101 FINAL Flashcards
Different responsibilities of different members of the healthcare team?
Physical therapist?
Occupational Therapist?
Physical therapist - musculoskeletal strength and conditioning
Occupational therapist - ADL, how to use and adapt to limitations for daily life
How many years is the RN license in NV good for?
How many hours or credits need to renew license?
2 years
30 credits
Where can you find the laws and regulations for nurses in each state?
Nurse practice act - defined by state board of nursing
What is an incident report?
When do you fill one out?
Incident report is Agency record of unusual occurrence
What are ranges for
PULSE RATE
RESPIRATIONS
BLOOD PRESSURE
Pulse - 60-100
Respir - 12-20
Bp 120/80
What is the normal range for blood glucose level?
70-100
What are the 4 different ways in which you can normally lose heat?
Radiation- exposure to cold
Conduction - lose through contact
Convection - blowing air
Evaporation - sweat
What are the different sites for palpating pulses?
Temporal
Carotid -ER
Apical
Brachial - inside elbow
Radial
Femoral - inside thigh
Popliteal - behind knee / bp
Posterior tibial - behind medial maleoulous / ankle
Dorsalis pedis - top of foot between big toe and little toe
Where do you place cuff when taking bp?
around upper arm
1 in above antecubital space/elbow
When do you use a diaphragm?
When do you use a bell?
Diaphragm - high-frequency sounds
Bell - Low-frequency sounds / murmur
What are the 5 steps of nursing process?
Assess
Diagnosis
Plan
Implement
Evaluate
What is the clinical judgment model in relation to ADPIE?
ASSESS - Recognize clues
ANALYZE/DIAG - Analyze Clues, Prioritize hypothesis
PLAN - generate solutions
IMPLEMENT - Take action
EVALUATE - Eval outcomes
What is IPPA
What system does not follow this?
Inspection
Palpate
Percuss
Auscultate
*abdomen = IAPP
What is the difference between medical asepsis and surgical asepsis?
Medical asepsis -not wearing sterile gloves, starting an IV
Surgical asepsis - sterile technique, wearing sterile gloves, inserting a catheter
What is difference between acitve ROM and PASSVE ROM
active - ppt able to do it themselves
Passive - ppt being assisted through motions
What does patient autonomy mean?
ability to make own decisions
Difference between arterial and venous problems?
ARTERY - relief with rest, plae. cynaotic , shiny, pulseless, cool, ISCHEMIC ULCER
VEIN - Relief with walking, brown, red, warm, STATSIS ULCER
What is receptive aphasia?
What is expressive aphasia?
Receptive - cant understand what ppl are saying/writing
Expressive - cant talk at all or doesn’t make sense
What is range of glascow coma scale?
What score is coma?
1-15
7 or less is coma
What order do you put on PPE and take off?
ON: Gown, Mask, Goggles, gloves
OFF: Gloves, goggles, gown, mask
What are the standard precautions?
Airborne?
Droplet?
Contact?
Standard - everyone gets. Handwashing PPE
Airborne - TB N95
Droplet - mumps/pertussis. MASK
Contact - CDIFF, gloves
How does blood flow through the heart?
Deoxygenated > Veins > RIGHT Atrium> RIGHT ventricle>Pulmonary artery> LUNGS> Pulmonary veins> LEFT atrium> LEFT ventricle>AORTA>arteries>System
What is the natural pacemaker of the heart?
SA node
what is the electrical pathway in the heart?
SA NODE>AV NODE>BUNDLE of HIS» Purkinje Fibers
What causes the bruit sound in carotid artery?
buildup of plaque. Atherosclerosis
What is the z pattern of the heart?
apical, pulmonic, erbs point, tricuspid, mitral
Where is S 2 the loudest? and what valves are you hearing?
Closure of Semilunar valves loudest at base
end of systole
Where is S1 the loudest? and what valves are you hearing?
closure of AV valves loudest at apex - top
beginning of systole
What is the formula to measure cardiac output?
SvXHR= C/O
What are the signs of LEFT sided HEART failure?
Pulmonary congestion, Dyspnea, orthopnea
What are the signs of RIGHT sided heart failure?
extremities edema
Venous distention
what is atelectasis
collapse of aveloi
What is the correct technique for listening to lung sounds?
Side to side 18 on back, 10 on front
DEEP breathes in and out through the mouth
Use diaphragm - high frequency sound
What are CRACKLES lung sounds?
Non-musical, popping sound/bubbling
Fine: roll hair between fingers by ear
Coarse: opening Velcro
Due to fluid, mucus or pus
What are WHEEZING lung sounds?
High pitched - like whistling
Due to airway narrowing/constriction
What are STRIDOR sounds?
in trachea
High-pitched during inspiration/trachea
Due to obstruction of upper airway/narrowing
What are RONCHI lung sounds?
Low-pitched, snore-like
Due to airway narrowing and secretions
What are the 2 different types of advanced directives?
Living Will - a list of all the things you want or dont want done, YES or NO. does not kick in until person cannot tell what
Durable Power of Attorney for Health Care - name of person who will make health care decisions if patient cannot make own decisions
What are the different ways to do nursing documentation?
ISBARR-
DAR
What does ISBARR stand for
Identification or intro/
Situation (why calling or telling)- what is going on right now - breathing
Background- COPD & surgery
Assessment - vital signs
Recommendation - breathing treatments
repeat (verbal order)
What are the risk factors for skin breakdown?
age
health
nutrition
hydration
What are the stages of pressure ulcers?
Stage I: redness - skin intact
Stage II: skin is broken
Stage III: into subQ fat layer
Stage IV: damage to muscle - deep into muscle and possibly bone
Unstageable: base of ulcer covered by slough and/or eschar in wound bed
What are the principles of pressure ulcer therapy?
Protect the wound
Provide a moist environment
Absorb excess exudate
Prevent maceration of wound edges
Remove necrotic tissue
What are 4 ways we can remove necrotic tissue?
-Autolytic debridement - self/the body natural enzymes to eat away at any dead tissue/ slough
-Mechanical debridement - wet to dry dressing (wet gauze/wring out/pack) ./ maggot
-Enzymatic debridement - use ointments or creams that have chemical properties / takes days to weeks
-Sharp debridement -scalpel
What are the 4 types of wound drainage?
Serous - clear
Sanguineous - bloody
Serosanguineous - watered-down blood
Purulent - thick yellow, green, tan, brown
What is Dehiscence?
Evisceration?
-Dehiscence - when a surgical wound comes apart – could be from coughing, sneezing, pulling
-Evisceration - when contents spill out of a open wound
What does the P, QRS, T Wave indicate?
P Wave - atrial depolarization
QRS Complex - ventricular depolarization
T Wave - ventricular repolarization
What is the PR interval?
PR Interval
Amount of time for the impulse to travel through the AV node to the bundle of His
In relation to oxygenation, what is diffusion? where does it occur?
Exchange of respiratory gases in the alveoli and capillaries (occurs at the alveolocapillary membrane)
Moving of molecules (CO₂ & O₂) from an area of higher concentration to an area of lower concentration
why would a patient who is hyperventilation develop paresthesia
Hyperventilation causes increased blood pH which causes a decrease in free ionized calcium (Hypocalcaemia), which causes paresthesia
What are early signs of hypoxia?
(Mental status ∆’s early sign)
Change in LOC
Restlessness
Apprehension
Inability to concentrate
Dizziness
Behavioral Changes
Cyanosis: Late sign of hypoxia
What is the proper technique for an incentive spirometer? and whats purpose?
Lips should completely cover mouthpiece
Have patient inhale slowly, attempting to reach goal volume
Encourage 5-10 breaths per session every hour
-Helps prevent atelectasis
Whats the different between low floe and high flow oxygen delivery systems?
Low-Flow Systems
amount of O2 delivered is variable and depends on the patient’s respiratory rate & breathing pattern
Nasal Cannula
Simple Mask
Nonrebreather
High-Flow Systems
patient’s entire inspired gas volume is consistently & predictably delivered by the system
Venturi Mask
What are the normal levels for
SODIUM
POTASSIUM
CALCIUM
MAGNESIUM
CHLORIDE
PHOSPHATE
Sodium: 135-145 mEq/L
Potassium: 3.5-5.0 mEq/L
Calcium: 8.6-10.2 mg/dL
4.5-5.1 mg/dL (ionized)
Magnesium: 1.3-2.3 mEq/L
Chloride: 97-107 mEq/L
Phosphate: 2.5-4.5 mg/dL
What are some signs of HYPO and HYPER volemia?
Hypovolemia
Tachycardia
Hypotension
-Thready Pulse
Decreased Skin Turgor
Orthostatic Hypotension
Dry Mucous membranes
Hypervolemia
Bounding Pulse
Crackles
Distended Neck Veins
Edema
Hypertension
what is normal PH
PAcO2
HCO2
PH - 7.35-7.45
PAcO2 - 35-45
HCO3 - 22-26
What are examples of complete and incomplete proteins?
Complete- meat, animal products, soy
Incomplete - beans, legumes
What is difference between saturated and unsaturated fats?
Most animal fats are saturated (limit to <7-10% of total calories)
Most vegetable fats are unsaturated
What is systole? what is Diastole?
Systole - a period of ventricular contraction
Diastole - a period of ventricular filling
What happens during S1?
AV valves close - beginning of systole
blood flows from ventricles into pulmonary artery and aorta
What happens during S2?
Close of Semilunar valves- end of systole
AV valves open and blood flows from atria into ventricles
What is coronary circulation
What are the 2 main coronary arteries?
Coronary circulation - circulation into the myocardium
Right and left coronary arteries
What is creatine phosphokinase (CPK) and troponin?
CPK (CK-MB)- enzyme will increase if MI
Troponin - protein gets released when damage to cardiac tissue
*Only elevated for a short time after MI
How can we treat an arterial occlusion?
Thrombolytic drugs
Angioplasty- cardiac catheter/groin/inflate balloon
Stent placement
How many BPM does SA node, AV node and bundle of his fire off?
SA - 60-100
AV - 40-60
Bundle - 20-40
What happens during Polarization, Depolarization and repolarization?
Polarization - K+ leak out of cell/makes it -
Depolarization - Inflow of Na+ & Ca+/makes it +//TRIGGERS Contraction
Repolarization - Return to resting / makes it -
What does the P, QRS, T wave mean?
P - Atrial depolarization
QRS - Ventricular depolarization
T - Ventricular repolarization
What is definition of cardiac output?
Volume of blood pumped by heart each minute
Contractility is affected by what 2 things?
-Venous return (starling law)- more volume = more stretch=greater contraction
-Inotropic effect - SNS - brain triggered to squeeze harder
What is the ejection fraction?
How much blood is ejected out of the left ventricle with each beat
AVG for adults is 55-65%
What are the 3 steps of respiratory physiology?
-Ventilation - moving gases in and out of lungs
-Diffusion - exchange of respiratory gases in alveoli and capillaries
-Perfusion- Pumping oxygenated blood into tissues and returning de-ox blood to lungs
What is the goal of ventilation for Co2 and O2?
Co2 - 35-45 mmHg
O2 - 95-100 mmHg
*Brain is triggered by Co2 levels
What are the 2 parts of the brain responsible for breathing?
Medulla - automatic/sensitive to narcotics
Cerebral cortex - voluntary
What is hyperventilation?
Caused by…
Excess exhaling of Co2
causes - anxiety, infection, hypoxia, compensation for metabolic acidosis
What is Hypoventilation?
Caused by..
Decrease in the amount of air entering alveoli
Inadequate amount of O2
Caused by an obstruction, atelectasis, too much o2 in COPD
Holter monitor/event monitor
Holter - Records for 24 hours
Event monitor - 1 month
Nasal Cannula
Delivers concentration of ?
Flow rates from ?
Concentrations 22-44%
Flow rate 1/2 to 6L/min
*usually admin humidified at 3L
2L/MIN of oxygen is what FiO2?
*every 1/2 L is what FiO2?
28%
every 1/2 L is 2%
A simple mask delivers what oxygen concentration? and flows between?
Delivers 40-60%
Flows between 5-8L/min
Nonrebreather delievers oxygen concentrations of ? and flows from?
Oxygen concentration 80-95%
Flows from 10-15L/Min
*used for respiratory distress, severe asthma, trauma
Venturi Mask
Delivers what specific oxygen concentration?
Specific - 24-40%
When would you use oropharyngeal suctioning?
When able to cough but unable to clear secretions
What is the autonomic bladder?
From injury or disease - just forms urine
no control - incontinent
What is stress incontinence?
Increased abdominal pressure
*Wearing tight clothing
*If coughing, sneezing, laugh may cause them to dribble urine
What is stress incontinence?
Increased abdominal pressure
*Wearing tight clothing
*If coughing, sneezing, laugh may cause them to dribble urine
Alcohol inhibits the release of
ADH
What is the primary organ of bowel elimination?
The large intestine
The large intestine extends from
Ileocecal valve to anus
What are the functions of the large intestine?
Absorption of water
Formation of feces
Expulsion of feces
What is peristalsis?
Contractions under control of autonomic nervous system
*Parasympathetic stimulates movement
*Sympathetic inhibits movement
How does hypertonic solution work?
Draws water into colon to extend it
What kind of solution is saline?
Isotonic
What is a colostomy?
Stoma?
Ostomy?
Colostomy - section of bowel surgically removed
Stoma - artificial opening
Ostomy - surgical procedure where artificial opening is created
