FINAL EXAM Flashcards
SATA 3 out of 5: How to irrigate a wound
a. Can be accomplished by sterile or clean technique. Cleanse in direction from the least contaminated area to the most contaminated area. When irrigating, all of the solution flows from the least contaminated area to the most contaminated area. Fluid retention is avoided by positioning the patient on his or her side to encourage the flow of the irrigant from the wound. From notes: When irrigating, keep 1 inch room above the wound, position patient on the side, clean in direction least to most contaminated, use warm water, saline or mild solution.
Know objective and subjective signs
a. Objective data are observable and measurable signs like the LVN is able to observe capillary refill, measure a patient’s BP and observe and measure edema – other terms for objective data are signs and objective cues. Eg 50mL dark green-tinged vomitus, BP 100/60 mm Hg, pulse 100/min, respirations 32/min, patient holds fist over sternum, wringing hands, pacing in the hall, dark circles under eyes, yawning, naps during the day, 1-cm x 2-cm open lesion on the left heel.
b. Subjective data are information that is provided by patient; statement about nausea and description of pain, fatigue and anxiety are examples of subjective data – other terms for subjective data are symptoms and subjective cues. Subjective data is hidden until shared by patient. Eg I feel nauseated, my chest hurts, I’m nervous, my foot hurts.
Know the parts of brain: thalamus, cerebellum, cerebrum and medulla:
a. Thalamus: serves as a relay station for sensory fibers travelling from the lower brain and spinal cord region to the sensory areas of the cerebrum, sorts out the sensory information, more precise interpretation, part of diencephalon; from book: relay structure and processing center for most sensory information going to the cerebrum
b. Cerebellum: the fourth major area, is the structure that protrudes from under the occipital lobe; located at the base of the skull, mediates reflexes, coordinates motor activity, evaluates sensory input, smooths out and coordinates voluntary muscle activity; helps in the maintenance of balance and muscle tone; has more than half of the neurons in the entire brain, the interior of the cerebellum is composed largely of white tracts, looks like a tree therefore called arbor vitae; the cerebellum is connected to the brain steam by three pairs of penducles, these connections allow the cerebellum to receive, integrate, and deliver information to many parts of the brain and spinal cord; concerned with the coordination of voluntary muscle activity and maintaining equilibrium and posture
c. Cerebrum: largest part of the brain, it is divided into the right and left cerebral hemispheres which are joined together by bands of white matter that form a large fiber tract called the corpus callosum; thin layer of grey matter called the cerebral cortex forms the outermost portion of the cerebrum; white matter makes up the bulk of the cerebrum, located right below the cerebral cortex; gyrus (convolution), fissures (sulci) – central, lateral and longitudinal; 4 lobes: frontal, parietal, temporal and occipital
d. Medulla: Medulla oblongata is the vital center – vital function (regulation of heart rate, blood flow, blood pressure, respiratory centers); reflex center for coughing, sneezing and swallowing; acts a relay for sensory and motor information; emetic center for vomiting (direct activation includes stimuli from cerebral cortex (fear), stimuli from sensory organs (distressing sights, bad odors, pain), and signals from equilibrium apparatus of the inner ear (spinning); indirect stimulation of the vomiting center comes from the chemoreceptor trigger zone (CTZ) located in the floor of the fourth ventricle – the CTZ can be stimulated by emetogenic compounds, such as anticancer drugs and opioids); part of the brain stem that connects the brain to the spinal cord
Know the hormones: aldosterone, ADH (antidiuretic hormone), ACTH, cortisol
a. Aldosterone: steroid; chief mineralocorticoid; regulation of blood volume, blood pressure, and the concentration of electrolytes, primary target organ is kidney; stimulates the kidney’s reabsorption of salt and water and excretion of potassium; salt-retaining hormone, works on distal tubule and upper collecting duct of the nephron unit; mineralocorticoid that causes the kidneys to reabsorb sodium and water and excrete potassium; helps regulate extracellular fluids and electrolytes (especially sodium Na+ and potassium K+); hormone of the adrenal gland; increases Na+, H2O reabsorption, increases blood volume, increases BP
b. ADH (antidiuretic hormone): stimulates water reabsorption by the kidneys; also constricts blood vessels; hormone of the posterior pituitary gland; primary target organ is kidney, causes the kidney to reabsorb water from the urine and return it to the blood; released in response to a concentrated blood (increased osmolarity) and decreased blood volume – both which occur in dehydration; other triggers for release of ADH are stress, trauma, and drugs like morphine; causes blood vessels to constrict, which elevates blood pressure; released to conserve water; absence of ADH results in diabetes insipidus
c. ACTH (Adrenocorticotropic hormone): stimulates the adrenal cortex to secrete steroids, especially cortisol; hormone of the anterior pituitary gland; tropic hormone aimed at and control other glands, target gland is adrenal cortex, stimulating adrenal cortex to secrete steroids
d. Cortisol: steroid; chief glucocorticoid (affect carbohydrates); hormone that is secreted in greater amounts during times of stress like physiologic stress eg disease, physical injury, hemorrhage, infection, pregnancy, extreme temperature, and emotional stress like anger and worry; Glucocorticoid that helps regulate glucose, fat and protein metabolism; is part of the stress response; increases blood glucose; steroid hormone of the adrenal gland; secretion involves hypothalamus (secretes a releasing hormone which then stimulates the anterior pituitary gland), pituitary gland (from the stimulation of the releasing hormone from the hypothalamus, secretes ACTH) and adrenal cortex (the ACTH stimulates the adrenal cortex to secrete cortisol)
SATA 2 out of 5: Functions of thymus gland:
a. Assists development of immune system before puberty, secretes thymosin (promotes the proliferation and maturation of lymphocytes in lymphatic tissue throughout the body, produces T cells (lymphocytes, defend the body against disease and infection and control the immune response)
SATA 3 out of 5: know the effects of epinephrine (adrenaline) and norepinephrine
a. Catecholamine hormones (secreted in emergency or stress situations) of the adrenal gland; secreted by the adrenal gland, stimulates the “fight-or-flight” response; increases blood glucose, elevates blood pressure, increases heart rate, coverts glycogen to glucose in the liver thereby making more glucose available to cells (increases glucose), increases metabolic rate of most cells thereby providing more energy, causes bronchodilation (opening of the breathing passages) to increase the flow of air into the lungs, changes blood flow patterns causing dilation of the blood vessels to the heart and muscles and constriction of the blood vessels to the digestive tract
Parts of the heart: aorta, right atrium, left atrium and pulmonary artery:
a. Aorta: oxygenated blood flows to the rest of the body from here; oxygenated blood is received from the left ventricle thru the aortic valve (aortic semilunar valve), one of the great vessels of the heart
b. Right atrium: thin-walled cavity that receives unoxygenated blood from the venae cavae (superior vena cava and inferior vena cava); the tricuspid valve separates the right atrium from the right ventricle and regulates the blood flow from right atrium to right ventricle
c. Left atrium: thin-walled cavity that receives oxygenated blood from the lungs through four pulmonary veins; has bicuspid (mitral valve) which separates it from the left ventricle and regulates flow of blood from left atrium to left ventricle; has a small ear-shaped sac called the left atrial appendage in the wall – it is a site of thrombus formation in persons with atrial fibrillation and therefore is sometimes clipped off surgically
d. Pulmonary artery: takes unoxygenated blood which is pumped from the right ventricle into the pulmonary artery through the pulmonic valve (pulmonic semilunar valve) to the lungs for exchange of CO2 with O2.
Know about passive range of motion exercises:
a. Range of motion exercises: movement of the body that involves the muscles and joints in natural directional movement; passive ROM performed by caregivers/carers – move joints to the point of pain
Know about body mechanics, lifting, moving client up in bed:
a. Bend the knees when moving patient up with pull sheet, get help from another co-worker, do not twist back, raise the level of the bed to level of your hip
b. Use trapeze bar – allows patient to raise the trunk from bed to assist in movement, allows patient to perform exercises that strengthen upper arms; slide patient towards yourself using a pull sheet – sliding requires less effort than lifting, pull sheet keeps to a minimum any shearing forces which can damage patient’s skin
c. Question from book: Which assistive device allows patients to pull with the upper extremities to raise their trunk off the bed, to assist in transfer from bed to wheelchair, and to perform upper arm exercises? Trapeze bar
Know about maintaining client’s privacy
a. Close curtains/draw the curtains in the room
Know about enzymes: trypsin, lipase, amylase and glycogen
a. Trypsin: one of the proteases (enzymes) secreted by pancreas that digests proteins to peptides and amino acids
b. Lipase: of the intestinal enzymes secreted by the enzyme that digests fats to fatty acids and glycerol
c. Amylase: a salivary enzyme secreted by the salivary glands that begins carbohydrate digestion to disaccharides; digests polysaccharides to disaccharides
d. Glycogen: animal starch, highly branched polysaccharide, form which human store glucose, stored primarily in the liver and skeletal muscle; performs two important roles: 1. Glycogen stores help regulate blood sugar – when blood sugar levels are low the glycogen in the liver is converted to glucose and released into blood and when blood glucose increases after a meal, the excess glucose is converted by the liver to glycogen for storage 2. Glycogen acts as a storage energy in skeletal muscle – when muscle contractile activity increases as in running glycogen is converted to glucose and burned as fuel
Know about villi, cilia, rugae
a. Villi: circular folds with fingerlike projections on the wall of the small intestines, function in the absorption of digestive end products; inside of the villi is composed of capillaries and lacteals; how the end products of digestion are delivered to hepatic portal system and lymphatics
b. Cilia: hairlike projections that move substances across the surface of a cell membrane
c. Rugae: part of the stomach that increases and decreases in size; thick accordion-like folds
Know about functions and content of: liver, small intestines, pancreas and gallbladder
a. Liver: synthesis of bile salts and secretion of bile; synthesis of plasma proteins; storage of glucose, fat-soluble vitamins, detoxification (main organ for drug detoxification); excretion of bilirubin, cholesterol, drugs; metabolism of carbohydrates, protein, fats; phagocytosis (Kuffer cells, macrophages); bile is formed from blood in the liver lobules and assists in digestion of fat, it is stored in the gallbladder; largest gland in the body
b. Small intestines: receives chyme from the stomach and digestive juices from the liver (bile) and pancreas (digestive enzymes); the process of digestion is completed in the small intestines; absorbs the end products of digestion and key substances such as iron and vitamins; moves the unabsorbed content into the large intestine; the small intestine consists of 3 parts: the duodenum, the jejunum and the ileum; digests, absorbs, and secretes hormones and digestive enzymes
c. Pancreas: secretes both endocrine and exocrine substances; in addition to digestive enzymes, the pancreas also secretes an alkaline juice rich in bicarbonate (this neutralizes the highly acidic chyme coming from the stomach into the duodenum); acinar cells secrete the pancreatic enzymes in their inactive form and the enzymes travel through the main pancreatic duct to the duodenum and are activated in the duodenum; pancreatic enzymes are the most important of all digestive enzymes
d. Gallbladder: concentrates and stores bile; fat in the duodenum stimulates release of the hormone cholecystokinin (CCK) which causes the gallbladder to contract, eject bile into common bile duct and duodenum; concentrates about 1200mL of bile each day
Kidney; know these parts and their functions: Glomerulus, Loop of Henle, Proximal Convoluted Tubule and Distal Convoluted Tubule
voluted Tubule:
a. Glomerulus: a cluster of filtering capillaries partially surrounded by the glomerular capsule called Bowman’s capsule (a C-shaped structure); urine formation begins here, glomerular filtration causes water and dissolved substances to move from the glomerulus into Bowman’s capsule; about 20% of blood that flows through the glomeruli is filtered into the tubules, the remaining 80% of the blood leaves the glomeruli by the efferent arterioles and continues into the peritubular capillaries; blood pressure determines glomerular filtration rate (GFR)
b. Loop of Henle: contains a descending and ascending limb – the ascending limb becomes the distal convoluted tubule
c. Proximal Convoluted Tubule: the Bowman capsule extends the glomerulus as a highly coiled tubule called the proximal convoluted tubule which dips towards the Loop of Henle; most re-absorption takes place in the proximal convoluted tubule – returns filtrate from the tubules to the blood of peritubular capillaries – the kidney chooses the type and quantity of substances it reabsorbs; tubular reabsorption is thru active (example: sodium pumped from tubule into peritubular capillary) or passive (example: H2O and Cl- passively follow sodium into peritubular capillary)
d. Distal Convoluted Tubule: ascending limb of Loop of Henle becomes distal convoluted tubule, the distal convoluted tubules of several nephrons units empty into a collecting duct; aldosterone secreted by adrenal cortex acts primarily on the distal convoluted tubule, stimulates the reabsorption of sodium and water and the excretion of potassium, increases blood volumes and blood pressure
Respiratory activity: CO2, PCO2 and bicarbonate
a. CO2 diffuses from cells to capillaries, a consequence of cell metabolism; in the lungs CO2 moves into the alveoli from the blood; 70% transported as bicarbonate, 20% transported as carbaminohemoglobin and 10% dissolved in plasma and transported
b. PCO2: Partial pressure of CO2 that CO2 contributes; main regulator of respiration; partial pressure of CO2; PO2 in the capillary is 45 mm Hg and PO2 in the alveoli is 40 mm Hg, CO2 diffuses from high pressure to low pressure – from capillaries to the alveoli; PO2 in the cells/tissues is 50 mm Hg while arterial is 40 mm Hg, therefore CO2 diffuses from the cells/tissues to the arterial blood
c. Bicarbonate: 70% of CO2 is transported as bicarbonate or HCO3-; blood carries most of the carbon dioxide in the form of bicarbonate
Respiratory activity: which event occurs in response to an increase in thoracic volume?
a. As volume increases, pressure decreases, air flows into the lungs (from higher pressure to lower pressure – from outside the nose into the lungs) - Boyle’s Law
Muscles, know the functions and location of: hamstring group, triceps, quadriceps femoris group
a. Hamstring group: (consists of biceps femoris, semitendinosus and semimembranosus) as a group they flex leg at knee, extend thigh at hip; antagonistic to quadriceps femoris
b. Triceps: the muscles extend the forearm at elbow, extends arm at shoulder, is also known as boxer muscles
c. Quadriceps femoris group: (consists of rectus femoris, vastus lateralis, vastus medialis, vastus intermedius) group used to extend leg at the knee (eg kicking a football); rectus femoris can flex thigh at hip; vastus lateralis is common site for intramuscular injections in children
What factors stimulate bones to grow thicker and wider in adults?
a. Osteoclastic and osteoblastic activity – osteoclasts are bone-destroying cells, they hollow out bone through bone resorption which widens the bone. Osteoblasts on the undersurface of the periosteum continuously deposit bone on the external bone surface. Whereas osteoblasts build new bone, osteoclasts, found on the inner bone surface surrounding the medullary cavity, break down bone tissue thereby hollowing out the interior of the bone; osteoblasts and osteoclasts gradually create a large, wide, hollow bone that is strong but not heavy
b. Weight bearing exercises
Contributing to a care plan, the cues that you will use to choose the nursing diagnosis for a problem:
a. Subjective and objective data, signs, symptoms and patient health history; nursing diagnosis is based on NANDA-I (North American Nursing Association – International), judgment, actual/pertaining to your problem (eg infection), identify the patient’s problems, identify human responses to health conditions or their concern about the problem (eg anxiety, fear, intolerance, nausea, grieving); clustering of data helps to identify patterns that assist with identification of patient’s health problems – done by grouping related cues together from data collected (eg thirst, dry skin, dry oral mucous membranes, increased body temperature and decreased urine output = cue cluster for “deficient fluid volume” which is a nursing diagnosis)
Where to locate the heart?
a. Located between second rib and fifth and sixth intercostal space
Nursing process, know the difference between: evaluation, implementation, assessment and planning
a. Evaluation: evaluate nursing interventions/care plans, were goals met; the nurse should make one of the three judgments or decisions: the outcome goals were achieved, the outcome was not achieved, the outcome was partially achieved; the plan of care is changed during this phase of nursing process; modifications can be made if outcome has been achieved, partially achieved or not achieved
b. Implementation: nursing interventions – plan, outcome, what to do; nursing interventions are activities that promote the achievement of the desired patient outcome, classified as physician prescribed (actions ordered by a physician for a nurse or other health care professional to perform or nurse prescribed (any actions that a nurse is legally able to order or begin independently; nurses write interventions for themselves or other nurses eg to provide back massage, turning patient every 2 hours, watching for complications); a properly written nursing intervention is specific for the problem, realistic for the patient, compatible with the medical plan of care and based on scientific, evidence based principles – should include: subject (nurse is assumed unless stated), action verb, and qualifying details eg ambulate the patient 30 feet 3 times a day at 0900, 1400 and 1900
c. Assessment: physical assessment – head to toe, subjective (verbal by patient, symptoms for example I feel dizzy), objective (what the nurse observes – observable and measurable signs for example blood pressure 190/100, capillary refill, edema, etc), interview to gather information about patient’s condition which includes psychological, sociocultural, spiritual, economic and lifestyle factors; complete assessment includes review and physical examination of the body systems: musculoskeletal, respiratory, gastrointestinal, cardiac, neurologic, genitourinary, integumentary and sensory; focused assessment involves data bout a specific health problem, especially when patient is critically ill, disoriented or unable to respond
d. Planning: nurse uses the nursing diagnosis to develop expected outcomes which must be SMART – specific, measurable, accurate, realistic, within a time frame; outcome is usually reversal of a problem eg problem is impaired skin, outcome is intact skin; example of outcome: the patient will transfer from bed to w/c 2x in my shift, the patient will verbalize relief of pain from 8/10 to 3/10 within 30 minutes after pain medication administration; outcomes can be long-term (eg use walker to ambulate at all times rather than wheelchair within the next 2 months) or short term goals (ambulate 20 feet every day with the assistance of her walker, increasing distance ambulated by 5 feet daily)
Standard precaution to prevent spread of infection, holding soiled linens:
a. Hold away from the body, use gloves
Preventing infection process
a. Hand hygiene
Know the difference between American Nurse Association (ANA) code and Nurse Practice Act
a. American Nurse Association (ANA) code: a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession – ethical obligations and duties of every nurse
b. Nurse Practice Act: the do’s and don’ts, identifies roles and responsibilities of the LVN; defines and limits the scope of nursing in a given state
What are the characteristics role and responsibilities of a vocational nurse?
a. Demonstrate professional behaviors of accountability and professionalism according to the legal and ethical standards for a competent licensed practical/vocational nurse; effectively communicate with patients, significant support person(s) and members of the interdisciplinary health care team incorporating interpersonal and therapeutic communication skills; collect holistic assessment data from multiple sources, communicate the data to appropriate health care providers and evaluate patient responses to interventions; collaborate with RN or other members of the health care team to organize and incorporate assessment data to plan/revise patient care and actions based on established nursing diagnoses, nursing protocols, and assessment and evaluation data; demonstrate a caring and empathetic approach to the safe, therapeutic, and individualized care of each patient; implement patient care, at the direction of an RN, a licensed physician, or a dentist through performance of nursing interventions or directing aspects of care, as appropriate to UAP
b. Nursing actions that are appropriate to the roles/responsibilities of the LVN: uses active listening techniques when interacting with a depressed patient, reports changes in vital signs to the supervising RN and HCP in a timely fashion, ensures that the correct medication is given to the correct patient at the correct time, collects data from the patient the family and previous medical records
SATA 4 out of 5: Know standards of care in hospitals applied by Florence Nightingale:
a. Provided sanitary conditions which were non-existent prior
b. Cleaned units, washed clothes
c. Knew nutrition important – nutrition improvement
d. Kept records, new equipment
Know the Maslow Hierarchy of Needs, know the difference between levels:
a. Physiologic: breathing, food, water, sex, sleep, homeostasis, excretion
b. Safety and security: security of body, of employment, of resources, of mortality, of the family of health, of property
c. Love and belongingness: friendship, family, sexual intimacy
d. Esteem: self-esteem, confidence, achievement, respect of others, respect by others
e. Self-Actualization: morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
About soap suds enema, what is purging
a. Priming; unclamp, fill with solution, then clamp = ready to use
SATA 4 out of 5: Every time after procedure, what are the information which are part of documentation that the nurse is required to document?
a. Documentation should be clear, concise, complete and accurate, date, time, type of procedure done, patient’s response to treatment, analgesics and/or medications, reason for performing the procedure, describes exactly what happened, any PPE used, document objectively, documentation should be narrative of the procedure done, document right after you do the procedure, patient teaching, sign and date
