Fundamentals of Nursing Chapters 50 and 51

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  1. What is the respiratory membrane?
    The membrane between the alveolar and capillary walls where gas exchange occurs.
  2. Name the structures of the UPPER respiratory tract.
    • Mouth
    • Nose
    • Pharynx
    • Larynx
  3. Name the structures of the LOWER respiratory tract.
    • Trachea
    • Bronchi
    • Bronchioles
    • Alveoli
    • Pulmonary capillary network
    • Pleural membranes
  4. What is inspiration?
    Inhalation, air flows into the lungs
  5. What is expiration?
    Exhalation, air flow out of the lungs
  6. What are the actions of inspiration?
    • Diaphragm and interostals contract
    • Thoracic cavity size increases
    • Volume of lungs increases
    • Intrapulmonary pressure decreases
    • Air rushes into the lungs to equalize pressure
  7. What are the actions of expiration?
    • Diaphragm and intercostals relax
    • Volume of the lungs decreases
    • Intrapulmonary pressure rises
    • Air is expelled
  8. When does gas exchange occur?
    This takes place after the alveoli are ventilated
  9. What affects diffusion?
    Pressure differences on each side of the respiratory membranes affect this action.
  10. When does gas exchange occur?
    After the alveoli are ventilated
  11. A patient is experiencing  hypoxia. Which of the following nursing diagnoses may be appropriate?
  12. While reading a physician's progress note, a student notes that an assigned patent is having hypoxia. What abnormal assessments would the student expect to find?
    Dyspnea, Tachycardia, and Cyanosis
  13. When a patient is described as being dyspneic, what signs/symptoms would they be showing?
    • C/O SOB
    • Nasal Flaring
    • Increased heart rate
  14. What is the function of the respiratory system?
    Gas exchange
  15. How does oxygen from inspired air diffuse?
    From the alveoli in the lung into the blood in the pulmonary capillaries
  16. How does carbon dioxide, produced during cell metabolism, diffuse?
    From the blood into the alveoli and it is exhaled
  17. The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has which of the following?
    An infection
    A fractured rib
    A turmor of the medulla
  18. What is the therapeutic effect of pursed-lip breathing?
    It prolongs the expiration to reduce airway resistance
  19. To prevent postoperative complications, the nurse assists the client with coughing and deep breathing exercises. This is best accomplished by implementing what?
    • Huff coughing every 2 hours or as needed.
    • This keeps their lungs clear
    • Coughing and breathing exercises are done together
  20. Which term does the nurse document to best describe a client experienceing shortness of breath when lying down, who must assume an upright or sitting position to breathe more comfortabley and effectively?
  21. What is the reason behind using an incentive spirometer?
    Expand collapsed alveoli
  22. What is a critical factor that must be taught to an individual using prescribed oxygen at home?
    The safety measures to prevent a fire
  23. Oxygen from the alveoli goes where?
    Into the pulmonary blood vessels
  24. Carbon dioxide from the pulmonary blood vessels goes where?
    Into the alveoli
  25. Oxygen must be transported from the lungs to the ________.
  26. When oxygen combines with hemoglobin, what does it become?
  27. What is the percentage of oxygen that combines with hemoglobin, in RBC's?
  28. Where is hemoglobin found and what does it do?
    • In the Red Blood Cells (RBC's)
    • Carries O2
  29. Carbon dioxide must be transported from the tissues to the ______.
  30. 97% of oxygen is carried by the hemoglobin, what happens to the other 3%?
    The remaining oxygen is dissolved and transported in plasma and cells
  31. What is continually produced in teh process of cell metabolism?
    Carbon Dioxide
  32. 65% of _______  _______, is carried in the red blood cells as _______.
    • carbon dioxide
    • bicarbonate
  33. 30% of _______ _______ combines with hemoglobin as _______.
    • carbon dioxide
    • carbhemoglobin
  34. _______ of carbon dioxide is transported in solution in plasma as _______.
    • 5%
    • carbonic acid
  35. How much carbon dioxide is carried inside the red blood cells as bicarbonate?
  36. What type of patient would use a venturi mask?
    A patient with COPD
  37. The nurse ensures that the simple face mask fits snuggly over the patient's face for what reason?
    To ensure they are getting the expected oxygen concentration
  38. What is a clue that would indicate a patient might have TB?
    Night sweats
  39. What are signs and symptoms of TB?
    • Fatigue
    • Persistent cough
    • Night sweats
  40. How much carbon dioxide combines with hemoglobin as carbhemoglobin?
  41. What are the factors that influence respiratory function?
    • Age
    • Environment
    • Lifestyle
    • Health status
    • Medications
    • Stress
  42. What could low-pitched snoring sounds, during inhalation indicate?
    Possible partial obstruction of the airway
  43. Which should the patient take first, their bronchodilator or their glucocorticosteroid?
    Take the bronchodilator first
  44. What does extreme inspiratory effort with no chest movement indicate?
    A complete blockage of the airway
  45. What are some common manifestations of impaired respiratory function?
    • Hypoxia
    • Altered breathing patterns
    • Obstructed or partially obstructed airway
  46. What is hypoxia?
    A condition of insufficient oxygen in the body
  47. What are the signs and symptoms of hypoxia?
    • Rapid pulse 
    • Rapid, shallow respirations and dyspnea
    • Increased restlessness or lightheadedness
    • Flaring of the nares
    • Substernal or intercostal retractions
    • Cynosis
  48. Why would you use an SCD?
    To promote venous return from the legs.
  49. What is a nursing diagnosis for COPD?
    • Nursing diagnosis for this disorder may include any of the following: 
    •  - - Ineffective airway clearance r/t bronchospasm and or secretion
    •  - - Activity intolerance r/t oxygenation/perfusion mismatch
  50. Which inhalant requires that the client rinse their mouth after administering the medication
    Powder inhaler (Advair diskus)
  51. What are the signs and symptoms of peripheral vascular disease?
    • Decreased peripheral pulses
    • Pale skin color
    • Cool extremities 
    • Decreased hair distribution
  52. What is a cough reflex?
    This is triggered by irritants in the larynx, trachea, or bronchi
  53. What is Biot's (cluster) respirations?
    • This may be seen in clients with central nervous system disorders.
    • Shallow breaths interruped by apnea.
  54. What are expectorants?
    • These medications loosen bronchial secretions, and are often found in combination with antitussives or analgesics. 
    • Can cause nausea and vomiting (N/V)
  55. What is Cardiac Output (CO)?
    • This is the amount of blood pumped from the ventricles each minute
    • Stroke Volume (SV) x Heart Rate (HR)
    • Important indicator of how the heart is functioning as a pump
  56. What is liquid oxygen?
    • This is O2 delivery system has 2 parts, a large stationary container, and a portable unit.
    • A portable unit can weight up to 10 pounds
  57. What is a flow meter?
    This device is attached to the oxygen unit or the wall to regulate the amount of oxygen a client is to receive.
  58. What is infiltrate?
    Cloudiness seen in the lungs, on an xray
  59. What is intrapleural pressure?
    This is always slightly negative in relationship to atmospheric pressure
  60. Prior to giving an antibiotic, what should you always get?
    Always get a culture (sputum, wound, etc.) prior to giving this medication.
  61. What are signs/symptoms of emphysema?
    • Loss of lung tissue elasticity
    • Narrowing of small airways
    • Hyperinflation of the alveoli (air trapping)
  62. What are cold medications and who can use them safely?
    • These are generally safe for children > 6 years
    • May contain pseudoephedrine, analgesic antihistimine
  63. What are the four rights of delegation?
    • Right Task
    • Right Circumstance
    • Right Person
    • Right Direction/Communication
  64. What are some signs and symptoms of a myocardial infarction?
    • This condition presents with:
    • Chest pain
    • Substernal and/or radiating pain to the left arm or jaw
    • Nausea
    • SOB
    • Diaphoresis
  65. What are precautionary methods used to reduce the risk of fire while O2 is in use?
    • Smoke only outside
    • Place cautionary signs on the outside of clients doors
    • Avoid materials that generate static electricity
  66. What is an incentive spirometer?
    • These are used to: 
    • Improve pulmonary ventilation
    • Loosen respiratory secretions
    • Expand collapsed alveoli
    • Facilitate gas exchange
  67. What is TB or Tuberculosis?
    • Infects 1/3 of the worlds population
    • Pt's c/o fever, worsening cough, night sweats, and weight loss
    • Caused by Mycobacterium terberculosis
  68. What is atherosclerosis?
    • Most common cause of impaired blood flow
    • Vessels narrow and become constricted
    • Coronary arteries are most affected
  69. What are portable oxygen tanks?
    • These items should be handled with caution. 
    • They should not be dropped or placed in high traffic areas or near heaters.
  70. What are the medications used for TB?
    • TB - RIPS
    • Rifampin (RIF)
    • INH (isoniazide)
    • PZH (pirazinamide)
    • Streptomycin or Ethanbutol
  71. What is hypoxemia?
    Decreased oxygen in the blood
  72. What are advance directives?
    These documents are required to be on file and followed in regards to the patient's wishes for any resuscitation and/or life sustaining treatment
  73. What is physical therapy?
    These services are provided for the residents at Skilled Nursing Facilities to help maintain their strength and mobility or finish their rehabilitation
  74. What are recreational activities?
    These programs are designed to keep the resident active cognitively and sometimes physically
  75. What are Long Term Care Resident's Rights?
    These include the right to manage your fincances and the right to a safe, clean, comfortable, home-like environment.
  76. Explain why a patient in hypoxic drive should not have high concentrations of O2
    • An individual who has COPD or Emphysema may be using their hypoxic drive for breathing. 
    • Normally an individual breaths because the body detects the CO2 receptors in their system, which triggers the urge to exhale the CO2 and then inhale oxygen.
    • However, individuals who have had their alveolar sacs streched, end up retaining high amounts of CO2. The body gets used to this environment and no longer recognized CO2 as an enemy. Thus, in hypoxic drive, it is the lack of O2 that causes an individual to breath.
    • So, if you give high concentrations of O2 to this individual, their body will detect the O2 and will not see a need to breath. The body sees a lot of O2 and doesn't see a need for more.
    • If you look in your fridge and see a lot of apples, you don't see a need to get more, right!? 
  77. What are some of the early and late symptoms of hypoxia?
    • Early RAT2:
    • Restlessness
    • Anxiety
    • Tachycardia/Tachypnea

    • Late to BED:
    • Bradycardia
    • Extreme restlessness
    • Dyspnea
  78. What are Kussmaul Respirations?
    • Abnormal respiratory pattern characteized by rapid, deep breathing, often seen in patients with metabolic acidosis
    • Abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis
  79. Describe Cheyne-Stokes (chān stōks)
    • The pattern of breathing with gradual increase in depth and sometimes in rate to a maximum, followed by a decrease resulting in apnea
    • Cycles ordinarily are 30 seconds to 2 minutes in duration, with 5–30 seconds of apnea
    • Seen with bilateral deep cerebral hemispheric lesions, with metabolic encephalopathy, and, characteristically, in coma from affection of the nervous centers of respiration.
  80. What is tachypnea?
    Fast breathing
  81. Define bradypnea
    Slow breathing
  82. What are Biots Respirations?
    • Rapid, short breathing with pauses of several seconds
    • Indicating increased intracranial pressure (usually present due to head trauma)
  83. What is orthopnea?
    • Difficulty breathing while lying down
    • Client may find it easier to breath in the tripod or orthopnic positions
  84. Define dyspnea
    • Difficulty breathing:
    • Shortness of breath
    • Nostril flaring
    • Increased heart rate
    • NOTE: stems from cardiac or respiratory problem
  85. What would be involved in the NURSING ASSESSMENT of respiratory issues?
    • Nursing history
    • Physical examination
    • Review of relevant diagnostic data
  86. What would be involved in the physical assessment of an individual with suspected respiratory issues?
    • Nurse observes: rate, depth, rhythm and quality of respiration
    • Inspects: Variations of shape
  87. What would be involved in the NURSING DIAGNOSIS of respiratory issues?
    • Ineffective Airway Clearance
    • Ineffective Breathing Pattern
    • Impaired Gas Exchange
    • Activity Intolerance
  88. What would be an ETIOLOGY in the nursing diagnosis of respiratory issues?
    • Anxiety
    • Fatigue
    • Fear Powerlessness
    • Insomnia
    • Social isolation
  89. What would be involved in the NURSING PLAN for an individual with respiratory issues?
    • Maintain a patent airway
    • Improve comfort and ease of breathing
    • Maintain or improve pulmonary ventilation and oxygenation
    • Improve the ability to participate in physical activities
    • Prevent risks associated with oxygenation problems such as skin and tissue breatkdown, syncope, acid-base balances, and feelings of hopelessness and social isolation
  90. What would be involved in the NURSING IMPLEMENTATION for an individual with respiratory issues?
    • Ensure a patent airway
    • Positioning (semi to high Fowler's position)
    • Encouraging deep breathing and coughing (Huff coughing, Diaphragmatic, and pursed lip breathing)
    • Ensuring adequate hydration (1500 to 2500 mL/day fluids)
    • Medications (take bronchodialators before steroids)
    • Incentive spirometry
    • Percussion, vibration, and postural drainage
    • Mucus clearance device
    • Oxygen therapy
    • Oxygen delivery systems
    • Artificial airways
    • Suctioning
  91. What do bronchodialators do?
    • Enhance the sympathetic nervous system
    • ~ Increase HR
    • ~ Increase BP
    • NOTE: anxiety and restlessness must be monitored
  92. What does incentive spirometry do?
    • Improves pulmonary ventilation
    • Counteract the effects of anesthesia or hypoventilation
    • Loosen respiratory secretions
    • Facilitate respiratory gaseous exchange
    • Expand collapsed alveoli
  93. What are the three main steps of PVD?
    • Percuss
    • Vibration
    • Drainage
  94. Explain the percuss of PVD
    • Cover the area with a towel or gown to reduce discomfort
    • Ask the client to breathe slowly and deeply
    • Alternate flex and extend the wrists rapidly to slap the chest
    • Percuss each affected lung segment for 1-2 minutes
  95. Explain the vibration of PVD
    • Place hands, palms down, on the chest are to be drained
    • Ask the client to inhale deeply and exhale slowly
    • During exhalation vibrate the hands
    • Vibrate during five exhalations
    • After each vibraation, ask client to cough and expectorate secretions
  96. What are the various ways of delivering oxygen therapy?
    • Nasal cannula (25-45%, 2-6 L/min)
    • Simple face mask (40-60%, 5-8 L/min)
    • Partial rebreather (40-60%, 6-10 L/min)
    • Nonrebreather mask (95-100%, 10-15 L/min)
    • Venturi mask (25-40%, 4-10 L/min)
    • Face tent (30-50%, 4-8 L/min)
    • Noninvasive Positive Pressure Ventilation 
  97. What are the artificial airways?
    • Oropharyngeal airway (OPA)
    • Nasopharyngeal airway (NPA)
    • Endotracheal Tubes (Oral and Nasal)
    • Tracheostomy
  98. What are the artificial airways used for?
    • To prevent aspiration
    • To keep the airway open
  99. What is a suctioning machine?
    • It is used to aspirate secretions through a catheter connected to a suction machine or wall suction outlet
    • Used when a client is unable to cough up and expectorate secretions
    • Inability to clear the airway will cause respiratory distress
  100. What would be involved in the NURSING EVALUATION for an individual with respiratory issues?
    • Collect data to evaluate the effectiveness of interventions
    • If outcomes were not achieved, explore the reasons, before modifyng the care plan
  101. What makes up the cardiovascular system?
    • Heart
    • Blood vessels
    • Blood
  102. What does the left side of the heart do?
    Pumps oxygenated blood into the arteries.
  103. How does deoxygentated blood return to the heart?
    It returns via the venous system into the right side of the heart.
  104. What does the blood do for the body?
    • 1. Transports oxygen, nutrients, hormones to cells
    • 2. Transports metabolic wastes from cells for elimination
    • 3. Regulates body temperature, pH, fluid volume
    • 4. Prevents infection, blood loss
  105. What is Cardiac Output (CO)?
    • The amount of blood ejected from the heart each minute
    • (Stroke volume (SV) x Heart Rate (HR) = CO)
  106. Define Stroke Volume (SV)
    Amount of blood ejected from the heart with each beat
  107. Define the Heart Rate (HR)?
    Number of beats per minute
  108. What is contractility?
    • Inotropic state of the myocardium
    • Strength of contraction
  109. What is inotropic?
    Affecting the force of muscle contraction. An inotropic heart drug is one that affects the force with which the heart muscle contracts. Ionotropic can be negative or positive.
  110. What is myocardium?
    • The muscular tissue surrounding the heart
    • Its job is to simulate the contractions of the heart to help get blood pumped throughout the body
  111. Define Preload
    Left ventricular end diastolic volume, stretch of the myocardium
  112. Define afterload
    Resistance against which the heart muscle must pump
  113. What type of risks are there for Coronary Heart Disease?
    • Modifiable Risks
    • Nonmodifiable Risks
    • Other Risk Factors
  114. What are the nonmodifiable risk factors for Coronary Heart Disease?
    • Heredity
    • Age 
    • Gender
  115. What are the modifiable risk factors for Coronary Heart Disease?
    • Elevated serum lipid levels
    • Hypertension
    • Cigarette smoking
    • Diabetes
    • Obesity
    • Sedentary lifestyle
  116. What are some of the other risk factors for Coronary Heart Disease?
    • Metabolic syndrome
    • C-Reactive Protein
    • Elevated Homocysteine Level
  117. Various conditions affect the cardiovascular function, in what ways?
    • The function of the heart as a pump
    • Blood flow to organs and peripheral tissues
    • The composition of the blood and its ability to transport oxygen and carbon dioxide
  118. What alterations in the cardiovascular function can cause decreased cardiac output?
    • Myocardial Infarction
    • Heart Failure
  119. What are some factors that can cause alterations in the cardiovascular function?
    • Decreased cardiac output
    • Impaired tissue perfusion
    • Disorders that affect composition or amount of blood available for transport of gases
  120. What are some of the symptoms of a myocardial infarction?
    • Chest pain
    • Substernal and/or radiating to left arm or jaw
    • Nausea
    • Shortness of breath
    • Diaphoresis
  121. What are some causes of heart failure?
    • Can develop if heart not able to keep up with the body's need for oxygen and nutrients
    • Usually occurs because of an MI
    • May result from chronic overwork of heart
    • Left-sided heart failure can result in pulmonary edema
  122. What are some conditions that increase preload?
    • Hypervolemia
    • Valvular disorders suc as mitral regurgitation
    • Congenital defects such as patent ductus arteriosus
  123. Define patent ductus arteriosus
    • A condition in which the ductus arteriosus does not close (a hole in the heart)
    • The ductus arteriosus is a blood vessel that allows blood to go around the baby's lungs before birth. Soon after the infant is born and the lungs fill with air, the ductus arteriosus is no longer needed. It usually closes in a couple of days after birth.
    • PDA leads to abnormal blood flow between the aorta and pulmonary artery, two major blood vessels that carry blood from the heart.
  124. What are some conditions that increase afterload?
    • Hypertension
    • Atherosclerosis
  125. What are some conditions that affect myocardial function?
    • Myocardial infarction
    • Cardiomyopathy (Enlarged, thick, rigid)
    • Coronary artery disease
  126. What are some signs/symptoms of heart failure?
    • Pulmonary congestion
    • Adventitious breath sounds
    • Shorness of breath
    • Dyspnea on exertion
    • Increased HR
    • S3 heart sound
    • Increased RR
    • Nocturia
    • Othopnea
    • Distended neck veins
  127. What can cause impaired tissue perfusion?
    • Atherosclerosis
    • Vessel inflammation
    • Arterial spasms
    • Blood clots
    • Incompetent valves of veins
    • Pulmonary emboli
  128. Where can atherosclerosis occur?
    • Coronary arteries
    • Brain
    • Peripheral arteries
  129. What are arterial spasms?
    Coronary spasms - cause prinzmetal angina at rest 
  130. What is prinzmetal angina?
    • A form of chest pain, pressure, or tightness (angina) caused by spasms in the arteries that supply blood to the heart.
    • It is a form of unstableangina, meaning that it occurs at rest, often without a predictable pattern.
  131. What is stable angina?
    Chest pain occurs in a predictable pattern during exertion or exercise.
  132. Why does nocturia occur in heart failure?
    • In cardiac failure, the heart is not able to meet the needs of organs, which include kidneys, due to failure of heart to pump out blood. Due to the failure of heart to pump out blood, it pools in the extremities leading to edema of legs and face.
    • At night when the patient lies down, the blood that had been accumulated in the extremities returns to the heart, hence the cardiac output during the night is slightly increased compared with during the day time.
    • This increased cardiac output perfuses kidneys, which in turn produces more urine to decrease the workload of the heart.
  133. What is atherosclerosis?
    • Most common cause of impaired blood flow to organs and tissues
    • Vessels narrow and become constricted
    • Distal tissues receive less oxygen and nutrients
    • Coronary arteries most affected
    • Obstruction of coronry arteries leads to myocardial ischemia, which leads to angina pectoris (chest pain)
    • Obstruction in vessels supplying brain results in TIA or stroke
  134. What are some complications that can occur with incompetent venous valves?
    • May allow blood to pool in veins
    •  - - Edema
    •  - - Decreased venous return to heart
    • Veins become inflamed
    •  - - Reduce blood flow
    •  - - Increased risk of thrombus formation
    • Thrombi may break loose
    •  - - Emboli
    •  - - Occlude blood supply A/C membrane
    •  - - Acute pulmonary embolism 
  135. What are some symptoms of an acute pulmonary embolism?
    • Sudden onset of shortness of breath
    • Pleuritic chest pain
  136. What are some symptoms of anemia?
    • Chronic fatigue
    • Pallor
    • Shortness of breath
    • Hypotension
  137. Define anemia
    Anemia is a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body tissues.
  138. What would be involved with the NURSING ASSESSMENT of an individual with a cardiac/circulation issue?
    • Comprehensive history
    • Physical examination
    • Review of relevant data, including cardiac monitoring
  139. What would be some reasons that a patient would be on a cardiac monitor?
    • In need of continuous monitoring
    • Known or suspected Cardio Vascular Disease (CVD)
    • During and after surgery
    • To monitor responses to drug therapy
    • At risk for serious complictions such as shock
  140. What are the blood tests that would be run and assessed for a cardiac/circulation issue?
    • Hemoglobin
    • Electrolytes
    • Creatine kinase (CK)
    • Troponin
  141. Why is the presence of troponin important when reviewing the labs, in relation to cardiac/circulation issues?
    • This is an enzyme that is released during an Myocardial Infarction (MI)
    • Levels tell you if there is an MI as a result of cell membrane damage.
    • Differentiates between an MI nd angina
  142. What are a few of the NURSING DIAGNOSIS that would be used for an individual with a cardiac/circulation issue?
    • Ineffective Peripheral Tissue Perfusion
    • Risk for Decreased Cardiac Tissue Perfusion
    • Decreased Cardiac Output
    • Activity Intolerance
  143. What would be a sign of ineffective peripheral tissue perfusion?
    • Cool feet
    • Weak pulses
    • Shiny nearly hairless shins/feet
  144. What would be involved with the NURSING PLAN (goal) of an individual with a circulation issue?
    • Maintain or improve tissue perfusion
    • Maintain or restore an adequate cardiac output
  145. What would be involved with the NURSING INPLEMENTATION of an individual with a circulation issue?
    • Elecate the client's legs
    • Avoid placing pillows under the knees or providing more than a 15 degree flexion
    • Encourage leg exercises for a client on bedrest
    • Promote ambulation as soon as possible
    • Encourage or provide frequent position changes
  146. What would be involved with the NURSING INPLEMENTATION of an individual with an impaired cardiac function?
    • Position the client in high Fowler's position
    • Monitor intake and output
    • Fluid restriction
  147. What would the nurse communicate to the patient, in relation to cardiac/circulation medication?
    help the client understand the purposes, effects, and side effects.
  148. What would be involved with the NURSING ASSESSMENT of an individual with a cardiac/circulation issue, in regard to their medication?
    • Assess effects of medications and potential complications
    • Assess intake and output and potassium levels, if appropriate, for clients receiving diuretics
    • Assess BP, HR, peripheral pulses, and lung sounds for clients reeiving positive inotropic medications
    • Monitor BP (including postural blood pressure) for client receiving antihypertensive medications
  149. How do you prevent venous stasis?
    • Positioning and leg exercises
    • Applying antiemboli stockings
    • Applying sequential compression devices (SCD's)
  150. What are the three cardinal signs that a patient needs cardiopulmonary resuscitation?
    • Apnea
    • Absence of a carotid or femoral pulse
    • Dilated pupils
  151. What are some stats on a cardiac arrest?
    • Within 20 - 40 seconds of a cardiac arrest the victim is clinically dead
    • After 4 - 6 minutes the lack of oxygen supply to the brain causes permanenet and extensive damage
    • Must initiate CPR immediately
    •  - - - Three cardinal signs must be present
  152. What would be involved with the NURSING EVALUATION of an individual with a circulation issue?
    • Collects data to evaluate effectiveness of interventions
    • If desired outcomes are not achieved, the nurse, client, and support person, if appropriate, need to explore the reasons before modifying the care plan
  153. What is the smallest of all microorganisms?
    A virus
  154. What is the scope of infections that a virus covers?
    Runs from the common old to AIDS
  155. True or False
    If you take an antibiotic soon enough, it can kill a virus.
    False - Antibiotics have no effect on a viral infection
  156. True or False
    For some viral infections you can get an antiviral medication.
  157. When is the common cold most contagious?
    1-4 days before symptoms and through the first 3 days
  158. How is the common cold transmitted?
    Occurs most frequently from contact with contaminated surfaces.
  159. True or False
    Rhinorrhea, nasal congestion, and coughing can decrease mucosal secretions?
    False, they increase mucosal secretions
  160. Most cold medications are __________?
  161. Define Sympathomimetic
    • Mimicking the effects of impulses conveyed by adrenergic postganglionic fibers of the sympathetic nervous system
    • Denoting a drug that mimics the effects of stimulation of organs and structures by the sympathetic nervous system. The sympathetic nervous system pertains to the part of the nervous system originating in the thoracic and lumbar regions of the spinal cord.
    • In general, it inhibits or opposes the physiological effects of another aspect of the nervous system, as in tending to reduce digestive secretions, speed up the heart, and contract the blood vessels
  162. What may a cold medication contain?
    • Pseudoephedrine
    • Analgesic
    • Antihistamine
  163. Cold medications are safe for children of what age?
    >6 years
  164. When should you call a doctor, prior to taking a cold medication?
    • If you have any of the following: 
    • Heart disease
    • HTN (hypertension)
    • Thyroid disease
  165. What are the side effects of a sympathomimetic?
    • Headache
    • Nervousness
    • Increased blood pressure
    • Insomnia
  166. What are the side effects of an antihistamine?
  167. List a few pieces of information about 2nd generation antihistamines.
    • Non-sedating antihistimines
    • Little to no effect on sedation
    • Trade names: Zyrtec and Claritin
  168. What are two kinds of cough medications?
    • Antitussives
    • Expectorants
  169. Define what an antitussive does
    • Act on medulla to suppress cough
    • Increased effect with other CNS depressants
  170. Define what an expectorant does
    • Loosen bronchial secretions
    • Found in combination with antitussives, analgesics
    • Can cause nausea/vomiting
  171. Define what nasal and systemic decongestants do
    • Produce vascular constriction within the nasal mucosa: decrease in fluid secretion
    • Nasal sprays and drops: can cause rebound nasal congestion
    • Tablet, capsule, and liguid (allergic rhinitis)
    • May cause the client to be "jittery" or restless: avoid caffeine
    • Check with a phyusician if on beta-blocker medication
  172. What is the biological name for Valley Fever?
  173. Describe Valley Fever (Coccidioidomycosis)
    • Fungal: mold/spore
    • Grows: in the soil of the southwest
    • Signs/Symptoms: Often asymptomatic or symtoms similar to influenza
    • Treatment: usually resolves without treatment
    • Worst case: Pleuritic pain, arthritis of knees, ankles, systemic infetion of skin and meninges of the brain (<1%)
  174. List a few of the lower respiratory tract disorders
    • Pneumonia
    • Pulmonary TB
  175. What is the etiology and pathophysiology of PNEUMONIA?
    • Inflammation of lung tissue
    • Usually caused by an infectious agent (bacterial, viral, fungal, or parasitic)
    • Can also be caused by inhalation of chemicals and aspiration of gastric contents
  176. What is a lifespan consideration for the elderly, when dealing with pneumonia?
    • Less air exchange
    • More air and secretions remain in the lungs
  177. What are the subjective signs and symptoms of pneumonia?
    • Dyspnea
    • Chest pain that increases on inspriation
  178. What are the objective signs and symptoms of pneumonia?
    • Fever
    • Chills
    • Increased WBCs
    • Cough
    • Purulent sputum
    • Crackles
    • Bronchial sounds
  179. What are some diagnostics that confirm suspected pneumonia?
    • Positive CXR
    • Positive sputum culture
  180. What is some collaborative care for pneumonia?
    • Drug therapy: Antibiotics based on C & S (diagnostics)
    • Oxygen therapy
  181. What is involved with the Nursing Care: ASSESSMENT of pneumonia?
    • VS; Breathing patterns
    • Color, amount, consistency of sputum
    • Adventitious lung sounds
    • Mental status changes
  182. Name a few of the Nursing DIAGNOSES for pneumonia?
    • Ineffective airway clearance r/t copious tracheobronchial secretions
    • Activity intolerance r/t oxygenation perfusion mismatch
    • Risk for deficient fluid volume r/t fever and dyspnea
  183. What is involved with the Nursing Care: PLANNING/IMPLEMENTATION for pneumonia?
    • Encourage coughing & deep breathing after CPT
    • Splint chest as needed
    • Collect sputum for C & S
    • Increase fluid intake to 3L/day
    • Maintian semi-Fowler's position
    • Monitor for s/s respiratory distress
    • Plan rest periods
    • Administer abx (antibiotics) as ordered
  184. What is involved with the Nursing Care: TEACH PATIENT/FAMILY with pneumonia?
    • Instruct pt. to cover nose and mouth when coughing
    • Teach preventative measures:
    • nutrition/fluids
    • Avoid respiratory irritants
    • Vaccinations
  185. What is the etiology and pathophysiology of Pulmonary Tuberculosis (TB)?
    • Lung infection caused by Mycobacterium tuberculosis
    • Predisposing factors include debilitating diseases like alcoholism, diabetes, and HIV infection
    • Causes fibrosis and calcification of lungs
    • Resistant strains
  186. Define Mycobacterium tuberculosis
    • Acid-fast bacillus
    • Spread via airborne droplets
    • Causes pulmonary tuberculosis (TB)
  187. What are the subjective signs and symptoms of TB?
    • Malaise
    • Pleuritic pain
    • Fatigue
  188. What are the objective signs and symptoms of TB?
    • Fever
    • Weight loss
    • Cough: becoming more persistent, productive or non-productive
    • Sputum: Green, purulent, yellowish mucoid or blood tinged
  189. What are some diagnostics that confirm suspected TB?
    • Skin test: PPD
    • Chest x-ray: positive CXR
    • Sputum: for AFB
  190. What is some collaborative care for TB?
    • Drug therapy
    • Long term: 6-9 months
    • First phase: 2 months
    • Second phase: 4-7 months
    • Combination Therapy required:
    • Isoniazid & rifampin or
    • Isoniazid, rifampin, & ethambutol or
    • Isoniazid, rifampin, & pyrazinamide
    • ***********************************************
    • Bedrest
    • Isolation: Airborne precautions, specially-ventilated room, HEPA mask for staff
    • Prophylactic therapy for immediate contacts (6 months - 1 year)
    • Nutrition: high-protein, high-vitamin, supplemental B6 to counter INH side effects
    • NOTE: Patient MUST comply with the drug regime, avoid antacids, ETOH, and sunlight
  191. What are the five (5) first line medications for TB?
    • I Refuse Every Piece of streptomycin!
    • INH: isoniazid (also used for prophylaxis w/exposure); Peripheral neuropathy and hepatotoxicity, visual problems, decreased food absorption rate, and may need vitamin B6 supplements
    • Rifampin (RIF): Hepatotoxicity, turns body fluids orange color
    • Ethambutol: Visual problems
    • PZH: Pyrazinamide
    • Streptomycin (possibly): Hepatotoxicity
  192. What is involved with the Nursing Care: ASSESSMENT of TB?
    • Fatigue
    • Anorexia
    • Fever: NIGHT SWEATS
    • Color and amount of consistency of sputum
    • Adventitious lung sounds
  193. Name a few of the Nursing DIAGNOSES for TB
    • Activity intolerance r/t impaired oxygenation
    • Noncompliance r/t long-term nature of therapy, medication side effects
  194. What is involved with the Nursing Care: PLANNING/IMPLEMENTATION for TB?
    • Provide for rest periods
    • Encourage coughing/deep breathing
    • Dietary teaching
    • Teach prevention of infection
    • Teach s/s hemorrhage - hemoptysis
    • Teach importance of adhering to medication schedule and the importance of follow-up
Card Set:
Fundamentals of Nursing Chapters 50 and 51
2012-10-21 20:08:48
Oxygenation Circulation

Week 8 Flashcards - Oxygenation and Circulation
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