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Semester One - Nursing 111 > Week Nine > Flashcards

Week Nine Flashcards

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1
Q

Occult Blood

A

Hidden blood

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2
Q

Carminative Enema

A

given to expel flatus. Solution releases gas in rectum which causes distention and stimulates peristalsis

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3
Q

Retention Enema

A

Introduces oil or medication into the rectum and signmoid colon. Softens feces, lubricates feces and colonic mucosa to facilitate passage of feces.

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4
Q

Cleansing Enema

A

Removes feces using a variety of solutions

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5
Q

Enema Function

A

Remove feces and/or flatus

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6
Q

Enema

A

A solution introduced to the rectum and sigmoid colon

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7
Q

Fecal Impaction

A

A mass of hardened, puttylike feces in folds of rectum

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8
Q

Signs of Fecal Impaction

A

passage of liquid fecal seepage and no normal stool

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9
Q

Time it takes to see oil retention enema results

A

30minutes - 3 hours

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10
Q

Nursing Considerations for Enema

A
  • Amount of fluid used
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11
Q

Soap Suds Enema

A

Cleansing soapy enema given to remove feces from colon. Relieves constipation and is a prep for diagnostic tests.

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12
Q

Action of Soap Suds Enema

A

Stimulates peristalsis by irritating mucosa and distending colon volume up to 1,000 mL H20 with soap

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13
Q

Oil Retention Enema

A

Retention enema that makes defecation easier. Mineral oil is commonly used.

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14
Q

What type of enema is a hypertonic enema?

A

cleansing enema

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15
Q

Hypertonic Enema

A

Cleansing sodium enema given to remove feces from the colon. Relieves constipation and preps for diagnostic tests.

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16
Q

Action of hypertonic enema

A

Draws water into the colon, distends the colon, irritates mucosa

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17
Q

Time it takes to see results from a hypertonic enema

A

5-10 minutes

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18
Q

Volume Hypertonic Enema

A

90-120 mL

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19
Q

What type of enema is a tap water enema?

A

Hypotonic cleansing enema

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20
Q

Carminative enema volume

A

180mL total

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21
Q

Volume oil retention enema

A

90-120mL

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22
Q

Tap water enema

A

Hypotonic Enema. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces.

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23
Q

Volume tap water enema

A

500-1000mL

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24
Q

What type of enemas should be administered to an infant or child?

A

isotonic

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25
Q

Enema temperature for infant or child

A

100 F or 37.7 C unless otherwise ordered

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26
Q

True or False: Elders may fatigue easily when administering an enema

A

True

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27
Q

What position is appropriate for administering an enema in a small child?

A

Dorsal recumbent position

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28
Q

How far should the tube be inserted for enema administration in infants?

A

1-1.5 inch

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29
Q

How far should the tube be inserted for enema administration in children?

A

2-3 inches

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30
Q

True or False: Tap water enemas should be used with caution in the elderly

A

True.

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31
Q

What should be assessed in elderly clients during enema administration?

A

vagal episodes, slow pulse, and irregular pulse

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32
Q

Nursing responsibilities for stool specimens

A
  • Have the client defecate into a clean bedpan or bedside commode
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33
Q

Therapeutic Nursing Interventions for rectal suppository

A
  • Hand hygiene and gloves
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34
Q

Anemia

A

lack of a normal number of red blood cells

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35
Q

Bradypnea

A

slow respiratory rate, usually below 10 respirations per minute

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36
Q

Cheyne Stoke Respirations

A

patter of breathing characterized by gradual increase of depth and sometimes in rate to a maximum level followed by a decrease resulting in apnea

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37
Q

Cyanosis

A

a bluish discoloration of the skin and mucous membranes

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38
Q

Diffusion

A

process by which molecules tend to move from an area where they are more concentrated to an area where they are less concentrated

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39
Q

Dyspnea

A

shortness of breath, difficult or labored respiration

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40
Q

Eupnea

A

normal relaxed breathing, easy

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41
Q

Hemoptysis

A

coughing up blood from the respiratory tract

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42
Q

Humidification

A

process of adding water to gas

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43
Q

Hypercarbia

A

the presence of an abnormally high level of carbon dioxide in the circulating blood

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44
Q

Hyperventilation

A

an increased depth and rate of breathing greater than demanded by the body needs

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45
Q

Hypoventilation

A

respiratory rate remains abnormally low and is insufficient to meet the demands for normal oxygen delivery and carbon dioxide removal. (most common cause of hypercapnia)

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46
Q

Hypoxemia

A

deficient amount of oxygen in the blood

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47
Q

Hypoxia

A

deficient amount of oxygen in tissue cells

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48
Q

Orthopnea

A

form of dyspnea in which the person can breathe comfortably only when standing or sitting erect

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49
Q

Productive Cough

A

cough with spitting of material from the bronchi

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50
Q

Nonproductive cough

A

dry, hacking, produces no secretions

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51
Q

Respiratory insufficiency

A

disturbance oflevels of oxygen and carbon dioxide in the blood stream, inability of body to meet oxygen nees andremove CO2

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52
Q

Tachypnea

A

an abnormally rapid rate of respiration, usually >20 breaths per minute

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53
Q

Oxygen Status Diagnostic Test Serum Hemoglobin

A

12-18g/100mL

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54
Q

Oxygen Status Diagnostic Test Serum Red Blood Cell Count

A

3.5-5.0 million/ cu. mm

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55
Q

Barrel Chest

A

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

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56
Q

Funnel Chest

A

pectus excavatum; depression in the lower portion of the sternum, may cause compression of the heart

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57
Q

Pigeon Chest

A

pectus carinatum; sternum displaced anteriorly; costal cartilage beside the protruding sternum are depressed

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58
Q

Biorhythms

A

an innate periodicity in an organism’s physiological processes, as sleep and wake cycles.

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59
Q

Circadian Rhythms

A

individual is awake when the physiologic and psychologic rhythms are most active and is asleep when the physiologic and psychologic rhythms are most inactive. Rhythmic repetition of patterns each 24 hours.

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60
Q

Hypnotic

A

depresses the central nervous system and usually produces sleep

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61
Q

Sedative

A

depresses the central nervous system to produce calm and diminished responsiveness without producing sleep

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62
Q

Sleep

A

a natural and periodic state of rest during which consciousness of the world is suspended

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63
Q

Somnolence

A

drowsiness; sleepiness

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64
Q

Insomnia

A

sleep abnormalities, including difficulty in falling asleep and wakefulness through the night

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65
Q

Hypersomnia

A

Excessive sleepiness, as evidenced by prolonged nocturnal sleep, difficulty maintaining an alert awake state during the day, or undesired daytime sleep episodes.

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66
Q

Narcolepsy

A

a sleep disorder characterized by sudden and uncontrollable episodes of deep sleep

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67
Q

Parasomnia

A

abnormal movement or emotions during REM and NREM and wakefulness. bruxism, enuresis, periodic limb movement disorder, sleep talking, sleep walking

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68
Q

Sleep Apnea

A

a sleep disorder characterized by temporary cessations of breathing during sleep and repeated momentary awakenings

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69
Q

Rest

A

calmness, relaxation without emotional stress and freedom from anxiety

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70
Q

NREM Sleep

A

75-80% of sleep, three stages

71
Q

Stage One NREM

A

very light sleep, drowsy, relaxed, can be awakened easily and lasts a few minutes

72
Q

Stage Two NREM

A

Light sleep which body processes continue to slow down. Lasts only 10-15 minutes but constitutes 44-55% of total sleep

73
Q

Stage Three NREM

A

Deepest sleep. only differs in the % of delta waves recorded during a 30 second period. HR and R drop 20-30% below waking hours, individual difficult to arouse. restores energy and releases growth hormones

74
Q

Changes during NREM sleep

A

BP falls, HR decrease, peripheral blood vessels dilate, cardiac output decreases, skeletal muscles relax, basal metabolic rate decreases, growth hormone level peaks, intracranial pressure decreases

75
Q

REM Sleep

A

rapid eye movement, q 90 minutes for 5-30 minutes, not as restful as NREM, dreams, brain highly active and brain metabolism increases by as much as 20%, may be difficult to arouse or NOT, voluntary muscle tone is decreased, gastric secretions increase, HR irregular, R irregular

76
Q

Functions of sleep

A

Restores normal levels of activity, normal balance among parts of the nervous system, necessary for protein synthesis, psychological well being

77
Q

Newborn sleep

A

16-18 hr

78
Q

Infant sleep

A

14-15 hr

79
Q

Toddler sleep

A

12-14 hr

80
Q

preschooler sleep

A

11-13 hr

81
Q

school age children sleep

A

10-11 hr

82
Q

adolescents sleep

A

9-10 hr

83
Q

adult sleep

A

7-9 hr

84
Q

older adults sleep

A

7-9 hr

85
Q

Nocturia

A

excessive urination at night

86
Q

Factors that affect normal sleep

A

illness, environment, lifestyle, emotional stress, stimulants and alcohol, diet, smoking, motivation, medications

87
Q

Sleep History Assessment

A

sleep history, pattern, problems, medications, health history, medical or psychiatric issues, physical examination, obstructive sleep apnea, sleep diary

88
Q

Normal Sleep Findings

A

awaken refreshed and not fatigued during day, fall asleep without difficulty

89
Q

Sleep deprivation findings

A

difficulty falling asleep, waking up during the night, difficulty returning to sleep, waking up too early in the morning, unrefreshing sleep, daytime sleepiness, difficulty concentrating, irritability

90
Q

Teenage sleep deprivation findings

A

difficulty waking, falls asleep, late for class, has to drink caffeinated bev, difficulty in school, irritable, anxious, angry, always on the run, naps and sleeps in on weekend

91
Q

Definition disturbed sleep pattern

A

time limited interruptions of sleep amount and quality due to external factors

92
Q

Defining characteristics disturbed sleep pattern

A

change in normal sleep pattern, verbal complaints of not feeling well rested, dissatisfaction with sleep, decreased ability to function, reports being awakened, reports difficulty falling asleep

93
Q

sleep deprivation definition

A

prolonged periods without sleep(sustained natural, periodic suspension of relative consciousness)

94
Q

defining characteristics of sleep deprivation

A

actue confusion, agitation, anxiety, apathy, combativeness, daytime drowsiness, decreased ability to function, fatigue, feeling nystagmus, hallucinations, hand tremors, heightened sensitivity to pain, inability to concentrate, irritability, lethargy, listlessness, malaise, perceptual disorders, restlessness, slowed reaction, transient paranoia

95
Q

safety measures for sleep in health care setting

A

put side rails up, place beds in low position, use night lights, place call bells within easy reach

96
Q

Ambien

A

Sonata

97
Q

Zolpidem

A

Zaleplon

98
Q

Ambien Use

A

short term treatment insomnia

99
Q

Ambien action

A

CNS depression at limbic, thalamic, hypothalamic levels, may be mediated by GABA, sedation, hynosis, skeletal muscle relaxant, anticonvulsant activity, anxiolytic action

100
Q

Side/Adverse effects ambien

A

lethargy, drowsiness, daytime sedation

101
Q

nursing implications ambien

A

administer after removal of cigarettes to prevent fires, after trying conservative measures for insomnia, 30min-1hr before bedtime for sleeplessness

102
Q

sonata use

A

insomnia

103
Q

sonata action

A

binds selectively to omega-1 receptor of the GABA receptor complex, sedation, hypnosis, skeletal muscle relation, anticonvulsant activity, anxiolytic action

104
Q

sonata side/adverse effects

A

lethargy, drowsiness, daytime sedation

105
Q

sonata nursing implications

A

administer after removal or cigarettes to prevent fires, after trying conservative measures for insomnia, immediately before bedtime for sleeplessness

106
Q

Phases of respiration

A

pulmonary ventilation, alveolar - capillary gas exchange, transport of gases, peripheral capillary gas exchange

107
Q

Pulmonary Ventilation

A

Movement of air between the atmosphere and the alveoli of the lungs (inspiration, expiration)

108
Q

Inspiration

A

active process

109
Q

Expiration

A

passive process

110
Q

Requirements for pulmonary ventilation

A

unobstructed airway, intact CNS, intact brain stem, ability of chest cavity to expand and contract, ability of lungs to expand and contract

111
Q

Alveolar - Capillary Gas Exchange

A

diffusion=distribution. movement of gases from an area of higher concentration to an area of lower concentration, diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries

112
Q

Transport of gases

A

Movement of gases lungs and heart, heart and tissues

113
Q

Requirements of transport of gases

A

intact cardiovascular system

114
Q

Oxygen is transported VIA what?

A

hemoglobin of RBC

115
Q

Carbon Dioxide transported VIA what?

A

RBC and is dissolved in plasma

116
Q

Peripheral Capillary Gas Exchange

A

Diffusion = Distribution. Movement of gases from an area of higher concentration to an area of lower concentration, diffusion of oxygen and carbon dioxide between the peripheral capillaries and body cells

117
Q

Right Side Heart

A

Pulmonary Ventilation

118
Q

Left Side Heart

A

Transport

119
Q

Lungs

A

gas exchange

120
Q

What mechanisms regulate the respiratory process?

A

neural control- brain stem: medulla oblongata and pons, cerebral cortex, chemoreceptors

121
Q

Medulla Oblongata and Pons

A

automatic control of R

122
Q

Cerebral Cortex

A

Voluntary or conscious control of R, singing, swimming

123
Q

Chemoreceptors

A

increase in carbon dioxide increase R, co2 blown off

124
Q

Aorta and Carotid arteries

A

decrease o2 increases R, increase o2, emergency ventilation, fight or flight response

125
Q

Stress

A

flight or fight mechanism

126
Q

Environment

A

Altitude, occupational hazards

127
Q

Lifestyle

A

exercise, smoking

128
Q

Health Status/Disease

A

lungs, nervous system, cardiovascular

129
Q

Age

A

infants, children, elders

130
Q

Factors that affect R function

A

stress, environment, lifestyle, diet, health status/disease, medications, age

131
Q

Factors affecting gas transport

A

effective cardiac pump, adequate peripheral blood vessels for diffusion, adequate amount of plasma intravascular, normal RBCs

132
Q

Infants R

A

30-60

133
Q

Child >1 year R

A

25

134
Q

Infant risk

A

maturing R center increases risk for R illness

135
Q

Elder Risk

A

decrease lung elasticity, decrease in ability to pump and transport gases, exposure to environmental hazards through life time, decrease immune response = risk for respiratory illness

136
Q

Information collected during nursing history when assessing oxygenation

A

restlessness, confusion, abnormal breathing patterns, cough, sputum, chest pain, fatigue, weakness, lightheadedness, med history respiratory, neurological, cardiovascular, environment, lifestyle, medications, diet

137
Q

Function of Iron

A

Formation of Hgb - transports oxygen

138
Q

Sources of Iron

A

organ meats, oats, prune juice

139
Q

Absorption of Iron

A

Vitamin C increases absorption, calcium decreases absorption

140
Q

Populations at risk for iron def

A

less than 18 months, pregnancy, lactation, menstruation, vegetarians, low socioeconomic groups

141
Q

Oxygen Sat normal

A

95-100%

142
Q

Areas to assess for cyanosis

A

nail beds, circumoral skin (around mouth), sublingual mucous membranes (under tongue), conjunctiva (eyes), earlobes, buccal mucosa (cheeks), lips, palms of hands, soles of feet

143
Q

RBC Venous blood sample

A

trasport mechanism for oxygen

144
Q

RBC normal value

A

3.5-5.0 million

145
Q

Hemoglobin

A

binging site for oxygen inside the RBC, dependent on adequate iron intake

146
Q

Normal Hgb

A

12-18g/100mL

147
Q

Hematocrit

A

indicates adequate percentage of RBCs and fluid

148
Q

Normal Hct

A

35-50%

149
Q

Normal Chest

A

symmetrical from side to side, prominent clavicle, flat sternum, anterior/posterior diameter 1/3 to 1/2 the transverse diameter

150
Q

Hypoxia

A

insufficient oxygen to body cells

151
Q

Signs of hypoxia

A

mental status change, restlessness, tachypnea, dyspnea, lightheadedness, tachycardia, cyanosis

152
Q

What information to be collected when assessing cough?

A

occurrence, triggers, productive or non-productive, sounds, presence of sputum-productive

153
Q

Sputum

A

Normal lung and airway secretions that may increase to compensate for disease

154
Q

Note sputum

A

color, amount, odor, consistency, presence of blood

155
Q

Definition of ineffective airway clearance

A

inability to clear secretions or obstructions from the R tract r/t obstructed airways (mucous, foreign body), R disease, smoke, airway spasm

156
Q

Defining characteristics of ineffective airway clearance

A

adventitious breath sounds, diminished breath sounds, cough, increase sputum, cyanosis, change in R depth (deep or shallow), dyspnea, orthopnea, tachypnea or bradypnea

157
Q

Definition of ineffective breathing pattern

A

Inspiration and/or expiration that does not provide adequate ventilation R/T fatigue, impairment of musculoskeletal, respiratory, neuromuscular systems, anxiety

158
Q

Defining characteristics of ineffective breathing pattern

A

dyspnea, othopnea, tachypnea, bradypnea, use of accessory muscles, increase A/P diameter, change in respiratory depth (increase or decrease)

159
Q

Definition for risk for activity intolerance

A

At risk for experiencing insufficient energy to complete ADLs

160
Q

Defining characteristics for risk for activity intolerance

A

respiratory signs and symptoms, cardiac signs and symptoms, de-conditioned status

161
Q

nursing interventions for oxygenation related nur dx

A

position patient to optimize R (fowlers), assist with deep breathing and coughing techniques, promote fluid intake, humidification, administer medications for cough/sputum production

162
Q

Why promote fluid intake?

A

liquefies secretions, facilitates expectoration, moistens mucous membranes

163
Q

Why humidification?

A

moistens airway, facilitates cough and expectoration

164
Q

Expectoration

A

coughing up and spitting out of material from the lungs

165
Q

Guaifenesin indication

A

productive and non-productive cough

166
Q

Guaifenesin action

A

increase volume of secretions, decrease viscosity of secretions

167
Q

Dextromethorphan Indication

A

non-productive cough due to irritation of airways

168
Q

Dextromethorphan action

A

suppresses cough center in medulla oblongata

169
Q

Nursing implications for dextromethorphan

A

treat other symptoms, decrease oxygen demand, monitor R, breathing, breath sounds, cough, sputum

170
Q

Health promotion measures that relate to healthy breathing?

A

change position frequently, exercise, ambulate, no smoking, avoid exposure to toxins, safety in the home, furnaces, gas appliances, smoke, and CO detectors

171
Q

What are the reasons for supplemental oxygenation

A

increase the amount of oxygen available for transport. based on symptoms, blood work, 02 sat

172
Q

Ferrous gluconate

A

more expensive than ferrous sulfate, easier on the stomach

173
Q

ferrous gluconate and sulfate

A

replaces iron stores necessary for RBC development for iron deficient anemia

Semester One - Nursing 111 (15 decks)

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