillow on overbed table |
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Sims' |
Lying on side with knee and thigh drawn upward toward chest |
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Prone |
Horizontal position when lying face down |
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Knee-Chest |
Patient kneels; weight of body supported by knees and chest, with abdomen raised, head turned to one side, and arms flexed |
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Lithotomy |
Lying supine with hips and knees flexed and thighs abducted and rotated externally |
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Trendelenburg |
Head low and body and legs elevated on an incline |
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Adduction |
moving a joint or extremity toward the midline of the body |
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Abduction |
Moving a joint or extremity away from the midline of the body |
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Internal Rotation |
Turning a joint or extremity toward the body's midline |
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External Rotation |
Turning a joint or extremity away from the body's midline |
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Flexion |
Decreasing the angle between two bones |
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Extension |
Straightening a joint |
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Hyperextension |
Moving a joint past normal extension |
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Supination |
turning the body or body part to face upwards |
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Pronation |
turning the body or body part to face downwards |
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Circumduction |
moving a body part in widening circles |
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Inversion |
turning feet inward - toes toward midline |
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Eversion |
turning feet outward - toes away from midline |
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Opposition |
touching the thumb to each finger |
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ROM |
Range of Motion - any body action involving the muscles and joints in natural directional movements |
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Performing ROM Exercises |
performed by PT or by nurse/NCT, indicated for patients confined to bed for long periods, performed passively by nurse or actively by patient, 2 hours per 24 hour period, perform exercise 3 times a day - twice a day |
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Red Flag of ROM |
stop movement if client complains of pain or if there is resistance |
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MS Assessment and Interventions |
Assessment: anthropometric measurements, ROM measurements
Intervention: active/passive ROM, individualized/progressive exercise program, participation in self-care, use of footboard or foot splint |
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Nursing Diagnosis |
Activity intolerance, impaired physical mobility/walking/gas exchange/skin integrity/urinary elimination/bowel elimination, ineffective breathing pattern/airway clearance/individual coping/ social isolation, Risk for injury/falls, sedentary lifestyle |
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Vital Signs |
Temp, pulse, respirations, BP, O2 & pain |
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What are Vital Signs used for |
monitor a pts condition, identify problems, evaluate response to intervention |
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how are Vitals regulated |
homeostatic mechanisms |
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Guidelines for measuring vital signs |
Nurse must be able to : measure VS correctly, know equipment & patient, be organized/use systematic approach, delegate measurement appropriately, analyze/interpret trends, begin interventions appropriately, communicate/document findings correctly |
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Temporal Temp Range |
36-38 C (96.8^F - 100.4^F) |
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Tympanic Temp Range |
37 C (98.6 F) |
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Oral Temp Range |
37 C (98.6F) |
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Rectal Temp Range |
37.5 C (99.5F) |
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Normal Pulse Range |
60-100 BPM |
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Normal Respiratory Range |
12-20 Breaths per Min |
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Normal BP Range |
<120/<80 (119/79) |
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Normal Pulse Pressure Range |
30 to 50 mmHG |
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SpO2 Normal Range |
95%-100% |
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Hypothalamus |
Thermoregulatory center - regulates body temperature |
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To maintain normal body temp |
Heat Gained = Heat Lost |
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Body Temperature |
Heat produced - Heat Lost = Body temp |
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8 types of temperature sites |
oral, axillary, rectal, tempanic membrane, temporal artery, esophageal, pulmonary artery & bladder temp |
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2 types of body temp |
core & surface |
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Core Temp |
temp of deep tissues, remains constant unless exposed to severe extremes in environmental temps, more reliable indicator of body temp |
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Surface Temp |
may vary a great deal in response to the environment |
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Factors Affecting Body Temp |
age, exercise, hormonal level, circadian rhythm, environment, temp alterations |
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Pyrexia |
*Fever* >39C or 102.2^F |