final
excretion
- most meds are eliminated through the kidney in the urine - liver and kidney function is lower with very young and old age groups - serum BUN, creatinine levels generally increase with decreased renal function - most meds are eliminated through the urine
What is ventilation? How is it assessed?
- movement of air in and out of the lungs; inhalation and exhalation - assessed by respiratory rate, depth and respiratory rhythm
Describe the two different kinds of exposures.
- natural: contact with the disease - artificial: parts of the infectious agent or inactivated version is given for the purpose of becoming immune to the disease agent it causes
the respiratory system is regulated by what two things
- neural = CNS controls respiratory rate, depth, and rhythm - cerebral cortex = voluntary control of respirs from impulses to spinal cord
pulse oximetry (SpO2)
- noninvasive indirect test - readings can alert to hypoxemia before clincial signs occur - healthy adult = 92-100% - COPD normal may be 85-88%
What is the normal rate for pulse? What is tachycardia? What is bradycardia?
- normal: 60-100 beats/min - tachycardia: above 100 beats/min -bradycardia: below 60 beats/min
What are the ranges for the following categories of BP? - normal: - elevated: - hypertension stage 1: - hypertension stage 2: - hypertensive crisis:
- normal: less than 120 and less than 80 - elevated: 120-129 and less than 80 - hypertension stage 1: 130-139 and 80-89 - hypertension stage 2: 140 or higher and 90 or higher - hypertensive crisis: higher than 180 and/or higher than 120
sputum specimen
- not a saliva specimen - mucus in deep lung - ideal specimen from deep bronchus
What are vital signs? What are the 4 vital signs we measure? How often do we measure vital signs?
- objective data indicative of physiologic functioning - pulse, respirations, temperature, and blood pressure - periodic monitoring depending on health status - frequency determined by: physician orders, routine policies per agency, admission and discharge, need to monitor response to therapy, client has a change of condition.
thoracentesis: pre-procedure
- obtain consent - invasive - assess coagulation studies
ABG measurements
- pH = 7.35-7.45 - PaCO2 = partial carbon dioxide 35-35 mm Hg - HCO3 = 21-28 mEq/L - PaO2 = partial oxygen 80-100 mm Hg - SaO2 = saturated oxygen 95-99%
What is important to remember when taking BP? (HINT: think about the patient)
- patient should be seated comfortably with the back supported and upper arm bared without constrictive clothing; legs should not be crossed - arm should be supported at heart level, and the bladder of the cuff should encircle at least 80% of the arm circumference - NO talking!
chest therapy
- percussion and vibration over thorax to loosen secretions in the affected area of the lung - contraindicated w/ long term steroid use due to brittle bones
phases of surgery
- perioperative: includes all 3 - preoperative: starts when decision to have surgery is made; ends when transported to surgery - intraoperative: OR unit taken to PACU - postoperative: anything past PACU unit until surgeon releases patient
What are the 2 types of nursing diagnosis categories? What's the difference? Give at least three examples of each.
- physiological needs: examples are acute pain, chronic pain, fatigue, insomnia, risk for poisoning, risk for trauma, activity intolerance - psychological needs (feeling based): hopelessness, fear, social isolation, risk for loneliness, ineffective coping
ABG post procedure
- place specimen on ice - not client's temp, O2 and ventilation if applicable - apply pressure on puncture site; long w/ anticoagulant therapry or bleeding disorder
What do the following terms mean? - polyuria - oliguria - anuria
- polyuria: abnormally large amount of urine - oliguria: abnormally small amount of urine - anuria: failure of kidneys to produce urine
roles of nurse
- preparing client for surgery (preoperative) - maintaining surveillance of client during surgery (intraoperative) - preventing complications (postoperative) - facilitating recovery after surgery (postoperative)
What is prerenal, renal, and postrenal?
- prerenal: circulating blood flow to kidneys decreased blood flow to renal tissues - leads to decreased urinary output (not enough blood to filtrate) - renal: injury to renal tubules themselves - end stage renal disease (most common) - postrenal: obstruction to flow - end of kidneys to where it comes out (reduces sensation in body)
Describe the functions of the respiratory system.
- primary: provides oxygen for metabolism in tissues and removes carbon dioxide (waste product of metabolism) from tissues - secondary: sense of smell, produces speech, maintains acid-base balance, maintains body water levels, and maintains heat balance
What is planning in the nursing process?
- prioritizing problems - identifying measureable outcomes (goals) and interventions - developing a nurse plan of care - written guidelines *NOTE: keep in mind Maslow's Hierarchy
What are the guidelines for assessment meaning what do you need to do when you enter a patient's room when assessing them? (7)
- privacy maintained - explain actions - organized - equipment ready - general observations to specific - monitor pain/comfort status - orderly process - head to toe - utilize effective communication (introduce yourself, explain actions, and identify concerns and answer questions)
Thorax/Lungs Auscultation
Deep breath with mouth open Posterior to anterior Compare side to side
What are things you should do when assessing pulse?
- don't obliterate it - note rate, rhythm, and volume - count for 30 secs if regular and multiply by 2 - count for 60 sec if irregular and assess for pulse deficit *NOTE: count the apical pulse for one min
What is hypotension? What are a few assessment findings? What are some potential causes?
- drop of below 90 systolic for an adult; individualized to age and condition - assessment findings: pallor, confusion, increased heart rate - potential causes: blood loss, vasodialation, side effects of drugs
What is the portal of exit? What will reduce the "exits" form the respiratory tract?
- leaving a host to enter another host (break in skin integrity, respiration, elimination) - cover mouth when sneezing and utilize mask when transferring client with droplet or airborne isolation
What are some factors that affect urinary elimination?
- lifestyle factors (diet, alcohol, caffeine) - sociocultural - developmental factors - psychological (male - stand) - physiological - surgical procedures - medications - pathological - fluid balance
Factors affecting respiration
- lifestyle: smoking, general health (exercising, nutrition, anxiety, substance abuse) - environmental: workplace (chemicals?), home, geographic (smog, elevation) - developmental: pre term infant (decreased surfactant), newborn toddler @ increased risk of URI due to close proximity to other children, 2nd hand smoke, conditions such as teething which incretions secretions which encourages bacterial growth, school age/adolescent - smoking, young/middle age adults - unhealthy lifestyle choices, sedentary lifestyle, smoking, stress, drugs, alcohol - physiological: exercise causes dyspnea on exertion, stress causes hyperventilation; cardiac disorders - causes inability of blood to perfuse the tissues; hematological disorders - decreased hemoglobin, hematocrit - GI bleed; respiratory disorders - restrictive disorders such as atelectasis, pleural effusion, hemothorax, pneumothorax; other factors - pregnancy, abdominal distention, muscle weakness, surgery, nerve dysfunction, MD, paralysis; skeletal abnormalities; obstructive disorders - pneumonia, asthma, ephysema, lung cancer, bronchiectasis, bronchiolitis
bronchography
- liquid contrast medium instilled into trachea followed by chest x ray of bronchial tree - used to detect abnormalities of bronchi
What is localized infection? What is systemic infection?
- localized: local redness (erythemas), warmth, swelling, purulent drainage - systemic: chills, elevated temp, increased serum white blood count (may progress to severe sepsis or septic shock)
What is maceration? What is excoriation?
- maceration: breakdown of skin because of water - excoriation: breakdown of skin because of chemicals
independent nursing interventions
- maintain patent airway - position client correctly - breathing/coughing exercises - hydration and humidification - ambulate
bronchoscopy: post-procedure
- maintain semi to high folwer's position - maintain NPO until gag reflex returns - monitor for bloody sputum
Name the advantages/disadvantages of an axilla thermometer temperature site.
- measurement lag time, inaccurate for infant and children
Name the advantages/disadvantages of a rectal thermometer temperature site.
- measurement lag time, rectal surgeries, diarrhea, unable to position, newborn - thermometer or probe could stimulate the vagus nerve in the rectum and cause cardiac arrhythmia
bronchoscopy: during procedure
- monitor ECG, P, BP, and R every 5 minutes - sedated by not completely out
thoracentesis: post-procedure
- monitor for signs of pneumonthorax, air embolism, and pulmonary edema - assess puncture site for bleeding and crepitus - apply pressure dressing
metabolism (detoxification)
- most biotransformation occurs in the liver - a medication must be metabolized to excrete * acetaminophen with poor liver function
the glottis is the
- most fundamental defense mechanism of the lungs - plays important role in coughing
unstageable pressure ulcer
Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by eschar or slough
stage 4 pressure ulcer
Full-thickness tissue loss, exposed bone, tendon and muscle
stage 3 pressure ulcer
Full-thickness tissue loss; subcutaneous may be visible (bone, tendon or muscle not exposed)
parental nutrition (PN) is used when?
GI tract is incapacitated OR not sufficient
informed consent
Gained before surgeon can perform surgery, (signed consent form)
What is body temperature? How is it measured?
Heat produced - heat loss = body temperature measured in Fahrenheit or Celsius
CLINICAL QUESTION A client presents with an oral temperature of 106 F and lethargy exposure warm weather and lack of fluids. What is different in the assessment and management of heat stroke from a fever related to an infection?
Heat stroke is not caused by infection; fever is. hyperthermia is treated by cooling body with soaks, sponge baths, cooling blankets. *NOTE: antipyretics are ineffective with hyperthermia.
antidysrhythmics
Medications can reduce cardiac contractility and impair cardiac conduction during anesthesia
antihypertensives
Medications such as beta blockers and calcium channel blockers interact with anesthetic agents to cause bradycardia, hypotension and impaired circulation
anticoagulants
Medications such as warfarin or aspirin alter normal clotting factors and thus increase risk of hemorrhaging; discontinue at least 48 hours before surgery
insulin
a patient's insulin requirements fluctuate after surgery (some may need more before or after and some pt's may need less)
restraints definition
a physical restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patinet to move
What is a reservoir?
a place where pathogens survive; human body may be a reservoir
compliance
ability of lungs to expand and contract * lose elasticity as you age
compliance
ability of the lungs to distend or expand in response to increased intra alveolar pressure
Clubbing of fingernails is normal/abnormal
abnormal
Fill in the blank. An _____________________ slow, fast or irregular pulse alters cardiac output. A ___________ pulse may not allow for the hear to fill and there is a reduced stroke volume.
abnormally; rapid
subcutaneous sites
above butt, upper arm, upper thigh, middle of back, abdomen
The lungs extend from ______________________ to ________________.
above the clavicles the diaphragm
delirium (acute confusion)
abrupt onset of confusion delirium indicates illness underlying problem reversible prognosis if condition corrected
delirium (acute confusion)
abrupt onset of confusion delirium indicates illness underlying problem reversible prognosis if condition corrected
Breath sounds can be
absent or diminished
systemic effects
absorption into the blood stream
schedule II controlled substances
accepted use, high potential for dependence and abuse
What is labored respirations?
accessory muslces
cumulative effect
accumulation of med(s) in the body faster than excreted; results in an increased action
CLINICAL QUESTION A client that is 2 year old is hospitalized for ORIF for a fractured tibia after a fall. They request medication for their child's pain. What medication is related to less gastric irritation? - aspirin - ibuprofen - acetaminophen - ketorolac
acetaminophen
What is a non steroidal medication that reduces body temperature?
acetaminophen
risks at school-age child stage
activities sports - head injury risk high bicycles have high injury risk
Methicillin Resistant Staphylococcus Aureus (MRSA)
acute care/ICU often screens patients w/nasal swab for this contact isolation precautions w/possible mask
circulation
acute/potential blood loss, listen to heart sounds through course of surgery, electrolyte imbalance, assess rate and rhythm of pule (compare to baseline), check distal points (CWMS)
constipation prevention
adequate fluids and fiber
ideal body weight (IBW)
adjusted for ethnicity and weight related complications
obstructive sleep apnea
administration of opioids increases risk of airway obstruction after surgery
upper respiratory infection
administration of opioids increases risk of airway obstruction after surgery
nutrition assessment
after NG, advance from ice chips, clear liquid, full liquid, soft, then regular
senile lentigines, lentigo
age spots "liver spots" benign- non-cancerous sun exposure
What factors affect temperature?
age, gender (hormonal changes), activity, illness/injury, medications, fluids (dehydration is related to increase temp.), circadian rhythm (body temp. peaks at 6 pm; lowest from 1-4 am).
antiemetic
agent to prevent or relieve nausea and/or vomiting
negative airflow
air coming into the room
Sinsues are ____________ cavities that provide _________________________
air filled (within hollow bones surrounding nasal passages) resonance during speech
positive airflow
air going out of the room
ambulatory surgery discharge
all PACU criteria met, no IV narcotics for 30 min, minimal nausea and vomiting, voided, able to ambulate if age-appropriate and not contraindicated, responsible adult present to accompany client, discharge instructions given and understood
CLINICAL QUESTION What information does the nurse need to interpret a blood pressure reading for a six year old child? - site of BP - activity prior to measurement - gender - age - height - type of equipment used
all of the above
glaucoma
altered pressure in eye loss of peripheral vision
restraints guidelines
alternatives to restraints must be used prior to restraints if you must use restraint follow agency policy: check 4 proper appliation and circulation, observe client every 15 minutes restraint must be removed every 2 hours for repositioning and ROM use quick release knots
renal disease
alters excretion of anesthetic drugs and their metabolites, increasing risk for acid-base imbalance and other complications
hypoventilation
alveolar ventilation is inadequate to meet O2 needs or eliminate
What are the basic units of gas exchange (diffusion)?
alveoli
alveolar ducts contain cluster of ____________
alveoli
preventing post op respiratory complications
ambulation, keep comfortable, oxygen, oral hygiene, deep breathing, coughing, spirometry
What is the nursing process?
an organized sequence of steps identified as assessment, nursing diagnosis, planning, implementation, and evaluation. *NOTE: REMEMBER ADPIE!
emergent delirium
anesthesia causes agitation
interventions to prevent falls (B)
avoid rugs and clutter on the floor entry w/o steps? no pet underfoot items in reach safety features in bathroom - bars by tub and shower, no slip surfaces
CLINCIAL QUESTION Your client arrived in the ED with a possible head injury with ear and nasal bleeding. The client is in a cervical collar and should not be turned. What route is appropriate to obtain a temperature?
axilla, temporal on femoral artery
wound drainage
bacteria of more than 100,000 organisms per gram are infected
nonblanching hyperemia
bad sign, no circulation present, deep tissue damage possible
non-rebreather mask: implementation
bag should collapse only slightly and never totally deflate during inspiration 60%-100% FIO2 at a liter flow that maintains the bag TWO THIRDS FULL
Gastrointestinal Auscultation location
begin in the right lower quadrant (RLQ) listen in all four quadrants
pre-op medications
benzodiazepines (sedative), h2-receptor antagonists (block release of gastric acid), antacids (changes pH of gastric acid in case someone would aspirate), analgesics (pain), anticholinergics (decreasing secretions), antiemetics (prevent vomiting)
pre-op teaching
best to complete as soon as decision for surgery is made in order to better educate pt w/brochures or DVDs and make them less anxious
pharmacodynamics
biochemical and physiological effects of drugs and mechanisms of action
What is stroke volume?
blood entering aorta with each ventricular contraction
BUN
blood urea nitrogen; many variables
enteric coated (EC) tablets and sustained released (SR) capsules
delay absorption until the medication reaches the small intestine
DTs
delirium tremens; brought on by withdrawal from alcohol
venture mask
delivers most accurate & precise oxygen concentration keep orifice for the Venturi adapter open & uncovered
albumin (protein) (historic)
depletion 2.7 or less 3.8-5.4 g/DL
prealbumin (right now)
depletion 9 or less 20-35 mg/DL
immobility complications psychosocial
depression sleep-wake disturbances developmental
therapeutic index
desired effects of medication without adverse reactions
during inspiration, the ____________________ descends into the ____________ causing _____________ pressure
diaphragm abdominal cavity negative
schedule IV drugs
diazepam, phenobarbital
What is dyspnea?
difficult breathing
mild stage AD minor neurocognitive disorder
difficulty w/instrumental ADLs (e.g. managing money, driving)
coffee ground emesis
digested blood
K and Na are electrolytes found where?
digestive tract and blood
antihistamines (OTC)
dimenhydrinate (Dramamine) diphenhydramine (Benadryl)
loneliness
discomfort associated with a desire or need for more contact w/ others feeling of depression, unrest, anxiety, unhappiness
loneliness
discomfort associated with a desire or need for more contact w/ others feeling of depression, unrest, anxiety, unhappiness
loneliness, risk for
discomfort associated with the desire or need for more contact with others
shoulder subluxation
dislocation of the shoulder joint
Diuretics
diuretics such as furosemide potentiate electrolyte imbalances (particularly potassium) after surgery.
S&S of hypoventilation
dizziness, HA, lethargy, disorientation, dysrhythmias, cardiac/respiratory arrest, changed mental status
meter dosed inhaler
does not go in mouth, exhale, activate inhaler, inhale, hold breath
hypoactive delirium assessment
drowsy, lethargic, voice or touch for a response slow motor activity difficulty focusing
hypoactive delirium assessment
drowsy, lethargic, voice or touch for a response slow motor activity difficulty focusing
medicare part D
drug benefit
contraindications
drug should not be taken
xerosis
dry skin
integumentary system and aging
dryness/itching r/t loss of oils in skin loss of elasticity wrinkles thinness yellowing hair loss & graying r/t decreased melanin nails yellow & thicken
type 1 diabetes occurs because of
due to B cell destruction, usually leading to absolute insulin deficiency
type 2 diabetes occurs because of
due to a progressive loss of insulin secretion on the background of insulin resistance
specific types of diabetes occur because of
due to other causes, (drug or chemical induced diabetes (such as with glucocorticold use))
What is dysrhythmia? What is arrhythmia?
dysrhythmia - irregular rhythm; described as regularly irregular or irregularly irregular arrhythmia - by definition this is no rhythm, however, commonly used also to describe a dysrhythmia
Otoscope
ear exam
the _______________ bronchi is wider, shorter, and more vertical than the __________ bronchi
right left
Cardiac Assessment Aortic valve
right 2nd ICS
An 88 year old client is receiving furosemide (Lasix) 40 mg po for HTN and heart failure. The client's nutritional intake of fruits and vegetables is lower during the winter.
risk for electrolyte imbalance
respiratory system and aging
risk for respiratory infections risk for activity intolerance confusion & tachycardia are signs of pneumonia
dementia interventions
safety- possible placement in nursing facility low stress- avoid confrontation, validation therapy, low stress environment
What drugs are the non steroidal anti-inflammatory drugs (NSAIDS)?
salicylates, aspirin, ibuprofen, ketorolac aspirin and aspirin like drugs
Edema- observation
say where it is (ankle, lower leg) Anasarca- generalized edema Ascites- abdominal edema Brawny= non-pitting/hard
sharp debridement
scalpel
Anticholinergic
scopolamine (transderm scope) inhibit vestibular stimulation (motion sickness) used to dry secretions before surgery side effects: dry mouth, drowsiness
causes of hypoventilation
sedation, broken ribs, incisions, gave a CAL too much O2
causes of delirium
sensory overload
what should you do with all liquid meds?
shake well before pouring
nasogastric tubes
short term - less than four weeks intact gag/cough reflex needed
immobility complications joint contracture
shortening of muscle fibers, ligaments, and tendons e.g. plantar flexion flexion most common
aspiration signs, causes, and prevention
signs - coughing, crackles or dimished lung sounds, fever causes - tube displacement, reflux from stoamch prevention - veryify placement, elevate HOB at least 30 degrees, check GRC, client should hold breath/exhale when removing nasogastric tube
carbohydrates
simple: glucose, dextrose, fructose complex: polysaccharides, whole grains source of energy and fiber; stored as glycogen
what is the correct placement when administering meds into the rectum?
sims position; suppository should be above anal rectal ridge
parenteral meds are packaged in
single use ampules single and multiple use vials pre-measured syringes and cartridges
What is the first line of defense in our bodies?
skin
What are the implications of incontinence?
skin breakdown
acrochordons
skin tags metabolic syndrome
What can you physically assess on your client for signs of adequate and poor nutrition?
skin, hair/nails, oral, weight changes
What is bradypnea?
slow breathing (less than 10 per min)
Anticholinergics, antihistamines, and antihypertensives do what to urinary elimination?
slow things down (builds up fluids)
How do opiates effect the digestive system?
slows down
the bronchioles subdivide into the ______________ and ______________ bronchioles
small terminal respiratory
Integumentary Macule
small, flat, e.g. freckle
dehiscence
edges of a wound start to come apart
evisceration
edges of wound have pulled apart and inside is starting to come out (get help, get it covered sterilely and call physician)
Erikson's stages of development late adulthood
ego development outcome: integrity vs. despair basic strengths: wisdom adjustment to the reality of aging & mortality; accept life
Erikson's stages of development late adulthood
ego development outcome: integrity vs. despair basic strengths: wisdom adjustment to the reality of aging & mortality; accept life
Systemic signs of Infection
elevated serum WBC count, general malaise, fever, mental confusion, loss of appetite
undermining
elevated serum WBC count, general malaise, fever, mental confusion, loss of appetite
Integumentary Vesicle
elevated, filled with serous fluid
Integumentary Pustule
elevated, pus filled
basal metabolic rate (BMR)
energy needed to maintain life-sustaining activities for a specifc period of time at rest
elemental or "predigested" enteral solutions
enters directly into intestine and skips stomach; rapidly absorbed in small intestine *note lactose allergies
Extended Spectrum Beta Lactam producers (ESBL)
enzymes that break down certain types of antibiotics & is multi-resistant e.g. E. coli contact isolation
What 2 hormones do the kidneys secrete?
erythropoietin and renin
ablative surgery
excision or removal of diseased body part example: amputation; removal of appendix or an organ such as gallbladder
proper technique for meter dosed inhaler
exhale, activate inhaler, inhale, hold breath
interventions for loneliness reminiscence
expression of feelings finding meaning in life
alveolar capillary membrane to pulmonary capillary bed is external/internal?
external
Ophthalmoscope
eye exam
What is orthopnea?
facilitated by sitting or standing
What may happen if balance is not achieved?
falls and injury
post fall syndrome
fear of falling; possible immobility issues
enteral nutrition: method for delivery bolus
fed very quickly; used for gastric feeding only; may cause nausea and vomiting, aspiration, cramping, and diarrhea
immune system and aging
fever & chills replaced w/ confusion & decreased functional ability
Crackles
fine-opening of alveoli course-Velcro sound- secretions
dysphagia: management
fluid are generally thickened to consistency of tolerated food remain sitting after meals for 30 min. monitor for aspiration
fluid volume excess
fluid restrictions plan for fluids w/ meds and meals frequent oral care avoid dry, salty, or sweet foods - dry mucous membranes keep fluids not intended out of sight
rapid weight changes reflects
fluid shifts
An 88 year old client is receiving furosemide (Lasix) 40 mg po for HTN and heart failure. The client's nutritional intake of fruits and vegetables is lower during the winter. This same client now has nausea from a viral illness. The client is not drinking fluids and also has episodes of diarrhea.
fluid volume deficit
nursing diagnoses (fluid and electrolyte imbalance)
fluid volume deficit fluid volume excess risk for electrolyte imbalance
The client has recovered form the viral illness. However, since the client stops taking the Lasix without consulting the HCP.
fluid volume excess
How do you deliver enteral nutrition?
fluids at room temp. verify placement residual check bag 12 in higher than insertion point HOB 30-45 during and 1-2 hours after right side for small intestine feeding start slowly, increase rates
WHAT IS THE NEXT ACTION? A client with diabetes has a low blood glucose reading (of 60 mg/DL) before meals and insulin is scheduled.
follow the policy for hypolycemia *POLICY: talk with staff nurse, treat with 15 grams carbohydrate, recheck blood sugar, if still not >70 mg/DL, repeat....
trade name (brand name)
followed by the sign TM; assigned by the manufacturing company
hyperventilation
forced respiration too much O2 or too little O2
vomiting
forcing the contents of the stomach up through the esophagus and out the mouth *risk for fluid and electrolyte loss
mild cognitive impairment
forgetting IMPORTANT appointments difficulty finding FAMILIAR PLACES FREQUENTLY forgets names WORRIED about memory loss
Rubs
friction between pleura layers
Neck assessment
further assessment is not a routine shift assessment, nor is palpation of carotid artery DO NOT palpate both sides of the neck at the same time
contusions
further underlying injury
gastric pH intestinal pH pleural pH
gastric pH - less than or equal to 4 intestinal pH - > 6 pleural pH - > 6
Orthostatic hypotension, post pyramidal hypotension (after eating), and systolic hypertension (from loss of elasticity of arteries) are all common in what age group?
geriatric
Herbal therapies
ginger, ginkgo, ginseng - these herbal therapies have the ability to affect platelet activity and increase susceptibility to postoperative bleeding. Ginseng increase hypoglycemia with insulin therapy.
opening between the true vocal cords is called
glottis
aspiration =
glottis not functioning
how do you administer meds into a vagina?
glove position - dorsal recumbent 2-4 inches insertion clean applicator maintain position 5-10 minutes
face tent
good for client w/ facial trauma and burns
aerosol mask
good for client who requires high humidity after extubation or upper airway surgery or thick secretions
blanching hyperemia
good sign, circulation still there (redness goes away)
as the lungs recoil, pressure in the lungs becomes _________________ than atmospheric pressure
greater causes air to move from alveoli to atmosphere
negative pressure draws air from an area of ____________ pressure to an area of ________________ pressure
greater (atmosphere) lesser (lungs)
return gastric residual volume(GRV) to stomach unless?
greater than designated amount
excessive consumption of _____________________ may affect anticoagulation w/ warfarin
green veggies or cranberry juice
What is the most common mode of transmission?
hands
induration
hard, firm
teratrogenic
harmful to the fetal development
Bronchial lung sounds
harsh and loud
lead poison: symptoms
headahces, irrability, reduced sensations, aggressive behavior, difficulty sleeping, abdominal pain, poor appetite, constipation, anemia
Bleeding risk with these meds.
heparin warfarin
seborrheic keratosis
hereditary
parenteral nutrition (PN)
high caloric intravenous nutriton given inravenously
hypercalcemia
high levels of serum calcium high calcium serum levels=muscle weakness
risks at adult developmental stage
high levels of stress assocaited w/ accidents
Wheezes
high pitched
schedule I controlled substances
high potential for dependence and abuse, not approved for general population
What does this lab value reflect? normal albumin; low prealbumin
history of adequate protein intake, but recently taking in less protein
What does this lab value reflect? nitrogen balance is low; BUN is low
history of low protein intake
What does this lab value reflect? low albumin; normal prealbumin
history of low protein intake, but recently taking in more protein
tuberculin syringe
holds capacity of 1 cc or mL, calibrated in hundredths of a mL with each one-tenth marked on the metric scale
medicare part A
hospital costs reimbursement for skilled care
neurological assessment
how does sensation come back, check often, LOC
family needs
how long it will take, education, spiritual care, cafeteria location, where pt will be after surgery. just don't forget the family
Nose: ________________, _____________, and ____________ inspired air
humidifies warms filters
"_____________ is the best expectorant."
hydration
antihistamines (prescription)
hydrooxyzine (Vistaril) promethazine (Phenergan)
_____________________ regulates temperature. ______ to ______ degrees F is the normal set point.
hypothalamus; 98.2 to 98.6 degrees F
postoperative temp change
hypothermia to 94 degrees F possible causes-effects of anesthesia, body heat loss in surgical exposure, BMR decreased elevation to 100.4 degrees F for first 24-48 hours after surgery-inflammatory response to surgical stress (coughing, deep breathing, moving) elevation about 100.4 degrees F for first 24-48 hours after surgery- lung congestion, atelectasis, dehydration (hydration is the best expectorant) Elevation above 100 degrees F on third day after surgery- wound infection, UTI, phlebitis, respiratory infection
single IV administration peaks
immediately
dysphagia: nursing diagnosis
impaired swallowing imbalanced nutrtion, less than body requirements risk for aspiration
antiemetics should not be used when?
in vomiting of unknown etiology *especially in children and adolescents
What do steroids do for the appetite?
increase
allow for ________ in amount of time to react
increase
Assess, plan, and evaluate nursing care related to respiratory arrest.
increase O2
What is hyperthermia?
increase in temperature related to inability to promote heat loss or reduce heat production.
__________________ body fat (20%) results in increased storage of the med and longer action of med in the body
increased
Assess, plan, and evaluate nursing care related to respiratory distress.
increased O2, find out why in distress (anxiety, stress, obstruction?) and fix it
Integumentary Jaundice
increased bilirubin related to liver disease yellow color best observed in the sclera
Integumentary Cyanotic
increased deoxygenated hemoglobin blue or ashen-gray skin/mucous membrane nail beds, lips, mouth, skin(severe cases)
normal drive to breath driven by
increased levels of CO2
symptoms of hyperglycemia
increased thirst, increased urination, fatigue, blurred vision, slow healing infections
Fill in the blank. An ________________ pulse may be related to lower oxygen levels in the blood to improve oxygen transport. _______ hemoglobin, hematocrit, and RBC levels reduce oxygen transport.
increased; low
hypertension
increases risk for cardiovascular complications during anesthesia
bleeding disorders
increases risk of hemorrhage during and after surgery
diabetes mellitus
increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment. Stress of surgery often results in hyperglycemia
How does supplemental O2 work?
increases the driving pressure for gas diffusion across the alveolar-capillary membrane
as the diameter of a syringe ___________ the diameter size _________________
increases; decreases
long term weight change
indicator of nutritional intake
anesthesia
induction- administering agents via endotracheal maintenance- keeping pt sedated emergence- decrease anesthesia and people wake up (shorter half life- people wake up earlier) side effects: cardiovascular depression, irritability, respiratory depression, liver and kidney damage
3 important nursing diagnoses
ineffective breathing pattern ineffective airway clearance impaired gas exchange
etiology (causes) of nausea and vomiting
infection impaired GI motility motion sickness disturbances of inner ear
wound and drains assessment
infection (redness and edema), hematoma, dehiscence and evisceration, hemorrhage (pressure and layer)
phlebitis
inflammation of vein
external respiration
inhalation to alveoli diffuses
intrinsic restrictive
inherent to the lungs e.g. pneumonia, sarcoidosis
silver
inhibits bacterial growth
parenteral generally means
injection route "around oral route" and is administered by IV, IM, and SC
risks at infant, toddler, and preschooler stages
injuries #1 cause of death in children over age 1 many of them are motor vehicle accidents
the work of breathing is ________________
inspiration
What do corticosteroids do?
interfere with hypothalamus, suppress fever response, not used to lower fever
peripheral blood stream to cells is external/internal?
internal
slough
soft, moist avascular tissue (from necrotic or devitalized tissue); may be white, yellow, tan, green, stringy or firmly adherent to the wound; it is a byproduct of autolysis
maceration
softened
Integumentary Nodule
solid, elevated
syrups
solution of sugar, thick, viscous
Expectoration
sputum expelled through mouth
how do you apply ointment to the eye
squeeze a thin ribbon of ointment along the lining of the sac from the inner to the outer canthus
lead poison
state medicaid programs require blood lead level tests @ 12 and 24 months 1 in 11 children have high level of lead in blood 1 in 7 children in Iowa at risk for developing learning disabilities, nerve problems or kideny damage due to lead poisoning
recommendations r/t gastric residual volume (GRV)
stop feedings if aspiration occurs withhold feedings if GRV over 500 mL follow agency policy and specific prescription for client
if a client has an NG feeding and needs meds
stop the feeding; flush w/15-30 mL between each med, flush w/30-60 mL of water at end (administer one at a time)
mental status & aging
stress impairs memory recent memory may occasionally diminish but long-term wont intelligence does not change decline in speed of problem solving & organization
mental status & aging
stress impairs memory recent memory may occasionally diminish long-term memory intact intelligence does not change decline in speed of problem solvign & organization
heart disease and peripheral vascular disease
stress of surgery causes increased demands on myocardium to maintain cardiac output.
What is cardiac output?
stroke volume x beats/min = cardiac output
toxicology
study of poisons - chemical substances harmful to the body *medications may have a toxic effect!
Assess, plan, and evaluate nursing care related to increased respiratory secretions
suctioning? maybe a bronchodialator? something to open up lungs and respiratory passages so there's no aspiration
epithelization
surface repair; regeneration of the epidermis across the wound surface
cells in the wall of the alveoli secrete ____________
surfactant
How do you prevent asepsis r/t enteral nutrition?
swab can w/ alcohol rinse wash hands and wear gloves do not touch areas of set that contact the feeding label container 4-8 hours open system 24 hours prepared bags available
dysphagia: diagnosis
swallow screening at bedside speech pathologist/speech therapist evaluation swallow studies - assessment of aspiration
symptoms of hypoglycemia
sweating, hunger, tremling, anxiety, confusion, blurred vision
S&S of hyperventilation
tachycardia, dizziness, SOB, tinnitus, blurred vision, disoriented
immediate post op
taken to PACU, patient is extubated
Percussion (assessment step 3)
tapping a body part
radon
tasteless, colorless, odorless gas *2nd leading cause of lung cancer deaths
laceration
tearing, irregular edges
Gastrointestinal oral assessment
teeth & dental health throat swallowing lesions mucous membranes- moisture indicates hydration
Dorsum of hand detects
temp variations in skin
hospice
terminal illness pallative
What is the major muscle of inspiration?
the diaphragm
airway resistance
the increase in pressure that occurs as diameter of airways decreases from mouth/nose to alveoli
Generic name
the official accepted name of a medication
t tube
the surgeon places a small tube, called a t tube, into the bile duct. The t tube allows bile to drain out of the patient's body into a small pouch, known as the bile bag.
multiple oral administration achieve
therapeutic range between minimum toxic concentration (MTC) & minimum effective concentration (MEC) Know "peak" & "trough"
eschar
thick, leathery necrotic tissue, devitalized tissue; dead tissue
purulent
thick, yellow, green, tan or brown
parietal pleura lines the ____________________ cavity
thoracic (outside)
Note _________, ______, and _________ about nausea
time nature amount
half life
time it takes for 1/2 of the original amount of drug in the body to be removed
aloneness
to be solitary, apart from others, undisturbed
Goal of supplemental O2 administration
to provide the lowest % of O2 that will maintain O2 saturation within normal range
anticoagulants
too much or not enough - ++++ many more
enzymatic debridement
topical application
total parenteral nutrition (TPN)
total nutritional intake given by intravenous nutrition through large veins
Palpation (assessment step 2)
touch and pressure light and deep
cardiac medication - digoxin (Lanoxin)
toxicity
T/F - No single temperature is normal for all people.
true
T/F - The core temperature is greater than the surface temperature.
true
T/F - Under most conditions voiding is voluntary.
true
T?F - herbal preparations are not approved by the Food and Drug Administration as a drug.
true
synergistic effect
two medications combined is greater the effect of medications given separately
additive effect
two meds act similarly * beta blocker and diuretic both lower blood pressure
How many parts are there of an actual nursing diagnosis and what are they?
two parts - problem and etiology (related factors) Example: acute pain r/t injury to surgical area *NOTE: sometimes there's a third part or defining characteristics Example: acute pain r/t injury to surgical area as evidenced by moaning, inactivity
needle size for adult
NOT HIGHER THAN 25 G FOR ADULT! 18-21 G for oil based or viscous solutions
preoperative checklist
NPO, mental status, discharge plan, consent, BP, temp, resp, pulse, SPO2, height, weight, designated driver (if needed), ID bracelet, advanced directives, etc.
Nonsteroidal antiinflammatory drugs (NSAIDs)
NSAIDs (ibuprofen) inhibit platelet aggregation and prolong bleeding time, increasing susceptibility to postoperative bleeding.
Does someone with a would need to get just the tetanus shot?
No they need TIG if they've had 0-2 prior doses of tetanus toxoid
immobility complications disuse atrophy
muscle weakness, loss of muscle strength, loss of ADLs, fatigue, disuse osteoporosis, and joint contractures *3% loss of muscle strength is lost each day the client is not mobile
low respirations
narcotics
occlude the ________ for 1 to 2 minutes to prevent overflow of medication
nasolacrimal duct * for meds that cause systemic effects
Pharynx is divided into 3 parts
nasopharynx oropharynx laryngopharynx passageway for respiratory and digestive tracts located behind oral and nasal cavities
GI elimination assessment
nausea and vomiting, distension and flatulence, paralytic ileus, hiccups, delayed gastric emptying
urgent surgery
necessary for patient's health; often prevents development of additional problems (e.g. tissue degeneration or impaired organ function); not necessarily emergency example: excision of cancerous tumor; removal of gallbladder for stones; vascular repair for obstructed artery (e.g. coronary artery bypass)
wet to dry
need to debride
vitamin C and A
needed for wound healing
granulation
new blood vessels or vascular bed and connective tissues in a wound bed
subcutaneous (SC/SQ) medications
no aspiration (pulling back plunger) for insulin, heparin and most SQ meds Generally 25 gauge, 1/2-5/8 needle length (insulin syringe up to 1/2 length and 28-29 gauge); usually 1 mL or less, 0.5 mL for child
heparin
no aspiration; inject slowly, wait 10 seconds after injecting before withdrawing needle; no massage
insulin
no aspiration; wait 10 seconds after injection before withdrawing needle; no massage
What is apnea?
no breathing
What does colonized mean?
no symptoms of illness, but host pathogens that may be transferred to others
What is eupnea?
normal rate and depth
Contraindications for deep palpation
not done for basic head-to-toe over painful areas, pulsating masses
routes: PO, SL, buccal
PO - oral, para os SL - sublingual buccal - cheeck
hypoventilation
not enough air moving in and out of the lungs
Valsalva maneuver is use/not used
not used pushing
regional anesthesia
numbs specific area
What is implementation?
nursing interventions: treatment base upon clinical judgment and knowledge a nurse performs to enhance client outcomes
despair
perceive failure in life fear death as they struggle to find a purpose to their lives
despair
perceive failure in life fear death as they struggle to find a purpose to their lives
elective surgery
performed on basis of patient's choice; is not essential and is not always necessary for health example: bunionectomy, facial plastic surgery, hernia repair, breast reconstruction
cosmetic surgery
performed to improve personal appearance example: blepharoplasty for eyelid deformities; rhinoplasty to reshape nose
blood flow through the lungs occurs via the ________________ and _____________
pulmonary system bronchial system
Inspection (assessment step 1)
purposeful observation
Assess, plan, and evaluate nursing care related to ineffective ventilation.
put on O2; risk for atelectasis; increased WOB = increased metabolism (need to stop this)
Pads of fingertips detect
radial pulse most sensitive part of the hand
What is tachypnea?
rapid breathing (more than 20 or 25 per min)
When taking a pulse what 4 things are you looking for?
rate, rhythm, strength, equality
nursing diagnosis for delirium
Confusion, Acute Risk for Injury, Fall Anxiety Fear
Vaccination
Active, acquired immunity is produced by vaccination; immunity similar to natural infection but without risk of disease
pulmonary function test (PFT)
- different tests used to evaluate lung mechanics, gas exchange, and acid-base distrubance through spirometric measurements, lung volumes, and ABGs - e.g. spirometry and peak flow meters
Obstructive respiratory disorders
- difficulty expelling all the air from lungs - e.g. pneumonia, asthma, emphysema, TB, lung cancer
4 mechanisms in respiratory process
- diffusion - transportation - ventilation - regulatory processes
four mechanisms of respiratory process
- diffusion: gas exchange of O2 and CO2 from an area of high concentration to an area of low concentration - transportation - ventilation: the exchange of air between the lungs and the atmosphere so that oxygen can be exchanged for carbon dioxide in the alveoli - regulation: enough O2 in and CO2 out to meet demands of the body
What are the 4 types of nursing diagnoses?
- actual nursing diagnosis: ineffective thermoregulation r/t infectious process - risk nursing diagnosis: risk for imbalanced fluid volume: risk factor: sepsis - health promotion nursing diagnoses: readiness for enhanced self health management expresses interest in smoking cessation - syndrome nursing diagnoses: post trauma syndrome
What are the acceptable ranges for respirations for the following age groups? - adult: - older adults: - infant: - toddler: - child:
- adult: 12-20 - older adults: 16-26 - infant: 30-50 - toddler: 25-32 - child: 20-30
What blood glucose range is recommended for critically ill clients?
140-180 mg/DL
Recheck blood sugar every _______ per hypoglycemia protocol.
15 min.
What is diffusion? What is perfusion? What is pulse oximeter?
- diffusion: movement of oxygen, carbon dioxide between the alveoli and red blood cells - perfusion: the distribution of red blood cells - pulse oximeter: indirect measurement of oxygen saturation (SpO2)
arterial blood gases (ABGs)
- direct and invasive test - useful to: diagnose acid/base imbalances or problems w/ oxygenation, monitor client's response to treatment
how do you administer ear drops in an adult? A child?
- adult: pull the auricle up and back to straighten external canal to instill ear drops - child: pull the auricle down and back for infants and children younger than 3 years of age * do not drop directly on the tympanic membrane
What do each of the following words mean? - afebrile - febrile - fever - pyrexia
- afebrile: no fever; temperature in normal range - febrile, pyrexia, fever: fever; alternation in the hypothalamic set point
What factors must be considered with a host?
- age - nutritional status - stress: release more cortisone - disease process - medical therapy: corticosteroids and immunosuppresants
What factors affect BP?
- age: >60 - circadian rhythm - gender: risk increases with postmenopausal women - exercise/activity: generally increases systolic - emotions/pain - smoking - diabetes mellitus - family history - caffeine
Define the following terms: - direct contact - indirect contact - droplet - airborne - vehicles - vectors
- direct contact: person to person - indirect contact: contaminated object - droplet: large particles (6 ft) - airborne: breathing air - vehicles: contaminated items - vectors: animals
considerations r/t bronchography
- informed consent - invasive - assess for allergies to dye - encourage coughing and deep - breathing afterwards
bronchoscopy: pre-procedure
- informed consent - invasive procedure - NPO - monitor coagulation studies
What factors affect pulse? Which ones increase pulse? Which ones decreased pulse?
- age: decreases w/ age - exercise: increases - stress/emotions: increase - body temperature - if the temp. increases: pulse increases w/ temp. - blood volume - blood loss occurs: pulse increases with decreasing blood volume - oxygenation - oxygenation decreases: pulse increases
Basic indicators of decreased renal function are
- an elevated creatinine and BUN - decreased glomerular filtration
What is urinary incontinence?
- involuntary loss of urine that is sufficient enough to be a problem (temporary or permanent) (continuous or intermittent)
Describe an antigen vs. an antibody.
- antigen: a live or inactivated substance (protein, polysaccharide) capable of producing an immune response - antibody: protein molecules (immuno-globin) to help eliminate an antigen
What are the steps of the nursing process in order?
- assessment - diagnosis - planning - intervention - evaluation
larynx
- below pharynx and above trachea at root of tongue - called the "voice box" - contains the false and true vocal cords
surfactant
- keeps alveoli inflated - is a phospolipid protein that reduces surface tension in the alveoli
Answer the following questions about acetaminophen or Tylenol. - What is the classification? - What is the action? What does it do? - What happens if overdose?
- Classification: antipyretic, analgesic - Action: relieve fever, pain, and discomfort; NO ANTIINFLAMMATORY ACTION! - Overdose: toxic to liver, hepatotoxicity
advantages, disadvantages, and patient nursing interventions of nasal cannula
(1-6 L/min: 24-44%) Used at flow rates of 0.5 to 6 L/min providing approximate O2 concentrations of 22-24% (at 1 L/min) to 40-44% (at 6 L/min) Exact amount of O2 administered depends on ventilation of client Flow rates higher than 6 L/minute do not significantly increase oxygenation Used for client with chronic airflow limitation (CAL, COPD) and long term O2 use DO NOT set rate higher than 2-3 L/min unless on mechanical ventilation Effective oxygen concentration can be delivered to both nose breathers and mouth breathers (though not quite as well) with use of a nasal cannula IMPLEMENTATION: Assess mucosa, as high flow rates have drying effect and increase mucosal irritation Assess skin integrity as O2 tubing can irritate skin Provide water - soluble jelly to the nares PRN Palace nasal prongs in nostrils with opening facing client - check frequently Add humidification as prescribed when a flow rate higher than 2-4 L/min is prescribed Check water level and change the humidifier as needed Assess client for changes respiratory rate or depth ADVANTAGES: Relatively comfortable for all ages Good for home setting Allows eating, drinking, mouth-breathing Adequate for short/long-term use Cheap DISADVANTAGES: Easily dislodged Requires patent nasal passages Dries mucosa of nares Not good if client is a mouth-breather
Describe the two different kinds of immunity.
- active: Protection produced by the person's own immune system; usually permanent (vaccine) - passive: Protection transferred from another person or animal; temporary protection that wanes with time (infant nursing)
advantages, disadvantages, and patient nursing interventions of non-rebreather mask
(10-15 L/min: 60-90%) Flexible, cone-shaped mask with reservoir bag attached Provides the highest concentration of the low-flow systems and can deliver an FIO2 greater than 90%, depending on patient's ventilatory pattern Most frequently used in the client with severe hypoxia and/or deteriorating respiratory status who might require intubation Has one-way valve between mask and reservoir and two flaps over the exhalation ports Valve allows client to draw his/her entire oxygen from the reservoir bag Flaps prevent room air from entering through the exhalation ports Reservoir bag should collapse only slightly and never totally deflate during inspiration 60-100% FIO2 at a liter flow that maintains the bag 2/3 full IMPLEMENTATION: Remove any mucus or saliva from mask Assess client closely (SpO2 and SaO2) Ensure that the valve and flaps are intact and functional during each breath Valves should open during exhalation and close during inhalation Suffocation can occur if the reservoir bag kinks or if the O2 source disconnects ADVANTAGES: Delivers highest possible O2 concentration without intubation or mechanical ventilation Not as drying to mucosa DISADVANTAGES: Impractical for long-term use Malfunction can build up CO2 and increase risk of suffocation Requires tight seal Eat/drinking uncomfortable/difficult
advantages, disadvantages, and patient nursing interventions of partial rebreather mask
(10-15 L/min: 60-90%) Mask with a reservoir bag (no one-way valve) that provides oxygen at a concentration of 40-90%, with flow rates of 6-15 L/min The client rebreathes one third of the exhaled tidal volume, which is high in oxygen, thus providing a high FIO2 Indicated for clients with severe hypoxia FIO2 delivered via partial rebreather mask Need flow rate high enough to maintain bag 23 full during inspiration 60-90% FIO2 is delivered at 6-10L/min Make sure reservoir does not twist or kink which causes bag to deflate Adjust flow rate to keep bag inflated 2/3 full during inspiration as deflation results in decreased O2 delivered and rebreathing of exhaled air ADVANTAGES: Can inhale room air through openings in mask if O2 is briefly interrupted DISADVANTAGES: Requires tight seal eating/talking uncomfortable Potential for skin breakdown
advantages, disadvantages, and patient nursing interventions of simple face mask
(6-12 L/min: 35-50%) Flexible cone-shaped face mask with metal strip to mold to nose Adjustable head strap, multiple exhalation ports Used to deliver O2 concentrations of 30%-60% (6-8L/min) for short-term or in emergency Minimal flow rate of 5-6L/min is needed to prevent rebreathing of exhaled air FIO2 delivered via simple face mask: FIO2 - fraction of or percentage of inspired oxygen Flow rate must be set to at least 5-6L/min to flush the mask of carbon dioxide 40% at 5L/minute 45-50% at 6L/minute 55-60% at 8 L/minute Good for mouth breathers Implementation Be sure mask fits securely over nose and mouth Poorly fitting mask reduces the FIO2 delivered Assess skin and provide skin care to the area covered by mask Pressure and moisture under the mask may cause skin breakdown Monitor client closely for risk of aspiration as mask limits client's ability to clear the mouth (esp. if vomiting occurs) Provide emotional support to decrease anxiety to client who feels claustrophobic Consult with physician regarding switching to nasal cannula during meals ADVANTAGES Provides high delivery of O2 for short periods of time DISADVANTAGES Difficult to eat/drink/talk Feeling of confinement Question use if danger of airway obstruction and/or aspiration Difficult to get a tight seal and keep in place Potential for skin breakdown Don't use if a CO2 retainer
gastrointestinal system and aging
**decreased acidity alters drug absorption**
Fall risks
**multiple medications** confusion poor balance and/or vision incontinence orthostatic hypotension poor lighting clutter
Edema- measurement
+1= 2mm +2= 4mm +3= 6mm +4= 8mm
nasal cannula
- 0.5-6 L/min - flow rate > 6 L does not increase oxygenation - good for CAL/COPD and long term use - use WATER-soluble jelly on the nares - add humidification when flow rate >2-4 L
CLINICAL QUESTION What route is appropriate for obtaining temperature for these clients? - A 6 year old child with a diagnosis of seizures. - A 70 year old is receiving oxygen by a mask with a diagnosis of pneumonia.
- 6 year old: temporal - 70 year old: agency policy
simple face mask
- 6-8 L/min (30-60%) - short term oxygen therapry or emergencies - min rate of 5-6 L to prevent rebreathing exhaled air and flud mask of CO2 - good for mouth breathers - pressure and moisture may cause maceration
Live attenuated vaccines
- Attenuated (weakened) form of the "wild" virus or bacterium - must replicate to be effective - immune response similar to natural infection - usually produce immunity with fewer doses
What does CBC stand for? What does hemoglobin (Hb) reflect? What is hematocrit (Hct)?
- CBC: complete blood count - hemoglobin (Hb): reflects red blood cells in the blood, needed oxygen transport - hematocrit (Hct): percentage of blood volume made up of RBCs *NOTE: Hb/Hct low = respirations, pulse, bp go up
Answer the following questions about ibuprofen or motrin. - What is the classification? - What is the action? What does it do? - What is a side effect? - It's contraindicated for who? Why?
- Classification: antipyretic; analgesic; anti-inflammatory, Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDS - Action: relive fever, pain, and discomfort - Side Effect: gastric distress (give with food); long term GI bleed risk - Contraindicated for children with flu or viral symptoms because it can cause Reye's syndrome (hepatic failure with inflammation, and severe encephalopathy)
Answer the following questions about aspirin (acetylsalicylic or ASA). - What is the classification? - What is the action? What does it do? - What is a side effect? - It's contraindicated (not to be used) for who? Why?
- Classification: antipyretic; analgesic; anti-inflammatory; antiplatelet - Action: relieve fever, pain, and discomfort - Side Effect: gastric distress (give with food); long term GI bleed risk - Contraindicated for children with flu or viral symptoms because it can cause Reye's syndrome (hepatic failure with inflammation, and severe encephalopathy)
Why would anatomy and physiology matter to respiration?
- Conditions or diseases alter respirations - Respiratory muscles, pleural space, lungs and alveoli must all function - Gases move into and out of the lungs through pressure changes - Diaphragm and intercostal muscles contract to create a negative pleural pressure and increase size of thorax - Diaphragm and contraction of the internal intercostal muscles allow for air to escape from the lung ***If alterations in any of these processes, respiration is affected!***
Where is the reservoir for the following: - E. coli - Staphlyococcus auerus - Staphylococcus epidermidis - Hepatitis A - Hepatitis B - Hepatitis C - HIV
- E. coli: colon - Staphlyococcus auerus: skin/wound - Staphylococcus epidermidis: skin - Hepatitis A: feces - Hepatitis B: blood, bodily fluids, sexual contact - Hepatitis C: blood, bodily fluids, sexual contact - HIV: blood, semen, vaginal secretions via sexual contact
What are the 4 nursing interventions for a fever?
- Fluid replacement (and electrolytes) - Antipyretics generally administered at 102 degrees F - Minimize heat production, limit activity -physical cooling (remove blankets, keep linen clean, and dry; cool cloths to head, neck, and axilla are no longer used for fever due to shivering)
safety factors of supplemental oxygen and how it works
- HOW IT WORKS: Increases concentration of O2 in the alveolar air space which increases the partial pressure of O2 in the alveoli This increases driving pressure for gas diffusion across the alveolar - capillary membrane Assess color and vital signs prior to and during tx with pulse oximetry Is a medication, O2 can be toxic, you need an order to administer - SAFETY: Place a "NO SMOKING, OXYGEN IN USE" sign at client's bedside and room door Avoid fire hazards (static electricity, electrical equipment, matches, cigarettes) Humidify the oxygen if necessary Clean or change the equipment per protocol Know and follow fire procedures
Describe methods and criteria for respiratory assessment.
- HPI (history present illness): Why are they here? - Past med/surg history - Family history: genetic disposal, heart disease - Social/personal history: smoking, work dangerous atomosphere, aspesis - Meds: meds for respiratory disease, meds that make SOB, narcotics suppress respirations - Physical exam: thoracic excursion - Diagnostic studies: ABGs, chest X ray, thoracentesis, bronchcoscopy, bronchography, sputum specimen, pulse oximeter, pulmonary function test, diagnostic skin test, pulmonary angiography
Define the following terms: - Health Care Associated Infections - Iatrogenic - Exogenous - Endogenous
- Health Care Associated Infections: acquired in a health care agency - Iatrogenic: infections from a procedure - Exogenous: do not normally exist, outside of the client - Endogenous: client's own flora becomes altered
Describe the anatomy and physiology of the upper respiratory tract.
- Nose: humidifies, warms, and filters inspiried air (cilia), and better to breath through nose - Sinuses: air filled cavities within hollow bones surrounding nasal passages; provide resonance during speech - Pharynx: located behind oral and nasal cavities; divided into oropharynx, nasopharynx, laryngopharyx; passageway for both respiratory and digestive tracts - Larynx: above trachea, below pharynx at root of tongue; voice box; contains two pairs of vocal cords - Glottis: opening between true vocal cords; plays important role in coughing (most fundamental defense mechanism of lungs); aspiration = glottis not functioning - Epiglottis: leaf-shaped elastic structure attached along one end of larynx; prevents food from entering tracheobronchial tree; closes over glottis during swallowing;
Know how to do palapatory systolic blood pressure.
- Palpate pulse: radial used - inflate cuff until pulse disappears - inflate cuff 30 mmHg higher when pulse disappears and note point when pulse reappears - used to estimate BP - wait 30 seconds - Assess with BP with stethoscope inflating cuff 30 mmHg above palpated systolic pressure
List three important nursing diagnoses related to oxygenation.
- Primary: ineffective breathing pattern, ineffective airway clearance, impaired gas exchange - Secondary: deficient knowledge, activity intolerance, disturbed sleep pattern, nutrition imbalance, anxiety
Explain tier one and tier two.
- Tier one: standard precautions (all patients get this) - Tier two: airborne, droplet, contact
Passive immunity
- Transfer of antibody produced by one human or other animal to another; temporary protection - sources: transplacental in infancy, many blood products, and immunoglobulin
What is urinary retention?
- accumulation of urine in bladder r/t inability to empty bladder (may progress to restless, uncomfortable, diaphoretic)
immunization schedules on test - birth - 2 months - 12 months
- birth: hepatitis B (first dose) - 2 months: hepatitis B (2nd dose), rotavrius (first dose), DTaP (first dose), Hib (first dose), PCV13 (first dose), IPV (first dose) - 12 months: hepatitis B (3rd dose), Hib (3rd or 4th dose), PCV13 (4th dose), IPV (3rd dose), annual influenza vaccination, MMR (first dose), varicella (first dose), hepatitis A (2nd dose series) - 65+: influenza annually, 1 dose Tdap then Td booster every 10 years, 2 doses VAR, 2 doses RZV OR 1 dose ZVL, 1 dose PCV13 AND PCV23, 2 or 3 doses of Hep A, 3 doses of Hep B, 1 or 2 doses MenACWY, 2 or 3 doses MenB, 1 or 3 doses Hib - what can be done at 12 months that can't be done earlier?: influenza, MMR, varicella, hepatits A
What are the requirements for the correct cuff size when measuring BP?
- bladder in cuff width should be 40% of arm circumference - bladder in cuff length should be 80% of arm for adult; 80-100% for child - cuff width should cover 2/3 of the upper arm
What is blood pressure? What is systolic BP? What is diastolic BP?
- blood pressure: force exerted by blood in arteries - arterial pressure - systolic BP: pressure during heart contraction - diastolic BP: pressure between heart contraction
distribution
- body tissues, protein sites; receptor sites - medications bound to protein (albumin) do not exert an effect - potential problem: low serum albumin is related to increased medication action
What is the most common site for BP assessment? How much higher is the systolic and the diastolic when using the thigh for BP?
- brachial: most common site (contraindicated with radial mastectomy and vascular access devices) - Thigh: systolic is 10-40 mmHg higher, diastolic similar to arm reading *NOTE: lower leg readings are not equal to upper arm; lower leg often used for infants and toddlers.
Explain how micturation occurs.
- brain suppresses bladder's detrusor muscle until person wishes to void - then bladder contracts and pelvic muscles relax
Inactivated vaccines
- can not replicate - generally require 3-5 doses - antibody titer May diminish with time - examples: hepatitis B, influenza, pertussis, diphtheria, tetanus - response mostly humoral
What are some things you should include in your assessment of urinary elimination?
- characteristics of urine - volume - time of day - pain - frequency - incontinence - lose urine when cough, sneeze, or after vaginal birth
What do each fire extinguishers used for? - class A fire - class B fire - class C fire - class D fire - class K fire
- class A fire: combustile material (wood, paper, cloth) - class B fire: flammable liquids and gases (gasoline, propane, and solvents) - class C fire: energized electrical equipment (computers, fax machine) - class D fire: certain metal (magnesium, lithium, titanium) - class K fire: cooking media (cooking oils and fats)
What should you look for when looking at a BM?
- color - consistency - shape - amount - odor - constituents (other things seen in it)
What characteristics of urine should you look for?
- color (pale yellow) - clarity (clear) - odor (should have no odor) - acid-base balance (4.6-8.0 pH) (most at 6.5) - specific gravity (weight of urine compared to distilled water - 1.003-1.035) - proteins - glucose (normal: 80-120) - bilirubin and urobilinogen (breakdown of hemoglobin and breakdown of bilirubin) - leukocyte esternase - blood (occult and RBCs) - ketone bodies (acetone) - WBC's - bacteria - casts - crystals
Why would anantomy and physiology matter to respiration?
- conditions or disease alter respirations - respiratory muscles, pleural space, lungs and alveoli must all function - gases move into and out of lungs through pressure changes - diaphragm and intercostal muscles contract to create a negative pleural pressure and increase size of thorax - diaphragm and contraction of the intercostal muscles allow for air to escape from the lung - if alterations in any of these processes, respiration is affected!
What are the modes of transmission?
- contact - air - vehicles - vectors
Name the advantages/disadvantages of an oral thermometer temperature site.
- contraindicated - unconscious, confused, seizures, infant-young child, oxygen by mask - need to wait 30 minutes after eating, drinking, smoking, gum... - reflects rapid change
Name the advantages/disadvantages of a tympanic thermometer temperature site.
- contraindicated with cerumen impaction, trauma to head, tympanoplasty - hearing aids must be removed
neural respiratory regulation
- controls respiratory rate, depth, and rhythm - cerebral cortex = voluntary control - medulla oblongata = automatic control
Explain when to count pulse and how long to count it.
- count immediately after pulse - count for 30 seconds if regular and a normal rate - count for full minute if irregular, less than 12 respiration/min or greater than 20.
Why do we assess the client's health status? (3 reasons)
- database for the nursing plan of care - determine patient's normal ranges and detect changes in condition - detect early signs of illness and complications
drug excretion ________________ if renal function is impaired. Renal impariment is likely if?
- decreases - glomerular filtration decreases, serum BUN elevates, serum Cr elevates
What is pulse pressure? What is the pulse pressure for a blood pressure reading 120/70?
- difference between systolic and diastolic; normal 30-50 - 120-70=50
Metabolism ____________ temperature. Muscular activity ______________ heat production. Shivering ___________ heat production. Vasocontriction of blood vessels _______________ body heat. Vasodialation of blood vessels ________________ body. Diaphoresis/perspiration __________ body.
- elevates - increases - increases - conserves - cools - cools
What factors affect respirations? Which increase? Which decrease?
- exercise: increase - acute pain: increase - anxiety: increase - smoking: increase - body position: varies - medications: opiates - neurological injury: varies - decreased hemoglobin: increased - pneumonia: increased - surgery: varies
Describe the anatomy and physiology of the lungs.
- extend from clavicles to the diaphragm - right is slightly larger than left (heart) - left lung more narrow (heart) - 2 lobes - divided into 3 lobes (upper, middle, lower) - right - parietal pleura lines inside of thoracic cavity (cells lining pleural produce thin fluid layer to lubricate visceral and parietal pleura - visceral pleura covers pulmonary surfaces - innervation of respiratory structures accomplished by phrenic, vagus, and thoracic nerves - blood flow through respiratory system occurs via pulmonary and bronchial system
non-rebreather mask
- flexible cone-shaped w/ reservoir bag & one way valve provides highest concentration of the low flow devices - can deliver FIO2 >90% used for sever hypoxia &/or deteriorating respiratory status that might require intubation
high flow devices
- flow of gas exceed volume of air - required for minute ventilation - meets total inspiratory air needs in precise amounts REGARDLESS OF RESPIRATORY STATUS - 24-100% at 8-15 L/min
What are the variables a pathogen needs to survive in a reservoir?
- food - oxygen (aerobic vs. anaerobic) - water (wet vs. dry) - temperature (warmth) - pH (acid changes in the GI and GU track inhibit growth) - light (ultraviolet light may eliminate pathogens)
Epiglottis prevents ______________
- food from entering tracheobronchial tree by covering the glottis - closes over glottis during swallowing
CLINICAL QUESTION A parent describes their 3 year old child's intake as mostly peanut butter sandwiches on white bread, juice boxes, fruit snacks, lunch meats, and chips. What nutrients are low? Does this child need a low fat diet?
- fruits, veggies, dairy low - no: too restricted
What do each of the following types of incontinence mean? - functional urinary incontinence - overflow urinary incontinence - stress urinary incontinence - reflex urinary incontinence - urge urinary incontinence
- functional urinary incontinence: can't get there quick enough - overflow urinary incontinence: involuntary release of urine from an overfull bladder - stress urinary incontinence: coughing, sneezing, running, heavy lifting puts pressure (stress) on bladder - reflex urinary incontinence: when bladder muscle contracts and urine leaks - urge urinary incontinence: loss of urine that occurs when person has strong, sudden need to void
List the signs and symptoms of hypothermia and what it is.
- generally less than 34 C or 93.2 F - pale, cool skin - listless - shivering until temp. extremely low - puffiness of skin - impaired coordination - slow pulse, slow respiratory rate, irregular heart rhythm - decreased cognitive function and sensation
Define the following terms: - hand hygiene - hand washing - antiseptic handwash - alcohol-based handrub
- hand hygiene: performing handwashing, antiseptic handwash, alcohol-based handrub, surgical hand hygiene/antisepsis - hand washing: washing hands with plain soap and water - antiseptic handwash: washing hands with water and soap or other detergents containing an antiseptic agent - alcohol-based handrub: rubbing hands with an alcohol-containing preparation
What is the mode of transmission for the following: - hepatitis A - hepatitis C - TB, varicella, measels - salmonella food poisoning - west nile virus
- hepatitis A: contact, unwashed hands - hepatitis: contact, indirect (needle), vehicle - TB, varicella, measels: airborne - salmonella food poisoning: contact, w/ vehicle (improperly handled food) - west nile virus: contaact, indirect, w/ vector
considerations r/t PFT
- hold bronchodilators before testing analegsics that suppress respiratory function - normal values of similar gender/age/race/height
Define the following types of enemas. - hypotonic - isotonic - hypertonic - soap
- hypotonic: fluid shift into cell; swells (tap water) - isotonic: best; no shift in fluid (saline) - hypertonic: fluid shift out cell; shrinks (feets) - soap: irritates lining of colon; makes defecate
Terminology
- hypoxia: inadequate tissue oxygenation at the cellular tissue level - hypoxemia: lowered concentration of O2 in the blood - hyperventilation: lungs remove CO2 faster than produced - hypoventilation: alveolar ventilation inadequate to meet body's O2 needs (or elimination CO2) - apnea: absence of respirations longer than 15 seconds - hyperpnea: increased respiration (hyperventilation) - hypopnea (decreased respiration (hypoventilation) - NORMAL: 12-20
Incontinence can be associated to what?
- immobility - weak pelvic muscles - can't get to bathroom quickly - ambulation - buttons (fine motor skills) - no grab bars - too tired
Varicella vaccine recipients should attempt to avoid who?
- immunocompromised individuals - pregnant women without documented history of chickenpox or laboratory evidence of prior infection - newborn infants of mothers without documented history of chickenpox or laboratory evidence of prior infection
What factors increase a susceptible host?
- impaired skin - impaired immunity
What are other causes of BP errors other than cuff size?
- impaired vision: eye level off - deflating cuff too quickly - deflating too slowly: high - uneven release - bias of reader - not waiting 2 min to repeat - not a resting BP: allow client to rest 5-10 min before procedure - crossed legs, tight clothes
hypoxia
- inadequate tissue oxygenation at the cellular level - S&S can't be measured directly; inferred from lab data and clincial observation
collaborative interventions
- incentive spirometer - chest physiotherapy - postural drainage - intermittent positive pressure - breathing - chest tube - supplemental oxygen - pharmacological agents
Voluntary movements ________________ temperature. Involuntary movements ______________ temperature (shivering). ________________ of blood alters temperature with vasodialation or vasoconstriction.
- increase temp. - increase temp. - circulation
What are the adverse effects of fever?
- increased oxygen consumption (higher metabolism - 10% for every degree C) - fluid loss - dehydration (fluid loss is approximately 600 mL/day, but up to 4000 mL or more possible with elevated temperature) - febrile seizure (risk with dehydration)
Define the following terms: - incubation period - prodromal stage - illness stage - convalescene
- incubation period: time between entrance and first symptoms - prodromal stage: nonspecific to specific symptoms, infectious - illness stage: symptoms specific to illness, generally infective - convalescene: interval when acute symptoms disappear, infection ability will vary with illness
Describe the following for influenza. - incubation - prodromal - illness
- incubation: 1-4 days - prodromal: one day prior to illness onset - illness: 50% of infected persons develop classic symptoms
Describe the following for measles. - incubation - prodromal - illness
- incubation: 10-12 days - prodromal: 3-5 day before the appearance of a rash; airborne precautions are indicated - illness: remain infected 4 days after the rash develops in health children
Plan nursing interventions to promote adequate ventilation (independent and dependent/collaborative).
- independent: maintain patent airway (ESSENTIAL), position client correctly, breathing/coughing exercises, hydration/humidification (best thing to help breath better), ambulation - dependent/collaborative: maintain/promote lung expansion, incentive spirometer, chest physiotherapy, postural drainage - collaborative: intermittent positive pressure breathing, chest tube, maintain/promote oxygenation
Describe the indications, side effects, and teaching for urinary antiseptics/antiinfectives (nitrofurantoin - furalan, macrodantin)
- indications: UTI - side effects: diarrhea, fever, chills, body aches - teaching: take w/ food but not anacids
Describe the indications, side, effects, and teaching for urinary antiseptics/antiinfectives trimethoprim (proloprim, trimprex) and tremethoprimsulfamethoxazole (Bactrim, spetraP
- indications: UTI - side effects: rash, itching, hypersensitivity - teaching: avoid sunlight
Describe the indications, side, effects, and teaching for urinary antispasmodics oxybutynin (Ditropan)
- indications: bladder instability - side effects: stomach pain, dry mouth, nausea, upset stomach - teaching: avoid dehydration and overheating, blurred vision
Describe the indications, side effects, and teaching for urinary antiseptics/antiinfectives methenamine (hiprex, mandelamine)
- indications: chronic UTI - side effects: crystal growth, blood in urine, painful urination - teaching: lots of fluids
Describe the indications, side, effects, and teaching for urinary antiseptics/antiinfectives fluroquinolones (quinolones) (Cipro and floxan)
- indications: cystitis - side effects: diarrhea, dizziness, abdominal pain, nausea - teaching: take w/ food, brown urine, no anacids, no under 18
Describe the indications, side, effects, and teaching for urinary analgesic (phenazopyridine hydrocholdride - pyridium)
- indications: irritation of urinary bladder - side effects: upset stomach, headache, dizziness - teaching: bright red/orange colored urine or BM?
Describe the indications, side, effects, and teaching for urinary anticholinergics (propantheline bromide - pro-bathine)
- indications: peptic ulcers - side effects: dry mouth, decreased sweating, dizziness, constipation - teaching: increase fluids
Describe the indications, side, effects, and teaching for urinary cholinergics (stimulents) bethanechol (urecholine)
- indications: urinary retention - side effects: diarrhea, vomiting, abdominal cramps/pain - teaching: no low BP, epilepsy, asthma
When assessing blood pressure what is an indirect method and what is a direct method?
- indirect method: auscultation manually or electronically - direct method: invasive, arterial line, critical care settings
What conditions impair muscle tone?
- indwelling catheter - immobility - child birth - surgeries/inflammation
What are the pediatric ranges for the following: - infant: - toddler: - preschooler: - school age: - adolescent:
- infant: 120-160 - toddler: 90-140 - preschooler: 80-110 - school age: 75-100 - adolescent: 60-90 *NOTE: infants under 100 caution!
What are the steps of the chain of infection?
- infectious agent - reservoir - portal of exit - mode of transmission - portal of entry - susceptible host
Define the following terms: - infectious agents - pathogen - communicable (contagious)
- infectious agents: microorganisms, bacteria, viruses, fungi, protozoa - pathogen: disease producing - communicable (contagious): transfer from one person to another
pulmonary angiography: pre and post procedure
- informed consent - alleriges to iodine, seafood, radiopaque dyes - have emergency resuscitation equipment available
primary functions of respiratory system
- provides oxygen for metabolism in tissues - removes carbon dioxide (waste product of metabolism) from tissues
What do each of the following words mean? - radiation - conduction - convection - evaporation
- radiation: heat loos without contact - conduction: heat loos by contact (ice bag) - convection: air movement (fan) - evaporation: diaphoresis (perspiration)
How do you modify the environment or behavior to alter body temperature of: - radiation - conduction -convection - evaporation
- radiation: remove/add blankets - conduction: ice bag; cool pack or warm pack - convection: fan - evaporation: diaphoresis, sponge bath
pulmonary angiography
- real time images w/ dye contrast - looking for PE or clot - inserted in the anticubital or femoral vein
How do you document vital signs?
- record on computer, graphic form or narrative per policy - follow up on any abnormal vital signs - document interventions and response
Restrictive Respiratory disorders
- redcued total lung capacity (TLC) - amount of air after deepest breath possible
What is respiration? External respiration? Internal respiration?
- respiration: exchange of oxygen and carbon dioxide - external: between alveolar and capillary membranes - internal: between blood and body cells
how do you administer drugs
- review the order carefully - read the med label three times - check the name band of the client - ask name (must verify two points - name and birth date) - give information - answer questions - administer med - observe the client take the med - document promptly and document response - monitor patient's response to a first dose of med (and further doses)
Describe the accessory muscles of respiration.
- scalene: elevate first 2 ribs - sternocleidomastoid: raise the sternum - trapezius and pectoralis muscles fix the shoulders
secondary functions of respiratory system
- sense of smell - produces speech - maintains acid-base balance - maintains body water levels - maintains heat balance
The nursing student is evaluating the response to medications. What lab values will be monitored? - simvastatin (Zocor) - furosemide (Lasix) - insulin glargine (Lantus)
- simvastatin (Zocor): cholesterol levels - furosemide (Lasix): sodium, potassiu, magnesium - insulin glargine (Lantus): blood glucose; A1C
What are outcomes?
- specific and measurable behavior or perception - response to a nursing intervention - an objective criterion for measuring goal achievement
What is the difference between subjective data and objective data?
- subjective data: information the client reports; symptoms - objective data: observable signs; not a judgment or opinion *HINT: subjective data is what the subject or the client tells you while objective data is observable or what you measure
Describe surfactant. What would happen if the surfactant collapsed?
- surfactant: chemical produced in the lungs to maintain surface tension of the alveoli - alveoli would collapse (atelectasis)
Why do you do an enema? What is a high enema? What is a low enema?
- surgical procedures - high enema: 18 in - low enema: 4 to 5 in
What is the normal temperature range in degrees F and degrees C? What is the average temperature for oral, tympanic, rectal, and axillary? What is the normal pulse rate? What is the normal respirations? What is the normal blood pressure?
- temperature range: 36 to 38 degrees C or 96.8 to 100.4 degrees F - Average oral/tympanic: 37 degrees C or 98.6 degrees F - Average rectal: 37.5 degrees C or 99.5 degrees F - Average axillary: 36.5 degrees C or 97.7 degrees F - pulse: 60 to 100 beats/min - respirations: 12 to 20 breaths/min - BP: less than 120/ less than 80
What is blood pressure influenced by? (4 things)
- the amount of resistance the heart has to overcome - peripheral vascular resistance - ability of arteries to stretch (elasticity) - decreased elasticity increases BP - cardiac output = stroke volume x beats/min - volume of circulating blood and viscosity of blood (increased volume and viscosity increases BP)
What happens if the cuff is.... - too large - too small - loose cuff
- too large: too low - too small: too high - too loose: falsely high *NOTE: there's also tube leaks, noise interference, clothing, hearing, failure to detect auscultatory gap
intramuscular injections (IM)
90 degree angle, Z tract method; dosage limit for deltoid: 0.5 mL for children and 1 mL for adults; dosage limits for lower sites: 1 mL for infant, 1-2 mL for small adults and 1-5 mL for adult with well developed muscle, 1 1/2 inch needle
2 inch pinch
90 degrees
Describe the anatomy and physiology of the lower respiratory tract.
- trachea: in front of esophagus; branches into right and left main stem bronchi (at carina) - carina: place where trachea divides - main stem bronchi: begins at carina; right bronchus slightly wider, shorter, and more vertical than left bronchus; pneumonia or fluid build up greater on right side; risk of aspiration greater on right side due to its shorter, wider status; divide into five secondary or lobar bronchi that enter each of the five lung lobes; lined with cilia (propel mucus up and away from lower airway to trachea where it can be expectorated or swallowed) - bronchioles: branch from secondary bronchi and divide; contain no cartilage and depend on elastic recoil of lung for patency; contain no cilia and not participate in gas exchange - alveolar ducts/alveoli: acinus indicates all strucutres distal to terminal bronchiole; alveolar ducts branch from respiratory bronchioles; alveolar sacs contain clusters of alveoli (basic unit of gas exchange); cells in alveoli secrete surfactant
absorption
- transfer of medication form site of administration into the blood - GI absorption - generally absorption is more rapid per Gi route when stomach and intestines are empty - acidity influences drug absorption - grapefruit juice increases levels of some medications - orange and apple juices lower effectiveness of beta blockers and antibiotics (Levofloxacin, Levaquin)
What is an upper UTI? What is a lower UTI?
- upper UTI: pyelonephritis - center of kidney (renal pelvis) (men) - S/S: flank pain, fever, chills, nausea, vomiting - lower UTI: cystitis - inflammation of bladder (women) - S/S: cloudy, dark yellow urine, slight tint red, proteins, foul odor
Name four places where you can find normal flora in the human body.
- urinary tract: normally sterile, high risk for helath care associated infection - gastrointestinal tract: normal flora may infect other sites, antibitotics many kill normal flora resulting in infections - blood: normally sterile, risk for sepsis if infections spread to blood - respiratory tract: risk for airborne and droplet transmission when infected
postural drainage
- use of gravity to drain secretions from segments of the lungs - indicated for COPD and CF
ABG pre procedure
- use radial, femoral, brachial artery - let client rest for 30 minutes - avoid suctioning prior - do not turn off oxygen unless need ABGs at room temp
low flow devices
- variable liter flow - supplements inspired room air - not as consistent % as high flow device - depends on client's respiratory rate, pattern, and ventilation
What are korotkoff sounds? What are the 5 phases?
- vibrations in arterial wall/changes in blood flow - five phases - systolic is the start of phase 1 - diastolic is phase 5 for adults and children when possible - diastolic phase 4 for children when indicated - Phase 1: a sharp thump - Phase 2: a whooshing sound - Phase 3: a softer thump than phase 1 - Phase 4: a softer blowing sound that dies - Phase 5: silence
What is pulse?
- wavelike sensation produced by movement of blood from heart condition; indirect measure of cardiac output
What is fluid balance?
- when fluids and electrolytes are in balance - an increase in fluid intake results in an increase in urine output
INR
0.76-1.27
speed of injection
1 mL per 10 seconds
Four mechanisms of respiratory process
1. Diffusion - gas exchange of O2 and CO2 from an area of high concentration to an area of low concentration 2. Transportation 3. Ventilation - breathing consists of inspiration (active) and expiration (passive) 4. regulatory processes of respiratory - neural (CNS controls respiratory rate, depth, and rhythm) and cerebral cortex (voluntary control of respirs from impulses to spinal cord)
CLINCIAL QUESTION A nurse is reviewing the admission data for clients presenting at an urgent care clinic at the time of 2100. What critical thinking process is needed in each situation? 1. A 2 year old child had temperature at 1800 of 100.2 tympanic. 2. An 84 year old client has a temperature of 99.8 oral and recent confusion. 3. A 20 year old client has a temperature of 100.6. The client has leukemia and just had chemotherapy. 4. A client had surgery two days ago and reports feeling "chilled" in the last hour and has a temperature of 99.2 oral.
1. Symptoms? no fever 2. No fever, but confusion 3. Should be worried 4. Should be worried
Match heat cramps, heat exhaustion, and heat stroke to the following definitions below: 1. Fatigue, may perspire, orthostatic changes possible; related to fluid and electrolyte loss 2. Slow painful muscle contractions related to fluid and electrolyte loss 3. Temp = > 104 degrees F, increased heart rate, inability to perspire, hot dry skin; loss of set point and ability to perspire
1. heat exhaustion 2. heat cramps 3. heat stroke
Match heat cramps, heat exhaustion, and heat stroke to what you need to do to reverse each. 1. Maintain ABCs, cooler environment, IV fluids, and hypothermia blankets (blankets that cool) 2. Cool down; soft drinks 3. Rest in cool place, correct fluid loss slowly
1. heat stroke 2. heat cramps 3. heat exhaustion
6 rights of medication administration
1. right drug 2. right dose 3. right client 4. right time 5. right route 6. right documentation
single oral administration peaks
1.6 hours
how long do you aspirate for?
10 secs
how long do you keep the needle in after injecting meds before removing needle?
10 secs
PT
11-12.5 sec; 85-100%
hemoglobin
12-18 g/100 mL (male 14-18) (female 12-16)
sodium
136-145 mEq/L
Platelet count
150,000 - 400,000/ul
platelet count
150,000-400,000/mm3
INR range
2-3
CLINICAL QUESTION A nurse just started the shift with clients. What client will need vital signs first? 1. A client just admitted to the unit for preoperative preparations for surgery. 2. The nursing assistant reports the client is two days postoperative is feeling "weak and sick". 3. The client will need a transfusion of packed red blood cells started in the next 30 minutes. 4. The client treated for diabetic control is being discharge is asking to leave now.
2. The nursing assistant reports the client is two days postoperative is feeling "weak and sick".
1 kg equals ? lb.
2.2 lb.
note loss/gain of ______ in a period of _________.
2.2 lb; 24 hours
1 in equals ?cm
2.5 cm
needle size for child
22-30 G for children
carbon dioxide
23-30 mEq/L
small dosages are measured in a ______ mL syringe or 1 mL tuberculin syringe
3 mL
when administering two more eye medications wait at least ___________ between medications
3 minutes
potassium
3.5-5.0 mEq/L
do not resume suction for _______ after med administration
30 min to 1 hour
Wait ___ btwn doses of same med. & ___ btwn doses of different meds. for meter doses inhalers
30 sec. 2-5 min. *rinse mouth & mouth piece w/ steroid use
activated PTT
30-40 sec
hematocrit
37-52% (male 42-52%) (female 37-47%)
What is the Simchart strength (volume) scale?
4+ bounding 3+ full, increased 2+ expected 1+ thread/weak/barely palpable 0 not palpable
aPTT
40-60 secs
1 inch pinch
45 degrees
there are _______ lobes of the lung
5 right - 3 left - 2
volumes less than ______ mL are measured using a syringe or a calibrated dropper
5 mL
WBC
5-10,000/mm3 (book says 5000-10,000/mm3)
Gastrointestinal Auscultation Active bowel sounds
5-35 per min. normal
pre-diabetes A1C
5.7% - 6.4%
diabetes A1C
6.5% or higher
PTT
60-70 sec
How much urine can the bladder hold?
600 mL or more
glucose
70-110 mg/dL fasting
The normally acceptable range for temperature in an adult is what?
96.8 to 100.4 degrees F
chloride
98-106 mEq/L
underweight BMI
< 18.5
normal BMI is?
< 25
normal A1C
< 5.7%
low blood sugar
< 70 mg/DL
Gastrointestinal Auscultation Hypoactive bowel sounds
<5 a minute
increased WOB =
= increased metabolism = need for more oxygen and this becomes a vicious cycle
overweight BMI
> 25 - 30
obese BMI
> 30
Gastrointestinal Auscultation Hyperactive bowel sounds
>35 occurs w/ diarrhea, laxatives
Describe the indications, side, effects, and teaching for antidiarrheals (slow things down)
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Describe the indications, side, effects, and teaching for laxatives (stimulents (contact))
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Describe the indications, side, effects, and teaching for laxatives (evacuant)
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Describe the indications, side, effects, and teaching for laxatives (osmotic - saline)
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Describe the indications, side, effects, and teaching for laxatives (stool softeners)
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Describe the indications, side, effects, and teaching for laxatives (bulk-forming)
?????????????? safest
fire mnemonic ABCD
A - all papers B - bottled gases and liquids C - computers and electric D - different metals
ABCDE rule for usual signs of skin cancer
A - asymmetry B - corder C - color D - diameter E - elevated *a sore that doesn't heal and a new growth
Adverse reaction
A health problem that is reported after someone gets a vaccine or medicine. May or may not have been caused by the vaccine or medicine.
VAERS
A national safety surveillance program co sponsored by the CDC and prevention and the FDA collecting information about adverse events that occur after the administration of vaccines licensed for use in the US
CLINCAL QUESTION Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1 degrees c (97 degrees F). the client's remaining vital signs are in the normally acceptable ranges. What should the nurse do next? A. Check the client's temperature history. B. Document the results; temperature is normal. C. Recheck the temperature every 15 minutes until it is normal. D. Get another thermometer; the temperature is obviously and error.
A. Check the client's temperature history (then document).
CLINICAL QUESTION The nurse recognizes clients with symptoms of mild hypothermia include: A. temperature of 94 F, pale skin, and slow response to questions. B. pulse of 55, respirations 10, temp. of 88, slurred speech, lethargic. C. decreased level of consciousness and temp of 39 C, skin cold and moist, BP 100/60 D. temp of 30 C, blood pressure 90/40, respirations 6, and unresponsive
A. temperature of 94 F, pale skin, and slow response to questions.
AD AS AU
AD: right ear AS: left ear AU: both ears
ventilation is dependent on
AIRWAY RESISTANCE patent airways intact neuromuscular and skeletal components
obese considerations
Airway issues, poor wound healing, increased blood pressure and respiratory problems, tend to have diabetes or CHF, poor mobility, high risk for embolus, atelectasis and have more instances of pneumonia
CLINICAL QUESTION What assessment finding does the nurse consider abnormal? A. a 4 month old has a pulse of 120 awake. B. a 70 year old client's pulse rate drops from 70 to 52 after ambulating. C. an 8 year old has a pulse of 100 with activity. D. a 20 year of has a pulse of 60 with exercise.
B. a 70 year old client's pulse rate drops from 70 to 52 after ambulating.
CLINICAL QUESTION A 40 year old client presents with a BP of 136/88 at a clinic for a routine physical and is overweight. The client does not have any complications or illness. what does the nurse anticipate including in plan of care? A. medications for hypertension B. life style modifications C. a return check up in a year D. encourage drinking fluids
B. life style modifications
advantages, disadvantages, and patient nursing interventions of portable O2
BEFORE TRANSFER Check that cylinder contains O2 Check that additional O2 source is available where client is transferred Check amount of O2 in cylinder (use cylinder key or wrench on valve stem and turn fully counterclockwise until needle on gauge indicates amount of available O2, turn back a half turn) Use only if gauge is greater than 500 psi Connect tubing or humidifier bottle with tubing to the flowmeter adapter and attach other end to client's oxygen cannula Adjust flow-control dial as per order Ensure cylinder is secured in holder before transfer (never between client's legs or next to client) Coil extra tubing under pillow or attach to linen or client's gown AFTER TRANSFER Attach client's tubing to wall oxygen Turn off O2 flow from the cylinder by turning the cylinder key clockwise until it is tight Remove any excess O2 in the pressure gauge by bleeding it. Turn the flow control dial back on until hissing sound stops and needle gauge has fallen to zero Turn flow-control dial off
Endoscopy
Bronchoscopy (trachea & bronchi)- NPO before, check return of gag reflex before fluids & food
water soluble vitamins
C and B complex; not stored in body
CLINICAL QUESTION When a client has heat stroke, what is the first action? A. offer fluids B. remove clothing C. assess respirations and pulse D. check BP
C. assess reparations and pulse
CLINICAL QUESTION The nurse reviews the prescribed order: Aspirin 650 mg by mouth four times a day. This medication is prescribed for an 8 year old. What assessment finding indicates this medication is contraindicated? A. muscle pain B. temp 102.0 F C. flu symptoms D. headache
C. flu symptoms
Convert 99.6 F to C.
C= (F-32) x 5/9 C= (99.6-32) x 5/9 C=37.5 C
Describe resources for the latest recommended immunization schedules across the life span.
CDC guidelines for immunization (pink book)
What pulse sites are peripheral?
Carotid, brachial, radial, femoral, popliteal, and posterior tibialis anterior.
How to administer oxygen
Choice of O2 delivery system device and liters of flow depends on client condition GOAL - to provide the lowest % of O2 that will maintain O2 saturation within normal range Assess for presence of chronic lung problems Never administer greater than 2-3 L/min per NC or 24-28% per mask if present Central chemoreceptors desensitized by high CO2 levels over long period of time and respirs are dependent on hypoxic stimulation of baroreceptors If O2 administered, O2 concentration increased rapidly and respirations decrease
mucokinetics
Class of drugs which aid in clearance of mucus from bronchial passages Includes mucolytic agents, expectorants, and surfactants Mucolytics thin secretions by dissolving chemical bonds within secretions and making them easier to pass (e.g. Mucomyst) Break down mucus Expectorants signal release of hydrating secretions to thin mucus (e.g. Guaifenesin, Robitussin) Hydration is the best expectant! Mucokinetics act as a detergent to liquefy and loosen secretions Mucomyst is an antidote for acetaminophen overdose HYDRATION IS THE BEST EXPECTORANT Mucolytics liquefy secretions but CAN'T BE MIXED WITH OTHER MEDICATIONS Expectorants loosen secretions and can be mixed with other medications
CLINICAL QUESTION The nurse is reviewing blood pressure readings for the clients at a screening clinic. What reading is normal? A. 70 year old client has BP of 134/70. B. 40 year old client has BP of 200/110. C. 60 year old client has BP of 86/54 after a few days of medication for hypertension. D. 56 year old client has BP of 140/74 taken on upper leg.
D. 56 year old client has BP of 140/74 taken on upper leg.
CLINICAL QUESTION Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 35 degrees C. the client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A. Report the value to the team leader. B. Document the results; temperature is normal. C. Recheck the temperature every 15 minutes until it's normal. D. Check the temperature again.
D. Check the temperature again.
CLINICAL QUESTION The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? A. Count respirations during the time the client is not talking to the visitor. B. Wait at the client's bedside until the visit is over and then count respirations. C. Tell the client it is very important to end the conversation so the nurse can count respirations. D. Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.
D. Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.
CLINICAL QUESTION The nurse is assessing a client with pneumonia receiving oxygen per mask. The nurse would accurately monitor the temperature by: A. removing the oxygen for a few minutes to obtain an oral temp. B. turning the client and obtaining a rectal temp. C. Taking an oral temperature with the oxygen in position. D. Resetting the electronic thermometer and using the axillary route.
D. Resetting the electronic thermometer and using the axillary route.
CLINICAL QUESTION One of the most common side effects of antihypertensive medication for the older adult is: A. congestive heart failure B. atrial fibrillation C. depression D. orthostatic hypotension
D. orthostatic hypotension
fat soluble vitamins
DEKA
Describe safe administration techniques when administering vaccinations.
DO NOT ASPIRATE!
intramuscular sites
DO NOT USE DORSOGLUTEAL SITE Ventrogluteal, vastus lateralis (thigh), deltoid
Preoperative assessment
DOCUMENT (nursing history, physical exam and focused exam on day of surgery- physical and emotional), Medical history, allergies and sensitivities, social and cultural considerations, spiritual considerations, psychosocial status
advantages, disadvantages, and patient nursing interventions of low flow devices
Deliver O2 at a variable liter flow designed to supplement inspired room air Provides airflow equal to the minute ventilation Not as consistent % of flow as a high flow device because it mixes with room air Amount of O2 delivered depends on a client's respiratory rate, pattern and ventilation
advantages, disadvantages, and patient nursing interventions of venturi mask
Delivers most accurate and precise oxygen concentration Based on a mechanism that pulls in a specific proportional amount of room air for each liter flow of oxygen An adapter is located between the bottom of the mask and the oxygen source; contains holes of different sizes that allow only specific amounts of air to mix with the oxygen Allows selection of the amount of oxygen desired FIO2 Delivered is 24-55% FIO2 with flow rates of 4-10L/min IMPLEMENTATION: Monitor closely to ensure accurate flow rate for specific FIO2 Keep the orifice for the Venturi adapter open and uncovered to ensure adequate oxygen delivery Ensure that mask fits snugly and tubing is free of kinks as FIO2 is altered if kinking occurs or if mask fits poorly Assess client for dry mucous membranes since humidity or aerosol can be added ADVANTAGES: Delivers most precise O2 concentration despite client respiratory pattern Doesn't dry mucous membranes DISADVANTAGES: $$$$$$$ Risk for skin irritation Requires tight seal Eating/drinking/talking difficult
schedule II drugs
Demerol, morphine, codeine
intradermal injections (ID)
Dermal layer of skin (just below epidermis), hairless site, upper chest, scapular area of back and inner forearm; generally up to 0.1 mL to produce wheal; 25-27 gauge, 1/4- 1/2 in. length @ 5-15 degrees
prevention of the hazards of immobility
Elimination: 2000-3000 mL/day & fiber Respiratory: incentive spirometer Metabolic: adequate nutrition Cardiovascular: reducing cardiac workload; preventing thrombus formations: medications Musculoskeletal: ROM Integumentary: turn every 1-2 hrs. Psychosocial Developmental
Neurological Hand Grips
Equal? Strength?
antihistamines
Exhibit anticholinergic effect An antihistamine effect occurs on the H1 (histamine) receptors This causes blocking of histamine release in the small blood vessels, capillaries, and nerves during allergic reactions For URI, relieve manifestations by suppressing mucous secretion (anticholinergic effect) Used for symptomatic relief of seasonal allergies Reduce symptoms of common cold 1st Generation H1 Antagonists Diphenhydramine (Benadryl) Promethazine (Phenergan) Dimenhydrinate (Dramamine) Side Effects Sedating Dry mouth Constipation GI discomfort 2nd Generation H1 Antagonists Loratadine (Claritin) Cetirizine (Zyrtec) Fexofenadine (Allegra) Desloratadine (Clarinex) NON SEDATING
advantages, disadvantages, and patient nursing interventions of high flow devices
Flow of gas exceeds volume of air required for a client's minute ventilation Meets total inspiratory air needs in precise amounts regardless of respiratory status Hi-flow systems include the venturi mask High flow system provide O2 concentrations of 24%-100% at 8-15L/minute When properly fitted, these devices deliver consistent and accurate O2 concentration that meets client's inspiratory effort
advantages, disadvantages, and patient nursing interventions of O2 tent
Explain procedure to child in an age-appropriate manner (along with parents) Set up tent according to institutional policy Set oxygen flow to correspond with oxygen % ordered, check at least every 4 hours Tuck the tent snugly around the mattress Plastic O2 hood best for infants Plan nursing care so tent is opened as little as possible If tent opened for extended time, turn up flow for a few minutes to compensate Monitor child's hair, clothing and linens frequently for moisture Monitor temperature and level of sterile distilled H2O in humidifier frequently
Convert 38 C to F.
F=(9/5 x C) + 32 F=(9/5 x 39) + 32 F= 100.4 F
advantages, disadvantages, and patient nursing interventions of face tent and aerosol mask
Face Tent: Fits over client's chin with top extending halfway across face; Oxygen concentration varies (21%-50%) but face tent is useful instead of a tight-fitting mask for the client who has facial trauma and burns; Mist should be present Aerosol Mask: For client who requires high humidity after extubation or supper airway surgery or for client who has thick secretions
creatinine
Female: 0.5-1.1 mg/dL; male: 0.6-1.2 mg/dL
Common vaccine reactions
Fever, malaise, headache
What are the phases of a fever? What happens during each one?
First: pyrogens (bacteria, viruses) trigger the immune system to stimulate the hypothalamus to raise the set point; epinephrine released; body conserves heat - chills, shiver Second: higher temperature; body warm and dry Third: if the body over heats, or pyrogens removed, the set point drops, vasodilation produces warm and flushed skin; diaphoresis occurs Fourth: return to normal ranges (endogenous antipyretics released)
medication to reduce thrombus formation
Heparin Enoxaprin (Lovenox; low molecular weight heparin) Warfarin (Coumadin) Dabigatran (Pradaxa)
what are the angles for IM, SC, ID?
IM - 90 SC - 45 to 90 ID - 15
fluid volume deficit
IV therapy? offer variety of fluids and keep in reach of client
local signs of infection
Induration, erythema, increased drainage, purulent, foul odor, increased pain at wound site
preparing client for surgery
Initiated when decision is made for surgery, collaboration among team members; focus is assessment, client and family teaching and interventions to promote client achievement of expected outcomes
Thorax/Lungs Inspection
Inspect/observe symmetry of thorax and movement of air
stage 1 pressure ulcer
Intact skin, non-blanchable redness (color may differ w/dark pigmented skin)
Neurological Metal Status Questions
Knowledge- "Tell me about your illness" Judgment-"When do you use your inhaler?" Abstract thinking- "An ounce of prevention is worth a pound of cure"
Examples of live attenuated vaccines
Measles, mumps, rubella, varicella, zoster
PE
pulmonary embolism signs: sudden SOB and chest pain
Cardiac Assessment Apical pulse
Mitral/apical valve PMI- Point of Maximum Impulse Adult- medial to the left midclavicular line @ 5th ICS Child- left MCL @ 4th ICS
Pulses
Monitor tissue perfusion Palpation CWMS- color, warmth, movement, sensation assess pedal pulses
Prescription antihistamines not given under ________ years of age
NOT GIVEN age 2 years or younger due to respiratory depression
Do you need to aspirate before giving immunizations?
No
pressure ulcer prevention
Nutrition/fluid status, observation of skin, up and walking, reposition, lift (don't drag), clean skin and continence care, elevate heel, risk assessment, support surfaces for pressure redistribution (NO ULCER)
What happens when resistance increases?
O2 delivery to alveoli decreases
OD OS OU
OD: right eye OS: left eye OU: both eyes
Which of the following sentences or phrases are examples of objective data? Which of the following sentences or phrases are examples of subjective data? - "My head hurts!" - irregular pulse - unsteady gait - poor appetite - ate 50% of meal - nauseated - emesis of 100 mL undigested food - temperature 99.6 degrees F
Objective data: irregular pulse, unsteady gait, ate 50% of meal, emesis of 100 mL undigested food, temperature 99.6 degrees F Subjective data: "My head hurts!", poor appetite, nauseated
antitussives
Opioid and nonopioid antitussives Opioids directly suppress cough reflex by action on the CNS Cough suppressant, symptom relief Opioid - codeine and hydrocodone (Increase viscosity; diarrhea) Non-opioid - dextromethorphan, Vicks, Formula 44, Robitussin - DM Opioids directly suppress cough reflex - will slow down - can increase viscosity and constipate - addictive. Good if an analgesia is needed. COUGH IS A NORMAL AND BENEFICIAL RESPONSE AS IT BRINGS UP SPUTUM AND REMOVES FOREIGN OBJECTS SO NOT GOOD TO SUPPRESS A COUGH IF IT IS PRODUCTIVE. But, if dry, hacking, fatigue-causing, inability to sleep or painful cough is present it is good to use - especially at night. May be narcotic, non-narcotic or combination of both/ can be used with other meds
Local vaccine reactions
Pain, swelling, redness at site of injection; usually mild
Gastrointestinal Abdominal Assessment
Palpation- soft/firm, ascites, distention (flatus, stool, bladder full?) When was last BM and voidance? Ask if there is pain during palpation
stage 2 pressure ucler
Partial thickness loss of dermis (shallow- maceration and escoriation if there is skin loss)
Cardiovascular Assessment
Peripheral & Apical pulses Perfusion/Edema Cardiac assessment
glucocorticoids
Prevent inflammation, suppress airway mucus production and promote responsiveness of the beta q2 receptors in bronchial tree Do NOT provide immediate effects Promotes decreased frequency and severity of exacerbations and acute attacks Short-term IV agents for status asthmaticus Inhaled agents for long-term prophylaxis of asthma Short-term oral therapy for chronic asthma Side Effects Must use 2 weeks before results Side effects worse if given orally Fluid retention HTN Mood swings Weight gain Elevated blood glucose levels Long-term use decreases immune system
Active immunity
Protection produced by the person's own immune system; usually permanent (vaccine)
Passive immunity
Protection transferred from another person or animal; temporary protection that wanes with time (infant nursing)
Sensory PERRLA
Pupils Equal Round React to Light Accommodate
What does RACE stand for? What does PASS stand for?
R - rescue A - activate the alarm C - confine the fire E - extinguish the fire/evacuate *move ambulatory clients first? P - pull A - aim S - squeeze S - sweep side to side
S&S of hypoxia
RESTLESSNESS, APPREHENSION, ANXIETY decreased LOC and concentration increased fatigue and dizziness behavior changes INCREASED PULSE RATE AND DEPTH OF RESPIRATION, DYSPNEA ELEVATED BP PALLOR/CYANOSIS
Musculoskeletal assessment
ROM gait and assistive devices post operative/injury
What is evaluation?
Reflects the degree to which the outcomes are achieved by nursing interventions; ongoing process leading to further planning and action
vasoconstrictors
Relieve nasal stuffiness Increase effect of sympathetic N.S. causes vasoconstriction of capillaries in nasal mucosa Pseudoephedrine OTC topical nasal spray (Afrin, Allerest, Sinex, Neo-Synephrine) Use ONLY 3-5 days maximum to prevent rebound nasal congestionf rom iirration to nasal mucosa Systemic Decongestants - primarily for allergic rhinitis (hay fever) Pseudoephedrine (Novafed, Sudafed), ephedrine Common side effects - jittery, nervousness, restlessness, rebound nasal congestion, increased BP and BG
post fall assessment SPLATT
S - symptoms @ time of fall P - previous # of falls or near falls L - location of falls A - activity engaged in @ time of fall T - time of fall T - trauma assocaited w/ fall
hemorrhage
S&S- heart rate up (after long enough it will fall), thready pulse, restlessness, cool, clammy and pale skin INCREASE FLUIDS
chronic S&S of hypoxemia
SOB, cardiac dysrhythmias, clubbed fingers, increased fatigue
administering drugs to older adults
START LOW GO SLOW; lab values and dosages of meds may not be the same for an older adult
Severe vaccine reactions
Seizures, high fever, fainting, allergic, lethargy
Gastrointestinal Inspection
Shape is symmetrical/irregular, round/flat, etc. umbilical or inguinal hernia
Of the types of temperatures/thermometers which ones are considered surface? Which ones are considered core?
Surface: oral, and axilla Core: rectal, tympanic, and temporal
GI prep
Take laxatives to clean out GI system so if the GI tract gets knicked for some reason, bowel will not get into the rest of the system (if it does, could cause serious infection
skin prep
Take laxatives to clean out GI system so if the GI tract gets knicked for some reason, bowel will not get into the rest of the system (if it does, could cause serious infection
TIG =
Tetanus Immunoglobulin
Vancomycin Resistant Enterococci (VRE)
contact isolation w/both hand washing & alcohol rinse b4 leaving room
natural exposure
contact with the disease
advantages, disadvantages, and patient nursing interventions of tracheostomy collar and T piece
Tracheostomy collar can be used to deliver high humidity and desired oxygen to client with a tracheostomy Set O2 at 10L/minute with a nebulizer Special adapter (T-piece) can be used to deliver any desired FIO2 to client with a trach, laryngectomy or endotracheal tube FIO2 Delivered: 24%-100% FIO2 with flow rates at least 10 L/min IMPLEMENTATION: Change delivery system to nasal cannula during mealtimes Assess that aerosol mist escapes from the vents of the delivery system during inspiration and expiration Empty condensation from the tubing to prevent the client from being lavaged with water and promote adequate flow rate Ensure there is sufficient water in the canister and change the aerosol water container prn Keep exhalation port on T-piece open and uncovered (if port occluded client can suffocate) Position T-piece so that it does not pull on the tracheostomy or endotracheal tube and cause erosion of skin at the trach site Make sure humidifier creates enough mist Mist should be seen during inspiration and expiration
T/F - vaccine doses should not be administered at intervals less than the minimum intervals or earlier than the minimum age.
True
preoperative diagnostic tests
Urinalysis, blood chemistry, ECG, ABGs, oximetry, coagulation studies (PT (INR), PTT- 0.76-1.27), liver function test, HIV, chest x-ray, blood type and cross, creatinine, BUN, PFT, pregnancy
bronchodilators
Use: Dilates bronchi and bronchioles; DECREASES resistance in respiratory airway; Increases air flow to the lungs; Most useful in obstructive lung diseases; Asthma and COPD are most common Symptoms: Dyspnea; Broncho-constriction and mucus COPD is not just one diagnosis but many! Dilate (relax) the narrowed bronchi and bronchioles (from asthma, chronic bronchitis, emphysema). Works on muscle of the bronchi. TWO CLASSIFICATIONS: SHORT ACTING Beta 2 agonists (get in trouble) E.g. Albuterol & LONG ACTING Beta 2 agonists (everyday) E.g. Salmeterol, Formoterol Anticholinergic Agents E.g. Ipratropium Result: bronchospasm relieved; histamine release inhibited; ciliary motility increased Side effects: Tremors, Anxiety, Angina, Insomnia, HA, Palpitations, Tachycardia, Increased BP Nursing actions: Evaluate client's respiratory status and vitals Explain difference between long and short acting control Advise client not to use more than the ordered dose Teach client correct administration of inhalation devices
symptoms of oxygen toxicity
Visual field loss Nearsightedness Cataract formation Bleeding Fibrosis Twitching Seizures Jerky breathing Irritation Coughing Pain SOB Tracheobronchitis Acute respiratory distress syndrome
What does win stand for?
Wash Identify Notify
antigen
a live or inactivated substance (protein, polysaccharide) capable of producing an immune response
Tent O2 administration
a "tent" around a mattress to trap O2 in plan nursing care so tent is opened as little as possible
What is a nursing diagnosis?
a clinical judgment that "... concerning human responses to health conditions/life processes or vulnerability for that individual family or group, or community that a nurse is licensed and competent to treat *NOTE: this is NOT an illness or a medical diagnosis; this is a health problem nurses are licensed to treat
diabetes meticullus
a disease in whcih the body does not produce or properly use insulin
What is orthostatic hypotension?
a drop of 20 mmHg systolic or 10 mmHg diastolic; BP is measured lying, sitting and/or standing up *pulse also assessed w/ BP
insulin
a hormone needed for glucose metabolism
scored tablets
contain and indented marking to make breakage for partial dosages
diphenhydramine (Benadryl)
anticholinergic effect inhibit vesibular stimulation (motion sickness) side effects: dry mouth, drowsiness
CLINICAL QUESTION An 88 year old client is prescribed ASA 80 mg once a day. The client has a medical history of cardiovascular disease and osteoarthritis. The client's vital signs are 37 degrees C-78-18-130/76. What is the most likely reason for this medication? - antipyretic - analgesic - antiplatelet - anti-inflammatory
antiplatelet
body image
anxiety levels, cardiac issues as they get older, poor pain management, decreased participation in self care
mentally or physically challenged considerations
anxiety levels, cardiac issues as they get older, poor pain management, decreased participation in self care
causes of hyperventilation
anxiety, infections, drugs, fevers, ASA OD, acidosis compensation
hyperactive delirium assessment
anxious, vigilant increased activity combative easily distracted, illusions, hallucinations
sentinel event alerts
any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness
internal respiration
anything after diffusion
What is a pulse deficit?
apical and radial counted at the same time and compared if pulse is irregular difference in rates - more than 2 beats/min
What pulse sites are used to assess perfusion?
apical, carotid, radial, brachial, popliteal, femoral, dorsalis pedis, posterior tibal
What pulse sites are generally used to assess rate?
apical, radial, brachial - infants
peri
around
CLINICAL QUESTION A client that is 2 year old is hospitalized for ORIF for a fractured tibia after a fall. They request medication for their child's pain. What medications will reduce inflammatory pain? - aspirin - ibuprofen - acetaminophen - ketorolac
aspirin, ibuprofen, and ketorolac *NOTE: ibuprofen would be the best option. *NOTE: Technically you should give a child aspirin because of Reye's syndrome. *NOTE: Ketorolac is normally used for postoperative pain and it can cause ulcers and GI bleeding.
interventions for circulatory complications
assess op sites, I&O, heart sounds
Incidents/sentinel events - What do you do first?
assess the client report the event prevent further events
I&O
assessment for fluid and metabolic status
________________ muscles can increase lung volume during inspiration
assessory
loneliness, risk for
at risk for experiencing discomfort associated w/ desire or need for more contact w/ others
immobility complications respiratory complications
atelectasis (collapse of alveoli): crackles and diminished breath hypostatic pneumonia (inflammation of the lung related to stasis or pooling of secretions): crackles, wheezes, cough w/ thick yellow sputum
Cardiac Assessment Extra sounds- S4
atrial filling, atrial gallop ten-ne-ssee a stiff wall
interventions to prevent falls (A)
avoid all 4 side rails, restraints, sedation alarms to detect motion no slip foot wear low beds adequate lighting clear pathways
trachea
branches into right and left main stem bronchi
interventions for hyperventilation
breathe into bag = caution w/ CAL belly breathing pursed lip breathing
post anesthesia report
brief history of client's health status, baseline and OR V.S., actual surgical procedure performed, results of diagnostic testing, administration of anesthetic agents and other medications, EBL, total volume of output from all tubes and drains, total volume in infused IV fluids and blood products
sanguineous
bright red, indicates active bleeding
general anesthesia
brings about reversible loss of unconsciousness
_____________________________ increases airway resistance
bronchoconstriction
Assess, plan, and evaluate nursing care related to acute airway obstruction.
bronchoscopy (see and remove object)
Integumentary Ecchymosis
bruising, red-purple-yellow
The kidneys help regulate ____________ and ________________ levels -- convers vitamin D to a usable form.
calcium and phosphate levels
pediatric considerations
can't afford to lose a lot of blood, can't control temperature very well, at risk of dehydration because of body surface area, at risk for respiratory issues
anticholinergic effects of meds
can't see, can't spit, can't pee, can't shit, can't think
malignant melanoma
cancer actinic keratosis- precancerous squamous cell carcinoma basal cell carcinoma lesions uneven color, irregular, growing, fail to heal
intermediate
care after discharge from PACU to surgical unit
main stem bronchi begins at the ______________
carina
What pulse site is contraindicated for general assessment?
carotid
bronchioles contain no ______________________
cartilage *depend on the elastic recoil of lungs*
dehydration causes, signs, and prevention
causes - hyperosmolar fluids draw water out of cells; lack of adequate water signs - weight loss, dry mucous membrnes, poor skin turgor prevention - monitor daily wiehgt, I & O, provide adequate fluid
tube clogging causes and treatment
causes - not flushing tubing, attempting to crush enteric coated tablets treatment - consider pancreatic enzymes - dissolve tablet
diarrhea causes and prevention
causes - rapid infusion, GI bacteria prevention - aseptic technique, reduce infusion rate, prevent contamination
dumping syndrome causes and prevention
causes - small intestine unable to contain bolus of fluids prevention - using the stomach as a reservoir; avoid large amounts directly into the small intestine; avoid hyperosmolar feedings
Why is it critical to maintain balance?
center of gravity minimizes body strain
indicators of illness
change in mental status falls dehydration decrease in appetite pain loss of function dizziness incontinence
interactions
changes in action due to other medications, nutrients * grapefruit juice and ace inhibitors (up) * aspirin for antiplatelet effect with ibuprofen (down)
immobility complications impaired gastrointestinal function
consitpation from reduced activity, fluid intake, fiber intake
Surfactant
chemical produced in the lungs to maintain surface tension of the alveoli
chemical respiratory regulation
chemoreceptors sensing changes H+, CO2, O2, and pH help maintain ABG values chemoreceptors stimulate neural regulators SHORT TERM ADAPTIVE MECHANISM
terminal bronchioles contain no _________________
cilia
the bronchi are lined with ____________
cilia
a simple face mask may cause _______________
claustrophobia * nasal cannula while eating???
primary intention
clean laceration, surgical incision
serous
clear, watery plasma
tertiary intention
closure of wound is delayed until more favorable healing conditions exist
geriatric considerations
clot formation issues, prone to pressure ulcers and skin tears, decreased cardiac reserve can cause decreased cardiac output, increased risk for atelectasis, blood oxygenation reduced, increased risk for reflux and indigestion, increased risk of shock w/blood loss, limited ability to eliminate drugs or toxic substances, etc...older you get, the higher the risk
cataracts
clouding in the lens of the eye blurred vision, difficulty w/ glares
Mucus
coats many epithelial surfaces secreted into fluids such as saliva
schedule III drugs
codeine combinations, propoxygphene
schedule V drugs
codeine cough meds
proliferative phase
collagen and capillary networks (new blood vessels) granulation, epithelialization, contraction and resurfacing, 3 to 24 days
remodeling phase
collagen scar continues to gain strength, usually fewer melanocytes. Takes months to years. 80% tensile strength the scar tissue
tracheostomy collar and T piece
collar used to deliver high humidity & desired oxygen t-piece is an adapter for tracheostomy, laryngectomy, or endotracheal tube empty condensation from tube to prevent client being lavage w/water
Integumentary Assessment
color temperature moisture lesions
conscious sedation
combo of medications which helps you relax and not feel pain
proteins
complete proteins, high quality proteins; contain all esstential amino acids to support growth and maintain nigtrogen balance; protein is needed for growth maintenance and repair of body tissue
iatrogenic effects
complications from treatment
readying client's room for return
compression device, oxygen, suction, open surgical bed, NG set up, emesis basin
extract
concentrated
vaccines
contain the same antigens or parts of antigens that cause disease, but the antigens in vaccines are either killed or greatly weakened. When they are injected into fatty tissue or muscles, vaccine antigens are not strong enough to produce the symptoms and signs of the disease but are strong enough for the immune system to produce antibodies against the antigen.
suspensions
contains small solid particles suspended in a fluid
body mechanics
coordniated efforts of the nervous and musculoskeletal systems
developmental tasks
coping w/ physical changes redirecting energy in new roles accepting life, point of view about death of spouse changes in living arrangements
developmental tasks
coping w/ physical changes redirecting energy in new roles accepting life, point of view about death of spouse & changes in living arrangements
Cardiac Assessment Auscultation
count apical rate for ONE FULL MINUTE lub-dub is one heart beat "lub"- S1, mitral & tricuspid close "dub"- S2, aortic & pulmonic
Pneumonia
crackles and wheezes
Atelectasis
crackles on inspiration clears with cough
tube clogging prevention
crush medications shake formula flush tubing with 30 mL water every 4 hours
enteric coated (EC) tablets and sustained released (SR) capsules should not be
crushed
kyphosis
curve of thoracic spine
enteral nutrition: method for delivery infusion
cyclic infusion vs. continuous drip advantages: reduced GRV and aspiration
What is assessment?
data collection - from interview, health history, physical examination , observation, diagnostic data, medical records, significant others, interdisciplinary team data analysis - data validation, data clustering
necrosis
death of cells or tissues
low dose heparin
decrease clots
antibiotics
decrease risk of infection
Does phenytoin (Dilantin) increase or decrease vitamin absorption? Does food change absorption?
decrease; yes slows
___________ excretion of medication, more medication remains in the body
decreased
_____________ hepatic circulation results in decreased metabolism of medications, more unmetabolized med available to alter the effectiveness of the med or increase the effect of the med
decreased
______________ body water results in increased concentration of med and more med available
decreased
_______________ serum albumin results in more free drug that is not protein bound with a greater concentration of medication in the body
decreased
late S&S of hypoxemia
decreased LOC, respiration rate, and BP, central cyanosis, cardiac dysrhythmias, cardiac arrest
immobility complications cardiovascular changes
decreased circulating blood flow results in pooling of blood decreased autonomic response of vasoconstriction also results in poor blood return to the heart & orthostatic hypotension orthostatic hypotension decreased cardiac output increased cardiac workload Increased cardiac workload often results in an increased pulse rate risk for thromboembolism DVT- deep vein thrombus VTE- venous thromboembolis Embolus FYI- Homan's sign not used
What does this lab value reflect? low albumin; low prealbumin
decreased protein ntake for a period of time
renal system and aging
decreased renal function: elevation of creatinine & blood urea nitrogen (BUN) in the blood/serum
nervous system aging
decreased sensory perceptions may alter responses mild short term memory loss decrease in conduction speed - increase in time to react
What would happen if the surfactant collapsed?
decreased surfactant can lead to atelectasis (collapse of alveoli that prevents normal exchange of O2 and CO2)
Hb and Hct
decreased w/ anemia, nutiritonal deficiency, blood loss, altered by hydration
Does fluoxetine (Prozac) stimulate appetite or decrease appetite?
decreases appetite
secondary nursing diagnoses
deficient knowledge activity intolerance chronic fatigue disturbed sleep pattern imbalanced nutrition anxiety
diuretic - furosemide (Lasix)
dehydration and hypotension
important points to teach
introduce self, identify purpose, determine client's knowledge, explain routine, familiarize client with operating room, remember significant others, explain post-anesthesia care, discuss relevant physical problems, demonstrate/evaluate client's performance of coughing, deep breathing, turning and transferring, extremity exercises, spirometry, any other potential equipment
major surgery
involves extensive reconstruction or alternation in body parts; poses great risks to well being example: coronary artery bypass, colon resection, removal of larynx, resection of lung lobe
minor surgery
involves minimal alteration in body parts; often designed to correct deformities; involves minimal risks compared with major procedures example: cataract extraction, facial plastic surgery, tooth extraction
Integumentary Wheal
irregular, elevated, localized edema
chronic confusion/dementia
irreversible, progressive deterioration of intellect & personality
benzodiazepines - diazepam (valium)
is long acting and exerts an effect for a longer time
CLINICAL QUESTION The nurse is assessing orthostatic BP measurements. An adult client has an apical pulse of 88 and a BP of 130/88 lying in bed. The nurse assists the client to sit up and the client refuses to stand. The client's apical pulse is 102 and the BP is 108/72. The client reports feeling dizzy. What will the nurse do next?
lay them back down
Cardiac Assessment Pulmonic valve
left 2nd ICS
Cardiac Assessment Tricuspid valve
left 4th ICS, sternal border
Integumentary Lesions
lesions are ANYTHING!!! document size, color, pattern
pharmacokinetics
liberation, absorption, distribution, biotransformation, and excretion of drugs
Auscultation (assessment step 4)
listen to sounds using a stethoscope step 2 in abdominal assessment
Auscultation General Points
listening area is quiet DO NOT LISTEN THROUGH CLOTHING stethoscope is flat on chest listen to 1-2 respiratory cycles sounds increase in pitch w/ inspiration and decrease w/expiration start auscultation at apex
advanced directives
living will tells doctors that you do not want a life-sustaining procedure done if you are not able to say so yourself and it will only prolong life, must be signed in front of two witnesses preferably not related to you POA: person to speak for you- can revoke at anytime
gastric tubes
long term feedings needed > 4 weeks
atelectasis
look for thoracic symmetry
benzodiazepines
lorazepam (Ativan) side effects: sedation
immobility complications disuse osteoporosis
loss of calcium from the bones, related to immoblization and non weight bearing calcium resorption: calcium loss from bones
macular degeneration
loss of central vision
moderate stage AD major neurocognitive disorder
loss of functional ADLs (e.g. incontinence, hygiene, bathing, dressing)
denuded
loss of tissue
White blood cells (WBC)
low levels at risk for an infection high levels may indicate an infection
abnormal drive to breath driven by
low levels of O2 e.g. COPD, CALs
What is hypoxemia?
low levels of arterial oxygen
Platelets
low levels risk for bleeding
Red blood cells (RBC)
low levels risk for fatigue
negative nitrogen balance
low nitrogen level in blood related to loss of protein
Gurgles
low pitched bubbling
hypoxemia
lower concentration of O2 in blood measured directly hypoxemia most common sign of hypoxia
place eye drop in
lower conjunctival sac, never directly onto the cornea
outcomes of adequate oxygenation
maintains patent airway maintains adequate ventilation maintains tissue perfusion/cellular oxygenation decreased anxiety & fear Maintains effective breathing pattern w/o fatigue or dyspnea
swallow studies
major diagnositc study in the evaluation of dysphagia is a barium x ray of the pharynx and esophagus with video fluoroscopy
depression
many older adults avoid complaining they are feeling sad or depressed, but have vague complaints or loss of interest/joy in life highest # of successfully complete suicides occur in old adult age group & are less likely to tell others of their intentions
Sputum
matter expectorated from respiratory tract describe amount, color, viscosity, odor
Gastrointestinal Auscultation absent bowel sounds
may indicate an "ileus," which is common after bowel surgery Ileus occurs b/c the rhythmic contractions (peristalsis) stop 1 min. in ea. quadrant or total of 5 min. auscultation if no bowel sounds heard
Cardiac Assessment Extra sounds -S3
may indicate heart failure Ken-tuck-y slushing in
What is an A1C?
measures average blood glucose for past 2-3 months
O2 is a _____________. O2 can be ___________________. You need an _____________________ to administer.
medication toxic order
Bronchovesicular lung sounds
medium
elixirs
meds in alcohol (and/or water)
Prokinetic dopamine receptor blocker
metoclopramide (Reglan) increases peristalsis side effects: diarrhea
allergic reaction
mild - rash severe - obstructed airway; anaphylatctic reaction
undesired weight gain or loss prevention
mointior daily weight, electrolytes, glucose, nitrogen balance observe skin, wound healing consult dietician/physician
nasogastric suction
monitor output tube may be irrigated normal saline is used for irrigation to prevent loss of electrolytes
adverse reactions
more severe reactions, undesirable
fire safety horizontal vs. vertical
move patients away from the fire on the floor level first (horizontal) if needed, evacuate to lower floors (vertical)
transportation
movement of O2 and CO2 to and from cells
diffusion
movement of gas from high to low concentrations
ventilation is the process of
moving air in and out
MDROs
multi drug resistant organisms
antagonistic effect
one medication decreases the other
secondary intention
open wounds
idiosyncratic reaction
opposite or unusual action
visceral pleura covers the ____________________ surfaces
pulmonary (inner-most layer)
risk factors for wound healing
obesity, diabetic, poor nutrition, low oxygenation, radiation, smoking (vasoconstriction)
Neurological Emotional State
observe facial/non-verbal expression, eye contact, activity, speech, interaction
Thorax/Lungs Posterior Thorax Excursion
observe hands moving apart palpation
carbon monoxide
odorless, colorless, non-irritative gas imapairs ability of hemoglobin to carry oxygen Symptoms: sleepiness, nausea, headache, throbbing temples, blurred vision, chest pain, confusion, shortness of breath, coma
medicine cup
often has a capacity of 30 mL or 1 oz
guidelines for fall risk assessment
older people asked routinely whether they have fallen in the last year and the frequency, context, and characteristics of the fall
serotonin receptor antagonist
ondansetran (Zofran) very effective for cancer not always effective for other types of nausea
Explain how to use an oral thermometer, rectal thermometer (adult and child), axilla thermometer, temporal thermometer, and tympanic thermometer.
oral - under the tongue in the posterior sublingual pocket rectal - adult: insert 1 to 1.5 inches direction of umbilicus; pediatrics: 0.5 to 1 inch axilla - dry axilla, maintain skin contact temporal - cross your Ts and then touch in the perfume spot, dry forehead tympanic - notice if earwax (cerumen) is present; right hand to client's right ear; adult: ear up and out; child under 3: point toward midpoint eye brow and side burns
physiology of swallowing
oral prepatory phase - involves chewing pharyngeal phase - occurs by advance of soft palate to posterior nasopharynegeal wall; larynx pulled upard and foward esophageal phase
antihypertensive
orthostatic hypotension
musculoskeletal system: assessment
osteoporosis kyphosis (hunchback) loss of height
extrinsic restrictive
outside anatomic boundaries of lungs e.g. kyphosis, scoliosis, pleurisy
toxicity
overdose, too much
high blood pressure
pain or stress
high respirations
pain, anxiety, shock
serosanguineous
pale, pink, watery, mixture of clear and red fluid
Integumentary Papule
palpable, small, e.g. nevus
peripheral parenteral nutrition (PPN)
partial nutrition given intravenous through smaller distal veins
artificial exposure
parts of the infectious agent or inactivated version is given for the purpose of becoming immune to the disease agent it causes
expiration is a ____________ process
passive
Neurological Orientation- long term
past events e.g. Where were you born? Where did you go to school?
QSEN standards
patient-centered care teamwork and collaboration evidence-based practice quality improvement safety informatics
intradermal sites
pecs, upper scapular area, forearm
respite care
periodic rest for care giver
Vesicular lung sounds
peripherally, softer
Neurological Orientation- short term
person, place, situation OR event oriented x4= person, place, time, AND event
What are the major nerves in the respiratory process?
phrenic nerve vagus nerve thoracic nerve
dependence
physical withdrawal symptoms; psychological dependence
risk at older adult stage
physiological changes falls accidents impaired mobility sensory or communcation impairment lack of safety awareness
Integumentary Turgor
pinch skin on lower arm upper chest for elderly elastic vs. non-elastic, "tents", slow
inflammation phase
platelets for clots, WBCs clean up, fibrin matrix for repair. localized redness, edema, warmth up to 3 days
malnourished conditions
poor wound healing and skin breakdown
PACU
post anesthesia care unit
antibiotics
potentiate anesthetic agents; could cause mild respiratory depression from depressed neuromuscular transmission if taken within 2 weeks before surgery
PAT (Pre-Admission Testing
pre-auth for Medicare or third party insurance payers, preoperative assessment and teaching, preoperative testing, establishes baseline for intra-operative phase, nursing responsibilities vary with type of surgical procedure and client's individual needs, primary goal is to place client in best possible condition for surgery through careful assessment and thorough preparation
side effects
predictable and often unavoidable; may be harmless or cause injury; may negate the beneficial effects
fever
predisposes patient to fluid and electrolyte imbalances and sometimes indicates underlying infection
pharmacy
preparation and dispensing of drugs
hearing and aging
presbycusis- loss of high pitched tones hearing loss impairs socialization safety issues
sight and aging
presbyopia (farsightedness)- loss of near vision use red night lights
immobility complications integumentary
pressure injury from prolonged ischemia-- pressure on the skin is greater the pressure inside the peripheral blood vessels
Capillary Refill
pressure on nail beds 1-2 sec. normal indicates perfusion
medicare part C
private insurance
immunization
process by which a subject is rendered immune or resistant to a specific disease
oxygenation
process whereby O2 is made available & CO2 is eliminated
dopamine antagonists: Phenothiazines
prochlorperazine (Compazine) side effects: sedation, hypotension, extrapyramidal symptoms (trmors: involuntary movements)
Cough Assessment
productive vs. non-productive
What reduces friction?
proper techniques
CLINICAL QUESTION An 88 year old client recovering from a colon resection at a nursing facility eats toast and tea for breakfast; crackers, vegetable soup, fruit cup and milk for lunch; ice cream for a snack, and 50 percent of the meatloaf, mashed potatoes, a cup of peas, cake for supper. What nutrients are low?
protein
negative nitrogen balances indicates
protein breakdown more protein lost than gained
What does this lab value reflect? BUN is high
protein catabolism, fever, stress... renal disease
fibrin
protein involved in the clotting of blood, a "mesh"
antibody
protein molecules (immuno-globin) to help eliminate an antigen
monitor for inappropriate use of meds
psychoactive drugs - consider short acting meds instead of long acting meds
What happens if antibiotics are taken orally with food
recommended
Integumentary Erythema
redness, warmth
ginseng
reduce stress, boost energy, may cause irregular heart beats
cranberry juice
reduces bacteruria, urinary tract infections
What does correct alignment accomplish?
reduces strain and risk for injury maintain muscle tone
integrity
reflects on life w/ happiness & contentment feeling fulfilled w/ deep sense that life has meaning & they have contributed to life
integrity
reflects on life w/ happiness & contentment feeling fulfilled w/ deep sense that life has meaning & they have contributed to life
Immobility complications decreased metabolism
related to decreased appetite, inadequate protein intake, tissue catabolism, muscle loss negative nitrogen balance = lack of adequate protein
The diaphragm and intercostal muscles ___________________ and the lungs _______________ at the end of inspiration.
relax recoil
palliative surgery
relieves or reduces intensity of disease symptoms; does not produce cure example: colostomy; debridement of necrotic tissue; resection of nerve roots
thoracentesis
removal of fluid or air from the pleural space via a transthoracic aspiration
procurement for transplant surgery
removal of organs and/or tissues from a person pronounced brain dead for transplantation into another person example: kidney, heart, or liver transplant
Magnetic Resonance Imaging (MRI)
remove jewelry, metals remove IV pumps- special pumps & monitors available Pacemaker or any metal in body?
urinary elimination assessment
renal failure- less than 30 mL an hour or blood in urine retention- palpate bladder, bladder scan, recatheterize infection- cloudy, foul smell, sediment
WHAT IS THE NEXT ACTION? A client with diabetes has a high blood glucose reading (of 200 mg/DL) before meals.
report and check for prescribed insulin
tolerance
requires increasing higher doses to achieve effect
isometric
resisting weight
alveolar ducts branch from the _____________________
respiratory bronchioles
abdominal or thoracic surgeries
respiratory involvement issues come with these surgeries (usually see pneumonia 3-5 days post-op)
Neurological Level of Consciousness (LOC)
responsiveness e.g. alert awake, responds to voice, noise, touch or pain, drowsy, sleeping, unresponsive to voice or touch
initial S&S of hypoxemia
restless, anxious, increase fatigue, dizzy, behavior changes, increased pulse rate, rate and depth of respirations, and BP
primary outcomes of post op
restore physiological functioning, promote healing, prevent complications
constructive surgery
restores function lost or reduced as result of congenital anomalies example: repair of cleft palate; closure of atrial septal defect in heart
reconstructive/restorative surgery
restores function or appearance to traumatized or malfunctioning tissues example: internal fixation of fractures; scar revision
type 2 diabetes
results from condition in which the body fails to properly use insulin
type 1 diabetes
results from the body's failure to produce insulin
Gag reflex
typically not assessed unless indicated
When would you use enteral tube feeding?
unable to eat/swallow, unable to eat enough nutrients due to increased requirements, need to rest area of digestive tract, altered ability to digest and absorb the nutrients
delirium interventions
uncluttered environment no restraints, alternatives, low beds, "sitter" low glare lighting REALITY ORIENTATION
nausea
unpleasant sensation in the epigastric area often associated with vomiting
fats (lipids)
unsaturated fats: omega 3/6 - essential; dietary intake needed saturated fats: limited intake recommended to 10% of the fat inake; fat intake needed for brain and nerve tissue, skin and hair health
Immobility complications urinary elimination
urinary stasis decreased urinary output on 5th to 6th day renal calculi risk urinary tract infection
autolytic debridement
use of moisture-retentive dressing to cover wound bed, necrotic tissue is removed through self-digestion
St. John's Wort
used for depression, interacts with many medications including antidepressants, and reduces effects of anesthesia
promethazine (Phenergan)
used for nausea, motion sickness, antihistamine for colds oral, suppository, IM & IV
ginkgo
used for seasonal affective disorder and memory, causes of serious bleeding events
wound vac
uses negative pressure to remove fluid and improve circulation; contraindicated with exposed vessels; count pieces of the wound packing`
splinting
using a pillow to hold abdomen when coughing after surgery
fall prevention
utilize night light keep floor surfaces clean & dry keep room uncluttered
________ generally have latex stoppers
vials
Bony part of palm at base of fingers detects
vibrations
Computed Tomography (CT)
views horizontal sections at various angles Prep: NPO? Dye? Anxiety?
hematemesis
visible blood
Sensory Assessment
vision hearing sensation to touch
dysphagia: assessment
vocal changes later signs: aspiration pneumonia, malnutrition, and weight loss
low blood pressure
volume deficit (shock or bleeding), narcotics
medicare part B
voluntary insurance program physicians' services
isotonic
waking
CLINICAL QUESTION A client that's 2 year old is hospitalized for a fracture tibia after a fall. While recovering from surgery on the second post operative day the client has these vital signs: 39.8 degree C-88-24-90/50. The client is crying and the parents are concerned about the child being less active (lethargic). They request ibuprofen for their child. A post operative prescription is: Ibuprofen 2.2 mg per pound, po, q4h. What additional information needs to be considered?
weight, lethargic
mechanical debridement
wet to dry dressing
Asthma
wheezing progressing to absence of breath sounds
discharge from PACU
when conscious, oriented, move all extremities, clear airway and effective cough, stable vital signs, I&O adequate, dressing dry or minimal drainage, oxygen saturation above 90%
nutrition prep
whether or not they need to be NPO, eat vitamin C to promote healing and don't smoke or drink
immediate care (from anesthesiologist to nurse)
who it is, age, gender, what they had done, airway, breathing, circulation (ABC), type of anesthesia
corticosteriods
with prolonged use, corticosteroids such as prednisone cause adrenal atrophy, reducing the ability of the body to withstand stress, before and during surgery dosages are often increased temporarily
delayed nutrition by 5 days could reduce
wound healing and increase infection risk
emergency surgery
◦must be done immediately to save life or preserve function of body part example: repair of perforated appendix or traumatic amputation control of internal hemorrhaging
diagnostic surgery
◦surgical exploration that allows health care providers to confirm diagnosis; often involves removal of tissue for further diagnostic testing example: exploratory laparotomy; breast mass biopsy