Final Midterm Review Flashcards
What is the acceptable temperature range for adults?
96.8-100.4
Average oral/tympanic temp in adults is…
98.6
Average rectal temp in adults is…
99.5
Average axillary temp in adults is…
97.7
Temperature control is regulated by…
the hypothalamus
The anterior hypothalamus controls heat _____.
loss
The posterior hypothalamus controls heat _____.
production
Radiation is the transfer of…
heat from one surface to another
Convention is the transfer of heat by…
air
A fan blowing on a surface promotes…
heat loss.
Conduction is the transfer of heat from…
one molecule to another of lower temperature
Dispursion of heat through air current is known as…
convection.
Name 5 methods of assessing temperature and the cautions of each.
- Orally; wait 20-30 mins after eating/drinking 2. Temporal; Forehead, not reliable due to variables 3. Tympanic Membrane; Watch for cerumen, eardrum and redness (indicating possible infection) 4. Axillary; Surface reading, caution of seat, add 1 degree to reading 5. Rectal; Contraindictions (should be used with those who have diarareah, rectal surgery, etc. Could effect cranial nerve 10
A pt presenting a temp of 104°F with no diaphorisis may be symptomatic of
heatstroke
A pt presenting with high temp and profuse diaphoresis may be symptomatic of
heat exhaustion
Someone who is hypovolemic needs…
water & electrolytes (Sugar/salt water)
What is cardiac output and how is it calculated?
• Total amount of blood pumped in 1 minute • HR x SV (Heart Rate x Stroke Volume)
What is arythmia?
This is when the heart beats too quickly, too slowly, or with an irregular pattern
What is dysrhythmia?
An abnormal heartbeat
Where are all the places you can take a pulse?
- Temporal (temples of head) 2. Carotid (at neck) 3. Apical (on chest surface) 4. Brachial (at bend of elbow) 5. Radial (wrist at thumb) 6. Femoral (where leg meets torso, toward groin) 7. Popliteal (behind knee) 8. Posterior tibial (inside of ankle bone) 9. Dorsalis pedis (top of foot)
When listening to the “lub, dub” of the heartbeat, the “lub” is known as __ and represents the closure of the ___ valves known as the _____ and the _____.
S1, AV, Tricuspid, Mitral/bicuspid
When listening to the “lub, dub” of the heartbeat, the “dub” is known as __ and represents the closure of the ___ valves known as the _____ and the _____.
S2, Semilunar valves, pulmonic, aortic
The five points at which to listen to the heart are represented by what acronym? Describe each point
All Patients Take Medicine • A= Aortic; Right sternal border at 2nd intercostal space • P= Pulmonic; Left sternal border at 2nd interncostal space • T= Tricuspid; Left sternal border at 4th intercostal space • M= Mitral; Left sternal border at 5th intercostal space at midclavicular line
Orthostatic hypotension is defined as a decrease in systolic blood pressure of __ mm Hg or a decrease in diastolic blood pressure of __ mm Hg within __ minutes of standing when compared with blood pressure from the sitting or supine position
20, 10, 3
How are pulse strengths documented and describe each.
0 = abscent, not palpable +1 = pulse diminished, barely palpable +2 = normal/expected +3 = full pulse, increased +4 = bounding pulse
When does exercise increase pulse rate?
during short-term exercise
Do positive chronotropic drugs increase or decrease pulse rate?
increase
Do negative chronotropic drugs increase or decrease pulse rate?
Decrease
A pulse deficit can indicate…
• The thrust of blood from heart is too feeble for wave to be felt at peripheral site • May indicate vascular disease is preventing impulses from being transmitted • Can also result from dysrhythmia
How is A/O assessed?
If the patient can name • person (who they are) • place (where they are) • time (date) You can also add • Current event
How do the following effect pulse rate?
- Sort-term Exercise 2. Long-term Exercise 3. Fever and Heat 4. Hypothermia 1. Sort-term Exercise = increases hr 2. Long-term Exercise = Decreases hr 3. Fever and Heat = Increase hr 4. Hypothermia = Decreases hr
How do the following effect pulse rate? 1. Hemorrhage 2. Standing or sitting 3. Lying down 4. Acute pain and anxiety 5. Diseases causing poor oxygenation such as asthma, COPD
- Hemorrhage = Increase 2. Standing or sitting = Increase 3. Lying down = Decrease 4. Acute pain and anxiety = Increase 5. Diseases causing poor oxygenation such as asthma, COPD = Increase
Orthostatic hypotension signs and symptoms include:
• Feeling lightheaded or dizzy after standing up • Blurry vision • Weakness • Fainting (syncope) • Confusion • Nausea
Pulse deficit is indicative of
vascular disease that is preventing impulses from being transmitted
Involuntary respiration is controlled by…
the brain stem
Ventilation rate is regulated by…
CO2 and O2 and hyrdogen ion concentration in arterial blood
What is the typical volume of air inhaled?
500mL
What are the three processes of respiration?
- Ventilation 2. Diffusion 3. Perfusion
Define ventilation.
• The movement of gases in and out of the lung • Inhalation/exhalation
Define Diffusion.
Movement of O2 and CO2 between the alveoli and red blood cells
Define Perfusion.
The distribution of red blood cells to and from the pulmonary capillaries
Respiration Vital measurements include:
• Respiratory rate • speed of breathing • Pattern • regular, labored, etc • Depth • shallow, deep, etc • SpO2 • Pulse oxymetry should read 95%-100%
Define: 1. Eupnea 2. Tachypnea 3. Bradypnea 4. Dyspnea
- Eupnea is normal, good, unlabored breathing, sometimes known as quiet breathing 2. Tachypnea is abnormally rapid breathing (over 20bpm) 3. Bradypnea is an abnormally slow breathing rate. 4. Dyspnea is difficult or labored breathing
Define: 1. Apnea 2. Orthopnea 3. Hyperpnea 4. Hypopnea
- Apnea is temporary cessation of breathing for several seconds. Persistent cessation results in respiratory arrest. 2. Orthopnoea is shortness of breath (dyspnea) that occurs when lying flat 3. Hyperpnea is increased depth and rate of labored breathing. (>20bpm, normal while exercising) 4. Hyperpnea is decreased depth and rate of breathing
Define: 1. Hemoptysis 2. Hyperventilation 3. Hypocarbia 4. Hypoventilation 5. Hypercarbia
- Hemoptysis is the coughing up of blood 2. Increased rate and depth (similar to hyperpnea) Hypocarbia may occur. 3. Lower than normal levels of CO2 in blood (can effect blood pH) 4. Decreased rate and depth (similar to hypopnea). Hypercarbia may occur. 5. Higher than normal levels of CO2 in blood (can effect blood pH)
Define Cheyne-Stokes respiration
• Respiratory rate and depth are irregular • alternating periods of apnea and hyperventilation • Cycle: slow, shallow breaths that gradually increase to abnormal rate/depth. Pattern reverses, breathing slows and becomes shallow, climaxing in apnea before respiration resumes • Sign of “impending doom” as it is common when approaching death
Define Kussmaul’s respiration
• Abnormally deep, regular at increased rate
Define Biot’s respiration
• Abnromally shallow for two or three breaths • followed by irregular period of apnea
What are some factors that influence BP?
S.A.M.S. A.G.E.D • Stressed • Activity/Weight • Medications • Smoking • Age • Gender • Ethnicity • Daily Variation
What are some Symptoms of Hypotension
• Pallor (paleness) • Skin mottling (spots or smears of color) • Clamminess • Confusion • Increased heart rate • Decreased Urine output
What is the BP range indicating Prehypertension?
• Systolic: 120-139 • Dyastolic: 80-89
What is the BP range indicating Stage 1 hypertension?
• Systolic: 140-159 • Diastolic: 90-99
What is the BP range indicating Stage 2 hypertension?
• Systolic: 160 and above • Diastolic: 100 and above
Orthostatic Hypotension may be related to
• fluid volume deficit • medications (diuretics or anti-hypertensive)
Orthostatic Hypotension symptoms include
• Dizziness • Light-headedness • Falling
Describe the effect of the following BP assessment errors: 1. Bladder/cuff to wide 2. Bladder/cuff to narrow/short 3. Cuff wrapped too loosely/unevenly
Effects 1. Bladder/cuff to wide = False Low Reading 2. Bladder/cuff to narrow/short = False High Reading 3. Cuff wrapped too loosely/unevenly = False High Reading
Describe the effect of the following BP assessment errors: 1. Deflating cuff to slowly 2. Deflating cuff to rapidly 3. Arm below heart level 4. Arm above heart level 5. Arm not supported
Effects 1. Deflating cuff to slowly = False High Diastolic 2. Deflating cuff to rapidly = False Low Systolic and False high Diastolic 3. Arm below heart level = False High BP 4. Arm above heart level = False Low BP 5. Arm not supported = False High BP
What does hypertension damage?
• Brain • Heart • Vessels • Kidneys
What are two types of Pain?
- Acute 2. Chronic
Define Acute Pain
• Patient is protective of the area • Identifiable cause, short duration • Limited tissue damage
Define Chronic Pain
• Prolonged pain associated with cancer or another long term ailment
What is the PQRST Pain Assessement?
• P: Precipitating or palliative - what makes it better/worse • Q: Quality - aching, shooting, stabbing, sharp, dull • R: Region - location of pain • S: Severity - 1-10 • T: Timing - when is it worse
What are the factors to report associated with Pain?
COLDSPA • Character • Onset • Location • Duration • Severity • Pattern • Associated Factors
What scale is used to assess pain for someone who is non-verbal?
FLACC • Face • Leg • Arm • Sudden reactionary movements to the above • Consolability • Crying
What are the three drug groups?
- Non-opiods 2. Opioids 3. Adjuvants (chemo, radiation)
NSAID stands for
Non Steroidal Anti Inflammatory Drug
NSAIDS are highly effective as _____, _____, and _____ agents.
analgesic, antipyretic and anti-inflammatory
What is the difference between selective and nonselective NSAIDS?
• NSAIDs (nonselective) can cause gastrointestinal bleeding • NSAIDs (selective) causes less gastrointestinal reactions
What are four side effects of opioids?
- Respiratory depression 2. Sedation 3. Nausea/vomiting 4. Constipation
What are the Six Rights of Medication Administration?
- Right Patient 2. Right Drug 3. Right Dosage 4. Right Route 5. Right Time 6. Right Documentation
What are the three checks for Medication Administration?
- Order to MAR 2. Medication to MAR 3. Patient to MAR
Name and detail the first check of Medication Administration
• First step is compare Order to MAR • When you do this, apply the six rights • Patient • Drug • Dosage • Route • Time • Documentation (confirms that all match)
Name and detail the second check of Medication Administration
• Second check is comparing the medication to the MAR • Confirm that the medication, dosage, route, and time are match • At this point note any special conciderations for the drug such as vitals/allergies, etc • ex. special direction to not give drug if BP is <60. Must check pulse and if lower, withhold, if above, proceed • Confirm that the medication is sealed • Confirm that it is not expired
Name and detail the third check of Medication Administration
• The third check is Patient to MAR • Confirm that the patient is correct w/ Bracelet IDx2 • Ask for allergies (Do you have any allergies to any medication, food, latex or anything else?)
Define Generic drug name
The manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia
Define Trade drug name
• Known as the brand or proprietary name. • Name a manufacturer markets the medication
What are the four phases of pharmacokinetics?
- Absorption 2. Distribution 3. Metabolism 4. Excretion
Define pharmacokinetic absorption.
The ability of a drug to be absorbed by cells, tissues, organs, systems and alter physiological functions
What are five factors that influence absorption?
- Route of administration 2. Ability to dissolve 3. Blood flow 4. Body surface area 5. Lipid solubility of medication
Pharmacokinetic distribution depends on what four factors?
- Chemical properties of the drug 2. Circulation 3. Membrane permeability 4. Protein binding
What are four factors to consider in drug metabolism?
- Medications are metabolized into a less potent or an inactive form 2. Biotransformation occurs under the influence of enxymes that detoxify, break down and remove active chemicals 3. Most biotransformation occurs in the liver 4. Kidneys, blood, intestines and lungs all play a role
What is drug excretion?
The method the body uses to rid the body of a drug.
Medications are excreted through:
• Kidney • Liver • Bowel • Lungs • Exocrine glands
What are the 7 types of medication action?
- Therapeutic effect 2. Side effect 3. Adverse effect 4. Toxic effect 5. Idiosyncratic reaction 6. Allergic reaction 7. Synergistic
Define: Therapeutic effect
Expected or predicted physiological response
Define: Side effect
Unavoidable secondary effect
Define: Adverse effect
Unintended, undesirable, often unpredictable drug effect
Define: Toxic effect
• Accumulation of medication in the bloodstream • Frequent use can cause accumulation
Define: Idiosyncratic reaction
• Over-reaction or under-reaction or different reaction from normal • Will require further follow up to discover why (mixed with other drugs, etc)
Define: Allergic reaction
Unpredictable response to a medication
Define: Synergistic effect
The combined effect of two medications is greater than the effect of the medications given separately.
What six factors make up a medication dose response?
- Onset 2. Trough 3. Plateau 4. Peak 5. Duration 6. Biological half-life
Define: Onset
Time it takes for a medication to produce a response
Define: Trough
Minimum blood serum concentration before the next scheduled dose
Define: Plateau
Point at which blood serum concentration is reached and maintained
Define: Peak
Time at which a medication reaches its highest effective concentration
Define: Duration
Time medication takes to produce greatest result
Define: Biological half-life
Time for serum medication concentration to be halved
What are the 5 routes fo medication administration?
- Oral 2. Topical 3. Inhalation 4. Parenteral 5. Intraocular
What are three methods of administration for inhalation?
• Inhale/sniff • Nebulizer (drop in vapor) • Endotracheal
What are the four parenteral methods of administration?
- ID; Intradermal 2. Sub-Q; Subcutaneous 3. IM; Intramuscular 4. IV; Intravenous
Name the sites and angle for an IM injection. Sites:
• Ventrogluteal (side of butt) • Vastus Lateralis (top of thigh) • Deltoid (shoulder) Angle: • 90°
entrogluteal site is is recommended for volumes greater than __ mL
2
Sub-Q injections are are absorbed more _____ than IM injections. slowly
due to low blood supply
Where are the sub-q injection sites located?
• Lateral surface of the upper arm • Upper back at the lower end of the scapula and down about 6” • upper ventral/dorsal gluteal areas (top of butt) • Belly under naval area
What are the angles of entry for IM, Sub-Q, and ID shots?
• IM = 90° • Sub-Q = 45° - 90° • ID = 5 - 15°
Regarding IM and Sub-Q injections, which do you pinch and which to you spread?
Sub-Q = pinch IM = spread
Give the typical volume amounts for the following injections: ID IM
Sub-Q • ID = < 0.5mL • IM = < 2mL for small muscles, <5mL for large muschles • Sub-Q = < 1mL, (but up to 2mL is safe)
What are the 6 types of orders MD’s use for medication administration?
- Standing/Routine 2. Single 3. Now 4. PRN 5. STAT 6. Prescriptions
Define: Single order
One time administration given for a specific reason
Define: Now order
• When a medication is needed right away, but not STAT • w/in 90 minutes
Define: PRN order
• Given when a patient requires it • Will still need to refer to timing to see when it can be administered
Define: STAT order
Given immediately in an emergency
What is a pressure ulcer?
A local injury to the skin over a bony prominence due to pressure and other factors
How does pressure result in an ulcer forming?
• If pressure over a capillary exceeds normal capillary pressure and the vessel is occluded (obstructed) for a prolonged time, tissue ischemia (shortage of blood supply/O2) occurs which can cause tissue death.
What is “blanching”
Normal red tones of skin are abscent when area is pressed and released.
What is “non-blanching”?
When an reddish area is pressed and released and no blanching occurs. Indicative of an ulcer/pressure issue.
What are the 6 risk factors for pressure ulcer development?
- Impaired sensory perception - unable to feel pressure or pain 2. Alterations in LOC - Confused and unable to verbalize 3. Impaired mobility - unable to change position independently 4. Shear (sliding of skin) 5. Friction (dragging of skin) 6. Moisture
How many stages are there in the classification of pressure ulcers?
4 only
Describe a Stage 1 pressure ulcer.
Intact skin with non-blanchable redness
Describe a Stage 2 pressure ulcer.
Partial-thickness skin loss involving epidermis, dermis, or both
Describe a Stage 3 pressure ulcer.
Full-thickness tissue loss with visible fat
Describe a Stage 4 pressure ulcer.
Full-thickness tissue loss with exposed bone, muscle, or tendon
What is the term for an ulcer that defies clear indentification of the 4 stages of pressure ulcer classification?
Non-stageable
Define unstabeable ulcer.
Pressure ulcer with full-thickness tissue loss in which the depth is obscured by slough and/or eschar in the wound bed.
What are the colors of slough?
• yellow • tan • gray • green • brown
What are the colors of eschar?
• tan • brown • black
Define a suspected deep tissue injury
A purple or marron localized area of discolored intact skin or blood-filled blister caused by damage to underlying tissue from pressure and/or shear.
Wound healing occurs by _____ or _____ intention.
Primary, secondary
When checking on wound healing, what are the items we are assessing? REEDA
• Redness • Ekymosis • Edema • Drainage • Approximation
Define the primary intention healing process
• This occurs when the would edges are approximated • ex. surgical incision is sewn up and winds up with minimal to no scarring
Define the secondary intention healing process
Secondary intention occurs when the would heals with non-approximated edges and leaves a scar
A surgical incision heals by _____ intention.
primary
A burn, pressure ulcer, or severe laceration heals by _____ intention.
secondary
Describe tertiary intention.
• occurs when the wound is left open for several days • while open, it is observed for signs of infection • closure is delayed until infection is resolved
What are the 4 types of wound drainage?
- Serous 2. Sanguineous 3. Serosanguineous 4. Purulent
Describe Serous wound drainage.
• This type of drainage is plasma that’s thin, clear and watery • During the inflammatory stage, a small amount of this bloody leakage is natural. • When this type of exudate occurs during other wound healing stages, it may be an indicator that the wound bed has undergone trauma, such as during dressing changes, which can hinder healing.
Describe Sanguineous wound drainage.
Drainage that is fresh blood and prevalent among deep wounds of full and partial thickness
Describe Serosanguineous wound drainage
• Leakage is thin and watery, and it’s pink in color (it can also be a darker red). • The pink tinge is the effect of red blood cells in the fluid, which is a sign that there is damage to the capillaries. • Such damage generally occurs during wound dressing changes and can disrupt the healing process.
Describe Purulent wound drainage.
• Wound appears milky • It’s generally gray, green or yellow • Most commonly thick in consistency, though some purulent exudate can be thin. • This may be a sign that the wound has an infection
What are five types of wound complications?
- Hemorrhage 2. Hematoma 3. Infection 4. Dehiscence 5. Evisceration
The Braden Scale is used for…
predicting pressure ulcer risk
What are the six categories used in the Braden Scale Score?
- Sensory perception 2. Moisture 3. Activity 4. Mobiility 5. Nutrition 6. Friction and shear
A Braden Scale Score of 23 indicates what level of risk for developing a pressure ulcer?
No Risk
A Braden Scale Score of 15-18 indicates what level of risk for developing a pressure ulcer?
At risk
A Braden Scale Score of 13-14 indicates what level of risk for developing a pressure ulcer?
Moderate Risk
A Braden Scale Score of 10-12 indicates what level of risk for developing a pressure ulcer?
High Risk
A Braden Scale Score of ≤ 9 indicates what level of risk for developing a pressure ulcer?
Very High Risk
How do we check for overall tissue perfusion?
• At the peripheral pulse • If pulse week, perfusion will be low • If pulse strong, perfusion will be high
On the Braden Scale, the higher the number the _____ the risk.
lower
What are four other factors (not on the Braden Scale) that can influence pressure ulcer formation?
- Tissue perfusion 2. Infection 3. Age 4. Psychosocial impact of wounds
What is the Jackson-Pratt Drainage Device?
A closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites.
What are the nursing responsibilities regarding the JP Drainage Device?
• Measure output • Assess T.A.C.O • Check tubing to make sure its not kinked or dislodged • If its coming apart call MD
What are the three types of Nursing Implementation?
- Independent 2. Dependent 3. Collaborative
How does the Nurse know what kind of dressing to use on a wound?
The doctor will indicate
What are five types of wound dressings?
- Dry/Moist 2. Film Dressing 3. Hydrocolloid 4. Hydrogel 5. Vacuum assisted closure (VAC)
Describe a film dressing. What stage ulcer is it used for?
• transparent to permit viewing of wound without opening it • adheres to undamaged skin • does not require secondary dressing • traps moisture over wound • Used for stage I and II ulcers
Describe a hydrocolloid dressing. What stage ulcer is it used for?
• Wafer dressing • protects wound from surface contamination • Used for Stage II and III ulcers
Describe a hydrogel dressing. What stage ulcer is it used for?
• gel-based wound care dressing • protects and provides a moist wound-healing environment • helps remove dead tissue from the wound bed during the healing process. • used for stage III and IV ulcers
How does a VAC work?
• uses a negative pressure to support healing
What are the Nurse responsibilities when a VAC is in use?
• Tell patient not to pull on it • Checked tubing to make sure its not dislodged • Beeping is a leak, call surgical team
