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314 EXAM 1 > EXAM 1 > Flashcards

EXAM 1 Flashcards

(78 cards)

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1
Q

Nursing Process

A

Assessment
Diagnosis
Planning
Implementation
Evaluation

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2
Q

Normal Vital Sign Ranges

A

Temp: 96.8-100.4
Pulse: 60-100
Respiratory: 12-20
Blood Pressure: 120/80
O2 sat: 95-100
Pain: 0-10

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3
Q

Assessing for with pulse

A

Rate
Rhythm
Strength
Symmetry

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4
Q

Cardiac Output

A

CO= HR x SV

Stroke vol is amount of blood that leaves the left ventricle with one pump

Therefore…

CO is the amount of blood pumped throughout one minute

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5
Q

Brachycardia

A

HR of less than 60

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6
Q

Tachycardia

A

HR of more than 100

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7
Q

What inc HR

A

During exercise
Fever
Emotions
Medication
Fluid loss
Sitting to standing
Low O2

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8
Q

What Dec HR

A

At rest
Hypothermia
Meds
Lying down

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9
Q

Blood Pressure

A

Pressure of blood forced on arterial walls

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10
Q

Systolic Pressure

A

Peak pressure exerted against arterial walls as ventricles contract and eject blood

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11
Q

Diastolic Pressure

A

Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest

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12
Q

What effects BP

A

Cardiac output
Peripheral vascular resistance
Blood volume
Blood viscosity
Blood flow
Vasoconstrict(inc)
Vasodilation (Dec)

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13
Q

Hypertension

A

Walls thicken, loss of elasticity
Elevated: 120-129/80
Stage 1 HTN: 130-139/80–89
Stage 2 HTN: 140/90

Basically too much blood is being pumped or vasoconstriction

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14
Q

Hypotension

A

Systolic pressure is <90

Inadequate pumping of heart, loss of blood vol, vascular dilation

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15
Q

Orthostatic hypotension

A

When you stand up too fast and blood pressure drops and causes a dizzy spell

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16
Q

3 factors that effect respirations

A

Ventilations
Diffusion
Perfusion

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17
Q

Ventilation

A

Movement of gases into/out of lungs

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18
Q

Diffusion

A

Movement of O2 and CO2 into/out of alveoli and RBCs

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19
Q

Perfusion

A

Distribution of RBCs to and from pulmonary caps

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20
Q

Assessment of respirations

A

Rate
Rhythm
Depth
Effort

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21
Q

Bradypnea

A

Rate is regular, but slow (below 12 per min)

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22
Q

Tachypnea

A

Rate is regular, but fast (above 20 per minute)

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23
Q

Dyspnea

A

Labored breathing

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24
Q

Orthopnea

A

Inability to breath when horizontal

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25
SOB
Shortness of breath
26
Hypoxemia
Low levels of O2 in blood
27
Hypoxia
Low levels of blood in tissues
28
Temperature equation
Temp = heat produced - heat lost
29
How to measure non-invasively
Oral, tympanic, temporal, axillary
30
Invasive temperature
Esophageal temp probe Rectal temp probe Temp sensing urinary cathader
31
Hypothermia
Core temp colder/below normal
32
Pyrexia (fever)
Due to hypothalamic set point; could be good because it is used as one of the bodies defense mechanisms
33
Hyperthermia
Dysfunctional regulation; not good
34
Pharmacokinetics
Movement and modification of medication inside the body Absorption Digestion Metabolism Excretion
35
First Pass Effect
When a (PO) drug is metabolized at a specific location and becomes a reduced [] by the time it gets to systemic circulation Reason why some PO meds need larger dosage
36
Therapeutic effect
Expected or predicted physiological response
37
Adverse effect
Unintended, unpredictable, or undesirable effect of med
38
Side effect
Predictable, unavoidable, secondary effect
39
Toxic effect
Accumulation of the drug in the bloodstream to a toxic level
40
Idiosyncratic reaction
Overreaction, underreaction, or different reaction
41
Allergic reaction
Unpredictable response to meds, foods, stings Can be life-threatening (anaphylaxis)
42
Med interactions
One med modifies the action of another
43
Med tolerance
More med is needed to achieve therapeutic response
44
Med dependence
Physical and psychological need for a drug
45
Onset
Time needed for drug to produce a response
46
Peak
Time needed to reach max efficacy
47
Trough
Lowest blood level of drug immediately prior to next dose
48
Plateau
When the blood level of a drug reaches a therapeutic level after the repeated doses
49
Duration
Time drug is present at a level to cause a response
50
Liquid Syringes
Amber color to not be confused Uses smallest one you can
51
Parenteral Meds
Invasive injections; aseptic technique needed
52
Intradermal Injection
Between skin layers Very short/fine gauge needle 5-15 degrees Vol:0.1mL
53
Subcutaneous Injections
Below skin into fat: ( lower ab, below scapula, above butt, back of arms) Slightly longer, larger gauge needle 3/8 to 5/8 45-90 degree: (if lean, pinch and insert at 45 | if obese, no pinch and 90) Vol: 0.5-1.5mL(adult) 0.5(child)
54
Intramuscular Injection
Z track Into muscle: (vastus lateralis, deltoid, ventrogluteal) Longer, same/larger gauge needle (obese: 3in | lean 1/2 to 1 in) 90 degree angle Vol: 2-5 mL (child, old, thin ppl: <2) (small child, old infant: <1) (small infant: .5)
55
Nociception
The objective physical phenomenon that allows us to detect pain
56
4 phases of nociception
Transduction (stim converts to energy) Transmission (electrical impulse sent to spinal cord) Perception ( recognition of pain in the brain) Modulation (release of inhibitory mediators: Dec sensation of pain and make you move)
57
Pain is…
SUBJECTIVE Pain is whatever the experiencing person says it is existing wherever he/she says it is
58
Types of pain
Acute Chronic episodic Chronic persistent Idiopathic
59
Sympathetic response to pain
Inc cortisol level Inc hr, rr, bp Inc blood glucose Muscle tension Dilation of pupils Dilation of bronchial Dec GI motility
60
Parasympathetic response to pain
Dec hr, rr, bp Rapid, irregular breathing Nausea
61
Intractable pain
Severe, constant, can’t be stopped, incurable
62
Phantom pain
Pain in body part that is no longer there
63
Referred pain
Pain perceived at a location other than site of stimulus
64
Pain threshold
The point at which someone feels pain
65
Pain tolerance
Level of pain you are willing to accept
66
Radiating pain
Pain extends from initial site to other parts
67
Objective signs
Vital signs, what you see, current and historical health records, all measurements of health status
68
Subjective Data
What your patient describes their pain as
69
Qualitative Assessment
Wong- Baker Faces (ages 3-7) Old cart
70
Quantitative assessment
NPASS (<1) FLACC (1-3) Pain level 0-10 (>7)
71
Old cart
Onset (when?) Location (where?) Duration (how long? Intermittent/persistent) Characteristics (sharp, cramping, burning) Aggravating factors Relieving factors Treatment
72
Diagnosis
Nurse gathers all data and forms a nursing diagnosis based on patients response to the alteration in health
73
Steps to making a diagnosis
1: identify and categorize assessment data 2: select the possible NANDA and validate each as a NANDA that is appropriate 3: complete the nursing diagnosis with the etiology or r/t phrase (why?) 4: include the defining signs and symptoms (AEB)
74
Implementation
Execution of a plan
75
Evaluation
Overseeing reactions of intervention to see if goals or met or if they are being work towards
76
How to measure diffusion and perfusion
SPO2
77
Capnography
Exhaled CO2
78
Normal temp
Afebrile

314 EXAM 1 (1 decks)

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