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NUR 111 Stud guide 5

NUR 111 Study guide for test 5

Cardiovasular assessment: Inspection -neck: JVD; <1 in. when upright -Precordium -heave/lift - visible elevation of chest wall - extremities: hair distribution, color (pink), vascularity (varicose veins, spider veins, etc.), edema, lesions (venous stasis ulcers), nails (color)
Cardiovasular assessment: Palpation -Precordium - Peripheral pulses: radial, dorsalis pedis, and posterior tibial - Equality and pulse amplitude - skin temperature: warm - Blanch test (capillary refill): should be <2 seconds
Heart sounds: S1 “lub” Systole; closing of tricuspid(right) and mitral(left) valves closing
Heart sounds: S2 “dub” Diastole; aortic and pulmonic valves closing
Heart sounds: S3 “Kentuc-ky” Abnormal diastole; “lub, dub, dub” can be aortic or pulmonic, normal in children up to young adult Sources: CHF, Fluid Overload
Heart sounds: S4 “Tenne-see” Abnormal between diastole and systole; Sources: Hypertension, Cardiomyopathy
Heart sounds: Aortic Auscultate at: 2nd ICS RSB
HHeart sounds: Pulmonic Auscultate at: 2nd ICS LSB
Heart sounds: Erb’s Point Auscultate at: 3rd ICS LSB; best place to hear heart murmurs
Heart sounds: Tricuspid Auscultate at: 4th ICS LSB
Heart sounds: Mitral (apical) Auscultate at: 5th ICS LSB; point of maximum intensity
Vascular sounds (carotid in notes): Bruit Blowing/swishing sound heard during auscultation; indicates obstruction
Vascular sounds (carotid in notes): Thrill Vibrations like a cat purring palpated on artery; palpate for after hearing bruit
CARDIAC CONDUCTION pathway SA Node->AV Node->Bundle of His->Right/Left Bundle Branches->Perkinji Fibers
Cardiac pacemakers: SA node The primary site that begins conduction of heart rate at 60-100 bpm
Cardiac pacemakers: AV node Takes over if the SA node fails with an intrinsic rate of 40-60 bpm; functions as the “gatekeeper” of misfired cardiac nerve impulses
Cardiac pacemakers: Perkinje fibers (ventricular) Take over if the SA and AV nodes fail with an intrinsic rate of <40 bpm
Blood flow through the heart Superior/inferior vena cavae->right atrium->tricuspid valve->right ventricle->pulmonic valve->lungs->left atrium->mitral valve->left ventricle->aortic valve->aorta->the body
Respiratory Anataomy: Upper airway Nose, pharynx, larynx, epiglottis
Respiratory Anataomy: Lower airway Trachea, right/left mainstem bronchi, segmental bronchi, terminal bronchioles
Respiratory Anataomy: Lungs Right lung: 3 lobes; upper, middle, and lower Left lung: 2 lobes; upper and lower
Respiratory assessment: Inspection -Chest shape and size - Symmetrical with equal rise and fall (flail chest) - Observe pattern, rate, and rhythm: regular vs. irregular, labored vs. unlabored - Retractions or nostril flaring - Nails and skin for cyanosis and clubbing
Respiratory assessment: Palpation - Tracheal position: midline - Symmetry of movement - Chest tenderness - Crepitus - Tactile fremitus: vibration when pt. verbalizes “99”;  vibration= pneumonia,  vibration= COPD or air trapping
Respiratory assessment: Percussion - Adults: resonance; Children: hyper resonance - Assesses for position, density, and changes - Not used unless by an advanced practice professionals
Respiratory assessment: Ascultation - At all sites for one full breath cycle - Side to side pattern beginning at apex down to the base - if abnormal sound is heard, have pt. cough then continue to auscultate
Lung sounds: bronchial Normal lung sound auscultated over trachea; harsh blowing sounds
Lung sounds: Vesicular Normal lung sound auscultated over mainstream bronchus; moderate blowing sounds
Lung sounds: Wheezing Abnormal lung sound; continuous high-pitched sounds created by air flowing through passages narrowed by secretions, swelling, or tumors
Lung sounds: Crackles Abnormal lung sound; Fine-coarse crackling sounds made by air moving through wet secretions
Lung sounds: Pleural friction rub Abnormal lung sound; grating sound caused by inflamed pleura rubbing against the chest wall
Assessment of oxygenation: Pulse ox Noninvasive technique for measurement of hemoglobin; can be placed on the finger, ear or toe; normal measurement of 95%-100%
Assessment of oxygenation/ventilation, acid/base status: ABG Arterial blood gasses; drawn from an artery
Oxygen delivery: Nasal Cannula Most commonly used low flow oxygen delivery system Flow rates: goes up by 4% per liter - 1L/min=24% Oxygen - 2L/min=28% Oxygen - 3L/min=32% Oxygen - 4L/min=36% Oxygen - 5L/min=40% Oxygen - 6L/min=44%Oxygen
Oxygen delivery: Simple Face Mask Low flow oxygen delivery system with a flow rate of 6-10L/min with 35-60% oxygen saturation - Disadvantages: difficult to talk or eat with it on
Oxygen delivery: Partial Rebreather Mask Low flow oxygen delivery system that allows rebreathing of expired CO2 with a flow rate of 6-15L/min with an oxygen saturation of 70%-90% - Disadvantages: difficult to talk or eat - Considerations: bag should only slightly collapse
Oxygen delivery: Non-Rebreather Mask Low flow O2 delivery system w/ covered vents with a 1-way valve on the mask; highest O2 saturation possible w/ a face mask - Flow: 6-15L/min = 60%-100% O2 - Disadv: difficult to talk or eat - Considerations: bag should only collapse slightly
Oxygen delivery: Venturi Mask High flow oxygen delivery system with vents in the face mask - Flow rate: 4-10L/min with oxygen saturation of 24%-55% - Consideration: occlusion of the vents can cause hypoxia or hyperoxia
Oxygen delivery: Humidification Added when oxygen delivery is over 4L/min
Oxygen delivery: Oropharyngeal Airway (OPA) Tube inserted into back of throat to keep tounge clear of airway - Meas fr mouth to back of jaw - Remove dentures, hyperextend neck, insert curved tip, rotate 180 degr - Auscultate BS - Turn on side to prevent aspiration - Remove q4h for mouth care
Oxygen delivery: Nasopharyngeal Airway (NPA) Tube from nose to pharynx to prevent trauma to mucous membranes caused by frequent suctioning - Measure from nostril to tragus of the ear - Lubricate airway with water soluble lubricant and gently insert into nare - Switch nostrils every 24 hr.
Pulmonary hygiene (pulmonary toilet): Incentive spirometry To encourage deep breathing for pt. at risk for pneumonia or atelectasis: post op, debilitated, or have lung problems - Instruct use for 10 times every waking hour - Instructions: Exhale, place mouth on mouthpiece, and inhale slowly
Pulmonary hygiene (pulmonary toilet): TCDB - Turn, cough, and deep breathe Promotes ventilation and gas exchange, Coughing loosens secretions and keeps airway open -perform every hour or at least 4 times per day -Slint any abdominal or chest injuries or surgeries with a pillow -Take a deep breath, cough, and turn
Health Policy: Licensure Legal authorization for practice
Health Policy: Certification Recognition of a program or an individual for meeting predetermined qualifications; requirements vary by state or jurisdiction
Health Policy: Registration Enrollment or listing (E.G. CNA listing on state registry)
Health Policy: Regulation Enforcement of laws and rules that have been established by legislation; typically at an organizational level
Health Policy: Accreditation Attests to the quality of an organization
Federal agencies: Medicare Federally funded healthcare for the elderly over 65 or for individuals with certain disabilities (e.g. end stage renal failure) - Part A: free - Part B: they pay for it
Federal agencies: CMS ( Centers for Medication and Medicaid Services) - Administers state children’s health programs -Largest purchaser of healthcare - Provides healthcare for over 70 million - Oversees the healthcare marketplace for Obamacare Medicaid: federally funded healthcare for low-income individuals
Federal agencies: DHHS Department for Health and Human Services: - Mission: to protect the health of all Americans and to provide services for those least able to care for themselves - Suborganizations: FDA and CDC
Federal agencies: OSHA Occupational Safety and Health Administration: - Mandates worker safety - Has ability to fine those who violate rules - Mandates that employers provide PPE
State agencies: NC DHHS Under Federal DHHS. Div: DHSR and HD. - DHSR: Department of Health Services Regulation: Investigates healthcare complaints; maintains Healthcare Personnel Registry (HCPR) - health dep: oversee communicable disease control and inspect restaurants
Nursing accreditation agencies:ACEN Accreditation Commission for Education in Nursing: accrediting agency for all types of nursing programs from practical to doctorate
Nursing accreditation agencies: TJC The Joint Commission: sets standards and accredits agencies such as hospital, surgery centers, home health agencies, etc. - Surveys agencies every 3 years - Standards and regulations change per state
Nursing accreditation agencies: CCNE Commission for Collegiate Nursing Education: accredits baccalaureate and graduate nursing programs
Define: Primary Nursing Nursing delivery system in which each client is assigned to an RN who assesses, plans, and provides direct care; RN does everything
Define: Team Nursing Nursing delivery system in which the RN is accountable but delegates tasks to the LPN and/or UAP who spend the most time providing direct care
Define: Functional Nursing Nursing delivery system in which tasks are assigned according to skill level
Define: Restorative Care Follow up services to restore health and functioning (e.g. rehab center, home health, etc.)
Define: Primary healthcare services Health promotion and illness/injury prevention services (e.g. wellness checkups, doctor visits, etc.)
Define: Tertiary healthcare services Specialized and highly technical care for pt. with highly complex issues such as: burns, severe trauma, transplants, etc. (e.g. regional referral centers, burn centers, etc.)
Define: Secondary healthcare services Diagnosis and treatment of disease and injury (e.g. diagnostic ceters, emergency departments, etc.)
Define: Charity Care Emergency care that is provided regardless of ability to pay (required by law in the ED)
Define: Home Care When care providers visit the home to provide some types of care and to teach the pt. and family how to manage care in the home and to evaluate pt. response to treatment
Define: Ambulatory Care Skilled nursing care provided in a healthcare agency such as a clinic or office where pt. is discharged in less than 24 hours - Goal: to treat the health problem and return the pt. to an independent living situation
Define: Hospice Care For terminally ill pt. with less than 6 months to expected death; may be performed at home or in a facility - Goal: pt. autonomy and relief of symptoms while supporting the pt. toward a peaceful death and family and others with their mourning process
Define: Custodial Care Care for pt. with functioning deficits in the ADLs; may be provided in an assisted living, adult home, or nursing facility - Goal: maintenance of functioning and maximum wellness in the face of disability
Define: Skilled Nursing Care Care provided after the initial recovery from an illness needing inpatient or following subacute care; skilled is still needed but on a less frequent basis; usually provided in a nursing facility - Goal: to restore function for discharge to home
Define: Subacute Care Provided after inpatient care; skilled care is still needed, just on a less frequent and intense basis; care is usually provide in a separate hospital unit or an acute care hospital - Goal: to restore function for discharge to home
Define: Long-Term Acute Care Care provided when an illness has stabilized but needs ongoing provision of highly skilled care such as: ventilator support or major wound care - Goal: to correct underlying problem with the eventual move to a less skilled level of care
Define: Acute Care Care for illness needing immediate hospitalization, tests, treatments, and/or monitoring that require the continuous availability of skilled nursing care - Goal: recovery from illness or injury and restoration to previous level of functioning
Nursing process: ASSESSMENT Identify assessment priorities -Organize to ensure systematic collection -Establish data: • history • examination • review record & nursing literature • consult w/ support persons and team -Continuously update database -Validate -Communicate
Nursing Process: DIAGNOSIS Interpret & analyze data -ID strengths and problems -Formulate & validate nursing diagnoses -Develop list of nursing diagnoses -Detect & refer problems beyond RN experience -Actual: 3 part (Diagnosis…R/T …AEB) -Risk for: 2 part (Diagnosis…R/T)
OuNursing Process: OUTCOME IDENTIFICATION AND PLANNING Establish priorities -Identify expected pt. outcomes -Select evidence-based nursing interventions -Communicate the plan of care -Must be: client centered and SMART -Begins with: “Client will…”
Nursing Process: IMPLEMENTING Carry out the plan -Continue data collection and modify plan of care as needed -Document care -Begins with: “Nurse will…”
Nursing Process: EVALUATING Measure how well pt. has achieved desired outcomes -Identify factors contributing to the pt. success or failure -Modify the plan of care, if indicated
Created by: mojoshare