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Exam 3
Comfort, Oxygenation, HWI, Legal, Mobility
| Question | Answer |
|---|---|
| Acute pain | Temporary, localized, identifiable cause- trauma,surgery,inflammation, lasts less than 6 months |
| Physiological Signs of Acute Pain | ↑HR, ↑ BP, ↑ RR, sweating, pallor, dilated pupils, and anxiety |
| Chronic Pain | Prolonged pain lasting longer then 6 months, not always associated with identifiable cause. Not always responsive to conventional medical treatment. |
| Physiologic Signs of Chronic Pain | Body adapts to physiological changes over time. May be associated with depression, constipation, and weight loss. |
| Recurrent Pain | intense pain with periods of no pain. Ex. Migraine |
| Progressive Pain | Pain associated with chronic condition that gets worse over time. Ex cancer, arthritis |
| Intractable Benign Pain | Pain that is always present ex. lower back pain |
| Nociceptive Pain | pain from damage or inflammation of the tissues, triggers nociceptor pain receptors causing pain. |
| Somatic Pain | Type of nociceptive pain relating to bones, joints, muscles, skin, connective tissue |
| Visceral Pain | Type of nociceptive pain related to the internal organs |
| Cutnaeous Pain | Type of nociceptive pain in the skin or SQ tissue |
| Referred Pain | pain felt in an area distant from the site of stimuli. Ex shoulder pain from a heart attack |
| Breakthrough Pain | Sudden flare up or increase in pain |
| Neuropathic Pain | pain experienced by people who have damaged or malfunctioning nerves. |
| Phantom Pain | Pain felt in a limb that the pt no longer has |
| Psychogenic Pain | pain in the absence of any diagnosed physiological cause. associated with psychological factors rather then physiological |
| What Assessment Acronym do you use for Pain? | PQRST |
| What does the P stand for? | Provocation- what was pt doing when it started, what makes it better or worse? |
| What does the Q stand for? | Quality- what does it feel like sharp, throbbing, stabbing, burning, crushing, shooting etc. |
| What does the R stand for? | Region/Radiation- where is the pain located? Does the pain radiate?Where? |
| What does S stand for? | Severity- use the pain scale for pt to rate the pain level |
| What does the T stand for? | Timing- when/at what time did pain start? how long did it last? how often does it occur? |
| When would you use the Wong Baker FACES Scale? | most often used with children, can ask them to point to which one they feel or observe based on their expression. |
| Who would you use the FLACC scale with? | Children less then 3 and nonverbal patients. |
| Who would you use the CPOT scale with? | Critical care patients |
| What does FLACC stand for? | Face, legs, activity, cry, consolability |
| What rating would mean severe discomfort on the FLACC scale? | 7-10 |
| What is rated in the CPOT scale? | Facial expression, body movement, muscle tension, compliance with the ventilator, or verbalization for nonintubated pts |
| What are the three types of breakthrough pain? | Incident- caused by movement Idiopathic- non known cause End of dose med failure before next dose is administered |
| Who might experience neuropathic pain? | pt with damaged nerves in CNS- stroke, MS, Parkinson's disease, spinal cord injury, fibromyalgia, diabetic neuropathy |
| How is Neuropathic pain described? | burning, pins and needles, aching, lacerating |
| What medications does neuropathic pain respond best to? | adjuvant medications- anticonvulsants, antidepressants, and local anesthetics |
| How might an infant display pain? | cry to express discomfort, may be consoled by being held, rocking, soothing words, rubbing/patting torso, pacifier, feeding |
| What are some pain considerations for adolescents? | Might not want to express pain in front of their friends. |
| What are some cultural values that effect pain? | Hispanic/Latinos- view pain as a punishment Chinese- view pain as imbalance of harmony in the universe |
| What are some barriers that prevent pts from getting adequate pain relief? | reluctance to report pain, reluctance to admit pain due to fear a disease is progressing, pain is inevitable, worries about side effects, want to be a “good” patient, regulatory issues, Fear of addiction so only wanting a little, poor assessment of pain |
| What are some alternative therapies for pain relief? | TENS RICE movement/restriction Massage Chiropractor Relaxation Distraction Pharmacological Surgery |
| What is the basal rate of a PCA pump? | Base rate- dose infused continuosly each hour (slowly) |
| What is the demand rate? | Dose given when button is pushed(immediate) |
| What is the maximum dose? | Most amount set per hour (prevents overdose) |
| Who can use a PCA pump? | Conscious to hear instructions Able to understand and follow instructions Able to push the button Pt expected to have severe pain for period of time (sickle cell crisis, post-op invasive surgery, burns) |
| What is the ceiling effect? | non-opioid drugs- once a pt consumes a specific dosage, consuming more will not produce a greater pain relief effect. |
| What are the pharmacologic therapies used for pain? | Non Opioids- NSAIDS, Tylenol Weak Opioid- Codeine, Hydrocodone, Tramadol Strong Opioid- Fentanyl, Hydromorphone, Meperidine, Morphine, Oxycodone Adjuvant Meds |
| What are adjuvant meds? | Potentiate effects of pain meds Antidepressants- amitriptyline Antianxiety- diazepam Anticonvulsants- gabapentin Corticosteroids- dexamethasone Local Anesthetics- lidocaine |
| What is the POSS Scale? | assesses the sedation level of a pt on opioids. score of 3 or 4 is unacceptable at 3 must lower the dose and monitor closely at 4 must stop opioid and consider naloxene. |
| What can inadequate pain control lead to? | ↓Sleep ↓Appetite →weight loss ↓Cognitive Ability, Mood disturbances→depression ↓Ability to perform ADL’s ↓ Mobility Slow recovery/healing ↓ Quality of life ↑ Risk of falls |
| What can cause fatigue? | Anemia Depression or grief Medications Persistent pain Sleep disorders Hyperthyroidism, hypothyroidism Regular use of alcohol or illicit drugs Chronic diseases |
| What gender is more at risk for fatigue? | Women |
| How can you prevent fatigue? | Lifestyle choices Balanced diet Daily exercise Good sleep hygiene Stress reduction |
| What are clinical manifestations of fatigue? | Drowsy, Lethargic, Weak. Palpitations, Dizzy, Anorexia, Slow movements, Blurry Vision, Can't concentrate, Impaired decision making, Slow reflexes, Sleep disturbance, Change in muscle tone, Depression |
| What is chronic fatigue syndrome? | Severe tiredness lasting longer than 6 months Not caused by primary condition Not relieved by stress reduction Don't feel rested after adequate sleep Forgetfulness, confusion, inability to concentrate Joint, muscles symptoms |
| How do you treat fatigue? | Treat underlying cause Good sleep hygiene Moderate exercise Cognitive behavioral therapy Complementary & Alternative Therapy (acupuncture, massage, relaxation techniques, herbal dietary supplements) |
| What is insomnia? | Have trouble falling or staying asleep can be acute or chronic Most common sleep disorder Severe insomnia can cause cognitive deficits ^ risk of accidents |
| What is hypersomnia? | Get enough sleep but still have daytime drowsiness |
| What are parasomnias? | Abnormal actions during sleep Potentially harmful Ex: Sleep eating, Sleepwalking(somnambulism), Grinding teeth(bruxism), Enuresis (bed wetting) |
| What are dyssomnias? | Subset of parasomnias Ex: restless leg syndrome- neurological disorder, urge to move legs while at rest, muscle twitches, jerking movement of legs. |
| What is sleep apnea? | Repetitive periods of complete or partial airway obstruction that cause 5 + apneic events (short pauses in breathing) Breathing pauses last 10-20 secs followed by loud snoring or waking. |
| What is obstructive sleep apnea? | Airway blocked by soft palate, tongue or uvula (snoring results) |
| What is central sleep apnea? | Muscles in chest and diaphragm fail |
| Risk factors of sleep apnea? | Obesity Large neck circumference Male more than female Smoking |
| Risk factors of insomnia? | Female more than male Over age 60 Mental health disorder |
| What diagnostic test is used for sleep disorders? | Polysomnography- sleeps study. Records brain waves, oxygen level in blood, HR and breathing, eye and leg movement. |
| How can you treat sleep related disorders? | Cognitive-behavioral therapy Good sleep hygiene Physical exercise Relaxation techniques Nasal strips(to open airways for sleep apnea) |
| What pharmacologic therapies are used for sleep disorders? | Sedative-hypnotic meds Antianxiety meds Insomnia- Temazepam, Zolpidem Restless Leg Syndrome- Clonazepam, Gabapentin Narcolepsy- Modafinil |
| How do you treat sleep apnea? | Weight Loss (if obesity cause) Avoid Supine position Continuous Positive Airway Pressure (CPAP) or BIPAP Surgery to remove obstruction |
| What is good sleep hygiene? | Practice calming bedtime rituals, Wear loose-fitting sleepwear, Comfortable position, Comfortable temperature Schedule meds to promote sleep Avoid daytime naps Avoid stimulants in the evening Schedule Exercise in morning or afternoon, not evening |
| What is narcolepsy? | Severe form of hypersomnia Daytime sleep attacks Hallucinations, sleep paralysis, cataplexy |
| What is somnambulism? | Sleepwalking |
| What is Bruxism? | Grinding teeth while sleeping |
| What is considered severe sleep apnea? | More than 30 apneic events |
| Risk factors of parasomnias? | Children Drug or alcohol abuse |
| Risk factors of restless leg syndrome? | Older age Stress Kidney disease Diabetes Parkinson disease |
| What is a CPAP machine? | forces air into our lungs at the end of expiration and doesn't let all of the air out. Single pressure. |
| What is a BIPAP machine? | Pressure changes during the cycle. Bilevel positive airway. An inhale and exhale pressure. |
| What is cataplexy? | Debilitating condition Person sudden feels weak and collapses at times of strong emotion (laughter, anger, fear, or surprise) |
| Antianxiety Meds | Half-life important for effectiveness Doses should start low, increased gradually Regular use can lead to tolerance, rebound insomnia Tapered dosages when stopping |
| Side Effects of Antianxiety Meds | Headache, dizziness, drowsiness, nausea Tachycardia Postural hypertension Older adults at more risk for side effects Drug, food, herbal interactions Some used only short term because of tolerance issues |
| End of Life Pain | usually wants comfort, not considered acute or chronic |
| Criminal Laws | When something is harmful to another or to society as a whole. Felony or misdemeanor. Punished through fines or imprisionment. |
| Civil Laws | Rights and duties of individuals. Punishment is usually through lawsuit. |
| What is a tort? | Civil wrong committed against an individual or individuals property. can be intentional or unintentional. |
| What are examples of breaking criminal laws? | Homicide Theft Falsifying records Insurance fraud Sexual assault Possession of controlled drugs Active euthanasia |
| What are examples of breaking civil laws? | Negligence Abandonment Malpractice Contract Violations Invasion of privacy Assault Battery False Imprisonment |
| What are examples of unintentional Torts? | Negligence Malpractice |
| What are examples of intentional Torts? [IF LABS] | Assault Battery Slander Libel False Imprisonment Invasion of Privacy |
| What is Negligence? | Conduct that deviates from what a reasonable person would have done in a particular situation. Compared against the average person who exercises average skill, knowledge, and judgement to determine liability |
| What is Malpractice? | Professional negligence, conduct that deviates from what another qualified person of the same profession would do in the same situation. Includes not following standard of care, and omitting care. |
| What is Assault? | Threat of bodily harm. Ex: If you don't provide a urine sample, we'll do a catheter on you to get a sample. |
| What is Battery? | Willful touching that is unwanted, embarrassing, or unwarranted. Ex: Injections given without pt consent |
| What is Slander? | False information spoken about a person, usually damaging their reputation. Ex: Spreading rumor someone has STD |
| What is Libel? | Published false statement that is damaging to someone's reputation. Ex: article written about someone comiting crime who didn't |
| What is False Imprisionment? | Unjustifiable detention of a person without legal warrant to confine them. Ex: confining person to their room Can result in civil & criminal actions |
| What is Invasion of Privacy? | Maintaining HIPAA privacy rule. Pt have rights to their personal space and belongings. |
| Who defines standards of care, professional conduct, and scope of practice? | State nurse practice act, laws and regulations. |
| What are some examples of Negligance? | Failure to follow standards of care Failure to use equipment in responsible manner Failure to communicate Failure to document Failure to assess and monitor Failure to act as a patient advocate |
| What is informed consent? | pt right to be informed of healthcare procedure or treatment Healthcare provider must explain, RN can only reinforce teaching |
| How must consent be obtained? | voluntarily, and without coercion |
| For nursing tasks what kind of consent is acceptable and used often? | Expressed or implied consent. Oral communication or complying with treatment |
| How is competency determined? | Medical condition Capacity to understand treatment benefits, risks, and alternatives. Ability to communicate a decision |
| How can a HCP prove a pt is imcompetent? | Prove that the pt is unable to understand the consequences of their own actions. |
| At what age is pt able to make own decisions? | 18 |
| Who ultimately decides pt's capacity to make their own decisions/ create a AD? | Physician or Judge. RN may help assess but not make decision |
| When is emergency informed consent used? | Imminent danger or loss of limb or life |
| When can't you use emergency consent? | When pt has previously refused procedure or treatment |
| Who are the standards of practice for nurses created by? | ANA |
| When is an exemption allowed for informed consent for minors? | Emancipated minors Court order for treatment Emergencies |
| What treatments are state law dependent that minors can seek treatment without parental consent? | Contraceptive services/ STI treatment Pregnancy Mental health/substance abuse treatment |
| What is the controlled substances act? | Tracking system Drugs classified by use, risk of abuse, and safety risks |
| What does it mean if a drug schedule is I or II? | Highest risk of abuse |
| What is the controlled substances tracking system? | Requires records are kept from manufacturing>pharmacy/hospital> provider > nurse > patient |
| What is the good Samaritan law? | Protects healthcare professionals that respond to an emergency outside of their workplace. |
| What is important to remember when responding to an emergency outside of work? | MUST adhere to standards of care and stay within scope of practice/ licensure. |
| Who is responsible for overseeing the nursing practice acts? | State board of Nursing |
| Under the NPA what must nursing students do? | Provide safe care Understand program/facility policies and procedures Demonstrate knowledge of pt condition, treatment, intervention, meds Perform care only to their level of knowledge Seek help before beginning a procedure |
| Who can execute an advanced directive? | a competent individual |
| What is the patient self determination act? | Providing written copy of rights regarding decisions Providing pt copy of facility AD policy Requires asking about AD Educate staff/community on AD Ensure pt discrimination doesn't occur for lack of AD |
| What is a durable power of attorney? | an individual the person names to make healthcare decisions on their behalf if the pt is no longer able to do so |
| What is a living will? | Specific instructions of what medical treatments the pt refuses in event they are no longer able to do so. Ex: hydration, TPN, resuscitation, and intubation. |
| Who can't be a witness to an AD? | Heir, relative, or PCP |
| What is the nurses role in AD's? | Assess if pt has one Reassure pt that they can change their mind at any time Educate pt and family on what life sustaining measure look like and what they do Support pt decision |
| What is the order of the next of kin? | SAPS 1. Spouse 2. Adult child 3. Parent 4. Adult Sibling |
| Which forms can't be filed and only the original copy is accepted? | MOST and DNR forms |
| What are we legally required to report as nurses? | Births/Deaths Neonatal deaths Communicable diseases (TB, STIs) Unethical, illegal conduct Abuse/ suspected Neglect Injuries from discharge of firearm Illness that appears to be poisoning Knife injury sus from criminal activity |
| What is Good Faith Immunity? | Protects healthcare workers from civil or criminal liabilities when reporting suspected child abuse, even if suspicions weren't correct, and no criminal action taken. |
| What question can you ask about service animals? | Is the dog a service animal required because of a disability? What work or task has the dog been trained to perform? |
| What physicians orders should be clarified? | Any order pt questions Any order if pt condition changes Question verbal order/ circumstances warranting verbal order Any order illegible, unclear, incomplete |
| Should you document an incident report in a pt medical record? | No, this allows it to be discoverable in court. |
| What is total assist/dependent transfer? | Client is conscious, but unable to help with transfer. Requires use of safe pt handling lift equip. |
| What is Maximum assist x2? | Two caregivers are required to provide 75% or more of the effort for any client movement. |
| What is Moderate assist? | 1 Caregiver is required to provide 50% of the effort for any client movement. |
| What is Maximum assist? | 1 Caregiver is required to provide 75% or more of the effort for any client movement. |
| What is Minimal assist? | 1 Caregiver is required to provide 25% of the effort for any client movement. |
| What is supervision assist? | Client needs caregiver present to provide guidance and verbal cues for safety. |
| How does mobility effect the cardiovascular system? | Decreases perphiral circulation Causes increase workload of the heart Edema from lack of fluid return Ischemia due to lack of oxygenated blood Increased risk of thrombus formation |
| What is the Virchow's triad? | 1.Damage to vessel wall 2. Alterations to blood flow 3. Changes in clotting (Hypercoagulability) |
| How does mobility effect the respiratory system? | Increased risk of atelectasis (due to inability to full expand lungs) Increased risk of pneumonia (decrease in volume and air exchange) |
| How does mobility effect the metabolic processes? | Decline in cellular energy requirements When your not moving around the calcium is not used up. |
| What is atelectasis? | When alveoli can not expand to exchange air. |
| What is a spirometer do? | Encourages deep breaths trying to combat effects on respiratory system due to hospitalization and immobility. |
| How does mobility effect GI system? | Slower intestinal processes because of less need for digestion. Less movement means less of a need for calories. Increased risk of constipation. |
| How does mobility effect the urinary system? | Increased risk of reflux back into kidneys can lead to acute kidney injury, renal calculus formation, and kidney infection. Risk for skin breakdown, infection, and negative self-image due to incontinence. |
| What happens to the bladder when pt has had catheter placed for extended period of time? | Bladder is a muscle so it gets weaker when it is not used. |
| How does mobility effect the skin? | Increased pressure everywhere but esp. bony prominences. Pressure injuries form due to ischemia, tissue death. |
| How does mobility effect the musculoskeletal system? | Not using can cause muscle tissue atrophy. Tendons and ligaments tighten or shorten causing painful contractures. Can increase bone reabsorption, leading to osteoporosis and increased risk of fractures. |
| What is abnormal bone growth? | Hypertrophic ossification- bone can grow in the muscles. |
| How does mobility effect the psychosocial system? | Effects mood & impacts ability to participate in ADLs When you aren't using your energy moving you don't feel as tired at night. |
| What is a key independent nursing intervention that you can do for a immobile pt? | Reposition every 2 hours! |
| What does ROM help with? | Increases circulation Stretches tendons Increases muscle use |
| How often should you reposition someone in a chair? | every 30 minutes every hour if they can do micromovements. |
| How many minutes of relief should chair repositioning include? | at least 2 minutes |
| What is hypoxia? | low oxygen in your tissues |
| What is hypoxemia? | low oxygen in the your blood |
| What is atelectasis? | when oxygen levels are low surfactant is not produced and alveoli collapse |
| What does surfactant do? | controls the surface tension and keeps alveoli from collapsing and sticking together. |
| What are the respiratory defense mechanisms? | Nasal hairs Sneezing Cilia Mucous Alveolar Macrophages Epiglottis Cough reflex |
| What is apnea? | no breathing |
| What is hypercabia? | high CO2 which triggers the CNS to breath |
| What is the trigger to breath in pt with COPD? | low O2 levels |
| What conditions make lungs less elastic? | COPD, Pulmonary fibrosis, sarcoidosis |
| What conditions may result in fluid buildup? | ARDS, Pneumonia, Pulmonary Edema |
| What conditions restrict lung movement? | Pleural effusion( fluid buildup gives the lungs less room to expand) |
| What does compliance mean in regards to respirations? | Ease of expansion of lungs Elastic recoil of chest wall |
| Where is the respiratory central for the CNS located? | Brain stem |
| What stimulates the diaphragm? | The phrenic nerve |
| What would happen if the phrenic nerve was paralyzed due to spinal cord disorders or neuromuscular disease? | Impacts ventilation and the stimulate of the diaphragm |
| What is an airway obstruction? | Foreign object, sputum, decreased cough reflex, airway narrowing due to inflamm, children have narrower airways |
| What are Cheyne stoke respirations? | Deep rapid breathing and slow shallow breathing with periods of apnea |
| What is Kussmaul breathing? | Deep and labored breathing pattern often seen in severe metabolic acidosis |
| What can cause inadequate ventilation? | Airway narrowing or obstruction Ineffective Breathing Excessive secretions Atelectasis (collapsed alveoli) Partial Lung collapse (pneumothorax) |
| What is a pneumothorax? | Partial lung collapse |
| What happens when there is a ventilation and perfusion mismatch? | decrease in PaO2 and increase in PCO2 |
| Why are infants at risk for poor oxygenation? | smaller airways= increased risk of obstruction Less alveoli= decreased gas exchange |
| Why are older adults at risk of poor oxygenation? | Decreased compliance= decreased gas exchange Respiratory muscles weaker= less gas exchange Weaker cough reflex= increased risk of aspiration |
| What are individual resp. risk factors? | Smoking is #1 Decreased LOC Non Mod: age , genetics (cystic fibrosis) |
| What does pink frothy sputum indicate? | Pulmonary Edema |
| What does blood tinged sputum indicate? | Trauma or PE |
| What does chocolate broth sputum indicate? | Lung Abscess |
| How could you make sure the pt is giving you a sputum sample and not oral secretion? | Have them huff cough |
| What is gram staining? | indicates bacterial infection |
| What does a CXR show? | Chest Xray shows whether there is air or fluid in the lungs, or collapse. Air is black Fluid is white. |
| If pt has low hemoglobin and hematocrit what does that mean? | not enough hemoglobin/ RBC to carry oxygen around |
| What is PaO2? What is the range? | amount of oxygen in the arterial blood. 75-100 |
| What is PaCO2? What is the range? | amount of carbon dioxide in the blood. 35-45 Less than 35 is alkaline, above 45 is acidic |
| What is HCO3? What is the range? | bicarbonate values from the kidneys. 24-28 |
| What is SpO2? What is the range? | percentage of hemoglobin molecules that are saturated with oxygen. 95-100 |
| What is the most important measurement of the ABGs? | Partial oxygen pressure (PaO2) |
| What is the tidal volume? | amount of air that movies in and out of the lungs in normal breathing, with each breathe. |
| What is forced vital capacity? | maximum amount of air that can be forced out of the lungs on exhale after taking a full inhale (max. intake) |
| What is forced expiratory volume? | measures volume air exhaled in first second. If airways are smaller will get less breathe out. Used with COPD pts where airways are narrower. Helps measure how open or constricted lungs are |
| What does a PFT measure? | Tidal Volume Total Lung Capacity (TLC) Forced Vital Capacity (FVC) Forced Expiratory Volume (FEV1) FEV1/ FVC ratio |
| What does a peak flow meter measure? | Forced Vital Capacity- how much you can blow out when you take a deep breathe in and force it all out. |
| When is the peak flow meter used? | usually with asthmatics should be done daily and tracked if having an asthma attack number will be less Pt should be standing, preform 3 times and report the average |
| Suffix of BETA 2 Agonists | "terol" |
| What is the short acting rescue inhaler? | Albuterol |
| Bronchodilators think- | Beta 2 Anticholinergics Methylxanthines M |
| Why is albuterol the medication of choice for acute respiratory distress? | its onset is 1-5 minutes |
| How long should a pt wait between puffs of albuterol? | 1 minute |
| What can overuse of SABA cause? | rebound bronchospasm |
| Side effects of beta 2 | ↑HR ↑B/P Think TTT Tremors Toss and turn (Insomnia) Tachycardia |
| Suffix of Anticholinergics | "pium" Think can't pee um |
| Use of Anticholinergics | COPD, Emphysema |
| Side effects of Anticholinergics | Bitter taste Epistaxis Dry mouth Blurred vision Headache Urinary retention Mucosal ulcers |
| How long should you wait in-between an anticholinergic and other inhaled medication? | 5 minutes |
| Suffix for methylxanthines | "phylline" feeling |
| Signs of theophylline toxicity? | Nausea Vomiting Insomnia Seizures |
| What is the therapeutic range of theophylline? | 10-20 |
| What should pt avoid when taking a phylline? | Caffeinated drinks |
| What are the side effects of a "phylline"? | S- stomach upset H- headache I- irritability T- Tachy HR/RR S tomach upset H eadache I rratability T Tachy HR T Tachy RR SHITT |
| Suffix for steroids | "sone" |
| What do steroids do? | provide long term anti-inflammatory actions. Best for chronic conditions |
| What should you educate pt about steroids? | Do not stop suddenly, must tapered Educate pt to rinse mouth after inhaling steroids |
| Side effects of steroids | Candidiasis ↑risk of infection osteoporosis weight gain fluid retention |
| How do we know a patient needs suctions? | See, hear or auscultate mucus or aspirate in airway (mouth, throat, trachea, lungs) |
| What position should a conscious pt be in when performing oropharyngeal suctioning? | Semi-fowler’s with their head turned to only side or with their neck hyperextended |
| What position should a unconscious pt be in when performing oropharyngeal suctioning? | Lateral position facing you (this position allows the tongue to fall forward, and facilitates drainage of secretions from the pharynx and prevents the possibility of aspiration) |
| Why is suction not applied during insertion of the catheter? | Suction is only applied on the way back out to prevent trauma to the mucus membranes |
| Which suctioning are sterile procedures? | Any suctioning into the pharynx or trachea: nasopharyngeal, oropharyngeal, nasotracheal, orotracheal |
| What suctioning is not a sterile procedure? | Bulb suction into the tip of the nares or a Yankauer in the mouth would not be sterile procedures. |
| What should be assessed prior to suctioning? | Breath sounds, RR, O2 sat, HR, level of consciousness, cough reflex, patency of nares if suctioning through the nares |
| What complications can occur during suctioning? | Stimulation of the gag reflex can lead to vomiting and potentially aspiration, Hypoxia, |
| What happens if you stimulate the vagus nerve while suctioning? | Dysrhythmias, including bradycardia |
| What is documented after suctioning? | Suction method used If there was a need for preoxygenation Amount, color & consistency of secretions Adverse effects of suctioning (hypoxia, dysrhythmia, aspiration, vomiting) Size of catheter used to suction |
| When you suction an infant what should you clear first? | the mouth then the nose to prevent aspiration of secretions in the oral cavity or throat. |
| When prioritizing nursing actions what is suctioning? | AIRWAY intervention. (Airway, Breathing, Circulation) |
| What does a incentive spirometer measure? | patient inhales to measure the volume of air inhaled. Helps your pt keep their lungs expanded, to prevent atelectasis. They should take slow, deep breaths in. |
| What is a Flutter valve (Acapella) | device vibrates and helps break up mucus in the lungs. Pt should exhale into device. |
| How should a pt breathe into a peak flow meter and what does it measure? | pt breathes hard and fast into the device to measure the expiratory flow from the lungs. |
| What does the abbreviation SpO2 stand for? | Peripheral capillary oxygen saturation |
| What is the normal SpO2 for a healthy adult? | >95% |
| What does the abbreviation PaO2 stand for? | Partial pressure of oxygen in arterial blood |
| What is the normal PaO2 for a healthy adult? | 75-100 Hg |
| What does the abbreviation FiO2 stand for? | Fraction of inspired oxygen |
| What is the FiO2 are you breathing now? | 21% |
| Why do we use humidification? | The flow of oxygen is drying |
| What should you tell the pt who require oxygen in regards to smoking? | That oxygen supports combustion, and in order to avoid facial burns, the patient should not smoke with oxygen on |
| What are the downsides of using humidification? | Noisy wet infection risk |
| What is the FiO2 of 1 L of oxygen? | 24% |
| What is a Squat pivot? | no lifting involved just pivoting over all weight on pt legs. Lateral move pivoting on new surface. |
| How much weight does a pt need to be able to bear for a squat pivot? | pt needs to bear weight on her feet but does not need to be strong enough to lift her feet |
| What is the hand placement for a squat pivot? | hand goes on the hip bone closest to the surface your moving to. Opposite hand lightly touches her shoulder. Pt hands ask them to hold onto their own arm. |
| How can you have the pt move their center of gravity? | by asking pt to scoot halfway up in the chair. |
| If pt is not able to scoot up in wheelchair, what should you do? | lean pt face into my hip and pull push to move pt closer up on chair |
| Where is the ideal place for a gait belt? | On pt hips. Walk alongside the pt with the gait belt. |
| If a pt stumbles backwards what should you do? | put up your knee and guide them to the floor. |
| What is a gait belt used for? | to help patients that are ambulatory |
| Why shouldn’t a pt lean down on the crutches? | Can cause damage to the brachial plexus nerve, which is called crutch paralysis |
| What is non weight bearing/swing through gait? | pt not putting any weight on injured leg crutches take place of the affected foot |
| What is partial weight bearing/touchdown? | Pt only using the front of their foot never the heel. Heel must stay off the ground at all times. |
| How should a quad cane be used? | keep the cane in line with the affected lane for opposite leg. |
| What is a bronchoscopy? | invasive procedure involves passing a camera into the trachea and bronchi to visualize airways. |
| What is a bronchoscopy used for? | Determine location and extent of disease Remove foreign objects Biopsy lesions Obtain respiratory secretions |
| What is a nurses role postop bronchoscopy? | NPO until gag reflex returns Vital Signs q15 mins x 1 hr, then q 30 mins for 2hrs Observe for dyspnea, confusion, lethargy, breath sounds Observe for cyanosis, hypotension, tachycardia, hemoptysis |
| What are potential complications from a bronchoscopy? | Airway swelling Hemorrhage Aspiration Infection |
| When is stridor heard? | in an upper airway obstruction |
| If a pt aspirates what side does the fluid go to typically? | Right lower lobe- because bronchioles are connected higher on the right. |
| Where is a thoracentesis pulling fluid from? | Thoracic cavity NOT the lungs |
| What are the potential post op complications for thorocentesis? | Hemorrhage Pneumothorax Infection |
| What signs and symptoms would suggest a pneumothorax? | Sudden ↑ RR, ↓O2 sat, diminished or absent breath sounds over area thoracentesis was performed |
| What are some prevention strategies to avoid respiratory issues? | Immunizations Smoking Cessation Proper Nutrition |
| What position is used for a pt in respiratory distress? | High Fowlers (90 degrees) |
| Why do we use fowlers position? | use gravity to move the diaphragm away from the lungs to reduce the work of breathing |
| Who should use an incentive spirometer? | Post op pts Pain management Obese pts Pt on bedrest |
| What are some nursing interventions for pt with chronic resp. issues? | Monitor for activity intolerance Space out nursing activities to allow O2 levels to recover Educate pt about spacing out activities |
| What is the benefit of using a nebulizer or inhaler? | Goes directly into the resp. tract, less systemic side effects |
| How long should a pt hold their breath after using an inhaler? | 10 seconds |
| How long should a pt wait between puffs for a beta 2 inhaler? | 1 minute |
| What position should a pt with an airway issue be in? | on side with head to the side to open up airway |
| Why might a pt with COPD lose weight? | Choosing between breathing and eating. Ensure to offer foods and snacks high in protien. |
| What do crackles indicate? | fluid in the lungs. high pitched popping sounds. |
| What does rhonchi indicate? | swelling of the larger airways. low-pitched sounds that continue through inspiration. |
| What does wheezing indicate? | Narrowing of the bronchi, heard on expiration high-pitched whistling sound. |
| What is the flow rate of a nasal cannula? | 1-6 L |
| When is humidity used? | anytime over 4L of oxygen or when requested |
| What is the flow rate of med flow nasal cannula? | up to 15 L |
| What drugs are used for acute asthma attacks? | A- albuterol I- Ipratropium M- methylprednisone |
| What is the maximum amount of oxygen administered with a high flow cannula? | 100% |
| What is the flow rate of the simple mask? | 5-10 L |
| What is the flow rate of the non-rebreather mask? | 8-15 L |
| What is the flow rate with the venturi mask? | 3-6 L |
| Who should you use the venturi mask for? | COPD pts because it gives specific amount of O2 not estimated |
| Who should you use a nasal cannula for? | pt with low oxygen requirement |
| What oxygen delivery method should you use when nebulizing medications? | Simple face mask |
| What is a tracheostomy used for? | upper airway obstruction |
| Who is an endotracheal tube used for? | unconscious pt |
| Which lifespan age do we screen for hearing? | newborn |
| Which lifespan age do we screen for visual acuity? | adolescent |
| How often do we screen for visual acuity? | q 3-5y until 40 |
| Which lifespan age do we do dental assessments? | infant |
| Which lifespan age do we monitor blood cholesterol levels? | young adult |
| What oxygen method heats the air? | high flow nasal cannula |
| Which lifespan age do we screen for phenylketonuria (PKU)? | newborn |
| Which lifespan age do we monitor BP? | infant, adolescent, young adult, middle adult, older adult |
| Which lifespan age do we monitor BG? | middle adult and older adult |
| Which lifespan age do we screen for breast cancer? | young adult, middle adult, older adult |
| Which lifespan age do we screen for colorectal cancer? | middle adult and older adult |
| Which lifespan age do we screen for testicular cancer? | middle adult and older adult |
| Which lifespan age do we screen prostate specific antigens? | middle adult and older adult |
| Which lifespan age do we screen for cervical cancer? | adolescent, young adult, middle adult, older adult |
| Which lifespan age do we do fecal occult blood tests? | middle adult and older adult |
| Which lifespan age do we perform skin assessments? | young adult, middle adult, older adult |
| What does agonal breathing mean? | gasping for air think agony |
| Use of bronchodilators | Asthma COPD Bronchitis |
| Who should avoid taking methylxanthines? | cardiac patients |
| What are the signs of theophylline toxicity? | VINS Vomiting Insomnia Nausea Seizures |
| What kind of drug is flonase? | steroid |
| When should Leukotrienes be administered? | in the evening |
| Uses of Leukotrienes | Asthma Allergic rhinitis Exercise induced bronchospasm |
| What should you check with leukotrienes? | Think L for liver Liver function test |
| What severe reaction can leukotrienes cause? | severe allergic reaction |
| What is cromolyn used for? | seasonal allergies asthma exercise induced bronchospasm allergic rhinitis |
| Side effects of cromolyn | throat irritation coughing skin rashes dry mouth |
| Acronym for Adolescent Screening | Visualizing Teeth Vagina ↑BP |
| What are the 3 levels of preventative services in HWI? | primary, secondary, tertiary |
| What is primary preventative services in HWI? | health promotion and illness prevention |
| What is secondary preventative services in HWI? | diagnosis and treatment |
| What is tertiary preventative services in HWI? | services to restore health following an illness |
| What is health promotion? | a way of thinking and acting in order to increase individs overall health and well-being regardless of their health and illness status or age |
| Examples of COMPLEMENTARY health [DHAMY CHG] | deep breathing, herbal supplements, acupuncture, meditation, yoga, chiropractor, hypnosis, guided imagery |
| What is illness behavior | ways that individs describe, monitor, and interpret their symptoms |
| What is injury | act/event that causes damage, harm, or loss to a body's functioning |
| What is disease | alteration in body funct that reduces capacity of or shortens the normal lifespan |
| What is illness | diminished funct of a person's physical, emotional, intellectual, social. or spiritual well-being |
| What is the definition of health? | a state of complete physical, mental, and social well-being, and not merely the absence of disease |
| What are the 7 components of wellness? | environment, spiritual, social, intellectual, emotional, occupational, physical |
| What are 3 signs of increasing wellness on the continuum? | good awareness of basic health, choosing a healthy lifestyle, actively following a healthy lifestyle |
| What are 3 signs of declining wellness on the continuum? | signs of disability, minor disability, major disability |
| What is health behavior? | the coping mechanism a person falls into when experiencing illness |
| what is sick-role behavior? | using the healthcare system for help and dependent behaviors such as avoiding responsibilities |
| Acronym for Young Adult Screening | all of the adolescents plus Because breast Change is Cholesterol Scary Skin |
| Acronym for Middle/Older Adult | Glucose Tests testicals Pro prostate Poopers |
| Who oversees the nursing practice act? | State Board of Nursing |
| Who defines nursing standard of practice? | ANA |
Created by:
cberna00
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