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Practical Nursing 101 > Unit III > Flashcards

Unit III Flashcards

(85 cards)

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1
Q

Guaiac

A

a test for blood in stool

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2
Q

Petechaie

A

Pinpoint, round, red, and purple spots on the skin like small blood vessels have popped

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3
Q

Tinnitus

A

ringing in the ears

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4
Q

Vertigo

A

dizzy whirling sensation

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5
Q

Peristalsis

A

movement of intestines

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6
Q

Concave

A

curving inward, sunken

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7
Q

Convex

A

curving outward, bulging

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8
Q

Ridged abdomen

A

firm, board like on palpation

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9
Q

striae

A

stretch marks

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10
Q

Atrophy

A

underdevelopment or wasting of muscle tissue

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11
Q

Parts of client interview

A 
o	Establish relationship; build report
o	Client and family history
o	Identify client preferences
o	Individualize care approach
o	Explore all aspects of the whole person (holistic approach)
o	Begin data collection for assessment
o	Use plain language
o	Therapeutic communication
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12
Q

Therapeutic communication techniques

A 
Active listening Open-ended questions
Clarifying
Back channeling
Probing
Close-ended questions
Summarizing
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13
Q

Sympathetic nervous system

A
  • Fight or Flight
  • Pupils dilate to see better
  • Bronchial tubes dilate to increase air flow, respiratory rate increases hyper oxygenate.
  • Heart rate increases to oxygenate the body
  • Blood pumps to large muscles to prepare for fight or flight
  • Digestive blood flow decreases due to shift in circulation.
  • Release of hormones; epinephrine and norepinephrine.
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14
Q

Parasympathetic Nervous system

A
  • Cool down phase

* Body systems return to normal

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15
Q

Signs and symptoms of Stress

A
  • Rapid, shallow breathing (tachypnea)
  • Dry mouth
  • Diaphoresis
  • Shakiness, tremors
  • Restlessness
  • Increased pulse (tachycardia)
  • Muscle tension
  • Rapid Speech
  • Frequent Urination
  • Dizziness
  • Anxiety
  • Irritability
  • Nausea
  • Changes in appetite
  • Feeling of shortness of breath
  • Chest pain or pain in other parts of the body
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16
Q

General Adaptation Syndrome Stage 1 Alarm

A

Body functions are heightened to respond to stressors, also called fight or flight response. Hormones are released, which cause elevated blood pressure and heart rate, heightened mental alertness, increased secretion of epinephrine and norepinephrine, and increased blood flow to muscles.

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17
Q

General Adaptaion Syndrome Stage 2 resistance

A

body functions normalize while responding to the stressor. The body attempts to cope with the stressor and return to homeostasis. Stabilization of blood pressure, heart rate, and hormones will occur.

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18
Q

General Adaptaion Syndrome Stage 3 Exhaustion

A

Body functions are no longer able to maintain response to stressor and the client cannot adapt. The end of this stage results in recovery or death.

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19
Q

Sources of stress related to hospitalization

A
  • New people
  • Wearing a gown
  • Lack of privacy
  • Dependent on others for food, bathroom, washing
  • Being awakened at all times
  • Too many or not enough visitors
  • Finance cost, family needs, pets at home
  • What will diagnosis be?
  • Medical terms they don’t understand
  • Waiting
  • Underlying mental health condition
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20
Q

Ways to reduce stress

A
  • Introductions
  • Explanations for everything
  • Orientation
  • LISTEN
  • Therapeutic communication
  • Provide privacy as much as possible
  • Allow independence
  • Hourly rounding
  • Answer call lights promptly
  • Be honest
  • Allow sleep
  • Visitors
  • Address concerns
  • Creature comforts
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21
Q

When measuring height…

A 
measure from crown of head to sole of foot
No shoes
Feet together
Back straight
Shoulders back
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22
Q

When measuring weight…

A

No shoes

For daily weights: same time of day, best if first thing in the morning, use same scale every day

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23
Q

Hypothermia interventions

A

COLD BELOW 95

Provide warm environmental temperature

heated humidified oxygen

warming blanket

warmed oral or IV fluids.

Keep head covered.

Provide continuous cardiac monitoring

Have emergency resuscitation equipment on standby

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24
Q

Hyperthermia Interventions

A

Fever above 102.2
Obtain specimens for blood, urine, or wound cultures as needed

Assess/monitor white blood cell counts, sedimentation rates, and electrolytes

Ensure prescribed cultures are obtained before administering prescribed antibiotics, to promote test accuracy.

Provide fluids and rest–>Minimize activity–> use a cooling blanket

Children and older adults are at risk for fluid volume deficit

Provide antipyretics (aspirin, acetaminophen, ibuprofen). Do not give aspirin to manage fever for children and adolescents who have a viral illness (influenza or chickenpox) due to the risk of Reye’s syndrome.

Prevent shivering, as this increase energy demand.

Offer blankets during chills and remove them when the client feels warm.

Provide oral hygiene and dry clothing and linens

Keep environmental temperature between 21-27 C

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25
Affect of age on respirations
decreases with age
26
Men and chilcren are what kind of breathers
diaphragmatic breathers; abdominal movements more noticable
27
Women breath using...
Thoracic muscles, chest movements are more pronounced
28
An upright body posistion allows chest wall...
to expand more fully
29
Amphetamines and cocaine can increase
Respiratory rate and depth
30
Opioids, sedatives, bronchodialators, and general anesthetics can decrease...
Respiratory rate and depth | Respiratory depression is a adverse reaction
31
An injury to the brain stem can decrease...
respiratory rate and rhythm
32
Anemia and high altitudes can cause
Impaired oxygen carrying comacity of blood
33
Cheyne-stokes
respirations that become faster and deeper, then slower, alternates with periods of apnea. Indicates end of life
34
Kussmaul's
Faster and deeper respirations without pauses. | Indicated end of life
35
Retractions
muscles of the chest wall/abdomen moving inward with inhalation, cue to work of breathing. Can occur in children and newborns
36
Nasal Flaring
Widening of nostils | cue to hypoxia
37
Cyanosis
blue discoloration of the skin/mucous membranes | Cue to Hypoxia
38
COPD normal SpO2
85-89%
39
Oxygen can require what type of monitoring
continuous or intermitten
40
Hypercapnia
increased carbon dioxide
41
If using oxygen no...
``` smoking petroleum products (chap stick) ```
42
How to assess orthostatic blood pressure
take pt’s BP and HR after the pt has been in the supine position for 3-10 mins. Next, have pt change to the sitting or standing position and immediately reassess BP and HR. Wait an additional 3 mins and repeat BP and HR. The pt has orthostatic hypotension of the SBP decreases more than 20 mmHg or the DBP decreases 10 mmHg or more with increase in HR. DO NOT DELEGATE.
43
S3, S4, Gallop
extra heart sounds | abnormal
44
Murmurs
blowing or swishing sound heard over heart, best heard with bell of stethescope. abnormal
45
Thrills
Vibration you can feel rare accompany murmurs or other abnormalities
46
Bruits
blowing/swishing sounds heard over blood vessels, listen with the bell abnormal
47
Cardiac changes with aging
Systolic hypertension Point of maximum impulse becomes more difficult to palpate because AP diameter of chest widens Coronary blood vessel walls thicken and become more ridid with narrowed lumen Cardiac output decreases and strength of contraction leads to poor activity tolerance Heart valves stiffen due to calcification Left heart ventricle thickens Pulmonary vascular tension increases Systolic blood pressure rises Peripheral circulation diminishes
48
When assessing lung sounds...
always listen directly on skin
49
Bronchial
Normal Medium pitched blowing sounds heard over trachea expiration longer than inspiration
50
Bronchovesicular:
Normal | medium pitched blowing sounds, heard over bronchial tubes and bronchioles, expiration equal to inspiration.`
51
Vesicular
Normal | soft, low pitched, heard over peripheral areas of the lungs, inspirations longer than expiration.
52
Crackles/rales
Abnormal | fine to coarse bubbly sounds, rice krispies sound, indicates fluid. Can be cleared up with coughing.
53
Wheezes
high pitched musical sounds, indicates airway constriction or obstruction.
54
Stridor
high pitched barking sounds, indicates more emergent airway construction or obstruction. Indicative of croup
55
Rhonchi
coarse, low pitched rumbling sounds, indicates fluid of mucous.
56
Pleural Friction RUb
dry grating, or rubbing sound, indicates inflammation at the lung lining, can be painful.
57
Absence of breath sounds in presence of respirations indicate...
collapsed or punctured lung; absence of lung lobe due to surgical collapse.
58
Expected changes in lung sounds with age
o Chest shape changes so that the AP diameter becomes similar to the traverse diameter (barrel chest), resulting in decreased vital capacity. o Chest excursion or expansion diminishes o Cough reflex diminishes o Cilia ineffectively removes dust and irritants from the airways. o Alveoli dwindle, airway resistance increases, and the risk of pulmonary infection increases. o Kyphosis
59
Kyphosis
an increased curvature of the thoracic spine due to osteoporosis and weakened cartilage, results in vertebral collapse and impairment of respiratory effort.
60
Neuropathic pain
related to a dysfunction of the nervous system, can often be burning, numbness/tingling, dull, heavy pressure.
61
Phantom Pain
pain after the loss of a body part where the body part would be.
62
Pain threshold
point at which person feels pain
63
Idiopathic pain
form of chronic pain without a know cause and pain exceeds typical pain levels
64
Pain Assessment
``` Intensity Location TIming Aggrivating factors Accompanying symptoms ```
65
When a client is in pain alway...
Convey acceptance caring monitor vital signs
66
Pharmacological Pain management methods
``` Opioids Nonopioids Adjuvant Patient-controlled analgesia Pain patch ```
67
Non-pharmacological treatents
``` relaxation techniques Electrical nerve stimulation distraction Imagery massage Acupuncture/acupressure Binders/braces Hydrotherapy Hypnosis PHysical therapy Heat/cold ```
68
Normal Capillary refill is...
3 seconds
69
If capillary refill is 3 seconds...
repeat on another digit first
70
Pupillary abnormalities may indicate
head trauma increased pressure inside the skull Always check respiratory status first--> Respiratory status is also affected by increased pressure in the skull
71
Active ROM
individual can actively move limbs
72
Passive ROM
Individual cannot actively move, limbs must be moved by another person.
73
Otunded
Client responds to light shaking but can be confused and slow to respond
74
Stuporous
the client requires painful stimuli to achieve a response; client may not be able to verballt respond
75
Glasgow coma scale
from 3(comatose) to 15 (alert)
76
When assessing the abdomen
Inspection, ascultation, palation
77
WHen ascultating the abdomen
RLQ-->RUQ-->LUQ-->LLQ
78
Normoactive bowel sounds
5-30 clicks/gurgles in 2 mins
79
Hypoactive bowel sounds
5 clicks/gurgles in 2 minutes
80
Hyperactive | bowel sounds
greater than 30 clicks/gurgles in 2 minutes or rumbling
81
Age considerations for elderly
o Allow more time for response, greater store of knowledge o Allow for periods of rest or breaks if needed o Do not stereotype: not all elderly require assistance, etc. o Allow for independence to the extent possible
82
Age considerations for Pediatrics
o Separation anxiety  allow parent to hold child during assessment o Stranger Danger o Language barrier o Fear  Allow familiar object like blanket, toy, etc. o Demonstrate assessment, ask permission
83
Age considerations for Adolescents
o Independence: allow for choices, ask permission o Privacy: allow to decide if parent present if possible o Personal space
84
Endocrine System disorders
Insomnia apnea snoring narcolepsy
85
When usig a pain patch...
applied to skin Monitor confused/psychotic patients closley Do not touch with bare skin WEAR GLOVES Do not cut

Practical Nursing 101 (10 decks)

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