Exam 4

Card Set Information

Author:
nhwyckoff
ID:
81324
Filename:
Exam 4
Updated:
2011-04-27 19:36:34
Tags:
Pain Sleep activity exercise
Folders:

Description:
Nursing Review
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user nhwyckoff on FreezingBlue Flashcards. What would you like to do?


  1. 44.2 Differentiate Isotonic, isometric, isokinetic, aerobic, and anaerobic exercise.
    • Isotonic (Dynamic) - muscle contraction and active movement. Running, Walking, swimming, and cycling Are examples (HR and CO quicken Increase)
    • Isometric (static or Setting) - muscle contraction without moving the joint- Squeezing a towel or billow between the knees. "quad sets"(Mild increase in HR and CO)
    • Isokinetic (resistive) -muscle contraction or tension against resistance: either isometric or isotonic usually with machines.
    • Aerobic- amount of oxygen taken in the body is greater than that used to perform the activity. Improve cardiovascular conditioning and physical fitness
    • Anaerobic- muscles cannot draw enough oxygen from bloodstream, additional energy for a short time, endurance training.
  2. 44.3 Compare the effects of exercise and immobility on body systems.
    Musculoskeletal System

    Exercise-Maintain size, shape, tone and strength of muscles (including the heart muscle),Nourish joints, Increase joint flexibility, stability, and ROM, Maintain bone density and strength.

    Immobility-Disuse osteoporosis, Disuse atrophy, Contractures, Stiffness and pain in the joints.
  3. 44.3 Compare the effects of exercise and immobility on body systems.
    Cardiovascular System

    Exercise- Increases HR, strenght of contraction, and blood supply to the heart and muscles, mediates harmful effects of stress.

    Immobility- Diminished cardiac reserve, Increased use of the valsalva maneuver, Orthostatic hypotension, Venous vasodilation and stasis, Dependent edema, Thrombus formation.
  4. 44.3 Compare the effects of exercise and immobility on body systems.
    Respiratory System

    Exercise- Increase ventilation and oxygen intake improving gas exchange, prevents pooling of secretions in the bronchi and bronchioles.

    Immobility- Decreased respiratory movement, pooling of respiratory secretions, Atelectasis, hypostatic pneumonia.
  5. 44.3 Compare the effects of exercise and immobility on body systems.
    Metabolic/Endocrine System

    Exercise- Elevates the metabolic rate, Decreases serum triglycerides and cholesterol, stabilizers blood sugar and make cells more responsive to insulin.

    Immobility- Decreased metabolic rate, Negative nitrogen balance, Anorexia, Negative calcium balance.
  6. 44.3 Compare the effects of exercise and immobility on body systems.
    GI System

    Exercise- Improves the appetite, Increases GI tract tone, Facilitates peristalsis.

    Immobility- Constipation
  7. 44.3 Compare the effects of exercise and immobility on body systems.
    Urinary System

    Exercise- Promotes blood flow to the kidneys causing body wastes to be excreted more effectively, Prevents stasis of urine in the bladder.

    Immobility- Urinary stasis, Renal calculi, Urinary retention, Urinary infection.
  8. 44.3 Compare the effects of exercise and immobility on body systems.
    Cognitive Function

    Exercise-Positive effects on decision-making and problem solving processes, planning, and paying attention, Induces cells in the brain to strenghten and build neuronal connections. Improved mood, learning, and performance.
  9. 44.3 Compare the effects of exercise and immobility on body systems.
    Other Effects of Exercise and Immobility

    Evidence that certain types of exercise increase spiritual health

    Immobility causes reduced skin turgor, and skin breakdown.
  10. 44.4 Identify factors influencing a person's body alignment and activity.
    • -Growth and development
    • -Nutrition, personal values and attitudes
    • -External factors, (i.e., temperature, humidity, availability of recreational facilities, safety of the neighborhood)
    • -Prescribed limitations, (i.e., Casts, braces, traction, activity restrictions including bed rest)
  11. 44.5 Assess activity-exercise pattern, alignment, mobility capabilities and limitations, activity tolerance, and potential problems related to immobility.
    • Activity and Exercise
    • * Nursing History
    • *Physical Examination:
    • -Body alignment
    • -Gait
    • -Appearance and movement of joints
    • -Capabilities and limitations for movement
    • -Muscle mass and strenght
    • -Activity tolerance
    • -Problems related to immobility
  12. 44.6 Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.
    • *For activity and exercise problems
    • -Activity Intolerance
    • -Risk for activity intolerance
    • -Impaired physical mobility
    • -Sedentary Lifestyle
    • -Risk for disuse syndrome
  13. 44.6 Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.
    • *Prolonged immobility:
    • -Ineffective Airway Clearance
    • -Risk for infection
    • -Risk for Injury
    • -Risk for disturbed sleep pattern
    • -Risk for situational Low self-esteem
  14. 44.6 Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.
    • *Examples of desired Outcomes
    • -Activity tolerance
    • -Body positioning
    • -Bowel elimination
    • -Fall prevention behavior
    • -Immobility consequences both physiological and psychocognitive
    • -Joint movement
    • -Mobility
    • -Respiratory status
    • -Ventilation and gas exchange
    • -Self-care
    • -Sleep
    • -Stress level
    • -Weight control
  15. 44.6 Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.
    • Overall Goals for problems related to mobility or activity
    • -Increased tolerance for physical activity
    • -Restored or improved capability to ambulate and/or participate in ADLs
    • -Absence of injury from falling or improper use of body mechanics
    • -Enhanced physical fitness
    • -Absence of any complications associated with immobility
    • -Improved social, emotional, and intellectual well-being.
  16. 44.7 Use safe practices when positioning, moving lifting, and ambulating clients.
    • Safe practice for positioning, moving, lifting, ambulating clients requires....
    • -Correct body mechanics (prevent injury)
    • -Correct body alignment (remove undue stress is not place on the musculoskeletal system)
  17. 44.7 Use safe practices when positioning, moving lifting, and ambulating clients.
    • General Guidelines for Moving and Lifting Clients
    • -Before moving, collect data on client's capabilities, comfort, ...
    • -If indicated, use pain relief modalities
    • -Prepare any needed assistive devices
    • -plan around encumbrances
    • -be alert to the effects of any medications
    • -obtain required assistance
    • -explain the procedure to the client
  18. 44.7 Use safe practices when positioning, moving lifting, and ambulating clients.
    • General Guidelines for Transferring a Client continued...
    • -Plan what to do and how to do it
    • -Obtain essential equipment before starting
    • -Remove obstacles
    • -Explain transfer to client and assistive personnel
    • -Support or hold client rather than equipment
    • -Explain what client should do
    • -Make written plan, including client's tolerance.
  19. 45.2 Identify the characteristics of the sleep states:NREM and REM sleep.
    NREM Sleep

    • -Occurs when activity in RAS inhibited
    • -Constitutes 75%-80% of sleep
    • -Consists of 4 stages
  20. 45.2 Identify the characteristics of the sleep states:NREM and REM sleep.
    • NREM Sleep Stages
    • Stage 1
    • -Very light sleep and lasts only a few minutes
    • -Feels drowsy and relaxed
    • -Eyes roll from side to side
    • -HR and RR drop slightly
    • -Can be readily awakened and may deny sleeping
  21. 45.2 Identify the characteristics of the sleep states:NREM and REM sleep.
    • NREM Sleep Stages continued
    • Stage II
    • -Light sleep lasts only about 10-15
    • -Body processes continue to slow down
    • -Eyes are generally still
    • -HR and RR decrease slightly
    • -Body temperature falls
    • -44% to 55% of total sleep
    • -Requires more intense stimuli to awaken
  22. 45.2 Identify the characteristics of the sleep states:NREM and REM sleep.
    NREM Sleep Stages continued

    • -Stages III and IV
    • -Deepest stages of sleep (delta or deep sleep)
    • -HR and RR drop 20% to 30% below waking hours
    • -Difficult to arouse
    • -Not disturbed by sensory stimuli
    • -Skeletal muscles very relaxed
    • -Reflexes are diminished
    • -Snoring is likely to occur
    • -Swallowing and saliva production reduced
    • -Essential for restoring energy and releasing important growth hormones.
  23. 45.2 Identify the characteristics of the sleep states:NREM and REM sleep.
    Characteristics of REM Sleep

    • Occurs every 90 minutes
    • Last 5-30 minutes
    • Acetylcholine and dopamine increase
    • Most dreams take place during REM
    • Brain is highly active
    • Brain metabolism increases as much as 20%
    • Distinctive eye movements occur
  24. 45.2 Identify the characteristics of the sleep states:NREM and REM sleep.
    • Characteristics of REM Sleep Continued
    • Voluntary muscle tone dramatically decreased
    • Deep tendon reflexes absent
    • May be difficult to arouse or may wake spontaneously
    • Gastric secretions increase
    • HR and RR often are irregular
    • Regions of brain associated with learning, thinking, organizing information are stimulated.
  25. 45.3 Describe variations in sleep patterns throughout the life span.
    Normal Sleep patterns & Requirements: Newborns

    • Sleep 16 to 18 hours a day
    • Periods of 1 to 3 hours spent awake
    • Enter REM sleep immediately
    • 50% NREM and 50% REM
    • Sleep cycle ~ 50 minutes
  26. 45.3 Describe variations in sleep patterns throughout the life span.
    • Normal Sleep patterns & Requirements: Infants
    • Awaken every 3 to 4 hours, eat, and then go back to sleep
    • Periods of wakefulness gradually increase
    • By 6 months, most infants sleep through the night
    • Establish a pattern of daytime naps
  27. 45.3 Describe variations in sleep patterns throughout the life span.
    • Normal Sleep patterns & Requirements: Toddlers
    • 12 to 14 hours are recommended
    • Most still need an afternoon nap
    • Nighttime fears and nightmares are also common
  28. 45.3 Describe variations in sleep patterns throughout the life span.
    • Normal Sleep patterns & Requirements: Preschool and School-age
    • -Preschool child (3-5 years) requires 11 to 13 hours of sleep
    • *Sleep needs fluctuate in relation to activity and growth spurts
    • -School-age child (aged 5 to 12) needs 10-11 hours of sleep
    • Most receive less
  29. 45.3 Describe variations in sleep patterns throughout the life span.
    Normal Sleep patterns & Requirements: Adolescents

    • Require 9-10 hours of sleep each night
    • Few actually get that much sleep
    • Circadian rhythms tend to shift
    • *Tendency to stay up later and wake later
  30. 45.3 Describe variations in sleep patterns throughout the life span.
    • Normal Sleep patterns & Requirements: Adults and Elders
    • Adults-Most healthy adults need 7-9 hours of sleep and individual variations
    • Elders-Tendency toward earlier bedtime and wake times, May show an increase in disturbed sleep, Need to sleep does not decrease with age.
  31. 45.4 Identify factors that affect normal sleep.
    Cite Examples of Factors that Affect Sleep Quality & Quantity with Study Partner

    -Illness, Environment, Lifestyle, Emotional Stress, Stimulants and Alcohol, Diet, Smoking, Motivation, Medication.
  32. 45.5 Describe common sleep disorders
    • Insomnia
    • Difficulty falling asleep
    • Waking up frequently
    • Difficulty staying asleep
    • Daytime sleepiness
    • Difficulty concentrating
    • Irritability
    • Risk factors
    • *Older age
    • *Female(hormonal)
  33. 45.5 Describe common sleep disorders
    • Excessive Daytime Sleeiness
    • Hypersomnia
    • Narcolepsy
    • Sleep apnea
    • Insufficient sleep
  34. 45.5 Describe common sleep disorders
    • Hypersomnia
    • Sufficient sleep at night but cannot stay awake during day
    • Caused by medical disorders: CNS, Kidney, Liver, Metabolic
  35. 45.5 Describe common sleep disorders
    Narcolepsy

    • Caused by lack of hypocretin in CNS that regulates sleep
    • Clients have sleep attacks
    • Sleep at night usually begins with sleep-onset REM period
  36. 45.5 Describe common sleep disorders
    • Sleep Apnea
    • Frequent short breathing pauses during night
    • More than 5 apneic episodes >10 sec/hr considered abnormal
    • Symptoms include snoring, frequent awakenings, difficulty falling asleep, morning headaches, memory and cognitive problems, irritability
    • types include obstructive, central, mixed.
  37. 45.5 Describe common sleep disorders
    Parasomnia

    • Behavior that may interfere with or occur during sleep
    • Arousal disorders-i.e. Sleepwalking, sleep terrors
    • Sleep-wake transition disorders-i.e.,sleep talking
    • Associated with REM sleep-i.e., Nightmares
    • Others-i.e., Bruxism
  38. 45.5 Describe common sleep disorders
    • Healthy Individuals who don't sleep
    • Experience sleepiness and fatigue during day
    • Attention and concentration deficits
    • Reduced vigilance
    • Distractibility
    • Reduced motivation
    • Fatigue, malaise, diplopia, dry mouth
  39. 45.7 Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems
    • NANDA Nursing Diagnoses
    • Disturbed Sleep Pattern-With specific descriptions such as "difficulty falling asleep" or "difficulty staying asleep"-Various etiologies may be involved and specified
  40. 45.7 Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems
    • Sleep pattern disturbances as etiology of other diagnoses:
    • Risk for injury
    • Ineffective coping
    • Risk for impaired gas exchange
    • Deficient knowledge
    • Anxiety
    • Activity intolerance
  41. 45.7 Develop nursing diagnoses, outcomes, and nursing interventions related to sleep problems
    • Outcomes for clients with sleep disturbances
    • Maintains (or develops) a sleeping pattern that provides sufficient energy for daily activities.
    • Enhance feeling of well being
    • Exhibits no signs of sleep deprivation.
    • Reports changing diet and making lifestyle changes to promote sleep.
    • Perfoms relaxation activity at bedtime.
    • Describes factors that promote/prevent sleep.
  42. 45.8 Describe interventions that promote normal sleep
    • Client Education
    • The importance of sleep
    • Conditions that promote sleep
    • Safe use of sleep medication
    • Effects of prescribed medications on sleep
    • Effects of disease states on sleep
  43. 45.8 Describe interventions that promote normal sleep
    • Bedtime Rituals
    • Altering or eliminating routines can affect sleep
    • Adults-Listeining to music to relax (Do not play music all night!)
    • -Reading
    • -Soothing bath
    • -Praying
    • Children
    • -Need to be socialized into presleep routine
    • -Usually preceded by hygienic ritual.
  44. 45.8 Describe interventions that promote normal sleep
    • Creating a Restful Environment
    • -minimal noise
    • -Comfortable room temperature
    • -Appropriate vintilation
    • -Appropriate lighting
  45. 45.8 Describe interventions that promote normal sleep
    • Promoting Comfort and Relaxation
    • Ensure a safe environment
    • Concerned, caring attitude
    • Relaxation techniques
  46. 45.8 Describe interventions that promote normal sleep
    • Medications
    • Sedative-hypnotics (induce sleep)
    • Anti-anxiety or tranquilizers
    • Be aware of actions, effects, risks of specific medications.
  47. 46.1 Discriminate between physiological and neuropathic pain categories.
    • Physiologic Pain
    • Experienced when an intact, properly functioning nervous system signals that tissues are damaged, requiring attention and proper care
    • Transient
    • Persistent
    • Subcategories-Somatic, Visceral
  48. 46.1 Discriminate between physiological and neuropathic pain categories.
    • Neuropathic Pain
    • Experienced by people who have damaged or malfunctioning nerves
    • Types-Peripheral, Central, Sympathetically maintained.
  49. 46.2 Describe the four processes involved in nociception and how pain interventions can work during each process.
    • Four Process involved in Nociception
    • Transduction
    • Transmission
    • Perception
    • Modulation
  50. 46.2 Describe the four processes involved in nociception and how pain interventions can work during each process.
    • Transduction
    • Pain receptors excited by stimuli: mechanical pressure/stretch, heat/cold chemicals
    • Stimuli cause release of biochemical mediators
    • Cells respond with neuromodulators
  51. 46.2 Describe the four processes involved in nociception and how pain interventions can work during each process.
    • Perception of pain is...
    • Universal experience
    • Life changing event
    • either felt or seen by the nurse
    • medical emergency when severe
    • Mystery of nature
    • Influenced by indiv. pain threshold
    • A matter of adaption
    • Influenced by neuromodulators.
  52. 46.5 Identify subjective and objective data to collect and analyze when assessing pain.
    • Pain Assessment Subjective Data
    • Comprehensive pain history includes (COLDERR)
    • Character
    • Onset
    • Location
    • Duration
    • Exacerbation
    • Relief
    • Radiation
  53. 46.5 Identify subjective and objective data to collect and analyze when assessing pain.
    • Additional Data to Obtain
    • Associated symptoms
    • Effect on ADLs
    • Past pain experiences
    • meaning of the pain to the person
    • Coping resources
    • Affective response
  54. 46.5 Identify subjective and objective data to collect and analyze when assessing pain.
    • Objective Data
    • Nonverbal responses to pain-Facial expression, Vocalization like moaning and groaning or crying and screaming, immobilization of the body or body part, purposeless body movements, behavioral changes such as confusion and restlessness, rhythmic body movements or rubbing.
  55. 46.5 Identify subjective and objective data to collect and analyze when assessing pain.
    • Pain Assessment Objective Data
    • Early physiologic responses-Increases BP, HR, RR,
    • Pallor
    • Diaphoresis
    • Pupil dilation
    • May be abesnt in people with chronic pain
    • Pain diary.
  56. 46.7 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain.
    • Treatment Plan
    • -Goals vary according to the diagnosis and its defining characteristics
    • -Select pain relief measures appropriate for the client, based on assessment data and input from the client or support persons.
  57. 46.7 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain.
    • Practice Guidelines
    • -Establish a trusting relationship
    • -Consider client's ability and willingness to participate
    • -Use a variety of pain relief measures
    • -use pain relief measures the client believes are effective
    • -Align pain relief measures with report of pain severity.
  58. 46.7 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain.
    • Practice Guidelines
    • -Encourage client to try ineffective measures again before abandoning
    • -Maintain unbiased attitude about what may relieve pain
    • -Keep trying
    • -Prevent harm
    • -Educate client and caregiver about pain
  59. 46.7 Individualize a pain treatment plan based on clinical and personal goals, while setting objective outcome criteria by which to evaluate a client's response to interventions for pain.
    • Pain Treatment Plan
    • -Include variety of pharmacologic and nonpharmacologic interventions
    • -Plan with wide range of strategies
    • -Document plan in client record and for home-care
    • -Involve client and support persons
  60. 46.8 Compare and contract barriers to effective pain management affecting nurse and clients.
    • Barriers to Effective pain management
    • -Lack of knowledge of the adverse effects of pain
    • -Misinformation regarding the use of analgesics
    • -Misconceptions about pain
    • -May not report pain
    • -Fear of becoming addicted
  61. 46.10 Describe pharmacologic interventions for pain.
    • Pharmacologic Interventions for pain
    • -Opioids (narcotics)
    • -Nonopioids/nonsteroidal anti-inflammatory drugs (NSAIDS)
    • -Co-Analgesic drugs
  62. 46.13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.
    • Analgesic Medication Administration Routes
    • -Oral
    • -Transmucosal, Transnasal
    • -Rectal
    • -Continuous Subcutaneous
    • -Intramuscular (IM)
    • -Intravenous (IV), Technology: PCA
    • -Intraspinous
  63. 46.13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.
    • Oral Administration
    • -Preferred because of ease of administration
    • -Duration of action is often only 4 to 8 hours
    • -Must awaken during night for medication
    • -Long-acting preparations developed
    • -May need rescue does of immediate release medication.
  64. 46.13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.
    • Transmucosa/Transnasal and Transdemal Administration
    • -Transmucosa and Transasal
    • *Enters blood immediately
    • *Onset of action is rapid
    • -Transdermal
    • *Delivers relatively stable plasma drug level
    • *noninvasive
  65. 46.13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.
    • Medication Administration
    • -Rectal~Useful for clients with dysphagia or nausea/vomiting
    • -Continuous subcutaneous infusion~Used for pain poorly controlled by oral medications.
  66. 46.13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.
    • Medication Administration
    • -Intramuscular, should be avoided, variable absorption, unpredictable onset of action and peak effect, Tissue damage
    • -Intravenous~ Provides rapid and effective relief with few side effects
  67. 46.13 Identify risks and benefits of various analgesic delivery routes and analgesic delivery technologies.
    • Benefits/Risk Routes and Technology
    • -Patient-Controlled Analgesia~Minimizes peaks of sedation and valleys of pain that occur with pm dosing, Electronic infusion pump, Safety mechanisms.
  68. 50.1 Outline the structure and function of the respiratory system.
    • Describe the Function of the respiratory system
    • -The function of the respiratory system is gas exchange.
    • -Oxygen from inspired air diffuses from alveoli in the lungs into the blood in the pulmonary capillaries
    • -Carbon dioxide produced during cell metabolism diffuses from the blood into the alveoli and is exhaled.
  69. 50.1 Outline the structure and function of the respiratory system.
    • Make a labeled drawing of these structures of the respiratory system on your own
    • Upper respiratory track- Mouth, nose pharynx and Larynx
    • Lower Respiratory tract-Trachea, Bonchi, Bronchioles, Alveoli, Pulmonary capillary network, and Pleural membranes.
  70. 50.3 Explain the role and function of the respiratory system in transporting oxygen and carbon dioxideto and from body tissues.
    • Feel what happens during inspiration
    • -Diaphragm and intercostals contract
    • -Thoracic cavity size increases
    • -Intrapulmonary pressure decreases
    • -Air rushes into the lungs to equalize pressure
  71. 50.3 Explain the role and function of the respiratory system in transporting oxygen and carbon dioxideto and from body tissues.
    • Feel what happens during exhalation
    • -Diaphragm and intercostals relax
    • - Volume of the lungs decreases
    • -Intrapulmonary pressure rises
    • -Air is expelled
  72. 50.3 Explain the role and function of the respiratory system in transporting oxygen and carbon dioxideto and from body tissues.
    • Describe process of gas exchange with your study partner
    • -Occurs after the alveoli are ventilated
    • -Pressure differences on each side of the respiratiory membranes affect diffusion
    • -Diffusion of oxygen from the alveoli into the pulmonary blood vessels
    • -Diffusion of carbon dioxide from pulmonary blood vessels into alveoli.
  73. 50.3 Explain the role and function of the respiratory system in transporting oxygen and carbon dioxideto and from body tissues.
    • Describe Oxygen transport with your study partner
    • -Oxygen transported from the lungs to the tissues
    • -97% of oxygen combines with hemoglobin in red blood cells and carried to tissues asoxyhemoglobin
    • -Remaining oxygen is dissolved and transported in plasma and cells
  74. 50.3 Explain the role and function of the respiratory system in transporting oxygen and carbon dioxideto and from body tissues.
    • Review Carbon Dioxide Transport with your study partner
    • -Carbon dioxide must be transported from the tissues to the lungs.
    • -Continually produced in the process of Cell metabolism.
    • -65% is carried inside the redblood cells as bicarbonate.
    • -30% combines with hemoglobin as carbhemoglobin (AKA, Carbaminohemoglobin)
    • -5% transported in solution in plasa and as carbonic acid.
  75. 50.4 Identify factors influencing respiratory function.
    • List Factors that influence Respiratory Function
    • Age, Environment, Lifestyle, Health status, Medication, Stress.
  76. 50.5 Identify common manifestation of impaired respiratory function.
    • -Hypoxia
    • -Altered breathing patterns
    • -Obstructed or partially obstructed airway
  77. 50.6 Describe nursing measures to promote respiratory function and oxygenation.
    • -Ensure a patent airway
    • -Positioning
    • -Encouraging deep breathing, coughing
    • -Ensuring adequate hydration
  78. 50.7 Explain the use of therapeutic measures such as medication, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function.
    • -Medication- Sympathomimetic alburterol (proventil, Ventolin) in Berman p. 1369
    • -Incentive spirometry
    • -Chest physiotherapy (PT)
    • -Postural drainage
    • -Oxygen therapy
    • -Artificial airways
    • -Airway suctioning
    • -Chest tubes
  79. 50.8 State outcomes criteria for evaluating client responses to measures that promote adequeat oxygenation.
    • Desired Oxygenation Outcomes
    • -Maintain a patent airway
    • -Improve comfort and ease of breathing
    • -Maintain or improve pulmonary ventilation and oxygenation
    • -Improve ability to participate in physical activities
    • Prevent risks associated with oxygenation problems
  80. 51.2 Identify factors influencing cardiovascular function.
    • -Cardiac output (CO)-Amount of blood ejected from the heart each minute
    • -Stroke volume (SV)- Amount of blood ejected from the heart with each beat
    • -Heart rate (HR)- Number of beats per minute
  81. 51.2 Identify factors influencing cardiovascular function.
    • Re-View factors influencing cardiovascular function
    • -Contractility-Inotropic state of the myocardium, strength of contraction
    • -Preload-Left ventricular end diastolic volume, stretch of the myocardium
    • -Afterload-Resistance against which the heart muscle must pump
  82. 51.3 Indentify major risk factors for the development of coronary heart disease.
    • -Non-modifiable- Heredity, Age, and Gender
    • -Modifiable risks-Elevated serum lipid levels, Hypertension, Cigarette smoking, Diabetes, Obesity, Sedentary lifestyle
    • -Other Risk Factors- Heat and cold, previous health status, stress and coping, dietary factors, alcohol intake, and elevated homocysteine level
  83. 51.4 Discuss the manifestations of cardiovascular disorders.
    - Can be altered by conditions that affect the function of the heart as a pump, blood follow to organs and peripheral tissues, the composition of the blood and its ability to transport oxygen and carbon dioxide.
  84. 51.5 Identify common resposnses to alterations in cardiovascular status.
    • Contrast NANDA diagnoses
    • Decreased Cardiac Output- Definition: inadequate blood pumped by the heart to meet metabolic needs
    • -Altered heart rate, Irregular heart rhythm, Palpitations, ECG changes (S & T 4749)
    • Ineffective Tissue Perfusion-Definition: decrease in oxygen that fails to nourish rain, heart, GI, and/or peripheral tissue at capillary level.
    • -Mental, behavior, speech changes, Chest pain, Dyspnea, BP changes in extremities, Claudication (ischemic muscle pain), weak/absent pulses, nausea, abd. pain, absent bowel sounds, abd. distention, decreased urine output.
  85. 51.5 Identify Key interventions for decreased cardiac output and ineffective tissue perfusion.
    • Decreased cardiac output- Administer oxygen as ordered, Report dizziness, fainting, cold clammy skin, fatigue, dyspnea, change positions slowly, reinforce clients need to report (chest pain, palpitations, weakness, dizziness, fainting/synope), practice stress reduction every 2 hours
    • Ineffective tissue perfusion- Measure, report, document VS, pulse oximetry q4h, daily wt, fluid balance, presence of pain, collect data on mental state, skin color/temp, heart sounds, lung sounds, urine output, food intake, bowel sounds, relieve anxiety and discomfort, keep client warm, and assist with ADL's , transfers and ambulation.
  86. 51.6 List signs of alterations in cardiovascular funtion.
    • How do these conditions affect cardiac output?
    • -Myocardial infarction- May decrease CO, SV, HR
    • -Heart failure-Decreased CO, SV, Increased HR, increased pre/afterload
    • -Irregular heart rhythms
    • decrease CO, SV
    • -Structural heart conditions
    • Decrease contractility, decrease CO, SV and alter HR
  87. 51.7 Identify and describe nursing measures to promote circulation.
    • Nurses promote circulation
    • -Elevate the client's legs (contrindicated in heart failure)
    • -Avoid placing pillows under the knees or providing more than 15 degree knee flexion
    • -Encourage leg exercises for a client on bed rest
    • -Promote ambulation as soon as possible
    • -Encourage or provide frequent position changes.
    • -Position the client in high fowler's position
    • -monitor intake and output
    • -fluid restriction

What would you like to do?

Home > Flashcards > Print Preview