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NUR 213 > Comprehensive Conceptual Assessments: Exemplar Caregiver Skills Development > Flashcards

Comprehensive Conceptual Assessments: Exemplar Caregiver Skills Development Flashcards

1
Q
  • Assess the patient systemically and comprehensively
  • Gather data
  • Verify data *****
  • cluster related information
  • determine the importance of information (relevant vs irrelevant). data does not need to be abnormal to be relevant. Notice trends whether it be upwards or downwards.
  • head to toe assessment versus focus assessment
A

Assessment

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2
Q

OLD CARTS
O - onset
L - location/radiation
D - duration

C - characteristics
A - aggravating factors 
R - relieving factors
T - timing
S - severity
A

Perform a comprehensive assessment of complex individuals. Focus on abnormal data.

  • if pain interventions are not relieved with treatments then it is no longer acute but chronic pain.
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3
Q

assessment using PQRST…
P: provoking factors. what factors precipitated the discomfort? what were they doing at the time of onset?
Q: quality. ask the patient to describe the pain/discomfort and its characteristics.
R: region/radiation. where is the pain? does it radiate? is there pain anywhere else?
S: severity. ask the patient to rate their pain/discomfort on a pain scale
T: time. how long has the patient had the pain. Does anything make it worse or better?

A

Pain assessment

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4
Q
  • interpret and analyze ALL data (lab results, H&P, assessment findings, mediation regimen)
  • formulate logical conclusions
  • initiate appropriate interventions
A

second phase of assessment

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5
Q
  • _______ client progress or lack of progress toward defined goals.
  • ______ medication therapies for effectiveness and client response.
A

Evaluate effectiveness of treatment.

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6
Q

adequate arterial blood flow through the peripheral tissues and blood that is pumped by the heart to oxygenate major blood organs. Perfusion is a normal physiologic process of the body without which death occurs.

A

Perfusion

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7
Q
  • trends of blood pressure
  • pulse
  • orthostatic hypotension
  • pulse pressure
  • pulse deficit
  • jugular vein distention
  • heart sounds
  • skin temperature
  • capillary refill
  • peripheral pulses
  • neuro status
  • altered cardiac electrical function
  • edema
  • dizziness/fainting
  • pain in fingers and toes
A

physical assessment of cardiac output and perfusion

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8
Q

how do you calculate cardiac output?

A

heart rate x stroke volume
normal range is 5 - 10 L/min
Ejection Factor normal range is: 50 - 60%

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9
Q

volume of blood in ventricles at end of diastole (end diastolic pressure) this is before contraction.
- increased in hypovolemia, regurgitation of cardiac valves, heart failure.
(decrease pre-load = decrease volume. vasodilation slows venous return.

A

preload

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10
Q

resistance left ventricle must overcome to circulate blood.
- increased in hypertension and vasoconstriction
increased afterload = increased cardiac workload.

A

afterload

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11
Q

complex, multi-step process by which blood forms a protein based structure in an appropriate area of tissue injury to prevent excessive bleeding while maintaining whole body blood flow.

A

clotting

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12
Q
  • know client’s baseline
  • 20-30 beat increase in heart rate is quite significant even if it’s within normal limits.
  • look at BP trends over hours and days rather than one reading
  • check changes pulses quality. How should you describe quality?
  • consider cap refill, edema, dizziness, syncope, nausea, chest, pain, and diaphoresis.
A

recognizing problems with perfusion

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13
Q
  • change client’s position. effect on cardiac output.
  • manipulate B/P
  • manipulate pulse
  • medications
A

interventions effecting perfusion

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14
Q

the process of oxygen transport to the cells and the carbon dioxide transport away from the cells though ventilation and diffusion.

A

gas exchange

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15
Q

the maintenance of arterial blood pH between 7.35 to 7.45 through control of hydrogen ion production, buffering and elimination.

A

acid-base balance

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16
Q

tracheal breath sounds are ____

A

loud

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17
Q

vesicular breath sounds are ____

A

lighter

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18
Q
  • ABG results
  • oxygen saturation
  • respiratory rate, depth, quality
  • skin, nail beds, and lips appropriate color
  • thorax symmetry, equal thoracic expansion bilaterally
  • trachea midline
  • scapulae symmetrical bilaterally
  • chest expansion
A

physical assessment of oxygenation (gas exchange)

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19
Q
  • ability to protect airway and work of breathing
  • sit client up listening anteriorly and posteriorly to all lung fields
  • assess airway, breathing and O2 requirements ***
  • assess skin color, chest shape and LOC
  • note client’s position
  • accessory muscle use, retractions, pursed lip breathing or nasal flaring
  • respiratory rate and character
  • crackles, wheezes, rhonchi, or plural friction rub
A

oxygenation (gas exchange)

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20
Q 
bradypnea
apnea
hypernea
kussmual (fix pH)
Cheyne-stokes (neuro issue) 
Biots (neuro issue)
A

abnormal respiratory breathing patterns

21
Q

fine crackles
coarse crackles
crackles/rales

A

discontinuous abnormal breathing sounds

22
Q

wheezes (late sign in fluid buildup)

rhonci (mucus)

A

continuous abnormal respiratory sounds

23
Q

the most common predictor for cardiac arrest is ______ or ShOB in over 40% of patients who coded.

A

tachypnea

24
Q

the body does not store _____

A

oxygen

25
Q

compensatory tachycardia with blood pressure ____ is a late sign of distress.

A

drop

26
Q

signs of clinical deterioration are evident as much as _______ hours before a respiratory or cardiac event.

A

6 - 24 hours

27
Q

drugs that affect upper airways

A

antihistamines and decongestants

28
Q

drugs that affect lower airways

A

bronchodilators, symphathomimetic, glucocorticoids, anticholinergics

29
Q
  • open airway, and positioning to promote chest expansion
  • treatment of hypoxia
  • alternate activity with rest
  • provide high protein, high caloric nutrition in small frequent servings for clients with hypoxia.
  • education to not begin smoking or to quit
  • limit air pollution exposure and allergens.
  • teach about immunizations and good hygiene practices.
A

interventions related to abnormal assessment of oxygenation.

30
Q

nasal cannula (24-44%) (1-6 LPM)
high flow nasal cannula (up to 100%)
face mask (35-50% humidified) adjust 6-12 LPM
non re-breathers (60-90% high flow) rates 10-15 LPM

A

oxygen therapy

31
Q
  • homeostasis depends on integration of respiratory, cardiovascular, renal, and behavioral systems.
  • primary route for excretion of water and ions-kidneys (essential for regulating volume and composition of fluids.)
  • lungs remove H and HCO3 by excreting CO2
  • behavioral mechanisms (thirst and salt appetite aid in fluid and electrolyte balance)
A

maintaining fluid and electrolyte balanace

32
Q

when administering a high level of oxygen the key is to ______.

A

monitor the patient

33
Q
  • intake and output relationships (how much output should our client have per hour?)
  • recent history of vomiting, diarrhea, or blood loss.
  • daily weight ***
  • assessment of mucous membranes for dryness
  • presence or absence of edema
  • lab results
A

assessment of fluid and electrolyte balance

34
Q

what is the range for normal output?

A

0.5 - 1 mL/kg per hour

35
Q

elevated with low fluid volume

A

blood urea nitrogen (BUN)

36
Q

lab value specific to renal function

A

Creatinine

37
Q

lab value indicative of kidney function

A

Glomerular filtration rate (GFR)

38
Q

lab value indicative of dehydration. the most common cause of dehydration is an elevated ____

A

hematocrit (HCT)

39
Q

s/sx:

  • bilateral flaccid muscle weakness
  • abdominal distention
  • constipation
  • postural hypotension
  • polyuria
  • cardiac dysrhythmias
A

hypo K

40
Q

s/sx:

  • bilateral flaccid muscle weakness
  • cardiac arrest if severe
  • cardiac dysrhythmias
A

hyper K

41
Q

s/sx:

  • increased neuromuscular excitability
  • muscle cramps, tetany
  • hyperactive reflexes, twitching
  • spasms: laryngeal, carpal and pedal *****
  • seizures
  • cardiac dysrhythmias
A

hypo Ca

42
Q

s/sx:

  • decreased neuromuscular excitability
  • muscle weakness
  • constipation
  • diminished reflexes
  • anorexia, nausea **
  • cardiac dysrhythmias
  • decreased LOC
A

hyper Ca

43
Q

s/sx:

  • increased neuromuscular excitability
  • muscle cramps and tetany
  • hyperactive reflexes and twitching
  • cardiac dysrhythmias
  • seizures
  • insomnia and nystagmus (involuntary eye movements)
A

hypo Mg

44
Q

s/sx:

  • decrease neuromuscular excitability
  • muscle weakness
  • flushing, and diaphoresis **
  • diminished reflexes
  • respiratory depression, and bradycardia ***
  • cardiac dysrhythmias
  • decreased LOC
A

hyper Mg

45
Q

strict intake and output
analyze client’s fluid status
facilitate oral intake
fluid replacements with the appropriate electrolytes
replace fluid from vomiting, diarrhea or blood loss
provide supplemental fluids for at risk patients
request antiemetic or antidiarrheal meds
teach clients on K wasting diuretics importance of potassium supplements.

A

interventions to related abnormal assessment of fluids and electrolytes

46
Q

prevention-modification of environment and behavior, screening, vaccination and treatment of infections. Prophylactic surgery (mastectomy, oopherectomy)

A

interventions in regards to cellular regulation

47
Q

healthy lifestyle education avoid high-calorie, high fat foods with no nutritional value.

A

interventions in regards to nutrition and glucose

48
Q
  • increase physical activity
  • BMI between 19 - 24.9
  • for adults older than 60 years BMI b/t 23-27
  • regulation of blood glucose with insulin as prescribed.
A

intervention to promote metabolism.

NUR 213 (20 decks)

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