NS 303 Exam 1 VS, Wounds, Urinary

olanjones's version from 2016-05-26 15:37

Vital signs terminology

Question Answer
Bradycardiarate of 60 or less
Tachycardiarate of 100 or more
TachypneaRapid breathing
HyperpneaDeep breathing
Bradypneaslow breathing
Apneaabsent breathing
Dyspneashortness of breath
Cheyne-StokesEpisodes of apnea alternating with hyperpnea

Blood pressure

Question Answer
Normotension<130 / <85
Mild hypertension130-139 / 85-89
Moderate hypertension140-159 / 90-99
Severe hypertension160-179 / 100-109
Hypertensive crisis> 209 / > 119
Temperature normal96.4 – 99.1 F (35.8 – 37.3 C)
Heart Rate normal60-100 adult
RR normal12-20 adult

Wounds – Types & Exudates

Question Answer
Incision Sharp instrument (knife, scalpel), Open wound, deep, or shallow
ContusionBlow from blunt instrument: closed wound, skin appears ecchymotic because of damaged blood vessels
AbrasionSurface scrape, either intentional or unintentional, open would involving the skin
PuncturePenetration of the skin and often the underlying tissues by sharp instrument, Open wound
LacerationTissues torn apart, often from accidents with machinery: Open wound, edges are often jagged
Penetrating WoundPenetration of the skin and underlying tissues, unusually unintentional (bullet, metal fragments): Open wound
Primary intention healingexpected when edges are clean (surgical incision) and are sutured together. Tissue loss in minimal or absent. e.g. surgical incision, abrasion, skin tear, damage to epidermis.
Secondary intention healingtraumatic open wound with tissue loss or wounds with high microorganism count. Heal slowly and scar tissue is formed.
Serous exudate clear, water, plasma
Purulent exudateThick, yellow, green tan or brown.
Serosanguineous exudatePale, red, watery: mixture of serous and sanguineous
Sanguineous exudateBright red, indicates active bleeding.

Urinary incontinence, catheterization

Question Answer
Urge incontinencesudden loss of urine day or night caused by caffeine intake, increased fluid intake, infections, lesions.
Stress incontinenceloss of urine associated with exertion. Coughing, laughing, sneezing or lifting.
Mixed incontinencesymptoms of urge and stress incontinence.
Reflex incontinence loss of urine without sensory awareness (spinal cord injuries)
Functional incontinence caused by meds or medical condition ( stroke)
Overflow incontinenceover distended bladder
Tx of IncontinenceKegel exercises, strengthen sphincters. Tense/release.
Kegelscan improve and prevent urinary problems such as incontinence.
Straight Cathetersingle lumen tube with small opening about 1.25 cm from insertion tip. They are inserted into bladder to drain it and then removed.
Foley Catheter(retention) is double lumened and has a balloon near tip to keep in place in bladder. This is an indwelling catheter. They are usually connected to a closed gravity drainage system Must keep catherization sterile

I & O

Question Answer
Items to record as Input-Oral fluids (water, milk, tea, juice, soup, cream)
-Ice chips (half the volume)
-Foods that are liquid at room temp (ice cream, gelatin, custard)
-Tube feedings
-Parenteral fluids (including blood transfusions)
-Intravenous medications
-Catheter or tube irrigants.
-(Pureed foods do not count.)
items to record as Output-Urinary output
-Vomitus and liquid feces
-Tube drainage
-Wound drainage
When is I&O documented?I&O is totaled at the end of every shift and are recorded in patient’s perm. record.
Normal daily output1500-2000 mL a day
Normal daily output40-80 mL an hour. 30-50 mL/hr too low.



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