Test 3 Flashcards
(77 cards)
1
Q
What is angina?
A
a temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles
2
Q
What is the purpose of an arterial blood gas?
A
diagnostic test examining arterial blood; used to determine the pressure exerted by oxygen and carbon dioxide in the blood
3
Q
Atelectasis is defined as:
A
incomplete expansion or collapse of a part of the lungs
4
Q
Bronchial and bronchovesicular sounds are explain as, and found where?
A
those heard over the trachea; high in pitch and intensity, with expiration being longer than inspiration
normal breath sounds heard over the upper anterior chest and intercostal area
5
Q
What is capnography?
A
A method to monitor ventilation and, indirectly, blood flow through the lungs
6
Q
Cardiopulmonary vs cardiovascular
A
relating to the heart and the lungs
relating to the heart and blood vessels
7
Q
Differentiate thoracentesis and hemothorax.
A
thoracentesis: aspiration of fluid or air from the pleural space
hemothorax: blood that develops in the pleural space
8
Q
Differentiate crackles vs wheezes.
A
crackles: fine, crackling sounds made as air moves through wet secretions in the lungs
wheezes: continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages
9
Q
Explain each of the following Hypoxia, hypoxemia, and ischemia.
A
hypoxia: inadequate amount of oxygen available to the cells
hypoxemia: deficient oxygenation of blood
ischemia: deficiency of blood in a particular area
10
Q
Diff between an endnote aches tube vs tracheostomy.
A
endotracheal tube: polyvinyl-chloride airway that is inserted through the nose or the mouth into the trachea, using a laryngoscope as a guide
tracheostomy: artificial opening made in the trachea through which a tracheostomy tube is inserted
11
Q
Define alveoli.
A
alveoli: small air sacs at the end of the terminal bronchioles that are the site of gas exchange
12
Q
What are ADL’s?
A
Activities of daily living needed for independent living
12
Q
What is Bruits?
A
Unusual sound, usually abnormal, heard in auscultation
13
Q
What is eccymosis vs petechiae?
A
Collection of blood in sub q tissue that cause purplish discoloration
Vs
Small purplish hemorrhagic spots on the skin that do not blanch with applied pressure.
14
Q
What is erythema?
A
Redness of skin
15
Q
What is the precordium?
A
Anterior surface of the chest wall overlying the heart and its related structures.
16
Q
What are some of the purposes of the health assessment?
A
Establish nurse/pt relation Data collection: (sub/obj) Baseline ID pt strengths ID actual/poten problems Changes in status
17
Q
What are some factors to assess during interview?
A
Bio Reason for visit Hx of present illness Past med hx Family hx Lifestyle/culture
18
Q
What “knowledges” should you be aware of before assessment?
A
Ethical-HIPPAA Theoretical-A/P facts Practice-apply assessment skill Pt situation- exam reason, dx, culture Self-skill/comfort
19
Q
What are some preps to take before beginning health assessment?
A
time Pt pain Table/bed Supplies Privacy-bathroom 1st No noise Gown pt Temp/lighting of room
20
Q
What are the necessary supplies for a phy assess, explain.
A
Snellen chart-eyes Otoscope-ear Ophthalmoscope-eyes Vaginal speculum-vag canal/cervix Tuning fork-auditory Percussion hammer-tendon reflex Nasal speculum-nose
21
Q
Name all the positions used and explain.
A
Supine (on back)-relaxes abs
Prone (on stomach)-assess of hip joint/posterior thorax
Dorsal recon ant (supine with Bent knees, arms at side or elevated by head)-used when supine is too difficult
Sims (side lying)-rectum/vagina
Fowlers (sitting)-v/s
Lithotomy (on back, leg in stirrup)-female rectum/vagina
Knee/chest (on hands/knees)-rectum
Standing-posture, gait, balance
22
Q
What are mass characteristics?
A
Exact measurement/shape Tenderness Pulsatile Consistency Surface mobility
23
Q
What are auscultation characteristics?
A
Pitch (high/low)
Loudness (soft/loud)
quality (swishing/gurgling)
Duration (short/med/long)
24
What are the palpating motions?
```
Light touch (1 cm)
Fingertips-tactile discrimination
Dorsum-temperature
Palm-general area of pulsation
Grasping-mass eval
```
25
What is the general survey?
Comprehensive exam (initial)
V/s, weight/height/ overall impression
Deviations lead to focused asses
General appearance (hygiene, mental state, body type
26
What is the general list of areas to be assessed in the phy asses?
```
Integumentary
Head/neck
Thorax/lungs
Cardiovascular/peripheral
Breast/axilla
Abdomen
Musculoskeletal
Neurological
Female/male genitalia
```
27
What are some factors that influence respiratory function?
```
Levels of health
Developmental considerations
Medications
Environment
Psychological health
```
28
What are some age related (older adult) changes in oxygenation?
Decreased gas exchange and increased work of breathing:
Decreased elastic recoil
Exp req accessory muscles
Fewer functional caps at alveoli
Decreased skeletal muscle strength in thorax
Reduc vital cap w/ inc resid vol
29
What are some age related (older adult) changes concerning decreased ventilation and ineffective cough?
Less air exchange; more secretions remaining in lungs
Drier mucous membrane
Altered pain sensation
Diff norms for body temp;fever atypical
Risk for aspiration(cause:slower gastric motility)
Impaired mobility/inactivity, effects of medication
30
What are some oxygenation changes in the older adult concerning decrease cardiac output and ability to respond to stress.
Reduction in elasticity of the heart tissue
Heart muscle less efficient(works harder pumping same amount)
Progressives atherosclerosis
Thicker cap walls (slower gas exchange/nutrient/ waste rate)
31
What are some nursing strategies for the older adult with dec gas exchange and increased work of breathing.
```
Rest periods(as needed)
Cessation (or moder) smoking
Teach breathing exercises, avoid air pollutants, narcotics, sleeping pills and use infection preventative measures (flu shot)
Caution for extreme weather
Use pillows
```
32
What are some nurse strategies to use for the older adult with dec vent and ineffective cough?
```
Increase fluid intake
Cool mist humidifier
Attend pulmonary exercise rehab
Disuse over the counter meds
Splint thorax and cough effectively
Supplemental oxygen
Avoid milk products if troublesome
```
33
What are some nurse strategies for the older adult with dec cardiac output and ability to respond to stress?
```
Daily physical activity;paced
Healthy low fat, low salt, with fruit, veg, whole grains.
Smoking cessation (or tobacco)
Reg check ups
Weight control
Med compliance
Stress reduction activities
```
34
What are the symptoms of hypoxia?
```
RAT (early) BED (late)
Restlessness
Anxiety
Tachycardia/tachypnea
Bradycardia
extreme restlessness
Dyspnea
```
35
What is the content of the comprehensive resp, cardio vas, and periph vas assessment?
Nurse hx (sub)-----
Demo data, Current/past health/family hx (HTN, CAD, clots, renal dz, DM, obesity, COPD), Resp/cardio hx
Environmental hx (occupation hazard),
Lifestyle (exercise, diet, meds,family/money stress, mental health, Tobacco use (pack/years).
Physical asses (obj)-----
Phy exam, breath pattern, cough, sputum, pain, resp effort, pulse of, diag tests: ABG-(radial, brachial or femoral, apply press 5-10 min, put on ice, send to lab), cytology study (sputum), endoscopic study (bronchoscopy), skins testing, chest X-ray, ECG, lung scan
36
What are the nurses duties concerning the thoracentesis procedure?
Witness consent (after provider explains procedure)
V/s (pre procedure)
Calm pt
Instruct not to deep breath/cough and remain still.
Position in sitting or on unaffected side with affected side arm above shoulder.
Asses during procedure: color, pulse, resp rate
Report deviations
Obtain specimens (label)
Monitor v/s after and for extreme coughing, dyspnea, bloody sputum.
37
What would be included in resp assessment: inspection?
```
Anterior, posterior, lateral:
Skin condition
Use of accessory muscles
Posture, breathing
Chest configure, and position of sternum
```
38
What are 4 types of chest configurations?
Normal (ap : lateral is 1:2, transverse is 2X anteroposterior diameter)
Pectus excavated (funnel chest)
Pectus carinatum (pigeon chest)
Dynamic hyperinflation
39
What is the correct order of assessment for resp/cardio?
Inspect
Palpating
Percussion
Auscultation
40
What content is included in cardiovascular assessment?
```
Heart sounds (s1 s2)
Peripheral color, temp, hair distrib, periph pulses, cap refil time, nail bed, Mucous membrane color, edema (location), varicosties.
```
41
What are 3 positions for lung maintenance?
Fowlers x3
Orthopneic
Tripod
42
What are 3 breathing exercises?
Deep breathing
Diaphragm breathing
Pursed lip breathing
43
What are some airway interventions?
```
Coughs:
Cascade
Hub
Quad
Meds:
Expectorants
Cough suppressants
Lozenges
MDI/DPI/nebulizer
Spirometer and Fluid intake, chest physiotherapy (percussion, vibration, postural drainage, suction: sterile suction for deep and yankauer for oral)
```
44
What are some methods of o2 delivery?
```
Nasal cannula
Simple mask
Part/non rebreather mask
Venturi mask
O2 tent
```
45
What is the job of the nurse once interventions have taken place?
Eval! Why? To determine outcomes met!
before/after: RR, P, BP, SaO2 level, lung sounds
After: use of access muscles
Did the client use cough/breath methods? What level achieve on spirometer?
Mucous? Thin/thick clear/tenacious
46
What are the levels of consciousness?
Alert and oriented (person, place, time, responds to stimuli)
Lethargic (drowsy/sleepy, spontaneous movements, can be gently aroused)
Stuporous (unconscious mostly, no spont. Movement, diff to arouse, responds to painful stimuli)
Comatose (cannot be aroused, unresponsive to painful stimuli, some reflex activity)
47
Where is s1 louder, s2?
S1-tricuspid/apical area
| S2-pulmonic aortic area
48
What makes up to bio data?
Name, address, gender, marital status, occupation, religious preference, healthcare financing, pcp
49
What makes up present health concerns?
Reason patient is seeking care
| Open ended questions
50
What is included in the medical hx?
Past illnesses, chronic health problems and tx, prev. Surg. Hospitalizations (alerts nurse to risk factors and provides insight into current symptoms)
51
What lifestyle data is necessary in assessment?
```
Smoking
Drugs/meds
Nutrition
Exercise
Sleep
```
52
What are the functions of the musculoskeletal system?
| Skeletal:
- supports soft tissue (posture)
- furnishes attachment (muscle,tendon, lig) to move bones
- protects (brain, heart, lung)
- mineral storage (calcium/fat)
- hematopoiesis
53
What are the functions of the musculoskeletal system?
| Muscle:
- Motion:skeletal muscle contraction pulls tendons to move bones
- Posture Mait: skeletal muscle hold stationary position
- Support: abd wall/pelvic floor
- heat production: contraction producing heat maintain body temp
54
What are the 3 general joint types?
Fibrous-synarthrotic(immove) sutures
Cartilaginous- amphiarthrotic (slight move) vetebrae
Synovial-diarthrotic (freely move) ball and socket
55
What are the diarthrotic joints (6)?
1. Ball and socket-(hip/shoulder):flex/ext, abd/add, rot
2. Condyloid-(wrist to palm):flex/ext, abd/add
3. Gliding-(carpals): flex/ext, abd/add
4. Hinge-(elbow):flex/ext
5. Pivot-(axis/atlas):rotate
6. Saddle-(trapezium/metacarpal thumb):flex/ext, abd/add, circumduction, opposition
56
Define the commonly used body positions/movements.
Abduction-lateral movement away from body
Adduction-lateral movement toward body
Circumduction-circular motion (abd, add, flex, ext all together)
Flexion-bent
Extension-straight Hyperextended-exaggerated
Dorsiflexion-backward bending (toes toward knee)
Plantar flexion-foot drop
Rotation-turning on axis Internal-toward midline External-away
57
what are the 5 special movements of the body?1
```
Pronation-prone position
Supination-supine position
Inversion-foot inward
Eversion-foot outward
Opposition-Rotation of thumb around long axis
```
58
Define the following:
Cartilage
Ligament
Tendon
Cart-hard non vasc connective tissue in joints
Lig-bone to cart
Ten-fibrous bands connecting muscle to bone
59
Define the following:
| Isokinetic isometric and isotonic exercises
Isokin-muscle contraction with resistance
Isomet-muscle tension with no length changes
Isotonic-muscle shortening (contract)
60
Define the following:
Paralysis
Paresis
Ankylosis
1. Strength absense due to nerve impairment
2. impaired muscle strength/weakness
3. joint immobilization
61
```
Define the following:
Atrophy
Flaccid
Spasticity
Tonus
```
1. Body structure size decrease
2. decreased muscle tone (hypotonicity)
3. increased muscle tone
4. partial muscle contraction(normal)
62
Define the following:
| Contracture
Permanently state of muscle contraction (hardened joint)
63
What is body alignment and its purpose?
Posture, permits balance
64
What makes proper balance?
Wider base of support and lower the center of gravity = greater stability.
Center of gravity=pelvic center (between pubic sym and umbillicus) vertical line of gravity passes thru center of gravity.
65
Coordinated body movement (moving, lifting) is thru the use of?
Levers and fulcrums.
Major muscle groups: flex/ext/abd of thighs
Flex/ext of knees, and upper/lower arms
66
What are the postural reflexes?
(Automatic movement maintaining body position/equilibrium.)
Musculoskeletal + nervous = balance:
-labyrinth: inner ear for orientation
-proprioreceptor: body part location resulting from joint stimulating nerves
-visual:posture by spatial relation to environment
-extensor/stretch: Hypoext stims reflex contraction to re-establish proper posture
67
What is the purpose/function of body mechanics?
Proper positioning for protection from activity stress.
Prevents injury/soreness in muscles/joints.
(Illness prevention and health promotion)
68
What is pt care ergonomics?
Conforming to worker capabilities
Increases pt comfort/dignity/safety
69
Compare the effects of exercise vs immobility of each body system:
Cardiovascular
Increase heart efficiency/fibrinolysin/venous return/blood flow throughout body, dec HR/BP
VS
Increase cardiac workload, risk for orthodontic hypotension and venous stasis (leading to venous thrombosis)
70
Compare the effects of exercise vs immobility of each body system:
Respiratory
```
Increase alveolar vent/diaphragmic excursion/depth/rate/gas exchange/expelled co2, dec work of breathing,
VS
Dec depth (lead to atelectasis and imbalance ph)/muscle Tonus/rate, increase resp. Secretion build up (congestion/infection), impaired gas exchange
```
71
Compare the effects of exercise vs immobility of each body system:
Musculoskeletal
Increase: muscle mass, tone, strength, joint mobility, efficiency/flex/coordination, nerve impulse efficiency. Decrease bone loss.
VS
Decrease:muscle size, tone, strength, coordination, endurance, risk for osteoporosis/contractures
72
Compare the effects of exercise vs immobility of each body system:
Metabolic
Increased Glucose/fatty acid conversion (2x more during exercise), triglyceride break down, gastric motility, body heat
VS
Decreased metabolism, muscle atrophy/weakness, fluid imbalance, GI probes, altered gas/nutrient exchange.
73
Compare the effects of exercise vs immobility of each body system:
Psychosocial
Increased energy/wellbeing/self concept, better sleep, pos behaviors
VS
Threatened sense of self, irreg sleep/wake pattern, depression, dec self concept/esteem
74
What are the senses that can be affected?
```
Visual
Auditory
Olfactory
Gustatory
Tactile (touch)
Stereogenesis (touch of object)
Kinesthetic/visceral (body awareness movement/inner organ)
```
75
Define the sensory alteration:
| Overload vs deprivation
Overload-too much stimuli (internal(self pain)/external (others, things)) not allowing brain to respond meaningfully, or not able to ignore it (nervous sys/caffeine)
Dep-too little stimuli (isolation), dec ability to receive stim (blind, etc), or inability to process environ stim (mental dis/cns depres)
76
What is sensory deficit and poverty?
Def-impaired function of one or more senses
Poverty-learning about things w/o actually experiencing it
