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3346 NURS > Exam 3 NURS 3346 > Flashcards

Exam 3 NURS 3346 Flashcards

1
Q

Acute Pain

A 
o	Acute <3 months
	Protective
	Focused at site of injury
	Self-limited
	Few psychological implications
	Relieved with treatment of underlying disease
	Recovery expected
	Activation of sympathetic nervous system (SNS)
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2
Q

Chronic Pain

A 
o	Chronic >3 months
	No biological benefit
	It is the disease
	Pain without injury
	Unrelenting 
	Psychological implications
	Treatment focused on symptom management
	Fair to poor chance of recovery
	Adaptation of the SNS
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3
Q

Referred

A

feel pain not at the site of origin

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4
Q

Radiating

A

start at site of origin and move out

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5
Q

Superficial

A

pain resulting from stimulation of skin

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6
Q

Deep visceral pain

A

pain resulting from stimulation of internal organs

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7
Q

Numerical Pain Scale

A

0-10 scale

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8
Q

Wong-Baker Faces Scale

A

Helpful with kids, people with other languages. People need to be cognitively aware of what 0-10 means

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9
Q

Richmond Agitation and Sedation Scale

A

+4 Combative to -5 Sedation

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10
Q

Behavioral Indications

A

 Vocalization
 Facial expressions
 Body movement
 Social interaction

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11
Q

Barriers to effective pain management

A

o Misconcenptions about pain
o Lack of knowledge
o Cultural beliefs about pain and pain interventions
o Controversy among healthcare providers

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12
Q

Complications of ineffective pain management

A

Undertreatment of pain can cause increased anxiety with acute pain and depression with chronic pain

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13
Q

• Identify non-pharmacologic pain relieving techniques

A 
o	Distraction
o	Prayer
o	Relaxation
o	Music
o	Massage
o	Heat/cold
o	Movement
o	Rest
o	Immobilization
o	Transcutaneous Electro-neural Stimulation (TENS)
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14
Q

Identify appropriate pain intervention using the WHO ladder

A

Step 1: nonopioid analgesics, NSAIDS
Step 2: weak opioids
Step 3: strong opioids, methadone, oral administration, transdermal patch
Step 4: Nerve block, epidurals, PCA pump, neurolytic block therapy, spinal stimulators

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15
Q

Acetaminophen: action, use of, serious side effects related to overdose

A

 Action: only inhibits COX in the CNS only: no anti-inflammatory or anti-coagulant effects
 Use of: antipyretic (reduced fever), analgesic (controls pain)
 Side Effect
 toxic doses-liver toxicity
 hypertension with daily use
 liver and renal disease
 contraindicated with alcohol
 DO NOT EXCEED MAX DAILY DOSE OF 4 GRAMS PER DAY
 Abdominal pain, nausea, vomiting and diarrhea are early signs of overdose.
Acetylcysteine will treat overdose of acetaminophen. Most effective when given within 8-10 hours

 Identify priority nursing actions

  • check BP
  • Assess for jaundice
  • Assess skin rash
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16
Q

o NSAIDs: general action, use of, adverse effects (aspirin, ibuprofen)
 Aspirin COX-1 and 2 Inhibitor

A 
Action	
Inhibit prostaglandins- lower inflammation and platelet aggregation inhibition
Adverse Effects
o	Gastric upset, heartburn, nausea, ulceration
o	Bleeding
o	Kidney dysfunction
o	Salicylism 
o	Reye’s syndrome
Drug interactions:
o	Anticoagulants
o	Glucocorticoids
o	Alcohol
Use and Expected Effects
o	Treatment of mild to moderate pain
o	Inflammation suppression
o	Fever reduction (antipyretic)

Identify priority nursing actions

  • Monitor for salicylism (tinnitus, vertigo, decreased hearing activity)
  • Prevent gastric upset by administering the medication with food or antacids
  • Monitor bleeding with long-term NSAID use
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17
Q

ID Medications within the classification opioids

A

codeine, hydrocodone, morphine, dilaudid

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18
Q

Explain the general action of opioids

A
  1. Binds to the opioid receptor in the brain
  2. Anagesia
  3. Sedation
  4. Euphoria
  5. Resp. Depression
  6. Decrease GI Motility
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19
Q

ID Nursing implications for administering analgesics

A
  • Stay away from placing on hair, tattoo, scars

- Check RR and monster level of consciousness

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20
Q

ID serious side effects of opioids

A
  • Respiratory depression
  • Sedation
  • Immune system suppression
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21
Q

ID Interventions to prevent side effects of opioids

A
  • Sedation: monitor level of consciousness and take safety precautions
  • Respiratory depression: monitor RR prior to administering and following administering
  • Orthostatic hypotension: tell client to sit or lie down if lightheadedness or dizziness occur. Have clients avoid sudden changes in position. Provide assistance with ambulation
  • Urinary retention: monitor intake and output assess for distension. Administer bethanechol, and catheterize
  • Nausea/ vomiting: administer antiemetics, advise clients to lie still and move slowly, and eliminate odors
  • Constipation: use a preventative approach (monitor bowel movements, fluids, fiber intake, exercise stool softeners, stimulant laxatives, enemas)
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22
Q

ID priority actions if side effects occur as a result of opioids

A

Moniter breathing
Naloxone
HOB up

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23
Q

Action of Naloxone

A

Reverse action of opioids by competing for same receptor sites

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24
Q

Explain use of PCA

A 
•	Patient is able to not wait for pain med. 
o	Decreases anxiety
•	Must be congintievly aware
•	May forget to push the button
•	People have died from PCA by proxy
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25
Q

Discuss the role of adjuvant analgesic drugs such as gabapentin in pain management

A

Originally meant to treat other conditions but in combination with opioids help treat pain

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26
Q

ATC v. PRN analgesic administration

A

Around the clock is scheduled doses at all times. Used when pain is anticipated so that client doesn’t need to be in unnecessary pain. Ex. Surgery, burns.
PRN: as needed is given when the pt reports pain

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27
Q

• Explain the role of kidney function in preventing medication toxicity

A

Main route of excretion. Filters out drugs.

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28
Q

Drug Tolerence

A

The drug doesn’t work as well anymore

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29
Q

Physical Dependance

A

A state of adaption due to the body needing the drug and not having it anymore

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30
Q

Addiction

A

primary, chronic, neurobiological disease. Impaired control over drug use, compulsive use.

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31
Q

What is ventilation?

A

movement of oxygenated air in and out of the lungs

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32
Q

What is perfusion

A

delivery of O2 to the tissues

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33
Q

What is diffusion(oxygenation)

A

exchange of O2 and CO2 in the capillaries(gas exchange)

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34
Q

Identify modifiable risk factors influencing oxygenation

A

o Smoking
o Environmental factors: pollution, elevation, cold/hot—cold air can cause bronchospasm, irritants, pollen
 Asthma: irritants initiate the inflammatory response
o Exercise
o Substance use

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35
Q

Explain client teaching to decrease risks associated with impaired oxygenation

A 
o	Obesity
o	Smoking
o	Substance abuse 
o	Stress
o	Environmental factors
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36
Q

Key Assessment Techniques for the Resp. System

A 
o	Rate, Rhythem, depth
o	Comfortable at rest?
o	O2Sat
o	Sign of increased work to breath
o	Auscultate lung sound
o	Cough: productive/nonproductive: sputum/no sputum
o	Sputum: color, consistency, odor
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37
Q

Identify cues associated with altered oxygenation

A

Early: Restlessness/anxiety, Increased resp. rate,
Increase work of breathing,
SOB with activity/DOE, Disorientation/confusion, Increased HR/extra beats

Late:
o	SOB at rest
o	Use of ancillary muscles
o	Combativeness
o	Bradycardia 
o	Hypotension
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38
Q

“Crackles”

A

Sound the rice crispies. Means that there is fluid in the lungs
Pneumonia, Aspiration, excess fluid
Interventions: tripod positioning, deep breaking, chest tubes

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39
Q

“Rhonchi”

A

Snore/ course sound. Secretions in the large bronchus.
COPD
Intentional coughing, coughing, hydrating

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40
Q

“Wheezing”

A

Whisling, high pitched almost musical sound.
Asthma, COPD, Airway obstruction
The higher the pitch the worse it is. If you here nothing then airway is completely obstructed
Positioning: HOB >45. Pursed lip breathing

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41
Q

Plearal friction Rub

A

when we have something causing irritation in or around our pleural space. You can hear it with inhalation. Rubbing together of inflamed pleural spaces.

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42
Q

Diminished lung sounds

A

Atelectasis: when alveoli are not filling with air. Can be chronic problem or can happen to patients with pain and decreased mobility. Due to not taking deep breaths and not filling alveoli with air. You’ll hear diminished sounds. Can’t hear air moving in and out as loud.

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43
Q

Rational ambulation

A

loosens secretions so they are easier to get rid of

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44
Q

Rational positioning

A

Position HOB >45. Tripod positioning. More straight airway and supports trunk muscles which increases surface area of the lungs

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45
Q

Incentive spirometer

A

Encourages voluntary deep breathing by providing visual feedback. Prevents atelectasis. Suck like a straw

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46
Q

Explain how deep breathing and intentional coughing help with airway clearance

A

o Deep Breathing: fill up alveoli and increase surface area for gas exchange in alveoli
o Intentional Coughing: loosen secretions and cough them up
 Acapella/Flutter valve: cough into valve and membrane in pickle vibrates

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47
Q

Explain how to perform incentive spirometry

A

o Incentive Spirometry: pt. take deep breath ball move up and ball move up and let out naturally

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48
Q

Discuss the purpose of chest physiotherapy and postural drainage

A

o Chest Physiotherapy: gently pound on back to loosen secretions. Vest that does it or nurse/RT can
o Postural Drainage: Change position every hour so don’t ever have secretions sitting long enough so stick. Abt 1-2 hrs

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49
Q

Discuss care of the client with a chest tube (purpose, assessment points, positioning of chest tube drain and client, and what to do when drainage suddenly increases)

A

Purpose: chest tubes can remove air and fluid in the pleural space. For people who have liver failure, cancer in the abdomen, ovarian cancer, post op from surgery. Chest tube reestablishes negative pressure in the lungs so the lungs can re -expand
Assessment points: evaluate RR, breath sounds, SpO2 levels, and insertion site for subQ emphysema
Positioning of chest tube, drain, and client: the drain always needs to be below the level of the chest to drain the fluid. The tube needs to an have unencumbered flow and needs to be secured to the chest wall. The fluid needs to leave the chest and get into the drainage. The drain needs to be below.
When drainage is suddenly increased: alert MD?

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50
Q

Explain why clamping of chest tubes is generally prohibited

A

 Could result in a tension pneaumothorax

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51
Q

Hypoventilation

A

o Hypoventilation: decrease movement of O2 in and out

 Ventilation not enough to supply body or eliminate CO2. Mental status change, dyrythmias, cardiac arrest

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52
Q

Hyperventilation

A

o Hyperventilation: increases movement of O2 in and out

 More CO2 being removed then produced. Creates acidbase imbalance. Anxiety, infection, increased body temp

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53
Q

Hypoxia

A

o Hypoxia: inadequate tissue perfusion(cellular level)

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54
Q

Differentiate between early and late signs of hypoxia

A

o Restlessness/anxiety
o Increased resp. rate
o Increase work of breathing
o SOB with activity/DOE
o Disorientation/confusion
o Increased HR/extra beats
o SOB at rest
o Use of ancillary muscles
o Combativeness
o Bradycardia
o Hypotension
o Cyanosis: mucous membranes. Also context.
 Progressing problem: later sign and indicates serious problem
 Acute problem: cyanosis may come early and is a serious sign
 Chronic problem: cyanosis might be always present and is not a good indicator of current status

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55
Q

Identify and prioritize interventions for respiratory distress

A

o Calm environment: dim lights, turn volume down on beeping, close the door. Decrease stimulation of SNS and decreases oxygen demand
o Positioning: HOB >45. Tripod positioning- allows to increase surface area.
o Coughing techniques
-Acapella/flutter valve (The purpose of these is to loosen secretions and also to cough them up.)

o Deep breathing
-Incentive spirometer
o oxygen administration
o Hydration: thins the mucus
o Pursed lip breathing: breath in through your nose, purse your lips and breathe out. The purpose is to get rid of CO2.
o Ambulation: helps increase deep breathing. Any type of mobility will help loosen secretions
o Postural drainage: positioning the client to expand the chest. Keep secretios moving
o Chest physiotherapy: cup hands and gently cupping along their back to loosen secretions
o Suction: pull out secretion because they are so tight
o Respiratory muscle training: helps increase surface area
o Breathing exercises

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56
Q

Explain appropriate positioning of a client in respiratory distress

A

Tripod or >45

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57
Q

Identify complications associated with hyperventilation, hypoventilation, and hypoxemia.

A

Hypoventilation: occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide. Can lead to respiratory acidosis and respiratory arrest.
Hyperventilation: a state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism. Can result in respiratory alkalosis.

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58
Q

Describe orthopnea

A

o SOB when laying flat

59
Q

Differentiate between nasopharyngeal and nasotracheal suctioning

A

o Nasopharyngeal: pt able to cough but unable to clear own secretions all the way out
o Nasotracheal: unable to cough, no artificial airway present

60
Q

Discuss the appropriate technique for sterile airway suctioning

A
  • The trachea is considered sterile and you do not want to introduce any other type of organisms to that area.
  • Because you do not want to cause infection in the lungs which can lead to pneumonia
61
Q

o Explain reasons why continuous suctioning is harmful

A

you can pull up mucous membranes- You will suck inside of the bronchial tree, causing inflammation, causing damage

  • Do not take out too much oxygen which causes decreased HR, o2 sat. will drop
  • Dry mouth
  • Infection and inflammation
  • hypoxemia
62
Q

Describe care for a client receiving oxygen via a nasal cannula

A

 Check orders
 Compare orders with what client is actually receiving
 Assess for skin breakdown (around ear, auricle, across the cheekbone,
 Client comfort
 Use of humidification
 Document respiratory assessment
 Wean as tolerated, if allowed by MD order
o Oxygen saturation less than or equal to 92%

63
Q

Simple O2 Mask

A

Useful for short periods such as pt transport. Contraindicated in pt who retain CO2. May induce feeling claustrophobia. Interrupted with eating and drinking. Increased risk of aspiration6-12 L/min. FiO2: 35-45%

64
Q

Venturi Mask

A

Provide specific amount of oxygen with humidity added. Low constant O2. Mask and therapy may irritate skin

65
Q

Non-rebreather mask

A

Hot and confining. May irritate skin and R. seal is necessary. Interpheres with eating and drinking. Bag may twist or kink. Use for short periods, delivers increases O2, easily humidifies. Does not dry mucous membranes. 10-15L/min. FiO2: 60-90%

66
Q

Explain how pt would eat when receiving O2 by mask

A

Depends on how much O2 and what kind of mask. Would be on nasal canal high flow while eating or would not be eating and getting nourishment through NG tube.

67
Q

Explain the effects of dehydration on the respiratory system

A

o Dries out mucous membranes and makes removal of pulmonary secretions difficult

68
Q

Discuss use of continuous positive airway pressure, Identify indications for this treatment

A

CPAP: delivers a constant pressure which forces air into the lungs when you inhale with a set pressure. The pressure helps the lungs expand. A pressure is also set at exhalation which helps keep the airways open. Helps increase oxygen levels in the lungs and decreases how hard a person has to work to breathe.
BIPAP
They help blow off CO2 and increase air/O2 getting to the bases of the lungs; they require an MD order and need respiratory therapy to set up in the hospital

Req. MD Order

69
Q

Identify key assessment techniques for the cardiac system.

A 
o	Blood pressure:
o	Heart sounds: Auscultate with 
o	Palpate pulse points
o	Auscultate over abdominal aorta and carotids
o	Temperature of skin
o	Edema
o	Color
o	Capillary refill
70
Q

Identify correct cardiac landmarks for auscultating: closure of mitral and tricuspic valves, closure of aortic and pulmonic valves

A

o Mitral: 5 intercostal space close to the boob
o Tricuspid: 4 intercostal space, close to the L external border
o Aortic- 2nd intercostal space. R. external border(1st spot we listen to)
o Pulmonic- 2nd intercostal space- L. ext border

71
Q

Describe the relationship between preload, afterload, contractility, and cardiac output

A

o Preload: amt blood into ventricle before contraction. Effected by blood volume
o Afterload: Resistance heart has to beat against
o Myocardial Contractility: actualy squeeze of muscle. Affected by damage
o HR: affected by drugs, age, volume, etc.
o Stroke volume: amt that leaves heart every time heart squeezes. Never 100%
o All work together to circulate blood efficiently and correctly

72
Q

Explain how afterload is affected by peripheral vascular resistance

A

o Afterload is the amt of resistance the heart has to beat against. If there is a lot of resistance, then the heart has to work harder.

73
Q

Identify complications occurring as a result of altered cardiac conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.

A

o Altered cardiac conduction: calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis and a decrease in the number of pacemaker cells in SA node.
o Altered cardiac output: primary coronary artery disease, cardiomyopathy, valvular disorders, and pulmonary disease.
o Impaired valvular function: heart murmurs, stenosis (hardening) or impaired closure of the valves. Left or right sided failure can occur.
o Myocardial ischemia: angina and myocardial infarction.
o Impaired tissue perfusion: myocardial infarction

74
Q

Identify what angina is and explain what causes it

A

o Angina: Lack of oxygen delivered to the heart muscle to the point where the cells are dying. Causes heaviness across chest, SOB, left arm pain, nausea, Transient imbalance between myocardial oxygen supply and demand.
A condition of severe pain in the chest. Insufficient oxygen to the heart muscle. Caused by narrowing of coronary arteries.

75
Q

• Describe the significance of the following findings

o Bruit

A

o Bruit: turbulent blood flow over an artery

76
Q

• Describe the significance of the following findings

o Murmur

A

turbulent blood flow over a valve

77
Q

Explain the cause of a myocardial infarction (MI):

A

blockage in coronary artery leading to lack O2 being delivered to heart. Impaired tissue perfusion.

78
Q

ID signs and symptoms of a MI

A 
	Tightness across chest
	SOB
	Jaw ache, left arm pain, numbness
	Diaphoresis
	Nausea
	Fear/feeling of doom
	Dizziness
79
Q

Explain how a MI puts a client at risk for heart failure

A

MI=heart muscle death. even if O2 restored those heart cells will never beat the same leading to impaired heart function

80
Q

Signs and Symptoms of Heart Failure

A

Fatigue, activity intolerance, weight changes due to fluid excess, edema, breathlessness, dizziness, and confusion. Crackles, SOB, cough, and dyspnea, tachycardia, nocturia, skin changes, behavioral changes: restlessness, anxiety, fear

81
Q

Discuss priority assessments for a client with heart failure (poor cardiac output)

A

HR, weight, blood pressure, assess level of fatigue

82
Q

Sinus Bradycardia

A

HR too slow. Fine. HR Assess

83
Q

Sinus Tachycardia

A

HR too fast. Fine. HR Assess

84
Q

Atrial Fibrillation

A

No P wave. Ventricular wave is irregular. Depend on how fast heart is going.

85
Q

Ventricular Tachycardia

A

SA node is fine. Heart is not coordinated. BP drop, dying, feel fine, feel dizzy. Need electrical shock to get out of rythem. BAD

86
Q

Ventricular Fibrillation:

A

fast then flutter. No blood circulating. No resp. CPR time. BAD WORST

87
Q

Nursing Interventions Dysrhythmias

A 
	ECG monitering
	Monitering VS
	O2 therapy
	IV access
	Administer meds
	Prepare to initiate CPR
88
Q

Explain indications for cardio-pulmonary resuscitation

A

o V-fib
o No pulse
o No resp

89
Q

Identify heart healthy foods

A

Leafy green vegetables, whole grains, berries, walnuts, almonds, avocados, beans, fatty fish and fish oil.

90
Q

Explain why is a low-sodium diet essential with cardiovascular disease

A

Na causes water retention

91
Q

Identify the physiologic processes that regulate fluid volume and fluid distribution

A 
Osmosis h20 moves from high to low []
Active Transport
Filtration
Diffusion
ADH: causes kidneys to retain h20o	Renin-Angiotensin-Aldosterone System: influence Na and H20 excretion
92
Q

Identify common fluid, electrolyte, and acid-base disorders

A 
o	Dehydration
o	Hypovalemia
o	ECF excess
o	Resp. alkalosis/acidosis
Metabolic alkalosis/acidosis
93
Q

Accurately calculate intake and output

A
  • Output includes urine, diarrhea, vomitus, gastric suction, drainage from postsurgical wounds or other tubes.
  • Intake includes all liquids that a person eats, drinks, or receives through nasogastric or jejunostomy feeding tubes. IV fluids. Water swallowed while taking pills counts.
  • Ice chips are half the volume (if 8oz cup, its 4 oz of liquid)
94
Q

Identify risk factors for dehydration

A 
o	Drainage
o	Burns
o	Hemorrhage
o	GI losses
o	Diabetes Insipidus
o	Inadequate intake
o	Cognitively impaired
o	Physical limitations
o	Fever
o	Hyperglycemia
o	Older adult
95
Q

Identify risk factors for fluid overload

A 
o	Heart Failure
o	Renal Failure
o	Syndrome of Inappropriate ADH
o	Long-term use of corticosteroids
o	Parenteral replacement
o	Liver Failure
96
Q

Explain how the stress response effects urine output

A

Stress causes ADH to increase, so less urine output. Cortisol can cause diuresis.

97
Q

Identify signs and symptoms of fluid volume excess and deficit

A 
o	Deficit
	Weight loss
	Thirst
	Decreased urine output
	Restlessness, confusion, seizures
	Hypotension
	Rapid, weak pulse
	Decreased capillary refill
	Decreased urine output
	Concentrated urine
	Weakness, dizziness
	Dry mucous membranes
	Decreased skin turgor
	Elevated hematocrit
o	Excess
	Weight gain
	Headache, confusion, lethargy, seizures, coma
	Dependent edema
	Increased blood pressure
	Jugular vein distention (full neck veins)
	Bounding pulse
	Lung auscultation: crackles, dyspnea(SOB)
	Lower hematocrit
98
Q

o Describe how fluid and electrolyte and acid base imbalance is reflected in the following assessments:

A

 Blood pressure
• Hypotension or orthostatic hypotension = ECV deficit
• Light-headedness on sitting upright or standing = ECV deficit

 Pulse
• Rapid, thread = ECV deficit
• Bounding = ECV excess

 Cardiac rhythm
• Irregular pulse and ECG changes = K+, Ca2+, Mg2+, and/or acid-base imbalance

 Neck veins
• Flat or collapsing with inhalation when supine = ECV deficit
• Full or distended when upright or semi-upright = ECV excess

 Mucous membranes
• Dry between cheek and gum, decreased or absent tearing = ECV deficit

 Level of consciousness
• Restlessness and mild confusion = severe ECV deficit
• Decreased level of consciousness (lethargy, confusion, coma) = hypernatremia, hyponatremia, hypercalcemia, acid-base imbalance

 Respiratory rate and rhythm
• Increase rate and depth = metabolic acidosis (compensatory mechanism); respiratory alkalosis (cause)
• Decreased rate and depth = metabolic alkalosis (compensatory mechanism); respiratory acidosis (cause)
 Reflexes
• Decreased deep tendon reflexes = hypercalcemia, hypermagnesemia
• Hyperactive reflexes, muscle twitching and cramps, tetany = hypocalcemia, hypomagnesemia

 Bowel sounds
• Decreased bowel sounds = hypokalemia

 Skin turgor
• Pinched skin fails to return to normal position within 3 seconds = ECV deficit

 Daily weight
• Loss of 2.2 lbs. or more in 24 hours = ECV deficit
• Gain of 2.2 lbs. or more in 24 hours = ECV excess

 Urine output, color, and specific gravity
• Urine output: small volume of dark yellow urine = ECV deficit

99
Q

Explain how diarrhea causes metabolic acidosis and impacts fluid status

A
  • Loss of bicarbonate (normal anion gap)
  • Metabolic acidosis occurs from an increase of metabolic acid or a decrease of base (bicarbonate). The kidneys are unable to excrete enough metabolic acids, which accumulate in the blood, or bicarbonate is removed from the body directly as with diarrhea.
100
Q

Explain how vomiting effects pH and fluid status

A
  • Loss of metabolic acid
  • Metabolic alkalosis occurs from a direct increase of base (HCO3-) or a decrease of metabolic acid, which increase blood HCO3- by releasing it from its buffering function.
101
Q

Explain how acid base imbalance contributes to Kussmaul respirations

A

Rapid or labored breathing

Try to get rid of CO2

102
Q

Differentiate between isotonic, hypertonic, and hypotonic fluids

A

o Isotonic: neutral solution. Stays in the intravascular space. Does not shift. Good for maintaining BP.
o Hypertonic: more than 280. Draws water from cells into the intravascular space.
o Hypotonic: less then 280. Water moves from intravascular space in cell and causes cells to swell. Treat cellular dehydration.

103
Q

Norm. Na+

A

135-145 mEq/L

104
Q

Norm. K+

A

3.5-5.0 mEq/L

105
Q

Norm Ca2+

A

8.6-10.2 mEq/L

106
Q

Norm Cl-

A

98-106 mEq/L

107
Q

Norm. Tot. CO2

A

22-30 mEq/L

108
Q

Norm. Mg2+

A

1.5-2.5 mEq/L

109
Q

Foods high in Na+

A

processed food

110
Q

Foods high in K+

A

tuna, dark leafy greens, stone fruit

111
Q

Food high in Ca2+

A

dairy

112
Q

Food high in Mg2+

A

nuts, beans, dark leafy greens

113
Q

Hyponatremia

A

<135

Altered mental statuso apprehension, headaches, decreased level of consciousness, coma, seizures

114
Q

Hypernatremia

A

> 145 Altered mental status
 Excessive thirst
hypotension

115
Q

Hypokalemia

A

<3.5 Cardiac dysrhythmias
 Respiratory distress
 GI
 Muscle weakness

116
Q

Hyperkalemia

A

> 5 Ventricular Fibrilation
 Cardiac arrest
 Muscle weakness
 GI

117
Q

Hypomagnesemia

A

 Cardiovascular (dysrhythmias)
 Neuromuscular (hyperreflexia)
 GI (decreased peristalsis)

118
Q

Hypermagnesemia

A

 Cardiovascular (bradycardia, heart block)
 Neuromuscular (hyporeflexia)
 Respiratory (decreased rate, shallow)
 GI (increased peristalsis)

119
Q

Hypocalcemia:

A

 Cardiovascular (dysrhythmias)
 Respiratory (Laryngeal spasms, stridor)
 Neuromuscular (twitching, numbness/tingling, Chvostek’s sign, Trousseau’s sign)
 GI (increased peristalsis)

120
Q

Hypercalcemia

A

 Cardiovascular (dysrhythmias)
 Neuromuscular (weakness, lethargy)
 Musculoskeletal (bone pain, fractures)

121
Q

Explain how potassium, calcium, and magnesium imbalances influence the cardiac system

A
  • Potassium: decrease of it causes cardiac arrhythmias, an increase causes cardiac arrest
  • Calcium: cardiac arrhythmias (only when extremely low or high)
  • Magnesium: palpitations, arrhythmias (only when extremely low or high), angina, high BP.
122
Q

Explain how calcium and magnesium imbalances influence the musculoskeletal system

A
  • Calcium: causes muscle contraction; imbalance—muscle weakness or severe cramping
  • Magnesium: imbalance—twitches, cramps, muscle tension/soreness.
123
Q

Describe positive Chvostek’s and Trousseau’s signs

A

 Chvosteks: cheek spasm above jaw
 Trousseau’s: when taking BP hand has involuntary spasm
Indicate hypocalcemia

124
Q

Explain how a low sodium level influences the central nervous system

A

H20 enters cells by osmosis causing cells to swell. Cerebral dysfunction. Then channels and neurons will not work properly

125
Q

Explain how hypoventilation contributes to respiratory acidosis

A

o pH: <7.35, PaCO2>45mmHg
o Retention of CO2 by lungs
 Lower BP with vasodilation
 Dyspnea. Hyperkalemia

126
Q

pH

A

acid-base balance of arterial blood- 7.35-7.45

127
Q

PaO2

A

pressure of dissolved O2 in plasma- 80-100 mmHg

128
Q

PaCO2

A

pressure of CO2 in arterial blood- 35-45mmHg

129
Q

HCO3

A

Bicarbonate which is a metabolic buffer for pH balance 22-26mEq/L

130
Q

SaO2: %

A

hemoglobin oxygen carrying capacity used- >95%

131
Q

Acid-base balance: Interpret whether the pH is normal, acidotic or alkalotic

A

 Normal: 7.35-7.45
 Acidosis <7.35
 Alkalosis >7.45

132
Q

Metabolic v. Resp. Acidosis:

A

• Metabloic Acidosis lower HCO3, low pCO2, low pH
• Resp. Acidosis: high pCO2, high HCO3, low pH
Metabolic: Focus on HCO3
Resp: Focus on pCO2

133
Q

Metabloc v. Resp Alkalosis

A

• Resp. Alkalosis: Low pCO2, low HCO3, high pH
• Metabloic: high HCO3, high pCO2, high pH
Metabolic: Focus on HCO3
Resp: Focus on pCO2

134
Q

Discuss purpose and procedure for initiation and maintenance of intravenous therapy

A

Purpose: med/comfort, rehydrate/maintain hydration, quick access, blood administration, nutrition

135
Q

Differentiate between peripheral and central line access

A

o Peripheral: most utilized med devices. Risk infection.
o Central Line Access: Over 64X greater infection then peripheral IV.
 Direct line access to large vein close to heart

136
Q

Differentiate between a continuous and intermittent bolus IV

A

Bolus IV: a relatively large volume of fluid or dose of a drug or test substance given intravenously and rapidly to hasten or magnify a response

  • Continuous: uninterruptedly given until instructed otherwise by physician
  • Intermittent: given over a set period of time at prescribed intervals and then stopped until the next dose is required
137
Q

Differentiate between a continuous and intermittent bolus IV

A

Bolus IV: a relatively large volume of fluid or dose of a drug or test substance given intravenously and rapidly to hasten or magnify a response

  • Continuous: uninterruptedly given until instructed otherwise by physician
  • Intermittent: given over a set period of time at prescribed intervals and then stopped until the next dose is required
138
Q

Determine priority assessments when caring for clients with IVs

A 
o	Occlusion, Phlebitis, Fluid overload
o	Adverse drug reaction
o	Vitals—infection
o	Skin—inflammation
o	Pain 
o	Electrolyte balance
139
Q

Explain methods to protect the skin and veins of the older adult during IV therapy

A

o Smallest catheter: not much fat. Match size catheter with size vein.
o Avoid back of hand. (Avoid posterior surface)
o Prevent tearing of skin(tourniquet)
o Avoid excessive tape

140
Q

Identify IV maintenance tasks that can be delegated to assistive personnel

A

AP can notify you if patient indicates any burning, bleeding, swelling, etc at catheter site. If dressing is wet or loose, if any alarms are going off. If fluid container is almost empty.
Basically they can report stuff

141
Q

Identify complications caused by inaccurate infusion rates

A

fluid volume overload

142
Q

Identify priority interventions for complications during IV therapy

A

 Infiltration: Move pump/stop, replace w/new, elevate arm
 Phlebitis: Stop the IV, relocate. Replace with new. Elevate arm, warm compress.
 Extravasation: stop the IV, take out and relocate, call the Dr.

143
Q

Complications of IV therapy

A

Risks of peripheral parenteral therapy:

  • Fluid overload
  • Electrolyte imbalance
  • DVT/ embolism
  • Occlusion
  • Nerve, tendon, ligament damage
  • Adverse drug reactions
  • Localized and systemic infections

3346 NURS (4 decks)

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