Exam 2✅ Flashcards
Infusion pump
Device that delivers a controlled amount of fluids, liquid nutrients or liquid edications into a client’s body.
Phlebitis
Is characterize by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area.
Infiltration
Is leakage of intravenous solutionsor medication into extravascular tissue. It occurs when the IV catheter is dislodged and fluid infuses into the tissue. It is characterized by edma, pallor, decreased skin temp. Around the site and pain. discontinue IV line and elevate the extremity.
Circulatory overload
Is a systemic complication of IV therapy that causes excess fluid in the circulatory sytem. The characteristics of circulatory overload include dyspnea, elevated blood pressure, edema, moist breath sounds when ausculating the lungs.
Delusions
Beliefs that are not based in reality and that reflects an unconscious need or fear.
Hallucinations
False sensory perceptions: seeing, hearing, smelling, feeling, or tasting objects that are not there.
Perception
Views of oneself and the world, influenced by culture, religion, family, experiences, expectations, and knowledge.
Reticular activating system
Part of the brain respnsible for bringing togethers information from the cerebellum and other parts as well as from the sense organs.
Sensation (sensory) information
Telling a patient what he or she will see, hear, smell, taste, or feel in a particular situation
Sensoristatsis
State of optimal sensory input, which differs for eac perso.
Sensory deprivation
Lack of meaningful sensory stimuli; monotonous input or interference with the processing of information; leads to behavioral changes ranging from boredom to psychosis
Sensory overload
State of arousal in which a person cannot manage the intensity or quantity of incoming sensory stimuli
Sensory perception
The ability to receive sensory input and transform the inputs through various physiologic processes into meaningful information
Accommodation
Test that engages a patient to look at a close object and then look at a distant object to see wheher patient’s pupils constrict to focus on the close object and dialte to see the distant object.
Circulation, motion, sensation (CMS)
A federal organization that pays for healthcare for low-income and elderly people and tracks healthcare outcome.
Expressive aphasia
Communication disorder in which the patient understands and follows directions but cannot verbally aand effectively communicate with the nurse.
Glasgow Coma Scale
Standardized assesment tool used when serial assesments are done for high-risk patients (e.g.; brain tumor, after brain surgery, after a cerebral vascular accident)
Nystagmus
Involuntary, rhythmic oscillations of the eyes
Receptive aphasia
Disorder in which patients cannot understand simple directions
Deliusions
Beliefs that are not based in reality and that refelcts an unconscious need or fear
Hallucinations
False sensory perceptions: seeing, hearing, smelling, feeling or tatsting objects that arae not there.
Perception
Views of onesself and the world, influenced by culture, religion, family, experiences, expectations, and knowledge.
Sensation (sensory) information
Telling a patient what he or she will see, hear, smell, taste, or feel in a particular situation.
Sensory deprivation
Lack of meaningful sensory stimuli; monotonous input or interference with the processing of information; leads to behavioral changes ranging from boredom to psychosis
Sensory overload
State of arousal in which a person cannot manage the intensity or quantity of incoming sensory stimuli
Sensory perception
The ability to receive sensory input and transform the inputs through various physiologic processes into meaningful information
Aphasia
Communication disrder that may affect speech, reading, and writing
Articulation
Enunciation (pronounce clearly) of words and sentences
Attention
Ability to concentrate on and take in specific sensory stimuli.
Cognition
Thinking and awareness; system by which sensory input, past experiences, and emotions are integrated and made meaningful.
Coma
Abnormally deep stupor occurring in illness or as a result of injury; external stimuli fail to arouse the patient
Communication
Interchange of information
Consciousness
State of awareness and full responsiveness to stimuli
Delirium
Reversible disorder of cognition; confusion
Dementia
Cognitive impairment as the result of irreversible organic changes in brain cell function
Comprehension
Capacity for understanding and resoning
Dysarthria
Disorders affecting either single or combined motor control of the muscle speech.
Judgement
Process of reasoning; ability to process incoming stimuli and to determine meanings that encompass many aspects of a situation
Learning
Multidimensional process of acquiring knowledge that depends on symbols, language, classifications, concepts, and other concrete operations along with abstract functions
Memory
Ability to recall a thought atleast once and usually again
Orientation
The basic process by which people know their location in the dimensions of time and place
Perceiving
Process of receiving and interpreting sensory stimuli that function as a basis for understanding, knowing, or learning
reality orientation
Nursing technique to help restore the patient’s awareness of reality
Cranial nerve I
Olfactory; sense of smell
Ask patient to identify mild aromas (ex: vanilla, coffee, chocolate, and cloves)
Cranial nerve II
Optic; vision; ask patient to read Snellen Chart
Cranial nerve III
Oculomotor; pupillary reflex; extraocular eye movement. Assess pupil reaction to penlight. Assess directions of gaze by holding your finger 18inchs from patient’s face. Ask the patient to follow your finger up and down and side to side.
Cranial nerve IV
Lateral and downward movement of eyeball asses directions of gaze. Test with cranial III nerve
Cranial nerve V
TRIgeminal; all three; sensation to corenea, skin of face, nasal (cheek, eyebrows, chin…)
Lightly touch cotton swab to the lateral sclera of the eye to elicit blink (or just ask them to blink). Measure senstaion of touch and pain on the face using cotton wissp
Cranial nerve VI
Abducens lateral movement of eyeall; asses directions of gaze. Test with cranial nerve III
Cranial nerve VII
Facial; facial expression; taste (anterior two thirds of tongue); ask patient to smile, forwn adn raise eyebrows. Ask patient to identify different tatsed on tip and sides of tongue. (Sweet, salt, sour)
Cranial nerve VIII
Auditory; hearing. Assess ability to hear spoken word.
Cranial nerve IX
Glossopharyngeal; taste (posterior tongue), swallowing, movement of tongue. Ask patient to identify tastes on the back of the tongue (salt, sweet, sour). Place tongue blade on posterior tongue while patient says “ah” elicit a gag respnse. Ask patient to move tongue up and down and side to side.
Cranial nerve X
Vagus; swallowing, movement of vocalcords, sensation of pharynx. Assess with cranial nerve IX by observing palate and pharynx move as a patient says “ah”
Cranial nerve XI
Spinal accessory; head and shoulder movement; sk patient to turn head side to side and shrug shoulders against resitance from examiner’s hands.
Cranial nerve XII
Hypoglosssal; tongue position; ask patient to stick out tongue to midline, then move it side to side.
Air embolism
Air bubble in the vascular spacce that may obstruct circulation.
Central venous catheters
A central venous catheter is a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. It is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs.
Colloid
Fluids that contain proteins or starch moldecules
Crystolloid
Fluids that are clear
Electronic infusion device (EID)
A drip chamber aka infusion pump.
Extravasation
When IV solutions inadvertantly leak into the subcutaneous tissues.
Hemolysis
EBC destruction.
Hypertonic
Of greater concentration than in body fluids
Hypotonic
Of lower concentration than in body fluids
Infiltration
Abnormal or accidental seepage or deposition of a substance into the tissues; accidental administration of IV fluids into subcutaneous tissues that occurs when the needle or catheter becomes dislodged from the vein
Intravenous (IV) therapy
Infusion of fluid into a vein to treat or to prevent fluid and electrolyte or nutritional imbalances may be used to deliver medications or blood products.
Isotonic
Osmotic concentration equal to that of body fluids
Needleless connectors
Available to provide access to secondary ports on IV tubing or for flushing access; provide an alteranative to needless to reduce the risk of injury from contaminated sharps during IV procedures.
Osmolarity
Concentration of solutes in a solution expressed as milliosmols per liter
Parenteral nutrition
Nutritional elements supplied through an intravenous route, usually into a central vein
Peripherally inserted central catheter (PICC)
Long-line catheter made of soft silicone or Silastic material that is place peripherally but delivers medications and solutions centrally.
Phlebtis
Inflammation or infection of a vein, manifested by redness, swelling, and tenderness along the course of the vein
Thrombophlebitis
Blood clot that accompanies vein inflammation
Total parental nutrition (TPN)
Administration of hypertonic solutions containing dextose, proteins, vitamins, and minerals to provide for nutritional deficits.
Venipuncture
Insertion of a needle or catheter into a vein
Vesicant
Highly irritating medication that can cause extensive tissue damage when it leaks into the subcutaneous tissues; exampes are chemotherapy and solutions with high or low pH.
Alveoli
Spherical, saclike epithelial structures in the lungs through which gas exchange occurs
Apnea
Absence of respiration; a potentially serious sleep disorder in which breathing repeatedly stops and starts; may be obstructive or central in origin
Arterial blood gas (ABG)
Laboratory test that provides more specific information concerning patient’s acid-base status and response to oxygen therapy./An arterial blood gas (ABG) test measures the oxygen and carbon dioxide levels in your blood as well your blood’s pH balance. The sample is taken from an artery, not a vein, and healthcare providers typically order it in certain emergency situations
Arterial oxygen stauration (SpO2)
Percent of hemoglobin staturated with oxygen; measured by pulse oximeter
Atelectasis
Collapse of alveoli
Bronchioles
Narrow airways that conduct air into alveolar ducts and alveoli/ smaller bronchi
Bronchospasm
Narrowing of the bronchioles caused by tightening of the smooth muscles in the airways
Cyanosis
Grayish, bluish, or purple skin tone
Sign of deprived from oxygen
Diffusion
Movement of molecules from an area of higher concentration to one of lower concentration
Dyspnea
Breathing that requires marked effort/ difficult breathing
EtCO2
(End tidal)ETCO2 is the amount of carbon dioxide (CO2) in exhaled air, which assesses ventilation. So a high ETCO2 is a good sign of good ventilation, while low ETCO2 is bad sign that represents hypoventilation.
Fraction of inspired oxygen concentration (FiO2)
The percentage of oxygen being inhaled; increase with oxygen administration
Hemoptysis
Cough out or spit out blood.
Hypercapnia
Abnormally high carbon dioxide in the blood.
Hyperventilation
Breathing in excess of metabolic demands, resulting in removal of too much carbon dioxide from the blood; indicated by decreased PaCO2
Hypoventilation
Breathing insufficient to meet metabolic demands and adequately remove carbon dioxide from the blood indicated by elevated PaCO2
Hypoxemia
Below normal amount of oxygen in the blood
Hypoxia
Decreased amount of oxygen available to the tissues
Oxygen saturation
Amount of oxygen in the blood
Partial pressure of carbon dioxide (PACO2)
The pressure exerted by carbon dioxide gas on surrounding structures; may be measured in the alveolus (PACO2), artery (PaCO2), or vein (PvCO2)
Partial pressure of oxygen (PAO2)
The pressure exerted by oxygen gas on surrounding structures; may be measured in the alveolus (PAO2), artery (PaO2), or vein (PvO2)
/ The partial pressure of oxygen, also known as PaO2, is a measurement of oxygen pressure in arterial blood. It reflects how well oxygen is able to move from the lungs to the blood. It is often altered by severe illnesses.
Pulse oximetry
uses infrared light and a sensor attached to the patient’s finger or earlobe to determine the percentage of hemoglobin that has combined with oxygen
Splinting
Use of a pillow to immobilize a wound when a patient has had abdominal or thoracic surgery
Tracheostomy
Permanent or temporary opening into the trachea through the neck
Ventilation
Movement of air in and out of the lungs; breathing.
Oxygen flow meter
The flow meter attaches to the oxygen ooutlet and regulates the amount of oxygen delivered to the client. It is important to confirm that the flow meter is atteached to the oxygen outlet (green oxygen label) and not the air outlet (designated by a yellow lable) before initiating oxygen therapy.
Nasal cannula
Common oxygen-delivery device consisting of a length of tubing with two small prongs that are inserted into the nares. Delivers concentrations of 24%-44% with flow rates from 1-6L/min. The exact concentration inspired depends on the flow rate, the client’s rate and pattern of breathing and the depth of respirations. Nasal cannula is usually used for clients who are noncritical with minor breathing problems and for clients who cannot or will not wear an oxygen mask; administers low-flow oxygen. Humidifier is not usually required, unless the flow exceeds 4 L/min.
Simple face mask
A fairkt high oxygen flow to prevent rebreathing of CO2. (Has holes on the side for CO2 to escape). And acurate FiO2 is difficult to estimate. A simple mask is usually used for clients who require a moderate flow for a short period of time. Can deliver 40%-60%. Of oxygen with a flow rate from 5-8 L/min. Consider humidification to keep client’s mucous membranes from becoming dry.
Nonrebreather mask
Is used to deliver high flow rates and high concentations of oxygen. The reservior bag allows a higher FiO2 to be administered. At flow rates slower than 6 L/min, the risk of rebreathing carbon dioxide increases. A valve closes during expiration so that exhaled air does not enter the reservoir bag and not rebreathed. The valves on the side ports of the mask allow exhalation but close on inspiration to prevent inhalation of room air. This provides the client with an oxygen concentration of nearly 100%.
Nonrebreather mask can deliver oxygen concentrations of 80-95% with flow rates 10-15 L/min.
- don not allow the reservoir bag to deflate or the oxygen source to deplete. Of the bag deflates, the oxygen source diminishes; the client will likely to breathe large amounts of exhaled CO2.
Venuri mask
Delivers fixed FiO2. The FiO2 depends on the flow rate or entarinment port size. Used for clients who have COPD when an acurate FiO2 is essential and CO2 buildup must be kept to a minimum. Humidifiers are usually not used with this devicce. I often used for clients who are critically ill and require administration of a specific concentration of oxygen.
- holes on each side to allow exhaled air to escape.
- the base of tthe mask gas a color coded adaptors. Each adaptors indicates which specifiic oxygen concentation the client will receive and at what flow rate to set the oxygen (different manufacturers may use different colors for adaptors, so alyws check the oxygen perscription and look carefully to see which adaptor should be used. )
- deliver accurate oxygen concentrations from 24-50% with flow rates from 4-10 L/min.
Face tent
Soft aerosol mask fits loosely around the client’s face and neck. For clients hwo feeel claustrophobic. Oxygen conccentration cannot be controled. Face tents are often used after nasal and oral surgery delivers 24-100% with flow rates of at least 10 L/min.
Manual resuscitation bag
Is used to provide high concentrations of oxygen to a client prior to a procedure (suctioning, intubating) and during respiratory or cardiac arrest. It can also be used to assit clents who are not breathing but not adequately. The bag has an oxygen port where oxygen tubing can be connected; flow meter is usualy set 10-15 L/min when performing manual resuscitation.
Tracheostomy mask/ tracheostomy collar
A small mask that fits over the client’s tracheostomy site. The maskhas an exhaltaion port that remains patent at all. Times and a pirt that connects to the oxygen source with large-bore tubing. The flow rate is usually set at 10 L/min with a neubulizer set at the apporpriate oxygen concentration.
T-peice
T-shaped adapter used to provide supplemental oxygen to an endotracheal (ET) or tracheosotomy tube. It is connected to oxygen source to the artifcial airway (ET or tracheostomy). Fow rate is usually 10 L/min with neubilizer set at the appropriate oxygen concentration.
Mechanical ventilation
Is used to maintain positive airway pressure and to improve alveolar ventilation without the need for an artificial airway/ breathing assited by either a positive or negative pressure device. Commonly used for clients with congestive heart failure, sleep disorders, and pulmonary diseases to improve oxygenation, reduce and reverse atelactasis, reduce pulmonary edema, and improve cardiac function.
Two types of noninvassive ventilation are continuous positive pressure (CPAP) and bilevel positive airway pressure (BiPAP).
CPAP
Continuous positive pressure ventilation provides airway pressure througght the client’s breathing cycle. Commonly use for patients with sleep apnea… the continuous positive pressure prevents the upper airway from collapsing.
BiPAP
Provides assitance during inspiration and keeps the airway from closing during expiration. It increases the amount of air in the lungs at the end of expiration reduced airway closure and improved oxygenation.
Extravasation
Similar to infiltraition, but extravasation can occur is the solution that leaked into the tissue contains a vesicant (vesicant medications and solutions are: chemotherapeutic medications, vancomycin, dopamine, adn digoxin).
-blistering of the skin, tissue necrosis, and ulceration can occur.
Speed Shock
Occurs when a client recieves an intravenous medication too rapidly, causing dizziness, chest tightness, flushed face, and other effects related to a toxic level of medication in the body.
Angina
Pain a nd discomfort about the heart, characteristic of myocardial ischemia; severe pain felt in the anterior chest, shooulder, left arm, neck and jaw.
Angina is where you have attacks of chest pain caused by reduced blood flow to your heart.
Automaticity
Heart’s capabilty of enerating its own elcetrical impluse, which is then conducted through specialized conduction fibers
Cardiac biomarkers
Proteins that are released from cells when tissue damage occurs. / Cardiac biomarkers are substances that are released into the bloodstream when heart muscle is damaged or stressed
Cardiac output (CO)
The amount of blood pumped by the heart each minute.
Contractility
Force of contraction
Diastole
Period of rest in the cardiac cycle, when the ventricles are not contracting and the coronary arteries are filling with blood
Dysrhythmia
Abnormality in hearth rhythm.
Endocardium
The innermost layer of the heart
Epicadium
The outer layer of the heart.
Intermittent claudication
Limb (arm or leg) pain cause by poor blood flow./
- Intermittent claudication is muscle pain that happens when you’re active and stops when you rest. It’s usually a symptom of blood flow problems like peripheral artery disease. Over time, this can get worse and lead to serious health problems and complications
Ischemia
Insufficient blood supply to a body part due to obstruction of circulation.
Metabolic Syndrome (syndrome X)
A genetic metabolic disorder characterized by diabetes, hypertension, atherosclerosis, centrally disturbed obesity, and elevated blood lipids.
syndrome X) is a clustering of problems associated with resistance to insulin and/or hyperinsulinemia
Myocardial Infarction (MI)
Ischemia of heart muscle and death of portions of the heart muscle from the decreased blood flow through the coronary arteries.
Myocardium
Layer of cardiac muscle that forms the walls of the heart
Perfussion
Passing of blood through an area.
Sequential compression devices (SCDs)
Devices tat sequentiality compress veins in the legs to promote venous return.
Shock
Severe circulatory insufficiency
Ex: the inability of an organ to perform its normal function: renal insufficiency.
Stroke
Cerebrovascular accident (CVA); involves a sudden onset of hemorrhage, blood clots, or other vascular lesions, causing damage to the brain
Syncope
A temporary loss of conciousness or fainting spell that may signal decreased perfusion to the brain.
Systole
Period of contraction of the ventricles
Transient ischemic attack (TIA)
Temporary cerebral ischemia due to transient (lasting only for a short time) interruption in blood supply.
is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and doesn’t cause permanent damage. Often called a ministroke, a transient ischemic attack may be a warning
Pfeiffer Mental Status
To provide an objective assessment of cognition; to alert health care personnel of changes in cognitive function.
A score of 7 or less indicates significant cognitive impairment.
Ex: what’s it days date
What day of the week is is?
How old are you?
Mini-mental StateExamination
To provide an objective assessment of cognition; to alert health care personnel of changes in cognitive function • Scores of 20 or below indicates significant cognitive impairment
Glasgow Coma Scale
To provide an objective assessment of consciousness; to alert health care personnel of changes in level of consciousness • Glasgow Coma Scale Scores of 13-15 correlate with mild brain injury, 9-12 with moderate brain injury, 3-8 with severe brain injury.
Romberg test (balance)
Stand with eyes open with feet together, but if they close their eyes, do they start moving around?
Rapid Alternating Movements
Have them place their hand on thigh and rapidly flip them over repeatedly .. or do finger touching with their thumb to each finger
Hemiplegia
Paralysis on one side of the body; usually caused by a stroke.
Paraplegia
paralysis of the legs and lower body, typically caused by spinal injury or disease.
Quadriplegia
paralysis of all four limbs; tetraplegia.
Quadriplegia happens when the damage is at the base of the neck or skull. The most common cause is trauma, such as from a sports injury, car accident, or fall. Other causes are: Multiple sclerosis.
Difference Between PAO2 and SAO2
The partial pressure of O2 (PAO2) is the pressure exerted by O2 on the arterial walls while saturation of O2 (SAO2) is the overall percentage of hemoglobin binding sites occupied by O2
What is the Difference Between SAO2 and SPO2
The main difference between SaO2 and SpO2 is that SaO2, or the arterial oxygen saturation, is the percentage of hemoglobin molecules in the arterial blood saturated with oxygen, but SpO2, or the peripheral oxygen saturation, is the percentage of hemoglobin molecules in the peripheral blood saturated with oxygen. Furthermore, SaO2 can be measured by blood gas analysis, while SpO2 refers to the SaO2 measured by the pulse oximeter
