Exam 2✅ Flashcards
(146 cards)
1
Q
Infusion pump
A
Device that delivers a controlled amount of fluids, liquid nutrients or liquid edications into a client’s body.
2
Q
Phlebitis
A
Is characterize by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area.
3
Q
Infiltration
A
Is leakage of intravenous solutionsor medication into extravascular tissue. It occurs when the IV catheter is dislodged and fluid infuses into the tissue. It is characterized by edma, pallor, decreased skin temp. Around the site and pain. discontinue IV line and elevate the extremity.
4
Q
Circulatory overload
A
Is a systemic complication of IV therapy that causes excess fluid in the circulatory sytem. The characteristics of circulatory overload include dyspnea, elevated blood pressure, edema, moist breath sounds when ausculating the lungs.
5
Q
Delusions
A
Beliefs that are not based in reality and that reflects an unconscious need or fear.
6
Q
Hallucinations
A
False sensory perceptions: seeing, hearing, smelling, feeling, or tasting objects that are not there.
7
Q
Perception
A
Views of oneself and the world, influenced by culture, religion, family, experiences, expectations, and knowledge.
8
Q
Reticular activating system
A
Part of the brain respnsible for bringing togethers information from the cerebellum and other parts as well as from the sense organs.
9
Q
Sensation (sensory) information
A
Telling a patient what he or she will see, hear, smell, taste, or feel in a particular situation
10
Q
Sensoristatsis
A
State of optimal sensory input, which differs for eac perso.
11
Q
Sensory deprivation
A
Lack of meaningful sensory stimuli; monotonous input or interference with the processing of information; leads to behavioral changes ranging from boredom to psychosis
12
Q
Sensory overload
A
State of arousal in which a person cannot manage the intensity or quantity of incoming sensory stimuli
13
Q
Sensory perception
A
The ability to receive sensory input and transform the inputs through various physiologic processes into meaningful information
14
Q
Accommodation
A
Test that engages a patient to look at a close object and then look at a distant object to see wheher patient’s pupils constrict to focus on the close object and dialte to see the distant object.
15
Q
Circulation, motion, sensation (CMS)
A
A federal organization that pays for healthcare for low-income and elderly people and tracks healthcare outcome.
16
Q
Expressive aphasia
A
Communication disorder in which the patient understands and follows directions but cannot verbally aand effectively communicate with the nurse.
17
Q
Glasgow Coma Scale
A
Standardized assesment tool used when serial assesments are done for high-risk patients (e.g.; brain tumor, after brain surgery, after a cerebral vascular accident)
18
Q
Nystagmus
A
Involuntary, rhythmic oscillations of the eyes
19
Q
Receptive aphasia
A
Disorder in which patients cannot understand simple directions
20
Q
Deliusions
A
Beliefs that are not based in reality and that refelcts an unconscious need or fear
21
Q
Hallucinations
A
False sensory perceptions: seeing, hearing, smelling, feeling or tatsting objects that arae not there.
22
Q
Perception
A
Views of onesself and the world, influenced by culture, religion, family, experiences, expectations, and knowledge.
23
Q
Sensation (sensory) information
A
Telling a patient what he or she will see, hear, smell, taste, or feel in a particular situation.
24
Q
Sensory deprivation
A
Lack of meaningful sensory stimuli; monotonous input or interference with the processing of information; leads to behavioral changes ranging from boredom to psychosis
25
Sensory overload
State of arousal in which a person cannot manage the intensity or quantity of incoming sensory stimuli
26
Sensory perception
The ability to receive sensory input and transform the inputs through various physiologic processes into meaningful information
27
Aphasia
Communication disrder that may affect speech, reading, and writing
28
Articulation
Enunciation (pronounce clearly) of words and sentences
29
Attention
Ability to concentrate on and take in specific sensory stimuli.
30
Cognition
Thinking and awareness; system by which sensory input, past experiences, and emotions are integrated and made meaningful.
31
Coma
Abnormally deep stupor occurring in illness or as a result of injury; external stimuli fail to arouse the patient
32
Communication
Interchange of information
33
Consciousness
State of awareness and full responsiveness to stimuli
34
Delirium
Reversible disorder of cognition; confusion
35
Dementia
Cognitive impairment as the result of irreversible organic changes in brain cell function
36
Comprehension
Capacity for understanding and resoning
37
Dysarthria
Disorders affecting either single or combined motor control of the muscle speech.
38
Judgement
Process of reasoning; ability to process incoming stimuli and to determine meanings that encompass many aspects of a situation
39
Learning
Multidimensional process of acquiring knowledge that depends on symbols, language, classifications, concepts, and other concrete operations along with abstract functions
40
Memory
Ability to recall a thought atleast once and usually again
41
Orientation
The basic process by which people know their location in the dimensions of time and place
42
Perceiving
Process of receiving and interpreting sensory stimuli that function as a basis for understanding, knowing, or learning
43
reality orientation
Nursing technique to help restore the patient’s awareness of reality
44
Cranial nerve I
Olfactory; sense of smell
| Ask patient to identify mild aromas (ex: vanilla, coffee, chocolate, and cloves)
45
Cranial nerve II
Optic; vision; ask patient to read Snellen Chart
46
Cranial nerve III
Oculomotor; pupillary reflex; extraocular eye movement. Assess pupil reaction to penlight. Assess directions of gaze by holding your finger 18inchs from patient’s face. Ask the patient to follow your finger up and down and side to side.
47
Cranial nerve IV
Lateral and downward movement of eyeball asses directions of gaze. Test with cranial III nerve
48
Cranial nerve V
TRIgeminal; all three; sensation to corenea, skin of face, nasal (cheek, eyebrows, chin…)
Lightly touch cotton swab to the lateral sclera of the eye to elicit blink (or just ask them to blink). Measure senstaion of touch and pain on the face using cotton wissp
49
Cranial nerve VI
Abducens lateral movement of eyeall; asses directions of gaze. Test with cranial nerve III
50
Cranial nerve VII
Facial; facial expression; taste (anterior two thirds of tongue); ask patient to smile, forwn adn raise eyebrows. Ask patient to identify different tatsed on tip and sides of tongue. (Sweet, salt, sour)
51
Cranial nerve VIII
Auditory; hearing. Assess ability to hear spoken word.
52
Cranial nerve IX
Glossopharyngeal; taste (posterior tongue), swallowing, movement of tongue. Ask patient to identify tastes on the back of the tongue (salt, sweet, sour). Place tongue blade on posterior tongue while patient says “ah” elicit a gag respnse. Ask patient to move tongue up and down and side to side.
53
Cranial nerve X
Vagus; swallowing, movement of vocalcords, sensation of pharynx. Assess with cranial nerve IX by observing palate and pharynx move as a patient says “ah”
54
Cranial nerve XI
Spinal accessory; head and shoulder movement; sk patient to turn head side to side and shrug shoulders against resitance from examiner’s hands.
55
Cranial nerve XII
Hypoglosssal; tongue position; ask patient to stick out tongue to midline, then move it side to side.
56
Air embolism
Air bubble in the vascular spacce that may obstruct circulation.
57
Central venous catheters
A central venous catheter is a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. It is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs.
58
Colloid
Fluids that contain proteins or starch moldecules
59
Crystolloid
Fluids that are clear
60
Electronic infusion device (EID)
A drip chamber aka infusion pump.
61
Extravasation
When IV solutions inadvertantly leak into the subcutaneous tissues.
62
Hemolysis
EBC destruction.
63
Hypertonic
Of greater concentration than in body fluids
64
Hypotonic
Of lower concentration than in body fluids
65
Infiltration
Abnormal or accidental seepage or deposition of a substance into the tissues; accidental administration of IV fluids into subcutaneous tissues that occurs when the needle or catheter becomes dislodged from the vein
66
Intravenous (IV) therapy
Infusion of fluid into a vein to treat or to prevent fluid and electrolyte or nutritional imbalances may be used to deliver medications or blood products.
67
Isotonic
Osmotic concentration equal to that of body fluids
68
Needleless connectors
Available to provide access to secondary ports on IV tubing or for flushing access; provide an alteranative to needless to reduce the risk of injury from contaminated sharps during IV procedures.
69
Osmolarity
Concentration of solutes in a solution expressed as milliosmols per liter
70
Parenteral nutrition
Nutritional elements supplied through an intravenous route, usually into a central vein
71
Peripherally inserted central catheter (PICC)
Long-line catheter made of soft silicone or Silastic material that is place peripherally but delivers medications and solutions centrally.
72
Phlebtis
Inflammation or infection of a vein, manifested by redness, swelling, and tenderness along the course of the vein
73
Thrombophlebitis
Blood clot that accompanies vein inflammation
74
Total parental nutrition (TPN)
Administration of hypertonic solutions containing dextose, proteins, vitamins, and minerals to provide for nutritional deficits.
75
Venipuncture
Insertion of a needle or catheter into a vein
76
Vesicant
Highly irritating medication that can cause extensive tissue damage when it leaks into the subcutaneous tissues; exampes are chemotherapy and solutions with high or low pH.
77
Alveoli
Spherical, saclike epithelial structures in the lungs through which gas exchange occurs
78
Apnea
Absence of respiration; a potentially serious sleep disorder in which breathing repeatedly stops and starts; may be obstructive or central in origin
79
Arterial blood gas (ABG)
Laboratory test that provides more specific information concerning patient’s acid-base status and response to oxygen therapy./An arterial blood gas (ABG) test measures the oxygen and carbon dioxide levels in your blood as well your blood's pH balance. The sample is taken from an artery, not a vein, and healthcare providers typically order it in certain emergency situations
80
Arterial oxygen stauration (SpO2)
Percent of hemoglobin staturated with oxygen; measured by pulse oximeter
81
Atelectasis
Collapse of alveoli
82
Bronchioles
Narrow airways that conduct air into alveolar ducts and alveoli/ smaller bronchi
83
Bronchospasm
Narrowing of the bronchioles caused by tightening of the smooth muscles in the airways
84
Cyanosis
Grayish, bluish, or purple skin tone
| Sign of deprived from oxygen
85
Diffusion
Movement of molecules from an area of higher concentration to one of lower concentration
86
Dyspnea
Breathing that requires marked effort/ difficult breathing
87
EtCO2
(End tidal)ETCO2 is the amount of carbon dioxide (CO2) in exhaled air, which assesses ventilation. So a high ETCO2 is a good sign of good ventilation, while low ETCO2 is bad sign that represents hypoventilation.
88
Fraction of inspired oxygen concentration (FiO2)
The percentage of oxygen being inhaled; increase with oxygen administration
89
Hemoptysis
Cough out or spit out blood.
90
Hypercapnia
Abnormally high carbon dioxide in the blood.
91
Hyperventilation
Breathing in excess of metabolic demands, resulting in removal of too much carbon dioxide from the blood; indicated by decreased PaCO2
92
Hypoventilation
Breathing insufficient to meet metabolic demands and adequately remove carbon dioxide from the blood indicated by elevated PaCO2
93
Hypoxemia
Below normal amount of oxygen in the blood
94
Hypoxia
Decreased amount of oxygen available to the tissues
95
Oxygen saturation
Amount of oxygen in the blood
96
Partial pressure of carbon dioxide (PACO2)
The pressure exerted by carbon dioxide gas on surrounding structures; may be measured in the alveolus (PACO2), artery (PaCO2), or vein (PvCO2)
97
Partial pressure of oxygen (PAO2)
The pressure exerted by oxygen gas on surrounding structures; may be measured in the alveolus (PAO2), artery (PaO2), or vein (PvO2)
/ The partial pressure of oxygen, also known as PaO2, is a measurement of oxygen pressure in arterial blood. It reflects how well oxygen is able to move from the lungs to the blood. It is often altered by severe illnesses.
98
Pulse oximetry
uses infrared light and a sensor attached to the patient’s finger or earlobe to determine the percentage of hemoglobin that has combined with oxygen
99
Splinting
Use of a pillow to immobilize a wound when a patient has had abdominal or thoracic surgery
100
Tracheostomy
Permanent or temporary opening into the trachea through the neck
101
Ventilation
Movement of air in and out of the lungs; breathing.
102
Oxygen flow meter
The flow meter attaches to the oxygen ooutlet and regulates the amount of oxygen delivered to the client. It is important to confirm that the flow meter is atteached to the oxygen outlet (green oxygen label) and not the air outlet (designated by a yellow lable) before initiating oxygen therapy.
103
Nasal cannula
Common oxygen-delivery device consisting of a length of tubing with two small prongs that are inserted into the nares. Delivers concentrations of 24%-44% with flow rates from 1-6L/min. The exact concentration inspired depends on the flow rate, the client’s rate and pattern of breathing and the depth of respirations. Nasal cannula is usually used for clients who are noncritical with minor breathing problems and for clients who cannot or will not wear an oxygen mask; administers low-flow oxygen. Humidifier is not usually required, unless the flow exceeds 4 L/min.
104
Simple face mask
A fairkt high oxygen flow to prevent rebreathing of CO2. (Has holes on the side for CO2 to escape). And acurate FiO2 is difficult to estimate. A simple mask is usually used for clients who require a moderate flow for a short period of time. Can deliver 40%-60%. Of oxygen with a flow rate from 5-8 L/min. Consider humidification to keep client’s mucous membranes from becoming dry.
105
Nonrebreather mask
Is used to deliver high flow rates and high concentations of oxygen. The reservior bag allows a higher FiO2 to be administered. At flow rates slower than 6 L/min, the risk of rebreathing carbon dioxide increases. A valve closes during expiration so that exhaled air does not enter the reservoir bag and not rebreathed. The valves on the side ports of the mask allow exhalation but close on inspiration to prevent inhalation of room air. This provides the client with an oxygen concentration of nearly 100%.
Nonrebreather mask can deliver oxygen concentrations of 80-95% with flow rates 10-15 L/min.
- don not allow the reservoir bag to deflate or the oxygen source to deplete. Of the bag deflates, the oxygen source diminishes; the client will likely to breathe large amounts of exhaled CO2.
106
Venuri mask
Delivers fixed FiO2. The FiO2 depends on the flow rate or entarinment port size. Used for clients who have COPD when an acurate FiO2 is essential and CO2 buildup must be kept to a minimum. Humidifiers are usually not used with this devicce. I often used for clients who are critically ill and require administration of a specific concentration of oxygen.
- holes on each side to allow exhaled air to escape.
- the base of tthe mask gas a color coded adaptors. Each adaptors indicates which specifiic oxygen concentation the client will receive and at what flow rate to set the oxygen (different manufacturers may use different colors for adaptors, so alyws check the oxygen perscription and look carefully to see which adaptor should be used. )
- deliver accurate oxygen concentrations from 24-50% with flow rates from 4-10 L/min.
107
Face tent
Soft aerosol mask fits loosely around the client’s face and neck. For clients hwo feeel claustrophobic. Oxygen conccentration cannot be controled. Face tents are often used after nasal and oral surgery delivers 24-100% with flow rates of at least 10 L/min.
108
Manual resuscitation bag
Is used to provide high concentrations of oxygen to a client prior to a procedure (suctioning, intubating) and during respiratory or cardiac arrest. It can also be used to assit clents who are not breathing but not adequately. The bag has an oxygen port where oxygen tubing can be connected; flow meter is usualy set 10-15 L/min when performing manual resuscitation.
109
Tracheostomy mask/ tracheostomy collar
A small mask that fits over the client’s tracheostomy site. The maskhas an exhaltaion port that remains patent at all. Times and a pirt that connects to the oxygen source with large-bore tubing. The flow rate is usually set at 10 L/min with a neubulizer set at the apporpriate oxygen concentration.
110
T-peice
T-shaped adapter used to provide supplemental oxygen to an endotracheal (ET) or tracheosotomy tube. It is connected to oxygen source to the artifcial airway (ET or tracheostomy). Fow rate is usually 10 L/min with neubilizer set at the appropriate oxygen concentration.
111
Mechanical ventilation
Is used to maintain positive airway pressure and to improve alveolar ventilation without the need for an artificial airway/ breathing assited by either a positive or negative pressure device. Commonly used for clients with congestive heart failure, sleep disorders, and pulmonary diseases to improve oxygenation, reduce and reverse atelactasis, reduce pulmonary edema, and improve cardiac function.
Two types of noninvassive ventilation are continuous positive pressure (CPAP) and bilevel positive airway pressure (BiPAP).
112
CPAP
Continuous positive pressure ventilation provides airway pressure througght the client’s breathing cycle. Commonly use for patients with sleep apnea… the continuous positive pressure prevents the upper airway from collapsing.
113
BiPAP
Provides assitance during inspiration and keeps the airway from closing during expiration. It increases the amount of air in the lungs at the end of expiration reduced airway closure and improved oxygenation.
114
Extravasation
Similar to infiltraition, but extravasation can occur is the solution that leaked into the tissue contains a vesicant (vesicant medications and solutions are: chemotherapeutic medications, vancomycin, dopamine, adn digoxin).
-blistering of the skin, tissue necrosis, and ulceration can occur.
115
Speed Shock
Occurs when a client recieves an intravenous medication too rapidly, causing dizziness, chest tightness, flushed face, and other effects related to a toxic level of medication in the body.
116
Angina
Pain a nd discomfort about the heart, characteristic of myocardial ischemia; severe pain felt in the anterior chest, shooulder, left arm, neck and jaw.
Angina is where you have attacks of chest pain caused by reduced blood flow to your heart.
117
Automaticity
Heart’s capabilty of enerating its own elcetrical impluse, which is then conducted through specialized conduction fibers
118
Cardiac biomarkers
Proteins that are released from cells when tissue damage occurs. / Cardiac biomarkers are substances that are released into the bloodstream when heart muscle is damaged or stressed
119
Cardiac output (CO)
The amount of blood pumped by the heart each minute.
120
Contractility
Force of contraction
121
Diastole
Period of rest in the cardiac cycle, when the ventricles are not contracting and the coronary arteries are filling with blood
122
Dysrhythmia
Abnormality in hearth rhythm.
123
Endocardium
The innermost layer of the heart
124
Epicadium
The outer layer of the heart.
125
Intermittent claudication
Limb (arm or leg) pain cause by poor blood flow./
- Intermittent claudication is muscle pain that happens when you're active and stops when you rest. It's usually a symptom of blood flow problems like peripheral artery disease. Over time, this can get worse and lead to serious health problems and complications
126
Ischemia
Insufficient blood supply to a body part due to obstruction of circulation.
127
Metabolic Syndrome (syndrome X)
A genetic metabolic disorder characterized by diabetes, hypertension, atherosclerosis, centrally disturbed obesity, and elevated blood lipids.
syndrome X) is a clustering of problems associated with resistance to insulin and/or hyperinsulinemia
128
Myocardial Infarction (MI)
Ischemia of heart muscle and death of portions of the heart muscle from the decreased blood flow through the coronary arteries.
129
Myocardium
Layer of cardiac muscle that forms the walls of the heart
130
Perfussion
Passing of blood through an area.
131
Sequential compression devices (SCDs)
Devices tat sequentiality compress veins in the legs to promote venous return.
132
Shock
Severe circulatory insufficiency
| Ex: the inability of an organ to perform its normal function: renal insufficiency.
133
Stroke
Cerebrovascular accident (CVA); involves a sudden onset of hemorrhage, blood clots, or other vascular lesions, causing damage to the brain
134
Syncope
A temporary loss of conciousness or fainting spell that may signal decreased perfusion to the brain.
135
Systole
Period of contraction of the ventricles
136
Transient ischemic attack (TIA)
Temporary cerebral ischemia due to transient (lasting only for a short time) interruption in blood supply.
is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and doesn't cause permanent damage. Often called a ministroke, a transient ischemic attack may be a warning
137
Pfeiffer Mental Status
To provide an objective assessment of cognition; to alert health care personnel of changes in cognitive function.
A score of 7 or less indicates significant cognitive impairment.
Ex: what’s it days date
What day of the week is is?
How old are you?
138
Mini-mental StateExamination
```
To provide an objective
assessment of cognition; to alert
health care personnel of changes
in cognitive function
• Scores of 20 or below indicates
significant cognitive impairment
```
139
Glasgow Coma Scale
```
To provide an objective
assessment of
consciousness; to alert
health care personnel of
changes in level of
consciousness • Glasgow Coma Scale
Scores of 13-15
correlate with mild
brain injury, 9-12 with
moderate brain injury,
3-8 with severe brain
injury.
```
140
Romberg test (balance)
Stand with eyes open with feet together, but if they close their eyes, do they start moving around?
141
Rapid Alternating Movements
Have them place their hand on thigh and rapidly flip them over repeatedly .. or do finger touching with their thumb to each finger
142
Hemiplegia
Paralysis on one side of the body; usually caused by a stroke.
143
Paraplegia
paralysis of the legs and lower body, typically caused by spinal injury or disease.
144
Quadriplegia
paralysis of all four limbs; tetraplegia.
Quadriplegia happens when the damage is at the base of the neck or skull. The most common cause is trauma, such as from a sports injury, car accident, or fall. Other causes are: Multiple sclerosis.
145
Difference Between PAO2 and SAO2
The partial pressure of O2 (PAO2) is the pressure exerted by O2 on the arterial walls while saturation of O2 (SAO2) is the overall percentage of hemoglobin binding sites occupied by O2
146
What is the Difference Between SAO2 and SPO2
The main difference between SaO2 and SpO2 is that SaO2, or the arterial oxygen saturation, is the percentage of hemoglobin molecules in the arterial blood saturated with oxygen, but SpO2, or the peripheral oxygen saturation, is the percentage of hemoglobin molecules in the peripheral blood saturated with oxygen. Furthermore, SaO2 can be measured by blood gas analysis, while SpO2 refers to the SaO2 measured by the pulse oximeter
