HEHI EXAM 1

RAAS system

angiotensinogen - renin - angiotensin I - ACE converting enzyme - angiotensin II - stimulation of aldosterone secretion - aldosterone - increased water and sodium retention - increased preload AND constriction of vascular smooth muscle for increased afterload

causes of hypophosphatemia

antacids refeeding syndrome

treatment of deep vein thrombosis

anti-coagulants, remove the clot

how to help with itching

antihistamine drug

psychosocial symptoms of pain

anxiety, depression, agitation

s/s of alkalosis

anxiety, irritability tetany seizures parathesia (numbness and tingling) hyperreflexia increased HR

what puts you at risk for respiratory acidosis?

anything that impairs airway, breathing, and gas exchange ex. COPD, opioid/sedatives

what is physical assessment informed by?

appropriate diagnostic testing such as pulse ox, imaging, and lab findings

assessing level of consciousness (AVPU)

assess verbal stimulation painful stimulation unresponsive evaluation of neuro state

on entry to the ED a patient who fell from a roof, what is nurse's priority action?

assess airway and stabilize cervical spine

what is nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?

assess breath sounds and resp efforts

kussmaul's respirations

associated with diabetic ketoacidosis deep, rapid breaths as your body works to break off excess acid

where can pain transmission be modulated?

at a number of levels, including the dorsal horn of the spinal cord and via descending inhibitory pathways

what would happen if there is a disruption of renal function?

at risk for acidosis

what makes ANP

atrial cells in the heart

what is compensation?

attempt to correct changes in blood pH and maintain acid-base

interventions for fluid overload

avoid pressure injuries change positions every 2 hrs elevate dependent areas remove excess fluid with diuretics (furosemide) monitor weight loss and increased UOP observe for electrolyte imbalance fluid restriction sodium restriction strict input + output monitoring

Primary survey/initial impression for respiratory system assessment

look for agitation, anxiety, restlessness, speech quality (hoarseness), skin color (pallor or cyanosis), exercise tolerance/body positioning

immediate action for Breathing

look, listen, and feel

assessing breathing

look, listen, feel. is patient breathing and is it adequate? Observe chest expansion, resp efforts, evidence of chest wall trauma or physical abnorm, work of breathing, use of aux resp muscles, RR, o2sats, auscultate lung sounds, chest wall movement

forming an impression of patient

look, listen, smell, feel (pulse, temp)

hypovolemia

loss of blood volume

hypokalemia causes

loss of gastric fluid (vomiting, NG suctioning) overuse of potassium-wasting diuretics corticosteroids low magnesium levels

sx of sleep apnea

loud snoring, episodes of apnea, excessive daytime sleepiness

if calcium is high, phosphate is _______

low

pressure within pulmonary circulation is _____

low

hypomagnesemia

low magnesium

hyponatremia

low sodium

example of compensated metabolic alkalosis

lower RR to retain CO2 to counteract increased bicarb

carbon dioxide levels controlled by what?

lungs

compensatory mechanism for metabolic acidosis

lungs blow off co2 to raise pH

compensatory mechanism for metabolic alkalosis

lungs retain co2 to lower pH

what makes ADH

made in hypothalamus, released by posterior pituitary

where is angiotensinogen produced

made in liver, circulates in plasma

what does ACE do/where is it made?

made in lungs, converts angiotensin I to angiotensin II

Which nursing action has the highest priority when caring fora client with any type of facial or laryngeal trauma?

maintaining a patent airway

what does sodium do?

maintains electrical charge in ECF maintains fluid balance in body "where sodium goes, water follows"

compensation

maintains homeostasis

what are potential threats to albumin synthesis

malnutrition liver disease

inflammatory soup

mast cells neutrophils bradykinins macrophages

what is VO2max?

max oxygen uptake that your issues can do

compliance

measure of lung and chest wall distensibility (ease in which structure can be stretched)

what does ADH do?

mediates insertion of aquaporins into nephron collecting duct cells; as a result more water is reabsorbed into the blood increases sodium reabsorption in the medulla of the kidney

loss of HCO3 or too much acid (non-carbonic) GI losses, diabetic ketoacidosis, sepsis

metabolic acidosis

low pH, low HCO3

metabolic acidosis

diarrhea puts you at risk of __________

metabolic acidosis stool moves through GI tract too fast to reabsorb the bicarb low pH, low HCO3 **confirm with ABGs

extreme vomiting puts you at risk of:

metabolic alkalosis

loss of metabolic acids TUMS OD suctioning diuretics

metabolic alkalosis

treatment of hypocalcemia

monitor for osteoporosis maintain safety/fall prevention replace with calcium supplements PO/IV, vitamin D phosphate binders

peripheral edema

most commonly seen in feet due to gravity general term for edema

kidney buffers

most powerful regulator of acid-base balance work horse, takes awhile to kick in

kidney pH control action

movement of bicarbonate formation of acids formation of ammonium

perfusion

movement of blood into and out of the capillary beds of the lungs to body organs

pulmonary blood flow

moves oxygenated blood out of the lung

non-pharmacologic complementary and integrative interventions to manage pain

music therapy acupuncture prayer and meditation

airways to consider

nasal, oral, tracheal

side effects of opioids

nausea itching constipation respiratory depression hypotension

physiological symptoms of pain

nausea, vomiting, diaphoresis, dilated pupils vital signs (HTN, tachypnea, tachycardia)

signs and sx of hypertonic dehydration

nausea, vomiting, headache, agitation, comas

NSAIDS are: nephrotoxic of hepatotoxic?

nephrotoxic

s/s of hyponatremia

neuro sx signs of fluid overload (bounding pulses, HTN)

name the 3 analgesic groups

non-opioid: acetaminophen, NSAIDs opioids: morphine, hydrocodone, oxycodone adjuvant analgesics: local anesthetics (lidocaine), muscle relaxants, anticonvulsants, antidepressants

full compensation returns pH to __________

normal

the body is constantly producing acid (especially CO2) as a result of __________

normal metabolic processes

what will full compensation look like?

normal pH

what goes into the psychosocial part of the comprehensive pain assessment?

patient distress, family support psych hx risk factors of aberrant use risk factors for undertreatment of pain

non-pharmacologic physical interventions to manage pain

patient education heat, cold, pressure therapeutic touch physical and occupational therapy exercise masssage

factors that may influence perception of pain

patient's knowledge and beliefs about pain

what would indicate a patient is in critical condition?

patients who appear lifeless obvious altered mental status patients who appear anxious pale, sweaty obvious trauma or bleeding

what is oxygen saturation

percentage of hemoglobin loaded with oxygen, can be measured by pulse oximetry (normal is 95-100%)

nursing care of asthma

raise HOB position in Fowler's position administer o2 monitor VS remain calm and reassuring encourage prompt med attn for infections encourage immunz administer meds as rx

simple airway interventions that can protect the pt while preparing for intubation or intervention

raise HOB suction pt's oral secretions head tilt/chin lift place in side-lying position if vomiting

what does aldosterone do?

reabsorbs sodium and fluid as part of RAAS

phosphate

regulated in same pathway as calcium inverse relationship

H+ and CO2 levels are directly _______

related

causes of hypernatremia

relative hypernatremia (diabetes, dehydration) absolute hypernatremia (excessive sodium intake or disorders of sodium reabsorption)

dorsal root ganglia

release neurotransmitters and inflammatory mediators that are going to help push that noxious stimulus/electrical stimulus up spinal cord to brain

descending inhibitory pathway

released to help manage pain GABA opioids serotonin noradrenalin

Ascending nociceptive pathways

released to signify pain/response to noxious stimuli glutamate, substance P, neurokinin 1, CGRP

mast cell

releases inflammatory mediators

what does a comprehensive respiratory assessment include?

relevant pt hx and phys exam incorporating IPPA

causes of metabolic alkalosis

removal of stomach acid either with NG tube suction or vomiting

interventions for exposure

remove all clothing, add blankets (temp control)

immediate action for Exposure

remove clothing

common causes for metabolic acidosis

renal dysfunction overproduction of other acids (lactic acid, buildup of ketone bodies) diarrhea

cause of hypermagnesemia

renal failure excessive intake of magnesium-containing laxatives treatment for premature labor

decreased tissue perfusion triggers the kidney to release ______ in the blood

renin

what does angiotensinogen do

renin breaks it down until it is angiotensin I

treatment of hypomagnesemia

replacement (PO/IV)

treatment of hypokalemia

replacement of potassium (PO or IV) bananas potassium sparing diuretics

low pH, high co2

respiratory acidosis

too much CO2 overdose

respiratory acidosis

COPD puts you at risk of:

respiratory acidosis (losing too much bicarb/co2)

high pH, low CO2

respiratory alkalosis

not enough CO2 hyperventilating "paper bag"

respiratory alkalosis

pain and anxiety are common cause of __________

respiratory alkalosis

respiratory zone of airways

respiratory bronchioles alveolar ducts alveolar sacs

respiratory unit

respiratory bronchioles alveolar ducts alveoli

what are the second line of defense for buffer system?

respiratory buffers (works in minutes)

neurochemical control of ventilation

respiratory center chemoreceptors vagus nerve

hypophosphatemia

respiratory issues due to high energy demands, leads to muscle weakness

s/s of opioid overdose

respiratory rate <12 AND/OR shallow respirations O2 saturation of <92%

how does the respiratory buffer work?

respiratory system adjusts pH in minutes by retention/elimination of CO2 from body hyperventilation and hypoventilation greater buffering power than chemical buffers

alpha-beta nerve fibers

respond to light touch, not involved in producing pain

goal for exposure

reveal other symptoms and thermo-management

which lung has three lobes?

right

pattern theory

role of impulse intensity and repatterning of the CNS

water follows __________

salt

a decrease in acidity will result in _______ respirations, attempting to hang on to ________

shallow; CO2

examples of mixed type pain

shingles, migraine, some back pains

define acute pain

short lived, temporary, localized

alterations of sodium are dangerous due to _____________ of cells

shrinking and swelling

s/s of hypocalcemia

skeletal muscle irritability trousseau's and chovsek's sign muscle spasms (tetany) hyperactive deep tendon reflexes fractures abdominal cramping and diarrhea hypotension

somatic pain

skin and MSK structures well-localized, sharp, throbbing dull, aching, cramping (deep)

what do c fibers transmit

slow, diffuse, dull pain

unmyelinated C fibers

small and conduct impulses slowly respond to thermal, mechanical, and chemical stimuli produce sensation of dull, diffuse, aching, burning, delayed pain GENERALIZED, UNLOCALIZED ACHING/BURNING majority are these type **

what do chemical buffers handle?

small fluctuations in H+ production during normal metabolic and health conditions RAPID RESPONSE

dark black sputum indicates

smoke exposure, chronic cigarette use in closed doors

relevant pt hx for respiratory assessment

smoking habits environmental/occupational exposures drug use allergies immunz resp disorders chronic disorder trauma, surgeries, hospitalizations recent travel

name 3 main ways for bronchi/bronchioles to become obstructed

smooth muscles surrounding bronchi/bronchioles contract tissue surrounding bronchiole swells due to inflammation mucus plugs

treatment of hypernatremia

sodium restriction replacement of fluids (hypotonic 0.45% IV) and free water

extracellular electrolytes

sodium, bicarbonate

what electrolytes are in the ECF?

sodium, chloride, bicarbonate

what is osmotic pressure determined by?

solute concentration (but primarily albumin)

water is a universal __________

solvent

if a pt has a low RR, we can assume that there is __________

some CO2 retention as well, can cause sedation

stridor

sounds like a seal, upper airway obstruction

what is a nociceptor

specialized sensory receptors responsible for the detection of noxious stimuli

spinothalamic tract

spinal cord --> thalamus periaqueductal gray (PAG) in mid brain contains high concentrations of opioid receptors and endogenous opioids, transmits signals important for pain localization

gate control theory (CGT)

spinal gate regulates pain transmission to higher centers of CNS. gate opens to increase pain, gate closes with non-nociceptive stimulation

what are the two main ascending pain pathways?

spinothalamic tract spinoreticular tract

wheezes

squeaky, musical, air passing through small passages narrowed by secretions and swelling

goal for circulation

stabilization of circulation

general strategies for pain relief

start with non-pharm therapies start with acetaminophen or NSAID start with short-acting opioids start with PO over IV pre-medicate 30 min before painful activities

how to treat laryngeal edema

steroids if allergic reaction, stop offending agent and give antihistimines

what stimulates nociceptors?

stimulated by mechanical, thermal, or chemical stimuli

allodynia

stimulus not normally painful now perceived as painful pain due to a stimulus that does not normally elicit pain. ex. sheets against skin

physiological effects of unrelieved pain - immune system

stress and pain can suppress immune system makes it harder to fight infection increased risk of clot formation

chronic pain modulators

stress, depression, anxiety, sleep disorders

acute pain triggers

stress, weather, infection, activity

general signs of airway compromise

stridor, choking, snoring, jagged respirations

hydrostatic pressure is _______ in the arterial ends of the capillaries

stronger

Hydrostatic pressure is ______ in the arterial ends of the capillaries, while osmotic pressure is stronger at the ________ ends of the capillaries

stronger; venous

dyspnea

subjective experience of breathlessness

goal for breathing

sufficient oxygenation and ventilation

interventions for circulation

supine position, IV access and fluids, control bleeding, trying to stabilize circulation

common signs of breathing impairment

tachypnea or bradypnea, shallow respirations, nasal flaring, accessory muscle use, tripoding, inability to finish sentence, restlessness and anxiety

immediate action for Circulation

take HR, assess capillary refill time

s/s of hyperkalemia

tall peaked T-waves muscle twitching paresthesia diarrhea cardiac arrest

what is elastic recoil?

tendency for lungs to return to the resting state after inspiration

In response to hypovolemia and hemoconcentration, what happens?

the RAAS and ADH encourage increased intake of water (by stimulating thirst) and encourage kidneys to retain more salt and water rather than urinate

what is osmolarity?

the concentration of solutes dissolves in blood

why does the left lung only have two lobes?

the heart sits in the way!

example of compensated metabolic acidosis

the lungs increase RR to blow off CO2 to compensate for a low bicarb/increased acid

what does hematocrit measure

the volume of RBC compared to the total blood volume

how do the kidneys play a role in managing acids?

they produce bicarbonate (to neutralize acids) and excrete hydrogen ions

what is the blood-gas barrier

thin and large area ideal for diffusion movement from area of high to low concentration

fluid intake via ______

thirst beverages, food, metabolism ~2500 mL/day

once you hit the vo2max, what do you use for energy?

through anaerobic glycolysis

where is calcium regulated?

thyroid gland (calcitonin) and parathyroid gland (PTH)

causes of upper airway obstruction

tongue edema or occlusion laryngeal edema tonsillar or pharyngeal abscess head neck cancer thick secretions stroke facial/tracheal/laryngeal trauma foreign-body aspiration

hypophosphatemia

too little phosphate

hypokalemia

too little potassium

hyperphosphatemia

too much phosphate

hyperkalemia

too much potassium

what is central pontine myelinolysis?

too rapid medical correction of sodium deficiency causes destruction of myelin leads to paralysis, dysphagia, "locked-in" syndrome

lower airways

trachea bronchi bronchioles alveolar ducts alveoli

conducting zone of airways

trachea, bronchi, bronchioles

TTMP Pain Pathway

transduction, transmission, modulation, perception

what do alpha delta fibers do

transmit rapid, sharp, localized pain

verbalize the pathway of pain

trauma - transduction (peripheral sensitization) - transmission (central sensitization) - modulation - perception of pain in brain

Nursing considerations for pulmonary embolism

treat with anticoagulation and thrombolytics monitor for bleeding call for help early apply o2 reassure pt place in high-Fowler cardiac monitoring obtain venous access monitor resp status closely

what does ACE do to angiotensin I

triggers release of other hormones

signs of distress

tripod positioning Levine's sign (chest pain or discomfort)

exsanguinating bleeding must be stopped immediately (T/F)

true

absence of objective sx of pain do not necessarily mean there is no pain (T/F)

true!

in COPD, the trigger to breathe is due to lower levels of o2 (T/F)

true.

what is COPD?

umbrella term for mix of chronic bronchitis and emphysema that occurs with constant inhalation of irritating particles causes: occupational exposure, smoking

multimodal analgesia

use of 2+ classes of analgesics or interventions to target different pain mechanisms

what is splinting?

using a pillow or other form of brace to relieve pain when coughing or moving from abd incision or broken ribs

what is the lung innervated by in the ANS?

vagus nerve

what are the three main compartments of fluid in body?

vascular (plasma) interstitial intracellular

osmotic pressure is stronger at the _________ of the capillaries

venous ends

what increases more during exercise: cardiac output or ventilation?

ventilation, to meet oxygen demand

angiotensin I

very slight vasoconstrictor, doesn't do much

triggers of asthma

viral infections, allergens, tobacco smoke, air position, exercise, beta-blockers

objective pain assessment

vital signs fight or flight response behavioral response

objective pain assessment

vital signs and physical exams

what is required for absorption of calcium?

vitamin D

what does upper airway do?

warms, humidifies, and filters air before it enters the lower airway

treatment of hypercalcemia

watch for osteoporosis telemetry calcium binders (calcitonin) loop diuretics fluids for hydration (0.9% NaCl)

hypertonic solution in EC space

water flows out of cell towards sodium in the EC space, cell shrinks/crenated

hemoconcentration

water is loss but substances remain

low ADH/vasopressin

water is not reabsorbed into blood, urine is dilute

high ADH/vasopressin

water is reabsorbed into blood, urine is concentrated

signs and symptoms of isotonic dehydration

weight loss decreased urine output weak thread pulse hypotension dry mucous membranes

chief complaint

what's going on? what brought you in?

what would you expect with asthma or COPD?

wheezing due to tightening/narrowing of airways

atelectasis

when a lot of alveoli are collapsed and not participating in gas exchange

anaerobic metabolism

when energy is converted from glucose to lactate when oxygen is not available effective, quick boost of energy

When does pain become a problem?

when it's no longer properly managed or it progresses and is uncontrolled, leading to very serious complications

when does pain occur?

when the tissue is damaged by exposure to chemical, mechanical, or thermal noxious stimuli and converted to electrophysiological activity (nociception)

what happens in diffusion

where oxygen enters the blood and carbon dioxide is removed

name those at risk for underassessment of pain

women smokers ppl with low edu levels injuries to lower extrem use of prehospital analgesics anxious expresses pain at lower urgency level anyone is at risk for pain

acidosis

you're holding onto too much co2, can eventually cause hyperkalemia

what determines the hydrostatic pressure ?

your BP higher your BP, higher the force driving fluid out into interstitial space

common causes of fluid overload

• Excessive fluid replacement • Kidney failure (late phase) • Heart failure • Long-term corticosteroid therapy • Syndrome of inappropriate antidiuretic hormone (SIADH) • Psychiatric disorders with polydipsia • Water intoxication

common causes of dehydration

• Hemorrhage • Vomiting • Diarrhea • Profuse salivation • Fistulas • Ileostomy • Profuse diaphoresis • Burns • Severe wounds • Long-term NPO status • Diuretic therapy • GI suction • Hyperventilation • Diabetes insipidus • Difficulty swallowing • Impaired thirst • Unconsciousness • Fever • Impaired motor function

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. What should nurse do first? Insert oral airway Do abdominal thrust maneuver Turn client to side Perform blind finger sweep

Administer abd thrust maneuver

PEEP - positive end expiratory pressure

Allows lungs to stay open b/c extra pressure of O2 & air gives longer for gas exchange to occur PEEP happens automatically in healthy lungs, but can be done externally (CPAP, BiPAP) if needed

5 A's for pain management

Analgesia: optimize pain relief Activities: optimize ADLs Adverse effects: minimize these Aberrant drug taking: avoid aberrant drug taking/addictions risk Affect: pain v. mood

what is usually the first sign of respiratory distress?

Anxiety/altered mental status is hypoxia until proven otherwise as it is usually the first sign of respiratory distress

causes of respiratory acidosis

Any condition that decreases gas exchange at the alveolar level or any condition that lowers RR will predispose pt to this ex. COPD, opioid overdose, decreased RR

risk factors for pulmonary embolism

Anything that causes hypercoagulability Prolonged immobility Surgery Pregnancy Obesity Advancing age Genetics Smoking̶ Estrogen therapy̶ Heart failure̶ Stroke̶ Cancer̶ Trauma̶ Irregular heart rhythms (atrial fibrillation)

pediatric assessment triangle

Appearance, work of breathing, and circulation to the skin.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? Increase oxygen flow to 3L/min Assess client's resp status Call emergency services for client Have client cough and expectorate secretions

Assess client's resp status

The patient, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in her lower chest. On assessment, the nurse notes there is no bubbling one exhalation in the water seal chamber. What action will the nurse perform first?

Assist the client to a side-lying position and re-assess the water seal chamber for bubbling

angiotensin converting enzyme (ACE)

an enzyme found on the surface of blood vessels in the lungs and other tissues with vasopressive action converts angiotensin I to angiotensin II

how do you know when you are thirsty?

an osmoreceptor in the hypothalamus detects changes in plasma osmolarity

what is anaerobic glycolysis?

energy not utilizing any o2

how do we get calcium?

enters body through dietary intake and absorption through intestinal tract

amount of water entering the body should _______ the amount of water leaving the body to maintain a constant level of body fluids

equal

goal for airway

establish patent airway

comprehensive pain assessment

evaluates effect of pain on quality of life

goal for disability (D)

evaluation of neuro state

what does effective gas exchange depend on?

even distribution of gas (ventilation) and blood (perfusion) in all portions of the lungs V/Q ratio (ventilation-perfusion ratio) impacted by gravity ex. standing up means more perfusion and less ventilation laying flat means most perfusion laying sideways means perfusion on side of heart, other side of lung won't have as much perfusion or blood flow

respiratory red flags

evidence of compromised or obstructed airway increased resp effort and accessory muscle use tachypnea, decreased speech tolerance pallor and cyanosis hypoxia despite o2 paradoxical chest wall movement decreased air entry/absent lung sounds altered LOC

hyperalgesia

exaggerated responses to stimuli, increased sensitivity to pain increased pain from a stimulus that normally provokes pain.

metabolic alkalosis

excess of HCO3 increased pH and HCO3 levels

hypervolemia

excessive flui volume edema heart failure kidney failure cirrhosis pregnancy

physiologic effects of unrelieved pain - endocrine system

excessive release of hormones --> poor metabolism/energy utilization weight loss tachycardia increased RR fever shock death

things that help assist transmission

excitatory neurotransmitters inflammatory soup

exposure assessment

expose skin, temperature

FLACC scale

face legs activity cry consolability

excitatory neurotransmitters

facilitate pain transmission glutamine, serotonin, acetylcholine, tachykinins, oxytocin, histamine, corticotropin-releasing hormone

excitatory modulation

facilitate pain transmission (glutamine, serotonin)

if we have met our vo2 max and still needing energy, our body compensates with a ________ RR and _______ HR

faster; increased

Psychosocial eval for respiratory assessment

fear of breathlessness reduced activity levels fatigue lowered self-efficacy and energy disrupted relationships anxiety significantly lowered mood

what is "the look test"?

feeling from environmental observations as well as first look at patient

Breakthrough pain:

flare up during normal activity, consider giving PRN short-acting PO or IV opioid

breakthrough pain

flare-up of pain that may occur randomly or as a result of normal daily activities, use PRN PO or IV opioid

pulmonary edema

fluid accumulation in the alveoli

extracellular fluid

fluid outside the cell, contains plasm, interstitial fluid, and other

management of dehydration

fluid replacement: oral fluids IV fluid (severe, unable to swallow)

treatment of hyponatremia

fluid restriction diuresis, salt tab fluid replacement with fluids (do not rapidly correct!)

what is hydrostatic pressure determined by?

fluid volume

what is intracellular fluid?

fluid within the cells, usually high in potassium and phosphate

respiratory compensation

for a metabolic problem

metabolic compensation

for a respiratory problem

hydrostatic pressure

forces fluid out of the capillary Determined by fluid volume More fluid=higher pressure This is why you see edema in congestive heart failure and chronic kidney disease

how to perform an initial assessment

form general impression assess mental status (are they alert?) assess airway assess breathing assess circulation determine patient priority and immediate interventions

nursing process in pain management

gather pertinent objective and subjective data develop individual POC nonpharm intervention pharm intervention reassess patient

angiotensin II

generalized vasoconstrictor of mainly arterioles, increases BP and increases filtration rate, which increases Na content stimulates kidneys to reabsorb more water releases aldosterone

role of genetics in pain modulation

genetics may explain 70% variability in experiencing pain

nursing interventions for sleep apnea

get fitted for cpap get scheduled for sleep study healthy lifestyle modifications (weight loss helps)

ventilation

gets gas to alveoli how many times gas is inspired and expired inhalation/exhalation lots of pressure involved (negative thoracic pressure for getting air in)

name some non-electrolytes

glucose, lipids, creatinine, and urea

excitatory neurotransmitters

glutamine

behavioral response when in pain?

groaning, moaning, grimacing, restlessness, muscle tensing, guarding, agitation

fowler's position

head and torse raised between 45 and 60 degrees

semi-fowler's position

head and torso raised between 15 and 45 degrees

immediate action for Airway

head tilt and chin lift

treatment of sleep apnea

healthy lifestyle modifications CPAP machine

risks of fluid overload

heart failure pulmonary edema complications of electrolyte abnormalities

assessment of dehydration

heart rate, pulses, BP orthostatic hypotension neck veins increased RR color, moisture, turgor of skin tenting of skin dry mucous membranes confusion fever? UOP less than 500 ml/hr weight dark, concentrated urine

how to treat chest pain

heat, splinting, pain med

what do electrolytes do?

help regulate myocardial and neurological functions, fluid balance, oxygen delivery, acid-base balance

why is water important to human body?

helps carry nutrients and oxygen to cells moistens oxygen for breathing helps convert fluid to energy protects and cushions vital organs helps body absorb nutrients removes wastes

Shift to the right in oxygen-hemoglobin dissociation curve

hemoglobin's decreased affinity for oxygen or an increase in ease which oxygen moves into cell reduced affinity increased temp increased H+/acidosis/low pH

Shift to left in oxygen-hemoglobin dissociation curve

hemoglobin's increased affinity for oxygen, doesn't let go into tissue decreased temperature decreased HCO3 alkalosis (high pH) and hypocapnia (decreased CO2)

patients with COPD with have a higher ________ and __________ because the body is compensating

hemoglobin; hematocrit

acetaminophen are: nephrotoxic or hepatotoxic?

hepatotoxic

adverse effects of acetaminophen

hepatotoxicity (liver)

______ osmolarity often is a sign of low blood volume

high

if calcium is low, phosphate is __________

high

pressure within systemic circulation is _______

high

thirst is a sensation (by the hypothalamus) that drives organisms to ingest water triggered by _______ osmolarity or high sodium and low blood volume

high

hypermagnemesia

high magnesium

hypernatremia

high sodium

what is tympany?

high-pitched and musical heard in air-filled abd organs like stomach and intestines

hypotonic solution in EC space

higher amount of sodium in cells, water follows sodium in causes cell to swell/get fat and eventually lyse (kills cell)

more fluid = ________ hydrostatic pressure, leads to _________

higher; edema

more solutes = __________ concentration and ___________ osmotic pressure

higher; higher

what does ADH do?

holds onto water (anti diuretic)

what is thirst based on

how dilute or concentrated blood is high osmolarity often is a sign of low blood volume

how to treat secretions

hydrate, encourage coughing, treat pain, splint

what is the pressure called that moves nutrients and o2 into the cells?

hydrostatic pressure

what is fluid movement regulated by?

hydrostatic pressure/capillary blood pressure osmotic pressure/colloid oncotic pressure

s/s of hypomagnesemia

hyperactive DTR muscle irritability dysrhythmias

chronic kidney disease can cause _________

hyperkalemia

administering furosemide will cause _________

hypokalemia

decreased tissue perfusion causes what

hypotension, low blood volume, low sodium, low oxygen

CAB

if a patient is having uncontrolled hemorrhage or is in cardiac arrest CAB Circulation Airway Breathing

Contradictions to NIPPV (CPAP or BiPAP)

if a pt can't protect their airway, these are a no go (vomiting, facial injuries, immobility to protect airway, impaired consciousness, impending respiratory decline)

what will uncompensated look like?

if either CO2 or HCO3 is normal (not bothered with helping the other)

contraindications to CPAP and BiPAP

immobility to protect airway impaired consciousness facial injuries nausea/vomiting impending respiratory decline

name the four quadrants of the pain matrix

immune system, nervous system, endocrine system, mood/beliefs

adverse effects of opioids

impaired gas exchange, respiratory depression constipation hypotension and orthostatic hypotension itching hyperalgesia (long-time use)

edema is the result of:

impaired lymphatic drain increased capillary permeability decreased oncotic pressure increased hydrostatic pressure

what causes third spacing?

impaired lymphatic drainage (lymphedema) increased capp permeability (inflammation) decreased oncotic pressure increased hydrostatic pressure (more fluid + more blood = more pressure)

what is dysphagia?

impaired swallowing (usually a neuromuscular problem) ex. stroke

causes of hypertonic dehydration

inadequate water intake diabetes insipidus diuretics vomiting diarrhea

an increase in CO2 levels results in an ________ in H+ ions

increase

increase in CO2 = ________ in H

increase

acids:

increase H+ most common in carbonic acid

purpose of RAAS system

increase blood volume and blood pressure

how do you treat water balance disorders?

increase water intake and reducing/stopping fluid loss

signs and conditions that cause alkalosis

increased RR nausea and vomiting

causes of respiratory alkalosis

increased RR results in blowing off too much CO2 pain/anxiety high elevation

when aldosterone is secreted, what happens?

increased blood osmolarity and blood volume

name ways that alkalosis happens

increased excretion of acids loss of GI contents (constant NG suctioning or vomiting) decreased production of acids (rare)

pulmonary edema results from:

increased hydrostatic pressure due to congestion (heart failure) inflammation causing capillary leakage (acute respiratory distress syndrome)

the more oxygen our body needs, our respiratory rate _______ to compensate for the increased demand, until you meet your vo2 max

increases

what does the RAAS system do?

increases blood volume and pressure

fluid overload

increases hydrostatic pressure forces fluid into the interstitial space causes edema

what does aldosterone do?

increases reabsorption of water and sodium

aldosterone does what?

increases sodium retention. which increases fluid retention and BP increases potassium excretion

as exercise/work increases, your oxygen uptake __________, until you hit _______

increases; vo2 max

how does ANP decrease blood volume and pressure

increasing glomerular filtration rate decreasing reabsorption of Na by nephrons inhibiting release of renin, aldosterone, and ADH

pneumonia

inflammation and consolidation of lung tissue due to an infectious agent

sinusitis

inflammation of mucous membranes

rhinitis

inflammation of nasal mucosa (viral or bacterial or allergens)

pharyngitis

inflammation of pharynx

what is bronchitis

inflammation, fibrosis, mucous secretions

friction rub

inflammed pleural space, sounds like leather rubbing

inhibitory neurotransmitters

inhibit pain transmission serotonin, norepinephrine, dopamine, GAPA, cannabinoids, opioids

inhibitory modulation

inhibit pain transmission (serotonin, GABA, cannabinoids, opioid receptors)

modulation

inhibition vs. amplification of signal

modulation

inhibition vs. amplification of signal (a balancing act)

When answering the call light for a patient on bedrest, the nurse finds the patient's visitor unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at least 2 minutes has passed since the client's first light came on. What is the nurse's priority action?

initiate CPR with chest compressions

specificity theory

injury activates specific pain receptors and fibers that project to the brain intensity of pain directly related to amount of associated tissue injury

name some electrolytes

inorganic salt, all acids and bases, some proteins

nursing consideration for dehydration management

insert IV, monitor IV site, monitor pulse rate and quality, monitor urine output, monitor BP

a nurse is developing a plan of care for a client who has COPD. the nurse should include which interventions in the plan? -restrict the client's fluid intake to less than 2L/day -provide the client with a low-protein diet -have the client use the early-morning hours for exercise and activity -instruct the client to use pursed-lip breathing

instruct the client to use pursed-lip breathing

causes of hyponatremia (less than 135)

intake of free water fluid overload loss of salt due to diuretic use

a nurse is assessing a client who has postop atelectasis and is hypoxic. which of the following manifestations should the nurse expect? -bradycardia -bradypnea -lethargy -intercostal retractions

intercostal retractions

name three spaces where fluids live

intracellular space intravascular space interstitial space (third space)

what two fluids does ECF consist of?

intravascular fluid/plasma (smallest component, v sensitive to shifts!) interstitial fluid

calcium and phosphate have an _________ relationship

inverse

calcium

ion with two positive charges exists in body in a bound form and ionized free form

signs of alkalosis

irritability, restlessness, tachycardia, neuromuscular tingling, cramping, tremor

s/s of hypokalemia

irritable heart - premature ventricular contraction paralytic ileus muscle cramps and spasms

assessing circulation

is it sufficient? Focus is adequacy of HR, BP, and overall perfusion by assessing skin, pulse, check for and control severe bleeding, skin color, temp, cap refill, heart sounds

assessing airway

is the airway open? Is the pt alert and talking clearly or crying loudly (then airway is open)? Take measures to open airway if not open. Airway includes nasal, oral, trachea. Goal is to re-establish a patent airway.

what happens to respiratory rate as your body produces more lactate for energy?

it increases to meet increased demand

What do we know about pain?

it is universal, complex, a personal experience, and a symptom

what do buffers do?

keep pH as close as possible to the pH of 7.35-7.45

which buffer system has the longest duration

kidney buffer

hyperalbuminemia

kidney disease increased albumin in blood

what does aldosterone do?

causes the nephron distal tubules to reabsorb more Na and water, which increases blood volume

ADH/vasopressin does what?

causes water retention and direct vasoconstriction

what does magnesium do

cell stabilizer low: irritability high: over-relaxation helps maintain potassium levels

chemoreceptors for ventilation

central receptors monitor pH in CSF afferent impulse from peripheral chemoreceptors in the carotid and aortic bodies that detect the partial pressure of CO2 (PaCO2) and the partial pressure of oxygen in arterial blood (PaO2), responsible for all increases in ventilation in response to arterial hypoxemia

signs of compromised airway

changed voice, noisy breathing (stridor), increased effort, decreased LOC, snoring respirations, voice or airway noises, secretions, foreign body?

key points for sodium

changes can cause NEURO issues (shrinks/swells brain cells) alterations in sodium concentrations often a reflection of body's underlying fluid status

The SpO2 of a patient receiving oxygen therapy by nasal cannula at 6L/minute has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to promote gas exchange before reporting the change to the primary health care provider?

check the tubing for kinks, leaks, or obstructions

what is the first line of defense in regards to buffers?

chemical (bicarbonate-carbonic buffer)

three different buffer systems

chemical (blood) - seconds respiratory - minutes renal - hours to days

how to treat pneumothorax

chest tube

2 things that cause COPD

chronic bronchitis, emphysema

expected findings for COPD

chronic dyspnea, productive cough, hypoxemia, crackles, wheezes, rapid and shallow respirations barrel chest hyperressonance on percussion thin extremities clubbing of fingers and toes pallor and cyanosis

what is asthma?

chronic inflammatory disorder of the airways with recurrent episodes of wheezing, dyspnea, chest tightness, and coughing

causes of hyperkalemia

chronic kidney disease acidosis cell lysis (crush injury or old RBC from blood transfusion) medications (ACE inhibitors, spironolactone)

hemoptysis indicates

circulation problem we need to address

what is a pulmonary embolism?

clump of material that lodges in blood stream and obstructs pulmonary blood flow **sx vague **most common cause of preventable death in hospitals

rhonchi

coarse, snoring sounds of air passing through large passages narrowed by secretions

signs of impaired circulation

color changes (altered from baseline) like pallor or cyanosis, temp changes (cool, clammy), sweating, decreased LOC, tachycardia or hypotension

mixed type pain

combo of nociceptive and neuropathic pain

fluid loss via _______

kidney/urine feces, sweat, small loss from lungs and skin ~400-600 mL/day

bicarbonate levels controlled by what?

kidneys

what keeps electrolyte concentrations constant?

kidneys

what makes renin

kidneys

what regulates magnesium

kidneys

where is renin released from?

kidneys

example of compensated respiratory alkalosis

kidneys excrete more bicarb to compensate for low CO2

example of compensated respiratory acidosis

kidneys increase bicarb production to compensate for high CO2 levels

compensatory mechanism for respiratory acidosis

kidneys retain increased amount of HCO3 to increase pH

what regulates potassium?

kidneys, excretion enhanced by aldosterone

what do kidney buffers react to?

large or chronic fluctuations in H+ production or elimination adjusts kidney's reabsorption or excretion of H+ or HCO3

comprehensive pain assessment

1. pain experience 2. psychosocial 3. medical hx 4. objective pain (phys exam and VS) 5. relevant lab and imaging studies

anatomy of pain pathway

1. transduction 2. transmission 3. modulation 4. perception

magnesium range values

1.7-2.1

a _________ drop in blood volume also triggers thirst (weak stimulus)

10-15%

sodium range values

135-145

in a healthy body, waht's the ratio of carbonic acid to bicarbonate ions?

1:20

an increase of ___________ in plasma osmolarity triggers the thirst center of the hypothalamus (strong stimulus)

2-3%

HCO3 acidic side

22 and less

HCO3 range

22-26

normal HCO3 level

22-26 (base)

HCO3 alkalotic side

26 and above

hypertonic IV fluids

3% NaCl, 5% NaCl used in severe hyponatremia or cerebral edema causes fluids to shift out of cell to ECF

phosphate range values

3-4.5

potassium range values

3.5-5

PaCO2 alkalotic side

35 and below

PaCO2 acidic side

45 and above

CO2 range

45-35

normal CO2 level

45-35 (acid)

what patient does ED nurse see first when assigned to care for four patients?

56 yo reporting chest pain and diaphoresis (sweating) that started 30 min prior

normal pH for arterial blood

7.35 - 7.45

acidotic side of pH

7.35 and below

levels for pH

7.35-7.45

alkalotic side of pH

7.45 and above

calcium range values

8.5-10.5

Partial pressure of oxygen (PaO2)

80-100 mmHg

high levels of sodium, Hypertonic

= water is going to travel outside of the cell and shrink

lower levels of sodium, Hypotonic

= water travels into the cell causing swelling and lyse

equal levels of sodium and water, Isotonic

=cell stays the same size cause no movement

pleural effusion

A buildup of fluid between the tissues that line the lungs and the chest. Increased inflammation and increased cap permeability. Due to increased hydrostatic pressure or low oncotic pressure leading to fluids leaking out of vessels into the pleural space

normal creatinine levels

A normal result is 0.7 to 1.3 mg/dL (61.9 to 114.9 µmol/L) for men and 0.6 to 1.1 mg/dL (53 to 97.2 µmol/L) for women.

signs of acidosis

depression of mental status (especially CO2 narcosis), generalized weakness due to decreased perfusion, EKG dysrhythmias

level 3 modulation

descending inhibitory pathway ex. PAG with high concentrations of opioid receptors and endogenous opioids

oxygen-hemoglobin dissociation curve

describes the percentage of hemoglobin saturated with oxygen at any given PO2

what is the aim of the respiratory assessment

determine respiratory status, identify deterioration in patients at risk and to guide and evaluate the effectiveness of treatment

muscles of inspiration

diaphragm intercostal muscles accessory muscles: scalene, SCM, nostrils, head, and neck muscles

signs of conditions that cause acidosis

diarrhea elevated blood sugar hypoxia/hypoperfusion COPD symptoms

education surrounding hyperkalemia

dietary changes side effects of medications when you start a pt on ACE-i or spironolactone

low osmolarity =

diluted more water, less solutes

what would you expect with pneumonia?

diminished breathing sounds over areas of consolidation coarse crackles

s/s of hypermagnesemia

diminished deep tendon reflexes

what is opioid tolerance?

diminished effect of one or more of the drug's effects over time, thought to be caused by down regulation of opioid receptors

treatment of hypermagnesemia

discontinue medication (high therapeutic range)

non-pharmacologic cognitive-behavioral interventions to manage pain

distraction guided imagery relaxation mindfulness

where are nociceptors

distributed throughout the body (skin, viscera, muscle, joints, meninges)

how to treat pulmonary edema

diuretics

treatment of chronic kidney disease

diuretics, fluid restriction, dialysis

treatment of increased hydrostatic pressure

diuretics, inhibit RAAS, fluid restriction, low sodium diet

When responding to questions in a health history, the patient reports that he usually expectorates about 2 ounces of thin, clear, colorless sputum daily, usually on getting up in the morning. What is the nurse's best action related to this finding?

document the report as the only action

isotonic IV fluids (most common!)

doesn't shift change of water from in/out of cell used for resuscitation 0.9% NaCl Ringer's lactate PlasmaLyte

level 2 modulation

dorsal horn (gate control theory) ex. if gate opens, pain signals going to brain

keep good lung ________

down (enhances ventilation and perfusion and healing and increases gas exchange)

what triggers release of renin?

drop in blood pressure, drop in Na concentration in distal convoluted tubule (DCT), increased SNS innervation

s/s of hypovolemia/dehydration

dry, cracked mucous membranes cool, clammy skin skin tenting decreased skin turgor hypotension sluggish capp refill decreased, thready pulse increased HR

physiological effects of unrelieved pain - GI tract

due to activation of SNS, GI motility impaired risk of intestinal obstruction in ileus

sx of pulmonary edema

dyspnea decreased oxygen saturation cyanosis restlessness confusion fine crackles on auscultation pink, frothy sputum

s/s of COPD

dyspnea productive cough pursed lip breathing barrel hest hypoxia and hypercarbia orthopnea polycythemia (excessive RBC)

s/s of pulmonary edema

dyspnea/orthopnea decreased o2 sats pink, frothy sputum fine crackles on auscultation fluid on x-ray

high and low levels of potassium can lead to fatal ____________

dysrhythmias

what is lymphedema?

edema due to destruction or damage to the lymph vessels causing lymph to not be drained properly **no blood pressure in affected extremities!

what is ascites?

edema in peritoneal cavity, manifested by a very characteristic, distended, fluid-filled abdomen

pulmonary edema

edema in the lungs presents an immediate threat to gas exchange because o2 can't swim

perception - descending pathways

efferent tracts (AWAY) carry motor signals from brain to the reflex organ via the spinal cord

transmission

electrical stimulus is sent to the dorsal horn and synapse at the second-order neuron (2nd step)

transmission

electrical stimulus is sent to the dorsal horn of the spinal cord and synapses at the 2nd order neuron

what carries electrical impulses across the cells?

electrolytes

diffusion

enables oxygen to cross blood-gas barrier movement of gases between airspaces in the lungs and bloodstream

s/s of altered mental state

lethargic obtunded non-responsive drowsy only responsive to pain pt not responding appropriately to questions

sx of hypotonic dehydration

lethargy coma muscle cramps

what makes angiotensin

liver

where is albumin synthesized?

liver

respiratory center in brain

located in brainstem that controls respiration by transmitting impulses to the respiratory muscles causing them to contract and relax

what does fight or flight response elicit in a pain response?

pallor, cool extremities, diaphoresis, decreased GI motility, dilation of pupils, increased blood glucose levels

causes of hypocalcemia

parathyroid disorders low calcium intake high phosphate levels low vitamin D

causes of hypercalcemia

parathyroid disorders low phosphate levels excessive oral intake

what regulates calcium

parathyroid hormone, thyroid hormone, vitamin D, phosphate levels

airborne precautions

pathogens transmitted by airborne route ex. TB, monkey pox

chronic pain

pathologic caused by disease or injury dysfunctional neuronal activity amplified response to normal stimuli doesn't help us

5 rights of medical administration

patient drug dose route time **monitor for effects or adverse effects

PCA

patient controlled analgesia ONLY patient hits the button lets them press button to deliver small amounts of a set amount of meds

nursing care for asthma

raise HOB give o2 monitor VS remain calm and reassuring encourage prompt medication attn for infections and appropriate immunz administer meds as rx

A nurse is caring for a client who is 1 day postop following gyn surgery and reports incisional pain. Which of the following actions should nurse take first? -determine time the client last received pain meds -measure client's vital signs, including temp -ask client to rate pain from 1-10 -reposition and offer back rub

-ask client to rate pain from 1-10

A nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates an understanding of the teaching? -I should increase my caffeine intake. -I will take my duloxetine in the morning, so I have more energy to accomplish tasks. -Low-impact aerobics can help reduce episodes of pain. -A course of chemotherapy treatment should provide a cure.

"Low impact aerobics can help reduce episodes of pain."

isotonic dehydration

***most common type **pretty equal loss of water and electrolytes unchanged osmolarity

what clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a patient with rehydration? select all that apply. -BP -deep tendon reflexes -hand-grip strength -pulse rate and quality -skin turgor -urine output

-BP -pulse rate and quality -urine output

a nurse is teaching a client who has emphysema about self-management strategies. which statements by the client indicates an understanding of the teaching? -I will inhale slowly through pursed lips to help me breathe better. -I will avoid getting a flu shot. -I will follow a daily diet high in calories and protein. -I will lie on my stomach to practice abdominal breathing every day.

-I will inhale slowly through pursed lips to help me breathe better

A nurse is providing preop teaching to a client about pain management using PCA system. Which of the following 3 statements should the nurse include? -There is minimal risk of an overdose of pain medication while using the PCA pump. -Push the button on the PCA prior to your pain level becoming severe so you can remain comfortable. -Your family member should push the PCA button for you while you are sleeping. -You will still have to request pain med from the nurse from time to time. -Using the PCA regularly while provide a consistent level of relief.

-There is minimal risk of an overdose of pain medication while using the PCA pump. -Using the PCA regularly while provide a consistent level of relief. -Push the button on the PCA prior to your pain level becoming severe so you can remain comfortable.

A patient has been receiving the same dose of an intravenous opioid for 2 days to manage post surgical pain. The patient reports the drug is no longer controlling the pain. What does the nurse suspect? -There is likely a history of addiction̶ -Tolerance to the opioid is developing̶ -Physical dependence is developing̶ -The client is opioid naïve

-Tolerance to the opioid is developing

Which of the following questions would be inappropriate while gathering the nursing history? -Why aren't you exercising like you're supposed to?̶ -How would you describe your pain?̶ -What kind of pain medication are you taking?̶ -Do you take any illicit drugs?

-Why aren't you exercising like you're supposed to?̶

how is co2 carried in blood?

1. dissolved into plasma 2. bicarbonate (HCO3) 3. binding to amino acids (carbaminohemoglobin)

a nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. prior to the procedure, which of the following nursing actions should the nurse complete first? -auscultate lung fields -assess pulse and respirations -assess characteristics of her sputum -instruct to slowly exhale with pursed lips

-assess pulse and respirations

A nurse is assessing a client's radial pulse and determines the pulse is irregular. Which of the following actions should the nurse take? -assess the apical pulse for a full min -assess apical pulse with Doppler -assess the pedal pulse for a full min -assess pedal pulses with Doppler

-assess the apical pulse for a full min

A nurse is caring for a client who is receiving HCL via PCA pump and reports continuous pain of 6 out of 10. Which should nurse do first? -administer bolus of meds -check display of PCA pump -obtain order for another pain med for breakthrough pain -encourage client to administer demand dose

-check display of PCA pump

a nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. the nurse should document that the client has which of the following respiratory alterations? -kussmaul respirations -apneustic respiration -cheyne-stokes respirations -stridor

-cheyne-stokes respirations

a nurse is caring for a client who has COPD. the client tells the nurse "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? -maintaining a semi-Fowler's position as often as possible -administering oxygen via nasal cannula at 2 L/min -helping the client select a low-salt diet -encourage the client to drink 2-3L of water daily

-encourage the client to drink 2-3L of water daily

a nurse is caring for a client who has pneumonia. which of the follow actions should the nurse take to promote thinning of respiratory secretions? -encourage the client to ambulate frequently -encourage coughing and deep breathing -encourage the client to increase fluid intake -encourage the regular use of the incentive spirometer

-encourage the client to increase fluid intake

a nurse is developing a plan of care for a client who is postop. which of the following interventions should the nurse include in the plan to prevent pulmonary complications? -perform range-of-motion exercises -place suction equipment at the bedside -encourage the use of an incentive spirometer -administer an expectorant

-encourage the use of an incentive spirometer

a nurse on a med-surg unit is performing an admission assessment of a client who has COPD with emphysema. the client reports that he has a frequent productive cough and is short of breath. the nurse should anticipate which of the following assessment findings for this client? -respiratory alkalosis -increased anteroposterior diameter of the chest -ox sat levels 96% -petechiae on chest

-increased anteroposterior diameter of the chest

a nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. which of the following instructions should the nurse include? -eat 3 large meals each day -limit water intake with meals -reduce protein intake -use a bronchodilator 1 hour before eating

-limit water intake with meals

a nurse is auscultating the lungs of a client who has pleurisy. which of the following adventitious breathing sounds should the nurse expect to hear? -loud, scratchy sounds -squeaky, musical sounds -popping sounds -snoring sounds

-loud, scratchy sounds

a nurse is caring for a client who has asthma and developed viral pharyngitis. which of the following findings should the nurse expect? -petechiae on the chest and the abdomen -WBC 16,000/mm^3 -negative throat culture -severe hyperemia of pharyngeal mucosa

-negative throat culture (VIRAL)

Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? -Reports acute pain at the surgical site -Persistent pain reported around the surgical site -Experiences neuropathic pain near the surgical site -Discomfort has progressed to chronic pain

-reports acute pain at the surgical site

a nurse is developing a plan of care for a client who is 12 hr postop following colon resection. which of the following interventions should the nurse include in the plan to reduce respiratory complications? -use incentive spirometer every 4 hr while awake -initiate ambulation after discontinuing the NG tube -maintain supine position with abd binder -splint the incision to support coughing every 2 hr

-use incentive spirometer every 4 hr while awake (???)

hypotonic IV fluid

0.45% NaCl used for cellular hydration causes fluids to shift from ECF into cell

best indicator of dehydration

1 L of water weights 1 kg changes in daily weight are the best indicators of fluid losses or gains!

pulmonary circulation controlled by what?

ANS

immediate action for Disability

AVPU - alert voice responsive pain responsive unresponsive

what VS do you take during resp exam?

AVPU, RR, BP, HR, SpO2, temp, cardiac telemetry

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which is the following strategies should the nurse include? Avoid prolonged sitting. Apply heat for 10 min every hr Sleep in side-lying position with flexed knees Sleep on soft mattress Try padded shoe insoles

Avoid prolonged sitting. Sleep in side-lying position with flexed knees Try padded shoe insoles

When assessing a patient 2 hours after a thoracentesis, the nurse notes the skin around the puncture site is swollen and a crackling is felt and heard when pressure is applied to the area. What is the nurse's best action?

Notify the respiratory health care provider

An assistive personnel (AP) reports a client's vital signs as tympanic temp 37.1 C (98.8 F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mmHg. Which of the following should the nurse remeasure? BP RR PR Temp

BP

on the arterial end of capillaries, which is higher?

BP, which means pressure is going OUT (arteries, away, OUT)

pleural effusion

Buildup of fluid in the pleural cavity Due to: increased hydrostatic pressure or low oncotic pressure leading to fluids leaking out of vessels into pleural space Inflammation and increased capillary permeability Ultimately this can prevent lung expansion Treat w/ diuretic or draining

any disruption in respiratory function can lead to __________________

CO2 buildup and acidosis

A nurse is caring for a client who is postop. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? Vital sign measurement Client's self report of pain severity Visual observation for nonverbal signs of pain Nature and invasiveness of surgical procedure

Client's self-report of pain severity

pulmonary embolism

Clump of material (often blood (thrombus) that lodges in blood stream and obstruct pulmonary blood flow̶ Most common cause of preventable death in the hospital Symptoms vague Many risk factors

nursing responsibilities for thoracentesis

Confirm consent is obtained - witness provider, don't obtain yourself Provide comfort to pt and assist w/ positioning Perform ongoing assessment of respiratory system & vital signs Dress wound & monitor for bleeding Send lab specimens If the pt later is anxious and complains of pain when deep breathing, you observe tachypnea and cyanosis, or you don't hear left lung sounds - don't leave pt, call for help, raise head of bed, provide O2, NOTIFY PROVIDER

A patient with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which patient statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm?

Now I will try to rest as much as possible and avoid any unnecessary exercise."

A nurse is providing info about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? -I will call for pain meds before previous dose wears off. -I will call for pain meds as my pain starts to increase again. -I will wait for you to evaluate my pain before asking for more meds. -I will ask for less meds to avoid addiction.

I will call for pain meds before previous dose wears off.

The nurse assessing an 88-year-old patient notices severe kyphosis that curves the patients spine to the right and bends her forward. Which change in respiratory function does the nurse expect as a result of this age-related change?

Decreased gas exchange as a result of ineffective chest movement

A young adult client with a new diagnosis of rheumatoid arthritis states, "the pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify the client is exhibiting which of the following defense mechanisms? Denial Displacement Rationalization Reaction formation

Denial

lab assessment of dehydration

ECG, elevated H/H, glucose, BUN electrolytes, osmolarity

cause of hypomagnesemia

ETOH decreased PO intake excessive duretic use

Excessive fluid volume (hypervolemia)

Edema Heart failure Kidney failure Cirrhosis Pregnancy

psychosocial interview for respiratory assessment

Fear of breathlessness Reduced activity levels Fatigue Lowered self-efficacy and energy Disrupted relationships Anxiety Significantly lowered mood Unemployment & disability

adverse effects of NSAIDs

GI bleeding, gastric ulcerations, nephrotoxic (kidneys)

A nurse is monitoring a client who is postop and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? Restlessness Grimacing Moaning Clenching Drowsiness

Grimacing, Clenching, Restlessness

what does homeostasis depend on?

H+ ion production being consistent and not excessive CO2 loss from body through breathing keeping pace with all forms of H+ ion production

key points for potassium

HEART, important for cell repolarization, especially cardiac repolarization hyperkalemia is fatal - peaked T waves. hypokalemia causes irritable heart.

key points for calcium

HEART/BONES, important for cardiac conduction, blood clotting, bone health

what is osmotic pressure?

HOLDS IN the force holding water in the vascular space works opposite of hydrostatic pressure controlled by albumin

A nurse is evaluating a patient with 9/10 pain caused by a broken finger. Which of the following vital signs does the nurse anticipate? Select all that apply. Tachycardia̶ Hypertension̶ Bradycardia̶ Hypotension̶ Tachypnea

Hypertension - elevated BP Tachycardia - elevated HR Tachypnea - elevated breathing

subjective pain assessment

OPQRST method

central sensitization

INCREASED RESPONSIVENESS OF NOCICEPTORS IN CNS. amplification of neural signaling within the CNS that elicits pain hypersensitivity ex. allodynia, hyperalgesia, fibral myalgia

peripheral sensitization

INFLAMMATION LEADING TO NERVE INJURY. inflammatory soup are released from damaged tissue and can stimulate nociceptors directly normally, peripheral hypersensitivty returns to normal when inflammation subsides or source of injury is removed inflamed nerve endings

key points for magnesium

INHIBITS LABOR, POTASSIUM's BUDDY. necessary for potassium absorption.

key points for phosphate

INVERSE TO CA. building block of ATP. low phosphate = muscle weakness

normal BUN levels

In general, around 6 to 24 mg/dL (2.1 to 8.5 mmol/L ) is considered normal.

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? Increased HR Decreased RR Hyperactive bowel sounds Decreased BP

Increased HR

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? Auscultate Percuss Inspect palpate

Inspect (IPPA)

spinoreticular tract

Involved in emotional aspects of pain Causes alertness and arousal in response to pain

JVD

Jugular vein distention, sign of heart dysfunction

trosseau sign

LOW CALCIUM inflation of BP cuff for 3-5 minutes will cause tetany/contraction of arm

chovstek sign

LOW CALCIUM tapping on cheek cause spasm/muscle irritability

levels of pain perception

Level one Periphery (A-B fibers): feels better when rubbed or pressure applied Level two Dorsal Horn (Gate control theory): if gate opens, signals going to brain Level three Descending inhibitory pathway: PAG with high concentrations of opioid receptors and endogenous opioids Level four Cortical: Helps activate PAG and interacts with different areas of the brain

how to treat occlusion

NPO, improve neuro status

A nurse is caring for a client who is postop following a cholecystectomy and reports pain. Which of the following actions should the nurse take? Offer client a back rub Remind client to use incisional splinting Identify client's pain level Assist client to ambulate Change client's position

Offer client a back rub Remind client to use incisional splinting Identify client's pain level Change client's position

A nurse is caring for a client who is 1 day postop following hip open reduction with internal fixation. The client is scheduled to begin PT in 30 min. Which of following actions should nurse take? Position client's legs in adducted position. Offer to administer analgesia. Tell client to bend forward at the waist when getting out of bed. Bathe and dress the client.

Offer to administer analgesia.

interventions for pneumonia

Oxygen, culture, antibiotics, supportive care, and health promotion (immunizations)

what is hydrostatic pressure?

PUSHES OUT on capillary walls The pressure that the fluid exerts on the walls of its container.

What is pain?

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage

The nurse is teaching a class on pain management strategies. Which patient requires additional teaching? -Persistent pain is a warning in my body that alerts the sympathetic nervous system -Acute pain has a quick onset and is usually isolated to one area of my body -My frozen shoulder causes musculoskeletal or somatic pain -Nociceptive pain follows a normal and predictive pattern

Persistent pain is a warning in my body that alerts the sympathetic nervous system

The spouse of a 78-year-old patient who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4 degrees F (39.7 degrees C). What is the nurse's primary concern for this client?

Pneumonia may be present

nursing care for COPD

Position to maximize ventilation (high-Fowler's); Encourage effective coughing or suction to remove secretions; Encourage deep breathing and use of an incentive spirometer; Administer breathing treatments and medications, as prescribed; Administer oxygen, as prescribed; positive pressure ventilation; chest physio

6 P's of dyspnea

Pulmonary bronchial constriction (smooth muscle constricting) Possible foreign body Pulmonary embolus (PE) Pneumothorax Pneumonia Pump failure

how to apply the ABCDE approach to patient prioritization

Recognize cues Analyze cues Prioritize hypotheses Generate solutions Take action Evaluate outcomes

When performing a medication reconciliation for a newly admitted client before planned abdominal surgery, the nurse notes that the patient is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm?

Record and display the information in a prominent place within the client's medical record.

A patient has just come to the floor after an inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the patient starts to vomit a large amount of liquid vomitus. What is the nurse's priority action?

Reposition the patient to the side and suction the mouth with a large-bore catheter.

Osmolarity:

SOLUTES; concentration of solutes dissolved in blood

A nurse enters an adults client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which action should the nurse take first? Summon code team Begin chest compressions Administer rescue breathing Open client's airway

Summon code team

any vomit in the airway that enters the lungs is very serious and often fatal (T/F)

TRUE

Pt with COPD have higher hemoglobin and hematocrit (T/F)

TRUE!

osmotic pressure

The net pressure that drives reabsorption—the movement of fluid from the interstitial fluid back into the capillaries Determined by solute concentration (but primarily albumin) More solutes=higher concentration and higher pressure

droplet precautions

Transmission by respiratory droplets generated by coughing, sneezing, talking ex. Seasonal influenza, pertussis, rhinovirus

acute pain signs

VS: may vary consistently with degree of pain severity Purpose: useful Central sensitization: short term; improves with healing of injury Neuropathic pain: increases likelihood of chronic pain when present in acute phase Nociceptive pain: often found during acute pain

chronic pain signs

VS: minimal or no change Purpose: Inhibits function and not useful Central sensitization: remains present despite absence of ongoing injury Neuropathic pain: common etiology of chronic pain Nociceptive pain: commonly present with some neuropathic pain

what causes increased capillary permeability?

almost always caused by an inflammatory reaction allows more fluid to leak out into the interstitial space

nerve fibers

alpha-beta alpha-delta unmyelinated (C)

osmosis

Water diffuses into area of higher concentration to area of lower concentration

what is third spacing

When fluid accumulates in a portion of the body from which it is not easily exchanged with the rest of the ECF (e.g., burns, blisters).

what is ANP

a hormone antagonistic to the angiotensin pathway decreases blood volume and pressure

angiotensinoGEN (BV, pressure, stored and inactive)

a plasma protein produced by the liver is released into blood stream converted into angiotensin I by renin

what is physical dependence?

a state of physiologic adaptation manifested by specific withdrawal sx caused by abrupt cessation of the drug

modulation

alterations in pain signals along the transmission of pain explains why individuals respond to the same stimulus differently

what are the primary gas-exchange units

alveoli

what is emphysema

alveoli destruction, loss of lung elasticity and hyperinflation of lung

how to help with constipation

ambulate frequently drink fluids take stool softeners monitor last BM

Define adjustment disorder

an emotional or behavioral reaction to a stressful event or change in a person's life.

muscles of expiration

abdominal wall, passive

hypoxemia

abnormally low partial pressure in arterial blood (PO2 < 60 mmHg) or low SpO2 (less than 90%)

how much is the interstitial space?

about 10-12 L

how much is the intracellular space?

about 25 L

how much is the plasma volume?

about 3.5-6 L

pharmacologic ways to manage pain

acetaminophen NSAIDs opioid neuropathic agents

diabetic ketoacidosis

acidity of the blood caused by the presence of ketone bodies produced when the body is unable to burn sugar; thus, it must burn fat for energy

pH of <7.35

acidotic

what is sensitization?

act to reduce the activation threshold of nociceptors so that the stimulation required to cause activation is less things that normally would not cause pain are now causing INTENSE pain

physiologic effects of unrelieved pain - cardiovascular system

activates SNS tachycardia HTN increased cardiac workload increased oxygen demand

what can MDMA induce?

acute hyponatremia

influenza

acute viral infection

health promotion of COPD

adequate nutrition fluid intake exercise conditions breathing techniques o2 therapy avoid infections take meds as rx warning signs smoking cessation

a nurse is caring for a client who develops a pulmonary embolism. which of the following should the nurse implement first? -give morphine IV -administer oxygen therapy -start an IV infusion of lactated Ringer's -initiate cardiac monitoring

administer oxygen therapy

where is aldosterone secreted from?

adrenal cortex, when sodium levels are low in ECF

what makes aldosterone

adrenal glands

what do ascending pain pathways do during transmission?

afferent tracts in the spinal cord to carry nociceptive sensory signals to higher centers in the brain

Crepitus

air bubbles under the skin that produce a crackling sound or crinkly feeling.

pneumothorax

air in lung causes pressure against the lung making it unable to expand

what does ABCDE stand for?

airway breathing circulation disability exposure

colloids IV fluid

albumin large non-water-soluble molecules that increase osmotic pressure in plasma volume

what are the chemical buffers?

albumin (majority), bicarbonate, phosphate

what regulates sodium?

aldosterone (sodium retention) ADH (alters total body water, sodium retention)

what is water balance regulated by?

aldosterone, ADH, and NP

which hormones play a part in controlling fluid balance?

aldosterone, ADH/vasopressin

pH<7.45

alkalotic

what will partial compensation look like?

all values out of whack (one is trying to compensate for the other)

what could excess lactic acid indicate?

byproduct of anaerobic metabolism impaired oxygen delivery or uptake possible sepsis

what does angiotensin II do?

causes secretion of aldosterone from adrenal cortex causes vasoconstriction slows kidney function increases blood volume maintain adequate tissue perfusion

a nurse is assessing a client who has COPD. the nurse should expect the client's chest to be which of the following shapes? -pigeon -funnel -kyphotic -barrel

barrel

how do we best understand the perception of pain?

best understood via the biopsychosocial model of health

ketone acids bind with _______

bicarb low measured HCO3, low pH

BiPAP

bilevel positive airway pressure (exhale normal, inhale with machine)

racist pain theories

black people have thicker skin and less sensitive nerves infants have underdeveloped nervous systems mean babies can't feel pain older adults should feel pain as part of aging

s/s of TB

bloody sputum night sweats fever weight loss **airborne precautions

what MAP must body maintain and why?

body must have sufficient fluid in vessels to maintain a perfusing blood pressure of MAP > 65 mmHg

health promotion to prevent pain

body, lifestyle, emotions, society, spirit, mind, environment

where is calcium stored?

bone matrix

where is magnesium stored

bones and cartilage

signs of fluid overload

bounding pulse, difficulty breathing, neck vein distention, edema

what does hyponatremia cause?

brain cells to expand, causing cerebral edema

what does hypernatremia cause?

brain cells to shrink

neuromatrix theory

brain produces pattern of nerve impulses drawn from various inputs including genetic, psychologic, and cognitive experiences

what does thalamus do?

brain's relay system for sensory input can either block pain signals or amplify them based on the patient's hx, psychology, and contextual factors

spinoreticular tract

brainstem (reticular formation) to thalamus to the somatosensory areas of the cerebral cortex, involved in the emotional aspects of pain, causes alertness and arousal in response to pain

pharm interventions for asthma

bronchodilators (inhalers) SABA (ex. albuterol) anticholinergic meds (ex. ipratroprium to allow SNS to increase bronchodilation) LABA (ex. formoterol, prevents attacks) anti-inflammatory agents (prophylaxis, corticosteroids, leukotriene antagonists, mast cell stabilizers)

crackles lung sound

bubbling, fluid in airway or opening of collapsed alveoli

compensatory mechanisms for maintaining acid-base balance

buffers

causes of isotonic dehydration

burns, vomiting, diarrhea

how is arterial blood regulated?

by hydrogen production and elimination

angiotensin II does what?

causes direct vasoconstriction stimulates release of aldosterone stimulates release of ADH

what is hypoalbuminemia?

causes edema due to decreased oncotic pressure

patient interview - focused respiratory

c/c relevant pt hx sx psychosocial eval

interventions for someone with pulmonary embolism

call for help early - MEDICAL EMERGENCY apply o2 reassure pt place in high-Fowler cardiac monitoring obtain venous access monitor respiratory sounds closely (saturation, work of breathing, lung sounds) monitor for breathing push anticoag and thrombolytics

Background pain:

cancer pain, burn pain, consider long-acting opioids or scheduled short-acting opioids

s/s of acidosis

cardiac dysrhythmias hypotension decreased LOC weakness/paralysis

treatment of hyperkalemia

cardiac monitoring short term: IV insulin and dextrose, calcium, albuterol long term: IV furosemide, K binder, dialysis

what does hemoglobin do?

carries oxygen in the blood, makes more available for use

what is a 2nd order neuron

carries signals from spinal cord to the thalamus

decompensation occurs when:

causative problem becomes more severe and additional problems occur LIFE THREATENING (requires intervention)

leukotrienes

cause airway muscle constriction

histamine

cause swelling

neuropathic pain

caused by lesion or disease affecting the nervous system (PNS or CNS)

nociceptive or inflammatory pain

caused by normal neural activity in response to tissue-damaging stimuli; can be acute or chronic

what is the direct effect of angiotensin II

causes arteries to constrict and increases CO resulting in increase in BP and blood volume decreases glomerular filtration rate resulting in water retention, increases thirst

what does aldosterone do?

comes from adrenal cortex increases sodium reabsorption, water follows, increases blood volume, which increases BP travels to hypothalamus to release ADH (antidiuretic hormone) to stimulate reabsorption of more water into body, increases blood volume, increases BP

hyperphosphatemia

common in chronic kidney disease treat with phosphate-binder high phosphate means there is low calcium - worry for their muscles!

treatment for impaired lymphatic drainage

compression (TED hose, ace wrap) massage elevation of affected extremity

how to treat peripheral edema

compression socks elevating extremities

high osmolarity =

concentrated less water, more solutes

myelinated A-delta fibers

conduct impulses rapidly responses to mechanical pressure stimulus produce sensation of sharp, localized, fast pain (chronically stimulated = tingly pain)

upper airway

conducting passageway (like a highway) nasopharynx oropharynx larynx (voice box)

afferent pathways

conducting pathway/TOWARDS CNS

sodium balance neuro changes

confusion headache lethargy or irritability coma seizures

risk factors for sleep apnea

congenital variation in oral cavity, pharynx, neck obesity

what are capillaries?

connectors between venous and arterial systems

perception of pain

conscious awareness of pain affected by cognition, moods, belief, genetics pain matrix

perception

conscious awareness of pain as a culmination of previous processes in the context of the individual's experiences

crystalloid, isotonic IV fluid

contains water, minerals (electrolyte) rapidly disperse to all body fluid normal saline, lactated ringers, PlasmaLyte

CPAP

continuous positive airway pressure (inhale/exhale with machine)

transduction

conversion of a noxious stimuli (chemical, mechanical, or thermal) into an electrical energy

what does renin do

converts angiotensinogen to angiotensin I

level 4 modulation

cortical, helps activate PAG and interacts with different areas of brain

cardinal sx for respiratory assessment

cough sputum dyspnea chest pain

A patient with severe angioedema and tongue swelling from a drug allergy, has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare?

cricothyroidotomy

signs of insufficient breathing

cyanosis, distended neck veins, tracheal deviation abnormal or absent lung sounds, use of accessory muscles

causes of metabolic acidosis

kidney failure, loss of bicarb in stool (diarrhea), increased production of acids due to metabolic dysfunction ex. lactic acidosis, diabetic ketoacidosis

interventions for someone with COPD

encourage high-calorie soft foods positioning to maximize ventilation encourage coughing/suctioning incentive spirometer positive pressure ventilation chest physio minimize liquids during meals encourage fluid intake throughout day (2L/day) exercise conditions breathing techniques o2 therapy avoid infections take meds as rx smoking cessation

nociceptive pain

damage to body tissues inflammation, sharp, achy, throbbing

neuropathic pain

damage to nerves shooting, stabbing, burning, "pins and needles"

how to help with orthostatic hypotension

dangle before ambulating monitor BP

bases:

decrease H+ most common is bicarbonate (HCO3)

long term consequences of pain

decrease in physical capability and mental health increased falls depression

name four ways that acidosis is caused

decreased excretion of acids increased production of acids decreased production of bicarbonate loss of bicarbonate

Hypoalbuminemia

decreased synthesis of albumin: liver disease malnutrition

hypovolemia

deficient blood volume, dehydration

Dehydration

deficient fluid volume/hypovolemia

fluid volume deficient = hypovolemia = ________

dehydration

s/s of hypernatremia

dehydration sx neuro signs (seizures, deep tendon reflexes) thirst since osmoreceptors drive the thirst response

lactic acidosis

demand our body does a lot of work and our body could not keep up with that demand, so we had to use a lot of anaerobic metabolism

what does pulmonary artery carry

deoxygenated blood from heart to lungs

what does potassium do?

depolarization for excitable tissues controlled by Na/K pump

what is central sensitization?

normal, non-noxious sensations are experienced as pain (allodynia) or mildly painful stimuli are experienced as agonizing (hyperalgesia) caused by problem with inhibition of pain signals or some derangement with the descending pathway and/or the thalamus

longstanding COPD patients often have ______ pH levels, even though their CO2 levels are ______

normal; high because kidney begins increasing amount of bicarb in the blood

partial compensation when pH is ____________

not quite normalized

isotonic solution in EC space

nothing happens, water stays in cell, sodium stays out (BALANCED)

a nurse is caring for a client who has active pulmonary TB. The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest xray? -ask the xray tech to come to the client's room to obtain a portable x-ray -wear a filtration mask and gloves during transport -have the client wear a mask -notify the xray department that the client requires airborne precautions

notify the xray department that the patient requires airborne precautions

pain intensity rating scales

numeric rating scale (1-10) wong-baker FACES pain rating scale faces pain scale - revised verbal descriptor scale - no pain, mild pain, moderate pain, severe pain

subjective pain assessment

nursing hx OPQRST psychosocial effects

Inspection during respiratory assessment

observe posture and breathing pattern use of accessory muscles nasal flaring tripoding pursed lips body habitus listen to audible breath sounds for rate and depth look at symmetry and chest diameter observe for trachial deviation, cyanosis, clubbing

what is asthma?

obstructive airway disease caused by an airway that is hyperreactive to antigens

lung biopsy

obtain lung tissue for examination

Green sputum indicates

old retained secretions, infection

how to diagnose sputum

onset and duration characteristics (color, consistency, volume) associated sx (fever, vomiting, SOB)

what to pay attention to for cough

onset and duration characteristics: dry, tickling, hacking, moist, wet? productive? self-treatment and effectiveness

OPQRST

onset and duration provocation or palliation quality of pain region and radiation severity time (hx)

what is OPQRST?

onset, provocation, quality, radiation, severity, time

interventions to re-establish airway

open airway (head-tilt, chin-lift), suction airway, administer high-flow oxygen, open, suction, secure, oxygen

visceral pain

organs poorly localized, diffuse, deep cramping or pressure, sharp, stabbing

what is the pressure called that moves CO2 and metabolic waste out of the cells?

osmotic pressure

on the venous end of capillaries, which is higher?

osmotic pressure, which means pressure is staying IN (veins, towards, IN)

what causes respiratory alkalosis?

overbreathing loss of CO2 leads to rise in pH pregnancy

hypoxia

oxygen delivered to tissues in inadequate to meet its metabolic demands

what is PaO2?

oxygen dissolved in plasma that is driving pressure to load hemoglobin with oxygen measured on an arterial blood gas (normal is 80-100 mmHg)

determinants of arterial oxygenation

oxygen saturation (measured by pulse ox) partial pressure of oxygen (PaO2)

interventions for someone with pneumonia

oxygen, culture, antibiotics, supportive care, health promotion (immunz)

what do pulmonary veins carry?

oxygenated blood to the heart

uncompensated

pH and one other value is abnormal

partial compensation

pH is NOT normal both CO2 and HCO3 are out of range

complete compensation

pH is normal, both CO2 and HCO3 out of range

procedural pain

pain as a result of a dressing change, chest tube insertion, etc. premedicate with PO opioid and PRN IV opioids during procedure, use local anesthetics

psychogenic pain

pain for which no physical cause can be identified

Procedural pain:

pain from dressing change, chest tube insertion, consider premedicating with PO opioid + PRN IV opioids or local anesthesia

what is pain a result of?

pain is a result of complex peripheral and central processes

what are nociceptors?

pain receptors

background pain

pain that is present even when you are completely at rest ex. cancer pain, burn pain consider long-acting opioid or scheduled short-acting opioid, plus adjuvants like SNRIs

s/s of hypercalcemia

painful bones renal stones abdominal groans psycho moans cardio/early: tachycardia and hypertension cardio/late: bradycardia and cardiac arrest neuro: lethargy, weakness, confusion nausea/vomiting, constipation muscle weakness, decreased deep tendon reflex kidney stones

a nurse is caring for a client with a tracheostomy. the client's partner has been taught to perform suctioning. which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? -attending a class given about trach care -verbalizing all steps in the process -performing the procedure independently -asking appropriate questions about suctioning

performing the procedure independently

Where are nociceptors located?

peripheral tissues of skin, muscles, organs, tissues, joints, tendons, or bones

level 1 modulation

periphery (alpha beta fibers) ex. bob's finger feels better when he rubs it after banging it with a hammer

chronic

persistent, lasts <3 months, diffuse

common antigens that trigger asthma

pet dander dust cold pollution

what plays an important role in all cell function due to role in ATP

phosphate

what innervates the diaphragm?

phrenic nerves

acute pain

physiologic normal functions of body helps us

treatment of altered mental state

place an endotracheal tube for airway protection if necessary

oncotic pressure is the force exerted by _____________ that draws fluid back into the interstitial space

plasma proteins (especially albumin)

what responses does the nurse expect as a result of infusing 500 ml of 3% saline IV solution into a patient over a 1 hr time period?

plasma volume osmolarity increase; blood pressure increases

what does calcium do

plays a role in cardiac conduction, bone health, blood clotting

COPD

poorly reversible airflow obstruction and an abnormal inflammatory response in the lungs

interventions for breathing

positioning, assisted ventilation, rescue breaths, trying to re-establish sufficient oxygenation and ventilation

examples of nociceptive pain

post-op pain arthritis mechanical low back pain ischemia, infection trauma and injury

examples of neuropathic pain

post-therapeutic neuralgia CRPS trigeminal neuralgia spinal root compression central pain sensory polyneuropathy (ex. diabetes, HIV)

osmoreceptors and angiotensin II trigger the ___________ to release ADH

posterior pituitary gland retains water and decreases blood osmolarity (makes it more dilute)

________ is critical for cardiac conduction

potassium

enough _________ can stop the heart

potassium

peaked T-waves

potassium is high

electrolytes

potassium, chloride, magnesium, phosphate, sodium, calcium

intracellular electrolytes

potassium, magnesium, phosphate

what electrolytes are in ICF?

potassium, magnesium, phosphate

hypotonic dehydration

primarily loss of electrolyte (particularly sodium) more salt LOSS than water decreased osmolarity head stroke leads to intracranial pressure

hypertonic dehydration

primarily loss of water more water LOSS than salt increased plasma osmolarity

clinical findings of pneumonia

productive cough, purulent sputum, dyspnea ortachypnea, rigors or chills, pleuritic chest pain, hypoxia, confusion

causes of metabolic alkalosis

prolonged vomiting NG suctioning Loss of HCl NAHCO3 (Tums) ingestion

cytokines

promote mucus production

what is albumin?

protein blocks that counteract hydrostatic pressure, pull fluid back into vessels

what are the aims of ABCDE approach?

provide life-saving treatment break down complex clinical situations into more manageable parts serve an assessment and treatment algorithm establish common situational awareness among all treatment providers buy time to establish a final diagnosis and treatment

dehydration - nursing interventions

provide oral fluids, determine amount of fluids needed, engage assisted personnel, infuse IV fluids at rate consistent, monitor response for adequate rehydration, assess IV site hourly for phlebitis, provide pt edu

s/s of anaphylaxis

pt has feeling of impending doom uticaria/hives angioedema - swelling in lips and tongue dyspnea

after assessing 4 pt, which will the triage nurse identify to be seen first in ED?

pt who reports slurred speech

6 P's of dyspnea

pulmonary bronchial constriction possible foreign body pulmonary embolus pneumonia pump failure pneumothorax

pink, frothy sputum

pulmonary edema

associated risks of fluid overload

pulmonary edema, electrolyte imbalances (like Na and K)

what to worry about with chest pain

pulmonary pain worse by cough, deep breathing, swallowing rubbing, sharp, stabbing sensation may be pleuritic chest pain

thoracentesis

puncture aspiration of pleural fluid or air consider positioning, VS, etc.