NUR 102 Final
Hyperventilation
-Def: breathing too fast (>20) -can be caused by anxiety, stress, hypovolemia, pain, medications -the body is breathing so fast that the co2 cannot build up to slow the breathing down to get in enough oxygen, resulting in low o2 -lightheaded, confusion, dizzy -WHAT TO DO: give them a bag or mask CAUSES HYPOXIA
Hypoventilation
-Def: breathing too slow (<12) -can be caused by narcotics, antidepressants, anesthesia, pain ALSO CAUSES HYPOXIA
Explain common vital sign findings with acute/chronic pain.
Acute pain stimulates the sympathetic nervous system, which responds by increasing pulse, respirations, and BP. Chronic pain stimulates the parasympathetic nervous system, which results in lowered pulse and BP.
An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period?
Administering prescribed analgesics; The priority is pain management; severe pain requires analgesics. Increased hydration is necessary to promote hemodilution, improve circulation, and prevent more sickling.
Mitral Valve Regurgitation:
A disorder of the heart in which the mitral valve does not close properly when the heart pumps out blood. It is the abnormal leaking of blood from the left ventricle, through the mitral valve, and into the left atrium, when the left ventricle contracts, i.e. there is regurgitation of blood back into the left atrium
How is a thrombus related to angina?
A thrombus can break loose from the vein wall and travel through the circulation (embolus) where eventually it obstructs a pulmonary artery or one of its branches causing sudden, acute chest pain, dyspnea, coughing, and frothy sputum.
In what structure of the pulmonary system does inhaled air come in contact with the blood of the pulmonary circulation?
Alveolar-capillary membrane; The lungs are composed of millions of alveoli. The alveoli are tiny air sacs with thin walls surrounded by a fine network of capillaries. Gases easily pass back and forth between the alveoli and capillaries. It is at the alveolar-capillary membrane that inhaled air comes in contact with the blood of the pulmonary circulation.
What should a nurse teach a non-nursing mother to help relieve the discomfort of engorgement?
Apply cold packs to the breasts frequently; application of cold constricts the vessels and numbs the pain caused by the distention of the vessels with lymph and blood.
Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient?
Ask another nurse to double-check the setup before patient use. As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient-controlled analgesia is contraindicated for those who are cognitively impaired.
A client with a hx of allergies to bees is brought to the emergency room with a bee sting and difficulty breathing. What client reaction should cause the nurse most concern?
Asphyxia; Hypersensitivity can produce an anaphylactic reaction with edema of the respiratory system, resulting in respiratory obstruction, respiratory arrest, and asphyxia.e
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis?
Aspirin; Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke.
Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain?
Assess the patient's respiratory status. Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's respiratory status because opioid analgesics can cause respiratory depression.
The mother of a 5-year-old child recovering from varicella (chickenpox) calls the nurse in the pediatric clinic, asking how the child's itching can be relieved. What is the best response by the nurse?
Pat the lesions while applying the prescribed calamine lotion.
A client who has a history of several myocardial infarctions is admitted to the hospital for an unrelated medical condition. Because of the client's history, the nurse is concerned about the possibility of the client experiencing right ventricular failure. For what early common indication of right ventricular failure should the nurse monitor the client?
Peripheral edema; Increased venous pressure resulting from backup of blood, as the right ventricle of the heart fails, forces capillary fluid to seep into interstitial spaces, resulting in peripheral edema.
What should nursing interventions achieve for a client experiencing an acute episode of bronchial asthma?
Raising mucus secretions from the chest; In addition to dilation of bronchi, treatment is aimed at expectoration of mucus. Mucus interferes with gas exchange in the lungs.
The duration of sleep is regulated by the:
Reticular activating system; In the morning, with an increase in environmental light, the hypothalamus is signaled to induce gradual arousal from sleep. The reticular formation is then activated by the stimuli from the cerebral cortex. The reticular formation is responsible for maintaining wakefulness. Together, the reticular formation and cortical neurons are called the reticular activating system (RAS). The RAS regulates the duration of sleep.
A 14-year-old girl in whom scoliosis has been diagnosed undergoes spinal fusion. On the first postoperative day her face is red, she is rigid, and she is crying because she is in pain. She has prescriptions for morphine sulfate for severe pain and an acetaminophen-codeine compound for moderate pain. What information should influence the nurse's choice of analgesic?
Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic.
For a patient scheduled for surgery, when is the best time to teach about the use of a PCA pump?
The day before the surgery when the client is awake and alert and not experiencing any postoperative pain.
What is respiration?
The exchange of oxygen and carbon dioxide across the alveolocapillary membrane (between the alveoli and the blood); from a greater concentration to a lesser concentration (diffusion).
What does the heart do when the client is experiencing decreased cardiac output?
The heart speeds up (tachycardia) because it does not understand why there is not enough total volume so it tries to pump more, faster.
What is ventilation?
The movement of air in and out of the lungs.
A four-year-old client is hospitalized for acute asthma exacerbation. What finding in an assessment of this patient requires action by the nurse?
Diminished breath sounds; At the beginning of an asthma episode, wheezing may be heard only with a stethoscope. As the severity of the episode increases, wheezing may become audible to the unaided ear. Children in severe respiratory distress may not demonstrate wheezing because of decreased air movement; diminished breath sounds in a child may signal an inability to move air, so this finding requires action.
What is the #1 symptom of anemia?
Fatigue
How does fear interfere with sleep?
Fear or loss of control, the unknown, and potential death results in the struggle to stay awake, which interferes with the ability to relax sufficiently to fall asleep.
How can a nurse best soothe a hospitalized infant who appears to be in pain?
Holding the infant; Physical contact provides security for a distressed infant.
What stimulates an individual to breathe?
Increased carbon dioxide stimulates an individual with no pulmonary diseases/disorders to breathe. The body wants to get rid of CO2 initially.
What teaching must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge?
Medications must be continued even when the child is asymptomatic.
What is the hormone that promotes sleep?
Melatonin; The levels of melatonin, which is the natural hormone that promotes sleep, decline in the latter decades of life. It is produced at night by the pineal gland in the brain.
What are some indicators of hypcarbia (hypocapnia)?
Hypocarbia (hypocapnia) is a low level of dissolved CO2 in the blood because of hyperventilation. In most cases, blood oxygen levels remain normal. Severe hypocarbia stimulates the nervous system, leading to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips.
A COPD client with a blood pH of 7.25 and PCO2 of 60 mm Hg indicates what complication?
Respiratory acidosis; The pH indicates acidosis; the PCO2 level is the parameter for respiratory function. The expected PCO2 is 40 mm Hg.
When do people tend to be the sleepiest?
Research has demonstrated that most people experience sleep-vulnerable periods between 2am-6am and 2pm-5pm.
What should the nurse first do when a patient requests pain medication?
assess the various aspects of the patient's pain; factors of pain should be assessed such as location, intensity, quality, duration, pattern, aggravating and alleviating factors and physical, behavioral, and attitudinal responses
Young and middle age:
YOUNG- drinking, smoking, lack of sleep/exercise MIDDLE AGE- start to see the effects of young age habits
What can cause a LOW preload?
dehydration, trauma/shock/blood-loss, immobility
When the atria contract, we call this...
depolarization (P-wave)
Alcohol _____ quality of sleep.
destroys
What should the nurse do first if the patient is choking on food?
determine if the patient can make any verbal sounds
Decreased Cardiac Output:
failure of the myocardium to eject sufficient blood volume to the systemic and pulmonary circulation
What is the number one reason that nurses do not effectively treat pain?
fear of the patient becoming addicted
What is the most common psychological patient response to pain?
fear related to loss of independence
What increases the work of the body?
fever, healing/wound healing
For a patient with a hx of severe chronic pain, what is the most important guideline associated with providing nursing care to this patient?
focusing on pain management intervention before pain becomes excessive
What is the most common cause of sleep deprivation in the hospital?
fragmented sleep (lots of interruptions)
Central Sleep Apnea
has to do with something in the brain that is not working properly
What is the number one reason why adolescents do not get enough sleep?
heavy participation in different activities
The purpose of pursed-lip breathing is to:
help maintain open airways
What is the purpose of chest physiotherapy?
helps clear the airway of excessive secretions
What diagnostic test reflects a response to iron deficiency anemia?
hemoglobin
What should the nurse explain to the patient is the primary reason why heat is used instead of cold?
increases circulation to the affected area
What patient outcome will support the conclusion that the use of a incentive spirometer was effective?
inspiratory volume will be increased
Myocardial Ischemia:
insufficient coronary artery blood supply to the heart Why? Blockage of blood flow through the coronary arteries (coronary thrombus which is a stationary clot/embolism which starts somewhere else and gets stuck in the heart)
What patient response indicates that the patient is not obtaining enough REM sleep?
irritability
Preemptive analgesia...
is administered before activity or interventions that may precipitate pain in an attempt to limit the anticipated pain
What kind of foods do we want to promote at night?
milk, cereal
What is your priority as a nurse for a patient that sleep-walks?
minimize anything that will cause them to fall
Why is the older adult more complicated when it comes to sleep?
more difficulty falling asleep and staying asleep and usually many co-morbidities
Preload refers to...
the amount of blood that is the venous system coming back to the heart after being circulated through the body
What are some smart tactics to use for patients with COPD or conversational dyspnea?
yes or no questions
When is exercise good for sleep?
you need at least 2 hours before you go to sleep without exercise
What people are you worried about having abnormal sleeping patterns?
night-shift workers
Who is the ineffective coping patient?
not been getting sleep and who has just been given a dx, refusing participation in activities, verbal abuse
Why is a premature infant's lungs different than an infant at term?
not enough surfactant makes for inability of lungs to open up
Pallor of skin/decreased or absent peripheral pulses in a client with decreased cardiac output occurs because...
of decreased blood-flow to the peripheral circulation.
To prevent aspiration, should the nurse position the patient who is unconscious?
on the SIDE to protect the airway
Which aspect of sleep should the nurse expect will be affected as a result of anxiety?
onset; anxiety increases norepinephrine blood levels through stimulation of the sympathetic nervous system, which results in prolonged sleep onset
What is a specific desirable outcome for a patient with lower extremity arterial disease?
palpable peripheral pulses
How do you know when someone has slept long enough?
patient report of how they feel about their sleep
What type of anemia results from the decrease in b12?
pernicious anemia
Which action is most effective in meeting the needs of a patient experiencing laryngospasm after extubation?
providing positive-pressure intubation
What should the nurse do FIRST when a client's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation?
raise the head of the bed
For a client with appendicitis, what would indicate that their pain is secondary to the appendicitis?
rebound tenderness
For a patient that is receiving 24% o2 via Venturi mask, what should the nurse do when a meal tray arrives?
request an order to use a nasal cannula during meals
What physiological factor places the older adult at the greatest risk during surgery?
respiratory excursion
Which clinical manifestation is most reflective of an early response to hypoxia?
restlessness; Early signs of hypoxia are restlessness, agitation, and irritability due to reduced oxygen to the brain
A patient who is struggling to breathe should be...
sitting up in bed
Which concept associated with rest and sleep must the nurse consider when planning nursing care?
sleep requirements increase during stress; Stress precipitates the sympathetic nervous system, increasing cortisone, norepinephrine, and epinephrine, which increase the metabolic rate. Physical and psychic energy expended is restored through rest and sleep.
Who is the risk for falls?
sleep walkers, confused at night, elderly patients, patients that didn't get enough sleep
Obstructive Sleep Apnea
soft palate is impaired; treated with CPAP/BPAP/ByPAP which is forcing air into mouth and nose allowing the soft palate to collapse
A client with painful swelling of a distal joint of the ring finger is found to be in the early stages of rheumatoid arthritis (RA). A test for the rheumatoid factor is negative. The client asks about the reliability of the test, stating, "I don't think the result is accurate. I have been diagnosed with RA, and I am in so much pain." How should the nurse respond?
"Laboratory tests often are negative in the early stages of the disease." The antibody called rheumatoid factor is present in 90% of advanced cases of arthritis; it frequently is not found in the early stages of the disease.
To determine a client's quality of pain, what sort of question should the nurse ask?
"What word best describes the pain you are feeling?" The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching, or stabbing.
What is TENS?
(transcutaneous electrical nerve stimulation) is considered a type of cutaneous stimulation in which electrodes attached to a battery-operated unit stimulate the skin and underlying tissues near the area of localized pain. Pain relief is provided by delivering small electrical units to the skin.
Heart Failure: Right Sided
-Accounts for 1/4 of all HF -Blood backs up into the pulmonary circulation from the left ventricle to the left atrium into the pulmonary circulation; if bad enough, backs into right side of heart and into venous circulation -Results from left-sided heart failure -If the lungs are damaged, they can start building up backed up fluid themselves and start a backward back up into the right side of the heart and then into the venous circulation -Results in: venous congestion, distended jugular veins, peripheral edema, ascites, weight gain
What assessment findings might the nurse expect to see in a patient experiencing hypoxia?
-Altered LOC -Cyanosis of skin and mucous membranes -Weak or absent peripheral pulses
For a client recently diagnosed with emphysema, some teachings would include:
-Avoid smoking. Smoking is a respiratory tract irritant and interferes with gas exchange in the alveoli. -Control temperature at home. Extreme temperatures and humidity place stress on the respiratory system; which also interferes with gas exchange. -Engage in proper oral care. Excessive mucus is often present in the mouth. Providing oral care also reduces the amount of microorganisms that can enter the trachebronchial tree; which can prevent infection.
Some points to remember with TENS use:
-Be sure to use conducting gel or conductor pads when applying electrodes to the skin. -Clean the skin where the electrodes will be placed and dry thoroughly. -Continuous stimulation can result in unpleasant muscle contraction and damage to the skin. -The electrodes can remain in place for several hours but should be removed daily and the site rotated to reduce skin irritation.
What are some expected findings for a patient with hypovolemia?
-Bounding pulse -Increased blood pressure -Crackles at bases of lungs
Disorders affected by sleep:
-CAD -Asthma -COPD -Diabetes -GI ulcers
What are problems associated with decreased inspired o2 concentration that affect respiration?
-COPD -chest wall injury -foreign body obstruction -choking -inflammation -high elevation -atelectasis -upper RI -pneumonia -incorrect oxygen administration
Heart Failure: Left Sided (CHF)
-Due to inability of the left ventricle to pump effectively, resulting in congestion of the systemic and pulmonary circulations -This can also be caused by increased afterload (hypertention, arteriosclerosis) -Results in: Pulmonary congestion and SOB if the blood is backing up into the lungs; Decreased cardiac output and fatigue because not enough RBCs and oxygen are getting to the tissues
Care of a patient with aspiration precautions include:
-Ensuring the client is sitting upright or with the head of bed elevated to eat and drink. -Break or crush her pills (if appropriate) before administration. -Keep suction setup available at all times.
Suggestions for applying heat or cold applications:
-Explain to the client the sensations to be felt during the procedure. -Instruct the client to report changes in sensation or discomfort immediately. -Provide a timer, clock, or watch so that the client can help you to time the application. -Keep the call light within the client's reach. -Refer to the institution's policy and procedure manual for safe temperatures. -Do not allow the client to adjust temperature settings. -Do not allow the client to move an application or place his or her hands on the wound site. -Do not place the client in a position that prevents movement away from the temperature source. -Do not leave unattended a client who is unable to sense temperature changes or move from the temperature source.
RIGHT SIDED HF SYMPTOM OVERVIEW
-Fatigue -Peripheral Venous Pressure -Ascites -Enlarged liver & spleen -May be secondary to chronic pulmonary problems -Distended jugular veins -Anorexia & complaints of GI distress -Weight gain -Dependent edema
What are some things that would cause decreased oxygen-carrying capacity?
-HEMOGLOBIN (anemia, iron, b12) -Why? dietary, gastric, surgery, colitis, pregnancy
Reasons for decreased cardiac output:
-Hypovolemia (not enough blood volume) which can be due to dehydration or blood loss -Valve disorders (mitral valve stenosis or regurgitation) -Coronary artery blockage which causes the heart not to beat as it should -Myocardial infarction (can result from a blockage as stated above) -Dysrhythmia: if the heart is not beating in its regular sinus rhythm, then the blood flow is not going to flow through the heart and out the left ventricle (A-fib where the atria may not be beating every time the ventricles contract so blood flow is not consistent from atria to ventricles---can cause a decrease in the blood that goes out the left ventricle because it is not coming from the left atrium) -Also, if the atria are not beating consistently then the blood flow can back up from the left atria into the lungs and cause congestion in the pulmonary system
What are prevailing characteristics of narcolepsy?
-Involuntary -Cataplexy -Hallucinations -Temporary paralysis The person with narcolepsy experiences a sudden, uncontrollable urge to sleep lasting from seconds to minutes, even though the person sleeps well at night. The person cannot avoid the "sleep attacks" but awakens easily. Narcolepsy is characterized by involuntary episodes of sleepiness, slurred speech, slackening of the facial muscles, a feeling of impending weakness of the knees, paralysis, and hallucinations. Some have other symptoms, such as cataplexy, a sudden loss of muscle tone usually triggered by an emotional event (e.g., laughter, surprise, or anger), but most only have hypersomnia.
When a client has Myocardial Ischemia, it results in:
-Ischemia: decrease in oxygen to the tissues of the myocardium (heart muscle) which results in tissue death -Angina: chest pain associated with decreased oxygenation of the myocardium -Myocardial infarction (heart attack) -Death
LEFT SIDED CHF SYMPTOM OVERVIEW:
-Paroxysmal Nocturnal Dyspnea -Elevated Pulmonary Capillary Wedge Pressure -Pulmonary Congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea) -Restlessness -Confusion -Orthopnea -Tachycardia -Exertional Dyspnea -Fatigue -Cyanosis
OVERVIEW OF FINDINGS IN A CLIENT WITH DECREASED CARDIAC OUTPUT:
-Restlessness and confusion -Fatigue and weakness -Dizziness and syncope -Decreased BP -Tachycardia -Dyspnea and SOB -Crackles -Pallor of skin -Distended jugular veins -Decreased or absent peripheral pulses -Decreased O2 sat levels
When using an incentive spirometer, the client should...
-Sit in a chair to facilitate diaphragmatic excursion and help maximize lung expansion -Coughing deeply after use to help mobilize secretions -use lips to form a seal around the mouthpiece to measure the volume of air inhaled
What you see in clients with impaired valvular function:
-Valvular regurgitation into the atrium resulting in mitral insufficiency or mitral incompetence -Increased preload because of the blood in the left atrium going back into the pulmonary system -Decreased preload for left ventricle as there is not enough blood volume to pump out with contraction -Decreased stroke volume/cardiac output
So, what can we do to promote sleep for the client?
-cluster nursing care -promote comfort -set the environment (reduce noise, dim lights, etc..) -promote bedtime routines -promote activity (within the 2 hour window) -stress reduction -sleep hygiene (do they prefer a shower before bed?)
What are other things that affect inspired oxygen?
-impaired chest wall movement -pleural effusion -pain -nervous system issues -pregnancy
Functions of sleep:
-improves learning and adaptation -reduces illness -maintains optimal immune performance
PREVENTING ASPIRATION FOR PATIENTS WHO ARE AT RISK:
-request meds in elixir or liquid form -break or crush pills, when appropriate -keep suction setup available for routine and emergency use -if the pt is intubated, keep the endotracheal or tracheostomy cuff inflated, and suction above the cuff before deflating the cuff -do not offer food or fluids if the patient is heavily sedated or in the initial recovery phase of anesthesia
School-age childern and adolescents:
-respiratory infections (school age) -adolescents: smoking
What do you see in a patient with ineffective airway clearance?
-trying to cough/breathe -crackles -wheezes
What kinds of things do you see in a patient that is working to breathe?
-use of accessory muscles -nasal flaring -sternal retractions -noise -wheezes -coughing -crackles
Infants/Children need ____ hours of sleep.
16-20
We do NOT want to increase a COPD patient's o2 to any more than ___.
4L
Adolescents need ___ hours of sleep.
9-11
During an initial assessment, what is a classic indicator that a client has COPD?
Barrel chest; Clients with COPD often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity.
DESCRIBE BLOOD FLOW THROUGH THE HEART.
Blood enters the heart through two large veins, the inferior and superior vena cava, emptying oxygen-POOR blood to the RIGHT atrium. At the same time, on the left side, the oxygen-rich blood that has gone through the lungs is coming back through the pulmonary veins and empties into the left atrium. Blood flows from right atrium to right ventricle while blood from left atrium to left ventricle. On the right side, the blood flows through tricuspid valve. The left side, blood flows through the mitral valve and then into the ventricles. When pressure in the ventricles gets high enough, the valves shut. Ventricles then contract and blood flows out of the right and the left side of the heart. From the right side, the blood flows through the pulmonic valve to pulmonary artery and into the lungs in a process called pulmonary circulation. On the left side, blood is pumped to the systemic circulation via the aortic valve into the aorta into the body. ***SUMMARY The RIGHT SIDE of the heart pumps OXYGEN-POOR blood through the PULMONARY circulation. The LEFT SIDE of the heart receives OXYGEN-RICH blood from the lungs and pumps blood through the SYSTEMIC circulation.
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by:
Causing local vasoconstriction, preventing edema and muscle spasm
What can cause a HIGH preload?
CHF, valve disfunction-usually mitral valve (fluid backs up when they do not close properly)
What is a major concern for infants and toddlers?
CHOKING
What is the waste product of cellular metabolism/respiration?
CO2
What is the nurse's primary priority when caring for a client with rheumatoid arthritis?
COMFORT- Because pain is an all-encompassing and often demoralizing experience, the client should be kept as pain-free as possible.
What would you see in a person with hypoxemia (low oxygen entering into the tissues)?
CONFUSION is the first symptom, restlessness, cyanosis, fatigue
A long-term problem for a client diagnosed with emphysema...
Carbon dioxide retention; Loss of alveolar surface area causes retention of carbon dioxide, which, after exhausting the available bicarbonate ions functioning as buffers, will cause a lower pH (respiratory acidosis).
What complications are most commonly associated with COPD?
Cardiac problems; COPD causes increased pressure in pulmonary circulation. The right side of the heart hypertrophies- causing right ventricular heart failure.
What systems do respiratory functions involve?
Cardiovascular, neurological, and musculoskeletal; The musculoskeletal and neurological systems regulate the movement of air into and out of the respiratory system. The cardiovascular system transports oxygen and carbon dioxide, which are exchanged in the lungs.
What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for an infant with this diagnosis?
Clubbing of fingers
When performing an admission assessment on a patient with pulmonary edema, what clinical finding is expected?
Crackles at bases of the lungs; Crackles are the sound of air passing through fluid in the alveolar spaces. In pulmonary edema, fluid moves from the intravascular compartment into the alveoli.
Why are beta-adrenergic blockers used for angina, acute myocardial infarctions, and CHF?
Decrease myocardial oxygen demand; They decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility.
What type of pain would a client be experiencing if they sustained a right hip fracture? Describe the other types of pain.
Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site.
Secondary Sleep Disorders:
Depression, hyper/hypothyroidism, pain, sleep apnea
A nurse is planning to teach the parents of a preschool child diagnosed with cystic fibrosis about why the child has respiratory problems. What should the nurse remember about the underlying pathophysiology?
Excessively thick mucus obstructs airways; Dysfunction of the exocrine glands leads to the secretion of mucus that is thicker and more tenacious than normal. The characteristics of this mucus cause it to pool in the lungs and make expectoration difficult. In addition to airway obstruction, children with cystic fibrosis are more likely to have respiratory infections.
For a school-aged child with cystic fibrosis, what pathophysiologic factor has the greatest impact on the child's health status and is the priority in the care plan?
Extremely thick mucus causing obstructed airways; Dysfunction of the exocrine glands leads to an excessive accumulation of thick mucus, a slower flow rate of mucus, and incomplete expectoration of mucus, all of which contribute to airway obstruction.
For a client admitted to the ICU with acute pulmonary edema, what rapidly acting IV diuretic should be anticipated to be prescribed?
Furosemide (Lasix); Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium.
A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?
Give prescribed drugs to promote bronchiolar dilation; Asthma involves spasms of the bronchi and bronchioles, as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client's breathing.
What is the carrier of CO2 and O2?
Hemoglobin (drops off O2 and picks up CO2)
What factor in a client's medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
Hepatitis B; Even in recommended doses, acetaminophen can cause severe hepatotoxicity in patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly should also use acetaminophen cautiously.
When iron is low, ____ is low, which makes ____ low.
Hgb, o2
The nurse enters a client's room and finds the client on the floor crying for help. It is obvious to the nurse that the client has sustained a hip fracture. Which action should the nurse take next?
Immobilize the affected extremity; The nurse should immobilize the affected extremity first. Further damage and internal bleeding could occur if the extremity is not immobilized.
For a client that has just returned from a bronchoscopy, the nurse instructs for the client to not consume any food or drink for several hours. Why does the nurse suggest these measures?
In order for a bronchoscope to be inserted, throat muscles are anesthetized-- diminishing the gag reflex which puts the patient at risk for aspiration.
To increase cardiac output...
Increase stroke volume (or) increase heart rate (or) increase both
Describe the correlation between iron and hemoglobin.
Iron is necessary for hemoglobin synthesis. Therefor, reduced intake of dietary iron results in iron deficiency anemia. Hemoglobin is the main component of RBCs and transports oxygen and CO2 through the bloodstream.
What is rest?
It is whatever the patient says is a stress-relieving activity for them. This could be running, reading, swimming, etc..
What is the #1 thing that stimulates state of WAKE?
LIGHT
What is the nurse's priority concern for a patient with partial and full-thickness burns of the chest obtained in a house fire?
Maintaining a patent airway is the priority; because of the proximity of the chest and nose/mouth, inhalation burns also may have occurred.
While caring for a young adult on a mechanical ventilator, the ventilator alarms sound. On entering the patient's room, the nurse notes that he is agitated and his skin is ashen and diaphoretic. His pulse oximetry shows an oxygen saturation of 78%. The nurse is unable to identify any obvious mechanical problems with the ventilator. The first step the nurse should take is to:
Manually ventilate him with an Ambu-bag. All the actions listed are appropriate and necessary. However, if you cannot quickly identify and correct a problem with the ventilator, you must ensure adequate ventilation until the problem can be identified and corrected. Your immediate response should be to manually ventilate the patient with an Ambu-bag. Your colleagues should assist you by troubleshooting the problem, assessing breath sounds, and notifying the physician.
A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do?
Mark the time and fluid level on the side of the drainage chamber; The fluid level and time must be marked so that the amount of drainage in the chest tube drainage system can be evaluated.
A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L, chloride 55 mEq/L, sodium 132 mEq/L, and potassium 3.8 mEq/L. The nurse determines that the results indicate:
Metabolic alkalosis; The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L; the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L; the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L; the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.
For a child with cystic fibrosis, the primary reason for chest physiotherapy is to:
Mobilize secretions; Cupping and clapping over the chest helps mobilize secretions so they can be expectorated, thereby relieving discomfort.
The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do?
Monitor for nonverbal cues of pain; Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further.
What can cause a decreased preload?
NOT ENOUGH BLOOD VOLUME due to blockage, DVT, blood loss, dehydration, coronary artery blockage (MI)
A patient receiving Morphine via PCA has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?
Naloxone administration; Naloxone is an opioid (narcotic) antagonist and will reverse respiratory depression caused by opioids.
A client who was stabbed in the chest is attached to a closed-drainage system and has a chest tube. What is an important nursing intervention when caring for this client?
Observing for fluid fluctuations in the water-sealed chamber; Fluctuations occur with inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged.
To control pain for the first two days after surgery for cancer of the pancreas, the client is receiving 10 mg of intravenous (IV) morphine sulfate (MS Contin) every four hours. When the client rests or sleeps between infusions, the nurse concludes that the:
Pain management is effective; Sleeping between doses of the pain medication indicates that the client is comfortable; therefore, the medication regimen is effective.
What assessment findings might the nurse expect to see in a patient with diabetes experiencing poor peripheral circulation?
Poor peripheral circulation that occurs with diabetes is characterized by weak or absent pulses; pale, ashen, or cyanotic skin; and cool skin temperature. Lack of hair, and shiny skin on lower legs and feet usually accompany peripheral vascular disease, such as what occurs with diabetes.
An appropriate nursing intervention for a neonate with respiratory distress syndrome would be to:
Position the infant to promote respiratory efforts; Positioning the infant with the head slightly hyperextended and changing the position every 1 to 2 hours helps respiratory secretions drain; this will increase oxygenation by enhancing respiratory efforts.
A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor. What untoward client response can be prevented by this nursing action?
Postural hypotension; After administration of certain antihypertensives or opioids, a client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when an upright position is assumed. Postural or orthostatic hypotension occurs, and blood supply to the brain is temporarily decreased.
A client is admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. What primary serum blood level should the nurse monitor?
Potassium; Potassium, a gastrointestinal (GI) constituent, moves quickly through the GI tract of a client with diarrhea and is not absorbed; therefore, serum potassium can become dangerously low and cause cardiac dysrhythmias.
Why is it important for the nurse to teach a caregiver how to monitor the oxygen saturation level of a relative who will receive home ventilator therapy?
Potential problems can be identified and acted on before serious consequences occur; Alterations in oxygen saturation can provide information about impending complications, permitting early intervention.
Which action should the nurse implement when performing tracheal suctioning for a client with a tracheostomy?
Preoxygenate the client before suctioning; Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn.
The nurse in the hospital who is trained in cardiopulmonary resuscitation (CPR) focuses on:
Pushing hard in the center of the chest about 100 compressions/minute. Key points of the most recent guidelines for trained professionals include the following: -Focus on effective, uninterrupted chest compressions. -Push hard, push fast in the center of the chest. -Administer about 100 compressions/min. -Perform 30 compressions to 2 breaths—for all victims except newborns. -Give breath over 1 second and make the chest rise visibly (Sayre, Berg, Cave, et al., 2008).
Acetylsalicylic acid (aspirin) is prescribed for a client with rheumatoid arthritis. The nurse understands that the major rationale for this treatment is:
Reduction of joint inflammation; The antiinflammatory action of aspirin reduces joint inflammation.
Why does skin become red after prolonged exposure to cold?
Reflex vasodilation occurs following the initial vasoconstricting effects of cold. Cold causes vasoconstriction. After prolonged exposure, reflex vasodilation occurs to restore adequate blood supply to the tissues.
What causes secondary sleep disorders?
Secondary sleep disorders occur when a disease causes alterations in sleep stages or in quantity of sleep. Depressed people may spend more time in bed; however, in general, they have difficulty falling asleep, experience less slow-wave (deep) sleep, spend less time in REM sleep, awaken early, and have less total sleep time.
For a client transferred to the ICU after a radial neck dissection, what position should the nurse place the client to facilitate respirations and promote comfort?
Semi-Fowler; The semi-Fowler position helps maintain the head and neck in functional alignment and facilitates respirations because the abdominal organs are not pressing against the diaphragm, which allows the thoracic cavity to expand without resistance.
The nurse in the hospital has a prescription to administer medication at 0400 to Mrs. Giovanni. Mrs. Giovanni is asleep when the nurse enters the room. She is difficult to arouse and confused. Identify the stage of sleep Mrs. Giovanni was likely in when the nurse awakened her.
Stage IV; Stage IV is the deepest sleep and the most restorative. In this stage, the delta waves are highest in amplitude, slowest in frequency, and highly synchronized. The body, mind, and muscles are very relaxed. It is difficult to awaken someone in stage IV sleep, and if awakened, the person may appear confused and react slowly.
When teaching a client with pulmonary tuberculosis about recovery after discharge, what is the most important intervention to include?
Taking medications as prescribed; Tubercle bacilli are particularly resistant to treatment and can remain dormant for long periods. Drugs must be taken consistently, or more drug-resistant forms may recolonize and flourish.
What is a primary reason for a school-aged child with cystic fibrosis to have recurrent episodes of bronchitis?
Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria; Cystic fibrosis is characterized by an overproduction of viscous mucus by exocrine glands in the lungs. The mucus traps bacteria and foreign debris that adhere to the lining and cannot be expelled by the cilia, resulting in obstruction of the airway and the development of a favorable environment for the growth of microorganisms, leading to infection.
After establishing a regular breathing pattern for a progressive relaxation activity, what instruction should the nurse provide after the patient has identified the area of muscle tension?
Tense the muscle fully. Once the muscle tension is identified, the client first tenses the muscle fully, then relaxes the muscle completely. In time, the client will be able to relax the tense muscles without first tensing them more fully.
What is stroke volume?
The amount of blood ejected from one ventricle with each beat. (50-75 mLs average each time the ventricles contract)
What is cardiac output?
The amount of blood that one ventricle can pump each minute. (4-6 liters per min, or 5 quarts is average)
What is perfusion?
The blood flow through the heart
Describe the two processes of ventilation.
The first process is the neural regulator which indicates the VOLUNTARY process of ventilating. However, this is limited in its control. Example, if we hold our breath, eventually chemical regulators called chemoreceptors located on the carotid and aortic bodies respond to changes in CO2, O2, and pH.
What will you see in patients with a decreased cardiac output?
The first three symptoms are restlessness/confusion, fatigue/weakness, and dizziness/syncope. Restlessness/confusion because of decreased of oxygen getting to the brain. Fatigue/weakness because of decreased overall blood flow or RBCs (which have the iron and Hgb that the cells need) not getting to cells (anemia). And dizziness/syncope because decrease in RBCs, decrease in total volume, or decrease in oxygen.
The clinic stocks a small number of scheduled medications, so the nurse obtains a dose of the perscribed medication for one of her patients. At the end of the shift, the nurse counts the remaining medications with the oncoming nurse and notes that the count is not accurate. What action should be taken in response to this inaccurate count?
The nurse should first consult with all nurses with access to the medications to determine if a medication was given to a client without proper documentation. This action will frequently solve the discrepancy. If it does not, the nurse manager should be consulted for further action to be taken based on the policy of the agency.
What are some signs of epidural catheter migration?
The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural analgesics. These are common signs of catheter migration, not spinal cord damage.
A patient that was given an opoid has very slow respirations and looks dusky from low oxygen levels when the nurse comes in after 15 minutes of administering the drug. What should the nurse do?
The patient may need some Narcan. Narcan reverses the effects of opoids.
There are specific protocols followed with a client is recieving scheduled (controlled) medications. What characteristic of scheduled drugs results in the need for specific protocols?
There is a high protential for abuse.
Why do dyspnea, SOB, and crackles appear in clients with a decreased cardiac output?
This is due to blood backing up into the left atrium and further into pulmonary circulation where fluid is built in the lungs.
For a post-op thyroidectomy client, the nurse should include what in the bedside setup?
Tracheostomy set and oxygen; A tracheostomy set and oxygen are necessary if the client experiences an acute respiratory obstruction as a result of postoperative edema, nerve damage, or tetany.
Mitral Valve Stenosis:
Valve does not fully open, restricting blood flow into the ventricle
Mitral Valve Prolapse:
Valve that separate the upper and lower chambers of the left side of the heart do not close properly
The QRS complex represents:
Ventricular depolarization; The QRS complex represents ventricular depolarization. The P wave represents atrial depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, visualization of atrial repolarization is obscured by the QRS complex. The T wave represents ventricular repolarization.
A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, the nurse should advise the client to take the prescribed as needed oxycodone and acetaminophen (Percocet):
When the discomfort begins; Pain is most effectively relieved when an analgesic is administered at the onset of pain, before it becomes intense; this prevents a pain cycle from occurring.
Describe gas exchange.
When the oxygenated blood goes through the left-side of the heart and to the tissues, where it is used via cellular metabolism, waste is created (CO2). There is then a buildup of CO2 that goes into the venous system, back into the right-side of the heart and then into the lungs where, through diffusion, is blown out from our lungs.
For what clinical manifestation associated with thrombophlebitis should the nurse monitor for the patient concerned about the risk?
acute chest pain
A health-care associated infection is one that is acquired...
after being admitted to the hospital.
Where does exchange of oxygen/carbon dioxide take place?
alveolar capillary/capillary cell membrane
What is sleep?
an altered state of consciousness
Why would a patient with obstructive sleep apnea be a high-risk postoperative patient?
anesthesia effects
What is a precipitating factor of pain?
anything that induces or aggravates pain
Who important vitamin produced in the stomach has a direct correlation with iron levels?
b12
REM
begins approximately 90 mins into sleep, skeletal muscle tone extremely flaccid, gastric secretions increase, dreaming
What is an internal stimulus that MOST commonly interferes with sleep?
bladder fullness
Narcolepsy...
can be w/ or w/out cataplexy (total loss of muscle involvement)
If preload is HIGH...
can cause edema in the lungs and ascites in the abdomen
What is bruxism?
clenching and grinding of the teeth that occurs during NREM2
What should the nurse explain to the patient is the primary purpose of bed rest?
conserves energy
What is orthopnea?
difficulty breathing laying down
Insomnia is..
difficulty falling OR staying asleep
What kind of activities can stimulate sleep for a child?
dimming lights, reading, etc..
Which are the most effective leg exercises the nurse should encourage a patient to perform to prevent circulatory complications during the postoperative period?
dorsiflexion exercises
NREM 1
easily awakened, barely dosing off
What should the nurse do to best help liquefy a client's respiratory secretions?
encourage the patient to drink more fluid
Shortened NREM sleep decreases restorative processes, resulting in ______.
excessive sleepiness
What are some things that require more o2?
exercise, pregnancy, increased blood volume
What position should the nurse place a client who had oral surgery admitted to the post anesthesia care unit?
lateral; this position facilitates the flow of secretions out of the mouth by gravity, keeps the tongue to the side of the mouth to maintain the airway, and permits effective assessment of the oropharynx and respiratory status
What kinds of things do you see in a patient who is sleep deprived?
less involvement in activities (eating, walking, participation in therapy, etc..)
What is the most important nursing intervention that supports a patient's ability to sleep in the hospital setting?
limiting unnecessary noise in the unit
NREM 2
little bit deeper sleep, still easily awakened but not as easy as NREM1
What stimulates a COPD patient to breath?
low oxygen NOT high co2 like the healthy individual
What can a low preload affect?
low stroke volume, low cardiac output
What should the nurse do when caring for a patient who has a chest tube after thoracic surgery?
maintain an airtight dressing over the puncture wound
If a patient is not getting enough REM sleep, what it lost?
memory, effective cognitive abilities
Afterload refers to...
the resistance in the arteries after the blood leaves the aorta, comes out of the heart and out to the body ***Think of going regular speed until hitting rush hour traffic (this traffic could be high pressure in the arterial system, hypertension, plaque in the arteries making a narrow route aka vasocontriction or arteriosclerosis)
Sleep-Wake disorders
think of the blind patient
What technique associated with diaphragmatic breathing is different from pursed-lip breathing that the nurse should include in the teaching plan?
tightens the abdominal muscles while exhaling
What is the goal of incentive spirometer?
to expand the alveoli and prevent atelectasis
Hypersomnia
too much sleeping
When the ventricles contract...
ventricular depolarization (QRS complex)
What are some physiological responses to insomnia?
vertigo, fatigue, headache
NREM 4
very difficult to awaken, growth hormone released, flaccid muscle tone, restful sleep, if awakened will be confused, vital signs will be significantly lower at this stage, sleepwalking and bed wetting
NREM 3
vital sign changes, initial stage of deep sleep, body begins to slow down, increasingly difficult to wake
