Nur 182 Unit 1 Flashcards
(87 cards)
1
Q
Respiration involves
A
Ventilation diffusion and perfusion. Activation of the respiratory center occur via impulse from chemo receptors located in the aortic arch and carotid artery be a stretch and Irritant Receptors in the long via receptors in muscle and joint. CO Is the most powerful respiratory stimuli causing an increase in Respiratory depth and rate. The cervical cortex of the brain allow voluntary control her breathing.
2
Q
Ventilation(breathing)
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Movement of gas in and out of the lungs. Inspiration(Inhalation)Is the active breathing in. Expiration(Exhalation)The act of breathing out. Has both autonomic and voluntary control.
3
Q
Diffusion
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The exchange of oxygen and carbon dioxide between the alveoli of the Lung and the circulating blood
4
Q
Perfusion
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The exchange of oxygen and carbon dioxide between the circulating blood and tissue cells
5
Q
Factors affecting respiration
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Each exercise acid base balance brain lesions increase altitude respiratory diseases Anemia Anxiety medication acute pain
6
Q
Age
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The respiratory rate decreases with age ranging from my normal range of 30 to 55 breaths per Minute and a newborn to 12 to 20 breaths per minute in an adult
7
Q
Exercise
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Exercise increased respiratory rate and death
8
Q
Acid base balance
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Alternation in acid base balance especially acidosis(Build up of acid in blood stream)Commonly results in increased rate and depth of respiration(Hyperventilation)
9
Q
Brain lesions
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Lesion of the brain or brain stem can cause a change in Both the death and rate of respiration most commonly manifested As Cheyne stroke respiration(Abnormal breathing pattern)
10
Q
Increase altitude
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As an adaptation to higher altitude healthy people may exhibit Cheyne stokes respirations Especially when asleep.Higher altitude also increased respiratoryRate and depth prior to adaptation by increasing hemoglobin level.
11
Q
Respiratory disease
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Any alternation in the normal respiratory structure may result in changes in respiratory rate death and patterns most often manifested as difficulty breathing using accessory muscles of respiration and increase rate the depth maybe shallower. smoking can alter the pulmonary airway resulting in an increase in respiratory rate at rest
12
Q
Anemia
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A decrease in oxygen carrying hemoglobin may result in an increased rate of respiration
13
Q
Anxiety
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Can cause sighing type respiration(increased depth)And increase rate
14
Q
Acute pain
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Increased respiratory rate but may decreased respiratory depth
15
Q
Eupnea
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Normal unlabored respirations
16
Q
Tachypnea
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Increased respiratory rated. Fever anxiety exercise respiratory disorder
17
Q
Hyperventilation
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An increase in carbon dioxide and a decrease in oxygen in the blood increase the rate and depth of respiration.There is more than Normal amount of air entering and leaving the long.Extreme exercise beer diabetic Keto acidosis(kussmaul respiration)
18
Q
Bradypnea
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Decrease in respiratory rate occurs in some pathological condition.Medication or brain damage
19
Q
Apnea
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Periods during which there is no breathing
20
Q
Dyspnea
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Difficult or labored breathing usually has rapid shallow respiration and appear anxious
21
Q
Orthopnea
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Type of dyspnea in which breathing is easier when the patient sit or stand
22
Q
Hypo ventilation
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Decrease rate and depth. Overdose of narcotic or anesthesia.
23
Q
Stethoscope
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Diaphragm is more useful for hearing high frequency sounds such as Respiratory sounds because they screens out low frequency sounds. The bell screens out high frequency sounds and is more useful for hearing low frequency sounds such as those commonly madeBy the heart and the blood within the vessels
24
Q
Hyper ventilation
A
An increase in carbon dioxide and a decrease in oxygen in the blood increases the rate and depth of respiration
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Hypoxemia
Deficientoxygenation of blood
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Hypoxia
In adequate amount of oxygen available to the cells
27
Chest pain
It may worsen with exercise eating or stress. Make sure you describe location radiation intensity and duration. What precipitated the pain in what relieve the pain
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Palpitation
He’s uncomfortable sensation in the chest may be described as flattering, skip beats, pounding, jumping, or irregularity
29
Dyspnea
A client with dyspnea may complain of shortness of breath or that he cannot get enough air. Paroxysmal Nocturnal dyspnea (PND) Occurs at night when the client is in supine position. Austin PND is associated with orthopnea, the need to use more pillows. Dyspnea on exertion(DOE)Is a common phrase. You should also describe what kind and Quantity of exertion bring on dyspnea. To position a dyspnic Client correctly in bed, placed a pillow lengthwise beneath the back and head. The bed is in semi Fowler’s position
30
Syncope
Syncope or fainting is the transom loss of consciousness. It is very important to describe the activity that perceive the syncope. Orthostatic hypertension may be the cause. Orthostatic hypertension is syncope that result from a fall and blood pressure when a person assume an erect position.
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Fatigue
Decreased cardiac output may cause fatigue. Fatigue has many other causes. It is important to indicate when and how long your client felt tired. Assessed fatigue with activities that could want to be done easily, such as walking up a flight of stairs.
32
Edema
Swelling of the legs is a form of dependent Adema. The client with heart disease has edema of both lower extremity’s that worsen as the day progresses. Adema could be reflected in a weight gain of 2 pounds or more in two days. It could also be reflected in a feeling of fullness or abdominal bloating all the time.
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Hemoptysis
Coughing up blood. It is important to ask If the sputum was blood tinged Or if there were actual clots of blood. Hemoptysis May also be associated with many pulmonary diseases.
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Cyanosis
This bluish discoloration is best seen first hard palate second Scalera third mucous membrane of the mouth and lips generalize. Or body organs are at affected from prolong hypoxia. Central cyanosis appear in highly vascular areas the lips nailbed tip of the nose ear and the underside of the tongue. In dark skin client access the oriole mucosal membranes and lips. This area will appear gray rather than the bluish tent down in light skin client
35
Orthopnea
What are open near usually occurs 1 to 2 minutes after a client lies down to get comfortable the client will prop them self up with a pillow. To assess the severity of the problem know how many pillows are use in any change in the number of pillows needed for relief. Sometimes orthopnea can be so severe that the client sleep upright in a lounge chair.
36
Erythema
Redness of the skin most often seen in the face and neck
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Jaundice
Yellow color of the skin Resulting in liver and gallbladder disease
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Pallor
Paleness of the skin often resulting from an in adequate amount of circulating blood or hemoglobin causing in adequate oxygenation of the body tissue
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Modifiable cardiovascular risk factors
Smoking, hypertension, obesity, physical inactivity, emotional stress,hypercholesterolemia
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Component of pain assessment
Patient verbalization and description of the pain. Duration of the pain. Location of the pain. Quantity and intensity of the pain. Quality of the pain. Chronologically of the pain. Aggravating factor of the pain. Alleviating factor of the pain. Physiologic indicator of the pain. Behavioral response. The back of the pain experience on activities and lifestyle. Patient self report. Report of family members other people close to the patient or caregiver who is familiar with the patient.Nonverbal behaviors. Physiological measures(Increase blood pressure and pulse).The absence of an increase in vital sign does not mean that he is not present.
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Comfort scale
Infants children adults who are unable to use NRS or Wong-Baker FACES pain rating scale.Relies on six behavioral And to physiologic Factors that determine the level of analgesia I needed to adequately relieve pain in these patient.
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Cries-pain scale
Neonates(0-6 months)
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FLACC scale( Face legs activity cry and consolability)
Infant and children two months to seven years who are on able to validate the presence of or quantify The severity of pain.Read each of the five categories on a scale of 0 to 2
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Wong-Baker faces pain rating scale
Adults and children three years and older and all patient care setting. Recommended for pain assessment in older adults.
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0-10 numeric rating scale
Adults and children nine years old and older in all patient care setting were able to use numbers to read the intensity of their pain.Recommended for older adults
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List of non-verbal indicators
Adults who are unable to validate the presence of work quantify the severity of pain using either the numeric rating scale or Wong-baker scale faces pain rating
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Oucher pain scale
Young children who can point to a face to indicate their level of pain
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PAINAD scale (Pain assessment in advanced dementia)
Patients who dementia is so advanced that they cannot verbally communicate.Observation of breathing, vocalization, facial expression, body language, and consolability.
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FPS-R ( Faces pain scale-revised)
Young children in parallel with numerical self rating scale. Patient use the depiction of a facial expression the best correspond with their pain. Recommended for older adults
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Payen behavioral pain scale
Useful with intubated Critically ill patients measurement of bodily indicators of pain and tolerance of intubation.
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Iowa pain thermometer
Vertical pain scale. Referred by older adult
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Vital signs
Blood pressure, pulse apical and radial, respiration, temperature and pain assessment And pulse oximetry.
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Blood pressure
The American Heart Association recommends requiring blood pressure as systolic muffling disappearance - 126/70/66. Low blood pressure hypotension 90/60 - confusion dizziness weakness pale cyanotic or cool skin. High blood pressure hypertension 130/80 - Headaches nosebleed flushing anxiety or pain.
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Apical radial pulse
Bradycardia heartbeat below 60 bpm.Tachycardia heart beats above 100 per minute. Normal finding heartbeat between 60 to 100 bpm. Quality normal bread or bounding.Rhythm abnormal or a regular.
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Respiration
Normal rate is 12 to 20 breaths per minute. If abnormal count respiration for a full minute. If audible breath sounds are heard Note on inspiration or expiration
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Temperature
If patient temperature is elevated ( 37.8 c or 100 f ) - febrile. Patient temperature is normal -afebrile. In the acute setting most temperature are obtain using an electronic thermometer. Glass thermometers are use for clients on isolation. Contra indication unable to hold thermostat in mouth too weak mouth breather oral surgery seizure disorder or recent hot or cold liquid in the last 15 minutes
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Pulse oximetry
Can be attached to finger toes or ear lobe. The following factors can interfere with the accuracy of oxygen saturation-Hypotension, hypothermia, Vasoconstriction, Movement of the finger, low perfusion, cigarette smoking, and finger nail polish. Normal for adults 95 to 100% acceptable range for elderly is 92% to 100% value less than 92% in adult may suggest respiratory compromise
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Pulse physiology
Horses are regulated by the autonomic nervous system through the sinoatrial node.Parasympathetic stimulation of the Vegas nerve flow the pulse rate while sympathetic stimulationIncreases the heart rate. The pulse rate is the number of Pulsation felt or palpated over the peripheral artery. This same pulse rate can be also heard over the apex of the heart(apical)
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Pulse amplitude
The quality of the path in terms of its fullness and strength assessed by the feel of the blood flow through the artery as describe one plus equal weak or Tready pulse 2+ equal normal pulse 3+ equals stronger than normal 4+ equal bounding pulses
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Dysrhythmia
Irregular pulse rhythm. Have Pauses without a pattern also called bisferiens, pulses alternans and bigeminal.
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Doppler ultrasound
A special tool used to assess peripheral pulses are difficult to palpation. And audio unit with an ultrasound transducer. Most often use on the pedal pulse.
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Pulse deficit
Difference between the apical pulse And the radial pulse.
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Auscultation heart sound
Aortic area -Second intercostal space to the right of the midsternum. Pulmonic area - Second intercostal space to the left of the midsternum. Erbs point-Third intercostal space left of the midsternum. Tricuspid area - Fourth intercostal space laugh of the midsternum. Apical area-Fifth intercostal space Left mid clavicular.
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Conditions that mayAltered heart rhythm
Infections, diseases of the heart muscle or conducting system, dehydration, overhydration, endocrine disorders, respiratory disorders,And head trauma.
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Normal capillary refill is less than three seconds.
Abnormal findings include an absent, week, thready pulse, A forceful or bounding pulses, and A asymmetrical pulse.So long capillary refill is associated with alternations in peripheral perfusion in cardiac output. Other assessment to determine arterialBlood flow include Allen’s test and buerger rest.
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Palpating Peripheral pulses
Use the pad of the index and middle finger to palpate pulse is for amplitude and symmetry.
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Peripheral vascular disease
Decreased blood flow in oxygenation of tissues.The skin of the lower extremities is typically peel and core, shiny with brown discoloration, and hairless. The toenails are thickened. Phlebitis ( Inflammation of a vein) Of the lower extremity is indicated by pain, redness, and swelling of the affected calf or thigh.
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Neurovascular assessment
Pain, Pallor, Peripheral pulses, paresthesia(sensation),paralysis,pressure.
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Common cardiovascular and peripheral vascular variation in newborns and children
Visible cardiac Pulsation if the chest wall is thin. Sinus dysrhythmia (The rate increases with inspiration in decreases with expiration).Presence of S3(in about 1/3 of all children - heart murmurs). More rapid heart rate ( until about 8 years of age)
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Carmen cardiovascular and Peripheral Vascular variation in older adults.
Difficult to palpate apical pulse. Difficult to palpate distal arteries. Dilated proximal artery.More prominent and tortuous blood vessels; varicosities common. Increase systolic and diastolic blood pressure. Widening pulse pressure.
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Impaired peripheral tissue perfusion
The state in which an extremity Has in adequate circulation which deprive the cells of nutrition and exchange of O2 and CO2. Assessing the parade for your vascular system include measuring the blood pressure, palpating peripheral pulses, and inspecting the skin and tissue to determine perfusion to the extremities.
72
Homans sign
I asked the patient if there is any soreness or pain in the calf while The Foot is Dorsiflex.If the patient has pain with Dorsey flexion the homam sign is Positive and may indicate an inflames vein(phlebitis) or and deep vein thrombosis (DVT)
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Assessing peripheral tissue perfusion
Palpate Pulse.Note capillary refill,Note the skin temperature, Note color change when the extremity is dangle. Inspect the nails for color and thickness. I asked the patient to describe the sensation in the extremities.homam sign. Assess the skin on the extremities for slow healing ulcer wounds shiny skin or lack of hair
74
SBAR
Stands for situation, background, assessment, and recommendations, provides a consistent method for handoff communication that is clear structured and easy to use. This technique was originally developed by the US Navy. The SB provide objective data, AR allow for presentation of subjective information. The QSEN Insert to revise the standard S bar form to include an initial identification of yourself and the patient(I) And the opportunity to ask and respond to a question or read back(R).
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I-SBAR-R
QSEN revised. Allows a nurse to clearly introduce one self and the patient when communicating with a caregiver during patient hand off or conversation with physician.
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Situation
I am calling about —-.The patient code status is ——. The Problem I am calling about is——.I have just assess the patient personally vital signs are——-. I am concerned about the——.
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Background
The patient mental status is—-. The skin is———.
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Assessment
This is what think the problem is——. The problems seem to be—-.The patient seem to be on stable I am may get worse we need to do something.
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Recommendation
Too physician ——-. Ex transfer the patient. Are any test needed? —- ex. EKG.
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Values
A belief about the worth of something about what matters That acts as a standard To guide one behavior. Values are formed during a lifetime involving influence from the environment family and culture.
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Value system
And organization of values in which each is rank among a continuum of importance often leading to a personal code of conduct.
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Professional values of a nurse
Atruism, autonomy, human dignity, integrity, and social justice.
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Altruism
The nurse concerns for the welfare of patients other nurses and other healthcare providers. Demonstrate understanding of culture believes in perspective of others. Advocates For patient. Take risk on behalf of patients and colleagues.Mentors other professionals.
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Autonomy
The right to self-determination. The nurse respect patient rights to make decisions about their healthcare. Plan care in partnership with patient. Honors the right of patients and families to make a decision about Healthcare. Provide information so that patient can make informed choices.
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Human dignity
Respect for the inherent worth and uniqueness of individual in population. Human dignity is reflected when the nurse values and respect our patients and colleagues. Provide cultural component and sensitive care. Protect the patient privacy. Preserve the confidentiality Patient and healthcare provider. Design care with sensitivity to individual patient needs.
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Integrity
Acting in accordance with an appropriate code of ethics and excepted standard of practice. The nurse is honest and provides care based on an ethical framework that is accepted within the profession.Provide on his information to patient and the public. Documents care accurately and honestly. Seek to remediate errors made by self or others. Demonstrate accountability for Own actions.
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Social justice
Upholding moral legal and humanistic principles. The nurse work to assure equal treatment under the law and equal access to quality healthcare. Support fairness and non-discrimination in the delivery of care. Promote universal access to healthcare. Encourage legislation and policy consistent with the advancement of nursing care and Healthcare.
