Final Flashcards
What is the normal range for arterial blood pH?
7.35 to 7.45
Maintenance of arterial blood pH is crucial for physiological balance.
What happens during acidosis?
Arterial blood pH falls below 7.35 due to too many hydrogen ions or too little bicarbonate
Acidosis can be respiratory or metabolic in nature.
What occurs during alkalosis?
Arterial blood pH rises above 7.45 due to too few hydrogen ions or too much bicarbonate
Alkalosis can also be classified into respiratory or metabolic types.
Name a risk factor for acid-base imbalance related to poisoning.
Salicylate ingestion
This can lead to metabolic acidosis.
What medical condition is a risk factor for respiratory acidosis?
COPD
Chronic Obstructive Pulmonary Disease can impair gas exchange.
List some health promotion strategies for acid-base balance.
- Living a healthy lifestyle
- Exercise
- Healthy diet
- Monitoring at-risk patients
What is cellular regulation?
Genetic and physiologic processes that control cellular growth, replication, differentiation, and function
Impairment can lead to abnormal tissue growth.
What are some risk factors for impaired cellular regulation?
- Older age
- Smoking
- Poor nutrition
- Physical inactivity
- Environmental pollutants
- Radiation
- Selected medications
- Genetic predisposition
What are some physiological consequences of impaired cellular regulation?
- Benign cell growth
- Malignant (cancerous) cell growth
What are the classifications of clotting?
- Increased clotting
- Decreased clotting
What are risk factors for increased clotting?
- Immobility
- Polycythemia
- Smoking
- Certain chronic health problems
What is cognition?
Complex integration of mental processes and intellectual function for reasoning, memory, and personality
List some risk factors for impaired cognition.
- Advanced age
- Brain trauma
- Disease or disorder
- Environmental exposure to toxins
- Substance use disorder
What are the physiological consequences of impaired cognition?
- Loss of memory
- Disorientation
- Impaired reasoning
- Impaired language skills
- Inappropriate emotions
What is the focus of comfort assessment?
Physical well-being, pleasure, and absence of pain or stress
What are the classifications of elimination?
- Continence
- Incontinence
- Retention
- Diarrhea
- Constipation
What are some risk factors for elimination issues?
- Aging
- Neurologic disorders
- Excessive laxative use
- GI infections
- BPH
What are the physiological consequences of poor elimination?
- Tissue integrity damage
- Depression
- Fluid and electrolyte imbalance
What is fluid and electrolyte balance?
Regulation of body fluid volume, osmolality, and composition
List some risk factors for fluid and electrolyte imbalances.
- Acute illnesses
- Severe burns
- Chronic kidney disease
- Poor nutrition intake
What are the physiological consequences of fluid overload?
Fluid overload can lead to electrolyte excess and other complications
What is gas exchange?
Process of oxygen transport to cells and carbon dioxide transport away from cells
List some risk factors affecting gas exchange.
- Lung conditions
- Smoking
- Environmental pollutant exposure
- Aging
What are the physiological consequences of impaired gas exchange?
- Inadequate oxygen transport
- Retention of carbon dioxide
- Respiratory acidosis
What types of immunity are there?
- Natural active
- Artificial active
- Natural passive
- Artificial passive
- Antibody-mediated immunity
- Cell-mediated immunity
What are risk factors for decreased immunity?
- Older age
- Chronic illnesses
- Low socioeconomic groups
- Not practicing a healthy lifestyle
What is infection?
Invasion of pathogens into the body that multiply and cause disease
List classifications of infection.
- Bacteria
- Viruses
- Fungi
- Parasites or protozoa
What are some physiologic consequences of inflammation?
- Redness
- Warmth
- Swelling
- Pain
- Loss of function
What is mobility?
Ability to perform purposeful physical movement of the body
What are risk factors for impaired mobility?
- Dysfunction of the musculoskeletal system
- Severe brain or spinal cord injuries
- Bedridden status
What is the process of nutrition?
Ingesting and using food and fluids, including proteins, carbohydrates, fats, vitamins, and minerals
What are some risk factors for poor nutrition?
- Older adults
- Obesity
- Social determinants of health
What types of pain exist?
- Acute
- Persistent (chronic)
What are some physiological consequences of acute pain?
- Nausea
- Vomiting
- Increased blood pressure
- Increased pulse
What is the definition of pain?
An unpleasant sensory and emotional experience
Pain is subjective and can vary greatly among individuals.
What are the two types of pain?
- Acute
- Persistent (chronic)
Acute pain is usually short-term, while chronic pain persists over a longer duration.
What are the mechanisms of pain?
- Nocioceptive
- Neuropathic
Nocioceptive pain is due to injury to body tissues, whereas neuropathic pain results from damage to the nervous system.
Who can experience pain?
Anyone
Pain can occur due to various factors including acute trauma and chronic diseases.
What are the physiologic consequences of acute pain?
- One or more sympathetic nervous system signs and symptoms
- “Fight or flight” reaction
- Nausea
- Vomiting
- Diaphoresis
- Increased blood pressure, respirations, pulse
- Dilated pupils
These symptoms indicate the body’s response to acute pain.
What can persistent pain lead to?
- Anxiety
- Depression
Persistent pain often does not trigger the acute stress response but can have significant psychological effects.
What factors should be assessed in pain assessment?
- Location
- Intensity
- Quality
- Onset, duration
- Aggravating or precipitating factors
- Effects on quality of life and daily function
- Psychosocial effects
Comprehensive pain assessment is essential for effective management.
What are some health promotion strategies related to pain?
- Often unavoidable
- Avoid high-risk activities
- Control pain after surgery
These strategies aim to minimize pain and its impact on health.
What are pharmacologic interventions for pain management?
- Opioids
- Non-opioids
These medications are commonly used to manage different types of pain.
What are non-pharmacologic interventions for pain management?
Depends on patient preferences
Integrative therapies can include methods like physical therapy, acupuncture, or relaxation techniques.
What does adequate arterial blood flow through peripheral tissues refer to?
Peripheral perfusion
It is essential for oxygenating major body organs and tissues.
What are the risk factors for impaired perfusion?
- Non-modifiable: Age, Gender, Family history
- Modifiable: Smoking, Lack of physical activity, Obesity
Identifying risk factors is crucial for prevention and management.
What are the physiologic consequences of impaired peripheral perfusion?
- Cool, pale, cyanotic distal legs
- Skin ulcers
- Gangrene
These complications arise from inadequate blood flow to the extremities.
What are the physiologic consequences of impaired central perfusion?
- Myocardial infarction
- Stroke
- Shock
These conditions can be life-threatening and require immediate medical attention.
What are health promotion strategies for improving perfusion?
- Improve nutrition
- Stop smoking
- Regular exercise
- Screening and monitoring
These strategies can help maintain healthy blood flow and prevent complications.
What is sensory perception?
The ability to perceive and interpret sensory input into one or more meaningful responses
This includes senses like vision, hearing, smell, taste, and touch.
What are the risk factors for impaired sensory perception?
- Aging
- Chronic diseases
- Mechanical or chemical trauma
- Genetic risk
- Drug therapy (e.g., ototoxicity)
- Physical trauma
- Occupational exposures
These factors can lead to decreased sensory function.
What are the physiologic consequences of impaired sensory perception?
- Physical injury (falls, other accidents)
- Inability to perform ADLs or ambulate independently
- May not be able to solely rely on verbal communication
- May not be able to use written communication
These consequences significantly affect daily life.
What should be included in the assessment of sensory perception?
- History
- Family history
- Determine risk factors
- Ask about use of aids (glasses, contacts, hearing aids)
- Basic assessment of vision and hearing
A thorough assessment helps identify areas of concern.
What are primary health promotion strategies for sensory perception?
- Avoiding risks (e.g., safety goggles, ear plugs)
Preventative measures can help protect sensory function.
What are secondary health promotion strategies for sensory perception?
- Screening (e.g., eye examinations)
Regular screenings can detect issues early on.
What are some interventions for impaired sensory perception?
- Drug therapy
- Corrective lenses or eye surgery
- Hearing aids
- Guide dogs
- Braille
- Closed-captions TV, computerized communication devices, sign language
- Psychosocial support
These interventions can enhance quality of life for those affected.
What does sexuality encompass?
Complex integration of physiologic, emotional, and social aspects of well-being
Sexuality is distinct from reproduction or gender identity.
What are the risk factors related to sexuality?
- Menopause
- Erectile dysfunction or prostate problems
- Drug therapy
These factors can impact sexual health and intimacy.
What are the physiologic and psychosocial consequences of impaired sexuality?
- Poor self-image and self-concept
- Impaired intimacy
These consequences can significantly affect relationships and personal well-being.
What should be assessed regarding a client’s sexuality?
- Ask about perception
- Partner(s)
- Protective measures
- History of STIs or sexual problems during intercourse
A thorough assessment helps address concerns effectively.
What are health promotion strategies for sexuality?
- STI screening
- Physical examination
Regular check-ups can help maintain sexual health.
What are some interventions for impaired sexuality?
- Drug therapy
- Referral to a qualified provider if problem is emotional or psychological
Addressing underlying issues is crucial for treatment.
What does tissue integrity refer to?
Intactness of structure and function of integument and mucous membranes
It can range from intact to impaired, affecting overall health.
What are the degrees of tissue damage?
- Partial-thickness
- Full-thickness
The degree of damage influences treatment strategies.
What are risk factors for impaired tissue integrity?
- Older age
- Certain medical conditions (e.g., malnutrition, neurologic disorders, diabetes mellitus)
- Unprotected skin
- Pressure injuries
Identifying these risk factors can help in prevention.
What are the physiologic consequences of impaired tissue integrity?
- Localized (cellulitis) or systemic (sepsis) infection
- Pain
- Difficulty healing
Impaired tissue integrity can lead to serious health complications.
What should be included in the assessment of tissue integrity?
- History
- Current chronic health problems
- Medications currently taken
- Full skin assessment
- Risk assessment tools (e.g., Braden scale)
- Serum albumin and pre-albumin levels
Comprehensive assessment is critical for effective management.
What are health promotion strategies for maintaining tissue integrity?
- Proper hygiene
- Proper nutrition
- Inspect skin daily
- Keep skin clean and dry
- Change positions
- Use evidence-based screening tools
- Protect skin and eyes from sun
These strategies can help prevent skin injuries and infections.
What are interventions for impaired tissue integrity?
- Preventative measures
- Adequate diet and nutrition supplements
- Drug therapy
- Chemical/surgical debridement
- Vacuum-assisted closure (VAC)
- Interventional procedures
These interventions can enhance healing and recovery.
What assessment finding requires immediate nursing intervention for a client who travels often, smokes, and eats fast food regularly?
Cool, pale feet
This may indicate impaired peripheral perfusion, which needs urgent assessment.
What is an appropriate nursing response to a client stating, ‘I am not really interested in sexual intimacy’?
Have you experienced pain or difficulty with intercourse?
This response aims to assess underlying issues that may affect intimacy.
Which individual is at highest risk for a cognitive concern?
69-year-old who drinks 3-4 beers daily and had surgery under general anesthesia this morning
Risk factors include advanced age, substance use, and surgery involving general anesthesia.
What are the four quadrants of the abdominal cavity?
- Right lower quadrant (RLQ)
- Right upper quadrant (RUQ)
- Left upper quadrant (LUQ)
- Left lower quadrant (LLQ)
These quadrants are used to localize abdominal organs and assess symptoms.
List the regions of the abdomen.
- Right hypochondriac region
- Right lumbar region
- Right inguinal region
- Epigastric region
- Umbilical region
- Hypogastric region
- Left hypochondriac region
- Left lumbar region
- Left inguinal region
These regions help in identifying the location of pain or abnormalities.
What are the accessory organs and vessels of the gastrointestinal tract?
- Liver
- Gallbladder
- Pancreas
- Abdominal aorta
- Spleen
These organs play crucial roles in digestion and metabolism.
What are the key physiological processes of the abdominal system?
- Metabolism
- Motility
- Secretion
- Digestion and absorption
- Area of relaxation
- Area of concentration
These processes are essential for the functioning of the gastrointestinal tract.
Why is the order of assessment techniques different for the abdomen compared to other body systems?
Inspection, auscultation, and palpation must be performed in that order to avoid altering bowel sounds and to ensure accurate assessment.
Auscultation can be affected by palpation or percussion, hence the different order.
What are the expected findings during skin inspection of the abdomen?
- Skin smooth, dry
- Even skin tone
Variations like moles, scars, and striae are also considered normal.
What are some unexpected findings during abdominal skin inspection?
- Lesions
- Bruising
- Dilated veins
- Purple striae
- Rashes
- Yellow coloring
These findings may indicate underlying health issues.
What are the expected findings when inspecting the symmetry and masses of the abdomen?
- Symmetry of movements with breathing
- No bulges or masses
Expected variations may include slight aortic pulsations and peristaltic movements.
What are the unexpected findings related to symmetry and masses during abdominal inspection?
- Localized bulges
- Visible masses
- Asymmetry of movements
- Visible intense pulsations
These findings may suggest abnormalities.
What are the expected findings regarding the shape and contour of the abdomen?
- Flat
- Even
- Slightly convex
- Rounded
Variations may include scaphoid or rounded with fat along the sides.
What are the unexpected findings in the shape and contour of the abdomen?
- Distention
- Marked concavity
These might indicate underlying issues such as fluid accumulation or organ displacement.
What are the expected findings for the umbilicus during abdominal inspection?
- Midline
- Inverted
Variations may include piercings or extraversion.
What are the unexpected findings for the umbilicus?
- Redness
- Discoloration
- Swelling
- Lesions
These findings may indicate infection or other complications.
What are the expected bowel sounds during auscultation?
- High pitched
- Gurgling
- 5-34 per minute
- Cascading
Variations may include borborygmus.
What are the unexpected findings for bowel sounds during auscultation?
- Hyperactive
- Hypoactive
- Absent
- Vascular swishing
These findings may indicate gastrointestinal issues.
What are the expected findings during palpation of the abdomen?
- Nontender
- Relaxed muscles
Variations may include voluntary guarding or increased fat.
What are the unexpected findings during abdominal palpation?
- Tenderness
- Masses
- Involuntary rigidity
These findings may require further investigation.
What are some health promotion interventions related to the abdominal system?
- Exercise
- Diet
- Testing
- Probiotics
These interventions can help maintain abdominal health and prevent issues.
What could be immediate interventions for unexpected findings during an abdominal assessment?
Immediate interventions might include further assessment, notifying a physician, and providing symptomatic relief.
Specific findings may dictate the exact interventions needed.
What are the layers of the heart?
- Pericardium
- Myocardium
- Endocardium
These layers serve different functions, with the myocardium being the muscular layer responsible for heart contractions.
List the chambers of the heart.
- Atria
- Ventricles
The heart consists of four chambers: two atria and two ventricles.
What are the main vessels of the cardiovascular system?
- Superior vena cava
- Inferior vena cava
- Pulmonary artery
- Aorta
These vessels are crucial for transporting blood to and from the heart.
Define the cardiac cycle components.
- Systole
- Diastole
Systole is the phase of contraction, while diastole is the phase of relaxation of the heart.
What are the expected findings when inspecting neck vessels?
- No distention
- Visible pulsations
These findings indicate normal venous pressure and blood flow.
What are unexpected findings during neck vessel inspection?
- Bulging or bounding
- Absence of pulsation
Such findings may indicate cardiovascular issues requiring further evaluation.
What are expected findings when palpating the neck vessels?
- Moderate strength and equal bilaterally
This indicates normal vascular health and function.
What are some unexpected findings during palpation of the neck vessels?
- Bounding
- Diminished
These findings may suggest vascular abnormalities.
What should be assessed when a client presents with chest pain?
- Vital signs
- Oxygen saturation
- Inspection for color and effort of breathing
- JVD
- Peripheral edema
Assessing these factors helps determine the severity and possible causes of chest pain.
What heart sounds are expected during auscultation?
- S1 and S2
- Apical pulse 60-100
These sounds represent normal heart function and rhythm.
What are some unexpected findings when auscultating heart sounds?
- Irregular
- Tachycardia
- Bradycardia
- Clicks, rubs, murmurs, gallops (S3 or S4)
- Friction rub
Such findings could indicate underlying cardiovascular conditions.
What are expected findings when inspecting extremities and peripheral pulses?
- Extremities symmetrical in size
- Skin intact
- Nails curved and normal skin color
These findings are indicative of healthy peripheral circulation.
What are some unexpected findings during extremity inspection?
- Asymmetry
- Skin tone variations
- Absence of hair
- Dilated, twisted veins
- Nail cyanosis or swelling
These findings may suggest vascular or circulatory issues.
What are expected findings when palpating peripheral pulses?
- Consistent skin temperature
- Capillary refill less than 2 seconds
- Pulses regular, equal +2
These indicate adequate blood flow and circulation.
What are unexpected findings when palpating peripheral pulses?
- Hot or cold temperature
- Lack of body hair
- Tenting skin turgor
- Delayed capillary refill
- Diaphoresis
- Absent, weak, bounding, unequal pulses
- Edema
These findings require further assessment and possible intervention.
What health promotion interventions are recommended for cardiovascular health?
- Annual screenings (blood pressure, glucose, cholesterol)
- Exercise
- Stress reduction
- Dietary changes
- Alcohol intake moderation
- Tobacco cessation
These interventions aim to reduce risk factors associated with cardiovascular diseases.
What documentation is required for a cardiovascular assessment?
Include findings from physical assessments, vital signs, and patient history.
Accurate documentation is essential for continuity of care and legal purposes.
Fill in the blank: The _______ is the phase of relaxation in the cardiac cycle.
Diastole
True or False: The apical pulse is expected to be between 60-100 beats per minute.
True
What should be done for a client with chest pain?
- Stop activity
- Positioning
- Oxygen
- IV access
- ECG monitoring
These actions are critical for immediate care in a potential cardiac emergency.
Describe the assessment process for a vascular ulcer.
- Inspect location, color, border, depth
- Measure surrounding tissue
- Palpate surrounding tissue, temperature, pulses
This thorough assessment helps determine the type and severity of the ulcer.
What is the purpose of Acid-Base Balance?
Maintain a steady balance between acids and bases to achieve homeostasis
Health problems lead to imbalance
What is acidosis in terms of pH?
<7.35
Indicates an excess of hydrogen ions
What is alkalosis in terms of pH?
> 7.45
Indicates a deficiency of hydrogen ions
Name the primary regulators of Acid/Base balance.
- Buffers
- Respiratory system
- Renal system
What role do buffers play in Acid/Base balance?
Act chemically to neutralize acids or change strong acids to weak acids
Primary regulators that react immediately
How does the respiratory system regulate Acid/Base balance?
Eliminates CO2
Responds within minutes/hours to changes in acid/base
What is respiratory acidosis?
Carbonic acid excess caused by respiratory failure, hypoventilation, or medications that suppress respirations
Monitor neurological and respiratory status
What is the compensation mechanism for respiratory acidosis?
Kidneys conserve HCO3- and secrete H+ into urine
What causes respiratory alkalosis?
Carbonic acid deficit caused by hyperventilation or hypoxemia from acute pulmonary disorders
What is metabolic acidosis?
Base bicarbonate deficit caused by tissue hypoxia, ketoacidosis, or kidney disease
What compensatory mechanisms occur in metabolic acidosis?
- Increased CO2 excretion by lungs
- Kussmaul respirations
- Kidneys excrete acid
What is metabolic alkalosis?
Base bicarbonate excess caused by prolonged vomiting or increased renal excretion of hydrogen ions
What are the normal arterial blood gas (ABG) values for pH?
7.35-7.45
What are the normal arterial blood gas (ABG) values for PaO2?
80-100
What are the normal arterial blood gas (ABG) values for PaCO2?
35-45
What are the normal arterial blood gas (ABG) values for bicarbonate?
22-26
Interpret the ABG: pH 7.33, PaCO2 67 mm Hg, HCO3 37 mEq/L.
Respiratory acidosis
Interpret the ABG: pH 7.18, PaCO2 38 mm Hg, HCO3 15 mEq/L.
Metabolic acidosis
Interpret the ABG: pH 7.60, PaCO2 30 mm Hg, HCO3 22 mEq/L.
Respiratory alkalosis
Interpret the ABG: pH 7.58, PaCO2 35 mm Hg, HCO3 50 mEq/L.
Metabolic alkalosis
What is the definition of metabolic acidosis?
Bicarb deficit caused by excess acid in the body or loss of bicarb from the body
What are common causes of metabolic acidosis?
- Lactic acidosis
- Ketoacidosis
- Renal failure
- Diarrhea
What are the clinical manifestations of metabolic alkalosis?
- Confusion
- LOC
- Hypotension
- Tetany
What causes respiratory acidosis?
Excess of dissolved carbon dioxide (carbonic acid); can be acute or chronic
What are common causes of respiratory alkalosis?
- Anxiety-induced hyperventilation
- Fever
- Early salicylate intoxication
What is the compensation for metabolic acidosis?
Rate & depth of respirations increase, eliminating additional CO2
What happens when a patient has metabolic acidosis corrected?
K shifts back into the intracellular space, can lead to hypokalemia & cardiac dysrhythmias
How does the renal system compensate for respiratory acidosis?
Kidneys conserve bicarbonate to restore carbonic acid:bicarbonate ratio
What is the primary intervention for respiratory alkalosis?
Teach client to breathe more slowly
Normal potassium level
3.5-5
Normal Calcium
9-10.5
Mag
1.3-2.1
What is this called and how do you test for it?
Trueso
Place blood pressure cuff on arm, inflate to
> patient’s SBP, keep inflated 1-4 minutes,
under the hypoxic condition, a palmar
flexion will occur if hypocalcemic = Positive Trousseau.
What is this sign and how do you test for it?
To test for Chvostek sign: tap the face just below and in front of the ear to trigger
facial twitching of one side of the mouth, nose, and
Cheek = hypocalcemia
What effect do hypertonic solutions (D5 ½ NS) have on cells?
Cause cells to shrink
Hypertonic solutions have a higher concentration of solutes compared to the inside of the cell, leading to water moving out of the cell.
What happens to cells in isotonic solutions (0.9% NS, LR)?
Remains the same
Isotonic solutions have the same solute concentration as the cell’s interior, resulting in no net movement of water.
What is the effect of hypotonic solutions (0.45% NS) on cells?
Cause cells to swell
Hypotonic solutions have a lower concentration of solutes than the inside of the cell, leading to water moving into the cell.
What situations would call for hypotonic solutions?
- Hyponatremia
- Diarrhea
- Vomiting
Hypotonic solutions are used to treat conditions where there is a need to replenish fluids or electrolytes.
In what situations are hypertonic solutions indicated?
- Low blood pressure
- Heavy fluid loss
- Too much potassium
- Diabetes
- Kidney disease
- Liver cirrhosis
- Burns or wounds
Hypertonic solutions are administered to manage specific medical conditions that require fluid balance.
When are isotonic solutions used?
- Low blood pressure
- Low sodium
Isotonic solutions help maintain blood pressure and electrolyte balance.
Name two symptoms of malnutrition.
- Malabsorption symptoms
- Tetany
Malnutrition can manifest in various ways, including difficulty absorbing nutrients and muscle spasms.
What are some causes of metabolic acidosis?
- Dialysis
- Renal failure
- Alcoholism
- Loop and thiazide diuretic use
Metabolic acidosis can occur due to impaired kidney function or excessive loss of bicarbonate.
What should be monitored during intravenous therapy?
- Infection
- Phlebitis
- Thrombosis
- Extravasation
- Thrombophlebitis
- Ecchymosis
- Hematoma
- Venous spasm
- Nerve damage
- Circulatory overload
- Catheter embolism
- Infiltration
Monitoring is crucial to prevent and identify complications associated with intravenous therapy.
What symptoms indicate phlebitis?
- Warm skin
- Red streaks from insertion site
Phlebitis is inflammation of a vein, often caused by irritation from the IV catheter.
What are the signs of thrombosis in an IV?
- Swelling
- Pain
- Skin discoloration
- Warm to touch
Thrombosis indicates the presence of a blood clot in the vein, which may require immediate intervention.
What happens in case of extravasation?
Leakage of a vesicant into tissue
Extravasation can cause tissue damage and requires prompt recognition and management.
What are the signs and symptoms of circulatory overload?
- Respiratory symptoms
Circulatory overload occurs when excess fluid accumulates in the circulatory system, potentially leading to respiratory distress.
What should you always check when discontinuing an IV?
Catheter tip
Ensuring the catheter tip is intact is critical to prevent complications.
True or False: Intravenous therapy can lead to nerve damage.
True
Nerve damage can occur if the IV catheter punctures a nerve, leading to symptoms like tingling or numbness.
Fill in the blank: __________ can occur due to excessive fluid administration in IV therapy.
[Circulatory overload]
Circulatory overload is a serious condition that requires monitoring during fluid administration.
What are the key features of heat stroke?
True medical emergency
Body temp may exceed 104° F (40° C)
High mortality rate without treatment
Exertional—sudden onset; from strenuous
physical activity in hot, humid conditions
Non-exertional (classic)—occurs over period of
time from chronic exposure to hot, humid
environment
What are the key
features of heat
stroke?
What are some complications of heat stroke?
- Multiple organ dysfunction syndrome
- Renal impairment
- Electrolyte and acid-base disturbances
- Coagulopathy
- Pulmonary edema
- Cerebral edema
List some interventions for snakebite hospital care.
- Supplemental oxygen
- IV lines for NSS or RL
- Continuous cardiac, BP monitoring
- Opioids
- Tetanus prophylaxis
- Wound care
- Broad-spectrum antibiotics
- Baseline laboratory values with CBC, CK, crossmatch
What should be done in the field for snakebites?
- Immobilize
- Keep warm
- NO alcohol
- Do not suck the bite
- NO ice
What is serum sickness?
Type III hypersensitivity reaction developing in 3 to 21 days with skin rash.
What symptoms progress in serum sickness?
- Fever
- Joint pain
- Pruritus (itching)
What is the mnemonic for identifying coral snake venom?
Red on yellow can kill a fellow, red and black venom lack.
What are the effects of a brown recluse spider bite?
- Ulcerative lesions
- Necrotic wound (necrotic arachnidism)
- Systemic effects (loxoscelism)
What is included in hospital care for a brown recluse spider bite?
- Topical antiseptic and sterile dressing
- Ice first four days
- Possible antibiotics
- Possible reconstructive surgery
- Supportive care for loxoscelism
What is a key treatment for a black widow spider bite?
- Monitor vital signs
- Opioid pain medication
- Muscle relaxants
- Tetanus prophylaxis
- Antihypertensive agents
- Treatment of pulmonary edema, uncontrollable hypertension, shock
What is the potential reaction from bee and wasp stings?
Potential for anaphylactic reaction.
What emergency care should be provided for bee and wasp stings?
- Remove stinger
- Apply ice pack
- Ensure airway, breathing, circulation
- EpiPen administration for allergic patients
What are symptoms of anaphylaxis?
- Respiratory distress with bronchospasm
- Laryngeal edema
- Hypotension
- Decline in mental status
- Cardiac dysrhythmias
True or False: Anaphylaxis is a life-threatening allergic response.
True
At what core body temperature does hypothermia occur?
Core body temp < 95°F (35°C)
What are the categories of hypothermia by severity?
- Mild: 90-97°F (32-36°C)
- Moderate: 82-90°F (28-32°C)
- Severe: below 82°F (< 28°C)
What is a management strategy for severe hypothermia?
- Prevent ventricular fibrillation
- Maintain ABCs
- May withhold IV drugs
- After-drop management
- Extracorporeal rewarming methods
What are the characteristics of frostbite?
- Initial pain
- Numbness
- Pallor of affected area
What is required for deep frostbite management?
Aggressive management in a medical facility.
What happens to SA nodal cells with aging?
They decrease as fibrous tissue takes over.
This contributes to changes in heart function and conduction.
How does aging affect conduction time in the heart?
Conduction time increases.
What occurs to the left ventricle as a person ages?
It enlarges and becomes stiff.
What is the impact of fibrotic changes on diastolic filling?
It decreases the speed of diastolic filling by half, which can decrease cardiac output.
What changes occur to the aorta with aging?
The aorta thickens and becomes stiffer, increasing peripheral resistance.
What is the consequence of increased peripheral resistance on blood pressure?
The left ventricle pumps against greater pressure, leading to greater systolic blood pressure.
How do baroreceptors change with aging?
They become less sensitive, leading to orthostatic hypotension.
What is infective endocarditis?
A microbial infection of the endothelial surface of the heart.
What increases the likelihood of developing infective endocarditis?
Having prosthetic heart valves or structural defects.
What is a common complication of right-sided infective endocarditis?
Emboli in the lungs.
Who is at increased risk for infective endocarditis?
Elderly individuals and those with more valve problems.
List some risk factors for infective endocarditis.
- IV drug users
- Hemodialysis
- Systemic infection
- Dental procedures
- Body piercings
What is the diagnostic method for infective endocarditis?
Three sets of cultures drawn over a 24-hour period prior to antibiotic treatment.
What confirms the diagnosis of infective endocarditis?
Microorganism found in 2 separate blood cultures.
What role does an echocardiogram play in diagnosing infective endocarditis?
It helps identify lesions and confirm the diagnosis.
What are the signs and symptoms of infective endocarditis?
- Development of heart failure
- Evidence of systemic embolization
- Petechiae
- Splinter hemorrhages
- Osler nodes
- Janeway lesions
- Roth spots
- Positive blood cultures
What is the most common complication of infective endocarditis?
Heart failure.
What symptoms are associated with right-sided infective endocarditis?
- Peripheral edema
- Weight gain
- Anorexia
What symptoms are associated with left-sided infective endocarditis?
- Fatigue
- Shortness of breath
- Crackles
What are potential sources of arterial emboli in infective endocarditis?
- Spleen
- Kidney
- GI tract
- Brain
- Extremities
What is a symptom of splenic infarction?
Sudden abdominal pain radiates to the left shoulder.
What are some symptoms of renal infarction?
- Flank pain radiates to groin
- Hematuria or pyuria
What are the cardinal symptoms of cardiac tamponade?
- Falling systolic blood pressure
- Narrowing pulse pressure
- Rising venous pressure
- Distant or muffled heart sounds
What are the signs and symptoms of rheumatic endocarditis?
- Tachycardia
- Cardiomegaly
- New murmur or change in existing murmur
- Friction rub
- Precordial pain
- EKG changes
- Heart failure
What is the drug of choice for treating rheumatic endocarditis?
Penicillin.
What is the recommended duration for antibiotic treatment in rheumatic endocarditis?
10 days.
What is the purpose of prophylaxis with antibiotics in rheumatic endocarditis?
To prevent infective endocarditis.
What does PAD stand for?
Peripheral Artery Disease.
What is the primary characteristic of PAD?
Systemic atherosclerosis leading to partial or total arterial occlusion.
What are the stages of PAD?
- Stage 1: Asymptomatic
- Stage 2: Claudication
- Stage 3: Rest pain
- Stage 4: Necrosis
What symptoms characterize Stage 2 PAD?
Muscle pain and cramping occurring with exercise, relieved by rest.
What symptoms are associated with Stage 3 PAD?
Common at night, described as numbness or burning in the distal extremity.
What are the symptoms of Stage 4 PAD?
Ulcers and blackened tissue on toes, forefoot, and heel, with a gangrenous odor.
What are some signs and symptoms of PAD?
- Loss of hair on lower calf, ankle, and foot
- Dry, scaly, dusky, pale, or mottled skin
- Thick toenails
- Pallor when extremity is elevated
- Rubor when extremity is lowered
- Muscle atrophy
What is the most sensitive indicator of PAD?
Posterior tibial pulse.
What diagnostic methods are used for PAD?
- MRA
- Doppler
- Ultrasound
- ABI
What is a nonsurgical intervention for PAD?
Exercise may improve arterial blood flow through collateral circulation.
What positioning should be avoided in PAD?
Raising legs above the level of the heart.
What is Virchow’s triad?
Stasis of blood, vessel wall injury, and altered blood coagulation.
What are common risk factors for DVT?
- Post-surgery (hip, knee, open prostate)
- Immobility
What are manifestations of DVT?
- Calf or groin tenderness
- Unilateral swelling
- Warmth and redness
What diagnostic tool is commonly used for DVT?
Venous duplex ultrasonography.
What lab test is ordered for suspected DVT?
D-dimer.
What is a key intervention for managing DVT?
Anticoagulant therapy.
What is the DASH diet?
A cardiac diet including fruits, veggies, whole grains, lean proteins, and low-fat dairy.
What does QSEN stand for?
Quality and Safety Education for Nurses
QSEN is an initiative aimed at preparing future nurses with the knowledge, skills, and attitudes to improve the quality and safety of healthcare systems.
Define Clinical Judgment.
The process of making informed decisions in patient care based on assessment data, critical thinking, and clinical expertise.
What is Patient-Centered Care?
Care that is respectful of and responsive to individual patient preferences, needs, and values.
What is the primary goal of Safety in nursing?
To keep the patient safe, free from harm, and minimize errors in care.
List the components of the SBAR communication tool.
- Situation
- Background
- Assessment
- Recommendation
What is Delegated Responsibility in nursing?
A nursing activity, skill, or procedure transferred from a licensed nurse to a delegatee, like an LPN/VN or assistive personnel.
Who is accountable for delegated tasks?
The nurse who delegates the task.
What are the 5 Rights of Delegation?
- Right task
- Right circumstances
- Right person
- Right communication
- Right supervision
What are the responsibilities of a Practical Nurse?
- Collect subjective and objective data and report changes
- Create a plan to address client problems under supervision
- Collaborate with RN to take action
- Evaluate the effectiveness of interventions
Define Evidence-Based Practice.
The integration of the best current evidence and practices to make decisions about patient care, considering patient preferences and clinical expertise.
What is the importance of Priority Setting in nursing?
It ensures that acute problems are addressed before chronic problems due to the higher risk posed by acute issues.
Differentiate between Unstable and Stable clients.
Unstable clients pose a greater threat and need care first, while stable clients can wait.
Fill in the blank: Urgent needs pose a greater threat to a client than a _______ need.
nonurgent
What are the steps in Abdomen Assessment?
- Inspect
- Auscultate
- Palpate
What changes occur in the respiratory system with age?
- Alveolar surface area decreases
- Diffusion capacity decreases
- Elastic recoil decreases
- Bronchioles and alveolar ducts dilate
- Ability to cough decreases
- Airways close early
- Residual volume increases
- Vital capacity decreases
- Efficiency of oxygen and carbon dioxide exchange decreases
- Elasticity decreases
What are some common labs used in a Respiratory Assessment?
- RBC
- ABG
- Sputum specimens
List some diagnostic tests used for respiratory assessment.
- Chest x-rays
- CT scans
- Pulse oximetry
- Capnometry
- Capnography
- Pulmonary Function Tests (PFTs)
- Exercise testing
