Exam 2 Flashcards
When do we asses vital signs? (5)
-On admission
-Any change in the health status
Immediately before and after surgery/invasive procedures
-Before giving certain medications
-Before and after nursing interventions that could affect vital signs
What are some factors that can affect vital signs?
-age
-gender
-race/hereditary
-medication
-exercise
Thermoregualtion deficiencies are common in what pts
Elderly and newborns
What may contribute to the development of hyperthermia ?
Exercise, activity and dehydration
When can you check for the highest and lowest temp
In the evening/night 8pm and 12mn
Early 4-6 am
Define body tempt and the various sites
It’s the balance between heat produced and heat loss from body
Oral recital axillary
What are some examples of contra indications for rectal thermometer
Recital surgery ,
new born ,
rectal bleeding,
cardiac disease or surgery ,
low wbc- neutropenia
low platelets count
Body temperature
Normal
Hypothermia
Hyperpyrexia
96.4-99.5
Below 96.4-
Hyperthermia- fever 100.8- 105.8
Greater than 105.8
What are some contraindications for oral temperature
Dyspnea
Unconsciously
Disorientation
Infants/children
Oral surgery
Oxygen mask
Within 15-30 min of drinking hot/cold , smoking chewing gum or candy
What’s the difference between febrile and a febrile
Fever vs non fever
What are the signs of fever?
Loss of appetite
Hot/dry skin
Thirst
Muscle aches
Fatigue
Respiration/pulse increase
Confusion in older adults
Imbalance in fluid/electrolytes
What are some interventions for pt with fever
Minitor temp /vitals
Check insensible water loss
Check level of consciousness
Monitor wbc, c &s lab values
Monitor inputs/outputs
Oral hygiene
Encourage fluid
Medicate with anitpyretics
Tepid sponge baths/cool packs
Monitor electrolytes
What are the 3 mechanism that involves hypothermia
Excessive heat loss
Inadequate heat production
Impairment of the hypothalamic thermoregulation
Heat loss from skin and respiratory tract
Signs of hypothermia ( body temp)
Decreased temperature
Severe shivering
Pale waxy skin
Increase bp ???
Disoriented
Drowsiness, lethargy coma
Poor muscle control
Decrease urinary output
What are some interventions for hypothermia
Monitor temp every 2 hrs
Administer blankets
Administer warming blankets as per md order
Admin warm fluids
Assess vitals frequently
Instruct pt to avoid extreme temperatures and dress adequately
What are the peripheral pulses
Temporal
Carotid
Brachial
Radial
Femoral
Popiteal
Posterior tibial
Pedal ( dorsalis pedis )
What are the pulse and respiration parameters
Adult
Aged adult
60-100 (80
40-100( 70
Factors of tachycardia
Pain
Strong emotions
Anxiety
Exercise
Prolonged heat exposure
Decrease bp or volume
Medication
Factors that effect bradycardia
Slow pulse at rest
In general male have slower pulse rate than female
Found in athletes
Medication such as beta blockers
Hypothermia
During sleep
Tell me about digoxin
Digoxin
Classified: cardiac glycosides
Increased contractility with increase co
Monitor electrolytes
Monitor therapeutic drug level
Know signs and symptoms of toxicity
What’s included in the upper and lower respiratory (
Mouth nose pharynx larynx
Trachea
Bronchi
Bronchioles
Alveoli
Pulmonory capillary
Pleural membranes
Oxygen transport
Transporter from the lungs to the tissues
97% of oxygen combines with hemoglobin in red blood cells and Carrie’s to tissues as oxyhemoglobin
Remaining oxygen is dissolved and transported in plasma and cells
( perfusion ? )
Carbon dioxide transport
Must be transported from the tissue to the lungs
Continually produced in the process of cell metabolism
65% is carried inside the red blood cells as bicarbonate
30% as catbheglobin
5% transported in solution in plasma and as carbonic acid
Diffusion ?
What’s the process of inspiration
Air flows into the lungs
Diaphragm and inter coastal contact
Thoracic cavity size increases
Volume of lungs increases
Intrapulmonary pressure decrease
Air rushes into the lungs to equalize pressure
Process of exhaling
Diaphragm and intercostals relax
Volunteer of lungs decrease
Intrapulmonary pressure rises
Air is expelled
Depth
Generally described as normal deep or shallow
Hypoventilation
Hyperventilation
Rhythm
The regularity of expiration
Normal rhythm is evenly spaced
Generally described as regular or irregular
Abnormal breathing patterns
Kussmsul’s breathing: blowing it puffing , deep rapid breathe ( metabolic acidosis blowing off co2
Cheyene strokes respiration: rhythmic waxing and waning of breaths from very deep to very shallow and temp apnea
Biot respiration: irregular, varying depths and rate followed by apnea
Hypercapnia: abnormal High level co2
Hypoxia ( oxygen)
Condition of insufficient oxygen anywhere in the body
Rapid pulse
E
Slid shallow respiration & dyspnea
Flaring of Nare’s
Cyanosis
Substernal or intercostal retractions
Obstructed or partially obstructed
Partial obstruction indicated by low pitch snoring during inhalation
Complete obstruction indicated by extreme inspiratory effort with no chest movement
Accessory to act “ use of accessory muscle can enhance lung expansion with oxygen drops ( copd)
COPD
Group of disorders characterized by impaired airflow in lungs
Asthma: bronchospasms , swelling of mucous membranes airway obstruction
Emphysema: inflammation of bronchial walls causes thickening and increased mucus
Chronic bronchitis: inflammation of bronchial walls causes thickening and increase mucus
Atelectasis: condition in which one or more areas in lungs have collapsed and can’t inflate properly
Nursing interventions to promote respiratory function
Ensure a patent airways
Positioning
Encourage deep breathing, coughing
Instruct pursed lip breathing or diaphragmatic breathing ( ob disease )
Adequate hydration
Assess vitals
Education: no smoking
Pain control
Ambulation
Monitor lab Val’s
How to promote respiratory functions
Medications ( nebulizer, steroids vaccines
Incentive spirometry
Chest pt
Postural drainage
Oxygen therapy
Artificial airway
Airway suctioning
Chest tubes
Meeting oxygen needs
Oxygen is considered a medication
No smoking
Avoid using oils in nasal area/body area
Avoid synthetic fabrics
Check flow meter rate
Nasal care
Humidication ( 4 or more l )
Check electrical equipment and make sure oxygen is attached to canister
Oxygen delivery system table
Nasal cannula : most commonly used
Simple mask
Partial rebreather
Nonrebreather mask: delivers highest concentration of oxygen
Venturi mask : most precious concentration of oxygen
What are some diagnostic test for oxygenation (6)
Pulse oximetry
Pulmonary function test:
Spirometer
Peak expiratory flow total lung capacity
Complete blood count ( cbc)
Arterial blood gas ( abg)
Chest radiography
What are the 3 physiological factors that influence blood pressure
Cardiac function / pumping of heart
Peripheral vascular resistance
Blood volume
Cardiac function
Stroke volume:
Cardiac output:
Stroke volume : quantity of blood flowing out of the left ventricles with each contraction
Cardiac output: the volume of blood pumped by the heart per minute
Co = sv times heart rate
Increase in co
The heart’s pumping action is strong and the volume of blood pumped into circulation increases
Condition that increase co causing increase bp
Increased blood volume as occurs during pregnancy, fluid retention
More forceful contraction of the ventricles as occurs during exercise
Decrease in co
The pumping action of the heart is weak
Less blood is pumped into the arteries
Causes decrease in bp
*conditions that decrease co include
Dehydration
Active bleeding
Damage to the heart
How does the vascular resistance effects the diastolic pressure causing increase in bp
Blood viscosity
Arterial size
Arterial compliance ( elasticity)
Blood volume :
Increase blood volume increase in blood pressure
Decrease blood volume decrease bp
Medications used for hypertension
Thiazide diuretics: hydrochloride (first line )
Loop diuretic: furosemide
Beta blockers: metoprolol
Ace inhibitors: enalapril ( first line )
What’s the difference between a drug and a medication
Any substance that positively or negatively alters physiologic functions
A drug specially administered for its therapeutic effect on physiologic function
Tell me about therapeutic
It cure, treatment or relief of symptoms diagnosis treatment and prevention of disease
Synthesized in the laboratory developed from plants mineral or animal sources
What do know about each medication
Generic name
Trade name
Route
Classified
Indication
Therapeutic action/goal
What is pharmacokinetics 4 phases
( Adem)
Metabolism: how it’s broken down,
Absorption : how will it get inside ( drug dose drug form, blood flow site and condition of absorbing surface )
Distribution: where will it go ( transport )
Excretion: how fast it leaves ( lungs gi breast milk saliva and feces )
Principles of med admin via gi tube
Elevate head of pt bed
Check placement , residual and patency
Use liquid meds when possible
When crushing meds ensure they are okay to be crushed ( no capsule or sustained release meds
After feuding mix one medication at a time with 15-30 ml of water and give each medication one at a time
Flush tube with 15-30 ml water before and after each administration
Most common route for parental injection
Sq
I’m
Intradermal
Intravenous
What are complications with distribution?
The availability can be limited by the body through barriers, blood /brain Barrier and placenta
Drug that binds with plasma protein can be prevented from immediately reaching tissue
Metabolism
Biotransformation of drugs
Mainly done by liver
Enzymatic effects cause drugs to be changed into a form more easy to excrete
P450 is one of the primary enzymatic pathways in the liver for drug transformations
First pass effect : most oral med experience this by going directly through propel circulation, inactivating much of a drug
Excretion
Process of removing the drug or it’s metabolites form body
Done primarily by kidneys
Renal impairment = decreased excretion of the medication and increase risk of toxicity
Poor kidney function requires low speeded of many meds
What is pharmacodynamic
The process by which drugs alter cell physiology and effect the body, these processes include:
Receptor agonist ( actives )
Receptors antagonist ( blocks)
Drug enzymatic actions
Therapeutic drug actions
Occurs by maintaining constant drug level in body
Half life : expected time for the blood concentration to measure one half of the original doe due to elimination
What is the therapeutic range
Serum level of concentration of the drug that produces desired effect without toxicity
Onset of action: time takes body to respond after administer
Peak : highest plasma concentration
Trough: lowest plasma concentration
Elder consideration
Altered memory
Decreased visual acuity
Decrease in renal function
Slow absorption from the gi
In creation proportion of fat to lean body mass
Decreased liver function decrease organ sensitivity
Altered quality of organ responsiveness
Decrease in manual dexterity
What are side effects vs adverse
Predictable but unwanted, sometimes unavoidable reactions to meds
Adverse : severe unwanted unpredictable drug reaction
May occur after 1 dose ( sever allergic response )
May occur over time ( eg anemia )
Allergic reaction: unpredictable immune response , rash hives runny nose
Anaphylactic reaction: severe allergic reaction and a medical emergency
Adverse drug cont.
Some can be predictable and manageable (side effects )
Others more serious allergy ( anaphylaxis) toxicity
Drug tolerance, drug to drug interactions and idiosyncratic effects are also possible adverse effect
Toxic effects:
Results form medication overdoes or buildup in the blood due to impaired metabolism and excretion
Medication interaction
Medication interaction is modified by the presence of another medication or food or herb
Synergistic: combined effect is greater than effect of each alone
Antagonist: drug effect is decreased when taken together greater poly pharmacy , greater herbal supplement
Signs of drug allergy
Rash
Urticaria
Fever
Diarrhea
Nausea
Vomiting
Original source of drugs
Plant
Animal
Minerals
Intradermal route :
Forearm, upper back, and scapular
Tb syringe
1 ml
5-15 degrees
Usually less than 0.5ml ( 0.01_ 0.1)
For allergy and skin sentivity
Sq route
Upper arm , abdomin, upper back and the upper dorsogluteal area
45-90 degree ( 1ml)
Syringe: 25 gauge 5/8 to needle ( no aspirating )
Heparin( 2 inch away from navel ) and insulin
What are the 2 types of carbohydrates
Simple : mono and disaccharides sugar
Complex : starch : bread rice pasta ( takes longer time to break down
What are the macro and micro nutrients
Carbs protein fats
Water
Vitamins
Minerals
Water
Where does the body store extra sugar
Liver
How much percent of our body is made of water
60%
How does water contribute to the overall health (5)
Regulates body temp
Excrete waste products
Digestion
Absorption
Transportation
Rda: 8-12
What are the complete and incomplete protein
Complete : meat dairy products , egg ( animal based) plant base ( soybean)
Incomplete: lacking 1 or more amino acid, need to or more incomplete to make complete
Eg beans, peas, nuts, seeds and grains
What’s the difference between saturated and unsaturated fact
Saturated us solied at room temp, fatty foods, bad bad , raises cholesterol serum
Unsaturated: good fat, liquid , lowers cholesterol serum
Mono: oils
Poly: corn, soybean , fish hearing
Lab values for cholesterol
Good greater than 60
Bad is less than 100
Total is less than 200
Elevated levels = atherosclerosis
What are the importance of proteins ?
Makes enzymes/hormones
Build muscle
Energy
Building block for amino acids
Must consume DAILY ( excess not stored
What happens to amino acids in the liver ?
It gets recombined into new proteins
Difference between catabolism vs anabolism
Breakdown of the complex substances into simpler ones = release energy
Synthesis simple substances into more complex substances = provide e gweh needed for tissue growth, maintence and repair
What are the fat soluble and water soluble vitamins?
Adek ( stored)
Vitamin c , b ( cannot be stored)
Most vitamins are active in the form of what?
Coenzymes
Classified at water or fat double
Absorbed through intestinal wall directly to bloodstream
What are some examples of macrominerals and micro minerals
Calcium, phosphorus and magnesium
Iron zinc magnenses and iodine
What vitamin helps to absorp iron?
Vitamin c
Iron is needed to make RBC
Takes on empty stomach
Osteoporosis
Bone weakening
1 in every 4 women over 60
Bone loss begins at 40
Menopause increase bone loss
Excercise and calcium intake for prevention
What are some ways to boast immune system
Vitamin c d selenium zinc
Hydration
Probiotic foods
Colorful foods: lean protein
High fiber diet
What’s the health weight standard
18.5 - 24.9
What are some indication of poor nutritional standard / health problem
Albumin level
Significant intention and unintentional chnage is weight
What does a clear diet consists of and what pt would it be appropriate for
Teas/coffee
Broth /jello
Short term
Provides sugar and fluid ( limit nutrients )
Reduce gi stimulation
Pt from surgery would get this diet
Full liquid diet
Foods and liquid
Liquid at room temperatures ( ice cream and yogurt )
Short term , Low protein
Pt who are acutely I’ll
( post operative progression
Soft diet
Minimum chewing
Provides more calories than full
Adequate in all nutrients
Individual with poor dentition , trouble breathing
Dysphasia
Trouble swallowing
Diagnose by speech therapist
Need thick fluids ( avoid aspiration )
Thin
Nectar
Honey like
Spoon thick
What is the dash diet
Approach dietary approach to stop hypertension
Low sodium and cholesterol
What’s the restriction on a renal diet
(3 ps)
Potassium protein sodium , phosphorus
What are some signs of malnutrition in pts
Brittle nails and hair , underweight , dry skin, strawberry tongue , red cracks at the sign of mouth
Overweight and underweight
What are the two types of diabetes
( have mela ready for pt getting insulin )
Type 1 : need insulin injections
Type 2: oral hypoglycemic
High risk for blindness, renal failure, poor wound healing neuropathy
Hypoglycemia
Early symptoms: shakes headaches , feeling hungry
15/15 rule
Blood sugar less than 50, glucagon ( injection )
Hyperglycemia
Thirst
Increase urination
Change in mental status
Fruity breath
Vision disturbances
Rule 15
1 tbs sugar or jelly
3-4 glucose tabs
4 oz of juice
5-6 oz of soda
7-8 gummy/life savers
Diabetic lab Val’s
4- 5.6 ( normal )
Over 5.7 to 6.4 is at risk
6.5 and above is diabetic
Goal for diabeteic is 7 %
8-9% is poorly managed
Anthropometric measurements
Height
Weight
Triceps skin fold
albumin, (3.5- 5.5) cholesterol ( good is over 60 , bad is less than 100,
, glucose ( 70-110)
Bun 7-20
creatinine male 0.6-1.2 female 0.5-1.1
Indirect measure of protein and fat stores
What does the nasal intestinal tube avoid?
Potential gastric reflex
But cause dumping syndrome
What pt benefits from peg tube
Comatose
Long term use
Minimize aspirations risk
What is the preferred method for gastric feeding ?
Intermittent
How often do we check residual ?
4-6 hrs
Goals is 50ml or less
Residual less or equal to 100 ml can be returned , may require further assessment
Intramuscular route
( hormones vaccine and antibiotics)
Deltoid : 1ml ( 5’8 to 1 1/2)
Needle 1-1-12 inch 20-25 gauge
( 3 -4 fingers beneath acromial process )
Rectus femoris
Anterior aspect
Ventrogluteal 3ml
Gluteus medias 3ml
( finger on anterior superior illiact spine , spread middle finger along illiact crest
Hold skin taut
What are some therapeutic measures to promote respiratory function
Pulse oximeter
Medication : steroid , nebulizer , mdis dpis
Incentive spirometer: help pt with respiratory disease and post op
Chest pt
Postural drainage: position and coughing to get out mucus
What is onset of action?
Time it takes the body to respond after administer
What does a high or low pulse indicate?
What’s the difference between pharmacodynamics and pharmakenetics?
Process in which the drug alter cell physiology and affect body
Refers to the effect the body has on the drug once the drug enters
Assessing blood pressure?
Width 40% circumference of arm
Bladder should cover 2/3 of arm
Korotkoff sounds crescendoing 5 phases
Oxygen requirement
Nasal cannula
Simple
Non rebreather
Venturi
1-6 l/min greater that 3 gets humidified
Never apply mask less than 5L/min ( risk of retaining co2 6-10 L/ min
Highest concentration, one way valve prevents rebreathing expired air from resolver bag 10-15L/ min
Venturi most precise , 4-6 L/min
Pharmaceutical vs therapeutic class
Refers to the mechanism of action, physiologic effect and chemical structure of the drug
Clinical indication for the drug
What is medication reconciliation?
The process of comparing a pt medication orders to all medications that the pt has been taking
Done every transition of care ( this include change in setting service practitioners to level of care
What do we asses for in regards to meditation?
Prescribed vs otc
Herbs
Allergies
Vision
Swallow
Pregnancy and lactation status
Culture and lifestyle
Cognitive and sensory status
Head to toe assessment
Labs
What are some nursing dianoses for med admin
Knowledge deficit
Ineffective therapeutic regimen management
Ineffective health maintenance
Dis tuned sensory perception
Impaired swallowing
Impaired me memory
Noncompliance
Outcome identification
Client teaching needs
Purpose of the meds
Compliance with schedule
Instruct in self monitoring for side effects
Potentiometer for interaction form otc meds
Assess the support system client has at home for discharge planning
Physiological response to medication
What are the assemble equipment
Medication card
Disposal medication cups/meds
Mar or computer printout
Pill crusher
Straw/drinking glass
Required syringes
Alcohol swabs
Gloves
Syringes disposal container
What are some implementation
Observe asepsis
Provide pt privacy
Perform assemseent as indicated
Use critical thinking skills
Follow preparation procedures
Observe any special instructions for soeric meds
Consult drug guide as needed
Educate pt
Administer as directed, provide assistance to clients where necessary
What does evaluation look like
Readers vital signs
Conduct appropriate follow up
Evaluate as an on going process
Report deviations from normal to the md
3 step approach to pain meds
1-3 pain scale is non opioid with/without coanalgesic
Moderate 4-6 weak opioid with /without non Opiod
Severe is 7-10 strong opioid around the clock scheduled doses
Opiod side Effects (8)
Respiratory depression
Sedation
N/v
Urinary retention
Blurred vision
Sexual dysfunction
Constipation
Pruitus
Define drug dependence
Norma response that occurs with repeated admin of Opiod for 2 or more weeks,
Manifest by occurrence of withdrawal symptoms
Define tolerance
Norman response that occurs with regular admin of Opiod and consists of decrease in one or more effect off the option ( sedation or analgesia )
Need more to have same effect
Opiod addiction
Diseases influenced by genetic , physiological and environmental factors
Hypotension vs hypertension
Hemorage /shock
Heart attack or heart failure, orthostatic bp age immobile , medication , dehydration
Symptoms: dizzy light headed
Primary or essential ( hypertension )
Secondary to another disease
Risk Factor for for stroke
Severe headache , Hight blood pressure fatigue
Drug enzymatic action
Bind an act on their target cell with specificy
Diabetic diet
Consistent carbs no concentrated sweets
What are the cardiac drug?
Morphine
Oxygen
Nitroglycerin
Aspirin
Direct affect on respiration
Less than 12? Hold meds
Oxygen meds
Bronchodilator: albuterol ( tachycardia)
Expectorant: make them cough up sputum , make sputum more mucus like
Suppressant: steroid, pretezone ( retain water
Nebulizer
What’s the steps in making an medical error?
Check pt condition immediately
Notify the nurse manager and pcp
Report incident using hospital policy
What are the pt expectation in administering self meds?
Know how and when to admin med
When to notify hcp
Expected and adverse effects
What does macronutrients and micronutrients do?
Macro supple the body’s energy while micro regulate body processes
BMR vs BMI
Energy required to carry out involuntary of the body at rest
The preferred method of ideal body weight for adults and children ( ratio of weight to height)
What are the groups that have limited BMI
Athletes,
people with edema,
Dehydration
Older population with low muscle mass
What are the calories per gram for carbs/ protein and fat
4/g 45-65% total cal for adults
4/g 10-35% of total cal for adults
9/g less than 10% should be saturated m
95% of fat in our diet ate from triglycerides
What lab Val’s are good indicator of malnutrition
Bun : reflects protein intake and body’s ability to detoxify and excrete the metabolic byproducts
Creatinine: levels are directly proportional to body mass
What’s the norm residual
Less than 10ml
Residual as much as 50ml may indicate upward displacement into the stomach
Rapid distribution vs slow
Heart liver kidney and brain
Muscle skin and fat
Therapeutic index
Is the ratio of its toxic level to the level that provides therapeutic benefits
Lab Val’s for warfarin
On : 15.5- 30 sec ( pt)
Off: 11-13.5
Inr : on 2.3
Off: 0.8-1.1
Hgb and htc%
Female 12-15 ( 36-44%)
Male 13.5 -16 ( 41-50 %)
RBC vs wbc
4.5-5.5 mill
4.5-11 billion
Heparin lab Vals
Normal ptt 30-40 sec
On : 45-100 seconds
What lab Val indicate a pt at risk for diabetes
5.7- 6.4
Absorption is determined by?
Route
Lipid solubility
Ph
Blood flow
Local contains at the site
Dosage
Alt asl lab Val ?
7-56 units per L
10-40 United per L
Carbs and fats rda
45/65 225-325 gm
25-35 cal ( recommend less than 10 %)
Types of fever ?
Intervention for bp
Dash diet
Weight loss
Na restriction and k supplements
Increase physical activity
What should you do if you notice the pt does not have gag reflex
Put on npo diet , then notify health care
How much inch do we insert for rectal temp
2.5 cm , 1 inch
What do you do incase of pulse deficit
We would reassess, before hcp
Tell me about nitroglycerin
It’s sublingual, dissolves quickly , it’s for angina ( chest pains )
You can take up to 3
If no change than emergency room could be progressing heart attach
Phebetis, vs infiltration
Cool then warm compression
Use warm , elevate arm
If temp is 101 what med would you give?
Teynol
What lab Val would you check for antibiotics
Complete blood count
When would you administer the humidifier
4L or more
How often do you change the in bag?
Change back 24 hrs,
Risk factors for hypertension
Smoking
Obesity
Sedative lifestyle
What’s an early sign of dig
Bradycardia
What position prevents aspiration
Sims position or side lying
Opiod addiction risk factors
Genetic, psychological and environmental
Purse lip breathing
Prolongs expiration
For stroke
Be fast
Balance
Eyes
Face
Arm
Speech
T time
