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NUR 101 > Unit 3 > Flashcards

Unit 3 Flashcards

1
Q

3 functions important to daily life that GFHP activity and exercise covers

A

cardiac
respiratory
muscles

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2
Q

Energy expenditure requires 4 main support systems

A

neuro
respiratory
cardio
muscles

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3
Q

Why is GFHP activity and exercise important?

A

1/5 of the population has some disability involving mobility or self-care
assessment can reveal lack of exercise which leads to poor muscle tone, balance problems, mental and physical fatigue
minimal exercise, sedentary lifestyle, imbalanced nutrition lead to obesity

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4
Q

Obesity places clients at risk for

A 
CAD
CVA
DM
decreased activity tolerance
impaired mobility
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5
Q

monitoring activity tolerance and ability to perform them is necessary

A

because it helps us identify client strength and physical ability.
and identify risk factors associated with activity intolerance

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6
Q

physiologic responses to activities/exercise

A

assess body’s attempt to meet O2 demands
assess for effective CO
O2 delivery to tissue.
decreased Hgb= not getting enough O2 to tissue

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7
Q

signs of decreased Hgb

A 
lethargy 
fatigue
anemia 
depression
organ failure
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8
Q

Cardiovascular system and activity

A

HR is good indicator of activity tolerance
should return to normal after 5 minutes of exercise
continued increase is abnormal

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9
Q

Cardiac Output

A

is the amount of blood ejected from the left ventricle with each contraction
HR x Stroke volume

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10
Q

How many liters does the heart pump a minute

A

usually 5

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11
Q 
Heart:
size 
Base
Apex 
Great vessels attatched
A

size of your fist
base= top of heart
apex= bottom of heart (where you hear the apical pulse
great vessels attached are the aorta, pulmonary artery, superior and inferior venacava and pulmonary vein

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12
Q

List the blood flow through the heart

A

S&I venacava, right atria, tricuspid valve, right ventricle, pulmonic valve, pulmonary artery, lungs, pulmonary vein, left atria, mitral valve, left ventricle, aortic valve, aorta to the body

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13
Q

Conduction pathway

A 
SA node
AV node
bundle of HIS
bundle Branches 
purkinje fibers
contractile fibers (muscle)
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14
Q

SA node pace

A

60-100

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15
Q

AV node pace

A

40-60

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16
Q

Bundle of HIS pace

A

20-40

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17
Q

P wave

A

atrial depolarization

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18
Q

PR interval

A

allowing ventricles to fill, pause of in AV node

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19
Q

QRS complex

A

ventricular depolarization

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20
Q

T wave

A

ventricular repolarization

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21
Q

Apical pulse techniques

A

rate 60-100 normal
stethoscope diaphragm= hear high pitched sounds
bell- low pitched sounds

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22
Q

what heart rhythm can cause a pulse deficit?

A

A-fib

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23
Q

First Heart Sound

A

S1, systole, ventricles contract, AV valves close, semilunar valves open (aortic, pulmonic), shorter than diastole, lub sound, with tachycardia less ventricular filling and diastole shortens

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24
Q

Second Heart Sound

A

S2, diastole, ventricles relax, SL valves closed, AV valves open, ventricular filling

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25
Q

Third heart sound

A 
ABNORMAL 
S3 heard in diastole 
can be heard in kids and young adults 
called VENTRICULAR GALLOP
use bell to hear
associated with CHF, AV valve insufficiency with rapid ventricular filling with vibrations
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26
Q

Fourth Heart Sound

A 
S4 
heard in late diastole/ early systole
called ATRIAL GALLOP 
use bell to hear
associated with CAD, HTN, aortic and pulmonary stenosis, acute MIs
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27
Q

Heart Valves

A

Aortic: located right of sternum at 2nd intercostal space
Pulmonic: left of sternum at 2nd intercostal space
Tricuspid: left of sternum 5th ICS
Mitral: 5th ICS medial to midclavicular line

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28
Q

Arteries

A 
flow away from the heart
high pressure vessels
strong
compliant- they don't give a lot
oxygenated blood 
most common used is radial
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29
Q

List the Artery Pulse sites

A 
Temporal 
carotid
brachial 
radial
femoral 
popliteal 
posterior tibialis
dorsalis pedis
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30
Q

Veins

A

Less sturdy/ expansible- enables them to store blood to decrease the workload of the heart
low pressure
valves in each vein keep blood flowing in forward direction to heart
deoxygenated blood

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31
Q

peripheral pulse assessment

A 
ease of palpation
rate
time interval between beats
rhythm
elasticity of vessels 
ausculatory findings
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32
Q

Grading pulses

A 
0= non palpable 
1+= weak 
2+= normal
3+= full easy to feel, less pressure
Bounding= may indicate heart condition
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33
Q

Pulse deficit

A

difference between apical and radial

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34
Q

vasodilation

A

widening of blood vessels

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35
Q

vasoconstriction

A

narrowing of blood vessels

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36
Q

JVD

A 
gives us info about R atrial pressure
disappears in upright position
distends when lying
HOB up 30-60 degrees 
turn head to the left
need good lighting 
distended in Right sided CHF
venous insufficiency
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37
Q

parasympathetic nervous system

A

innervates thru vegus nerve, which supplies the SA node, atrial muscle fibers, and AV node
Causes a decrease in HR
rest and digest

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38
Q

sympathetic nervous system

A

supplies all areas of the atria and ventricles
HR increases when stimulated.
Fight or flight.

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39
Q

Baroreceptors

A

located in walls of carotid sinus and aortic arch
detect BP changes and respond
built to detect and notify the brain

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40
Q

factors that stimulate the CNS to send messages

A

stress, trauma, infection, fever, pain, fear, anxiety.

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41
Q

Cardiovascular deficits lead to

A

chest pain, fatigue, weakness

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42
Q

Respiratory deficits lead to

A

dyspnea, cough, SOB, orthopnea, BP to decrease

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43
Q

Musculoskeletal deficits lead to

A

leg cramps, pain

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44
Q

Angina definition and signs and symptoms

A

decreased O2 to heart, precipitated with activities

CP, C tightness, squeezing, pressure,

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45
Q

Aortic Aneurysm definition and S&S

A

dilation of vessel wall

constant intense CP that radiates to back, anterior chest and abdomen

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46
Q

Pericarditis definition and S & S

A

heart sac inflammation

sharp pain aggravated by deep breathing

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47
Q

activity tolerance classifications with Heart disease (1-4)

A

Class 1: has heart disease but asymptomatic. activity isn’t a real problem
Class 2: slight limitation of physical activity no distress at rest, activity causes fatigue, dyspnea or angina
Class 3: significant limitation of activity, no distress at rest. low intensity activity causes fatigue, palpitations, dyspnea or angina
Class 4: symptoms at rest angina or dyspnea at rest, any activity aggravates symptoms

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48
Q

Pulmonary chest pain description

A

pleuritic pain (sharp/ knife like) SOB and poor tolerance to activities

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49
Q

Claudication

A 
not getting good flow
intermittent sharp, cramping, squeezing pain in legs after activity
pain in calf muscle after walking 
caused by ischemia, atherosclerosis
pain decreases with rest
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50
Q

Musculoskeletal pain

A

caused by direct palpation (rule out ischemia)
localized bone pain
check tendons, joints and muscles

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51
Q

fatigue

A

decreased energy levels
assess for cause (physiologic/psychologic)
physical work, infection, disease

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52
Q

Weakness

A

decreased muscular strength
rarely from psychologic problems
sxplore cause
may require additional testing.

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53
Q

SOB/dyspnea

A

can be cardiac, pulmonary or pschogenic
difficulty lying flat
assess for orthopnea, CHF or COPD
assess if during exertion or at rest.

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54
Q

coughing

A

assess if pulmonary or cardiac

note if it’s productive

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55
Q

self care ability rating 0-4

A 
0- independent
1- requires use of equipment device 
2- assist of 1 person
3- assist of 1 person and equipment
4- dependent on others, does not participate
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56
Q

CBC

A

hgb, hct, plt, RBC, WBC.

anemia if values are decreased

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57
Q

Lipid profile

A

for cholesterol

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58
Q

lipoprotein

A

atherosclerosis or CAD if increased

59
Q

serum enzymes

A

troponin

MI

60
Q

Structures within the thorax

A 
Mediastinum: 
Heart
aortic arch
superior vena cava
lower esophagus 
lower trachea
61
Q

Right pleural cavity

A

lung with 3 lobes

62
Q

Left pleural cavity

A

lung with 2 lobes

63
Q

Primary muscles of inspiration

A

diaphragm

intercostal muscles

64
Q

accessory muscles of respiration

A 
sternocleidomastoid
scalenus
pectoralis minor
serratus anterior 
rectus abdominus muscle
65
Q

upper airway structures and functions

A

nose pharynx larynx trachea

conduct air to lower airway
protect from foreign matter
warm filter humidify inspired air

66
Q

lower airway structures

A 
trachea 
R/L main stem bronchi
segmental/subsegmental bronchi
terminal bronchioles
alveoli: where gas exchange occurs
67
Q

increased compliance respirations

A

easy lung expansion

68
Q

decreased compliance respirations

A

difficult to expand increased stiffness of lung more effort to breath

69
Q

surfactant

A

protein phospholipid that decreases surface tension of alveoli to prevent collapse and decrease breathing efforts

70
Q

external respiration

A

pressure gradient

71
Q

internal respiration

A

cellular level with exchange of O2 and CO2

O2 to cells via diffusion

72
Q

Pons

A

regulates respiratory rhythm

73
Q

Medulla

A

controls respiratory rate and depth

depends on CO2, O2 and HCO3 ion concentration in blood and body tissues

74
Q

Abnormal breath sounds

A

Crackles

wheezes

75
Q

Normal lung sounds

A

Bronchial- normal in child and young adults >40 is abnormal, heard over the trachea. Loudest sound.

Broncho-vesicular- heard over the anterior and posterior area of the bronchi

Vesicular- heard through lung fields.

76
Q

Crackles

A

heard on inspiration, expiration or both
may or may not clear with coughing
causes atelectasis (alveolar collapse)

heard with smphysema bronchitis, pneumonia, CHF, pulmonary edema, pulmonary fibrosis and COPD

sounds like crackling, bubbling related to fluid in small airways and alveoli

77
Q

Fine Crackles

A

lower airways, high pitched sound wet.

78
Q

coarse crackles

A

upper airways louder pitch

79
Q

Wheezes

A

heard on inspiration, expiration, or both and with or without stethoscope.
heard with asthma, pneumonia, bronchospasms, airway obstruction, foreign body or tumor.

sounds like continuous musical, high pitched rt air rushing in over narrow obstructed airways

80
Q

plural friction rub

A

heard on inspiration or expiration
does not clear with coughing
painful on inspiration
post pleural effusion removal, MI, pericarditis, pneumonia and pleurisy

sounds like grating.

81
Q

Hypoxemia

A

blood oxygen levels drop below normal

PaO2 tells how much O2 the lungs are delivering to blood and tissues

82
Q

mild hypoxemia

A

PaO2 60-79 mmHg

83
Q

moderate hypoxemia

A

PaO240-59 mmHg

84
Q

Severe hypoxemia

A

PaO2 less than 40 mmHg

85
Q

Hypoxia

A

blood unable to take adequate amount of O2 to tissues
occurs during internal respirations

signs and symptoms
agitations 
anxiety
change LOC 
headache
irritability 
restlessness
tachypnea
late symptoms:
bradycardia 
cardiac dysrhythmias 
bradypnea
retractions
86
Q

pH

A

7.35-7.45 acid base level of H+ ion

87
Q

PaO2

A

80-100 mmHg tells how much O2 lungs delivering to blood and tissues

88
Q

PaCO2

A

35-45 mmHg tells how well lungs getting rid of CO2

if increased resp acidosis if decreased resp alkalosis

89
Q

HCO3

A

22-26 mEq/L assesses H ion levels

bicarb

90
Q

SaO2 saturation

A

95-100% O2 saturation of hemoglobin

91
Q

respiratory acidosis

A

low pH high CO2

92
Q

respiratory alkalosis

A

high pH low CO2

93
Q

metabolic acidosis

A

low pH low HCO3

94
Q

metabolic alkalosis

A

high pH high HCO3

95
Q

PROM

A

passive range of motion

nurse does for patient

96
Q

AROM

A

active range of motion

patient can perform

97
Q

Lordosis

A

abnormal concave of lumbar spine

booty pop

98
Q

kyphosis

A

abnormal increased rounding of the thoracic curve

hunchback of notre dame

99
Q

scoliosis

A

lateral deviation of the spine

100
Q

elimination is a _________behavior so it requires

A

biopschosocial

privacy
appropriateness of location, discussion, disposal of waste.

101
Q

I&Os provide information on

A

fluid balance

102
Q

Incontinence may cause

A

anxiety depression and social isolation

103
Q

Urinary retention is common after

A

surgery

104
Q

factors influencing bowel function

A

diet, age, activity, exercise, stress, drugs, pathology

105
Q

alimentary tract

A 
from mouth to anus
esophagus
stomach
intestines
rectum
anal canal
106
Q

functions of GI tract

A

ingest and digest food
absorb nutrients electrolytes and water
excrete waste

107
Q

oral cavity

A

mouth and oropharynx
teeth- adults have 28, 32 if wisdom teeth are intact

saliva- 1200 ml/day
digestion

108
Q

liver

A 
largest organ 
functions:
bile
transfer bilirubin from blood to gallbladder
protein, CHO fat metabolism 
glycogen storage
synthesis of plasma proteins
detoxification
storage of iron, vitamin A&B
109
Q

gall bladder

A

concentrates and stores bile

located in the RUQ

110
Q

pancreas

A 
endocrine: 
insulin 
glycagon
gastrin
exocrine:
bicarb
pancreatic enzyme
111
Q

spleen

A

store RBC and platelets
activates B/T lymphocytes
RBC production

112
Q

abdominal quadrants

A

RUQ
LUG
RLQ
LLQ

epigastric
periumbelical
suprapubic

113
Q

bowel elimination amount r/t

A

amount and composition of ingested food

114
Q

absorption

A

passive process of converting semi liquid chime into formed fecal mass

115
Q

peristalsis

A

wave like movements that propel feces to sigmoid and rectum

116
Q

borborygmi

A

audible sounds produced by hyperactive peristalsis

associated with intestinal obstruction

117
Q

defecation

A

movement of feces from bowel
reflex initiated when stool enters rectum
internal and external sphincters relax allowing for defecation
if continuously suppressed results in constipation/fecal impaction

118
Q

tarry stool

A

black
caused by upper GI bleed
bleeding, iron, licorice, peptobismol

119
Q

green stool

A

spinach, in kids= increase passage of stool thru bowels

120
Q

white/ grey stool

A

gallbladder problems or antacids

121
Q

yellow stool

A

increased fat r/t malabsorption

122
Q

Red stool

A

lower GI bleed

check for surface bleeding, hemorrhoids or fissures

123
Q

occult

A

not seen with the naked eye

possible causes are cancer of the GI tract

124
Q

factors affecting bowel elimination

A 
medications:
laxatives
antibiotics
psychological:
boredom
stress
depression
125
Q

tenesmus

A

rectal pain associated with urge to defecate and feeling or incomplete emptying after defecation

126
Q

ulcerative colitis

A

inflammation of the colon and rectum

can have up to 30 episodes of diarrhea/day

127
Q

crohns

A

inflammatory problem of the large or small intestines

lesion on the intestinal wall, cramping, fever

128
Q

diverticulitis

A

colon pouching, with constipation abd pain

+ for occult (blood) stools

129
Q

hemorrhoids

A

dialated veins in rectum
internal or external
can cause pain, bleeding, swelling with stools

130
Q

anal fissures

A

cracks in the rectum.

131
Q

neurological injuries

A

can alter GI functioning

132
Q

obstructive problems

A

block the passage way of stools

can be serious if not corrected

133
Q

IBS

A

spasm of the colon with cramping & pain

134
Q

gastroenteritis

A

viral or bacterial inflammation with diarrhea

135
Q

malabsorption

A

problems digesting fats, proteins, CHO

causes rapid emptying and diarrhea with weight loss or malnutrition

136
Q

polyps

A

wart like growth on the intestinal wall

can grow in clusters and become cancerous

137
Q

illeostomy

A 
surgical diversion of the ileum
stool is liquid or semi liquid
limited control
700-800ml a day is average norm
can do a continent ileostomy with a kock pouch: to help control, has nipple valve for removal of stool
138
Q

colostomy

A

large intestine brought to the abdominal wall
opening on abdominal wall called stoma
location depends on the stool consistency
ascending more loose than descending
control depends on location
may be temp. to rest bowel
has external appliance for stool
correct fitting of appliance is importantn to decrease skin irritation.

139
Q

diet/fluids

A

need adequate hydration to provide weight, bulk and softness to stools
dehydration-> hard feces, constipation
6-8 glass of water daily, high fiber diet

140
Q

activity/exercise

A

helps with muscle tone in abdomen and pelvis
helps propel stool
decreased mobility causes weakness and decreased peristalisis

141
Q

laxatives

A

can become dependent
can be harmful practice especially for the elderly
avoid chronic use

142
Q

four classes of laxatives

A

lubricants: mineral oil
bulk formers: fiber all, citrual
saline cathartics: MOM, Epsom salts
stimulants: sennekot, correctol, castor oil

143
Q

assessment of abdomen

A 
IAPP
inspect: skin, contour
auscultate: listen in 4 quadrants with diaphragm of stethoscope.
palpate in four quadrants
percuss

NUR 101 (3 decks)

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