Exam 1 Flashcards
D5W
isotonic, used to KVO, supplies 170 calories/liter, excessive infusion can cuase hyponatremic encphalopathy and death from brain swelling
NS
isotonic, used to expand plasma volume, provide Na & Chloride, used for burns, GI fluid loss, metablic alkalosis, NO CALORIES
use caution with CHF pts
LR
isotonic, used for correction of metabolic acidosis, diarrhea, burns, fluid of choice for acute blood loss, NO CALORIES
D5 1/3 NS
isotonic, used to replace fluid and electrolytes, supplies 170 calories/liter
D10W
hypertonic, used when TPN is interrupted & until it is restarted, supplies 340 calories/liter
D5LR
hypertonic, used to replace gastric fluid loss, 170 cal/liter, dont use on liver disease pt
D5NS
hypertonic, used to replace fluid and electrolytes, supplies 170 cal/liter
D5 1/2 NS
hypertonic, used to replace fluid and electrolytes, 170 cal/liter, prepackaged availble with 20 mEq KCL
1/2 NS
Hypotonic, used to replace fluid & electroylets, no calories
pH
7.35-7.45
PaCO2
35-45
HCO3
22-26
PaO2
80-100
SaO2
96-100
myoglobin
men less than 92, women less than 76
TNI
less 0.4
BNP
less 100
Triglycerides
less 150
Cholesterol
less 200
HDL
more than 45
LDL
less than 130
PTT
21-35 sec
PT
10-14 sec
INR
1
valves or ortho pts 2-3
digoxin
0.8-2
Na
135-145
K
3.5-5.0
Cl
95-105
Mg
1.2-2.5
BUN
7-20
Creatinine
0.5-1.4
Hgb
13-16 or 12-15
Hct
41-50 or 36-44
RBC
4-5.5
Platelet
100-450 K
Ca
8.8-10.3
Glucose
60-110
HgA1C
less 6%
WBC
4500-10000
bronchidilators
decrease bronchospasm
beta adrenergic agonists
relax bronchial smooth muscle, decrease airway resistance
ex. albuterol, atrovent, symbicort, advair, xopenex
anti-cholinergic
inhibit cholinergic receptors on bronchial smooth muscle
ex. atrovent, spiriva
inhaled corticosteroids
anti-inflammatory, decrease mucus secretion
ex. pulmicort, flovent, advair, symbicort
leukotriene modifiers
decrease production of mucus/edema of airway wall
ex. singulair
ACE Inhibitor
prevent conversion of angiotensin I to II; decrease peripheral artery resistance
-pril
ARB’s
block vasoconstricting & aldosterone effects on angiotensin II by blocking itat AT1 receptors in vascular smooth muscles causing vasodilation
-sartan
Beta Blockers
block beta 1 in the myocardium & beta 2 in bronchial & vascular smooth muscle, decreases HR, CO & contractility
-olol
calcium channel blockers
inhibit flow of extracellular calcium across cardiac cell membranes & vascular tissue, relax arterial smooth muscle, decrease HR
-pine
insulin
helps with the passage of glucose, K, Mg across cell membranes, controls storage and metabolism of carbs, proteins & fats, promotes conversion of glucose to glycogen in the liver
somogyi effect
rebound hyperglycemia associated with chronic excessive insulin dosages, may need to increase intake or lower insulin does at night
down phenomenon
abnormal early morning increase in blood sugar, usually between 0200-0800, can be from insufficient insulin at night, incorrect med dose, or carbs at bedtime
lipodystrophy
depression at injection site due to break down of adipose tissue and not rotating injection sites
lipohypertrophy
accumulation of subQ tissue at injection site due to not rotating sites
rapid insulin
Humalog
onset 10-20 minutes
peak 1-3 hours
duration 3-5
short acting insulin
Humulin
onset 30-60 minutes
peak 1-5 hours
duration 6-10 hours
intermediate insulin
NPH
onset 1-2 hours
peak 6-14 hours
duration 16-24 hours
long acting insulin
Lantus
onset 1 hour
peak non
duration 24 hours
what insulin is IV only
regular
Heparin
blocks conversion of prothrombin to thrombin & fibrinogen to fibrin, prevents formation of new clots & extension of existing clots
- check platelets, S/sx bleeding
- SE: pruritus & buring at injection site
system of pt care delivery tht\at focuses on the achievment of outcomes within approp. time frames and resources
case mangagement
ensures the quality \, efficiency and cost effectiveness of services provided, manage 100% of all hospitialized pts
clinical case mangaement
stresses collar\boration between the individual pt, family, Mds, and other health care providers
community case management
what is the mission of community case management
encourage wellness and prevent illness
if a pt needs more than one home visit per week can they use community case management
no,
does community case management need a MD order
no but it is recommended
what are the key elements of patient centered medical home
facilitates communication and collaboration among providers, improves pt care outcomes, reduces health care expenditures
requires killed care, acute illness or acute exacerbation of illness, requires intermittent or \frequent visits, homebound clients
home health
is a Md order required for home halth
yes, along with authorization from the payer (insurance)
te ICU is designed to observe the vital function of
ventilation, circulation, assimulation, elimination
what is required in an ICU Rn
anticipate needs, eye for detail in observations of the process necessary to life, has the ability to deal with critical situations with speed, precision, and accuracy
Critical care nursing
holistic and family approach, high burn out rate, most common cause is emotional overload
pt conditions admitted to critial care units
severe trauma, mahor surgery with high risk surgical pts, MI, CVA, GI hemorrhage, dialysis, special procedures
what is the last sense to leave a pt
auditory
a reduction in the degree of sensory input
sensory deprivation
Sx of sensory deprivation
loss of sense of time, delusions, illusions, hallucinations, restlessness, psychosis sx
excessive sensory stimuli
sensory overload, caused by tension and anxiety increase when exposed to continuous periods of time without adequate rest
pts who are prone to sensory deprivation or overload are
very young, old, post-op, unconcious
altered emotional state occuring in a highly stressful enviornment
ICU syndrome/psychosis
how can you prevent ICU syndrome/psychosis
clock, calender, tret pt as individual, allow to make decisions, touch, visting hours
high priority
life threatening
intermediate priority
do not directly threaten a persons life although may result in unhalthy physical or emotional consequesces
low priority
problems that the person can handle themselves, require minimal assitance
the process of assigning work from one organizational level to another or superior to subordinate
delegation of authority
obligation, what must be done to complate a task
responsibilty
power to make final decision and give command
power
accepting ownership for the results or lack therof
accountability
preparing scheme for doing
planning
controlling use of time
time management
each person remains accountable for the work delegated
principle of delegation
nursing process
assessment, evaluation, nursing judgement
may not be delegated
a tool which can be used to delegate effectively
job descriptions
freedom to act within est. guidelines
authority
steps to help in better delegation
think before you delegate, be specific when you delegate, monitor the results, give praise
5 rights of delegation
task, circumstances, person, direction, supervision
normal breath sounds are
soft and breezy
discontinuous breath sounds
only heard either during inspiration or exhalation
abnormal breath sounds are also called
advantisous
crackes/rales
pneumopina or atelctesis, deflated or blocked airways, heard in the bases of lungs
wheeze
high pitch musical, constriction of airways, COPD, asthma
rhonnci
snoring, disappears after cough, cystic fibrosis, COPD
strider
hear without stehascope, loud high pitch croup, epiglitis
plural friction rub
creacking door, caused by pleural viseral rub, VERY PAINFUL
absent
silent
cutting back on activities
radical surgery
S1
Lub, mitral and tricuspid closing, found 5th intercostal space midclavicular line
S2
second intercoastal space, right sternal border, Dub, diastolye, simi lunar valve, hear with radial pulse
S3
,abnormal heart sound, ventricular gallop, common in children, sounds like ken-tuck-ey, early diastolye, associated with valve disfunction
S4
abnormal heart sounds atrial gallop, Ten-nes-see, hear before S1, late diastolye, seen in MI, angina, HTN, CAD, aortic dysfunction
murmur
sound like whoosh, fell a thrill, hear a brue
thrill and bruie
a turbulant blood flow found in both dialstole and systolic
chart a murmur
grade it I/VI, II/VI, etc.
I/VI is barely audible, III/VI sounds same as S1/S2, Vi/VI dont need a stethscope to hear (loud with palpable thrill
first level priority
airway problems, breathing, cardiac or circulation, VS concerns
secondary level priority
LOC chane, untx medical problems, acute pain, abnormal lab values, risks of infection
third level priority
lack of knowledge, activity, rest, family coping
consists of clarification, simplification, organization, and rationalization of ideas
critical thinking
venous insufficency
pooling of blood = valve problem, S/sx of edema, guarder sign, irregulaar ulcers with discharge, puritis, pain relieved by walking, dependent cyanosis, skin will feel warm to touch,
arterial insufficnancy
absent or diminsihed pulses, cool to touch, sluggish cap refill, dependent rubor, elevation pallor, pins and needles, decrease sensation
proactive approach, prevent adverse events
early nure intervention team
reactive approach, rapid immediate care to unstable pt
tapid response team
pain during ambulation
claudacation
direct percussion
tapping directly on skin
indirect percussion
tapping on hand that is directly on the skin
blunt percussion
strike with ulnur surface of your hand, used to ID the size, loaction and density, helps to determin if the mass is air filled, solid or fluid filled
tempany
high pitch, over abdomen (WNL)
resonance
low pitch normal sound over hallow organs such as lung
hyper resonance
loud booming sound heard over hyper inflated lung such as empazema
dull
soft thud like, heard over all dense organs
flattness
soft and high pitched, heard over bones, tumors
normal size of pupils are
3-5-cm
5 P’s of Nural assemssemtn
paralysiss, pulses, pain, pallor, parasteshia (numbness)
crainal nerves
olfactory (smell) sensory
optic (sight) sensory
occular motor (movement of eyes, pupils) Motor
troclear (movement of eyes) motor
trigeminal (chewing, feeling on face) m & s
Abducens (movement of eyes) motor
Facial (smiling, taste) S&M
Accustic (hearing & equillibrium) S
Glossopharangeal (tasting, swallowing, gag reflex) S&M
Vagus (tasting, swallowing, gag reflex) S&M
Spinal accessory (neck, tripezious, sternoclaidomastoid muscles) M
Hypoglossal (stick your toungue out) M
why are vascular access devices used
to have IV access for over 7 days
Glascow coma scale
standardized tool, quick and easy check eye opening, motor response, verbal response 15 fully intact 4-7 unconscious/coma 0-3 deep coma
an indwelling IV catheter inserted centrally or peripherally and threaded into the superior vena cava and right atrium
central catheters
*can cause arrhythmias or valve damage
decortication
injury is above brain stem, flexed, not good
decerabration
extended, injury involves the brain stem
placed directly into vessel, placed in a large vein such as jugular vein or neck or the femoral vein in the groin, temporary, sutured to skin at insertion side
non-tunneled central catheter
surgically tunneled through tissue into vein, has a cuff that stimulates tissue growth, needed for long period of time, MD must remove
tunneled central catheter
permanent device that consists of 2 parts, a catheter attached to a small reservoir and a single or double lumen, surgically inserted and removed
implanted port
for all assesments besides GI
inspect, palpate, percuss, auscultate
GI: inspect, auscultate, palpate then percuss
speed shock with access device
pushing a med too fast, S/Sx severe HA, chest pain, arrhythmias, death
can a parent/surrogate decision maker refuse a blood transfusion
no
contains red blood cells, white blood cells, and platelets
whole blood
PRBCs
whole blood, removed plasma, used to raise Hct & Hgb while minimizing volume increase
plasma
contains albumin, fibrogen, globulins, and other clotting factors
FFP
plasma frozen within hours of donation, must be thawed before use
platelets
small cellular components of blood that help the clotting process by sticking to the lining of blood vessels
cyroprecipitated, AHF
removed from plasma by freexing and then slowly thawing the plasma, rich in clotting facots
leukopenia
total WBC less than 4,000
with the Rh system what can Rh- not recieve
+ blood
with the Rh system what can Rh + recieve
any blood
with group O blood who can you donate to, who can you recieve blood from
can donate to anyone
recive only from O
with group A who can you donate to, who can you recieve blood from
can donate to A, AB
recive from O, A
with group B who can you donate to, who can you recieve blood from
can doante to B, AB
recieve from B, O
with group AB who can you donate to, who can you recieve blood from
can donate to AB
recieve from A, B, O, AB
one unit of RBC will increase your Hgb how much
1 g/dl
blood product to unit time
hang within 30 minutes from arrival to floor, complete transfusion within 4 hours from lab (or it can f\grow bacteria)
what is used to prime the blood tubing before the blood arrives
ONLY NS
new tubing is to be used with every transfusion
Blood transfusion procedure
VS prior, start at 50 ml/hr for 1st 15 minutes, then increase up to 125 ml/hr, monitor BVS Q 15 minutes
acute hemolytic reaction
low back pain, chills, pain at IV site, hypotension
febrile non hemolytic reaction
chills, increase of temp over 2 degrees, seen with mult transfusions of 5 or more
circulatrory overload reaction
cough chest and back pain, dyspnea, cyanosis, crackles
htn
150/90
