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NP II Test 1 > Test 1 > Flashcards

Test 1 Flashcards

1
Q

Physiological Factors Affecting Oxygenation

A
  • Decreased oxygen carrying capacity
  • Hypovelemia (Low blood volume)
  • Hypoxia
  • Conduction disturbances in the heart
  • Hyperventilation
  • Hypoventilation
  • Trauma
  • Nervous system alterations
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2
Q

Lifestyle Risk Factors Affecting Oxygenation

A
  • Poor nutrition
  • Inadequate exercise
  • Smoking
  • Substance abuse
  • Stress
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3
Q

Assessment of Oxygenation (Hx)

A
  • Pain
  • Fatigue
  • Smoking
  • Dyspnea
  • Cough
  • Wheezing
  • Environment
  • Allergies
  • Medications
  • Respiratory infections
  • Health risks
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4
Q

Physical Assessment of Oxygenation

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
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5
Q

Signs of Difficulty Breathing

A 
Early:
- Panic
- Sweating
Late:
- Hypotension
- Cool, clammy skin
- Cyanosis
- Nasal flaring
- Retractions
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6
Q

Deep Breathing and Cough

A
  • Helps clear the lungs of mucus and secretions
  • Often asked after surgery
  • Opens up air passages
  • Use pillow to splint a patient’s incision
  • Teach them pre and post OP
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7
Q

Checklist for DB&C

A
  • Assess the patient’s respiratory status. Observe for signs and symptoms associated with hypoxia
  • Perform hand hygiene
  • Assist patient to the most comfortable Fowler’s position
  • Provide pillow to splint incision if pre/post operative thoracic or abdominal surgery
  • Explain procedure and purpose/rationale for DB&C
  • Have patient take 2-3 deep breaths inspiratory through the nose (hold for 3 sec.) and expire. through the mouth
  • On the third or fourth DB have patient cough 3 times without inhaling in between
  • Instruct patient to DB 2-3 times per hour
  • Perform hand hygiene
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8
Q

O2 Therapy

A
  • Room air = 21%
  • 1LPM = 24%
  • 2LPM =28%
  • 4LPM = 35-40%
  • Nasal Cannula = 2-4LPM
  • Nasal Catheter = 1-6LPM
  • Simple Mask = 4-8LPM (30-60%)
  • Venturi Mask = 24-50%
    Non-Rebreather Mask = 10LPM (80-90%)
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9
Q

Checklist Applying Nasal Cannula/ O2 Mask

A
  • Assess respiratory status and observe for signs and symptoms of hypoxia
  • Perform hand hygiene
  • attach nasal cannula or mask to oxygen tubing and attach tubing to oxygen source
  • Adjust oxygen flow rate to prescribed dosage
  • Apply oxygen delivery device properly and adjust to patient’s comfort
  • Allow sufficient slack of oxygen tubing
  • Perform hand hygiene
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10
Q

Checklist Incentive Spirometry

A
  • Perform hand hygiene at bedside
  • Assist patient to most comfortable Fowler’s position
  • Demonstrate how to place mouthpiece correctly
  • Instruct patient to inhale slowly and maintain a constant flow through the unit, then hold breath for at least 3 seconds and exhale slowly
  • Have patient repeat 5-10 times per hour as tolerated
  • Perform hand hygiene
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11
Q

Checklist Peak Flow Meter

A
  • Perform hand hygiene
  • Assist patient to most comfortable Fowler’s position
  • Slide mouthpiece into base of scale at zero position
  • Instruct patient to take deep breath and place mouthpiece in mouth and close lips around it, making a firm seal
  • Instruct patient to blow out as hard & fast as possible through the mouth, in one breath
  • Repeat procedure two more times, documenting highest reading
  • Perform hand hygiene
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12
Q

Breath Sounds

A
  • Vesicular: longer inspiration and short expiration
  • Broncho-vesicular: equal inspiration and expiration
  • Bronchial: short inspiration and long expiration
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13
Q

Adventitious Breath Sounds

A

Continuous
- Wheezes: prominent on expiration; high pitch; asthma, bronchitis and bronchial tumour
- Rocnhi: lower pitch wheezes
Discontinuous
- Crackles: bubbly quality; fine (lower lung fields; soft and short)
- Coarse: louder, popping sounds; lower pitch; longer duration; any area of the lungs

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14
Q
A
  • Peak flow meter used before and after nebulization, to see if it worked
  • The major stimulus for breathing are the O2 and CO2 blood levels
  • No smoking or heat source near oxygen tank or someone using O2 therapy
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15
Q

Documenting

A
  • Accrediting agencies: Canadian Council on Health Services Accreditation (CCHSA)
  • Documentation/reporting are different in different institutions
  • Ethics, legalities, medical/agency guidelines influence documenting
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16
Q

Purpose for Recording

A
  • Communication
  • Legal documentation
  • Education
  • Funding / resource management
  • Research
  • Quality review
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17
Q

Guidelines for Reporting

A
  • Factural
  • Accurate
  • Complete
  • Current
  • Organized
  • Complies with standards
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18
Q

Documenting Systems

A
  • Narrative
  • Problem oriented medical records (POMR)
  • Source records
  • Charting by exception
  • Critical pathways or caremaps
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19
Q

Narrative Charting

A
  • Chart in chronological order
  • Sentence structure is usually preferred
  • Columns to organize the narrative may be used (columns may include treatment, nursing observations, comments, etc)
  • Time consuming
  • Should be legible
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20
Q

SOAP

A
  • Subjective data
  • Objective data
  • Assessment
  • Plan
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21
Q

SOAPIE

A
  • Implementation

- Evaluation

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22
Q

SOAPIER

A
  • Revision
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23
Q

Focus Charting

A
  • Used to encourage nurse to focus on positive rather than negative charting
  • Three columns: date/hour; focus; progress notes
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24
Q

Charting by Exception

A
  • Only significant findings/exceptions are charted
  • Flow sheets / charts are used in which check off marks are recorded
  • An Asterisk (*) means that a standard or norm of care was not implemented
  • Also means that a narrative has been added to explain why is was not implemented
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25
Q

Critical pathways

A
  • AKA critical paths, clinical pathways, care paths

- Varifying formats

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26
Q

PIE

A
  • Problem
  • Implementation
  • Evaluation
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27
Q

Common Record-Keeping Forms

A
  • Admission nursing history form
  • Flow sheets and graphic records
  • Client care summary or kardex
  • Acuity record or workload measurement system
  • Standardized care plans
  • Discharge summary forms
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28
Q

Documentation in non-acute care

A
  • Home health care

* Long term health care

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29
Q

Computerized Documentation & the electronic health record

A
  • Advantages – (weren’t listed, but…) faster, legible, etc

- Disadvantages – for older employees perhaps harder to learn, layout, etc

30
Q

Reporting

A
  • Change-of-shift reports
  • Telephone reports
  • Transfer reports
  • Incident reports
  • Telephone or verbal orders
31
Q

Hypoglycemia

A
  • Low blood sugar (less than 4mmol/L)

- Anyone with diabetes who is taking insulin or anti-hyperglycemic agent is at risk

32
Q

Hypoglycemia May occur if …

A

o Eat less than planned during the day
o Take more meds than planned
o Are more active than planned
o Have alcoholic drinks without eating

33
Q

Hypoglycemia Symptoms

A 
o	Shaking
o	Fast heartbeat
o	Sweating
o	Hunger
o	Anxiety
o	Nausea
o	Headache
o	Impaired vision
o	Dizziness
o	Irritability
o	Drowsiness/fatigue
o	Unconscious
34
Q

How to Treat Hypoglycemia

A

o Intake of 15g of carbohydrates (ie; glucose tabs, small juice, 6 life savers)
o Recheck q15mins. If still low, treat again.

35
Q

Hypoglycemia Testing

A
  • Step 1: Insert test strip
  • Step 2: confirm code #
  • Step 3: Apply sample (to obtain sample it makes it easiest if you massage the blood from base of finger to tip, & the pointer finger is usually avoided)
  • Step 4: Results in seconds
  • Target #s 5-7 mmol/L
  • Most tester require solution testing every so often to ensure tester is working adequately
36
Q

Hyperglycemia

A

• high blood sugar – anything over 7mmol/L
• Symptoms
o dry mouth
o frequent urination
o smell (from mouth) / taste of sweetness

37
Q

Acuity Records / Case Management

A
  • provide a method of determining the hours of care and staff required for a given group of clients
  • coordinates health care services and links them to clients and their families while streamlining costs and maintaining quality.
38
Q

Change of Shift Report

A
  • nurses report information about their assigned clients to the nurses working on the next shift. The purpose of the report is to provide continuity of care among nurses who are caring for a client.
39
Q

Charting by Exception

A
  • focuses on documenting deviations from the established norm or abnormal findings. This approach reduces documentation time and highlights trends or changes in the client’s condition.
40
Q

Consultation / Critical Pathways

A
  • another form of discussion whereby one professional caregiver gives formal advice about the care of a client to another caregiver
  • multidisciplinary care plans that include client health concerns, key interventions and expected outcomes within an established time frame.
41
Q

Data-Action-Response (DAR)/ Documentation

A
  • include both subjective and objective data, the action or nursing intervention and the response of the client.
  • Systematic organization, storage, retrieval, and dissemination of specialized information
42
Q

Evidence-Based Practice / Flow Sheet

A
  • the use of the most current and valid research findings as the basis for clinical decisions
  • a graphic summary of several changing factors, especially the patient’s vital signs or weight and the treatments and medications given
43
Q

Focus Charting

A
  • involves use of DAR notes. Addresses client concerns: a sign or symptom, a condition, a nursing diagnosis, a behaviour, a significant event, or a change in a client’s condition.
44
Q

Incident Report

A
  • a document, usually confidential, describing any accident or deviation from policies, or orders involving a patient employee, visitor or student on the premises of a health care facility
45
Q

Kardex/ Objective Data/ Problem- Intervention- Evaluation (PIE)

A
  • Trademark for a card filing system that allows quick reference to the particular needs of each patient for certain aspects of nursing care
  • Data you observe
  • simplifies documentation by unifying the care plan and progress notes
46
Q

Problem-Oriented Medical Record (POMR) / SOAP (IE)

A
  • method of documentation that emphasizes the client’s problems
  • involves subjective data, objective data, assessment, and plan (intervention, evaluation)
47
Q

Narrative Charting

A
  • The nurse may be asked to chart in chronological order the events that occur including the gathering of information. A sentence structure is usually preferred although the use of columns to organize the narrative may be used. There may be a separate column for treatments, nursing observations, comments, etc. Narrative charting is time consuming, so legibility is extremely important if the notes are to be understood by those reading them.
48
Q

Standardized Care Plan/ Subjective Data

A
  • preprinted, established guidelines that are used to care for clients who have similar health problems
  • data the client tells you
49
Q

Transfer Reports

A
  • (given when a client is transferring units) includes the following information:
    • Name, age, name of primary physician, and medical diagnosis
    • Summary of progress up to the time of transfer
    • Client’s current health status
    • Allergies
    • Emergency code status
    • Client’s family support
50
Q

Nursing Process

A
  • The process that serves as an organizational framework for the practice of nursing. It encompasses all of the steps taken by the nurse in caring for a patient: assessment, nursing diagnosis, planning, implementation, and evaluation
51
Q

Enema / Cleansing Enema

A
  • a solution or compound that is introduced into the rectum with the purpose of cleansing the colon or for diagnostic procedures
  • an enema, usually composed of soapsuds, administered to remove all formed fecal material from the colon
52
Q

Retention Enema/ Fleet Enema

A
  • a medicinal or nutrient enema specially formulated so that it will remain in the bowel without stimulating the nerve endings that would ordinarily result in evacuation
  • Trademark for an enema containing, in each 100 ml, 16g sodium biphosphate and 6g sodium phosphate, packaged in a plastic squeeze bottle fitted with a 5 cm pre-lubricated rectal tube
53
Q

Suppository/ Ventillation / Perfusion

A
  • an easily fusible medicated mass to be introduced into a body orifice, as the rectum, urethra, or vagina
  • Process of moving gases into and out of the lungs
  • Distribution of red blood cells to and from capillaries
54
Q

Compliance/ Resistance/ Tidal Volume

A
  • The ease with which lungs can expand
  • ^ opposite
  • The volume of air inspired/expired dying each normal, quiet respiratory cycle
55
Q

Inspiratory Reserve Volume (IRV)/ Expiratory Reserve Volume (ERV)

A
  • Extra volume of air that can be inspired with maximal effort after reaching the end of normal inspiration
  • The maximum amount of gas that can be exhaled from the resting end-expiratory level
56
Q

Vital Capacity/ Residual Volume/ Total Lung Capacity

A
  • The volume of air that is exhaled by a maximal expiration following a maximal inspiration
  • Volume of air remaining in the lungs after maximum expiration
  • Volume of air contained in the lungs at the end of a maximum inspiration
57
Q

Eupnea/ Bradypnea/ Tachypnea

A
  • easy, free respiration
  • abnormal slowness of breathing
  • abnormal, rapid breathing
58
Q

Hyperventilation/ Hypoventilation

A
  • Abnormally fast or deep respiration resulting in the loss of carbon dioxide from the blood, thereby causing a decrease in blood pressure and sometimes fainting
  • Breathing at an abnormally slow rate, resulting in an increased amount of carbon dioxide in the blood
59
Q

Apnea/ Dyspnea/ Orthopnea

A
  • Transient absence of spontaneous respiration (Respirations cease for several seconds)
  • difficulty breathing
  • Dyspnea that is relieved in the upright position
60
Q

Cheyne-Stokes Respiration/ Biot’s Respiration

A
  • Abnormal pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing
  • Respirations abnormally shallow for 2-3 breaths, followed by regular period of apnea
61
Q

Adventitious Breath Sounds / Crackles/ Wheezes

A
  • abnormal breath sounds
  • small, sharp sounds heart on auscultation
  • musical sounds that sound like a squeak
62
Q

Stridor/ Stertor/ Pleural Friction Rub

A
  • Harsh sound heard on in halation caused by air passing through a constricted passage
  • Noisy inspiration occurring in coma/ deep sleep
  • Friction rub sound caused by inflammation of the pleura
63
Q

Cyanosis/ Hemoptysis/ Hypoxia

A
  • Blue-ish tinge of the skin and mucous membrane due to increase in the amount of deoxygenated hemoglobin in the blood
  • blood sputum
  • lack of oxygen supply to the tissue
64
Q

Hypoxemia/ Barrel Chest

A
  • Abnormal lack of oxygen in the blood in the arteries

- A chest permanently resembling the shape of a barrel

65
Q

Kyphosis/ Clubbing

A
  • Abnormally increased convexity in the curvature of the thoracic spine as viewed from the side
  • Condition affecting the fingers and toes in which the extremities are broadened and the nails are shiny and abnormally curved
66
Q

Normal O2 Sats

A

95-100

67
Q

BP

A

100-140/60-90

Hypertension (high blood pressure)
Hypotension (low blood pressure)

68
Q

Systolic Pressure / Diastolic Pressure

A
  • This is the maximum pressure in an artery. It occurs when the heart contracts; when it is beating, and blood is being pumped through
  • This is the minimum pressure in an artery. It occurs just before the heart contracts; in between heartbeats. It occurs when the heart is resting
69
Q

Heart Rate

A

Normal: 60-100 bpm

Tachycardia (rapid heart rate)

Bradycardia (lower heart rate)

70
Q

Respirations

A

Adult: 12-20
Newborn: 30-60
Child: 20-30
Older Adult: 16-25

NP II Test 1 (1 decks)

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