Interventions Final Review

Kent State Foundations of Nursing Interventions Final Exam

4 stages of infection

Incubation (no symptoms), Prodromal (nonspecific symptoms), Illness (specific symptoms), Convalescence (recovery phase).

Contact precautions examples

MRSA, C. diff, RSV.

Droplet precautions examples

Influenza, pertussis, meningitis.

Airborne precautions examples

TB, measles, varicella.

Protective precautions use

Immunocompromised patients (e.g., stem cell transplant).

Incubation stage of infection

Pathogen replicates, but no symptoms are present yet.

Prodromal stage of infection

Early, nonspecific symptoms such as fatigue or malaise begin.

Illness stage of infection

Disease-specific signs and symptoms appear; this is the most contagious stage.

Convalescence stage of infection

Symptoms resolve and the body begins to recover.

3 phases of the inflammatory response

1. Vascular and cellular response 2. Exudate production 3. Tissue repair

Vascular and cellular response phase of inflammation

Blood vessels dilate, WBCs migrate to the injury site, causing redness, heat, and swelling.

Exudate production phase of inflammation

Fluid and WBCs collect at the site, forming pus or clear drainage.

Tissue repair phase of inflammation

Damaged tissue is regenerated or replaced with scar tissue.

Antibody-mediated immunity

Immune response where B cells produce antibodies to fight extracellular pathogens.

Cell-mediated immunity

Immune response involving T cells that attack infected or abnormal body cells directly.

5 types of pain by cause

Nociceptive, Neuropathic, Idiopathic, Psychogenic, Referred.

Nociceptive pain

Pain from normal activation of nociceptors due to actual tissue damage; described as sharp, aching, or throbbing.

Neuropathic pain

Pain caused by nerve injury or dysfunction; described as burning, shooting, or tingling.

Idiopathic pain

Pain with no identifiable physical or psychological cause.

Psychogenic pain

Pain that is influenced by psychological factors but has no identifiable physical cause.

Referred pain

Pain felt in a location different from the source of the injury or disease.

Somatic pain examples

Musculoskeletal: bones, joints, skin.

Visceral pain examples

Organs: GI, bladder, thoracic cavity.

Signs of impending death

↓ Appetite, ↓ Urine output, Mottled/cyanotic skin, Irregular breathing (Cheyne-Stokes), ↓ LOC.

Physical changes after death

Algor mortis (cooling), Rigor mortis (stiffening), Livor mortis (purple discoloration from blood pooling).

Algor mortis

The postmortem cooling of the body.

Rigor mortis

The stiffening of the muscles after death, typically within 2-4 hours.

Livor mortis

Purplish-red discoloration of the skin from blood pooling after death.

Difference between palliative care and hospice

Palliative = comfort at any stage; Hospice = terminal, <6 months, no curative intent.

Stages of grief (Kubler-Ross)

Denial, Anger, Bargaining, Depression, Acceptance.

Normal grief

Common reactions to loss that are time-limited and decrease in intensity over time.

Anticipatory grief

Grief that occurs before the actual loss, often when death is expected.

Disenfranchised grief

Grief that is not acknowledged by society, such as loss of an ex-spouse or pet.

Complicated grief

Prolonged or intense grief that interferes with functioning and does not improve over time.

Idiosyncratic effect of medication

An unusual or opposite effect unique to the individual (unpredictable).

Synergistic drug interaction

Combined drugs create a greater effect together than alone.

antagonistic drug interaction

One drug reduces or blocks the effect of another.

6 rights of medication administration

Right patient, right medication, right dose, right route, right time, right documentation.

patient rights during medication administration

Right to: be informed, refuse medication, have medication history taken, receive labeled medications safely, and not receive unnecessary medications.

signs of IV infiltration

Swelling, coolness, pale skin, discomfort, and sluggish or stopped IV flow.

signs of IV phlebitis

Redness, warmth, tenderness, and a hard or cord-like vein.

signs of local IV infection

Redness, warmth, swelling, pus at the site.

signs of systemic IV infection (sepsis)

Fever, chills, increased HR, hypotension.

signs of fluid overload from IV therapy

Crackles, dyspnea, edema, increased BP, jugular vein distention.

onset, peak, and duration of rapid-acting insulin (e.g., lispro)

Onset: 10-15 min, Peak: 30-90 min, Duration: 3-5 hrs.

onset, peak, and duration of short-acting insulin (e.g., regular)

Onset: 30-60 min, Peak: 2-4 hrs, Duration: 5-8 hrs.

onset, peak, and duration of intermediate-acting insulin (e.g., NPH)

Onset: 1-3 hrs, Peak: 8 hrs, Duration: 12-16 hrs.

onset, peak, and duration of long-acting insulin (e.g., glargine)

Onset: 1-2 hrs, Peak: none, Duration: 24 hrs.

types of debridement used in wound care

Sharp, Mechanical, Chemical/Enzymatic, Autolytic, Biosurgical.

sharp debridement

Using sterile instruments (scalpel/scissors) to cut away necrotic tissue.

mechanical debridement

Physical removal (wet-to-dry dressings or irrigation).

chemical/enzymatic debridement

Topical agents to dissolve dead tissue.

autolytic debridement

Body's own enzymes in moist environment to digest tissue.

biosurgical debridement

Sterile maggots that eat necrotic tissue.

4 wound healing phases

Help Injured Patients Mend- Hemostasis, Inflammatory, Proliferative, Maturation.

hemostasis wound healing phase

Clotting begins, platelets aggregate.

inflammatory wound healing phase

WBCs clean debris (edema, erythema, pain).

proliferative wound healing phase

Fibroblasts build tissue, granulation forms.

maturation/remodeling wound healing phase

Collagen reorganized, scar strengthens.

5 signs of wound infection

Redness, Swelling, Heat, Pain, Purulent (yellow/green) drainage.

serous exudate

Clear, watery drainage. Common in mild inflammation or healing wounds.

sanguineous exudate

Bright red, indicates active bleeding. Normal post-op day 1.

serosanguineous exudate

Pale pink, mix of clear fluid and blood. Common in healing wounds.

purulent exudate

Thick, yellow/green/brown, foul-smelling. Indicates infection.

diverticulosis

Pouch-like herniations in intestine; no inflammation.

diverticulitis

Inflammation/infection of those pouches; pain, fever, GI upset.

key signs of MH

Muscle rigidity, ↑ CO₂, ↑ Temp (late sign), Tachycardia, Dark urine (rhabdo), Tx = Dantrolene.

signs of thromboembolism

Red, swollen, painful limb (DVT); chest pain or SOB (PE).

prevent thromboembolism in surgical patients

Early ambulation, leg exercises, compression devices, anticoagulants.

thrombophlebitis

Inflammation of a vein with clot formation.

signs of thrombophlebitis

Tenderness, redness, and swelling along the vein.

manage thrombophlebitis

Elevation, warm compresses, anti-inflammatory meds, possibly anticoagulants.

Creatinine

↑ = impaired kidney function → affects drug clearance.

Normal Creatinine value

Normal: 0.6-1.2 mg/dL

Hemoglobin (Hgb)

↓ = anemia = ↓ oxygen perfusion risk during surgery.

Normal Hemoglobin (Hgb) value

Normal: 12-18 g/dL

Prothrombin Time (PT)

↑ = bleeding risk. Important for warfarin patients.

White Blood Cell Count (WBC)

↑ = infection; ↓ = immune suppression.

Normal White Blood Cell Count (WBC) value

Normal: 5,000-10,000/mm³

Albumin

↓ = poor wound healing, malnutrition risk.

Potassium (K⁺)

↓ or ↑ → cardiac arrhythmias, especially under anesthesia.

Normal potassium (K⁺) value

Normal: 3.5-5.0 mEq/L

Glucose

↑ = risk of infection, delayed healing. ↓ = hypoglycemia risk under anesthesia.

respiratory system regulate blood pH

Controls the level of CO₂; increased CO₂ = ↓ pH (more acidic), decreased CO₂ = ↑ pH (more alkaline)

renal system regulate blood pH

excreting or reabsorbing H⁺ and HCO₃⁻; retains HCO₃⁻ to ↑ pH or excretes H⁺ to ↓ acidity

Acidosis risk electrolyte imbalance

Hyperkalemia (↑ K⁺); monitor potassium levels closely.

Alkalosis risk electrolyte imbalance

Hypocalcemia (↓ Ca²⁺)

Uncompensated ABG

One value (CO₂ or HCO₃⁻) is normal and the other is abnormal; pH is still abnormal.

Partially compensated ABG

pH, PaCO₂, and HCO₃⁻ are all abnormal

Fully compensated ABG

pH is normal but both CO₂ and HCO₃⁻ are abnormal.

Hypotonic solution

Solution with lower osmolarity than blood; used to rehydrate cells in hypertonic dehydration.

Examples of hypotonic IV solutions

0.45% NaCl, D5W (once inside the body)

Isotonic solution

Solution with equal osmolarity to blood; used for volume replacement in hypovolemia or blood loss.

Examples of isotonic IV solutions

0.9% NaCl, Lactated Ringers, D5W (in the bag)

Hypertonic solution

Solution with higher osmolarity than blood; used for severe hyponatremia and cerebral edema.

Examples of hypertonic IV solutions

D10W, 3% NaCl, D5LR, D5NS

-Natremia

Sodium

-Kalemia

Potassium

-Calcemia

Calcium

-Magnesemia

Magnesium