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regulatory exam 3
| Question | Answer |
|---|---|
| Definition of pneumonia | -infection -inflammation of the airway & alveoli (due to microorganisms, bacteria, and viruses) |
| Pneumonia : expected findings | -weakness - cough -anxiety -chest discomfort -fever/chills -tachypnea -crackles -productive cough -decreased o2 -dyspnea -purulent sputum -increased HR,RR |
| Pneumonia : Lab Tests | - sputum culture - elevated WBC - chest xray (showing "consolidation" or "density") |
| pneumonia: health promotion | -hand hygiene - avoid crowds, esp immunocompromised people, very young, and elderly - flu and pneumonia vaccines -tobacco cessation |
| Define COPD | - Chronic, nonreversible -obstruction of airflow from the lungs -copd includes both chronic bronchitis and emphysema -characterized by recurring lung infection -usually diagnosed during middle age -common cause- smoking/environmental hazards |
| Normal respiratory assessment | clear lung sounds bilaterally, RR normal for age, chest symmetrical, unlabored breathing, skin/nailbed/mucosa normal color, 95-100 spo2 |
| RR for infants, 1month-2month, adult | 30-60, 25-30, 12-24 |
| Breathing pattern: Cheyne-Stokes | end of life breathing, increase then shallow, then apnea |
| Breathing pattern: Biot's | irregular with abrupt pauses, neurologic |
| Breathing patterns: Apneustic | gasping, short insufficient expiration, neurologic |
| Breathing patterns: Kussmaul's | fast and deep with no pauses, metabolic issue |
| What is Chronic bronchitis (t | - Airway problem - produces excessive mucus (hypersecretion) |
| What is emphysema | - causes enlarged alveoli that has reduced elasticity |
| Clubbing | result of chronically low arterial o2 |
| Barrel chest | hyper-inflated, normal in infants, usually COPD |
| Pulmonary function test and nursing consideratons | -measures lung volumes, flow rates -don't smoke 6-8 hours prior |
| Normal Hgb, Hct, WBC | 12-16, 14-18 37-47%, 42-50% 4-12 |
| Normal PaO2, PaCo2 | 80-100 35-35 |
| Sputum diagnostic | identifies microorganisms |
| MRI vs CT vs Chest Xray | -identifies tumors or structural issues -3D images to identify densities, PE's -visualizes bones, heart, fluid, foreign bodies, diaphragm |
| Ventilation-perfusion scans | uses radioactive markers to visualize blood supply and gas exchange, identifies PE's |
| Infant respiratory | nose breathers, irregular respiratory patterns, fetal hemoglobin causes shortened RBC life and leads to anemia |
| Children respiratory | faster RR, less alveolar surface area, shortened airways |
| Older adult respiratory | diminished strength of respiratory muscles, less elastic alveoli, reduces gas exchange and erythrocytes |
| Glucocorticoids action indiaction example | -prevents inflammation, airway muscus production, and mucosa edema -asthma attacks, COPD exacerbations -Beclomethasone (inhaled), Prednisone (oral) |
| Steroid symptoms | insomnia, weight gain, hyperglycemia, risk of fungal infection in mouth |
| Bronchodilators: Beta 2 adrenergic agonists action indication example | -selectively activate receptors in bronchial smooth muscle -asthma -Albuterol (short-acting), Salmeterol (long-acting) |
| Expectorants action indication example | -increases cough production, thins mucus -upper respiratory disorders -Guanifenesin (Mucinex) |
| Bronchodilators: Methylxanthines action indications example | -relaxation of bronchial smooth muscle -chronic asthma, COPD -Theophylline |
| Mucolytics actions indications example | -thin and enhance flow of secretions -upper respiratory disorders -Acetylcsteine (also for tylenol overdose) |
| Antihistamines actions indications examples | -Blocks H1 receptors of histamine in small blood vessels and capillaries -relieves itching, sneezing, rhinorrhea, motion sickness -Diphenhydramine (Benadryl), Loratadine (Claritin), Cetirizine (Zyrtec) |
| Antitussives- opioids action indications example | -suppression of cough by working on CNS to increase cough threshold -non productive cough to decrease intensity and frequency -Codeine |
| Antitussives- non-opioids action indication example | -suppression of cough by working onCNS (like opioids) -nonproductive cough -Dextromethorphan (Robitussin) |
| pneumonia: Nursing Care | - elevate HOB - breathing treatments -admin supplemental O2 - promote rest -nutrition/hydration - deep breathing, coughing, incentive spirometer - admin meds antibiotics, bronchodilators, anti-inflammatories -assess skin for ulcerations from o2 |
| COPD expected physical assessment findings | -barrel chest -dypsnea -clubbing -use of accessory muscles -thin extremities -enlarged neck muscles -pallor -cyanosis -crackles - wheezes -cough - hypoxia -hypoxemia -tachypnea -poor nutrition due to lack of energy |
| COPD: compensatory mechanism | increased production of RBC, blood becomes thick, hemoglobin and hematocrit increases. Pulmonary artery pressure increased and leads to pulmonary hypertension, and blood can backflow into right side of heart elevated: RBC, HGB, HCT |
| COPD: Nursing Care | - pursed lip breathing technique -elevate HOB - admin supp o2 -Monitor skin breakdown from o2 - adequate nutrition -monitor/assist suction -administer meds -promote exercise and rest -educate on home o2 if indicated |
| Anemia | reduction of circulating RBC or Hgb, decreased o2 perfusion, underlying problem |
| Types of anemia | Hemorrhagic: blood loss Aplastic: inadequate production of RBC (usually kidneys not doing their job) Hemolytic: problem is within spleen, increased destruction of RBC Sickle Cell: genetic mutation Nutritional Deficiency: B12, folic acid, iron |
| Nursing care for anemia | encourage dietary intake of iron/B12/folic acid, monitor 02, administer meds, blood products, teach energy conservation |
| Iron rich foods folic acid foods | -fortified cereal, breads, fish, poultry, beans -spinach, lentils, banana, fortified grains, juice |
| Thrombocytopenia | reduced or non-functioning platelets |
| Types of thrombocytopenia | idiopathic, thrombotic, heparin-induced |
| COPD: oxygen care | only give enough o2 to maintain sats between 88% and 92% *if you give COPD pt too much oxygen pt will lose urge to breathe |
| Idiopathic thrombocytopenia | autoimmune, lifespan of platelets reduced |
| Thrombotic thrombocytopenia | autoimmune, platelets coagulate in capillaries, reduces availability |
| Heparin-induced thrombocytopenia | result of heparin use |
| thrombocytopenia assessment findings | bleeding, tachycardia, hypotension, diaphoresis, bruising, organ failure |
| thrombocytopenia labs | low Hgb and Hct, low fibrinogen, PT and PTT prolonged |
| thrombocytopenia nursing care | assess HR and BP, monitor labs, administer blood products, avoid NSAIDs, avoid injury, bleeding precuations |
| Pulmonary embolism risk factors | immobility, travel, surgery, oral contraceptives, pregnancy, obesity, hypercoaguability, trauma, sepsis, DVT, afib, long bone fractures, cancer, central lines, age |
| PE health promotion | smoking cessation, physical activity, diet, avoid prolonged sitting, compression stockings, SCDs, weight |
| PE assessment findings | anxiety, pain, pleural friction rub, cough, hemoptysis, dyspnea, air hunger, tachycardia, diaphoresis, cyanosis, elevated d-dimer |
| define Asthma | - chronic and intermittent - reversible airway obstruction due to inflamed airways - unknown cause, genetics is a factor, often "triggered" |
| Asthma: expected physical assessment | -dyspnea -chest tightness -anxiety -wheezing -mucous --use of accessory muscles -prolonged exhalation -low o2 sat |
| Asthma: Nursing Care | - Elevate HOB - admin supp o2 -initiate iv access - monitor resp and cardiac status including rhythm -provide rest and minimize exertion during attack - use calm/reassuring care and communication -admin meds: bronchodilators + anti-inflammatories |
| Define RSV | -affects bronchi and bronchioles - very common - can be dangerous for very young and very old |
| RSV: Expected Findings ( initial) | -rhinorrhea, intermittent fever, congestions, pharyngitis, coughing, secretions, sneezing, wheezing, possible eye/ear infection |
| RSV: expected finding (illness progression AND Severe illness) | Progression: increased fever, tachypnea, retractions, refusal to nurse/feed, coughing, secretions Severe: apnea, poor air exchange, cyanosis, tachypnea (70 breaths per min) |
| define cystic fibrosis | -genetic, inherited condition -exocrine glands are not working, affecting many body systems -increased mucous production in airway - increased risk of respiratory infections -median life expectancy: 30yrs |
| Cystic Fibrosis: Stages of manifestations + expected symptoms | EARLY: wheezing, rhonchi, nonproductive cough INCREASED: dyspnea, paroxysmal cough, emphysema, atelectasis Advanced: barrel chest, cyanosis, clubbed fingers, multiple infections, pulmonary hypertension |
| How is cystic fibrosis tested for ? | sweat chloride test - measures amount of salt in sweat - CF pts have increased amount of salt in sweat due to dysfunction of exocrine glands |
| Cystic fibrosis : nursing care | - prevent infections - airway clearance therapy/techniques ( that video that had all the techniques that we dont need to know) |
| Nasal Cannula: liter and fio2 range? | 1-6L fio2: 0.24-0.44 (or 24-44%) |
| Simple Face mask: liter and FIo2 range | 5-12 liter fio2: 0.30-0.60 |
| face masks with reservoirs | partial rebreather: 15L, 0.35-0.60 nonrebreather:15L, 0.60-0.80 |
| define CPAP | -constant air pressure -provides pressure to maintain patent airway for patients with obstructive sleep apnea |
| define BIPAP | -gives two pressures, one for inhalation, one for exhalation - helps to remove CO2 for COPD patients |
| define sickle cell anemia | -red blood cells have sickle shape making them hard to move through veins. Sickle shape sticks to veins causing clots -blood is not transferring enough oxygen to brain -inherited |
| Sickle cell anemia: at risk, symptoms, triggers, treatment | At risk: black/african american population Symptoms: pain, fatigue, SOB Triggers: cold (causes vasoconstriction), stress Treatment: focuses on pain management, admin oxygen to support o2 |
| sickle cell anemia: nursing care / interventions | - promote hydration -promote rest -pain management meds - use of o2 monitor due to pain meds - oxygen administration |
| Blood transfusions : indication | - blood loss -anemia -kidney failure -coagulation factor deficiency hemophilia -thrombocytopenia -burns -hypoproteinemia |
| What are the different types of blood products? | -packed RBCs -platelets -cryoprecipitate -albumin -fresh frozen plasma |
| transfusions: PRIOR nursing considerations | - type and cross match for donor compatibility - normal saline (ONLY) -special tubing and filter -order, consent, patient education -check ID with another RN -vitals and baseline assessment |
| transfusions: DURING nursing considerations | -stay with patient for 15-30 minutes -monitor for change in vitals |
| transfusions: AFTER nursing considerations | -vitals and document -dispose in biohazard |
| transfusions: pt education | - expect frequent vitals/assessment, it might feel cold, educate on what to report |
| how quickly must blood be transfused | within 4 hrs |
| define acute hemolytic reaction (onset, symptoms, underlying cause) | - within 10 mins -pain @ iv site, elevated HR, BACK/FLANK pain, hypotension, chills/fever, anxiety, blood tinged urine, SOB, chest tightness -cause: error in blood compatibility |
| define Febrile reaction (onset, symptoms, underlying cause) | -within 2hrs -chills/fever, hypotension, flushing, tachycardia -temp increase of 1.8 F (1 C) -cause: antibodies react to antigens in donor blood |
| define mild allergic reaction (onset, symptoms, underlying cause) | - up to 24hrs - hives, itching, flushing -cause: immune response histamine reaction, sensitivity to plasma - remember, another word for hives is urticaria |
| define severe allergic reaction (onset, symptoms, underlying cause) | -up to 24hrs -bronchospasm -bronchoconstriction -narrow airway -hypotension -can lead to shock cause: immune response histamine reaction, sensitivity to plasma |
| Define: transfusion-associated circulatory overload TACO (onset, symptoms, underlying cause) | -anytime during transfusion - SOB, dyspnea, hypertension, tachycardia, JVD, cough, anxiety -cause: too much blood too quickly |
| what are your first couple actions in all transfusion reactions EXCEPT taco | -STOP infusion -change tubing, with new tubing admin normal saline - notify provider, monitor vitals |
| What are your first nursing action for TACO | -notify provider ( to determine if you should stop or slow transfusion) -Raise HOB -Give o2 -diuretics -probs morphine |
| define erythropoietin (hematopoietic agent) | purpose: acts on bone marrow to increase production of RBCs uses: anemia, cancer/chemo, CKD *given IM usually |
| define cyanocobalamin (b12 supplement) | purpose: activate folic acid for DNA production and cellular health use:b12 deficiency due to inability to absorb, malnutrition *given IM or oral |
| Glasgow Coma Scale: List eye opening response scale with points | - eyes open spontaneously +4 -eyes open to verbal command, speech, or shout +3 - eyes open to pain (not applied to face) + 2 - no eye opening +1 |
| Glasgow Coma Scale: list Verbal Response scale with points | -oriented +5 -confused conversation, but able to answer questions +4 -inappropriate responses, words discernible + 3 -incomprehensible sounds or speech + 2 - no verbal response + 1 |
| Glasgow Coma Scale: list Motor Response scale with points | -obeys command for movements+6 -purposeful movement to painful stimulus+5 -withdraws from pain+4 -abnormal (spastic) flexion, decorticate posture+3 -extensor (rigid) response, decerebrate posture+2 -no motor response+1 |
| Intracranial regulation:abnormal assessment findings | - decreased consciousness -changes in sensory & perception - changes in memory & cognition -dilated, constricted , nonreactive pupils -posturing (decorticate, decerebrate) -seizure activity -lateralizing signs -nuchal rigidity -nausea/vom |
| Seizure definition | erupt, abnormal, uncontrolled electrical discharge of neurons |
| Epilepsy definition | chronic reoccurrence of seizure activity |
| Seizure risk factors | genetics, head trauma, fever, cerebral edema, infection, exposure to toxins, stroke, brain tumor, substance withdrawal, electrolyte/fluid imbalance |
| Seizure triggers | increased physical activity, stress, hyperventilation, fatigue, excessive alcohol or caffeine, bright lights, substances like cocaine, aerosols, glue |
| Seizure type: both hemispheres | -may begin with an aura -Tonic -Clonic -Myoclonic -Atonic -Postictal phase is characterized by confusion and lethargy after the seizure |
| Definitions: Tonic Clonic Myoclonic Atonic | -stiffening of muscles -rhythmic jerking -affects the extremities -muscle tone is lost |
| Seizure type: partial/focal | -one hemisphere -complex partial, lip-smacking, finger rolling -simple partial, unusual sensations, pain, smells -consciousness may be maintained |
| Seizure nursing actions | keep safe, maintain airway, O2, suction, loosen restrictive clothing, do not restrain, document, maintain side-lying, assess injuries and vitals, neuro checks, determine trigger |
| Seizure precautions | implement for history or risk of seizure, O2, suction, pad rails, bed in low, maintain IV access |
| Vagal nerve stimulator | implanted device, treatment for partial seizures, magnet held over generator at onset of seizure, MRI's contraindicated |
| Med given during seizure | diazepam, lorazepam |
| Barbiturates action symptoms toxicity | phenobarbital -CNS depressant -drowsiness, sedation, depression, decreases warfarin -Nystagmus, ataxia, respiratory depression, pinpoint pupils |
| Hydantons action symptoms nursing considerations | Phenytoin -anticonvulsant, blocks excessive firing -nystagmus, ataxia, double vision, cognitve impairment, gingival hyperplasia, rash, cardiac effects -give slow via IV to avoid cardiac dysrhythmias, interferes with vitamin K and may cause bleeding i |
| Define decorticate posturing | - abnormal motor movement with arm, wrists, and fingers flexed inward and plantar flexion |
| Define decerebrate posturing | - abnormal motor rigidity with extension of arms, legs, pronation of the arms, plantar flexion |
| Define Kernigs and Brudzinskis Signs | - Kernig: resistance to extension of the leg while hip is flexed -Brudzinskis: when nurse flexes pts neck, knee flexes in response ***both signs of meningeal infection |
| intracranial regulation: Lifespan Considerations | - At birth, brain function is limited to primitive reflexes -cranial sutures are ossified by age 12, with no expansion of skull after age 5 -aging process is associated with reduction in brain size, weight, and number of neurons |
| Lumbar puncture: nursing considerations (pre, intra, post) | PRE: - assess use of anticoags -instruct pt to void -assist pt into cannonball position INTRA: -Assist provider, provide emotional support POST: -monitor for bleeding inform pt to remain side lying for several hours to reduce CSF leak and headache |
| EEG: nursing considerations (pre,intra,post) | PRE: -review meds, avoid stimulants/depressants 12-24hrs prior -educate of no risks INTRA: -attach electrodes -initiate electrical activity (flashing/bright lights) POST: -resume normal activities *assesses electrical activity of the brain |
| Carbamazepine symptoms nursing considerations | -low dose intially, may cause blood disorders, edema, fluid overload, skin disorders, photosensitivity, Steven-Johnson syndrome -double vision, dizziness, ataxia, headache, cognition minimally effected |
| Valproic acid nursing considerations | may cause GI effects of N/V, hepatotoxicity, pancreatitis, thrombocytopenia, birth defects |
| Lamotrigine symptoms nursing considerations | -dizziness, blurred vision, headache, somnolence, aphasia -risk for suicide, may cause aseptic meningitis, skin disorder |
| Levetiracetam symptoms | dizziness, weakness, anxiety, depression, agitation, risk for suicide |
| Topiramate symptoms nursing considerations | -dizziness, ataxia, anxiety, double vision, impaired cognition -may cause nausea, weight loss, anorexia, increased body temp, metabolic acidosis, glaucoma, kidney stones |
| Seizure med patient education | -don't miss a dose -blood draws for therapeutic levels -talk to provider before taking any drug -wear medical alert bracelet -teach fam member how to help |
| Status epilepticus definition and causes | -medical emergency, seizure lasting longer than 5 min or repeated in 30 min -sudden antiepileptic withdrawal, infection, TBI, cerebral edema, metabolic disturbances - |
| define seizure/seizure activity | -abrupt, abnormal, excessive, uncontrolled electrical discharge of neurons |
| define epilepsy | -chronic recurrence of seizure activity |
| risk factors for seizures | -genetics -head trauma -fever -cerebral edema -infection -exposure to toxins -stroke -brain tumor -substance withdrawal -fluid/electrolyte imbalance |
| triggers for seizures | - increased physical activity -excessive fatigue -stress -hyperventilation -excessive alcohol -excessive caffeine -exposure to bright/flashing lights -substances such as cocaine, aerosols, glue |
| seizure types :generalized | involves both hemispheres, may begin with aura -tonic: stiffening of muscles -clonic: rhythmic jerking -myoclonic: affects extremities -atonic: muscle tone is lost (aka drop attack) -absent: looks like daydreaming after seizure:confusion/lethargy |
| Seizure types: partial/focal | -involves just one cerebral hemisphere -complex partial: lip-smacking, finger-rolling) -simple partial (unusual sensations, pain, offensive smells) -consciousness may be maintained |
| Seizures: Nursing Actions DURING seizure | -protect from injury -privacy -maintain airway with positioning - admin o2 -suction @bedside -loosen restrictive clothing -do not restrain -do not insert anything into mouth -admin meds -document |
| Seizures: Nursing Actions AFTER seizure | -maintain side lying -assess for injuries -vitals -allow for rest -neuro checks -reorient pt, provide calm environment -try to determine if ther was an aura or triggering event -document |
| Seizure precautions | -implement for those with hx of seizures or at risk -set uo o2 and suction at bedside -pad siderails -bed in lowest position -maintain IV access for med administration |
| Define Vagal Nerve Stimulator | -implanted device -treatment of PARTIAL seizures -a magnet is held over the generator at the onset of the seizure -MRIs are contraindicated |
| Encephalitis definition | inflammation of brain and meninges |
| Encephalitis causes and symptoms | -epstein barr virus, rabies, west nile, herpes simplex, autoimmune -headache, myalgia, malaise (general unwell feeling), fever, AMS |
| Normal body temp | 36.2-37.6C |
| Hyperpyrexia | temp above 41.5C |
| Risk factors for abnormal thermoregulation | autoimmune disorders, burns, injury to hypothalamus, infection, inflammation, long surgical procedures, metabolic conditions, pre-term birth, malnutrition, trauma |
| Malignant hyperthermia | severe reaction to certain drugs used for anesthesia, results in muscle weakness, is an inherited autosomal disorder |
| Nursing interventions for hyperthermia | remove excess clothing and blankets, provide cool packs, hydrate, antipyretic |
| Nursing interventions for hypothermia | passive and gentle warming, warm drinks, must be slow to minimize dysrhythmias, cardiac monitoring required |
| define meningitis | -infection of brain and spinal cord -more specifically meninges |
| what are the types of meningitis | -viral meningitis (most common) -fungal meningitis (occurs in those with HIV/AIDs) -Bacterial meningitis (meningicoccal meningitis): medical emergency with high mortality rate causing death within 24hrs if untreated |
| Meningitis risk factors | -immunocompromised -invasive, neurological procedures -measles, mumps ,herpes -crowded living conditions -*anything that leaves portal of entry into skull/CSF/etc |
| meningitis: physical assessment findings | -constant, sometimes severe, headache -nuchal rigidity -light sensitivity (photophobia) -positive kernigs sign -positive brudsinskis sign -fever,chills -rash -seizures -nausea, vomiting *peds:HIGH PITCHED cry, difficulty sleeping |
| meningitis: Nursing interventions | Isolate pt asap reduce fever with antipyretics or cooling blanket report infection to health department (bacterial) decrease external stimuli elevate HOB to 30 degrees maintain safety/seizure precautions monitor for increased intracranial pressure |
| complications to monitor for with meningitis | -SIADA (syndrome of inappropriate antidiuretic hormone), septic emboli, and shock |
Created by:
Katelynsw27