Foundations Midterm Exam

Preamble

We the people of the United States, in order to form a more perfect union, establish justice, ensure domestic tranquility, provide for the common defense, promote the general welfare, and secure the blessings of liberty to ourselves and our posterity, do ordain and establish this constitution for the United States of America

sodium

135-145

potassium

3.5-5
(stat lab, important for electrical system)

chloride

95-105

bicarbonate

22-24

BUN

10-20

Creatinine

.5-1.0

Glucose

80-100

Calcium

8.5-10

Magnesium

1.8-2.5

Phosphorus

2.5-4.5

Hemoglobin

12-14

Hematocrit

40-45

WBC

5000-10000

RBC

4.5-6 million

Absolute Neutrophil

greater than 2 (put in protective isolation at 1.5)

Albumin

3.5-5

Goal of Aseptic Technique

safely care for yourself and the patient

AAPIE

Assessment, Analysis, Planning, Implementation, Evaluation

PPE

personal protective equipment; gowns, gloves, goggles, face shields, respirators; teach the patient it is for your and their safety

Resistant organisms

-Resistance is a global issue
-First step is to stop the spread of microbes with good hand washing

Colonizations

-organism is present in or on the body, but not causing illness
-patient or nurse can be colonized and become a carrier and spread the disease

Infection

the organism is actively causing illness

Antimicrobial Resistance

-resistance of microorganisms to an antimicrobial medicine to which it was previously sensitive
-can withstand attack by medication
-develops with resistance gene in the bacterial DNA

Enterococcus

-gram positive cocci normally in the lower GI tract and genitals
-can become pathogenic and cause UTI, wound infections, septicemia, endocarditis
-VRE is vancomycin resistant enterococci

Staphylococcus aureus

-gram positive cocci normally on skin and in nose
-can invade body, cause minor infections to fatal outcomes
-MRSA

Clostridium difficile (C. diff)

-commonly acquired in hospital after antibiotics
-causes severe diarrhea and GI issues, inflammation of the colon

Tuberculosis

resistant to the most effective drugs

Antibiotic Regulating rules

-banned feeding antibiotics and related drugs to livestock
-using large amounts in cattle raising is contributing to resistance bacteria

Prevent Resistance

-appropriate antibiotic use
-education
-appropriate precautions to prevent transmission

How infections spread

-improper PPE
-unclean and contaminated surfaces/equipment
-Vectors
-Vehicles
-Conact, droplet, or airborne

Contact isolation

-make sure to glove and wash hands
-C. diff
-Norovirus
-MRSA
-VRE
-lice, scabies
-Hep A
-Shigella

Droplet isolation

-wear gloves, wash hands, always wear a mask, visitors should wear a mask
-Diptheria
-Pertussis, Rubella, Mumps
-Influenza
-Invasive Neisseria meningitidis
-Invasive haemophilus

Airborne Isolation

-Use negative pressure rooms (air rushes into the room, keeps air from going into the hall), N95 masks, eye protection, gowns
-Measles
-TB
-COVID
-Varicella, chicken pox
-SARS

When to wash hands

-before patient contact
-after patient contact
-before clean/aseptic procedure
-after touching patient surroundings
-after exposure risk
-when hands are visibly dirty

7 attributes of symptoms

-location
-quality
-quantity
-timing
-setting
-exacerbating factors
-associated manifestations

PQRST

-Provoking factors
-Quality
-Radiation
-Severity and symptoms
-timing and triggers

Primary Assessment

LOCs, ABCs

starting assessment

-ask about health history and heart problems
-past medical history and surgical history
-hypertension
-medication
-establish a baseline of vitals

pitting edema

+1: barely there 2mm
+2: indentation less than 4mm, still see ankle contour
+3: indentation greater than 6mm for several seconds
+4: indentation greater than 8mm very marked, minutes

Non pitting edema

-visibly swollen extremities
-disorder of the lymphatic system such as lymphedema

Heart Sounds

-S1 is closure of the mitral and tricuspid valves (LUB, heard best at the apex)
-S2 is closure of the aortic and pulmonic (DUB, best heard at base)
-S3 and S4 are extra heart sounds

S3 and S4

-extra heart sounds
-use the bell and press lightly over the mitral and tricuspid areas

S3

-left ventricle failure, blood sloshes back down into the heart
-heard at the apex with the bell
-shows heart failure, blood failed to exit the ventricle

S4

-hypertension causing a stiff wall
-ventricle is stiff, non-compliant, as in ventricle hypertrophy

Murmurs

-caused by valve issues, can't close/open properly

stenotic murmur

- valves are too tight and small, obstructing blood flow
-will hear turbulence because the valves are not opening enough
-valves are "stuck"

Incompetence/regurgitation

-valves not closing, letting blood slosh back in
-heard in systole, S1 (lub) and S2 (dub)

Bruit

-turbulent blood in arteries, called a vascular murmur
-athlerosclerotic narrowing of the artery

Blood flow through the heart

SVC --> Rt atria --> Tricuspid --> Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt ventricle --> aortic valve --> aorta --> Body

systole and diastole

-closure fo the mitral and tricuspid is S1, onset of systole
-closure of aortic and tricuspid is S2, onset of diastole
-between S1 and S2, during systole, is when mitral regurgitation is heard

jugular vein distention

-sticking out of the jugular vein where the heart beats
-this can happen in heart failure because there is so much volume in the vasculature system

Respiratory

-breathing
-Diaphragm lower, volume increases, sternum raises

right sided lobes

3

left sided lobes

2

Inspection

-rate
-rhythm
-use of accessory muscles to breathe
-nasal flaring can indicate respiratory distress
-color
-Molting (CO decreases and random patterns of vasoconstriction/dilation happen
-clubbing (caused by hypoxia)
-Deformities (can lead to impaired gas exchange)

congenital pectus excavatum

posterior displacement of lower aspect of sternum

pectus carinatum

chest wall in outward position, prevents complete exhalation

percussion

dullness on auscultation instead of resonance when fluid is present

palpation

-tenderness, lesions, masses, crepitus, tracheal deviation
-tactile fremitus

tactile fremitus

-increases with consolidation, pneumonia, atelectasis, bronchitis
-Decreases with pneumothorax, emphysema, asthma, pleural effusion

percussion

dullness on auscultation instead of resonance when fluid is present

vesicular breath sounds

inspiration sounds longer than expiration

bronchovesicular breath sounds

inspiration and expiration sound equal

Bronchial breath sounds

inspiration sounds shorter than expiration

adventitious breath sounds

Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles.

crackles

(rales) abnormal, discontinuous, adventitious lung sounds heard on inspiration

coarse crackles

loud, bubbly noise heard during inspiration; not cleared by a cough

fine crackles

short high pitched sounds during inspiration

wheezes

continuous high-pitched whistling sounds produced during breathing

Ronchi

Rattling noise of mucous in the lungs

nasal cannula

up to 6L, can be humidified
-can lead to pressure ulcers behind ears

AFM/Simple face mask

6-10L

Non-Rebreathers

6-15L, set so the bag is always partially inflated

flow meter

gauge used to regulate O2 delivery

Venti Masks

COPD

tracheostomy tubes

air needs to be warmed and humidified

nebulizers

albuterol for asthma, can be expensive

Sputum

-yellow/green
check for infection, purulent, also smells
-blood tinged
hemoptysis (injury)
-Rusty (injury)
-Thick
concerned about mucous plug

Pulmonary Toilet

-sit the patient up
-deep breathing
-incentive spirometry
-teach effective coughing
-splinting the abdomen with a pillow
-postural drainage/chest physiology
-maintain hydration
-bronchodilators (albuterol)
-lifestyle changes/environmental changes

smoking

-in the brain, nicotine activates the same reward system as do other drugs of abuse such as cocaine or amphetamine, although to a lesser degree
-increases heart rate and blood pressure and restricts blood flow to the heart muscle

Condition C respiratory

-Less than 10 or greater than 30 with acute symptoms of respiratory distress
-New onset of severe difficulty breathing
-New pulse oximeter reading less than 85% for more than 5 minutes despite administration of O2

Condition C heart rate

Less than 40 or greater than 140 with acute new symptoms

Condition C blood pressure

systolic= less than 80 or greater than 200
diastolic= greater than 110

Condition C mental

-New onset of significant lethargy or difficulty awakening
-Sudden collapse
-Seizures
-Sudden loss of movement or paralysis

Condition C color

-Gray, blue, dusky
-Suicide
-Bleeding into airway
-Narcan use without immediate response

Temperature

-Regulated by the hypothalamus
-Senses core body temp, set point responsibility
-Extreme elevations or reductions can cause cell damage and death
-Can inactivate proteins and enzymes

Oral temp

-Most common site; goes deep in the sublingual pockets
-May not be an option is someone had surgery or a seizure, but generally comfortable for pt
-Advantages: easy, pretty close to core body temp
-Disadvantages: food and drink can alter temp, must wait 10 min

Tympanic Temp

-Easy rapid access
-Unaffected by PO intake or smoking
-More variability than other sites

Rectal Temp

-Closest to core temp, one degree warmer than oral
-Gold standard of short internal temps
-Generally requires 2 people to take

Axillary Temp

-Last resort, not very reflective of core temp
-1 degree cooler than oral
-Least accurate
-Takes a long time and temp will lag behind core temp

Fever management

-Cool the patient, remove covers, cool the room
-Do a neuro assessment
-Check WBC (may be elevated)
-Call doctor around 101
-Does patient need meds, fluids
-Hypothermia blanket, not ice packs

Fever Benefits

-Defense mechanism
-WBC production
-Suppresses bacterial growth
-Interferon production, fights viruses

heat stroke

-Elevated temp related to the body's inability to promote heat loss or reduce heat production
-High mortality rate
-Hot, dry skin
-Flushed, rapid pulse or slow, weak pulse
-Body temp over 104
Common in young, old, athletes

Hypothermia

-Mild is 96 and above
-94 and below will cause loss of consciousness, low heart rate, low blood pressure, and low respiratory rate
-May be cyanotic
-May look dead, but not dead until warm and dead

Hypothermia intervention

-Remove wet clothes
-Layer clothes and blankets
-Warmer environment, heating pad
-Give warm liquids (not ETOH or caffeine due to dilation)
-Warmed IV, ECMO
-Cover head

Pulse

-Regulated by the autonomic system through cardiac sinoatrial node
-Can be stimulated by the autonomic nervous system
-Number of contractions in one minute
-Carotid, brachial, radial, femoral, dorsalis pedis, posterior tibial
-Look for strength and symmetry
-10% of population does not have pedal pulse

Contractility

-Heart contracts, ejecting blood
-Stroke volume (60-70cc) includes preload (blood volume pre contraction), afterload (what the right and left ventricle have to overcome to make blood leave), contractility (one ventricular contraction is one pulse)
-Amount of blood that comes out of the heart per minute is cardiac output
-Should be 4-8L per min

pulse ox

-Measure percent of hemoglobin that is saturated with oxygen
-Only use to make you worry, never to make you feel good
-Baseline is important, over 90% is ok
-If 86%, give oxygen, if that does not help, call a code

Breathing

-Controlled by the medulla and pons
-Activated by impulses from chemoreceptors
-Increase in CO2 is the most powerful respiratory stimulant in healthy people
-Normal is 12-20
-Note rate and depth of breathing