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NURS 330 > Quiz 1 > Flashcards

Quiz 1 Flashcards

1
Q

Normal heart rate

A

60-100

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2
Q

Normal blood pressure

A

120/80

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3
Q

Normal respiration rate

A

12-20

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4
Q

Normal temperature

A

36.5-37.5 (varies with age)

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5
Q

Normal oxygen saturation

A

Sp02 greater than 95$

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6
Q

Early signs of hypoxia

A
  • Anxiety, irritability, confusion
  • lethargy
  • Dyspnea when moving
  • increased RR
  • mild WOB
  • increased HR
  • Diaphoresis
  • SpO2 slight lower and PO2 lowering
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7
Q

Late signs of hypoxia

A
  • Lethargy
  • combativeness
  • dyspnea at rest
  • pause to breath when talking
  • severe (moderate) WOB
  • hypotension, cyanosis, cool/clammy skin
  • diaphoresis
  • Sp02 below 90% and P02 below 60mmHg
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8
Q

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are some mild signs of hypoxia?

A

Lethargy, dyspnea on exertion, Sa02 of 93%, mild WOB

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9
Q

Nurse is caring for a patient with asthma. Which method should the nurse use to determine the patients oxygen saturation?

A

Least mild way - pulse oximetry

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10
Q

Dyspnea

A

Shortness of breath regardless of the position (respiratory and cardiac disease)

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11
Q

Orthopnea happens when

A

Breathlessness sensation when laying down - relieved by sitting or standing (COPD and heart failure)

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12
Q

Paroxysmal nocturnal Dyspnea

A

Wakes patient from sleep (heart failure)

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13
Q

Subjective data during head to toe respiratory assessment

A

Background info on respiratory diseases, shortness of breaths, productive cough, what ever else the patient may say

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14
Q

Head to toe respiratory assessment (objective data)

A
  • using oxygen (is it working?)
  • work of breathing
  • symmetrical chest rise
  • listening to breath sounds
  • sputum
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15
Q

Auscultation

A

Listening through stethoscope

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16
Q

Fine crackles (BS)

A

Passing through small air passages and alveoli
- end of inspiration
- hair rolled between fingers

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17
Q

Medium coarse crackles

A

I’m bronchioles, bronchi, and trachea
- like hair crackles by louder and at early to mid inspiration

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18
Q

Wheezes (rhonchi)

A

Passing through small airways by secretions, swelling, tumors (common with asthma)
- continuous (expiration)
- high pitched, musical, wheezing

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19
Q

Stridor

A

Partially obstructed trachea
- crowing sound
- during inspiration

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20
Q

Decreased air entry

A

Collapsed alveoli
- decreased to no sounds of air (very quiet)

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21
Q

Cyanosis

A

Blue skin
- not enough circulating oxygen
- late sign of Dyspnea and hypoxia

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22
Q

Clubbing

A

Thinking of nail bed

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23
Q

How should a normal chest x-ray look

A

Dense materials (heart, bones) are white and lungs (air filled) should appear black

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24
Q

Pulse oximetry

A

Non invasive
- measures Sp02 (oxygen saturation) in blood

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25
Q

Arterial blood gas (ABG)

A

Measures oxygen (P02) and carbon dioxide (PC02) in the blood and tests acidity pH
More invasive

26
Q

Nursing care for patient with respiratory illness

A

POSITION PROPERLY
- teach breathing techniques
- effective coughing
- manage fluids
- meds
- oxygen
- activities of daily living
- explore lifestyle and activities adaptations to increase quality of life

27
Q

Flowers position

A

Help facilitate ventilation by pulling diaphragm down (gravity helps pull air into lungs)

28
Q

Tripod position

A

Helps diaphragm move downwards to increase volume to pull air into lungs (lay sideways in bed or stand with hands on knees)

29
Q

What are controlled breathing techniques

A

Pursed lip breathing, diaphragmatic breathing, breathing focus

30
Q

Pursed lip breathing

A

Slows breathing, increase peep to open alveoli, breath in through nose (2) and out through puckered lips (4)

31
Q

Diaphragmatic breathing

A

Expanding abdomen when breath in and inhaling big

32
Q

ICOUGH

A
  • incentive spirometer exercise
  • cough and breath deep
  • oral care
  • understand icough practices
  • get out of bed and move
  • head of bed elevated
33
Q

What areas do respiratory diseases effect

A

Airways and lungs

34
Q

What are the 2 types of chronic respiratory diseases

A

Restrictive and obstructive respiratory disease

35
Q

Restrictive respiratory disease

A

Reduces volume of air lungs can hold, lose elasticity and ability to expand (pneumonia)

36
Q

Obstructive respiratory disease

A

Blocked/narrowed airways that are difficult to do gas exchange (asthma and COPD)

37
Q

What is the number one cause of chronic respiratory disease

A

Smoking

38
Q

Breathless scale

A

Grade 0: strenuous exercise
- 1: SOB when walking up hill (hurrying)
- 2: walks slower, makes stops to catch breath
- 3: stops after 100m or few mins
- 4: too breathless to leave house, dressing

39
Q

What is pneumonia

A

Inflammation of the lung tissue and alveoli (gas exchange)

40
Q

Infectious pneumonia

A

Caused by bacteria (fungus, Viral)
- walking pneumonia (mild)

41
Q

Non-infectious pneumonia (aspiration)

A

Swallowed foreign substance
- people at risk have (decreases LOC, dysphasia, NG tube

42
Q

What is the inflammatory process of pneumonia

A

Fluid goes into tissues and fluid blood goes in after to try and fight off the infection creating a wet/warm environment for bacteria to grow

43
Q

Opportunist pneumonia

A

Lowered immune system
- HIV, chemotherapy, long-term corticosteroid use

44
Q

Hospital acquired pneumonia

A

48hrs after admission
- most lethal, immunocompromised

45
Q

Causes of pneumonia

A
  • Congestion (fluid in lungs) COPD, Cancer, smoking
  • low white blood cells (can’t fight infenction)
  • microphages and microcilia damaged and can’t remove foreign objects
46
Q

Risk factors of pneumonia

A
  • weak cough (ineffective)
  • aspiration
  • feeding tubes
  • meds slowing breathing
47
Q

Phase 1 of pneumonia

A
  • congestion days 1-2
  • inflammatory response (fluid fills alveoli)
  • cough
48
Q

Phase 2 of pneumonia

A
  • Red hepatization
  • 3-4days
  • lungs red and firm (high blood levels)
  • influx of neutrophils
49
Q

Phase 3 of pneumonia

A
  • gray hepatization
  • 5-7 days
  • RBC broken down and blood flow decreases (gray color)
50
Q

Phase 4 of pneumonia

A
  • Resolution
  • day 8-4weeks
  • exudate digested and destroyed by microphages or coughed up
51
Q

Signs and symptoms of pneumonia (assessment)

A
  • varies from cause
  • fever, fatigue, exercise intolerance, cough (dry to congested), chest wall pain, tachypnea (altered Sp02), complains of SOB, increased WOB, crackles or diminished air sounds (only in certain areas)
52
Q

Diagnostic to pneumonia

A
  • chest x-ray (needed)
  • CBC blood test, WBC count (high with infection), neutrophils (elevated with infection), Sp02 decrease, get sputum sample if productive
53
Q

Nursing interventions with pneumonia

A
  • monitor
  • raise head of bed
  • balance activity with periods of rest
  • high calorie and high protein
  • 2-3L water
  • ICOUGH protocol
54
Q

Patient education (pneumonia)

A
  • watch for symptoms
  • prevention (less smoking, healthy diet and exercise, hydration
55
Q

Complications to watch for with pneumonia

A
  • respiratory failure
  • sepsis (infection in blood stream)
  • pleural effusion
56
Q

What is pleural effusion

A

Fluid in between parietal and visceral pleura limiting lung capacity (lungs can collapse)

57
Q

What is asthma

A

Inflammatory chronic condition that causes airway obstructions

58
Q

What are the 2 ways airways can be obstructed with asthma

A

Inflammation and bronchoconstriction

59
Q

Inflammation constriction in asthma obstructs where?

A

Interior of airway

60
Q

Bronchoconstriction obstructs what airway with asthma

A

Exterior
- internal membranes swell
- outside muscles are less effected
- narrowing bronchi and bronchioles
- can be caused by PNS activation.

61
Q

Common asthma triggers

A

Allergens, respiratory infections, exercise, inhaled irritants, emotional stress

NURS 330 (4 decks)

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