Med Surg Exam Flashcards
What does ADPIE stand for?
Assessment, Diagnosis, Planning, Implementation, Evaluation
What do you do during the assessment phase?
Gather info, review history
Most communication takes place in the____ stage
assessment
What do you do during the diagnosis phase?
identify problem list
What do you do during the planning phase?
develop goals, desired outcomes
What do you do during the implementation phase?
perform nursing actions
What do you do during the evaluation phase?
determine whether goals were achieved
Therapeutic communication
face to face process of interacting that focuses on advancing the physical and emotional well being of a patient
Nurses use therapeutic communication to provide_____ and _____ to patients
support and information
Examples of personal factors that can impede accurate communication
emotional and social support, cultural and language difference, lifestyle differences, cognitive factors
Examples of environmental factors that can impede accurate communication
physical factors and societal factors
Examples of symmetrical relationships
equal:friends and colleagues
Examples of complementary relationships
unequal: difference in status and power such as between a nurse and patient or teach and student
Communication is __% verbal and __% nonverbal
10%, 90%
about how you say it not what you say
Verbal Language
represents public self
can be straight forward comments or can be used to distort, conceal, deny or distinguish true feelings
Verbal communication is
language
Nonverbal communication is
body language
Nonverbal communication
covers wide range of human activities from body movements to responses to messages of others
Double messages
are conflicting messages or mixed messages
Types of nonverbal communication
facial expressions, touch, eye contact, posture, gait, gestures, general physical appearance, mode of dressing and grooming, sounds and silence, electronic communication
Effective communication skills include
appropriate, sensitive use of silence
active listening
clarifying techniques, paraphrasing(restating and reflection of feelings)
exploring
projective questions(what if)
presupposition questions(assumed to be true, left unstated)
Everything you hear is ___ by the patients filters and your own filters
modified
Active listening principles strengthens the patients ability to use____ to solve problems
critical thinking
Undivided attention is when the nurse communicates patient is
not alone
Problematic areas for the nurse when interpreting specific verbal and nonverbal messages of the patient include
communication
use of eye contact
perception of touch
cultural filters
Therapeutic communication techniques
using silence
summarizing
offering self
giving recognition
accepting
voicing doubt
Non therapeutic communication
Asking excessive questions
disapproving
asking why questions
minimizing feelings
Aims of patient education
maintaining and promoting health
preventing illness
restoring health
facilitating cooping
Cognitive learning domain
storing and recalling of new knowledge in the brain
Psychomotor learning domain
learning a physical skill
Affective learning domain
changing attitudes, values, and feelings
Which action is an example of cognitive learning?
A. A patient demonstrates how to change his wound
dressing.
B. A new mother follows instructions for caring for the
umbilical cord.
C. A patient describes how to portion food to maintain
within a prescribed calorie range.
D. A patient expresses renewed confidence following a
teaching session on caring for her mother at home.
C. A patient describes how to portion food to maintain
within a prescribed calorie range.
Factors affecting patient learning
age and developmental level
family support networks
financial resources
cultural influences
language deficits
health literacy level
What does ISBARR stands for
Identify/info
Situation
Background
Assessment
Recommendation
Read back of orders/response
What happens during the situation part of ISBARR
vital signs obtained, stress concerns
What happens during the background part of ISBARR
check mental status, skin observation
What happens during change of shift/hand off reports
-basic identifying info about each patient(name, room #, bed designation, diagnosis, attending and consulting physicians
-current appraisal of each patients health status
-current orders
-abnormal occurrences during change
-any unfilled orders that need to be continued
-patient and family questions and concerns
-reports on transfers and discharge
What are the 4 p’s
pain, position, potty, and proximity
Traditional knowledge
passed down from generation to generation
Authoritative knowledge
comes from expert, accepted as truth based on persons perceived expertise
Scientific knowledge
obtained through scientific method of research
T/F
Traditional and authoritative knowledge are
practical to implement, but are often based on subjective
data, limiting their usefulness in a wide variety of settings.
true
Types of nursing knowledge
science
philosophy
process
Science nursing knowledge
knowledge in and out of nursing
Philosophy nursing knowledge
study of wisdom, fundamental knowledge and process used to constrict life
Process nursing knowledge
conceptual frameworks and theories
Influences on nursing knowledge
historical
societal
Culture
shared beliefs system, values and behavioral expectations that provide social structure for daily living
Define roles and interactions with others and in families and communities
True or false.
Culture includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one’s family.
true
Subculture
Large group of people who are members of a
larger cultural group
Example of subculture
nursing is the subculture of healthcare
Groups in society are
dominant group
minority group
Dominant group
-usuallty the largest group
Group has the most authority to control values and
sanctions of society
Minority group
smaller group
A physical or cultural characteristic identifies the people
as different from dominant group.
Cultural assimilation (acculturation)
Minorities living within a dominant group lose the characteristics that made them different.
Values replaced by those of dominant culture
Culture shock
The feelings a person experiences when placed in a different culture
May result in psychological discomfort or disturbances
Which of the following occurs when members of a minority group, living with a dominant group,
begins to blend in and lose the characteristics that
made them distinct?
A. Cultural imposition
B. Cultural conflict
C. Cultural assimilation (acculturation)
D. Cultural shock
Cultural Assimilation
Ethnicity
Sense of identification with a collective cultural group
shared identity, bond or kinship people feel with their country of birth or place of ancestral origin. Largely
based on group’s common heritage
Race
Typically based on specific characteristics
Skin pigmentation, body stature, facial features, hair
texture
Stereotyping
The assumption that all members of a culture or ethnic group act alike
Stereotypes are ___ and ___ beliefs about people
preconceived and untested
Negative stereotypes are
racism, sexism, ageism
Cultural imposition
Belief that everyone should conform to the majority belief
system
Cultural blindness
Ignores differences and proceeds as if they did not exist
Culture conflict
People become aware of differences and feel threatened.
Response—ridiculing beliefs and traditions of others to make themselves feel more secure
Ethnocentrism
Belief that one’s ideas, beliefs, and practice are the best or superior, or are most preferred to those
of others
Which term describes what occurs when a nurse believes that one’s own ideas, beliefs, and
practices are the best or superior to those of colleagues and patients?
Ethnocentrism
Cultural Influences on Health Care
Physiologic variations
Reactions to pain
Mental health
Gender roles
Language and communication Orientation to space and time(sitting too close/too far from patient
Family support
Socioeconomic factors
food and nutrition
Be sensitive to nonverbal signals of discomfort such as
holding or applying pressure to the painful area or avoiding activities that intensify the pain.
T/F
The health care system is a culture of its own, with nursing being its largest subculture.
true
Religious beliefs may prohibit the presence of males, including husbands, in the delivery room.
This may be observed among
devout Hindus and Orthodox Jews
Traditional Western medicine uses medication administration as a method of
treatment
Encourage caregivers to participate in spiritual behaviors or practices such as____to enhance spiritual well-being when appropriate.
prayer, attending religious services
Orthodox Jews maintain a Kosher diet which excludes
seafood
Buddhist belief to not move deceased patient until
cold
The Islamic religion does not prefer the use of health care
professionals of the___unless it is difficult to locate one of the same gender.
opposite gender
____woman usually bathed and cared for by family members
post-op and/or while hospitalized
Chinese
What are the elements of cultural competence
Developing self-awareness
Demonstrating knowledge and understanding of a patient’s culture
Accepting and respecting cultural differences
Not assuming that the health care provider’s beliefs and values are the same as the client’s
Resisting judgmental attitudes such as “different is not as good”
Being open to and comfortable with cultural encounters
Accepting responsibility for one’s own cultural competency
Who may refuse breathing exercises and performing own hygienic care
Chinese women
A nurse is conducting an intake interview with a client. Which should the nurse do to best facilitate
therapeutic communication with this client?
A. Talk about expectations.
B. Use probing questions.
C. Ask direct questions.
D. Listen attentively
D. Listen attentively
A client’s son has just died. The client states, “I can’t believe that I have lost my son. Can you
believe it?” Which is the nurse’s best response?
A. Touch the client’s hand and say, “I am very sorry.”
B. Leave the room and allow the client to grieve in private.
C. Encourage a family member to stay and provide support.
D. Assume a serious facial expression and say, “I can’t believe it either.”
A. Touch the client’s hand and say, “I am very sorry.”
A nurse identifies that a usually talkative client is withdrawn. Which is the nurse’s best response?
A. “What is bothering you?”
B. “You are very quiet today.”
C. “Tell me what you’re upset about.”
D. “Why are you so withdrawn today?”
B. “You are very quiet today.”
A client is being discharged to a nursing home. While preparing the discharge summary, the client
says, “I feel that nobody cares about me.” Which is the nurse’s best response?
A. “You feel as if nobody cares.”
B. “We all are concerned about you.”
C. “It’s hard to be angry at your family.”
D. “Your family doesn’t have the skills to care for you
A. “You feel as if nobody cares.”
A client tells the nurse, “The doctor just told me I have cancer” and then begins to cry. Which is the
best response by the nurse?
A. “Try to focus on something else.”
B. “Sometimes it helps to talk about it.”
C. “Deep breathing may help you regain control.”
D. “Tears are good because it gets it out of your system.”
B. “Sometimes it helps to talk about it.”
. A client has a history of verbally aggressive behavior. One afternoon the client starts to shout at
another client in the lounge. Which are appropriate responses by the nurse? Select all that apply.
A. ____ “Stop what you are doing.”
B. ____ “Let’s go talk in your room.”
C. ____ “Sit down until you are calm.”
D. ____ “Come with me for a walk in the hall.”
E. ____ “Do not raise your voice in a hospital.”
B. ____ “Let’s go talk in your room.”
D. ____ “Come with me for a walk in the hall.”
A nurse is collecting data for an admission nursing history. Which question by the nurse is best to
open the discussion?
A. “What brought you to the hospital?”
B. “Would it help to discuss your feelings?”
C. “Do you want to talk about your concerns?”
D. “Would you like to talk about why you are here?”
A. “What brought you to the hospital?”
A nurse is using military time when entering information into a patient’s clinical record. Which
number in military time should the nurse enter to document a wound irrigation that was
implemented at 9 p.m.?
A. 0900
B. 1900
C. 2100
D. 2300
C. 2100
A nurse is caring for a confused patient with a diagnosis of dementia of the Alzheimer’s type. Which
should the nurse say when assisting the patient to eat?
A. “Please eat your meat.”
B. “It’s important that you eat.”
C. “What would you like to eat?”
D. “If you don’t eat, you can’t have dessert.”
A. “Please eat your meat.”
A mother whose young daughter has died of leukemia is crying and is unable to talk about her
feelings. Which is the best response by the nurse?
A. “Everyone will remember her because she was so cute. She was one of our favorites.”
B. “As hard as this is, it is probably for the best because she was in a lot of pain.”
C. “She put up the good fight but now she is out of pain and in heaven.”
D. “It must be hard to deal with such a precious loss.”
D. “It must be hard to deal with such a precious loss.”
A patient states, “My wife is going to be very upset that my prostate surgery probably is going to
leave me impotent.” Which is the best response by the nurse?
A. “I’m sure your wife will be willing to make this sacrifice in exchange for your well-being.”
B. “The surgeons are getting great results with nerve-sparing surgery today.”
C. “Your wife may not put as much emphasis on sex as you think.”
D. “Let’s talk about how you feel about this surgery.”
D. “Let’s talk about how you feel about this surgery.”
Which should a nurse never do when documenting information on a patient’s electronic medical
record? Select all that apply.
A. _____ Leave the patient’s medical record open on the computer screen when entering the patient’s
room to administer a medication.
B. _____ Share information verbally about a patient with another nurse who is also caring for the
patient.
C. _____ Document nursing care administered to a patient immediately after it is completed.
D. _____Give a personal access code to another member of the health-care team.
E. _____Document exact quotes of a patient’s subjective information.
A. _____ Leave the patient’s medical record open on the computer screen when entering the patient’s
D. _____Give a personal access code to another member of the health-care team.
A client is admitted to the hospital with multiple health problems. Which nursing intervention is
least effective in meeting the client’s psychosocial needs?
A. Addressing the client by name
B. Assisting the client with meals
C. Identifying achievement of client goals
D. Explaining care before it is to be given to the client
B. Assisting the client with meals
Examples of Nursing Diagnosis associated with Nutrition
-Impaired swallowing
-Dysfunctional Gastrointestinal Motility
-Imbalanced Nutrition:Less Than Body Requirements
- Impaired Oral Mucous Membrane
-Nausea
Autonomy
self sufficiency-competent
In safety, if you see something, you _____ _____
say something
not a solo efforts-works as a team
Beneficence
kind and true
Nonmaleficence
no harm
Justice
honest and fair
A go kit for yourself and family is used for
shelter in place or evacuation-circumstance specific
Individual readiness
General disaster readiness for
individual healthcare workers and their family and significant others is essential for a readied workforce
and critical to the national preparedness goal
What is the acronym we use for fire safety?
RACE
R is race stands for
rescue anyone in immediate danger
The A in RACE stands for
activate fire code system and notify
appropriate personnel
The C in RACE stands for
confine fire by closing doors and windows
The E in RACE stands for
evacuate patients and persons to a safe area
Institution policy usually identifies plans for
vertical, horizontal or both
Critical policy points include
-planned rendezvous locations
-accountability of personnel and patients
Types of hazards include
CBRNE
-Chemical
-Biological(includes infection)
-Radiation(includes nuclear)
-Natural(includes flood, fire, wind)
-Explosives
Alpha particles
do not penetrate deep enough to penetrate dead layers of intact skin and can be shielded using a thin layer of clothing or paper
How to get rid of external contamination
remove clothing and shower with soap and water
How to get rid of internal contamination
-incorporated in body
need medicine to help excrete it
Beta particles
can penetrate human skin to the germinal layer
– standard PPE provides some protection against most beta participle’s
Gamma particles
can penetrate into human tissue. Dense materials (lead, concrete) needed for shielding. PPE provides little shielding from gamma radiation but will prevent contamination of the skin by these materials. Gamma radiation frequently accompanies the emission of alpha and beta radiation.
How do you remove external contamination
removing clothing by rolling OUTSIDE to INSIDE to contain it
Internal contamination can occur by
-inhalation
-ingestion
-absorption(skin, mucous membrane)
-injected
Internal contamination half-life can be reduced by administering
-Prussian blue
–DTPA (Diethylenediamine Penta-Acetate)
Exposed radiological patients are
not contaminated
ex-laying on the beach, having an X-ray
What are the 4 phases of emergency management phases
-Prevention
-Preparedness
-Response
-Recovery
Prevention phase
(occurs before)/Mitigation (occurs before and then during and after to reduce new identified risks)
- Identify what can cause a fire, create Emergency Operation Plan (All Hazard Policy)
Preparedness phase
(occurs before)
-Education, training such as learning to use a fire extinguisher (PASS – Pull Pin, Aim, Squeeze trigger, Sweep)
Response phase
(occurs during) –
-Fire Alarming for incident - Evacuate floor
Recovery phase
(occurs after) –
-Return to pre-incident operations – wellbeing, basics needs(food, water, shelter), emotional needs
Examples of internal disaster
fire
Examples of external disaster
hurricane, tornado
Examples of medical countermeasures
-biological products of vaccines, blood products, antibodies
-drugs
-Devices(PPE, face masks, gloves, respirators)
Examples of administrative measures
Policy and procedures – requiring the use of isolation categories
Examples of environmental countermeasures
Negative pressure room, anterooms, HEPA filters
What is the best precaution to control infection
hand hygiene
Hierarchy of infection control practices(from top to bottom)
-elimination(physically remove hazard)
-substitution(replace hazard)
-engineering controls(isolate people from hazard)
-administrative control(change way people work)
-PPE(protects workers)
PPE has
expiration dates
-recommended to only use NIOSH approved equipment
What are the steps of donning?
- Gown
- Mask or respirator
- Goggles or face shield
- Gloves
What are the steps of removing donning?
1.Gloves
2. Goggles or face shield
3.Gown
4. Mask or respirator
5. Wash hands
For contact precautions, you need
gloves and a gown at minimal
For droplet precautions, you need
a mask
For airborne precautions, you need
particular respirator
Example of enteric contact
C. diff
For enteric contact, you need
gloves upon entering room
Must use soap and water for at least 20 seconds
For airborne, you wear a N95 respirator which
filters airborne droplet nuclei particles that are 0.3 microns or larger, fit tested annually.
Level A of PPE
selected when the greatest level of skin, respiratory and eye protection is required
Level B of PPE
Usually first responder, includes the highest level of respiratory protection, SCBA but with a lesser chemical resistant skin protection than LEVEL A.
-Breathing apparatus, air source tank
Level C of PPE
The concentration and types of airborne substances is known and the criteria for using air purifying respirators are met
Level D of PPE
-work clothing
-Basic splash and respiratory protection
When using a fire extinguisher, the first step in PASS is:
Pull the pin
A building’s fire alarm system function that provides the earliest warning of a fire is
A. Sprinklers
B. Employees
C. Smoke detectors
D. Public address system
C. Smoke Detecters
Which of the following statements are true: (select all the apply)
A. Elevators can be used to evacuate a building on fire.
B. The most likely route for evacuation of patients is down stairwells.
C. Sprinklers are activated automatically by heat.
D. The risk of fire is higher when construction activity is present.
B. The most likely route for evacuation of patients is down stairwells.
C. Sprinklers are activated automatically by heat.
D. The risk of fire is higher when construction activity is present.
There is a fire is a microwave oven. You activate the alarm, ask another staff member to call
security and you locate the nearest fire extinguisher. Which of the following steps is
incorrect:
A. Pull the pin with the fire extinguisher upright
B. Aim at the base of the flames
C. Squeeze the lever while sweeping the nozzle slowly back and forth
D. Replace the fire extinguisher in its original position when the fire is safely out
D. Replace the fire extinguisher in its original position when the fire is safely out
The purpose of closing doors during a fire is to
A. Contain
B. Rescue
C. Alarm
D. Evacuate
A.Contain
If a fire alarm is sounded, the fire/smoke zone doors as part of a building fire alarm system
will:
A. Close automatically
B. Should be propped open to facilitate lateral evacuation
C. Will remain open until someone closes them
D. Will remain in their usual position
A. Close automatically
- A lateral evacuation of a patient care area involves:
A. Closing all patient care and other doors on the unit
B. Evacuating the patient through the smoke/fire to a safe zone
C. Conducting a head count of all patients and staff in the safe zone
D. All of the above
D. All of the above
The fire alarms sound on a patient care unit. You begin closing doors. A visitor asks nervously
what is going on. You respond:
A. The hospital has frequent fire drills and closing all doors is a part of our fire action plan
B. There is a fire close by and we should prepare to evacuate
C. I’m not sure what is going on!
B. There is a fire close by and we should prepare to evacuate
A visitor decides to break the rules by having a quick cigarette in the bathroom. He
accidentally drops the cigarette into the trashcan and a fire ignites. Which of the following
statements are true: SELECT ALL THAT APPLY.
A. Patients in the room should be removed from the room
B. Visitors should be removed from the room
C. Occupants of adjacent rooms may need to be moved as a precautionary measure.
D. There is no need to activate a pull station since the fire can be easily extinguished.
A. Patients in the room should be removed from the room
B. Visitors should be removed from the room
C. Occupants of adjacent rooms may need to be moved as a precautionary measure.
Sprinklers are activated when:
A. There is smoke in an area during a fire
B. Someone activates a pull station during a fire
C. Heat from a fire activates a sprinkler
C. Heat from a fire activates a sprinkler
When rescuing patients from hospital wing to wing (same level, different buildings), you first
evacuate patients:
A. Horizontally
B. Vertically
C. North
D. South
B. Vertically
When rescuing patients from hospital wing to wing (same level, different buildings), you first
evacuate patients:
A. Horizontally
B. Vertically
C. North
D. South
B. Vertically
When rescuing patient from a hospital wing with no connecting building you will evacuate
patients
Horizontally
Vertically
North
South
Horizontally
A nurse’s priority during a fire is to: (Select all that apply)
A. Patient evacuation
B. Accountability of patients and staff
C. Using the fire extinguisher to put the fire out.
A. Patient evacuation
B. Accountability of patients and staff
Donning, don the equipment, identify by 1-2-3-4-5 the correct order of PPE, according to the
CDC.
Gown
Eye protection
Hand hygiene
Gloves
Respiratory protection (mask)
Gown 2
Eye protection 4
Hand hygiene 1
Gloves 5
Respiratory protection (mask) 3
Disease type examples that require an N95
- TB
- Small pox
- Severe acute respiratory syndrome (SARS)
- Varicella -zoster
Disease/illness types that require a surgical mask
RSV) – Respiratory syncytial, influenza, pertussis,
Examples of contact isolation
impetigo, diphtheria, herpes, enteroviral illness, major abscesses, rotavirus. scabies, Cliff, Hep A, staph, pediculosis, escherichia coli, shigella, viral conjunctivitis,
Examples of droplet isolation
pneumonia, sepsis, meningitis, parvovirus B19, rubella, plague, influenza, strep A, mumps, pertussis,
Examples of airborne isolation
SARS, TB, small pox, measles, varicella,
ostomy
small/large bowel is brought to outside of the skin(surface)and is attached the abdomen and then will be removed
T/F you want your patient to void first when obtaining a stool collection
True
Tell whether the following statement is true or false.
When collecting stool using the technique “timed specimen,” the nurse should consider the
first stool passed by the patient as the start of the collection period.
True
Colonoscopy enters through
the anus, upon through the colon
Which of the following direct visualization tests uses a long, flexible, fiberoptic–lighted
scope to visualize the rectum, colon, and distal small bowel?
A. Esophagogastroduodenoscopy
B. Colonoscopy
C. Sigmoidoscopy
D. UGI series
B. colonoscopy
Enema
bag of fluid that is hung that is entered in anus
Types of enemas
Cleansing
Retention
Oil-retention: lubricate the stool and intestinal mucosa, easing defecation
Carminative: help expel flatus from the rectum
Medicated: provide medications absorbed through the rectal mucosa
Anthelmintic: destroy intestinal parasites
Commonly used enema solutions
tap water(hypotonic distends intestine, softens stool), normal saline(isotonic) distends intestine, soften stool(Castile) soap, hypertonic, oil(lubricates)
Which enema would be used for a patient with intestinal parasites?
A. Oil-retention enema
B. Carminative enema
C. Nutritive enema
D. Anthelmintic enema
D. Anthelmintic enema
Nasogastric tube
Inserted to decompress or drain the stomach of fluid or unwanted stomach contents
Used to allow the gastrointestinal tract to rest before or after abdominal surgery to promote
healing
Inserted to monitor gastrointestinal bleeding
Bowel training programs consist of
Manipulate factors within the patient’s control.
-Food and fluid intake, exercise, and time for defecation
-Eliminate a soft, formed stool at regular intervals without laxatives.
-When achieved, continue to offer assistance with toileting at the successful time.
T/F Ostomy should always be pink or red and moist/shiny
True
Locations of ostomies
-Sigmoid colostomy
-Descending colostomy
-Transverse colostomy
-Ascending colostomy
-Ileostomy
Ileostomy has liquid where a colosctomy has
formed stool
Illeostomy is spouted at least____ from skin
2cm
Colostomy is at the
mucosa level with the skin
Size of stoma should stabilize within
6-8 weeks
An enterostomal tube may be placed through an opening created into the___ or _____
stomach(gastrostomy) or into the jejunum(jejunostomy)
What is the preferred site for a patient who are comatose
gastronomy
What is the preferred site for a patient who are comatose
gastronomy
What kind of feeding do you give someone with a functioning GI tract
enteral feeding
parental for non functioning
Short term intervention if gut is not functioning
use peripheral without venous access for short time (less than 2 week) or as a bridge to a
central line
Long term use- subclavian vein or peripherially inserted centrl cathether (PICC Line) (more
inF&E lesson)
Decompression of GI tract is used to
give the bowel a rest-vacuum out stomach contents
How do you measure for placement for a tube feeding
from the nose to the earlobe to the diploid
when inserting an NG placement, instructor the patient to
put their chin down to their chest
Initial confirmation for checking tube placement
X ray of CO2 monitor
CO2 detector on the tube end will remain what color if in the stomach(no CO2)
Purple
yellow if its in the lungs
Gastric pH of stomach
5-6
short term for enteral feeding is how many weeks
4 or less weeks
NG tube or micro bore
Raise bed how many degrees if using intermittent feedings
30-45 degrees
Dumping syndrome
feeding too quickly and entering small intestine too fast causing nausea, weakness sweating and diarrhea
When do you use parenteral feeding
when gut needs to heal or is not functioning
How long do you use a parenteral feeding
less than 2 weeks
Severity
low acuity, pt is less complexed and more stable
High acuity
more complexed, less stable
Homeostasis
A relative stable equilibrium is the state between interdependent elements,
especially as maintained by physiological processes in the human body.
allostasis
the process by which the body responds to stressors in order to regain homeostasis.
When a system is maintaining balance, it is in state of
homeostasis
When a system is out of balance, it is in
allostasis
Top players to receive oxygen
heart, brain, head lungs
stomach and kidneys are lower
What are the critical value for a nurse to know for BP?
less than 120/80 is normal, 120-139
/80-89 is prehypertensive and 140/90 is considered hypertensive.
hypotensive
systolic at 90-115 is considered hypotensive but can be a normal
finding in an athlete. So you need to assess other factors to determine if it is a pathological low
BP.
Primary
promotion of health
Secondary care
screening for early diagnosis and treatment
Tertiary care
treatment for restoration and rehabilitation
BP measures____ while acuity is _____
tissue perfusion, how sick is sick
Bedside tilt factors
-systolic of +/- 20
-diastolic+/- 10
-HR increase by 20
Positive tilt factors
-decrease in systolic by 20
-decrease in diastolic by 10
-HR increases by 20
Delegation
the process for a nurse to direct another person to
perform nursing tasks and activities.
Rules of Delegation
-Right Circumstances
-Right Task
-Right Person
-Right Direction and Communication
e. Right Supervision and Evaluation
Delegation requires nursing judgement decision that are always
outcome focused and includes prioritization
Hypoxia
inadequate amount of oxygen
available to cells.
Hypercapnia is
CO2 retention
When hypoxia occurs the body tends to
hyperventilate to bring in more air (oxygen) and
more CO2 is expelled
General Adaptation syndrome
emerges when patient is sick, response to stress
3 stages- alarm reaction, resistance and exhaustion
Temp
status of environment cellular function or organ and tissue
Heart rate
circulatory ability, tissue perfusion
Respiration
O2/CO2 of gas exchange, stability within body, ability to support tissue perfusion of homeostasis
BP
circulation of tissue perfusion
Vital signs
major indicator of problem, can depend on institution
Standing orders
orders set preapporved
1st level of delegation
vitals, airway breathing, circulation
2nd level of delegation
acute, mental status change, elimination problems
3rd level of delegation
more long term
chemoreceptors
specialized cells capable of detecting O2, CO2 and hydrogen concentration changes
where are the central chemoreceptors located?
in the brain stem medulla
central chemoreceptors
normal respiratory drive, stimulated by increase in CO2, ventilatory drive and rids body of CO2
where are the peripheral chemoreceptors located?
in carotid/aortic bodies
peripheral chemoreceptors
stimulated by decrease in PO2, account for increased ventilation resulting from hypoxemia, monitor in arterial blood
normal breathing
rids body of CO2 + brings in O2, increases CO2 value, the most potent + PRIMARY stimulus to brain, stimulates ventilation
volume
big/small breath flow (ease of breath)
pressure
force of breath
inhale
diaphragm contracts
exhale
diaphragm relaxes
airway resistance
opposition ventilation, when airway narrows resistance increases and flow decreases
lung compliance
flexible, stretch lungs
lung elasticity
lung tissue expands inhalance and recoils expiration
surfactant
reduce surface tension and keeps alveoli open
oxygenation
delivers O2 saturated blood to tissues
ventilation
exchanges gases, removal of CO2 from body
Hypoxia
Inadequate amount of O2, leads to hyperventilation
Hypercapnia
CO2 retention, occurs when CO2 is not diffused fro blood
PAO2
O2 in alveoli
FIO2
fraction inspired O2
respiratory quotient
valued on diet and metabolic state
PEEP stands for
Positive End Expiratory Pressure
recruits airflow to aid gas exchange
PEEP
Interventions to improve perfusion
Positioning height of bed, adequate hydration, lip breathing, chest PT, deep breathing exercises, diaphragmatic breathing
BLS airway
Oropharyngeal, nasal trumpet, head tilt chin lift, jaw thrust
meds inhaled directly into lungs
nebulizers, metered doses and dry powder inhalers
BVM
use 1 hand, 2 can be too large, match bagging rate
Oropharyngeal airway
measure center mouth/jaw to earlobe
oxygen airways
jaw thrust, head tilt chin lift
SPO2
% of saturated hemoglobin compared to total amount of hemoglobin in blood (goal-95%)
ETCO2
immediate evaluation of CO2 elimination
normal ETCO2
35-45
hypoxemia levels
PAO2 < 60, SAO2 < 90
O2 toxicity
decreases surfactant (affects alveoli fn), pulmonary edema
COPD pathophysiology
resp. system becomes insensitive to normal fluctuations of CO2
example of high flow delivery
nasal cannula
nasal cannula
delivers heated humidified O2
noninvasive ventilation
applies pressure to support upper airway, decreased work of breathing, increased lung compliance, improved pulmonary ventilation
perfusion
blood flow to lungs
BiPAP
works on “natural” airway pressure changes
CPAP
provides continuous pressure on airways at all times so “small” airways don’t collapse and airway pressure is maintained (allows for gas exchange)
