Section 1 Flashcards
(361 cards)
1
Q
Physiology
A
The study of the functional activities of the body
2
Q
Pathophysiology
A
The study of disordered function of the body
3
Q
Compensatory Mechanisms are
A
The body’s attempt to restore homeostasis
4
Q
When compensatory mechanisms are not adequate, function becomes disordered leading to
A
pathological mechanisms or disease.
5
Q
How do we define Stress?
A
A real or perceived threat
6
Q
How do we define Goals when it comes to stress?
A
Adaptation
7
Q
The Stress coping process is
A
a compensatory process with physiological and psychological components
8
Q
How do we define Stressors?
A
An internal or external event or situation that creates the potential for physiologic, emotional, cognitive, or behavioral changes in the individual
9
Q
What are the 3 classifications of stress?
A
- Day-to-day
- Major, complex occurrences
- Life events
10
Q
What is “hardiness”?
A
Perspective on stress that it can be meaningful, is a learning opportunity, giving it a positive spin with determination/grit
quality that can be taught - essential for coping with stress
11
Q
What are the two branches of the Autonomic Nervous System (ANS)?
A
- Sympathetic Nervous System (SNS)
2. Parasympathetic Nervous System (PSNS)
12
Q
It is the ___, with its neurotransmitter of norepinephrine that is activated in response to stress.
A
SNS
13
Q
The body’s physiologic response to stress is a ___ response that affects the entire body.
A
rapid and short-lived
14
Q
What is an example of a compensatory mechanism?
A
Increased respiratory rate after sprinting
15
Q
Stress causes
A
imbalance to equilibrium
16
Q
Which type of stress impacts health in the greatest way?
A
Day-to-day
17
Q
Examples of “major, complex occurrences” classification of stress
A
Hurricanes, terrorism, floods
18
Q
Helping patients to ____ is important in the stress coping process
A
identify stressors
19
Q
Remember that the PNS is the ___ system
A
“rest and repose”
the SNS is activated by stress
20
Q
Because of the ___ produced by the SNS, the body experiences ___ effects during stress
A
norepinephrine
adrenergic
21
Q
Common adrenergic effects of stress
A
- Shunting of blood TOWARDS the heart and brain and AWAY from the GI system and peripheral –> because of this, patient can look pale and feel cool
- Bronchodilation –> respirations become rapid, but shallow
– Increased blood sugar and lipid levels
22
Q
Alpha receptors affect the ___ and cause ___
A
arms and legs
Peripheral vasoconstriction
23
Q
Beta 1 receptors affect the
A
cardiac system
positive inotropic and chronotropic (increase heart rate and force of contraction)
24
Q
Beta 2 receptors affect the ___ and cause ____
A
lungs
cause bronchodilation
25
4 maladaptive ways of coping with stress
1. Drugs and alcohol
2. “Type A” personalities (impatient, competitive, hostile)
3. Denial
4. Avoidance
26
People tend to have a ____ of behavior during stress
characteristic pattern
27
___ is most essential for nurses helping patients deal with stress, as is enlisting support
Patient teaching
28
4 main Nursing Implications for stress
1. Early identification of stress
2. Promote a healthy lifestyle
3. Use education
4. Enlist support
29
Infants are about ___ % water
70-80%
30
Adults are about ___% water
60%
31
Geriatric/elderly are about ___% water
45-50%
32
What 2 patient populations are most at risk for fluid imbalance?
infants and elderly
33
___ hospital patients require IV fluids. The only time a patient doesn't need IV fluids is if they're ____
Most
eating and drinking normally
34
Intracellular fluid (ICF) is ___ of overall body fluid
2/3
35
What is the prime cation of ICF?
K+ (potassium)
36
What are the 2 components of extracellular fluid (ECF)?
1. Intravascular (Plasma)
| 2. Interstitial
37
extracellular fluid (ECF) is ___ of overall body fluid
1/3
38
What is the prime cation of ECF?
Na+ (sodium)
39
For intake and output, remember that 1 oz =
30mL
40
The walls between the ECF and ICF are ___, meaning that water and electrolytes can flow back and forth
porous
41
On average, people usually take in about ___ mL of fluids per day, as well as ___ mL from food
1300mL
1100mL from food
42
Oxidation accounts for __ mL fluid input
200mL
43
Total average daily input and output should be
2600mL
44
On average, urine accounts for ___ mL fluid output, feces accounts for ___ mL fluid output, and insensible (lungs and skin) account for ___ mL?
1500 mL urine
200mL feces
300mL from lungs, 600 from skin
45
```
If the I and Os reads breakfast as:
-4 oz of apple juice
-6 oz of coffee
-2 oz milk
-2 slices of toast
-1 pat of butter
What is the total intake in oz?
```
12 oz (don't count the toast and butter)
46
hydrostatic pressure is
The pressure exerted by a fluid at equilibrium at a given point within the fluid, due to the force of gravity
weight and volume of water
47
If we give too much fluid too fast, the increased volume can lead to increased ____ which will lead to ____
hydrostatic pressure
leaking fluid out of the intravascular area -- this causes edema
48
Osmotic Pressure
of particles in each compartment that keeps water where it is suppose to be
49
Osmolality
of particles in a kg of fluid
50
Osmolality normal levels
285-295 mOsm/L
51
Osmolarity
of particles in a L of fluid
52
1L water =
1 kg (2.2 lbs)
53
Remember that water diffuses from a ___ concentration to a ___ concentration
high to low
54
What are the 3 main things that draw water and increase osmotic pressure?
1. Glucose
2. Albumin
3. Sodium
55
Osmolality and osmolarity are often used interchangeably, but ___ is used more often in clinical settings
osmolality
56
As osmolality increases, patient may develop
fluid deficit
57
As osmolality decreases, patient may develop
fluid volume excess
58
When blood volume or BP is low, ____ detect change in pressure
baroreceptors
59
What 2 hormone-related processes occur when blood pressure is low?
1. Renin-Angiotensin-Aldosterone System
| 2. Posterior pituitary releases ADH
60
What 2 things happen in the Renin-Angiotensin-Aldosterone System?
1. Renin secretes angiotensin I, which activates angiotensin II and leads to increased BP
2. Renin leads to the secretion of Aldosterone, which means the kidney retains H2O and Na -- this increases blood volume and pressure
61
What happens when the posterior pituitary releases ADH?
the kidney retains H2O and BP and blood volume are increased
62
Remember that increased BP means increased
preload
63
When blood volume and blood pressure are high, ___ is secreted by the atria and ___ is secreted from the ventricles
ANP
BNP
64
BNP is most often used in measurement because
it's a lab test that can find out if patient issues are cardiac or pulmonary in origin
65
If patient issues related to high BP and blood volume are cardiac-related, BNP would be
very high
66
ANP and BNP are ___ enough to totally overcome the compensatory mechanism of the baroreceptors and reactive systems
NOT
67
How do both ANP and BNP decrease blood pressure?
they decrease systemic vascular resistance which increases the loss of water and Na
68
Atrial Natriuretic Peptide (ANP) is secreted by the ___ when the blood volume or BP is ___
atria
high
69
Atrial Natriuretic Peptide (ANP) and B-type Natriuretic Peptide (BNP) both inhibit
Renin-Angiotensin and the SNS
70
BNP is a diagnostic tool for what types of conditions?
CHF, PE, and pulmonary HTN
71
B-type Natriuretic Peptide (BNP) is secreted by the ___ when ____
by the ventricles when heart muscle is stretched
72
Shock is ___ process
dynamic
73
when a patient goes into shock, it affects
every single body system
74
shock is a state of inadequate circulation, which means
inadequate blood flow to vital organs (brain and heart) which means inadequate delivery of oxygen at the cellular level
75
When a patient is in shock or cardiac arrest, one of the issues is ____ due to lack of oxygen
buildup of lactic acid
76
The decrease of oxygen to cells in shock forces them to start producing ATP ___, as opposed to it being a ___ process normally
anaerobically
aerobic is normal
77
Shock occurs at the ____ level and leads to ___
cellular
cell death
78
3 types of shock
1. hypovolemic
2. cardiogenic
3. distributive (circulatory)
79
In hypovolemic shock, there is a loss of ___ but theoretically the ___ is still functioning properly
circulating volume
heart
80
In hypovolemic shock, the patient becomes ___ and ____
hypoperfused and hypoxic
81
hypovolemic shock can occur in trauma and surgery patients because of
loss of blood
82
hypovolemic shock can occur in burn patients because of
loss of plasma
83
hypovolemic shock can occur in FVD patients with severe dehydration because of
loss of water
84
in Cardiogenic shock, ___ failure occurs in the ___
pump
left ventricle (the working force of the heart)
85
in Cardiogenic shock, when the left ventricle is not able to pump the blood out through the aorta to the rest of the body in a sufficient manner, it causes a
drop in cardiac output
86
in cardiogenic shock, though there may be enough blood in circulation, ____
the heart is not able to move it forward so you’re not getting the perfusion of blood
87
Causes of cardiogenic shock
massive MI/heart attacks
arrhythmias (severe brady or tachy cardia)
anything that can knock out the beating of the left ventricle
88
Distributive (Circulatory) shock is ____ which leads to ____, because the cells are not perfused adequately
massive vasodilatation
pooling of blood in the extremities
89
In distributive shock, the increase in capillary permeability causes decreased
BP and CO
90
3 types of distributive shock
Neurogenic
Anaphylactic
Septic
91
In neurogenic distributive shock, blood gets trapped in ___, which causes ____
blood gets trapped in the periphery
decrease in cardiac output and spinal pressure
92
Causes of neurogenic distributive shock
spinal cord injuries
it's one of the adverse effects of spinal anesthesia
93
Anaphylactic shock is characterized by a release of ___ that causes ___
release of histamine etc. that cause vasodilatation - dropping BP and CO
94
Examples of anaphylactic shock
penicillin allergy
bee sting
blood transfusion reaction
95
Septic shock is often the result of ____, such as in patients with ____
toxins released from bacteria
bad systemic infections, uncontrolled pneumonia
96
3 stages of shock
1. compensatory
2. progressive
3. irreversible
97
Characteristics of shock due to hypoxia
Restlessness (change in LOC)
and a subtle increase in respiratory rate (higher than 20)
98
the compensatory stage of shock often
passes so quickly that we miss it
99
True or false: during compensatory shock, all of the patient's compensatory mechanisms are still working.
True
100
You've been taking care of patient all morning and they’ve been talking to you, everything seems fine, maybe you leave the room for 10-15 minutes and when you come back, you find that he’s leaning over, covers are disjointed, he’s not answering questions with astuteness, appears anxious. What do you do first?
Assess the patient (RR, vital signs, 02 sat)
and call rapid response, or provider (some superior) to come look at the patient
check them for postural hypotension, monitor closely
101
In shock, by the time blood pressure begins to drop, we know that
damage has already been done at the cellular level
102
In the progressive stage of shock, compensatory mechanisms have ___ and patient would be treated in the ___
failed
ICU
103
chances of survival from shock depend on
the pre-shock level of health
104
In progressive stage of shock, fluid starts moving from the ____ to the ____, which causes ____ and ____
moves from the intravascular TO them interstitial
causes EDEMA and drop in cardiac output
105
disseminated intravascular coagulation (DIC) occurs in the progressive phase, and is
massive tiny clotting throughout the body - you see simultaneous clotting AND bleeding (fingers and hands may look blue but they’re also bleeding)
106
Irreversible stage of shock is when the patient
is not responding to treatment
severe organ damage, organ failure, can lead to death
107
Overarching Goals for Managing Patient with Shock (2)
1. limit any further damage
2. improve cardiac functioning
improve oxygenation but DECREASING patient’s oxygen demand
108
In what position should you put a patient in shock?
Modified Trendelenburg - feet at 20 degrees
109
Why do we put shock patients in Modified Trendelenburg?
in order to increase venous return from the legs and bring that blood back into circulation
110
Key parts of shock prevention are
early recognition (restlessness, increase in RR)
careful, constant observation, frequent vital signs
give oxygen - until people arrive to help, put nasal cannula at 2-3L
111
For shock patients, intake and output should be recorded
every hour
112
We give isotonic solutions like ringer's lactate and normal saline (most often used) because
it’s more apt to stay intravascularly and we increase the pressure/volume
113
In terms of comfort for shock patients, we need to recognize that the patient may feel cool because they're vasoconstricted. How should you help them?
if you start layering blankets on them, BP will fall even lower - just put LIGHT COVERS on them and put patient on complete bedrest
114
whether your patient is awake or unconscious, we don’t know when hearing stops, so
you should talk to them, explain what's going on
115
For shock patients, all medications are given
IV
not PO because blood is shunted away from GI tract, not IM because there’s poor perfusion to periphery
116
Goals for medication with shock patients are to ____ AND ____
maintain cardiac output AND decrease cardiac workload
(even though these are two totally opposing pharmacological plans) - must be continually titrated
117
2 prime classifications of medications that are used with shock patients
1. Adrenergics (Dopamine, dobutamine)
| 2. Vasodilators (Nitroglycerin - Tridal)
118
Adrenergics such as dopamine or dobutamine help to ____ in shock patients
increase the cardiac output, help with peripheral vasoconstriction which increases afterload
also a positive inotropic so you’ll have better cardiac contractility
119
Vasodilators such as Nitroglycerin (Tridal) help to ____ in shock patients
decrease preload, which helps the heart not work as hard
| if you decrease the afterload because you have arterial vasodilatation, that also decreases the cardiac workload
120
If the IV infiltrates with a shock patient, what do you do?
get it out and have it restarted!
121
When giving medications to shock patients, make sure that these meds are piggybacked onto our IV, because
that way the lines are preserved and you can stop and start the meds if you need without cutting off or changing the line
122
Vasodilators and adrenergic medications work best when patient has ___, so normally after they are given IV push, the nurse will follow them with ____
pH within normal limits
20 mL of fluid - just open the IV a little bit and let some run in - helps push the medication into central circulation
123
Other PRN medications for shock patients
norepinephrine, epinephrine, anti-arrhythmic
124
“Central lines” usually go into the ___ so that we can ___
right atrium
measure pressures - they can be floated into the pulmonary artery
125
2 ways of inserting right heart catheters - which is less risky?
1. subclavian
| 2. interjugular (less risky)
126
What is the concern with inserting the right heart catheter through the subclavian?
you run the risk of puncturing lung and creating pneumothorax
127
right atrial pressure runs about 6-12, so if patient is less than 6 they have ___, if higher than 12 they have ___
FVD and need more fluids
FVE - be careful
128
When establishing a central line, make sure that the X-ray team is there so that
you can make sure that the catheter is in the correct area (right atrium)
129
6 types of shock complications
```
shock lung or ARDS
GI bleeding
renal failure
liver failure
DIC
MODS (multiple organ dysfunction syndrome )
```
130
hallmark signs of shock lung or ARDS in shock patients are:
Pa02 keeps dropping even though we keep turning up the percentage of oxygen
chest x-ray looks like total whiteout
131
7-10 days after initial shock symptoms, ____ can develop. What is the prophylactic measure?
ulcers (stomach bleeding)
we start them on PPIs before this as a prophylactic measure to prevent that bleeding
132
Shock patients can appear restless because
they are hypoxic, decrease in circulation to the brain
133
How often should you monitor a patient in hypovolemic shock, and what complications are you looking out for?
ever 5-10 minutes because his condition can change quickly and we are concerned that things could deteriorate from here.
Monitoring for: drop in BP that might indicate moving from compensatory to progressive state of shock.
Also for mental status, respiratory, acid-base abnormalities
134
Nursing interventions to decrease restlessness in shock patients include:
Give oxygen that was ordered
Reassure, explain what doing
Ask about pain level, try to get an order for pain medication
135
From case study - order of carrying out orders in event of trauma shock
1. Oxygen at 2 liters/minute via nasal cannula
2. Place two large bore IV’s and infuse 0.9% normal saline at 125 cc/hr in each line
3. Obtain complete blood count, serum electrolytes
4. Type and cross for 4 units of blood
5. Flat plate of the abdomen stat
136
Normal saline is always hung with ___. Because ____
blood
it’s isotonic, and if we’re anticipating that the patient may need a blood transfusion, this is the correct solution to pair with the blood (D5W can cause clotting)
137
COPD is an umbrella term which includes ___ and ___
chronic bronchitis and emphysema
138
COPD affects ___ million adults in the US
11.4
139
COPD is the __ leading cause of death in the US
4th
140
COPD is projected to rank ___ in 2020 for burden of disease world-wide.
5th
141
24 million american adults have evidence of impaired lung function, which suggests
an under-diagnosis of COPD
142
Cigarette smoking is the ___ controllable risk factor for the development of COPD.
primary
143
Alpha 1-antitrypsin (AAT) deficiency is a COPD genetic risk factor that is more often seen in ____ patients
caucasian
144
COPD: Emphysema is
A slowly progressive disease characterized by destruction of the alveoli
145
by the time COPD symptoms are evident, there is already
irreversible damage to their lungs
146
Emphysema causes ____, leading to ____
destruction of the alveoli
decreased surface area for gas exchange
147
In COPD, expiration becomes an ___ process and patients work hard to get the air in and especially to get the air out
active
148
COPD: Emphysema signs during the nursing assessment (10)
1. SOB, shallow
2. Chest wall rigidity
3. Chronic productive cough
4. Prolonged expiration
5. Expiratory wheezes
6. Appearance changes: clubbing
7. mental changes due to hypercapnia and hypoxia
8. right-sided heart failure
9. chronic lung infections
10. coma -stupor -death
149
patients with right-sided heart failure are going to look like
the patient with FVE (lot of edema)
150
Nursing Diagnoses: COPD
Emphysema or Chronic Bronchitis
- Ineffective Breathing pattern
- Potential for alterations in cardiac output
- Fear related to dyspnea
- Impaired gas exchange
- Potential for infection
- Potential for injury: safety
- Knowledge deficit
151
Nursing Diagnoses: COPD
Emphysema or Chronic Bronchitis
- Ineffective Breathing pattern
- Potential for alterations in cardiac output
- Fear related to dyspnea
- Impaired gas exchange
- Potential for infection
- Potential for injury: safety
- Knowledge deficit
152
Overarching medication goal for patients with COPD Emphysema is to
improve gas exchange
153
For patients with COPD Emphysema, you should give __ L/day fluid as long as their heart, kidneys and lungs can take it
2-3
154
Remember that all bronchodilators have ADE, so give them cautiously through IV, if PO with water - watch vital signs and breath sounds - must listen to breath sounds and get RR ____ giving medication
before
155
Give bronchodilators ___ corticosteroids
before
156
For patients with mild COPD Emphysema, administer what medications?
short acting bronchodilators
157
For patients with moderate COPD Emphysema, administer what medications?
Long acting bronchodilators AND short acting bronchodilators for break through
158
For patients with severe COPD Emphysema, administer what medications?
Long acting bronchodilators AND short acting bronchodilators for break through AND add a steroid
159
Pulmonary Function Tests are
Comparisons of forced expiratory volume (FEV) to forced vital capacity (FVC) are used to classify COPD as mild to very severe
160
Forced Expiratory Volume:
How fast the air in the lungs can be moved in and out in 1, 2 and 3 seconds (FEV1)
161
Forced Vital Capacity:
How much air volume can be moved in and out of the lungs (FVC)
162
Medications to treat COPD Emphysema
1. bronchodilators (adrenergic, anticholinergics, Methylxanthines)
2. anti-inflammatory meds (corticosteroids
163
How do Bronchodilators work?
- Relieve bronchospasm
- Reduce airway obstruction
- Increase O2 distribution
164
2 types of adrenergic bronchodilators used for patients with COPD Emphysema - prototypes and when they are used
1. B2 Selective Short acting
Prototype: albuterol (Proventil)
Use: For occasional tx during an acute exacerbation
2. B2 Selective Long acting
Formoteral (Foradil), Salmeterol (serevent)
Use: Daily for maintenance
165
B2 Selective Long acting adrenergic bronchodilator is ___, and is used ___
Formoteral (Foradil), Salmeterol (serevent)
used Daily for maintenance
166
B2 Selective Short acting adrenergic bronchodilator is ___, and is used ___
albuterol (Proventil)
used For occasional tx during an acute exacerbation
167
Anticholinergic bronchodilators work by
Blocking the PSNS, acetylcholine which leads to bronchodilation and drying of secretions
168
Anticholinergic bronchodilators for acute events
ipratropium bromide (Atrovent)
169
Anticholinergic bronchodilators for daily maintenance
Tiotropium (Spiriva)
170
Examples of Methylxanthines (bronchodilators) - what are they used for?
Aminophylline
Theophylline
Daily maintenance
171
What corticosteroid is used for acute exacerbation in COPD patients?
Prednisone (methylprednisolone)
172
What corticosteroid is used for daily maintenance only for severe or advanced COPD cases
flunisolide (Aerobid)
173
3 qualities for chronic bronchitis (type of COPD), defintion
1. excessive mucus secretions
2. chronic cough
3. dyspnea
these three things have to last 3 months or more in 2 consecutive years
174
2 main causes of chronic bronchitis
1. Recurrent lower RT infections
| 2. Smoking
175
primary prevention in the context of COPD patients
taking normal, healthy people and getting them to stop smoking, improve diet, start working out (working with healthy patients that have unhealthy habits)
176
secondary prevention in the context of COPD patients
trying to help patient who has COPD (just been diagnosed) to stop smoking
177
3 main nursing interventions for patients with chronic bronchitis
1. Prevention
2. Treat Respiratory Tract infections
3. Increase fluid intake
178
_____ is the most common chronic disease of childhood
Asthma
179
Asthma is
a chronic but reversible inflammatory disease of the airways
180
What number of Americans are diagnosed with asthma? What's the financial burden?
22.2 million Americans diagnosed
Financial impact is $16.1 billion dollars in direct care and lost productivity
181
asthma triggers the release of what 4 things?
1. Histamine
2. Bradykinin
3. Prostaglandins
4. Leukotrienes
182
Key signs and symptoms of asthma during nursing assessment
- Cough
- Wheezing (sometimes so loud you can hear w/out steth)
- Dyspnea
- Anxious & fearful
- Color (may be pale or can become cyanotic, depending on the degree of hypoxia)
- Diaphoresis
- Pulse may be weak, very rapid
- ABGs and O2 Sat would show a little hypoxia (PaCO2 tends to be pretty normal, or maybe slightly decreased (a little hypocapnic))
183
when PaCO2 starts rising in an asthma patient, this signals
"this patient is exhausted - they can’t keep this up” and something acute needs to be done or else they will go into respiratory distress
184
3 main goals of nursing interventions for patients with asthma
1. Improve air flow
2. Relieve symptoms
3. Decrease future attaches
185
During an asthma attack, what are the 4 things you should do for the patient?
1. Give oxygen
2. Stay with the patient
3. Breathing exercises
4. Comfort
186
When patients have an acute asthma attack and end up in the ER, we often treat them with
sub-Q epinephrine
187
Mast cell stabilizers are best for what type of asthma?
exercise-induced
188
Albuterol can be used ___ or ____ often first category choice for patients with asthma
for rescue
less than 2x/week
189
Atrovent is usually given via
inhaler
190
Atrovent is usually given via
inhaler
191
Short-acting meds for asthma
- B1 and B2 Adrenergic bronchodilators (Epinephrine, ephedrine)
- B2 Selective Adrenergic bronchodilators (albuterol - Proventil)
- Anticholinergic (ipratropium bromide - Atrovent)
192
Long-acting meds for asthma
- Corticosteroids
Long-acting bronchodilators:
- Mast Cell Stabilizers
- Adrenergic: Beta 2 agonist
- Methylxanthines
- Leukotriene Inhibitors
193
What type of B1 and B2 Adrenergic bronchodilators are given to patients with asthma, and why?
Epinephrine (Adrenaline) -- for Tx in the ER
Ephedrine -- this is In many OTC tx
both are short-acting
194
What type of B2 Selective Adrenergic bronchodilators are given to patients with asthma, and why?
Albuterol (Proventil)
Short acting
For occasional tx, exercise induced asthma or a rescue inhaler
Often first category of drug choice
195
What type of Anticholinergic meds are given to patients with asthma, and why?
ipratropium bromide (Atrovent)
short acting
MAY be used pre-exercise for exercise induced asthma
196
What two types of corticosteroids are given to patients with asthma, and why?
1. Daily maintenance: inhaler
Prototype: flunisolide (Aerobid)
2. Acute exacerbation: systemic
Prednisone (methylprednisolone)
197
What type of Mast Cell Stabilizers are given to patients with asthma, and why?
cromolyn sodium (Intal)
Daily maintenance
May prevent exercise induced asthma
NOT for acute treatment
198
True or false: all the long-acting bronchodilators are used for daily maintenance, NOT acute attacks?
true
199
What type of Methylxanthines are given to patients with asthma, and why?
Aminophylline, Theophylline
as a long-acting bronchodilator (daily maintenance only)
200
What type of Leukotriene Inhibitors
| are given to patients with asthma, and why?
zarfirlukast (Accolate)
as a long-acting bronchodilator (daily maintenance only)
201
Status Asthmaticus can be caused by the same things that bring on a regular asthma attack, but the issue is
that treatments do not end up working
these patients often end up in the ICU on IV bronchodilators or IV corticosteroids
202
Step 1 and 2 (aka mild asthma patients) may be started on ___ or ____
short-acting beta agonist OR low dose inhaled corticosteroid
203
Step 1 and 2 (aka mild asthma patients) may be started on ___ or ____
short-acting beta agonist OR low dose inhaled corticosteroid
204
Bronchiole is the ___ and consists of ____
Unit of respiration
alveoli & capillary
205
How many lobes are in each of the lungs?
3 lobes on R
| 2 lobes on L
206
Parietal Pleura lines the ___, while Visceral Pleura lines the ____
PP: lines the thoracic walls
VP: lines the lungs
207
diffusion of gases occurs in the
alveoli and capillary
208
mediastinum consists of the
great vessels and heart btwn sternum and spinal column
209
as the trachea comes down, the right mainstem bronchus tends to be ____ as opposed to the left, which diverts more sharply
straight
210
What is the first thing you want to do after they've intubated the patient, before there is any tape on the tube?
the FIRST thing you want out of your pocket is your stethoscope and IMMEDIATELY listen so that you can hear breath sounds on both sides
211
Alveoli produce a surfactant which
is a phospholipid which helps to decrease surface tension each time we exhale, decrease the work of breathing
without this we’d have to work really hard to open up the alveoli
212
decrease in alveoli-produced surfactant occurs in
ARDS
213
There is ___mL dead space in the average adult (1 mL for every pound)
150mL
214
The use of accessory muscles during inspiration indicates what?
Quantifies the “work of breathing”
215
2 late signs of difficulty breathing in adults
flaring nostrils
| mouth breathing
216
Ventilation is
movement of air in and out
217
inspiration is an ____ process where ____
active
negative pressure is created within thorax - air is sucked in
218
during trach/ventilator weaning, the question is:
can patient generate enough negative inspiratory force to get a breath in? they need to be alert enough, have thoracic cavity strength
219
patient must have NIF higher than ___ to consider weaning
20-25
220
Normal NIF is
60
221
Respiration is
Breathing – gas exchange occurs
| At the cellular level
222
ability of air to move in and out is based on
pressure change
223
inhalation is ____, whereas exhalation is ____
negative
positive
224
the rate of inhalation or respiratory is affected by the
resistance in the airways
225
resistance is determined by
the diameter of the airway
226
as the resistance ____ greater effort is needed by the patient to breathe
increases
227
Cough, 2 types
Protective reflex
Types:
Dry/nonproductive
Wet/productive
228
if a patient is cyanotic, that’s a ___ sign of hypoxia
late
229
for patients with orthopnea, ask how many pillows do you sleep on at night? -- normal vs. abnormal
1-2 is normal; 3-4 is abnormal (document as 3 pillow orthopnea)
230
SOB =
breathlessness, usually indicates high C02
231
DOA =
dyspnea on exertion, labored breathing
232
Hemoptysis
patient coughing up blood
233
Where are the 2 cough reflexes?
1 cough reflex at back of throat, one at the carina
234
What is stridor, and what does it usually mean?
High pitched
Medical emergency
usually denotes acute airway obstruction (might be what you hear if a child swallows a grape or a toy
235
keep in mind that chest pain is ___ in respiratory illnesses
not that common
we may see it with pulmonary or lung cancer, or pulmonary embolism but it’s more of a late sign, not an early sign
as a general rule, COPD asthma general bronchitis do not have chest pain associated with them
236
CAT scan is
a series of narrow beam x-rays done in cross-section
237
On a chest x-ray, if there's fluid in the lungs, it will
be whited out because fluid is heavier than air - see it at the bottom
238
Whenever you see “oscopy” it means
they are looking in somewhere
239
When is informed consent necessary, who does it, and what does it need to involve?
necessary to have a procedure of any kind done
as an RN and as a student you cannot get a consent form
usually done by the person who is performing the procedure, who tells them the benefits, risks, and possible alternatives
240
lung scan
injecting radioactive isotopes into vein and watch circulation through pulmonary vasculature - can also be inhaled
241
After a bronchoscopy, what are the 3 main points for assessment?
Assess ABCs (airway, circulation, breathing)
Gag reflex
Dysphagia
242
after a Bronchoscopy, don’t give the patient anything to eat or drink unless
you’re sure they can swallow
243
pulmonary function tests usually involve ___ and are used to ____
some kind of incentive spirometer
give a baseline and used to make initial diagnoses
also used to monitor the success of treatment
244
pulse oximeter reads ___ and measures ___
reads the SaO2 - measures oxygen saturation
Norm: > 95%
245
if a patient has a nasal cannula, it’s often run at
2-3L/min
anything over 4 is quite high and usually uncomfortable for the patient
246
mask gives about somewhere between ___ % oxygen
35-60%
247
partial rebreather has ____ so that the patient takes back in some of the CO2 they exhale
a bit of respiratory alkalosis
248
non-rebreather mask delivers
the highest percent of oxygen we can give a patient without intubating
249
venturi mask is best for what kind of patient, and why?
best for patient with COPD because its exact - most precise method
250
when a patient has a trach, they’ve lost the ability to ____, so they need to have ____
they’ve lost the ability to breathe through their nose which filters and humidifies the air, so they either need to have a trach collar that’s humidified or getting more fluid
251
PPV
pushes the tidal volume into the patient, inspiration becomes positive
252
at the end of expiration, the pressure is still
positive
253
PEEP is
a predetermined positive pressure that’s going to be maintained at the end of expiration
patients on PEEP never have a negative
they can usually have a lower percentage of O2 - helps keep the alveoli open
254
In normal respiration, inspiration is ___ and expiration is ____
negative
positive
255
When a patient is on a positive pressure ventilator, inspiration is ____ and expiration is ____
positive
negative
256
When a patient is respirating on PEEP, inspiration and expiration are both
positive
257
9 times out of 10, if you see an incentive spirometer, ask the patent
how to use it - they're often wrong
they should be INHALING when they use this, not exhaling
258
Incentive Spirometers are used for what 3 things?
1. used post-op to prevent atelectasis or pneumonia
2. used as a way to stimulate maximum expiration
3. give pain meds before using if ordered
259
when should percussion never be done?
after surgery
260
How does percussion work, and what is the correct placement?
percussion helps to loosen mucus by cupping hands
you want something between your hands and the skin, starting above the level of the kidneys
start at the bottom and go up - keep an eye on the monitor
261
pursed lip breathing creates ___ in the airways, helping to ____
positive pressure
helps to prolong exhalation (COPD, emphysema) so that they can get out more CO2
262
The higher the patient's head, the better ____
the expansion of the thoracic cavity to be able to take deep breaths
263
Humidity helps to ____
keep the secretions loose so they can cough it up
2000-3000mL fluid per day
264
What are examples of hypotonic crystalloids, and how do they work?
0.33% NS
0.45% NS
D5W
Shifts fluid out of vessel into cells
Hydrates cells
265
What are examples of isotonic crystalloids, and how do they work?
(> 250 mOsm/L)
0.9% NS
Lactated ringers
- No fluid shift
- Vascular expansion
- Electrolyte replacement
266
What are examples of hypertonic crystalloids, and how do they work?
(>375 mOsm/L)
D5 0.45% NS D5 0.9% NS
Hypertonic Saline
- Shifts fluid intravascular
- Vascular expansion
- Electrolyte replacement
267
3 main nursing considerations with hypertonic crystalloids
1. May irritate veins
2. May cause FVE
3. May cause hypernatremia
268
3 main nursing considerations with isotonic crystalloids
1. May cause FVE
2. Generalized edema
3. Dilutes hemoglobin
269
3 main nursing considerations with hypotonic crystalloids
1. May worsen hypotension
2. Can increase edema
3. May cause Hyponatremia
270
4 types of colloids
1. Albumin 5% or 25%
2. Dextran
3. Hetastarch (HES)
4. Mannitol 5% or 25%
271
3 main Action/Uses of Albumin (colloid)
Keeps fluid intravascular
Maintains volume
Replace protein and tx shock
272
2 Action/Uses of Dextran (colloid) and Hetastarch (colloid)
Shifts fluid into vessels
| Vascular expansion
273
2 Action/Uses of Mannitol 5% or 25% (colloid)
Oliguric diuresis
| Eliminates cerebral edema
274
Note that all colloids may cause
FVE
275
Fluid volume excess (FVE) is also known as
Hypervolemia
276
Signs of FVE in patients
- Rapid weight gain
- Peripheral and Perioribital edema
- JVD, bounding HR, increased BP
- increased CVP, R atrial P
- SOB, pulmonary crackles
- low HCT, Na
- Personality changes
- increase capillary hydrostatic pressure: CHF
- decreased in Plasma Proteins: Cirrhosis, Malnutrition
- Obstructed Lymphatics: Breast Cancer surgery w/ lymph node dissection
- Kidney Malfunction: Renal disease
- increased Capillary permeability: Allergies, Infection, Toxins
- Medications: Steroids, NSAID, Estrogen, some BP meds
277
2nd spacing edema is
Localized or generalized
278
Examples of 3rd spacing edema (4)
1. Ascites
2. Pulmonary edema
3. Pleural effusion
4. Pericardial effusion
279
FVE patients should be kept on a ___ diet
A low Na diet, with low H2O
280
Patients with FVE are often given ___ or ___ medications
Lasix (diuretic)
Intravenous hypertonic therapy: Albumin
281
Fluid volume deficit (FVD) is also known as
Hypovolemia
282
Common Clinical Situations for FVD (3 categories)
Decreased Intake:
NPO, Nausea
Coma, Immobilized
3rd space shift
Increased Output:
- Diarrhea/Fistulas
- Vomiting/ GI suctioning
- Hyperventilation/ Tracheostomy
- Fever/ Excessive perspiration
- Burns/ Hemorrhage
Decreased Absorption of Fluid:
Intestinal Obstruction
283
What are the signs and symptoms of of FVD?
- Thirst, Dry mouth, Sordes
- decreased Skin Turgor
- increased temperature
- Oliguria/ Anuria
- increased HCT, increased Serum Na, increased BUN
- Restlessness, delirium, convulsions
- decreased BP, postural hypotension
- decreased CVP, decreased atrial pressure, flat neck veins
284
increased HCT, increased Serum Na, increased BUN are all signs of
FVD
285
One way to assess for hypovolemic shock in patient with FVD is to check for
Postural hypotension
286
Critical values for sodium (Na)
160
287
Critical values for Potassium (K)
6.0
288
Critical values for Blood Urea Nitrogen (BUN)
80 or >
289
Critical values for Creatine
4 or >
290
Critical values for Glucose
500
291
Sodium normally dwells in the ___, and is the ___ regulator of H20
ECF
prime
Gain Na, gain water
Lose Na, lose water
292
When Na
Hyponatremia
293
4 main causes of Hypocalcemia
Inadequate intake of calcium
Anorexia
Renal failure
Lasix
294
3 main causes of Hypercalcemia
increased bone reabsorption
Cancers (bone and others)
immobility
295
3 main signs of Hypercalcemia
1. Serum Ca > 10.5
2. Lethargy, weakness
3. decreased reflexes, constipation
296
4 key interventions for Hypercalcemia
Decrease calcium intake
Lasix
Calcitonin
Ambulation
297
___ % of calcium is in the bones. Only ___ % of ingested calcium is absorbed
99% in bones
30- 50% of ingested calcium is absorbed
298
Normal calcium levels
8.5 – 10.5 mg/dL
299
Main sign of Hypocalcemia is
Tetany (intermittent muscle contractions) leading to convulsions
300
Emergency intervention for Hypocalcemia is
CaCl or Ca Gluconate IV
301
Intervention for chronic Hypocalcemia
Increase dietary Calcium or Ca supplements
302
Potassium is a major ___ ion, and is ___ stored by the body
intracellular
not
303
Note that lab values for potassium are ____ levels only
intravascular
304
Normal levels of potassium
3.5 – 5.2 mEq/L
305
Signs of hypokalemia
K
306
Causes of hypokalemia
Loss from GI tract
Diet: Eating disorders
Diuretics
307
Interventions for hypokalemia
Administer K+
PO: Klor, KDor
IV: KCL
308
With hypokalemia, what are the 3 main ECG signs?
Depressed ST segment
Low T
Prominent U wave
309
With hyperkalemia, what are the 3 main ECG signs?
Low P wave
Widening of QRS segment
Peaked T
310
Causes of hyperkalemia
```
Kidney failure
Intake of excess K
Crush injuries
Burns
Addison's disease
```
311
Signs of hyperkalemia
```
K > 5.2
Irregular heart beat
Nausea
Slow weak, or absent HR
Paresthesias, muscle cramps
ECG changes
Acidosis
```
312
Interventions for hyperkalemia
```
Calcium Gluconate
IV fluids
IV Na Bicarbonate
Hemodialysis
Kayexalate
Insulin and Glucose IV
```
313
Hypernatremia is when Na is
> 145 mEq/L
314
If hypernatremia is due to water loss, how should you intervene?
IV Fluids: D5W
Oral glucose-electrolyte solutions – low Na
315
If hypernatremia is due to excess Na, how should you intervene?
Restrict Na intake
316
CNS signs of hypernatremia
restlessness, irritable, delirium, twitching, seizures, coma
317
Signs of Hypernatremia with FVD
```
Thirst
poor skin turgor
rapid HR
decreased BP
increased temp
oliguria
```
318
When Hypernatremia is due to water loss, some of the causes may include:
- Excessive Fluid loss:
(diarrhea, open burns, fever, excessive perspiration, heat stroke, diuretics)
- decreased Fluid intake
- Hyperglycemia
- Renal failure
319
When Hypernatremia is due to Na Excess, the main cause may be:
Hypertonic NG tube feedings
or
Diabetes Insipidus
320
When Hyponatremia is due to loss of Na, the two main cause may be:
Diuretics: Lasix
Loss of GI fluids
Also:
Decreased ADH due to adrenal insufficiency (Addison's)
Renal Disease
321
When Hyponatremia is due to gain of water, the main cause may be:
* Excess electrolyte-poor IV fluids
Also:
Excess H20 to hypotonic tube feedings
Irrigation of NGT w/ tap H2O
SIADH
322
4 patient cases in which H20 intake is greater
- CHF
- Polydipsia
- Liver failure
- Renal failure
323
Na of 115 or less may cause:
muscle twitches, focal weakness, seizures
all these can lead to coma
324
If a patient is displaying neurological symptoms of hyponatremia, what should you administer?
3% or 5% NS IV
325
When Na
hyponatremia
326
Main signs of shock due to hypoxia:
Restlessness (change in LOC) and a subtle increase in respiratory rate (higher than 20)
327
The type of IV fluid we give a patient can affect the
osmotic pressure in the body
328
Hypertonic solutions can be very irritating to the veins, so you’d prefer them to be given
into a larger vessel (i.e. antecubital, central line)
329
Giving a small amount of colloids (250mL) can be the same effect as
4L of crystalloids
so a small amount of colloids has a bigger impact
330
Albumin is a ___ colloid
natural
331
Dextran and Hetastarch are ____ colloids.
synthetic
332
if you have a major trauma patient that is in shock and you need to give them blood, you need to _____ BEFORE you give the dextran and hetastarch
type and cross them (come up with the exact blood match)
333
Mannitol is often used with neuro ICU patients with _____
cerebral edema
334
dependent edema
someone that’s upright with hands at their sides, hands may get swollen – if they’re on their feet, their legs may get swollen – if patient is laying flat in bed, the sacral or scrotal area can become edemous
335
ascites is
fluid in the abdominal/peritoneal cavity
336
pulmonary edema is
fluid in the alveoli
337
pleural effusion
fluid in the pleura between the lungs
338
pericardial effusion
if there’s an infection, the excess fluid can fill this area so that the fluid begins pressing on the heart – the heart therefore has less and less room to contract/beat because of the increased pressure
this can cause decreased cardiac output, lightheadedness
339
Sordes is
brown, crusty material can develop on patient’s lips or in their mouths – mouth care and oral hygiene is critically important
340
postural hypotension
change of more than 15 mm in systolic from lying to sitting
341
Most frequent causes of loss of sodium is ___ and ____
DIURETICS (Lasix) and loss of GI fluids
342
Hypernatremia is often associated with
FVD
343
Increase of extracellular sodium causes intracellular fluid to shift out of the cells and into
the intravascular space, and the cells can become dehydrated
344
If sodium comes back 121 means the patient definitely has
hyponatremia
345
If patient has hyponatremia, give fluids only up until
the neurological signs and symptoms decrease
346
Aldosterone will excrete potassium when
the kidneys are retaining sodium and water
347
For the patient on DIGOXIN – low potassium levels will ____ the effect
increase
348
Hypokalemic patients will have a very low ___ wave on the EKG
T
349
burns can cause hyperkalemia, especially during the first ____ hours when the cells break and release potassium
24-48
350
Trusseau’s sign
a test for hypocalcemia where the hand will contract into a claw almost spontaneously
351
Chvostek’s sign
a test for hypocalcemia where tapping on the facial nerve will cause a contraction
352
As you assess your patient, you find he has +2-pitting edema up to his knees, a rapid, bounding pulse, and shortness of breath. Your nursing diagnosis is
Fluid volume excess
353
When assessing a patient with fluid volume deficit (FVD), you would expect to find
Oliguria
354
Your patient is hemorrhaging from his surgical incision. As the nurse, you expect that compensatory mechanisms associated with hypovolemia will cause
Him to be normotensive
355
The patient is admitted with severe vomiting for 24 hours. She is exhausted and weak. Her ECG (electrocardiogram) shows a flattened T wave. The most likely potassium value for this patient is
2.5 mEq/L
356
Your patient is transferred from the ICU to your unit with a CVP (central venous pressure) line in place. CVP readings are taken to determine
Hypovolemia
357
The order is for KCL (potassium chloride) IV for a patient with severe hypokalemia. In administering the KCL, the nurse is aware that KCL
Should be administered at 10 mEq/hour or less
358
For inspiration to occur the intrathoracic pressure must be
Negative
359
The major cause of emphysema in this country is
Cigarette smoking
360
A priority nursing diagnosis for a patient with emphysema
Ineffective breathing patterns
361
In teaching the newly diagnosed asthma patient, it is most important to stress that she:
Take her medications as prescribed
