NUR 111 Study guide for test 5
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| 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)
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| 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
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| Heart sounds: S1 “lub” | Systole; closing of tricuspid(right) and mitral(left) valves closing
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| Heart sounds: S2 “dub” | Diastole; aortic and pulmonic valves closing
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| 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
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| Heart sounds: S4 “Tenne-see” | Abnormal between diastole and systole;
Sources: Hypertension, Cardiomyopathy
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| Heart sounds: Aortic | Auscultate at: 2nd ICS RSB
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| HHeart sounds: Pulmonic | Auscultate at: 2nd ICS LSB
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| Heart sounds: Erb’s Point | Auscultate at: 3rd ICS LSB; best place to hear heart murmurs
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| Heart sounds: Tricuspid | Auscultate at: 4th ICS LSB
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| Heart sounds: Mitral (apical) | Auscultate at: 5th ICS LSB; point of maximum intensity
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| Vascular sounds (carotid in notes): Bruit | Blowing/swishing sound heard during auscultation; indicates obstruction
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| Vascular sounds (carotid in notes): Thrill | Vibrations like a cat purring palpated on artery; palpate for after hearing bruit
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| CARDIAC CONDUCTION pathway | SA Node->AV Node->Bundle of His->Right/Left Bundle Branches->Perkinji Fibers
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| Cardiac pacemakers: SA node | The primary site that begins conduction of heart rate at 60-100 bpm
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| 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
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| Cardiac pacemakers: Perkinje fibers (ventricular) | Take over if the SA and AV nodes fail with an intrinsic rate of <40 bpm
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| 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
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| Respiratory Anataomy: Upper airway | Nose, pharynx, larynx, epiglottis
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| Respiratory Anataomy: Lower airway | Trachea, right/left mainstem bronchi, segmental bronchi, terminal bronchioles
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| Respiratory Anataomy: Lungs | Right lung: 3 lobes; upper, middle, and lower
Left lung: 2 lobes; upper and lower
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| 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
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| 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
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| Respiratory assessment: Percussion | - Adults: resonance; Children: hyper resonance
- Assesses for position, density, and changes
- Not used unless by an advanced practice professionals
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| 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
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| Lung sounds: bronchial | Normal lung sound auscultated over trachea; harsh blowing sounds
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| Lung sounds: Vesicular | Normal lung sound auscultated over mainstream bronchus; moderate blowing sounds
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| Lung sounds: Wheezing | Abnormal lung sound; continuous high-pitched sounds created by air flowing through passages narrowed by secretions, swelling, or tumors
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| Lung sounds: Crackles | Abnormal lung sound; Fine-coarse crackling sounds made by air moving through wet secretions
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| Lung sounds: Pleural friction rub | Abnormal lung sound; grating sound caused by inflamed pleura rubbing against the chest wall
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| 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%
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| Assessment of oxygenation/ventilation, acid/base status: ABG | Arterial blood gasses; drawn from an artery
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| 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
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| 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
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| 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
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| 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
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| 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
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| Oxygen delivery: Humidification | Added when oxygen delivery is over 4L/min
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| 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
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| 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.
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| 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
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| 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
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| Health Policy: Licensure | Legal authorization for practice
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| Health Policy: Certification | Recognition of a program or an individual for meeting predetermined qualifications; requirements vary by state or jurisdiction
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| Health Policy: Registration | Enrollment or listing (E.G. CNA listing on state registry)
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| Health Policy: Regulation | Enforcement of laws and rules that have been established by legislation; typically at an organizational level
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| Health Policy: Accreditation | Attests to the quality of an organization
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| 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
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| 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
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| 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
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| Federal agencies: OSHA | Occupational Safety and Health Administration:
- Mandates worker safety
- Has ability to fine those who violate rules
- Mandates that employers provide PPE
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| 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
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| Nursing accreditation agencies:ACEN | Accreditation Commission for Education in Nursing: accrediting agency for all types of nursing programs from practical to doctorate
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| 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
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| Nursing accreditation agencies: CCNE | Commission for Collegiate Nursing Education: accredits baccalaureate and graduate nursing programs
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| 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
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| 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
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| Define: Functional Nursing | Nursing delivery system in which tasks are assigned according to skill level
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| Define: Restorative Care | Follow up services to restore health and functioning (e.g. rehab center, home health, etc.)
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| Define: Primary healthcare services | Health promotion and illness/injury prevention services (e.g. wellness checkups, doctor visits, etc.)
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| 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.)
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| Define: Secondary healthcare services | Diagnosis and treatment of disease and injury (e.g. diagnostic ceters, emergency departments, etc.)
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| Define: Charity Care | Emergency care that is provided regardless of ability to pay (required by law in the ED)
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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)
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| 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…”
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| Nursing Process: IMPLEMENTING | Carry out the plan
-Continue data collection and modify plan of care as needed
-Document care
-Begins with: “Nurse will…”
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| 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
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