TEST 1 Terms continued

Blood pressure

- Force of the circulating blood against arterial walls

- The principal determinants of blood pressure are cardiac output (CO) and systemic (peripheral) vascular resistance (SVR).

Blood Pressure Formula

BP = CO × SVR (Cardiac Output × Systemic Vascular Resistance)

Cardiac Output (CO)

The amount of blood the heart pumps into the circulatory system in 1 minute.

Systemic Vascular Resistance (SVR)

The amount of constriction or dilation of the arteries and the diameter of blood vessels.

Pulse Pressure

The mathematical difference between systolic and diastolic pressures.

Primary Hypertension

High blood pressure characterized by increased systolic and diastolic pressures with no known cause.

Secondary Hypertension

Elevated blood pressure caused by another underlying disease condition, such as kidney disease.

Nursing interventions for Hypertension

- Cessation of smoking or use of smokeless tobacco

- Weight control

- Modification of alcohol intake

- Physical activity

- Stress reduction

- Dietary modifications

- DASH diet

Hypotension

- Systolic blood pressure

Autonomic Nervous System Regulation of Pulse

-Parasympathetic stimulation decreases heart rate

- Sympathetic stimulation increases heart rate via SA node.

Dysrhythmia

Irregular heart rhythm, generally with an irregular pulse

Pulse Deficit

The difference between the apical heart rate and the radial pulse rate.

Tachycardia

A resting heart rate greater than 100 beats per minute.

Factors leading to Tachycardia

- Exercise

- Fever

- Medications

- Changing positions

- Acute pain

- Stress, anxiety, or fear

- Hypovolemia, shock, heart failure, or hemorrhage

- Hypoxia

Nursing interventions for Tachycardia

- Monitor for pain

- Monitor for anxiety and restlessness

- Monitor for manifestations of low cardiac output - fatigue, dizziness, hypotension, chest pain, and low oxygen saturation

- Monitor for adverse affects of medications

- Protect client from injury

Bradycardia

A resting heart rate slower than 60 beats per minute.

Factors leading to Bradycardia

- Long-term physical fitness

- Hypothermia

- Medications

- Changing positions

- Chronic severe pain

- Hypothyroidism

- Relaxation

Nursing Actions for Bradycardia

- Monitor for manifestations of low cardiac output - dizziness, hypotension, chest pain, syncope (fainting), diaphoresis (sweating) dyspnea, and altered mental status

- Monitor for adverse effects of medications

- Protect client from injury

Ventilation, Diffusion, and Perfusion

- Ventilation: exchange of O2/CO2 in lungs

- Diffusion: exchange between alveoli and RBCs

- Perfusion: flow of RBCs to/from pulmonary capillaries.

Tachypnea and Bradypnea

Tachypnea: regular breathing pattern >20 breaths/min; Bradypnea: regular breathing pattern

Sources of Heat Loss

- Conduction (direct contact),

- Convection (air currents)

- Evaporation (gases/sweat)

- Radiation (indirect contact with cooler surface).

Thermoregulations

- Balancing body temperature

- Can maintain a fairly constant temperature through shivering, sweating, vasoconstriction, and vasodilation.

- Produces heat through metabolic processes, physical activity, and shivering

- Body loses heat to the environment through conduction, convection, evaporation, and radiation.

Direct contact

Infectious agent is directly moved from an infected person to another person. E.g. - herpes simplex virus

Indirect contact

Infectious agents are transferred to an individual when the individual makes physical contact with contaminated items and surfaces E.g. - staph aureus from a patient wound gets on a bedrail or bedside table which others then touch.

Airborne route

Small particulates found in the air (infectious agents) move into the airspace of another person. Smaller than droplet particles, can travel over long distances, stay suspended in the air for longer periods of time, can lead to the potential for others outside of the room to inhale them.

Droplet route

Infectious droplets from a client spread through the air and come in contact with mucosa of a host (nurse, other patient, etc.). Droplets are larger and are released with sneezing, coughing, singing, and talking are examples.

Vehicle transmission

Involves transmission from contaminated items to multiple persons - contaminated food or water

Vector-borne transmission

transmission of infectious agents through animals such as an insect or rodent. E.g. - lyme disease which is transmitted by ticks.

Susceptibility

Pathogen must overcome resistance mounted by host's defenses. Not everyone who is exposed to an infectious agent will become ill. Some never exhibit symptoms but can be carrying the infectious agent and can transmit it. Factors that can increase susceptibility - age (as we age, immune system does not work as effectively), level of immunity at the time of exposure, surgical procedures, some medications (chemo drugs)

Bacteria

most significant and most prevalent in hospital setting

- Can be described by shape (rods, spheres or spirals), gram positive or gram negative (gram positive have thicker cell walls), stained violet as reaction to the Gram stain. Gram negative (have a thin cell wall) and do not stain violet.

Can be treated with antibiotics

- Aerobic - bacteria that thrive and grow with oxygen

- Anaerobic - can survive and grow where there is no oxygen

Virus

smallest of all microorganisms

- visible only under a microscope, examples - common cold, COVID 19, Hep B and C, AIDS

Treated with antivirals

fungi

plant-like organisms present in air, soil, and water

- yeast Infections, thrush, athlete's foot, ringworm

Treated with antifungal medication

parasites

organisms that live on or in a host and rely on it for nourishment

- malaria is a disease caused by a parasite invading a mosquito that feeds on humans, tapeworms

Stages of Infection

Incubation period, prodromal stage, acute illness, period of decline, and convalescent period.

Incubation

Time between pathogen entering the body and showing of signs and symptoms, organisms are growing and multiplying, length of incubation may vary

E.g. - common cold has an incubation period of 12 hours to 3 days, tetanus has an incubation period ranging from 3 to 21 days

Prodromal

client begins having initial manifestations as the infectious agent replicates

Acute illness

Manifestations of a specific infectious disease process are obvious, stage where it is most severe.

Period of decline - manifestations begin to wane as the number

Convalescent

Recovery from infection, varies based on severity of the infection, signs and symptoms disappear and the body returns to a healthy state

Closure Methods: Secondary Intention

• Wound is left open to heal naturally, often resulting in more significant scarring.

- tissue loss, takes longer to granulate, risk of infection, scarring

Closure Methods: Tertiary Intention

• Delayed closure due to infection or other factors, combining aspects of primary and secondary intentions.

- wide/deep wound, dehisced, will heal when no infection/edema

Acute wounds

•These are recent injuries that typically follow a predictable healing trajectory, such as surgical incisions. They typically heal in four to six weeks.

Chronic wounds

•These are wounds that don't progress through the normal stages of healing, often due to underlying conditions like diabetes or vascular insufficiencies. Pressure injuries, diabetic foot ulcers, and vascular ulcers are all chronic wounds.

Open wounds

•Injuries where the skin is broken, exposing underlying tissues. Examples include abrasions, lacerations, and punctures.

Closed wounds

•Injuries where the skin remains intact, such as contusions or hematomas.

Full thickness wounds

•These extend through the entire dermis and into the subcutaneous tissue or beyond. They involve total loss of skin layers and may expose fat, muscle, or bone. Healing often occurs by secondary intention and may require surgical intervention.

partial thickness wounds

•These affect only the epidermis and part of the dermis. These injuries typically heal more quickly because epithelial cells can regenerate from intact skin structures such as hair follicles.

Complex wound

• is an acute or chronic injury to human skin tissues that does not respond to conventional treatments in a timely manner.

Slough

•Soft, moist, devitalized tissue that is typically yellow, white, or even gray, indicating the need for debridement.

Dressing types: Alignate

•Made from seaweed-derived materials (sodium and calcium fibers), these dressings are highly absorbent and form a gel when in contact with fluid.

Dressing types: Antimicrobial

•Infused with agents like silver or iodine, these help reduce bioburden and manage infection.

Dressing types: Collagen

•Made from bovine, porcine, or avian collagen, these dressings support the body's natural healing processes and also supports the re-epithelialization process.

Dressing types: composite

•Multi-layered dressings that combine several functions, such as absorption, protection, and bacterial barrier.

Dressing types: foam

•Soft, absorbent dressings that provide cushioning and absorb moderate to heavy exudate. They help maintain a moist environment while protecting the wound from external contaminants.

Dressing types: gauze

•Woven or non-woven materials used for cleaning, packing, or covering wounds. It can be used wet or dry but often requires frequent changes.

Dressing types: hydrocolloid

•Occlusive or semi-occlusive dressings made of substances that form a gel in the presence of exudate, maintaining a moist environment.

Dressing types: hydrogel

•Water- or glycerin-based dressings that provide moisture to dry wounds, promoting autolytic debridement.

Dressing types: occlusive

•A non-permeable type of dressing that completely seals a wound from air and moisture, creating an anaerobic environment. This helps maintain a moist wound bed, which can accelerate healing and protect against external contaminants.

Dressing types: semi-occlusive

•A semi-permeable dressing that partially seals the wound, allowing some air and moisture vapor to pass through while still maintaining a moist environment. It offers protection while supporting gas exchange and moisture balance.

Attached

•The edge connects smoothly to the wound base. This is a normal, healthy finding.

unattached

•The edge separates from the wound base, which can create hidden pockets or spaces.

welldefined

•The border is clear and distinct from the normal skin around it.

Indistinct (diffuse)

The border is blurry and hard to trace, often signaling swelling or irritation.

Dehiscence

•Partial or total rupture of an approximated wound, often involving multiple layers.

Evisceration

• Dehiscence that involves protrusion of visceral organs through wound.

Hemorrhage

•Emergency loss of blood through the wound, including underlying layers.

epibole (rolled)

• The outer skin edge curls or rolls under itself. This stops new skin cells from growing across the open space.

Erythema

•This is the redness of the skin resulting from increased blood flow to capillaries in the area, which often signals inflammation, irritation, or infection.

Hyperkeratotic (callused)

•The edge becomes thick, hard, and dry like a callus. It forms around long-lasting (chronic) wounds.

Hypertrophic

•This refers to an overproduction of collagen in the healing phase, leading to a raised, thickened scar that remains within the boundary of the original wound.

Fibrotic

•The edge feels rigid, scarred, and hard to the touch.

Wound Border: Macerated

•The skin right next to the edge looks soft, white, and wrinkled because it stays too wet.

Wound Border: Indurated

•The tissue around the border feels hard and firm, which usually means there is inflammation or infection.

Wound Border: Advancing

A tiny ring of pale pink new skin moves inward from the border. This is a positive sign of healing.

Golden Rule of Nursing Documentation

if its not documented it didnt happen

closure methods: primary intention

•Wound edges are brought together surgically, leading to minimal scarring.
- little lost tissue, surgical, rapid healing, low scarring