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Semester One - Nursing 111 > Week Nine > Flashcards

Flashcards in Week Nine Deck (173)
1

Occult Blood

Hidden blood

2

Carminative Enema

given to expel flatus. Solution releases gas in rectum which causes distention and stimulates peristalsis

3

Retention Enema

Introduces oil or medication into the rectum and signmoid colon. Softens feces, lubricates feces and colonic mucosa to facilitate passage of feces.

4

Cleansing Enema

Removes feces using a variety of solutions

5

Enema Function

Remove feces and/or flatus

6

Enema

A solution introduced to the rectum and sigmoid colon

7

Fecal Impaction

A mass of hardened, puttylike feces in folds of rectum

8

Signs of Fecal Impaction

passage of liquid fecal seepage and no normal stool

9

Time it takes to see oil retention enema results

30minutes - 3 hours

10

Nursing Considerations for Enema

- Amount of fluid used

11

Soap Suds Enema

Cleansing soapy enema given to remove feces from colon. Relieves constipation and is a prep for diagnostic tests.

12

Action of Soap Suds Enema

Stimulates peristalsis by irritating mucosa and distending colon volume up to 1,000 mL H20 with soap

13

Oil Retention Enema

Retention enema that makes defecation easier. Mineral oil is commonly used.

14

What type of enema is a hypertonic enema?

cleansing enema

15

Hypertonic Enema

Cleansing sodium enema given to remove feces from the colon. Relieves constipation and preps for diagnostic tests.

16

Action of hypertonic enema

Draws water into the colon, distends the colon, irritates mucosa

17

Time it takes to see results from a hypertonic enema

5-10 minutes

18

Volume Hypertonic Enema

90-120 mL

19

What type of enema is a tap water enema?

Hypotonic cleansing enema

20

Carminative enema volume

180mL total

21

Volume oil retention enema

90-120mL

22

Tap water enema

Hypotonic Enema. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces.

23

Volume tap water enema

500-1000mL

24

What type of enemas should be administered to an infant or child?

isotonic

25

Enema temperature for infant or child

100 F or 37.7 C unless otherwise ordered

26

True or False: Elders may fatigue easily when administering an enema

True

27

What position is appropriate for administering an enema in a small child?

Dorsal recumbent position

28

How far should the tube be inserted for enema administration in infants?

1-1.5 inch

29

How far should the tube be inserted for enema administration in children?

2-3 inches

30

True or False: Tap water enemas should be used with caution in the elderly

True.

31

What should be assessed in elderly clients during enema administration?

vagal episodes, slow pulse, and irregular pulse

32

Nursing responsibilities for stool specimens

- Have the client defecate into a clean bedpan or bedside commode

33

Therapeutic Nursing Interventions for rectal suppository

- Hand hygiene and gloves

34

Anemia

lack of a normal number of red blood cells

35

Bradypnea

slow respiratory rate, usually below 10 respirations per minute

36

Cheyne Stoke Respirations

patter of breathing characterized by gradual increase of depth and sometimes in rate to a maximum level followed by a decrease resulting in apnea

37

Cyanosis

a bluish discoloration of the skin and mucous membranes

38

Diffusion

process by which molecules tend to move from an area where they are more concentrated to an area where they are less concentrated

39

Dyspnea

shortness of breath, difficult or labored respiration

40

Eupnea

normal relaxed breathing, easy

41

Hemoptysis

coughing up blood from the respiratory tract

42

Humidification

process of adding water to gas

43

Hypercarbia

the presence of an abnormally high level of carbon dioxide in the circulating blood

44

Hyperventilation

an increased depth and rate of breathing greater than demanded by the body needs

45

Hypoventilation

respiratory rate remains abnormally low and is insufficient to meet the demands for normal oxygen delivery and carbon dioxide removal. (most common cause of hypercapnia)

46

Hypoxemia

deficient amount of oxygen in the blood

47

Hypoxia

deficient amount of oxygen in tissue cells

48

Orthopnea

form of dyspnea in which the person can breathe comfortably only when standing or sitting erect

49

Productive Cough

cough with spitting of material from the bronchi

50

Nonproductive cough

dry, hacking, produces no secretions

51

Respiratory insufficiency

disturbance oflevels of oxygen and carbon dioxide in the blood stream, inability of body to meet oxygen nees andremove CO2

52

Tachypnea

an abnormally rapid rate of respiration, usually >20 breaths per minute

53

Oxygen Status Diagnostic Test Serum Hemoglobin

12-18g/100mL

54

Oxygen Status Diagnostic Test Serum Red Blood Cell Count

3.5-5.0 million/ cu. mm

55

Barrel Chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

56

Funnel Chest

pectus excavatum; depression in the lower portion of the sternum, may cause compression of the heart

57

Pigeon Chest

pectus carinatum; sternum displaced anteriorly; costal cartilage beside the protruding sternum are depressed

58

Biorhythms

an innate periodicity in an organism's physiological processes, as sleep and wake cycles.

59

Circadian Rhythms

individual is awake when the physiologic and psychologic rhythms are most active and is asleep when the physiologic and psychologic rhythms are most inactive. Rhythmic repetition of patterns each 24 hours.

60

Hypnotic

depresses the central nervous system and usually produces sleep

61

Sedative

depresses the central nervous system to produce calm and diminished responsiveness without producing sleep

62

Sleep

a natural and periodic state of rest during which consciousness of the world is suspended

63

Somnolence

drowsiness; sleepiness

64

Insomnia

sleep abnormalities, including difficulty in falling asleep and wakefulness through the night

65

Hypersomnia

Excessive sleepiness, as evidenced by prolonged nocturnal sleep, difficulty maintaining an alert awake state during the day, or undesired daytime sleep episodes.

66

Narcolepsy

a sleep disorder characterized by sudden and uncontrollable episodes of deep sleep

67

Parasomnia

abnormal movement or emotions during REM and NREM and wakefulness. bruxism, enuresis, periodic limb movement disorder, sleep talking, sleep walking

68

Sleep Apnea

a sleep disorder characterized by temporary cessations of breathing during sleep and repeated momentary awakenings

69

Rest

calmness, relaxation without emotional stress and freedom from anxiety

70

NREM Sleep

75-80% of sleep, three stages

71

Stage One NREM

very light sleep, drowsy, relaxed, can be awakened easily and lasts a few minutes

72

Stage Two NREM

Light sleep which body processes continue to slow down. Lasts only 10-15 minutes but constitutes 44-55% of total sleep

73

Stage Three NREM

Deepest sleep. only differs in the % of delta waves recorded during a 30 second period. HR and R drop 20-30% below waking hours, individual difficult to arouse. restores energy and releases growth hormones

74

Changes during NREM sleep

BP falls, HR decrease, peripheral blood vessels dilate, cardiac output decreases, skeletal muscles relax, basal metabolic rate decreases, growth hormone level peaks, intracranial pressure decreases

75

REM Sleep

rapid eye movement, q 90 minutes for 5-30 minutes, not as restful as NREM, dreams, brain highly active and brain metabolism increases by as much as 20%, may be difficult to arouse or NOT, voluntary muscle tone is decreased, gastric secretions increase, HR irregular, R irregular

76

Functions of sleep

Restores normal levels of activity, normal balance among parts of the nervous system, necessary for protein synthesis, psychological well being

77

Newborn sleep

16-18 hr

78

Infant sleep

14-15 hr

79

Toddler sleep

12-14 hr

80

preschooler sleep

11-13 hr

81

school age children sleep

10-11 hr

82

adolescents sleep

9-10 hr

83

adult sleep

7-9 hr

84

older adults sleep

7-9 hr

85

Nocturia

excessive urination at night

86

Factors that affect normal sleep

illness, environment, lifestyle, emotional stress, stimulants and alcohol, diet, smoking, motivation, medications

87

Sleep History Assessment

sleep history, pattern, problems, medications, health history, medical or psychiatric issues, physical examination, obstructive sleep apnea, sleep diary

88

Normal Sleep Findings

awaken refreshed and not fatigued during day, fall asleep without difficulty

89

Sleep deprivation findings

difficulty falling asleep, waking up during the night, difficulty returning to sleep, waking up too early in the morning, unrefreshing sleep, daytime sleepiness, difficulty concentrating, irritability

90

Teenage sleep deprivation findings

difficulty waking, falls asleep, late for class, has to drink caffeinated bev, difficulty in school, irritable, anxious, angry, always on the run, naps and sleeps in on weekend

91

Definition disturbed sleep pattern

time limited interruptions of sleep amount and quality due to external factors

92

Defining characteristics disturbed sleep pattern

change in normal sleep pattern, verbal complaints of not feeling well rested, dissatisfaction with sleep, decreased ability to function, reports being awakened, reports difficulty falling asleep

93

sleep deprivation definition

prolonged periods without sleep(sustained natural, periodic suspension of relative consciousness)

94

defining characteristics of sleep deprivation

actue confusion, agitation, anxiety, apathy, combativeness, daytime drowsiness, decreased ability to function, fatigue, feeling nystagmus, hallucinations, hand tremors, heightened sensitivity to pain, inability to concentrate, irritability, lethargy, listlessness, malaise, perceptual disorders, restlessness, slowed reaction, transient paranoia

95

safety measures for sleep in health care setting

put side rails up, place beds in low position, use night lights, place call bells within easy reach

96

Ambien

Sonata

97

Zolpidem

Zaleplon

98

Ambien Use

short term treatment insomnia

99

Ambien action

CNS depression at limbic, thalamic, hypothalamic levels, may be mediated by GABA, sedation, hynosis, skeletal muscle relaxant, anticonvulsant activity, anxiolytic action

100

Side/Adverse effects ambien

lethargy, drowsiness, daytime sedation

101

nursing implications ambien

administer after removal of cigarettes to prevent fires, after trying conservative measures for insomnia, 30min-1hr before bedtime for sleeplessness

102

sonata use

insomnia

103

sonata action

binds selectively to omega-1 receptor of the GABA receptor complex, sedation, hypnosis, skeletal muscle relation, anticonvulsant activity, anxiolytic action

104

sonata side/adverse effects

lethargy, drowsiness, daytime sedation

105

sonata nursing implications

administer after removal or cigarettes to prevent fires, after trying conservative measures for insomnia, immediately before bedtime for sleeplessness

106

Phases of respiration

pulmonary ventilation, alveolar - capillary gas exchange, transport of gases, peripheral capillary gas exchange

107

Pulmonary Ventilation

Movement of air between the atmosphere and the alveoli of the lungs (inspiration, expiration)

108

Inspiration

active process

109

Expiration

passive process

110

Requirements for pulmonary ventilation

unobstructed airway, intact CNS, intact brain stem, ability of chest cavity to expand and contract, ability of lungs to expand and contract

111

Alveolar - Capillary Gas Exchange

diffusion=distribution. movement of gases from an area of higher concentration to an area of lower concentration, diffusion of oxygen and carbon dioxide between the alveoli and the pulmonary capillaries

112

Transport of gases

Movement of gases lungs and heart, heart and tissues

113

Requirements of transport of gases

intact cardiovascular system

114

Oxygen is transported VIA what?

hemoglobin of RBC

115

Carbon Dioxide transported VIA what?

RBC and is dissolved in plasma

116

Peripheral Capillary Gas Exchange

Diffusion = Distribution. Movement of gases from an area of higher concentration to an area of lower concentration, diffusion of oxygen and carbon dioxide between the peripheral capillaries and body cells

117

Right Side Heart

Pulmonary Ventilation

118

Left Side Heart

Transport

119

Lungs

gas exchange

120

What mechanisms regulate the respiratory process?

neural control- brain stem: medulla oblongata and pons, cerebral cortex, chemoreceptors

121

Medulla Oblongata and Pons

automatic control of R

122

Cerebral Cortex

Voluntary or conscious control of R, singing, swimming

123

Chemoreceptors

increase in carbon dioxide increase R, co2 blown off

124

Aorta and Carotid arteries

decrease o2 increases R, increase o2, emergency ventilation, fight or flight response

125

Stress

flight or fight mechanism

126

Environment

Altitude, occupational hazards

127

Lifestyle

exercise, smoking

128

Health Status/Disease

lungs, nervous system, cardiovascular

129

Age

infants, children, elders

130

Factors that affect R function

stress, environment, lifestyle, diet, health status/disease, medications, age

131

Factors affecting gas transport

effective cardiac pump, adequate peripheral blood vessels for diffusion, adequate amount of plasma intravascular, normal RBCs

132

Infants R

30-60

133

Child >1 year R

25

134

Infant risk

maturing R center increases risk for R illness

135

Elder Risk

decrease lung elasticity, decrease in ability to pump and transport gases, exposure to environmental hazards through life time, decrease immune response = risk for respiratory illness

136

Information collected during nursing history when assessing oxygenation

restlessness, confusion, abnormal breathing patterns, cough, sputum, chest pain, fatigue, weakness, lightheadedness, med history respiratory, neurological, cardiovascular, environment, lifestyle, medications, diet

137

Function of Iron

Formation of Hgb - transports oxygen

138

Sources of Iron

organ meats, oats, prune juice

139

Absorption of Iron

Vitamin C increases absorption, calcium decreases absorption

140

Populations at risk for iron def

less than 18 months, pregnancy, lactation, menstruation, vegetarians, low socioeconomic groups

141

Oxygen Sat normal

95-100%

142

Areas to assess for cyanosis

nail beds, circumoral skin (around mouth), sublingual mucous membranes (under tongue), conjunctiva (eyes), earlobes, buccal mucosa (cheeks), lips, palms of hands, soles of feet

143

RBC Venous blood sample

trasport mechanism for oxygen

144

RBC normal value

3.5-5.0 million

145

Hemoglobin

binging site for oxygen inside the RBC, dependent on adequate iron intake

146

Normal Hgb

12-18g/100mL

147

Hematocrit

indicates adequate percentage of RBCs and fluid

148

Normal Hct

35-50%

149

Normal Chest

symmetrical from side to side, prominent clavicle, flat sternum, anterior/posterior diameter 1/3 to 1/2 the transverse diameter

150

Hypoxia

insufficient oxygen to body cells

151

Signs of hypoxia

mental status change, restlessness, tachypnea, dyspnea, lightheadedness, tachycardia, cyanosis

152

What information to be collected when assessing cough?

occurrence, triggers, productive or non-productive, sounds, presence of sputum-productive

153

Sputum

Normal lung and airway secretions that may increase to compensate for disease

154

Note sputum

color, amount, odor, consistency, presence of blood

155

Definition of ineffective airway clearance

inability to clear secretions or obstructions from the R tract r/t obstructed airways (mucous, foreign body), R disease, smoke, airway spasm

156

Defining characteristics of ineffective airway clearance

adventitious breath sounds, diminished breath sounds, cough, increase sputum, cyanosis, change in R depth (deep or shallow), dyspnea, orthopnea, tachypnea or bradypnea

157

Definition of ineffective breathing pattern

Inspiration and/or expiration that does not provide adequate ventilation R/T fatigue, impairment of musculoskeletal, respiratory, neuromuscular systems, anxiety

158

Defining characteristics of ineffective breathing pattern

dyspnea, othopnea, tachypnea, bradypnea, use of accessory muscles, increase A/P diameter, change in respiratory depth (increase or decrease)

159

Definition for risk for activity intolerance

At risk for experiencing insufficient energy to complete ADLs

160

Defining characteristics for risk for activity intolerance

respiratory signs and symptoms, cardiac signs and symptoms, de-conditioned status

161

nursing interventions for oxygenation related nur dx

position patient to optimize R (fowlers), assist with deep breathing and coughing techniques, promote fluid intake, humidification, administer medications for cough/sputum production

162

Why promote fluid intake?

liquefies secretions, facilitates expectoration, moistens mucous membranes

163

Why humidification?

moistens airway, facilitates cough and expectoration

164

Expectoration

coughing up and spitting out of material from the lungs

165

Guaifenesin indication

productive and non-productive cough

166

Guaifenesin action

increase volume of secretions, decrease viscosity of secretions

167

Dextromethorphan Indication

non-productive cough due to irritation of airways

168

Dextromethorphan action

suppresses cough center in medulla oblongata

169

Nursing implications for dextromethorphan

treat other symptoms, decrease oxygen demand, monitor R, breathing, breath sounds, cough, sputum

170

Health promotion measures that relate to healthy breathing?

change position frequently, exercise, ambulate, no smoking, avoid exposure to toxins, safety in the home, furnaces, gas appliances, smoke, and CO detectors

171

What are the reasons for supplemental oxygenation

increase the amount of oxygen available for transport. based on symptoms, blood work, 02 sat

172

Ferrous gluconate

more expensive than ferrous sulfate, easier on the stomach

173

ferrous gluconate and sulfate

replaces iron stores necessary for RBC development for iron deficient anemia