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314 EXAM 1 > EXAM 1 > Flashcards

EXAM 1 Flashcards

1
Q

Nursing Process

A

Assessment
Diagnosis
Planning
Implementation
Evaluation

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2
Q

Normal Vital Sign Ranges

A

Temp: 96.8-100.4
Pulse: 60-100
Respiratory: 12-20
Blood Pressure: 120/80
O2 sat: 95-100
Pain: 0-10

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3
Q

Assessing for with pulse

A

Rate
Rhythm
Strength
Symmetry

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4
Q

Cardiac Output

A

CO= HR x SV

Stroke vol is amount of blood that leaves the left ventricle with one pump

Therefore…

CO is the amount of blood pumped throughout one minute

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5
Q

Brachycardia

A

HR of less than 60

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6
Q

Tachycardia

A

HR of more than 100

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7
Q

What inc HR

A

During exercise
Fever
Emotions
Medication
Fluid loss
Sitting to standing
Low O2

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8
Q

What Dec HR

A

At rest
Hypothermia
Meds
Lying down

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9
Q

Blood Pressure

A

Pressure of blood forced on arterial walls

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10
Q

Systolic Pressure

A

Peak pressure exerted against arterial walls as ventricles contract and eject blood

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11
Q

Diastolic Pressure

A

Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest

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12
Q

What effects BP

A

Cardiac output
Peripheral vascular resistance
Blood volume
Blood viscosity
Blood flow
Vasoconstrict(inc)
Vasodilation (Dec)

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13
Q

Hypertension

A

Walls thicken, loss of elasticity
Elevated: 120-129/80
Stage 1 HTN: 130-139/80–89
Stage 2 HTN: 140/90

Basically too much blood is being pumped or vasoconstriction

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14
Q

Hypotension

A

Systolic pressure is <90

Inadequate pumping of heart, loss of blood vol, vascular dilation

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15
Q

Orthostatic hypotension

A

When you stand up too fast and blood pressure drops and causes a dizzy spell

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16
Q

3 factors that effect respirations

A

Ventilations
Diffusion
Perfusion

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17
Q

Ventilation

A

Movement of gases into/out of lungs

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18
Q

Diffusion

A

Movement of O2 and CO2 into/out of alveoli and RBCs

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19
Q

Perfusion

A

Distribution of RBCs to and from pulmonary caps

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20
Q

Assessment of respirations

A

Rate
Rhythm
Depth
Effort

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21
Q

Bradypnea

A

Rate is regular, but slow (below 12 per min)

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22
Q

Tachypnea

A

Rate is regular, but fast (above 20 per minute)

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23
Q

Dyspnea

A

Labored breathing

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24
Q

Orthopnea

A

Inability to breath when horizontal

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25
Q

SOB

A

Shortness of breath

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26
Q

Hypoxemia

A

Low levels of O2 in blood

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27
Q

Hypoxia

A

Low levels of blood in tissues

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28
Q

Temperature equation

A

Temp = heat produced - heat lost

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29
Q

How to measure non-invasively

A

Oral, tympanic, temporal, axillary

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30
Q

Invasive temperature

A

Esophageal temp probe
Rectal temp probe
Temp sensing urinary cathader

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31
Q

Hypothermia

A

Core temp colder/below normal

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32
Q

Pyrexia (fever)

A

Due to hypothalamic set point; could be good because it is used as one of the bodies defense mechanisms

33
Q

Hyperthermia

A

Dysfunctional regulation; not good

34
Q

Pharmacokinetics

A

Movement and modification of medication inside the body

Absorption
Digestion
Metabolism
Excretion

35
Q

First Pass Effect

A

When a (PO) drug is metabolized at a specific location and becomes a reduced [] by the time it gets to systemic circulation

Reason why some PO meds need larger dosage

36
Q

Therapeutic effect

A

Expected or predicted physiological response

37
Q

Adverse effect

A

Unintended, unpredictable, or undesirable effect of med

38
Q

Side effect

A

Predictable, unavoidable, secondary effect

39
Q

Toxic effect

A

Accumulation of the drug in the bloodstream to a toxic level

40
Q

Idiosyncratic reaction

A

Overreaction, underreaction, or different reaction

41
Q

Allergic reaction

A

Unpredictable response to meds, foods, stings

Can be life-threatening (anaphylaxis)

42
Q

Med interactions

A

One med modifies the action of another

43
Q

Med tolerance

A

More med is needed to achieve therapeutic response

44
Q

Med dependence

A

Physical and psychological need for a drug

45
Q

Onset

A

Time needed for drug to produce a response

46
Q

Peak

A

Time needed to reach max efficacy

47
Q

Trough

A

Lowest blood level of drug immediately prior to next dose

48
Q

Plateau

A

When the blood level of a drug reaches a therapeutic level after the repeated doses

49
Q

Duration

A

Time drug is present at a level to cause a response

50
Q

Liquid Syringes

A

Amber color to not be confused

Uses smallest one you can

51
Q

Parenteral Meds

A

Invasive injections; aseptic technique needed

52
Q

Intradermal Injection

A

Between skin layers
Very short/fine gauge needle
5-15 degrees
Vol:0.1mL

53
Q

Subcutaneous Injections

A

Below skin into fat: ( lower ab, below scapula, above butt, back of arms)
Slightly longer, larger gauge needle 3/8 to 5/8
45-90 degree: (if lean, pinch and insert at 45 | if obese, no pinch and 90)
Vol: 0.5-1.5mL(adult) 0.5(child)

54
Q

Intramuscular Injection

A

Z track
Into muscle: (vastus lateralis, deltoid, ventrogluteal)
Longer, same/larger gauge needle (obese: 3in | lean 1/2 to 1 in)
90 degree angle
Vol: 2-5 mL (child, old, thin ppl: <2) (small child, old infant: <1) (small infant: .5)

55
Q

Nociception

A

The objective physical phenomenon that allows us to detect pain

56
Q

4 phases of nociception

A

Transduction (stim converts to energy)
Transmission (electrical impulse sent to spinal cord)
Perception ( recognition of pain in the brain)
Modulation (release of inhibitory mediators: Dec sensation of pain and make you move)

57
Q

Pain is…

A

SUBJECTIVE
Pain is whatever the experiencing person says it is existing wherever he/she says it is

58
Q

Types of pain

A

Acute
Chronic episodic
Chronic persistent
Idiopathic

59
Q

Sympathetic response to pain

A

Inc cortisol level
Inc hr, rr, bp
Inc blood glucose
Muscle tension
Dilation of pupils
Dilation of bronchial
Dec GI motility

60
Q

Parasympathetic response to pain

A

Dec hr, rr, bp
Rapid, irregular breathing
Nausea

61
Q

Intractable pain

A

Severe, constant, can’t be stopped, incurable

62
Q

Phantom pain

A

Pain in body part that is no longer there

63
Q

Referred pain

A

Pain perceived at a location other than site of stimulus

64
Q

Pain threshold

A

The point at which someone feels pain

65
Q

Pain tolerance

A

Level of pain you are willing to accept

66
Q

Radiating pain

A

Pain extends from initial site to other parts

67
Q

Objective signs

A

Vital signs, what you see, current and historical health records, all measurements of health status

68
Q

Subjective Data

A

What your patient describes their pain as

69
Q

Qualitative Assessment

A

Wong- Baker Faces (ages 3-7)
Old cart

70
Q

Quantitative assessment

A

NPASS (<1)
FLACC (1-3)
Pain level 0-10 (>7)

71
Q

Old cart

A

Onset (when?)
Location (where?)
Duration (how long? Intermittent/persistent)
Characteristics (sharp, cramping, burning)
Aggravating factors
Relieving factors
Treatment

72
Q

Diagnosis

A

Nurse gathers all data and forms a nursing diagnosis based on patients response to the alteration in health

73
Q

Steps to making a diagnosis

A

1: identify and categorize assessment data

2: select the possible NANDA and validate each as a NANDA that is appropriate

3: complete the nursing diagnosis with the etiology or r/t phrase (why?)

4: include the defining signs and symptoms (AEB)

74
Q

Implementation

A

Execution of a plan

75
Q

Evaluation

A

Overseeing reactions of intervention to see if goals or met or if they are being work towards

76
Q

How to measure diffusion and perfusion

A

SPO2

77
Q

Capnography

A

Exhaled CO2

78
Q

Normal temp

A

Afebrile

314 EXAM 1 (1 decks)

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