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Theory I Exam 1
Aseptic Technique
Invasive Procedures
Skin Integrity Broken
Sterility
Hands Up for Scrubbing
Keep Objects in View
Only Sterile Objects in Field
Only Sterile Touches Sterile
Contamination
Edges of Sterile Field
If Sterility Questioned
If Wet or Prolonged Exposure to Air
Considerations
Never Leave Sterile Area
PPE Order
2 mins
Pressure Ulcers
Risk Factors
Prolonged Immobilization
Neurologic Disease
Decreased Level of Consciousness
Classification
Stage 1: Intact Skin with Non-blanchable Erythema
Stage 2: Partial Thickness Skin Loss
Stage 3: Full-thickness Skin Loss without Fascial Involvement
Stage 4: Full-thickness Skin Loss with Fascial Involvement
Histamine Dilates and Increases Capillary Permeability
Macrophages Engulf Pathogens
Macrophage Signals Cells With Cytokines
Responding Neutrophils Cross Capillary Wall
B And T Lymphocytes Arrive At Injury Site
2 mins
Types of Wound Healing
Types of Wounds
Acute
Chronic
Healing Process
Primary Intention
Approximated Edges
Secondary Intention
Edges Not Approximated
Tertiary Intention
Delayed Closure due to Infection and Necrosis
2 mins
Braden Scale
Characteristics
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
2 mins
Normal Electrolyte Lab Values
Potassium (K+)
3.5 to 5.0 mEq/L
Calcium (Ca2+)
8.5 to 10.5 mg/dL
Phosphate (PO43–)
2.5 to 4.5 mg/dL
Magnesium (Mg2+)
1.5 to 2.5 mEq/L
Sodium (Na+)
135 to 145 mEq/L
Chloride (Cl–)
95 to 105 mEq/L
2 mins
Hypernatremia
Assessment
> 145 mEq/L Na+
Change in LOC
Extreme Thirst
Orthostatic Hypotension
Dry Flushed Skin
Muscle Twitching
Seizures
Priority Interventions
Treat and Prevent Dehydration
Hypotonic Solutions (0.225% or 0.45% NaCl)
Sodium Restriction
Diuretics
2 mins
Hyponatremia
Assessment
< 135 mEq Na+
Nausea and Vomiting
Decreased LOC
Confusion / Lethargy
Seizures
Priority Interventions
Assess Airway
Reduce Diuretic Dosage
Fluid Excess Hyponatremia
Mannitol (Osmitrol)
Fluid Restriction
Fluid Deficit Hyponatremia
Hypertonic Solution (3% or 5% NaCl)
2 mins
Hypokalemia
Assessment
< 3.5 mEq/L
Muscle Weakness
Arrhythmia
U Wave
Ileus
Hyporeflexia
Interventions
IV K+ Infusion at 5-10 mEq/hr
Give Orally with Food
Nursing Considerations
Monitor Respiratory Status
3 mins
Hyperkalemia
Assessment
> 5.0 mEq/L K+
Abdominal Cramps
Muscle Weakness
Diarrhea
Arrhythmia
Tall, Peaked T Waves
Interventions
IV Calcium
Infusion of Glucose and Insulin
Loop or Thiazide Diuretics
Kayexalate
Dialysis
Prevention Education
2 mins
Hypocalcemia
Muscle Spasms
Assessment
< 8.5 mg/dL Ca2+
Decreased Bone Density
Tetany
Chvostek's Sign
Trousseau's Sign
Increased DTR
ECG Changes
QT Prolongation
Considerations
Oral and IV Replacement of Ca2+
Seizure Precautions
2 mins
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