Exam 2 Flashcards
1
Q
Where does the airway begin & end?
A
Begins at nose, & ends at terminal bronchiole
2
Q
Upper airway consists of
A
nose, larynx, pharynx, & epiglottis
3
Q
Lower airway consists of
A
trachea, bronchial tree, R & L Bronchi, segmental bronchi & terminal bronchioles
4
Q
Function of lower airway
A
conduct air, clear mucus by cilia, & produce pulmonary surfactant
5
Q
Which is more anterior ? The trachea or the esophagus?
A
tracheae is anterior to the esophagus (hence back to sleep)
6
Q
Trachea ends & becomes right & left lungs where?
A
at the 2nd intercostal space
7
Q
Where do the lungs begin & end?
A
Apex of lungs extend above the clavicle
Base of lungs at the 6th rib
8
Q
Posteriorly, lungs begin at ___
Base of lung at_?
A
Lungs begin @ T1
Base of lungs at T10
Deep breathing= T12
9
Q
Right side of lung
A
Has 3 lobes, separated by Horizontal fissure
10
Q
What are the other fissures of the lungs called?
A
Oblique fissure
ends at 6th rib
11
Q
Right lower lobe
A
is practically under armpit
12
Q
On the left anterior lobe we mostly auscultate
A
upper lobe
ends at 6th rib mid-clavicular, starts under armpit T3
13
Q
Right thorax
A
5th rib mid axillary line unites all 3 lobes
14
Q
Left thorax
A
Oblique fissure from T3 beginning -6th rib mid clavicular line
15
Q
Factors that affect respiration
A
Hunchback of scoliosis
Air trapped in spaces
Copriised respiration
16
Q
Right middle lobe
A
is not a part of posterior right lobe
17
Q
Position
A
tripod position=can’t breathe–> drop diaphragm to try to expand their lung volume
18
Q
Activity & exercise
A
promotes pulmonary exercise & respond better to respiratory distress
19
Q
Pregnancy
A
3rd trimester
orthopnea: not able to be comfortable while laying flat
20
Q
If patient is having a hard time breathing first thing you should do is
A
put the head of their bed up
21
Q
Smoking
A
contributes to lung disease: macrophages in lung destroy the protein that allow the lungs to expand.
> mucus production
22
Q
Air pollution
A
Room air is 21% oxygen
23
Q
Asbestos & coal dust
A
cause lung disease
24
Q
Cough is/signals
A
Cough is most important lung defense
Clears irritating substances in lungs
warning signal
25
Generation of cough
Histamine released due to irritated substance
26
Non-described, long standing cough
Something more serious is going on
| Warning sign of HF, lung cancer, HTN
27
Productive cough has what characteristics
Produces sputum: volume, consistency, color & odor
28
Is shortness of breathe subjective?
Yes, you cannot tell just by looking at them. Explore degree with pt.
29
Word for subjective SOB
Dyspnea
30
What are the characteristics of central hypoxia?
confusion, anxiety, inability to follow direction
31
Signs of respiratory distress?
clubbed nails, tripod position, nasal flaring
32
breathing pattern characteristics
Rate, rhythm & depth
33
Signs of effort to breathe
distressed, diaphragmatic, labored, pursed lips
34
skin color
general color, lip color, nail bed
35
Hyperpnea
tachypnea but deeper
36
Hypoventiliation
breathing less than 12 bpm but more shallow
37
Cheyne-stokes
periods of apnea
Last 10-60 sec flowed by periods of hyperventilation
Common in people in comas or about to die
38
Pectus Excavatum
Congenital deformity
Hollow chest: internal cartilage & ribs are concave
Applies pressure to heart & lungs
Treatment: invasive surgery
39
Pectus Carintum
Pigeon chest--> sternum protrudes
Repair is easy
Develops during school age
40
Spinal Deformities
Hyphotic spine: more difficult to breathe,
| < stature
41
Barrel Chest
Round chest configuration
Sternum pushed out
Common in COPD
1:1 ratio instead of normal anterior thorax is 2x as big as posterior
42
Normal chest configuration
Anterior/posterior diameter if chest is 1/2 the length of the transverse
43
Barrel chest
1:1 diameter of the chest
| Commonly seen in: emphysema, cystic fibrosis, infants & elderly
44
Respiratory expansion
Palpation, assessing the symmetry of the chest expanding during inhale & exhale
Thumbs on T10 vertebrae with fingers spread apart, look for thumb movement & symmetry
45
Where to begin acultation?
on the back
Listen side--> side
Top to bottom
Compare to other side & look for asymmetry
46
Bronchial sound charactersitics
Over the trachea & larynx, LOUD, inspiration 1/3 of expiration
47
Bronchiovesicular
Over the sternum, 2-3 intercostal space
T3 & T4
I=
48
Vesicular sound
Everywhere else
Inspiration 2/3 expiration 1/3
GENTLE
49
When normal lungs are displaced?
Breathe sounds are diminished in intensity
50
Adventitious breathe sounds are...
Always abnormal but not always significant
51
The larger the airway
The louder the sound
52
Crackles
High pitched and discontinuous
Heard at the end of inspiration
Does not clear with coughing
Sign of buildup of phlegm & fluid in alveoli
53
Pneumonia crackles
Consolidation of alveoli
Airspace is filled with excaudate & anti-inflammatory modifirs
Crackles & bronchial breath sounds
54
Pulmonary Edema
Develop crackles due to excess of fluid in alveoli
| Becomes more coarse over time
55
s/s of pulmonary edema
Dyspnea, SOB, lower, lower O2 saturation, air hunger, orthopnea, have productive cough
56
Wheeze
Heard on inspiration & expiration (usually louder on expiration)= continuous
High pitches/ musical
57
Asthma is...
| What type of adventitious breathe sounds will you hear with it?
Wheeze
| Chronic inflammation of the lungs: contact with allergen triggers- narrows airway & lungs swell
58
Stridor
Strong wheeze, obstructed airway associated with upper larynx & trachea
59
Croup is associated with ___ breathing
associated with stridor on inspiration, expiration sounds like barking seal
Swelling & inflammation of vocal cords & throat
60
Rhonchi
snoring, low pitched o
Heard on inspiration & expiration
May clear with coughing
Caused by air bubbling past secretions in large airways
61
Ronchi is associated with
Bronchitis
Inflammation of bronchi causing an > production of mucus on lining of upper airways
Air passing through mucus membrane causes bubbling rhonchi
62
Pleural friction rub
Low pitches, dry grating sound
| Heard on inspiration & expiration
63
Pleural friction rub is associated with:
Pleurisy: inflammation of the lining of the lungs
-deeper breaths the more pain they experience
Breathe shallowly and < frequently
-hypotonia- (< muscle tone)
-hyperventilation
64
Pleural Effusion
Diminished or absent breathe sounds over effected area.
| Collection of pleural fluids that is outside the lungs.
65
Pleural effusion is associated with:
Pneumothorax: Lung has collapsed, air around the lung cannot contract
You will hear normal breathe sounds on one side & none on side that is collapsed
66
Hemothorax
collection of blood outside the lungs
67
Chest Physiotherapy
Percussion called clapping! Also can do vibrations= manual compression & tremor on chest wall
Purpose: to loosen & mobilize secretions & cause clearance. Use gravity
68
People with _____ illnesses have large secretions & don't have productive cough
pneumonia, cystic fibrosis, COPD
69
Chest X-ray
can see fluid/air in pleural space
Collapsed or under-inflated lung. Consolidation
Position of catheter tube
70
Peak flow meter
measure peak EXPIRATION
Reflects size of airways, severity of illness= how constricted
male expires ~600mL/min
Female expires ~475mL/min
71
Incentive spirometry
Measures maximal inhalation
8-10 breaths/Hr w/a
Male inhales ~3200mL
Females inhale ~2600mL
Prevents pneumonia & collapsed lung
Get secretions in lungs at level to be coughed out
72
aerosol therapy:
| small volume nebulizers:
Add moisture to O2 delivered
| Hydrates thick sputum (delivered to deep area of respiratory tract)
73
side effects of bronchodilators
>HR, BP, RR, agitation, anxiety, fluid retention
74
Aerosol therapy: steroids
Pt uses 4/5 L of O2
Inhale slowly, or hold breathe, exhale through nose, inhale
Keep in mouth until all medication is gone
Mouth care after they finish
Assess pt before & after pt uses med
75
Sputum culture
lab test (30 min) or C&S both tell you which antibiotics to order
76
after surgery there's a risk for
lung collapse since cough reflex was suppressed, after surgery= pt in pain, alveoli not inflating secretions being retained
77
Types of cough
Deep cough: no pain, take a deep breathe & forceful expiration
Stacked cough: in pain
Series of short, quick coughs
Take in deep breathe in but force out is quick
78
Pursed lip breathing
Pt is having a difficult time breathing, keeps bronchial expanding
breathe through nose (for count of 2)
Exhale through the lips (for count of 4)
79
Lowest possible oxygen saturation & gas pressure in blood
93% o2 stat
| 68% gas pressure in blood
80
at what point should oxygen be humidified
5mL
| always used during high flow oxygen
81
Nasal cannula has how much O2 dispersion?
```
24-44%
2L=28%
3L=32%
4L=36%
5L=40%
6L=44% (MAX AMOUNT)
```
82
Simple mask
40-60% oxygen
Most common but not specific, put oxygen at 5L and they receive 40-60% oxygen
contraindicated for people who need specific amounts of oxygen
83
Venturi
```
Delivers 24%-50% oxygen. Has potential to give more than nasal cannula, but can control unlike simple mask
Blue=24%
Yellow= 28%
White= 31%
Green= 35%
Pink= 40%
Orange= 50%
```
84
Reservoir mask
| 1st type
```
Rebreather mask (50-70% of oxygen)
Non-specific
```
85
reservoir mask 2nd type
Non- rebreather mask (80-90% oxygen)
Bag attached to bottom: stays inflated all the time
White disks on each side of the patients mask
Disks off: patient rebreathing little CO2
Flow meter 10-15mL
86
Pts with COPD
no more than 32% oxygen
| have humidor gently bubbling
87
Artificial Oral airway
for patients who are unconscious, extends t back of tongue & throat
prevents tongue from blocking airway
NEVER TAPE
88
Ambu Bag
Delivers artificial respiration
Use at normal RR
Never depress bag fully
89
how to keep oral secretions thin?
drink fluids
90
breathes sounds that are moderate "blowing" with I=E are
Bronchovesicular
91
What category of medications may be administered via nebulizer to open airways?
Bronchodilators
92
s/s f hypoxia
dyspnea, tachycardia, cyanosis
93
What question might the nurse ask to assess for orthopnea
How many pillows do you sleep with at night?
94
crackles are caused by
moisture in airway
95
How often should nurse check pt for effective coughing?
Q2hr
96
Postoperative pt can cough more effectively by:
holding a pillow or folded bath blanket over the incision
97
wheezes occur during
inspiration & expiration
98
The nursing process includes
Assessing, Diagnosing, Outcome Identification, Implementation, & Evaluation
99
The purpose of an assessment is to
Establish baseline VS & function
Determine normal fxn
Determine presence of dysfunction (maintain prior level f functioning)
100
Appraisal of the total patient situation
Physical, psychological, emotional, sociocultural, spiritual
101
Do you validate nursing diagnosis with the pt?
Yes
102
Assessment Data
Directly from patient or patient’s significant other (if impaired)
103
Secondary source of data:
- Family members, significant other from patient not impaired
- Health records
- Lab values, diagnosed test
104
Objective Data
BP, Vomiting, Age
105
Nursing Diagnosis is based on
Our assessments provide basis for nursing diagnosis
| Identified pt problem
106
Actual Diagnosis has 3 factors
1) Diagnostic label
2) Relatable factors (etiology causing factor)
3) Defining characteristics (s/s, validates diagnosis)
107
how do you make a diagnosis stateent for risk?
2 part statement:
| Diagnostic label related to etiology causes
108
Patient goals are written
As behavioral statements from patients POV
109
Cognitive
pt understands or has knowledge
110
Psychomotor
pt demonstrates that they can perform a skill
111
Psychologic:
Physical change in parameter
112
Affective
indicates change in pts attitude, values, and beliefs
113
Goal Outcome criteria
Pt will do what action, how well, & by when
114
What is an example of an affective outcome?
Mother will verbalize the benefits of following discharge instructions
115
Nursing Interventions
Independent nursing actions, physician initiated interventions, & collaborative interventions
116
Intervention and Rationales for Pain
Intervention: teach patient correct dosage, time frame, and precaution for taking analgesia
Rationale: knowing when and how to take pain medication will maximize pain relief and minimize adverse effects
117
Evaluation
Indicate if the outcomes/goals were met or unmet
Indicate actual behavior as supporting evidence
If goal was not met , make recommendations for revising the plan of care
118
What activity is carried out during the implementing step of the nursing process?
Planned nursing actions (interventions) are carried out.
119
A nurse writes down the following outcome for a depressed patient: "By 6/9/12, the patient will state three positive benefits of receiving counseling." This is an example of which of the following types of outcomes:
affective
120
Who or what is the primary source of information for a nursing history:
the patient
121
Which of the following are verbs that are helpful in writing measurable outcomes:
Define, list, verbalize
122
A student identifies Fatigue as a health problem and nursing diagnosis for a patient receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this patient problem:
I think fatigue is a problem for you; do you agree?
123
What type of data would you call nausea and abdominal pain?
subjective
124
Which of the following patient care concerns is clearly a nursing responsibility:
Monitoring health status changes
125
This is an example of a:The patient will be able to list five symptoms of infection on discharge
well written outcome
126
Which part of this diagnosis is considered the problem statement?
Processes related to Alzheimer's disease as evidenced by incoherent language.
Disturbed thought process
127
Can you give a pt's spouse info over the phone w/o their permission?
No
128
HIPPA
1 Provides provision for patient: they can see and copy medical records at any time
2 Viewing medical records: patient is allowed, cannot review medical record unless that is your patient for that day
3Telephone conversation: who ru talking 2? Do u have permission to talk w them?
4Hallway/waiting room conversation: not talking about patients, keep patient conversation confidential
5Information to family members and friends: need to get patient’s permission
129
Goals of documentation?
```
Delivery of quality patient care
Continuity of care
Communication of treatment goals
Progress toward goals
Interdisciplinary consistency
```
130
Pt transfer should be done:
face to face, give synopsis of pt
131
SBAR
S= situation, what is occurring at the time
B=background, what lead up to current situation
A= assessment, what is going on
R=recommendation, what do we want/expect to correct current problem
132
Quality inferential statement
Seemed/appeared statement: not inappropriate
We can infer things based on knowledge and relationship of patient
But must provide reason why you think this is occurring
Documentation Errors
133
How to document errors on hard copies
Single line in the error
Write word ERROR
Take accountability (name, credential, time)
134
SOAP Notes
Subjective
Objective: measurable
Analysis
Plan: what should be done
135
DAR Note
Data, Action, Response
136
Charting By Exception
Conclusive to electronic record
Identify what hospital course should look like and critical pathway toward getting better
Much of it is a checklist
Variable chart
137
Electronic Heath Record
```
The patient is focus of the chart
Report the facts
New/change information and objectives
Support subjective data with objective feeds
Chart things done for the patient
Avoid personal opinions and biased statements
Chart problems with actions taken
Chart patient response and reaction
```
138
In which of the following cases should a progress note be written:
When admitting a patient, When receiving a patient postoperatively, When a procedure is performed
139
What is evaluated when conducting a nursing audit
Patient records
140
Decode versus encode
```
decode= pt understanding the message
recode= encoded message that nurse must decode
```
141
Genuineness
present yourself honestly and spontaneously
142
Empathy
ability to perceive another person's’ situation and view it from that perspective
143
Concreteness
Promote understanding & sensibility
144
Vocal paralanguage
Our words & how we deliver them: Tone, pitch, volume, rate of speech
145
3 elements of communication
words 7%
tone 38%
body language 55%
146
Validating
You state the words as you heard them
147
Clarifying
You make sure you understand what the pt said
148
Reflection
repeating what the person said or describing the person's implied feeling--> restate emotional component
149
Directing/focusing: ask for elaboration on the topic
asking for elaboration on a topic
| Tell me more about _______
150
What term describes a nurse who is sensitive to the patient's feelings but remains objective enough to help the patient achieve positive outcomes:
empthetic
151
Narrow index of therapeutic & toxicity
Liver
Kidney
GI
152
Height + weight can be used pharmokinetically
Body surface areas (BSA) used for drug dose calculations
153
FDA
```
Responsible for public safety of drug
Responsible for sales and marketing (effectiveness)
controls drug advertisement
Control what drugs need prescriptions
Prevents unsafe drugs for being marketed
```
154
Class 2
most perscribed drugs, usually narcotics, highly reguated, require 2 nurses
155
Class 5 drugs
OTC drugs
156
Drug order components
```
Patient name
Date and time written
Medication name
Medication dose
FREQUENCY OF ADMINISTRATION
Route of administration
SIGNATURE WHO GAVE THE ORDER
```
157
One time order
usually a loading dose
158
repeat order
use judgement with your assessment, usually a time parameter and may be ordered to give but otherwise use your judgement
159
1 grain=
60 mg
160
1mg=
1000mcg
161
1000mg
1,000,000mcg
162
1mL
15 gtts (drops)
163
15mL=
3tsp= 1TBL
164
30mL =
1 fl oz
165
240mL
8fl oz= 1 cup
166
How to pour liquid meds
```
Pour liquid medication at eye levels
Read dose at the base of meniscus
Pour away from label
Drug calculation:
Drug on hand/quantity on hand= dose required/ X quantity desired
```
167
3 administration checks
check drug matches, MARS when retrieve medication
Re-check ever med after retrieval against MAR
Before give each med, check MAR
168
Document
As soon as given, & give reason, document response to medication, 15-30 min after given
169
AD AS AU
```
AD= right ear
AS= Left ear
Au= both ears
```
170
NOC
night
171
DS
Double strength
172
ung
ointment
173
Write out daily, every other day, write out unit, use mL, use international units
tid is not as accurate as Q8hr
No QD or anythin
174
Do not use transdermal patch if
pt has temp > 102
175
when administering oticlly in adults
pull pinna up and back.
| after giving meds, massage tragus
176
when administering otically in kids
pull pinna down and back
177
Intradermal injection locations:
inner forearm, upper arm, across scapula
178
technique for bevel needle in intradermal injection
Control depth
DO NOT BEVEL DOWN,Bevel down will push into subcutaneous tissue.
Inject at 5-15 degree angle
179
Measure induration of intrdermal injection
hardening of bleb is a positive reaction
180
Subcutaneous injection
```
0.5-1.0mL
small gauge 25-28 gauge
Sites: abdomen, upper arm, back of thigh
Needle length
Needle insertion angle
1 inch bunch: 45 degrees
2 inch bunch: 90 degrees
```
181
Insulin
```
agitate suspension
Observe for lipodystrophy: depression of the skin due to bad rotation and cold insulin injection
Use one inch rule
25-30 gauge
1/2-5/8 in needle
Draw from NPH last
```
182
Heparin
25-28 gauge
5/8-7/8 needle length
insert away at 90'
183
Intramuscular Injection
use 3-5mL injection
19gauge-25 needle
5/8in-3in needle
Z-tracking recommended for all IM injections
184
Deltoid IM
```
Max 2mL
midaxillary line
2.5-3cm below acromion process
5/8-1.5 in needle
Close to radial nerve & brachial artery
```
185
Vastus Lateralis
Best for toddlers
Not around nerves or vessels. Inject into outer middle third
5/8 -1.5 needle
186
Ventrogluteal
```
Free of blood vessels & major nerves
Considered safest & least painful
Not recommended for older adults
typically 1.5 in
up to 3 mL
Landmark: greater trochanter (heel of hand), anterior superior iliac ===spine (pointer), iliac crest (middle finger)
```
187
Dorsogluteal
Not recommended
Close to sciatic nerve
Superior gluteal artery
Thick layer of fat
188
Draw up orders
Draw up vial before ampule
Draw up multi-dose before ampule
Prefilled syringes are norally overfilled
189
Actovial
when you press down to the top, the diluent mix with the powder
190
Which parts of the needle should be kept sterile?
The needle, the inside of the barrel & the part of the plunger entering the barrel
191
What should you do if your needle is coated with liquid?
change needle
Viscous that can't be in subcutaneous tissue change needle
Always change for z-tracking
192
Tuberculin Syringe (Tb)
```
Small and narrow
Holds 1 mL
.01 marking
¼ or ½ needle
change needle for SL or IM use
```
193
Factors to consider for needle length
¼ - 3 inch)
Muscle mass
Adipose tissue
Look at patient and make judgment
194
Factors to consider for needle diameter
14-29
Lower number: the larger diameter
Considered by viscosity or medication to be administer
195
Contaminates the plunger after the medication is drawn into the syringe do you have to discard it?
No, administer as prescribed
