Final Exam Study Guide Flashcards
Identify factors that influence cardiovascular function
Age
Stress
Allergic reaction
Altitude
Pregnancy
Nutrition
Obesity
Exercise
Tobacco
Substance abuse
meds
S/S of Left Sided Heart Failure
Crackles
SOB
Productive cough (frothy/pink)
PE
Dyspnea
Decreased SPO2
Increased RR, HR, BP
Cardiomyopathy
Edema
Weight gain
Cyanosis/pallor
Confusion
Bounding pulses
Fatigue
Cool to touch/wet skin
S/S of Right Sided Heart Failure
Peripheral edema/JVD
Abdominal distention/pain
Murmurs
Full feeling in stomach
Urgency to urinate
Nausea/vomiting
Increased BP
anorexia
S/S of Anemia
Tachycardia
Fatigue
Pallor
Confusion
Diminished pulses
S/S of Peripheral Artery Disease (PAD) and what is it?
Buildup of fatty, cholesterol-containing deposits on artery walls (atherosclerosis)
Coldness in lower leg or foot
Leg numbness or weakness
No pulse or weak pulse
Cramping after activities
Shiny skin on leg
Vasodilators: function, suffix, example
Dilate blood vessels and ease cardiac workload
-pril
Ex: nitroglycerin
Beta-Adrenergic Blockers: function, suffix, example
Reduce workload of heart and reduce oxygen consumption (relax heart)
-olol
metoprolol
Positive Inotropic Agents: function, example
Improve effectiveness of heart’s pumping action without excess workload or oxygen demands (decreases heart rate, for heart failure)
Ex: digoxin
Diuretic: function, example
Reduce volume of circulating blood; prevent accumulation of fluid in pulmonary circulation and body tissues (heart failure)
Ex: furosemide
Anticoagulants: function, examples
Blood thinner (prevents clots)
Ex: heparin, enoxaparin
S/S of Arterial Insufficiency
Pallor/cyanotic/necrotic
Cool to touch
Diminished/weak/absent pulses
Slow cap refill
Wounds (dry/necrotic)
Loss of hair
Pain upon activity (intermittent claudication)
S/S of Venous Insufficiency
Erythema/”ruddy”
Swelling, edema, oozy
Warmth
Painful (esp when extremity is dependent [hanging down])
Wounds with drainage
Cognitive Domain of Learning: definition, examples
Storing and recalling of new knowledge in the brain
Ex: lecture, panel, discovery, written materials
Psychomotor Domain of Learning: definition, examples
Learning a physical skill
Ex: demonstration, discovery, printed materials
Affective Domain of Learning: definition, examples
Changing attitudes, values, and feelings; encouraging
Ex: role modeling, discussion, audiovisual materials
Identify factors that can affect learning
Age and developmental level
Family support networks
Financial resources
Cultural influences
Language deficits
Health literacy level
Identify strategies for motivating learners
Let them know what’s in it for them
Teaching in a way that the client prefers or learns best in
Metabolic Acidosis: causes, S/S
Causes: kidney failure, liver failure, severe diarrhea (ASSidosis)
S/S: kussmaul breathing (deep and fast), hyperkalemia
Metabolic Alkalosis: causes, S/S
Causes: loss of gastric contents; vomiting (AHHlkalosis)
S/S: HYPOventilation
Respiratory Acidosis: causes, S/S
Causes: HYPOventilation= drug overdose, opioids, sleep apnea, COPD, asthma
S/S: increased bicarbonate
Respiratory Alkalosis: causes, S/S
Causes: HYPERventilation= pain, anxiety, fear
S/S: decreased bicarbonate
S/S of Hypervolemia: VS, skin, neuro, CV/pulmonary, GU, labs
VS: HTN, increased temp, bounding pulses, increased RR/HR
Skin: moist/wet/oozy skin/wounds, warm, redness, edema, moist mucous membranes
Neuro: decreased mobility, decreased ROM, confusion, weakness
CV/Pulmonary: tachycardia, tachypnea, crackles, regurgitation in heart, productive cough, dyspnea, JVD, S3 sounds
GU: increased urination, clear urine
Labs: decreased Hct, K, Na, osmolality
S/S of Hypovolemia: VS, skin, neuro, CV/pulmonary, GU, labs
VS: hypotension, weak pulses, increased RR/HR, decreased SPO2
Skin: dry, cool, pallor, decreased skin turgor, dry mucous membranes
Neuro: confusion, weakness, lethargy, cramping, no perspiration
CV/Pulmonary: tachycardia, tachypnea, orthostatic hypotension, weak pulses, slow cap refill
GU: decreased urination, dark/concentrated urine, no output
Labs: hyperkalemia, hypernatremia, increased Hct, increased Hgb, increased osmolality
Hypotonic Fluids: function, uses, examples
ECF moves inside cell; CELL SWELLS
Uses: dehydrated cells, DKA, hyperglycemia
Ex: 5% dextrose in water (D5W), 0.25% NaCl (¼ NS), 0.45% NaCl (½ NS)
Isotonic Fluids: function, uses, examples
Increase ECF volume (blood volume)
Uses: bl loss, surgery, vomit, diarrhea, dehydration
Ex: lactated ringers, 0.9% NaCL
Hypertonic Fluids: function, uses, examples
ICF moves outside of cell; CELL SHRINKS
Uses: swollen cells, cerebral edema, HYPONATREMIA
Ex: 5% dextrose in 0.45 NaCl, 5% dextrose in 0.9% NaCl, 3% NaCl
Phlebitis: definition, S/S, intervention
Inflammation of a vein
Pain, increased skin temp, redness
D/C IV line, apply moist WARM compress, monitor IV site for redness/tenderness to prevent infection
Infiltration: definition, S/S, intervention
Leakage of IV solution or med into extravascular tissue (does not irritate tissue)
Edema, pallor, decreased skin temp around site, pain
D/C IV line, elevate extremity, WARM compress to absorb fluid
Extravasation: definition, S/S, intervention
IV catheter becomes dislodged and med infuses into tissues (irritates tissue)
Pain, stinging, burning, swelling, redness at site
D/C IV line, apply COOL compress, admin antidote if exists for med
Factors that cause slowed peristalsis
Some foods: cheese, milk, etc
Narcotic pain meds
Antacids
Iron supplements (black/dark brown stools)
Stress
Immobility
Nerve damage (e.g. abdominal surgery/spinal cord injury)
Food allergies
Dehydration
Factors that cause rapid peristalsis
Antibiotics
Laxatives
Magnesium
Vitamin C
Stress
Food allergies/lactose intolerance
Infections
Bowel diseases: IBS, celiac, crohn’s, ulcerative colitis
Caffeine
List nursing interventions that promote normal bowel elimination
Avoid stimulant laxatives (cause painful peristalsis/diarrhea which could lead to dehydration/electrolyte imbalance)
Adequate fiber intake (increases wt and size of stool and softens it)
AT LEAST 6-8 glasses of water per day
Maintain regular eating schedule
Avoid holding it in (causes more water to be absorbed in colon)
Be active/exercise
White or clay-colored stool
absence of bile or use of antacids
Light brown stool
diet high in milk products (light color is from the Ca)
Pale, fatty stools
malabsorption of fat
Black, tarry stool
use of iron meds, upper GI bleeds, lg quantities of red meat
Red stool
bleeding in lower intestinal tract or hemorrhoids
Narrow, pencil shaped stool
intestinal constriction (inflammation)
Small, marble shaped stool
Constipation/slow peristalsis/dehydration
Hard stool
Constipation/slow peristalsis/dehydration
Liquid stool
diarrhea/rapid peristalsis
Strong, foul odor stool
Blood, infection (C. Diff)
Small amounts of water, “oozy” stool
can see it in bowel obstruction
Ileostomy: location, complications, stool consistency
In ileum of small intestine, avoids all colon
Increase caloric diet and supplements (risk of malnutrition)
Watery stool
Ascending Colostomy: stool consistency
pudding thick stool
Transverse Colostomy: stool consistency
less watery/semi-formed stool
Sigmoid Colostomy: stool consistency
formed stool
Stoma assessments- what should be assessed, what is “normal”, and what is “abnormal”
Expected to be beefy red and moist
Assess peri area for skin breakdown
Black or cyanotic tissue is abnormal
Factors that caused increased urinary output
Diabetes, UTIs (sometimes), diuretics, increased fluid intake
Factors that cause decreased urinary output
Dehydration, high fever, antihistamines and drugs with anticholinergic effects, some antidepressants
Know nursing considerations of diuretics
Watch potassium, and other electrolyte levels
Systolic BP > 100
Give in morning, not before bed
Be able to identify the “normal” amount of urinary output in health persons
At least 30 mL/hr or 720 mL/24 hrs
50-60 mL/hr is ideal
Clean catch urine
Collected during midstream (sterile specimen)
Sterile Urine Specimen
May be obtained by catheterizing pt’s bladder or taking specimen from indwelling catheter
24 Hour Collection of Urine
All urine is collected for 24 hours
List nursing interventions that promote normal urination
Adequate fluid intake
Ambulation
Compare NSAIDS vs opioid analgesics
NSAIDs are given for mild pain
Opioids are given for severe pain
Somatic Pain
Pain perceived by muscles, joints, tendons/ligaments, bones
Visceral Pain
Pain perceived by internal organs
Cutaneous Pain
Pain perceived by skin
Burns, tears, bruises, scrapes
Radiating Pain
Pain that travels from one body part to another
Referred Pain
Pain that is perceived in an area distant from point of origin
Gallbladder/pancreas pain can refer to back
Jaw pain during MI (mainly females)
Phantom Pain
Pain that often occurs with an amputated limb where receptors and nerves are clearly absent
Psychogenic Pain
Cause of pain cannot be identified
Associated w/ psychological factors; mental or emotional problems can make pain worse
Ex: back pain
S/S of Acute Pain
Increased vital signs
Severe pain can cause reflex action to escape the cause
Anxiety is usually present
The pain is not all consuming
S/S of Chronic Pain
Normal or decreased vital signs
Tends to consume entire person (demands total attention)
Physically and emotionally exhausting
Ongoing irritability, fear, isolation, fatigue, anger, helplessness, stress/anxiety, DEPRESSION
Identify factors that influence pain
Culture/ethnicity
Family
Sex
Gender
Age
Environment
Support
Anxiety/stress
Previous pain experience
Identify the components of a pain assessment
Onset
Provoking factors
Quality
Region/radiating
Severity
Time (duration)
Factors that influence sleep and rest
Sleep patterns
Motivation
Culture
Activity level
Smoking
Alcohol (decreases sleep quality)
Stress
Illness
Certain meds
Incontinence
Pain
Nausea
Environmental factors: temp and humidity
Consequences of lack of sleep
Obesity= increased appetite and decreased metabolism
Anxiety
Risk for= DM, HTN, stroke, substance abuse, depression, GI issues
Decreased alertness and response time (impaired driving)
Fatigue/sleepiness
Decreased immunity = increased risk of infections
Describe nursing strategies to promote sleep
Prepare a restful environment
Promote bedtime rituals
Offer appropriate bedtime snacks (light carb/protein) and beverages
Promote relaxation and comfort
Respect normal sleep-wake patterns
Schedule nursing care to avoid disturbances
Use meds to produce sleep
Patient education to promote sleep
REM Sleep
Eyes dart back and forth quickly
Small muscle twitching, such as on the face
Large muscle immobility, resembling paralysis
Irregular RR; sometimes apnea
Rapid/irregular pulse
BP increases or fluctuates
Increase in gastric secretions
Metabolism increases; body temp increases
Encephalogram tracings active
REM sleep enters from stage II of NREM sleep and reenters NREM sleep at stage II: arousal from sleep is difficult
Constitutes about 20 to 25% of sleep
Stage 1 NREM
Transitional stage between wakefulness and sleep
Relaxed state but still somewhat aware of surroundings
Involuntary muscle jerking may occur
Stage normally only lasts minutes
Person can be aroused easily
Constitutes only about 5% of total sleep
Stage 2 NREM
Falls into a stage of sleep
VS begin to decrease
Person can be aroused with relative ease
Constitutes 50 to 55% of sleep
Stage 3 NREM
The depth of sleep increases, and arousal becomes increasingly difficult
Deepest sleep
Everything is decreased (VS, metabolism, relaxation,etc.)
Composes about 10% of sleep
Stage 4 NREM
“Pre-REM sleep”
Alpha Waves
Early portion of Stage 1 NREM
Relaxed and sleepy
Low frequency, high amplitude waves
Beta Waves
REM sleep and awake
WAKEFULNESS
Delta Waves
Stage 3 and 4 NREM (deep) sleep
Theta Waves
During stage 1 and 2 NREM (light) sleep
Mainly seen in children
Hypersomnia
Condition characterized by excessive sleeping, especially daytime sleeping
When awake are often disoriented, irritated, restless, slower speech and thinking processes
MVA risk due to drowsiness or falling asleep while driving
Insomnia
Difficulty falling asleep, intermittent sleep, or early awakening from sleep
Feeling tired, lethargic, irritable, difficulty concentrating, delirium
Obstructive Sleep Apnea
Potentially serious sleep disorder in which the throat muscles intermittently relax and block airway during sleep, causing breathing to repeatedly stop and start
Sleepiness, fatigue, insomnia, snoring, observed apnea, irritability, fall asleep during boring activities, difficulty concentrating, slower reaction times
Risk of hypoxia
Narcolepsy
Condition characterized by an uncontrolled desire to sleep
Hallucinations, sleep paralysis, cataplexy (loss of skeletal muscle tone lasting from seconds to 1 to 2 minutes)
Can fall asleep quickly and during any activity
Parasomnias
Patterns of waking behavior that appear during sleep (sleepwalking, sleep talking, nocturnal erections)
Risk for injury
Somnambulism
sleepwalking
risk for injury/falls
Restless Leg Syndrome
A condition in which patients are unable to lie still and report experiencing unpleasant creeping, crawling, or tingling sensations in the legs
Irresistible urge to move legs when sensations occur
Sleep Deprivation
A decrease in the amount, consistency, and quality of sleep; results from decreased REM or NREM sleep
Loss of concentration, inattention, irritability
Total Cholesterol: Normal Range
<200
HDL Cholesterol: Normal Range
> 40
LDL Cholesterol: Normal Range
<100
WBC: Normal Range
5-10 billion/L
Serum Albumin: Normal Range
3.4-5.4 g/dL
ESR: Normal Range
0-15 males; 0-20 females
RBC: Normal Range
3.6-6.1 million/mcL
Hemoglobin: Normal Range
11.1-15.3 g/dL
Hematocrit: Normal Range
33.7-46%
Platelets: Normal Range
150-450 billion/L
PT: Normal Range
11.1-13.5 sec
INR: Normal Range
0.8-1.3 sec
INR: anticoagulant use range
2.0-3.0 sec
PTT: Normal Range
25-35 sec
PTT: Heparin
1.5-2.5x (25-35 sec)
Ejection Fraction: Normal Range
desired: 50-70%
bad: <40%
Brain Natriuretic Peptide (BNP): Normal Range
<100 pg/mL
Potassium: Normal Range
3.5-5.0 mEq/L
Sodium: Normal Range
135-145 mEq/L
Calcium: Normal Range
8.5-10.2 mg/dL
ABGs: pH: Normal Range
7.35-7.45
ABGs: PaCO2: Normal Range
35-45 mmHg
ABGs: HCO3: Normal Range
22-26 mEq/L
ABGs: PaO2: Normal Range
80-100 mmHg
Blood Urea Nitrogen (BUN): Normal Range
7-24 mg/dL
Creatinine: Normal Range
0.5-1.5 mg/dL
Glomerular Filtration Rate (GFR): Normal Range
> 90 mL/hr
Serum Osmolality: Normal Range
275-295 mOsm/kg
Urinalysis: pH: Normal Range
5.0-9.0 (average 6.0)
Urinalysis: Specific Gravity: Normal Range
1.002-1.030
Urinalysis: Protein: Normal Range
<20 mg/day
Urinalysis: Glucose: Normal Range
Negative
Urinalysis: Ketones: Normal Range
Negative
Urinalysis: Nitrities: Normal Range
Negative
Urinalysis: Leukocyte Esterase: Normal Range
Negative or <5 per high power field
Urinalysis: Crystals: Normal Range
Negative
Urinalysis: Casts: Normal Range
Rare or negative
Urinalysis: Bacteria: Normal Range
Negative
