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112 Cards in this Set
- Front
- Back
S/S Fracture |
-pain (not always) -edema -deformity -shortening -loss of function -decreased sensation -tingling -bruising |
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Time frame for bone healing |
14 days - 1 year |
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Closed reduction vs. open reduction |
CLOSED: Bone externally manipulated into position & immobilized with a bandage, cast or traction (without surgery) - ORIF OPEN: Bone surgically exposed& realigned - OREF |
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Purpose of a cast; types of Casts |
External immobilization of affected structures -plaster of paris - heavier, intact longer -synthetic - lighter, dries quickly, more freedom |
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Nursing Considerations with Ortho |
-elevate cast -neurovascular assessment -manage pain -ice for 10-15 min -turning pt. - skin integrity -teaching about positioning -teach dalteparin injection |
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Cast Assessment |
-pain -edema -skin integrity -odour -itchiness -neurovascular assessment |
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What is traction? |
-extend and hold body part in specific position -uses ropes, pulleys and weights attached to a fixed point below injury -force of pull from weights is exerted on bone |
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Why are the elderly at risk for hip fractures? |
-decreased reaction time -failing vision -lessened agility -decreased muscle tone -degeneration *1/3 of post-op hip replacement elderly pt. die |
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Total Hip Replacement (THP, THA) |
Acetabulum: Polyurethane socket Femur Head: metallic replacement Femoral Canal: stem of prosthesis femoral canal |
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Hip Precautions |
-don't lift knee above hip (>90 degrees) -don't cross legs -don't adduct past midline -don't twist legs -don't use low chairs -don't take long strides |
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Ortho Complications |
-compartment syndrome -hemorrhage -infection -DVT -fat embolism -dislocation of prosthesis |
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6 P's of compartment syndrome |
-paresthesia (tingling or numbness) -pain (that opioids don't help) -pressure - increased -pallor - coolness -paralysis -pulselessness (diminished/absent pulses) |
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Benign Prostatic Hypertrophy |
-Age-related -Men >50years at risk -Enlargement of the prostate gland -R/T hormonal changes |
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BPH S/S |
-Dysuria -Frequency/nocturia -Hesitancy -Urgency -Dribbling -UTI’s -Hematuria -Decreased force of stream |
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Complications of BPH |
-Increased pressure in bladder -Stasis in bladder…infection -Hydronephrosis -Renal insufficiency…failure |
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Diagnosing BPH |
DRE: Digital rectal exam Men>40 yrs should have DRE done annually PSA:Prostate Specific Antigen (Blood test)-Increased with BPH (PSA is even higher with cancer) |
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TUPR |
Transurethral prostatic resection(TUPR/TURP) -Preferred method; -fast recovery -Less complications -Removes inner portion of prostate, via urethra, with use of endoscope -Best for removal of small amounts of tissue -Spinal anesthetic |
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BPH Tx |
-Proscar (Finasteride): decreases PSA and slows growth -Flomax CR (Tamulosin Hydrochloride): relaxes muscles in prostate and bladder – enables more complete bladder emptying Temporary solutions / procedures: -A catheter with a balloon is inserted into the urethra and inflated where urethra is narrowed by enlarged prostate – balloon is removed at the end of treatment procedure -Stents may also be used to widen urethra – these need to be changed regularly(inserted as collapsed than opened as cylindrical tubes inside urethra) |
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Prostate Cancer |
- 2nd most common cancer in men -2nd leading cause of death Occurs>50yrs age; peak at 75Commonlymetastatic -Requires radical surgery and radiation; androgen suppression -Removal of prostate and adjacent tissues if tumour invasive -High risk of impotence; incontinence |
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Bladder Tumours |
-Common in men 50-70 yrs; as well as women -May require trans urethral resection of bladder tumour; cystotomy and resection of the bladder |
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Post-op TURP |
-Risk for DVT -bleeding -fluid overload -obstruction -incontinence -UTI *CBI |
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Why use CBI? |
-To prevent clot formation and prevent obstruction -Slows bleeding (d/t coolness and pressure from fluid influx) -Often up to 24hrs post-op; depending on color of returns |
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Rate of CBI |
-Irrigates 0.9% NS, through bladder, via triple lumen catheter -Rate of flow runs according to returns…rapid (wide open), moderate, slow. -Initially fast, then moderate/slow, as returns become lighter in color *Use nurses judgement |
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CBI Assessments |
-Bed rest (flat) until CBI d/c’d(easier fluid evacuation and decrease clot buildup & less pressure on operative site) -Monitor returns for bleeding/clots and color of returns; constant flow Hydrate patient; VS -Check irrigation bags and returns frequently; Bags staggered and should not empty -May need to change bags q20-40 min -Empty drainage bag/ bucket frequently -Check tubing for kinks -Slow irrigation as returns become pink |
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Pt assessments with CBI |
-Assess bladder -Pain?Spasms? -Slight distension/firm? -Normal to feel bladder fullness and need to void -Acute pain abnormal; obstruction? -Can relieve spasms with B&O supps -DVT-Homan’s sign? Calves? -Excessive bleeding? Hemorrhage? Clots? |
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24-36 hours post-op CBI |
CBI d/c’d…when returns are light pink -Ambulate after CBI d/c’d; cautiously -If bleeding occurs/persists-rest; increase fluids, decrease activity |
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Post-CBI Teaching |
-Increase fluids -Assess urine flow, color… -Avoid heavy lifting; prolonged sitting for 4 – 6 weeks (pressure may cause bleeding) -Mild burning when urinating -Avoid constipation -Call physician if fever; severe burning; dysuria; bright red urine; blood clots in urine -No sex for 6 weeks (pressure may cause bleeding) |
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Terminal signs of increased ICP |
-coma -bilaterally fixed and dilated pupils -respiratory arrest -absence of motor response (flaccid) |
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Late Signs of increased ICP |
-decreased LOC -unilateral or bilateral pupilary changes -ineffective breathing pattern -abnormal motor response - decorticate or decerebrate |
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Early signs of increased ICP |
-altered LOC -unilateral pupil change in size, equality and or reactivity -altered resp pattern -unilateral hemiparesis |
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What happens earlier than decreased LOC |
LOC changes |
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What happens to the pupils when cranial nerve is compressed? |
pupils dilate and become more sluggish |
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What are you testing with verbal response? |
-long term memory -short term memory -interemdiate memory |
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Pronator Drift |
Pt sitsor stands with eyes closed, arms out straight, slightly lateral, palms up.Watch for drift of the arms out of position. (Symtpomaticof cerebellar damage – proprioception = unconscious perception of movement andspatial orientation) |
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One side of brain swells - pupils? |
same side pupil will dilate |
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Motor Response - Localizes |
nurse squeezes trapezius on each side. pt attempts to move opposite hand towards affected tapezius |
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Motor Response - Withdraws |
pt withdraws from a pain stimulus to all 4 limbs |
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Motor Response - Flexion |
-decorticate posturing with trapezius squeeze |
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If you can't wake pt, what do you do? |
Call a code |
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Motor Response - Extension |
Decerbrate posturing with trapezius squeeze |
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PERL (for GCS assessment) |
Pupils equal and reactive to light |
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Seizure Precautions |
1. Padded Side Rails 2. Suction and O2 available 3. IV insitu 4. Oral Airway |
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What is ORIF? |
-open-reduction internal fixation- Incision closed with staples - May or may not have drain in place |
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What is OREF? |
-Open-reduction external fixation -immobilizes bones to facilitate healing -surgeon percutaneously places pins or screws into the bone on both sides of the fracture -pins are secured together outside the skin with clamps and rods (i.e. the "external frame”) |
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What are some assessments and interventions with a patient with a cast? |
1) Neurovascular assessment 2) Pain…types of medications: opioids 3) Edema…elevate above heart 4) Skin care at edges…actions? 5) Foul odour…S & S of infection...take V/S, check labs for infection, inform surgeon 6) Itchiness…actions? 7) Documentation |
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Necrotizing fasciitis |
- commonly known as flesh-eating disease - is a rare infection of the deeper layers of skin and subcutaneous tissues which easily spreading across the fascial plane within the subcutaneous tissue - is a severe disease of sudden onset that progresses rapidly |
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Cachexia |
- weakness and wasting of the body due to severe chronicillness |
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Chemo precautions |
-the need to protect the patient from the outside world (positive pressure room to keep air from outside out) -PPE to be worn by staff and visitors |
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review of how to clean a wound |
from clean to dirty (center, side, side) |
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Is it okay for LPNs to d/c a wound drain? |
YES (according to CLPNBC), but check facility policy and also WITH A DOCTORS ORDER, of course! |
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What are 4 types of Sking/Wound closure procedures? |
1) skin glue (for small tears like on a finger) 2) steristrips 3) staples (surgical clips) 4) sutures |
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What is the purpose of having a wound closure? |
to close surgical wounds & to repair lacerations *Goal is to promote healing by primary intent.* |
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What is primary intent?
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-wound edges come together neatly -stops any bleeding -preserves tissue function -prevents infection -restores cosmetic appearance -promotes rapid healing -this type of healing is usually from a surgical incision, not laceration |
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What are the phases of wound healing? |
Inflammatory Phase: 0-4 days Proliferation Phase: 5-21 days Maturation Phase: up to 1 year |
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What is secondary intention healing? |
-wound edges are not well approximated -takes way longer to heal that primary intention -usually seen with a laceration (instead of surgical incision) -scarring will be more evident -may have increased chance of being dirty/contaminated (higher risk of infection) |
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Patient teaching for wound healing |
-Nutrition: increase vit C & protein to speed healing time up -splinting when moving around, coughing to prevent dehisence |
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When you have an order to d/c staples/sutures, what should you check? |
*Use Nrg Judgment when assessing wound prior to removing sutures/staples. -check dr's order/facility policy -assessment (edema, infection, no dehisence) -if wound starts to open, STOP!! -take sutures/staples out alternately, to see how wound will take it -apply steristrips to reinforce where the staples/sutures were -document how many were taken out |
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types of sutures |
1) continuous (LPNs cannot remove these!) 2) Interrupted (similar to staples - we can remove these!) 3) Retention - rubber or elastic (LPNs cannot remove these either!!) |
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Hemovac |
-a portable wound suction device that is compressed to provide gentle suction - an internal spring slowly expands to create a negative suction pressure of approximately 45 mg Hg. -enhances healing by removing fluid or air from the peri-wound area -suction is lost as drainage accumulates (empty regularly) |
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Jackson-Pratt |
-small wound drain that uses negative pressure to draw out drainage from a wound -enhances healing by removing fluid or air from the peri-wound area -suction is lost as drainage accumulates (empty regularly) |
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Penrose Drain |
-no suction, passive drainage -drains onto gauze surrounding drain sponge -surgeon will say when to pull/cut drain sponge -REMEMBER to pin drain sponge to gauze, as it could slip into wound if not secured! |
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What types of acute or chronic conditions put someone at higher risk for dehiscense? |
-smoking -DM - longer healing time -HTN -obesity -poor nutrition -life style -immunosuppressant -Resp issues -other infection -age |
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What is the difference between a complex and surgical wound? |
Complex - secondary intention: longer healing time, may need packing, more frequent changes Surgical - primary intention: faster healing time |
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What are you assessing when emptying a wound drain system? |
1) Colour 2) amount 3) consistency/substance (clots or other debris) 4) odour 5) that the drain is insitu 6) that suture is in place (if you are changing dressing) |
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What are 4 potential complications an LPN might observe for in surgical wound? |
1) infection 2) dehiscence 3) eviseration 4) hematoma |
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What is tertiary intention? |
-delayed primary intention -wound is left open to drain toxins, and then will be closed when infection |
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What do you do if you are doing your QPA and your patient is falling asleep, or cannot be woken up? |
DO NOT MOVE ON!! This needs to be resolved before moving to other assessments. |
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What is one thing you can tell your patient to raise their oxygen level? |
Deep breathing and coughing exercises |
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How do you measure a wound? |
Length (head to toe direction) Width (from side to side) Depth (use sterile cotton-tipped applicator to measure) |
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Description of surrounding skin of wound... |
Intact, macerated, hard, red, scaly |
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what is maceration? |
the softening and breaking down of skin resulting from prolonged exposure to moisture. |
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What is exudate? |
is any fluid that filters from the circulatory system into lesions or areas of inflammation (It can be a pus-like or clear fluid) |
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what is sanguineous drainage? |
-This type of wound exudate is also known as the fresh blood that comes from a recent wound, and is characterized by a bright red color -Most commonly, it is seen in partial thickness and full thickness wounds. |
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what is serous drainage? |
bodily fluids that are typically pale yellow and transparent |
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What is serosanguineous drainage? |
-containing or relating to both blood and the liquid part of blood (serum)-it usually refers to fluids collected from or leaving the body (fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood) |
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What is purulent drainage? |
consisting of, containing, or discharging pus. |
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Induration |
-Localized hardening of soft tissue of the body -The area becomes firm, but not as hard as bone |
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Debridement |
-the process of removing nonliving tissue from pressure ulcers, burns, and other wounds. -LPNs can only rinse out wounds, no surgical removal of necrotic tissue (RNs/Wound care RNs would be doing this - collaboration) |
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Discharge Teaching |
-Keep dressing clean and dry -Splint area before coughing -Good nutrition, adequate rest -Call MD or go to ER if: Excessive bleeding Redness, pain, excessive swelling Increased or foul smelling exudate Fever Flu-like symptoms |
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Hematoma
|
bleeding that is trapped within tissues or organs |
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slough |
dead tissue that has been shed |
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granulation |
soft pink/red tissue comprised of capillaries and fibrous collagen |
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absess |
a cavity containing pus and surrounded by inflamed tissue, formed as a result of localized infection |
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approximation |
drawing two tissue surfaces close together as in the repair of a wound |
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dehiscence
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the separation of a surgical incision or rupture of a wound closure, typically an abdominal incision.
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epithelialization |
the regrowth of skin over a wound |
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evisceration |
the protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall |
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necrosis |
localized tissue death that occurs in groups of cells in response to disease of injury |
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vacuum assisted closure (VAC) |
-a dressing or filler material is fitted to the contours of a wound (which is covered with a non-adherent dressing film) and the overlying foam is then sealed with a transparent film -A drainage tube is connected to the dressing through an opening of the transparent film. A vacuum tube is connected through an opening in the film drape to a canister on the side of a vacuum pump |
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staples |
-pieces of stainless steel wire that are used to close certain surgical wounds |
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Sutures |
-surgical stitches taken to repair an incision, tear, or wound -material used for sutures are silk, catgut, wire, or synthetic material |
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chest tube clamps |
called "Kelly Clamps" - RNs use these when there is a suspected air leak in the chest tube system |
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mediastinal shift |
-The build-up of pressure in the pleural cavity causes the mediastinum (which contains the heart, trachea, esophagus and great vessels) to shift to the unaffected side -also causes compression of the lung on the unaffected side. -also called "Flail Chest" |
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What is the purpose of a chest tube? |
to remove air/fluid from the pleural space and to restore normal intra pleural pressure so that the lungs can re-expand -also used to measure drainage from lungs |
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Types of chest tube drainage systems |
Wet (collection chamber, water seal chamber, suction control chamber) Dry (contains no water, but works similarly by having a regulator to dial the desired negative pressure (ex:Heimlich Valve) |
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collection chamber |
-receives fluid and air from the chest cavity -fluid stays in this chamber while air vents into the 2nd compartment |
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water seal chamber |
-contains 2cm of water, acting as a one-way valve -incoming air from the collection chamber bubbles up through the water |
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suction control chamber |
applies controlled suction to the chest drainage system by regulating the negative pressure when it exceeds a certain pressure |
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pleural effusion |
-an abnormal accumulation of fluid in the intra pleural spaces of the lungs -characterized by: chest pain, dyspnea, adventitious lung sounds, nonproductive cough |
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hemothorax |
a collection of blood in the pleural cavity |
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pneumothorax |
-the presence of air or gas in the pleural space, causing a lung to collapse -characterized by: sudden sharp chest pain, followed by rapid breathing, decreased breath sounds and cessation of normal chest movements of the affected side; tachycardia, diaphoresis, elevated temp, dizziness, anxiety |
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negative pressure |
a less than ambient atmospheric pressure, such as in a vacuum |
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negative pressure isolation rooms |
-used for patients with an airborne transmitted disease -airflow goes from the corridor into the patients room, and is then exhausted/vented outside |
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fluctuation |
a wavelike motion of fluid in a body cavity or apparatus |
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air leak |
-indicated by rapid, vigorous bubbling in the water seal -consistent with a tear in the pleura, bronchopleural fistula, or a crack or leak in the drainage system |
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tension pneumothorax |
-characterized by: chest pain and resp distress, tachycardia, tachypnea in the initial stages; quieter breath sounds on one side of the chest, low O2 SAT and BP, and displacement of the trachea away from the affected side |
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thoracotomy |
surgical incision into the chest wall. |
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pleura |
is the thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung. |
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intrapleural space |
-place between the parietal and visceral pleura -also called pleural cavity |
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empyema |
the collection of pus in a cavity in the body, especially in the pleural cavity. |
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valsalva maneuver |
-the action of attempting to exhale with the nostrils and mouth, or the glottis, closed -This increases pressure in the middle ear and the chest, as when bracing to lift heavy objects, and is used as a means of equalizing pressure in the ears |
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the purpose of a neurovascular assessment |
-a systematic approach for recognizing neurological &/or circulatory impairment of an extremity -used by nurses to assess pulses, CWMS, cap refill,radial nerve, ulnar nerve, median nerve, femoral nerve, peroneal nerve, tibial nerve |