Exam 1 Flashcards
1
Q
An unpleasant and emotional experience with tissue damage
The most common reason for seeking health care
It is whatever the patient says it is
Also known as the 5th vital sign
–this is good for when the patient isn’t able to tell you, you can look at their vital signs – you will feel anxious and have an elevated vitals such as HR & BP
A
Pain
2
Q
The Joint Commission Standards State that..
A
Pain is assessed in all patients and all patients have the right to appropriate assessment and management of pain
3
Q
Define acute pain..
A
It is expected to have a short duration and it is usually related to injury
ex: getting a paper cut, damage has occurred, but it is short and will get better
4
Q
Define chronic pain..
A
This pain can last a long time/happens over a long period of time, this pain lasts longer than injury, can last throughout a person’s life
5
Q
Define cancer related pain..
A
This pain is difficult to treat, especially once its in the bone, accompanies cancer, can also be looked at as breakthrough pain
6
Q
Define breakthrough pain..
A
This is a combination on chronic and acute pain, chronic pain with short bursts of acute pain
7
Q
Pain is classified by what 2 things..
A
Location - chest pain
Etiology - angina (cause)
8
Q
What are negative effects of acute pain on patients..
A
Cardiovascular system/HR, and BP increase
Decrease in respirations
Depression of immune system- vulnerable to disorders
Increase in hormones
Sleep changes and deprivation
9
Q
What are negative effects of chronic pain on the patients..
A
Can become depressed easily
Can have increased disabilities
Can have suppression of the immune system
10
Q
What are 5 factors that influence pain
A
Past experiences: what kinds of pain have you felt before
Anxiety: patients may be unsure what to expect from the procedure so teaching/education may alleviate anxieties, depression can fit here as well
Culture: some cultures don’t express pain while some cultures express it more than others
Age: infants will cry or withdraw from pain, toddlers/children could get fussy or grumpy from pain
Gender: boys may not want to express their pain
11
Q
Best ways of assessing pain..
A
ASK the patient
Pain scales
12
Q
Characteristics of assessing pain
A
PQRSTU - look in notebook
13
Q
These act on CNS to inhibit activity of ascending nocioceptive pathways
A
Opioid analgesics (narcotics)
14
Q
These decrease pain by inhibiting cyclo-oxygenase (enzyme involved in production of prostaglandin)
They also increase the risk for bleeding
A
NSAIDs
15
Q
These block nerve conduction when applied to nerve fibers
Ex: Lidocaine
A
Local anesthetics
16
Q
The fastest route for drug administration
And timing for drug administrations
A
IV - faster than oral
Although the oral route is preferred, cause its cheap, easy, and tolerated well
Meds can be given around the clock (ATC) or as a preventative approach
17
Q
What are gerontologic considerations for drug administration
A
Elderly are going to have more side effects, because they are having more drug interactions
More chronic diseases
Need more time in between doses due to liver and kidney functions
18
Q
Side effects of opioids..
A
Nausea and vomiting
Sedation
Constipation
Pruritis- itching
Respiratory depression
–if respirations get too low while sleeping, wake them up and if respirations come back up they’re okay
–Narcan will reverse/bring back respirations
19
Q
What is tolerance
A
When a higher dose of the drug is needed for the same level of pain as last time, because patient has built up a tolerance to the drug
Patients with chronic pain and cancer pain often experience this
20
Q
What is dependence
A
Physical symptoms that occur from drugs/opioids being taken away
21
Q
What is addiction
A
When the drugs produce a psychological effect that the patient needs to take it to feel better
22
Q
What is PCA
A
Patient Controlled Analgesic
-if the IV site looks bad that means the meds are not going in
23
Q
Patients should remain flat during these because they could get headaches from standing up
A
Intraspinal administrations
24
Q
What are the 3 phases of perioperative nursing
A
Preoperative - before surgery
Intraoperative - surgery to the post anesthesia care unit
Postoperative - PACU to then visit with a doctor
25
Actions performed during pre-admission testing
```
Pre surgery assessment
A health history interview
Patient & family teaching
Pre-op orders and instructions are understood
All consent and forms signed
Allergy information is given
Begin planning discharge
```
26
Special considerations for the elderly during the pre-op period
They have more chronic diseases
They have more sensory problems
Its harder for them to get back to normal quickly
-respiratory and cardio complications are the greatest cause of post op mortality
27
Special considerations for the obese during the pre-op period
They are at a high risk for infections
| Risk for complications
28
Special considerations with ambulatory surgeries
Need to make sure that patients have a ride home
| -ambulatory meaning they walked in but wheeled out
29
Special considerations in an emergency surgery
They go right in and hope for the best
| -they don't check labs or health histories
30
The patient tells you that they do not understand the surgery and ask you to explain the procedure, what do you do?
It is not your role to explain the procedure or its risks, benefits, or alternatives. You should let the surgeon know that the patient is not understanding the procedure and ask him/her to explain it again
-you are allowed to clarify things the patient asks that the surgeon said
31
What should you do if a patient states they have an allergy to something?
Ask what happens they have a reaction
-if the patient states that they break out in hives, have difficulty breathing, or experience angioedema (swelling under the surface of the skin, similar to hives) then the reaction is definitely an allergic one
32
List aspects of informed consent
Should be in writing
Should contain an explanation of the procedure
Patient should understand this procedure
Patient should not be under any sedation
Consent must be obtained by the physician
Patient signature must be witness by a staff member
33
Those who cannot sign informed consent
```
Under 18 years old
Cognitively impaired
Mentally ill
Sedated
Someone being forced, not autonomous
```
34
What are some general pre-op nursing interventions
Keep patient's pain at a 3 or less
Show emotional support and respect
Patient safety - rails up and call lights
Antiseptic wash of the skin with betadine
No smoking at least 24 hours before surgery
No alcohol before surgery
35
What are the immediate pre-op nursing interventions
Administering pre-anesthetic medications
Documenting
Transporting the patient to surgery
36
What is the role of the circulating nurse
Advocates for the patient's well being
Makes sure the patient has what they need
Continually assess the patient for injury
Helps to execute patient interventions
Verifies consent
37
What is the role of the scrub nurse
Interacting with the surgeon and providing what ever they need
Performing a surgical hand scrub
Setting up the sterile field/table
Preparing sutures, ligatures, and special equipment
38
What are some intraoperative complications
Nausea & vomiting - patient could start gagging, use suctioning
Malignant hyperthermia - temp/fever spike, susceptible in people with large bulky muscles, muscle rigidity (stiffness) and distortion, increased HR, assess for this prior to surgery
Hypothermia- patients temperature falls, glucose metabolism is reduced
Hypoxia- watch for respiratory complications, depression, aspiration (inhaling things, could inhale their own vomit)
Anesthesia awareness - when the patient becomes cognizant of what is going on while under anesthesia, they recall in the incident, they will have an increase in BP, HR, and movement
Anaphylaxis- shock related to an allergy
DIC (disseminated intravascular coagulation)- bleeding and clotting within the vessels, you should assess for bleeding at IV sites or old puncture areas, the patient will go to ICU and probably receive fresh frozen plasma to replace the clotting factors
39
Adverse effects that could occur because of surgery or anesthesia
Allergic reactions or drug toxicity reactions
Cardiac dysrhythmias
CNS changes such as over or under sedation
Trauma including burns
Hypotension
Thrombosis (a clot of the circul. system: veins, ateries)
Spinal headache with an epidural
40
Nursing interventions for the patient while in surgery
```
Reduce anxiety
Reduce latex exposure
Prevent positioning injuries/protect patient from injury
Serve as the patient advocate
Monitor and manage complications
```
41
What are specific things to do to protect the patient's safety or prevent them from injuries
```
"Time out"
Identify the patient correctly
Get informed consent
Verify that a health history & physical exam were done
Check the results of diagnostic tests
Assess for allergies, especially latex
Checking for all equipment and needs, tools, accessible blood
Don't leave patient sedated
```
42
What is the nurses's role in PACU
Perform baseline assessments and reassessments
Make sure there were no complications from surgery
Check vitals every 15 minutes
Provide patient care until patient has recovered
43
What should be reported during discharge or outpatient
Give instructions to the patient & responsible adult with them, patients cannot go home by themselves:
Discharge planning, teaching, and assessment
Follow up care plans
What to watch for
Prescriptions
Phone numbers
44
Name ways of maintaining a patent (open) airway
Oxygenation & ventilation
Head of bed at least 15 degrees up
Have them turned to the side a little bit
Vomiting? Hypoxia? Suctioning
45
What is looked at in a quick assessment of the patient post surgery
Cardiovascular system: look at skin color, pulses, and capillary refills
Musculoskeletal system: have them walk, sit up, and perform leg exercises (this will also help to increase circulation, prevent venous stasis, and promote respiratory functions)
Neurological systems: assess their LOC and orientation, response, do they need warm blankets?
Fluids/electrolytes: measure their I&O, make sure their IV is infusing
Gastrointestinal tract: check oral care, bowel sounds, check for distention (stomach will feel like its getting tighter or bigger) and nausea & vomiting
Skin: check the surgical site, check for abrasions, ulcers, dry intact dressings, and drains
Kidneys: check for bladder distention, make sure they are voiding at least 30 mL/hr of urine, make sure they are voiding within 6-8 hours
46
When relieving pain and anxiety what should you do
Check pain scale/level
Check anxiety level
Quiet, reduce noise, low light
Give pain meds (opioids IV) and check respirations after
47
When contents/organs actually pop out of the body
Evisceration
48
Opening a wound many times due to infection
Dehiscence
49
Anesthesia by inhalation or IV
Patients under this anesthesia are not arousable
Patients need an artificial airway
General anesthesia
50
Anesthesia injected around the nerves so the region supplied by nerves is affected
Regional anesthesia
51
Anesthesia injected into tissues where the planned incision is located
Ideal for short minor surgeries
Local anesthesia
52
This depresses consciousness and can maintain patent airways
Conscious or moderate sedation
53
What is the purpose of the respiratory system
```
Homeostasis- maintaining internal stability and equilibrium
Gives you a sense of smell
Contributes to speech
Warms and filters air
Gas exchange
```
54
What are the structures of the upper respiratory tract
Nose/nasal passage
-passage of air to and from the lungs
Sinuses
-serves as a resonating chamber for speech, also a common site of infection
Pharynx
- tube like structure that connects the nasal and oral cavities to the larynx
- passageway for the respiratory and digestive tract
Tonsils & adenoids
-encircle the throat, important in guarding the body from invasion through the throat or nose
Larynx
-voice box, connects the pharynx and trachea
Trachea
--windpipe, passageway between the larynx and bronchi
55
What are the structures of the lower respiratory system
Lungs
- elastic chambers enclosed in the thoracic cage
- right lobe consists of upper, middle, lower
- left lobe consists of upper, lower
- the right lung is bigger because the heart is on the left
Pleura
-serous membrane that lines the lungs and wall of the thoracic cavity
Bronchi, bronchioles
- connective tissue containing arteries and nerves
- several within all the lobes of the lungs
Alveoli
-oxygen and carbon dioxide exchange take place here
56
Part of ventilation
(moving air in and out of the lungs)
(CO2 out and O2 in)
when the diaphragm relaxes
Expiration
57
Part of ventilation
(moving air in and out of the lungs)
(CO2 out and O2 in)
when the diaphragm contracts
Inspiration (shorter than expiration)
58
3 normal breath sounds
Vesicular - resting, loud
Bronchovesicular
Bronchial - more after exercise, loud
59
3 abnormal or adventitious breath sounds
Crackles - with pneumonia, sounds like blowing bubbles through a straw into a drink
Wheezing - with asthma, sounds like a creaky door
Friction rubs - pleuritic, sounds like rubbing sand paper together
60
What happens with your breathing as you age
Your alveoli lose elasticity (flexibility/buoyancy), making it harder to move air in and out of the lungs
61
Carbon dioxide is an..
Acid
62
What is respiratory acidosis..
When you hold your breath for longs periods of time, you'll get a build up of acid since carbon dioxide is acid and its not leaving the body if you are holding your breath
63
What is respiratory alkalosis..
When you are anxious, panting, breathing really heavy.. you are blowing a lot of carbon dioxide (acid) out and leaving your insides without acid and high alkaline levels
64
What is pulse oximetry
A noninvasive method to monitor oxygen saturation of blood
Use a pulse oximeter
Normal levels are 95-100%
65
A pulse ox is unreliable or reads inaccurately if..
The patient has painted nails
Poor circulation
Raynauds - blue fingers - may need to warm them up
66
Name diagnostic tests
Pulmonary functions test
-performed to assess respiratory functions and to determine the extent of the issue
Aterial blood gases
-aid in assesing the ability of the lungs to provide adequate oxygen and remove carbon dioxide
Sputum specimens
-best right when you wake up, blow your nose really well, rinse out your mouth because we aren't interested in mouth bacteria)
Chest x-ray
-for pneumonia, COPD
Computerized tomography (CT scan)
- can distinguish fine tissue density
- more detailed than CXR
Magnetic resonance imaging (MRIs)
-no radiation exposure with an MRI
Bronchoscopy
-direct inspection of larynx, trachea, and bronchi
Thorascopy
- Incision through the ribs into the lungs
- fluids and tissue obtained for analysis
Thoracentesis
-Aspiration of puss, infectious fluid, etc. from the pleural space with a tube
Biopsies
-the excision of a small amount of tissue
67
Inflammation of the mucous membranes of the nose, may be infectious, allergic, or inflammatory
-common cold
Rhinitis
68
Inflammation of the throat, usually viral or bacterial
| -can be acute or chronic just like in sinusitis
Pharyngitis
69
Inflammation of the nares and paranasal sinuses, including frontal, ethmoid, maxillary, and sphenoid, sinuses, more formally called rhino___
Sinustis
70
Inflammation of the tonsils, usually due to an acute infection
Tonsillitis
71
Inflammation of the larynx, may be caused by voice abuse, exposure to irritants, or infectious organisms
Laryngitis
72
Most common major suppurative (producing puss) complication of sore throat
Peritonsillar Abcess
73
When your whole body is infected by whatever is causing your infection
Sepsis
74
Middle ear infection
Otitis media
75
What are signs and symptoms of an upper respiratory infection
```
Headache
Cough
Hoarseness
Stuffiness
Generalized discomfort/tenderness
Fatigue
```
76
Interventions to help with upper respiratory infections
Increase fluid intake (2-3L a day)
Rest/comfort & in an upright position to help with drainage
Analgesics to relieve pain - tylenol (not for inflammation)
Not talking, communicate by writing
Gargling
Ice collar
77
Describe live vs. attenuated vaccines
Attenuated are weakened
Pregnant women or immunocompromised patients should not receive live vaccines
A flu vaccine is attenuated
-everyone over 6 months of age needs a flu shot
A flu nasal mist is live
78
Define epitaxis
Hemorrhage or bleeding from the nose
79
Risk factors for epitaxis
```
Drying
Infection
Cocaine
Trauma
Aspirin use
Blood thinners
```
80
How should you care for patient with epitaxis
```
Assess the bleeding
Monitor airways and breathing
Check vital signs
Reduce anxiety
Apply pressure
Tell patient not to:
-tilt their head back
-touch their nose
-blow their nose
```
81
What is TB
an airborne, mycobacterium
82
Signs and symptoms of TB
```
Weight loss
Anorexia
Night sweats
Fatigue
Low grade fever
```
83
What are medications for TB
Isoniazid (INH)
Vitamin B6
Need to be in negative pressure room
*Do not go into room unless wearing special fit mask
84
What is atelectasis?
An alveoli collapse, causing poor air movement
| It is sometimes caused by not being able to breath after surgery
85
Symptoms of atelectasis
```
Cough
Sputum production
Low grade fever
Respiratory distress
Anxiety
Infection
Symptoms of hypoxia
Low O2 saturations
```
86
Ways to prevent hypoxia
Change the patients position frequently, cause them to move
Encourage movement as well, walking
Encourage deep breathing and coughing to mobilize or break up secretions
Incentive spirometer
Opioids to prevent respiratory depression
Postural drainage and chest percussions
Suction to remove secretions
87
Keys to suctioning
Trachea has to be a sterile procedure, the nose or mouth is a clean procedure
Insert on the inhale, not while the patient is swallowing
No more than 10-15 seconds for the entire procedure
88
What are the 2 types of pneumonia (a respiratory infection)
Community acquired pneumonia, way easier to treat
| Hospital acquired pneumonia
89
How would you care for a patient with pneumonia
```
Take vital signs
Remove secretions
Encourage coughing to clear/improve the airways
Postural drainage
Encourage 2-3L of water a day
Humidification of O2
Chest xrays
Sputum samples
Auscultation
```
90
Special considerations for the elderly with pneumonia
They are going to be harder to treat
They are going to have an altered mental status
They are going to have an increased respiratory rate
91
What is COPD?
Chronic obstructive pulmonary disease
- when your airflow is obstructed or limited
- preventable and treatable
92
What could happen to certain COPD patients if given O2
Some patients are sensitive to O2 and increasing their O2 intake may actually cause them to retain too much carbon dioxide
93
What is the strongest predisposing factor for developing asthma
Allergies
94
What are quick relief or short term asthma medications
Taken by patients with acute asthma
Prevents exercise induced asthma
Rescue inhaler: Albuterol
95
What are long term, asthma controlling medications
Usually taken with other meds to control asthma
Not for acute asthma
Used to prevent attacks
Steroids
96
How is peak flow monitoring used for asthma patients
Measures the highest airflow during a forced expiration
| -helps to measure asthma severity
97
Patient teaching for someone going home with long term oxygen
Explain the proper flow rate
The required number of hours to be on oxygen
Dangers of oxygen
98
Patient teaching for incentive spirometers
Sit up straight
Inhale slowly
Cough to clear your lungs when you are done
99
Therapy that is used to remove bronchial secretions, improve ventilation, and increase the efficiency of the respiratory muscles. It includes postural drainage, chest percussion and vibration, and breathing retraining.
Chest physiotherapy
100
A result of decreased effective hemoglobin concentration. This in turn causes a decrease in the oxygen carrying capacity of the blood..
Anemic hypoxia
101
What is apiration
breathing in anything that gets into your lungs
102
How to prevent aspiration
```
Elevate the head of the bed
Keep them in a side lying position
Tube feeding infusion is okay, but hold feeding when putting the head of the bed back down any time
Suction when providing oral care
Speech therapy to help with swallowing
Swallowing evaluations
```
103
What is a pulmonary embolism
An obstruction of the pulmonary atery
-if the clot breaks off it can head to your heart
Usually from the legs
Due to poor blood flow
104
What are risk factors for pulmonary embolism
```
Certain disease states:
Heart disease
Trauma
Post OP
Diabetes
COPD
Pregnancy
Obesity
Oral contraceptives
Constrictive clothing
```
105
Prevention and treatment of pulmonary emboli
Exercise, ambulation
| Anticoagulants (lovenox/heparin)
106
What is sleep apnea
When a person's breathing is interrupted during sleep
107
Risk factors for sleep apnea
```
Sedatives
Smoking
Males
Over the age of 40
Allergies
Family history
```
108
Ranges for hypertension
less than 120/80 - normal
up to 139/89 - prehypertension
up to 159/99 - stage 1 hypertension
more than 160/100 - stage 2 hypertension
109
What is primary or essential hypertension
When you are not sure why you have hypertension
110
What is secondary hypertension
When your hypertension is secondary to something
111
HTN leads to..
```
CVD
Heart failure
Stroke
Kidney failure
Morbidity (diseases)
Mortality
```
112
Specific causes for hypertension (secondary HTN)
```
Kidney disease
Narrowed renal (kidney) arteries
Hyperaldosteronism
Meds
Pregnancy
Narrowing of the aorta
```
113
Clinical findings with HTN
Vision: changes in the retina
CAD: can have chest pain and heart attack
Left ventricle hypertrophy: left ventricle is too big
114
Medications for HTN and side effects
Diuretics and beta blockers
- block sympathetic nervous system which will lower HR and BP
- side effects: hypotension, mental depression, light headedness, nausea, vomiting, GI distress
115
HTN urgency
no organ damage yet
116
HTN emergency
organ damage
- reduce BP by 25% in the first hour
- reduce to 160/100 over 6 hours: gradually
117
olol-
beta blockers
118
semide-
loop diuretics
119
pril-
ACE inhibitor
120
dipine-
Calcium channel blocker
121
thiazide-
Thiazide diuretic
122
statin-
Cholesterol reducer
123
sartan-
ARB (angiotensin receptor blocker)
124
Risk factors for HTN
```
Smoking
Physical inactivity
Overweight
Diabetes
Men over 55
Women over 65
```
