Test 2

Nursing 385 with Vincensi at Hope College

About this deck

By: Chris B.
Created: 2011-02-18
Size: 16 flashcards
Views: 39

About StudyBlue

STUDYBLUE makes things that make you better at school. Things like online flashcards with photos and audio. Things like personalized quizzes and friendly reminders about when (and what) to study next. Think of it as a digital backpack™: access to all of your study materials online and on your phone. STUDYBLUE exists to make studying efficient and effective for every student, for free. Join us.

“Simply amazing. The flash cards are smooth, there are many different types of studying tools, and there is a great search engine. I praise you on the awesomeness.”
Dennis

Sign up (free) to study this.

What are the risk factors for falls?

Fall history
Elimination problems
Cognitive impairment
Depression
Medications or medical conditions
Mobility concerns
Deconditioning
Poor judgment
Acute illness
Sensory deficits
Alcohol use
Environmental factors
Assistive devices

What components should you identify with a fall patient?

Activity at the time of the fall
Precipitating factors
Location and witnesses
History of previous falls
Past medical history
Medications

What should you look for during a physical exam?

Visual acuity (glasses in use, etc)
Cardiovascular system (carotids, heart, BP, chest pain, etc)
Extremities and injuries (bruises, fractures, signs of abuse, head injuries)
Neuro system (alert, oriented, signs of CVA, PERRLA, Loss of consciousness)
Labs (UA, pulse ox, blood sugars, lytes, H&H)
Assistive devices in use or not used
Gait assessment

List the intrinsic factors that can prevent falls and minimize injuries

Review medications
Assess alcohol use
Assess cognitive function
Assess mood
Provide and maintain devices for sensory deficits
Are they deconditioned. Need referral to PT to increase strength
Evaluate gait and balance.
Emphasize and assess use of assistive devices for ambulation.
Assess continence needs
Caregiver understanding of fall risk and prevention

List the extrinsic factors that can prevent falls and minimize injuries

Evaluate environment
Evaluate footwear and feet
Utilize bed exit alarms as appropriate
Use shower and toilet grab bars
Elevated toilet seats
Frequently used items on lower shelves in the home
Remove clutter and clear pathways

Community-acquired pneumonia

A lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization. Result from bacteria, fungal, virus; most common is strep.

Hospital-acquired pneumonia

Pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization. Mostly from influenza, pseudomonas, E. coli, strep and staph.

Fungal pneumonia

Inhaled spores, histoplasmosis, aspergillums, Candida (yeast infection), inhaled cat litter

Aspiration pneumonia

Refers to the sequelea occuring from abnormal entry of secretions or substances into the lower airway. Food, water, vomitus, or toxic fluids are the triggering mechanisms for the pathology of this type of pneumonia.

Opportunistic pneumonia

Pneumonia seen patients who have the following conditions:
1. Malnutrition
2. Immune deficiencies
3. Transplants and been treated with immunosuppressive drugs
5. Receiving radiation therapy, chemotherapy, or corticosteriods
Caused by viral and bacterial agents, carinii, fungi and CMV.

Pneumococcal pneumonia

The most common cause of bacterial pneumonia and is caused by Streptococcus pneumoniae organism.

Signs and Symptoms of Pneumonia

Fever ranging from 99-101 F
Chills
Productive cough with purulent sputum
Pleuritic chest pain
Confusion
Hypoxia
Nausea
Loss of appetite
(more on pg. 567)

Nursing Care for Pneumonia

Antibiotics and medication teaching
Fluid intake
Rest
Analgesics and antipyretics
O2 therapy if appropriate
Deep breathing exercises
Takes several weeks to recover

Cor pulmonale

Right-sided heart failure; an enlargement of the right ventricle due to high blood pressure in the lungs usually caused by chronic lung disease.

Etiology and Pathogenesis of Cor pulmonale

Genetic causes and unknown causes --> pulmonary endothelial injury --> vasoconstriction --> remodeling (vessel wall thickening) --> sustained pulmonary hypertension --> right ventricular hypertrophy
The most common cause is COPD and almost any disorder that affects the respiratory system.

Physical Assessment Findings of Cor pulmonale

Dyspnea
Chronic productive cough
Wheezing respirations
Retrosternal or substernal pain
Fatigue
Hypoxemia
Polycythemia
Peripheral edema
Weight gain
Distended neck veins (JVD)
Full, bounding pulses
Enlarged liver
Chest x-ray that shows an enlarged right ventricle and pulmonary artery.

About this deck

By: Chris B.
Created: 2011-02-18
Size: 16 flashcards
Views: 39

About StudyBlue

“Simply amazing. The flash cards are smooth, there are many different types of studying tools, and there is a great search engine. I praise you on the awesomeness.”
Dennis