NR 462: Exam 2 Flashcards
Hypoxia Signs/Symptoms
RAT BED
Early Signs:
- Restlessness
- Anxiety
- Tachycardia/Tachypnea
Late Signs:
- Bradycardia
- Extreme Restlessness
- Dyspnea
Important assessments obtained during a focused respiratory assessment include
- auscultation of lung (breath) sounds.
as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration
Crackles
Presence of acid-fast bacilli in the sputum indicates
active tuberculosis.
decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath
Hypoxia
strongly binds to hemoglobin, making it unavailable for oxygen binding and transport
Carbon monoxide
When the body cannot meet the increased oxygenation need, what happens?
- increased metabolic rate
- breakdown of protein and wasting of respiratory muscles,
- increasing the work of breathing.
Saline has been found to cause more side effects when…
- suctioning and does not increase the amount of secretions removed.
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
Incentive spirometer
What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia?
Fingernails and their base
is used to distinguish benign and malignant pulmonary nodules
Positron emission tomography (PET)
involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax.
Thoracentesis
Postoperatively there is an increased risk for
- atelectasis from anesthesia
- restricted breathing from pain.
he nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to a 35-year-old female employee. Which question should the nurse ask before administration of this vaccine?
Could you be pregnant now?
Clear nasal drainage suggests leakage
- of cerebrospinal fluid (CSF), presence of glucose
- A drip pad may be applied, but the patient should not be reassured that this is normal.
The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis?
Maxillary Pain
The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect?
Gastrostomy tube
because the effects of treatment make it difficult to take in enough nutrients orally
A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse?
Contraction of neck muscles during inspiration
The school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus?
- Cover the nose when coughing.
- Obtain an influenza vaccination.
- Stay at home when symptomatic.
To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do
- adequate fluid intake
- Splint the chest when coughing.
- Instruct patient to cough at end of exhalation
What precautions is influenza
Droplet
What is the perimeter of droplet
5’ perimeter
A flu patient developed crackles in the lungs, what have they developmed
Pneumonia
physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance?
Respiratory Rate 28
Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia?
Increased vocal fremitus on palpation, bronchial breath sounds, egophony, and crackles in the affected area
What is the priority nursing intervention in helping a patient expectorate thick lung secretions?
Increase fluid intake to 3 L/day if tolerated.
An increased risk of pulmonary embolism is associated with
- obesity
- malignancy
- heavy cigarette smoking
- prolonged air travel with reduced mobility
When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication?
Antibiotic
Hypertension- Nursing Care
DIURETIC
- Daily Weight
- Intake and Output (I & O)
- Urine Output
- Response of BP
- Electrolytes
- Take Pulses
- Ischemic Episodes (TIA)
- Complications:
Collapsed Alveoli
Atelectasis
Hyptertension Complications 4C’s
- Coronary Artery Disease
- Coronary Rheumatic Fever
- Congestive Heart Failure
- Cerebral Vascular Accident
Create labs for someone with metabolic acidosis
low pH low HCO3
Labs for someone with Metabolic Alkalosis
High pH High HCO3
Respiratory Acidosis Labs
- pH Low
- PCO2 High
Normal Value for HCO3
22-26
Normal Value PCO2
34-45
Lab values when only partially compensated
all three values will be abnormal. One value will be working harder to compensate.
Lab Value when fully compensated
pH will be normal
Diseases that can cause Acid Base Imbalances
- COPD
- Pulmonary Edema
- Pneumonia
- Hyperkalemia-Acidosis,
- Hypokalemia Alkalosis,
Step 1: Blood has cicrulationg through the body, lost its oxygen and collected CO2, where does it enter?
- Right Atrium of the heart through the Vena Cava
Step 2: Right Atrium Contracts and pumps blood through which valves?
Tricuspid valve and right ventricle
Step 3 of 9: The Right Ventricle pumps blood where?
- Through the pulmonary artery into the lungs
Step 4: What do the tiny blood vessels (capillaries) in the lungs do?
absorb CO2 from blood and replace it with oxygen
Step 5: oxygenated blood flows through the pulmonary vein and into where?
- Left Atrium
Step 6: Oxygenated blood pumps throu the mitral valve and into where?
Left Ventricle
Once the blood has gone through the aortic arch, what are the option for where blood can be pumped?
- thru carotid artery into the brain
- auxiliary arteries into the arms
- aorta and into the torso/legs
Step 8: Blood moves through the arteries, then through capillaries, where does it return?
Veins
Step 9: What is the last step of the cardiac cycle?
Deoxygenated blood will return to the heart
this pumps blood to pulmonary circulation
right ventricle
pumps blood to the systemic circulation
left ventricle
this is a valve between LA & LV
Mitral Valve
Valve betwee RV & Pulmonary Aorta
pulmonic valve
Contraction of Myocardium
Systole
Relaxation of Myocardium
Diastole
Normal Value for Mean Arterial Pressure
Must be greater than 60
as the average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP).
Mean Arterial Pressure
(CO X Systemic Vascular Resistance) + Central Venous Pressure
Amount of blood ejected from the left ventricle with each beat
Stroke Volume
How much output of blood does the heart put out
4-6 liters
peptide hormone secreted by the cardiac that in pharmacological doses promotes salt and water excretion and lowers blood pressure
natriuretic peptide
this hormone lives in the Atria
a- natriuretic peptide
This hormone lives in the ventricle
B-natriuretic peptide
What happens to heart function in older adults?
- the heart muscles decrease
- become stiff
- Need for pacemakers
What drug are older adults are less sensitive to?
Beta Adrenergic Agonist Drugs
Define Preload
- How much the heart stretches before it contracts
- higher the preload, the harder the heart has to work
What is another name for preload
End Diastolic Volume
Define Afterload
- the tension developed in the wall of the left ventricle during ejection.
Good Cholesterol
HDL
Bad Cholesterol
LDL
Why would you test CBC for a patient with Anemia?
- would have low red blood cells
- would have a hard time carrying oxygen
- Tachycardia
Define Hypertension
Force exerted by the blood against the walls of the blood vessel. No symptoms. (sys above 140, diastole above 90)
Modifiable Risk factors of hypertension
- sodium intake
- smoking
- stress
Non Modifiable Risk factors for hypertension
- Family History
- African American
Symptoms of Hypertension
- “silent killer”
- Any damage from high BP
- dizziness
- Headache, pressure in the brain
- Fatigue
- Dyspnea
- Problems w/ retina
Assessing someone with Hypertension
- Health HX
- Phys Exam
- BP in both arms
- Manual BP
- Patient should be seated quietly for 5min
- Take 2 Measurements
Goal for patient with Hypertension
- Control BP
- Reduce CVD Risk Factors
Nursing Inverventions for someone with Hypertension
- empathy
- motivation/adherence to therapy
- consider cultural beliefs
- Taking meds
Menu for someone with Hypertension
- DASH diet
- Fish every week
- Fruits, Vegetable
- Lots of Water
- Potassium
- Low Sodium
What is a hypertension Crisis?
- Diastolic blood pressure above 140.
- Not taking meds or undermedicated.
- Treat it with IV. Monitor bp.
1 Drug for Hypertension
Diuretics
Right Sided Heart Failure
- Chronic Respiratory Problems
- Ascites
- Cor Pulmonal
- Weight Gain
- MI
- Ab Pain
- JVD
- Hepatomegaly
- Peripheral Edema
Left Sided Heart Failure
- Most Common
- Pulmonary Congestion
- Crackles
- Poor Oxygenation
- S3, Increase Afterload
- Irregular Palpitations
- Pulmonary Edema
- Diastolic and systolic dysfunction
- Blood backing up into right atria
Diastolic Failure
- Ventricles become stiff, cannot relax
- Normal Ejection Fraction
- Low BP
- Low Cardiac Output
- Pulmonary Congestion
- Poor Exercise Tolerance
Systolic Fairure
- Ventricles Swell
- Decrease in left ventricular ejection fraction
Normal Ejection Fraction
55%
Difference between Left Sided Heart Failure Vs. Right Sided Heart Failure
- RT- Peripheral Edema
- LF- Pulmonary Edema
Diagnostic Testing for Heart failure
- BNP
- ANP
- Creatnine Kinase
- Troponin
- Fibronogen
- Chest Xray
- EKG
- Coronary Angiogram
- Echogram
What is the exercise stress test for heart failure
- Put them on a treadmill 5 min
- walk test
- pass/fail
Clinical Manifestation of Acute Decompensated Heart Failure
- Dyspnea,
- orthopnea
- fatigue
- Paroxysmla Nocturnal dyspnea
- Waking up feeling like their suffocations, because of reabsorption of fluid.
- Persistent dry cough.
- Frothy (bubbly) blood tinged sputum (pink).
- Cyanoisis
- Clammy Skin
sample list of vital signs for a patient in distress ADHF
- Irregular pulse
- low urine put
- Weight gain
- Fluid retention
- Anorexia
Nursing Diagnosis for a patient with heart failure
- Activity Intolerance
- Fluid Volume Excess
- Impaired Gas exchange.
Goals for a patient with Heart Failure
- Decrease Intravascular Volume (diuretics)
- Decrease Preload
- Decrease After load (vasodilation)
- Reduce Anxiety
Patient positions for a patient with high fowlers
High Fowlers
Aneurism Definition
weakend blood vessel
What are outcomes of ventricular dysfunction
- Diminished Quality of Life
- Reduced Exercise Tolerance
Ejection Fraction Definition
- Fraction of blood pumped out for the ventricle with each heart beat
- Applies to right and left
- SV/End Diastolic Volume
Complications of Heart Failure
- Pleural Effusion
- Fatal Dysrrythmias
- AFib
- Respiratory Acidosis
Define Ventilator Acquired Pneumonia
- 48 hours after intubation, before the onset of the event
Aspiration Pneumonia Definition
- Aspirated something into their lungs
- Decreased LOC
Hospital Acquired Pneumonia
- Occurring 48 hours or longer after admission
- Not incubating at time of hospitalization
Causes of Pneumonia
- Smoking
- Secondhand smoke
- Asthmna
- Genes
- pollution and fumes
COPD Patient Assessment
- Use Pursed Lipped Breathing
- Use Oxygen as prescribed
- Close ended question
- High Fowlers, Orthopnea, Tripod
- Chest percussions
- Respiratory Rate
- Lung Sounds
- Heart Rate increased
- Sputum culture in the morning
- 6-8 wks deep breathing exercises
Nutrition w/ COPD patient
- adequate fluid intake
- Small meals more frequently
- Avoid foods that cause gas
- High Calorie
- High Protein diet
- Instructo to cough at end of exhalation
Signs of COPD
- productive cough for 3 or more months in each of 2 successive years
- Dyspnea
- Chronic Fatigue
- Bluish Red Color Skin
- Pulmonary Hypertension
Describe the patient with advance COPD and Cor Pulmonale
- Damaged to lung tissue
- Acute respiratory failure
- Depression/anxiety.
- Anger.
- Pulmonary Hypertension.
right sided heart failure caused from pulmonary hypertension. Caused from COPD
Cor Pulmonale
nursing diagnosis for a patient with advanced respiratory diseases.
- Hyperthermia Related to Infectious Illness,
- ineffective airway clearance,
- pneumonia
- pulmonary embolism
- Activity Intolerance
- Inadequate Nutrition
- Social Isolation
- Impaired Gas Exchange.
- Anxiety.
- Risk for Infection
- Ineffective Coping
- Fatigue.
- Ineffective Breathing Pattern
- Insomnia
movement of air into and out of lungs
Ventilation
Movement of blood through the lungs. Blood clot blocks
Perfusion
movement of gases between the lung and blood. Heart Failure.
Diffusion
Maximum airflow rate during forced expiration.
Peaked Expiratory Flow rate, (every asthma patient)
the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath
vital capacity
measures how much air a person can exhale during a forced breath.
Forced Expiratory Volume
Define Stage 1 Hypertension
SBP between 140 and 159 mm Hg or DBP between 90 and 99 mm Hg.
Define Stage 2 Hypertension
SBP 160 mm Hg higher or DBP 100 mm Hg or higher.
Treating Heart Failure Mneumonic
- Upright
- Nitrates
- Lasix
- Oxygen
- Ace Inhibitors
- Digozin
- Fluids (decrease)
- Afterload (decrease)
- Sodium Restriction
- Test (Dig, ABG, K)
CORE measures x4
- Angiotensin Converting Enzyme Inhibitor LVSF
- LVG assessment
- Smoking cessation counceling
- HF discharge instructions
A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because:
Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells.
A patient has the following arterial blood gas (ABG) results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. When assessing the patient, the nurse would expect the patient to experience:
Hypertonic muscles with cramping.
What is elastic recoil
Negative pressure in the lungs. Suctioning
Acid Base imbalances from Lung Diseases
- COPD
- Pneumonia
- Pulmonary Edema
- Pulmonary Embolism
Acid Base Imbalances From Kidney Disease
- DiabetesHypertension, kidney disease, nephrotoxic drugs, congenital renal disease
myocardial muscle protein released after injury or infarction
Troponin
What happens to a patient’s acid base imbalance when in cardiac arrest
Acidosis
Describe the purpose of pursed lip breathing in the COPD Patient
To reduce overall work of brathing
A patient with heart disease has developed pulmonary edema w/ difficulty breathing. The nurse notes that the patient is breathing at a rate of 28/min and has oxy sat of 90% on room air. Which best describes the first response of the nurse?
administer oxygen through a face mask to correct saturation levels
Causes for dyspnea
- obesity
- Heart Disease
- Arrhythmias
- Asthma
- COPD
- Bronchiectasis
A nurse is reviewing principles of good nutrition for a patient w COPD. What suggestion regarding nutrition would support the health of the patient w/ COPD
Achieve and maintain a healthy weight
obesity contributes to complications of COPD
This is a type of heart catheterization procedure. A type of dye that’s visible by an X-ray machine is injected into the blood vessels of your heart.
Coronary Angiogram
This is an enzyme found in the heart, brain, skeletal muscle, and other tissues. Increased amounts are released into the blood when there is muscle damage.
Creatnine Kinase
