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Exam 3 study guide

Terms in this set (136)

Blood flow through the heart
Deoxygenated blood → superior vena cava → right atrium → tricuspid valve → right ventricle → pulmonary valve → pulmonary artery → LUNGS → BECOMES OXYGENATED → pulmonary vein → left atrium →mitral valve—> left ventricle → aortic valve → aorta → REST OF BODY
Cardiac Ischemia
'Ischemia'= low oxygen; decreased oxygen supply to the heart
Alveoli
Small air sacs at the end of the terminal bronchioles that are the site of gas exchange
Atrioventricular (AV) node
a node of specialized heart muscle located in the septal wall of the right atrium; receives impulses from the sinoatrial node and transmits them to the atrioventricular bundle
Adventitious
abnormal breath sound heard over the lungs
Atelectasis
Complete/partial defect of alveoli may lead to incomplete expansion or collapse of a
part of the lungs
Capnography
a method to monitor ventilation and, indirectly, blood flow through the lungs
Cardiac Function/Diagnostics
Holter monitor: wear at home
ECG/exercise stress test: run on treadmill
Thallium stress: chemical stress test if exercise fails or is contraindicated
Echocardiogram
Cardiac catheterization
Cardiac Output
CO= SV X HR
^^ stroke volume
Healthy= 3.5 to 8L
This varies based on the body and can fluctuate
Hypertension
Systolic: >130mmHg
Diastolic: >80mmHg
Increases with age
Risk factors for heart disease and stroke
'Silent Killer'
Tx: Medications, lifestyle changes
Hypotension
Hypotension (Low blood pressure) occurs when blood flows through your blood vessels at lower than normal pressures
internal respiration
also can be described as diffusion: gas exchange at the cellular level; exchange of oxygen and carbon dioxide between the circulating blood and tiss
Perfusion
the process by which oxygenated blood passes through body tissues
The perfusion of lung tissue also depends on the person's activity level
Perfusion to the body's tissues depends on an adequate blood supply and proper cardiovascular functioning to carry oxygen and carbon dioxide to and from the lungs
Central perfusion
heart, brain, lungs
Tissue perfusion
transfer of gas to tissues
Hydrostatic pressure
Pushing force. A "dam" pushing force of water generating pressure
Oncotic (colloid osmotic) pressure
pulling force. Large things like protein, lipids, pulls things to them
Hypovolemia
body loses fluid like blood or water
Hypervolemia
too much fluid in the body
Which lab/diagnostic tests would be most appropriate for a client with cardiopulmonary issues?
ABG/pH analysis
Capnography
CBC
Peak Expiratory Flow Rate
Thoracentesis
Troponin
Echocardiogram
Sputum Culture
Cardiac Enzymes (CK-MB)
Serum Electrolytes- K+
Cholesterol, LDL, HDL, triglycerides
BNP
C-reactive protein
The patient with hypertension is prescribed a low sodium diet. The nurse teaching him about allowed foods should include which item?
Summer squash
Avoid canned soups
Shrimp would have been acceptable as well as oatmeal just need to be aware of what kind and the ingredients
The "pacemaker" of the heart- where does the transmission of electrical impulses in the heart begin?
The SA node
Three stages of blood clotting:
Constriction of the blood vessel
Formation of a temporary "platelet plug"
Activation of the coagulation cascade
Scope of clotting
Assessment: Pt. perspective
Abnormal bleeding/clotting
Pt. History: Genetics
Smoking
Immobility
Nursing Care: Assess for bleeding/clotting
Monitor coagulation labs
Client safety
Hydration, nutrition, elimination, mobility, pain
Anticipatory guidance/education
Blood clot
A blood clot is a mass of blood that forms when platelets, proteins, and cells in the blood stick together (coagulation)
Deep Vein Thrombosis
a medical condition that occurs when a blood clot forms in a deep vein
Pulmonary Embolism
blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung
Hemophilia
a disorder in which blood doesn't clot normally
Factor V Leiden
a mutation of one of the clotting factors in the blood
Increases your chance of developing abnormal blood clots
Legs (deep vein thrombosis) and lungs (pulmonary embolism)

LEADS- Leads to possible clot- leads to legs and lungs
Fluid and Electrolyte deficit
dehydration, food poisoning
Fluid and Electrolyte excess
too hydrated, consuming too much
Potassium
Found in metabolic panel (BMP). It helps your nerves to function and muscles to contract. It helps your heartbeat stay regular. It also helps move nutrients into cells and waste products out of cells.

NORMAL - 3.5 - 5.0 mEq/L
(POT GUMMY- $3.50 for 5mg)
Hyperkalemia
excess of potassium in the extracellular fluid
Hypokalemia
insufficient amount of potassium in the extracellular fluid
Magnesium
Renal. Magnesium enters the cell through selective channels across the apical membrane, driven by the transmembrane negative electrical potential

NORMAL values: 1.5 - 2.5 mg/dL
(MAGnifying glass you can see 1.5 to 2.5 bigger than normal)
Hypermagnesemia
excess of magnesium in the extracellular fluid
Hypomagnesemia
insufficient amount of magnesium in the extracellular fluid
Sodium
Found in metabolic panel (BMP). It is very important for maintaining blood pressure. Sodium is also needed for nerves, muscles, and other body tissues to work properly. When the amount of sodium in fluids outside cells drops below normal, water moves into the cells to balance the levels

NORMAL values: 135 - 145 mEq/L
(Sodium is OD, ODD numbers 1,3,5 = 135-145)
Hypernatremia
excess of sodium in the extracellular fluid
Hyponatremia
insufficient amount of sodium in the extracellular fluid
Phosphorus
Renal. It is needed for the growth, maintenance, and repair of all tissues and cells, and for the production of the genetic building blocks, DNA and RNA.

NORMAL values: 2.5 - 4.5 mg/dL
(PHOR= 4 US= 2 (me & you = 2) = 2.5-4.5 * don't forget the .5!!!)
Tonicity
Concentration of a solute in a solvent- "particle in liquid"
Hypotonic
Lower solutes (cells expand)
Water enters- PULLS
Less particle concentration outside cell, more inside cell, CELL SWELLS
Hypertonic
higher solutes (cells shrink)
Water exits - PUSHES
More particles outside cell, less inside
Isotonic
BLOOD
Same concentration inside the cell as outside- movements will be the same/equal
Osmosis
Movement of water across semipermeable membrane
(part of passive transport)
Diffusion
Movement of particles across a semipermeable membrane
(part of passive transport)
Active Transport
"going against the grain", low to high concentration, REQUIRES ENERGY
Filtration
Pressure pushes things through filter, pushing through barrier or semipermeable membrane
Intracellular
About 70% or ⅔ of bodily fluids
Extracellular
About 30% or ⅓ of bodily fluids
3rd spacing
fluids shifts, goes into other spaces/places
The majority of bodily fluids distributed in adults?
Intracellular space (2/3)
Water movement through a semipermeable membrane?
Osmosis
Solute or particles movement through a semipermeable membrane?
Diffusion
Movement of substances against a concentration gradient?
Active transport
Passage of fluids through a permeable membrane?
Filtration
The "pushing" force in capillaries and interstitial spaces?
Hydrostatic pressure
The "pulling" force in capillaries and interstitial spaces?
Colloid osmotic pressure
Responsible for moving fluids from the interstitial space back into the capillaries?
Interstitial hydrostatic pressure and Capillary colloid osmotic pressure
Albumin
protein in blood; maintains the proper amount of water in the blood
How to assess for fluid & electrolyte balance
General Appearance - sunken or swollen
Tearing and salvation- dry mouth, no tears
Vital signs- HR increased, RR increased, Temp decreased
Edema and pitting- 3rd spacing of fluids, fluid excess
Neuro (A&O)- confusion
Color and temp of skin- dry, pale, warm vs cool
Skin turgor of tongue- dry
Priority F&E imbalance interventions
Client history
Neuro assessment
Daily weight
Serum and urine labs
q4 vital signs
0.9% normal saline
isotonic (same as blood)
Increased osmolality
dehydration
Decreased osmolality
fluid increase
Hyperactive bowels X4
expected w/ diarrhea
Dehydration does not cause hyperactive bowel sounds
An electrolyte that is a major cation in intracellular spaces?
Potassium (K)
An electrolyte that is a major cation in extracellular spaces?
Sodium (Na)
Gas Exchange
Alveoli
Hypoventilation
breathing that is too shallow or too slow to meet the needs of the body
Dyspnea
impaired breathing
Hyperventilation
rapid or deep breathing, usually caused by anxiety or panic.
Hypoxemia
low O2 in blood
Gas exchange Additional considerations
Levels of health: Comorbididties, ability to maintain adeequate gas echanvge
Development: Children have smaller shorter ariwayrs, elderly may have comorbidities
Meds: Are they taking something like bronchodialotors or narcotics that impair gas exchange? Prone to panic disorders?
Lifestyle: Varys person to person. How healthy are they? Do theyr excersize?
Environment: Where do they live? Is it a healthy environmetn?
Psychological health: Psychological issues that impaire gas exchange?

(SMOKING CESSATION IS NOT HIGHEST PRIORITY)
Respiratory nursing care
Assessment
Pt. perspective
Hx
Diagnostic studies: chest x-rays
Acute care- coughing/deep breathing, positioning, oxygen therapy, incentive spirometry, suctioning, artificial airways, pneumothorax, hemothorax
Pt. teaching: pursed lip breathing, diaphragmatic breathing, home oxygen therapy
Peak Expiratory Flow
Used w/ asthma
Green: 80-100%
Personal best, no limitations
Yellow: 50-80%
Caution/slow down
Narrowing of airways, mild symptoms
Red: < 50%
Severe narrowing of airway
** medical attention required IMMEDIATELY
Supplemental Oxygen
Nasal cannula (low flow)
Oximizer (high flow)
Simple face mask
Venturi mask
Partial non-rebreather
Non-rebreather
Bag valve mask (BVM)
PAP, CPAP
Ventilation
Pneumonia
Inflammation of terminal bronchioles & alveoli
Viral Pneumonia
nonproductive cough or clear sputum
Bacterial Pneumonia
productive cough of white, yellow, or green sputum
s/s of pneumonia
fever, chills, dyspnea on exertion, sharp stabbing chest pain in inspiration, w/ ronchi or crackles on auscultation
Treatments for Pneumonia
antibiotics, bronchodilators, corticosteroids, pain management, supplemental oxygen, deep breathing, incentive spirometry, increase fluids, increase activity as tolerated
Developmental considerations for Pneumonia
Children may experience retractions & nasal flaring
Viral pneumonias > bacterial pneumonia in children of all ages
Older adults w/ pneumonia may experience confusion
Promotion oxygenation, comfort, & breathing
Healthy lifestyle
Vaccination
Pollution free environments
Reducing anxiety
Nutrition & fluid intake
Positioning
Humidified oxygen
Breathing techniques
Incentive Spirometry
Arterial blood gas
a diagnostic test examining arterial blood; used to determine the pressure
exerted by oxygen and carbon dioxide in the blood
Crackles
fine, crackling sounds made as air moves through wet secretions in the lungs
Oxygenation
the process of providing cells life-sustaining oxygen
Wheezes
continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages
Incentive spirometer
a hand-held device that helps people to take slow, deep breaths
The client is breathing very quickly. Which term is the best way to describe this finding?
Tachypnea
The client SPO2 is currently 92%. Which term best describes this?
Hypoxia
What is the term for what a nurse auscultates when there is fluid in the lungs?
Crackles
Which of the following are age-related concerns for oxygenation?
More secretions remain in lungs
Slower rate of gas exchange due to thickened capillaries
Fewer functional capillaries
Increased use of accessory muscles
Mucous membranes are drier
Which type of breathing would benefit a client with dyspnea and feelings of panic?
Pursed lip breathing
What is another term for gas exchange at the cellular level?
Diffusion
Interrelated concepts with gas exchange
Anxiety
Acid-base balance
Perfusion
Nutrition
Mobility
Fatigue
Circadian rhythm
rhythm that completes a full cycle every 24 hours; synonym for diurnal rhythm
Insomnia
difficulty in falling asleep, intermittent sleep, or early awakening from sleep. Sleep Hygiene
Melatonin
a natural chemical produced at night that decreases wakefulness and promotes sleep
Sleep cycle
passage through the four stages of NREM sleep (I, II, III, IV), then reversal (IV, III,
II), and finally, instead of reentering stage I and awakening, entering REM sleep and returning to stage II
Stage 1 & 2 of sleep cycle
easily awakened, very light
Stage 3 & 4 of sleep cycle
deeper levels, restorative sleep (mainly stage 4), best quality!
Decreased metabolism, decreased HR, decreased RR, actually getting rest
NREM stage 1 of sleep cycle
NREM stage 2→ NREM stage 3→ NREM stage 4→ NREM stage 3→ NREM stage 2→ REM Sleep→ REPEAT back to stage 2 (continuous cycle until awoken)
OSA (obstructive sleep apnea)
the absence of breathing during sleep
non-rapid eye movement (NREM) sleep
non-rapid eye movement that characterizes four
stages of sleep
rapid eye movement (REM) sleep
stage that constitutes 20% to 25% of a person's nightly
sleep; person is difficult to arouse during this stage

helps memory, hyper alert state of sleep, increased HR, good quality sleep but not restorative

REM sleep is important for early brain development, cognition, and memory
sleep
state of altered consciousness throughout which varying degrees of stimuli preclude
wakefulness
Rest
a condition in which the body is in a decreased state of activity, with the consequent
feeling of being refreshed.
Restorative Sleep
giving body a break, slows down
Memory consolidation
convert short term memory into long term
Biological processes of sleep
Increased protein synthesis
Increased tissue repair
Decreased basal metabolic rate
What systems are affected by sleep deprivation?
Fluid and electrolyte
Neuro
Mental health
Muscular
GI
Psychological
Immune system
Mood & affect
CV system
Metabolism
Motor performance- equilibrium
Memory storage
What Affects our sleep?
Consider AGE! Elderly have a harder time sleeping, bladder issues, polypharmacy.

Developmental considerations
Motivation
Culture
Lifestyle & habits
Environmental factors
Psychological stress
Physical illness
Medications
How can we promote sleep?
Establish sleep habits, routine or bedtime rituals
Promote comfort & relaxation
Warm environment or cool, whichever the patient prefers
Toileting
Preparing for restful sleep
Sleep related breathing disorder
obstructive sleep apnea
Hypersomnolence
Narcolepsy; "sleepy" at wrong part of the day
Circadian Rhythm Sleep-wake Disorder
Characterized by a recurrent pattern of sleep disruption caused by an alteration of the circadian system, or a mismatch in the sleep wake schedule required by the person's environment and circadian sleep wake cycle. The mismatch results in insomnia or excessive sleepiness. Specifiers: delayed sleep phase type, advanced sleep phase type, irregular sleep wake type, non-24 hour sleep wake type, shiftwork type, and unspecified type. Also episodic, persistent, or recurrent
Parasomnia
"Nightmares", mostly pediatric sleep disturbances
Sleep related movement disorders
restless leg syndrome
Sleep paralysis
unable to move for few minutes, just before going to sleep or awakening
Sleep deprivation
any significant loss of sleep, resulting in problems in concentration and irritability
Hypnagogic hallucinations
dream like auditory or visual experiences while going to
sleep
Autonomic behavior
performance of routines w/o awareness
A nurse is caring for a client with narcolepsy. Which is the most serious consequence of this disorder?
Potential for injury
How can the holistic nurse best support a client's ability to sleep in the hospital setting?
Limiting unnecessary noise on the unit
The nurse is teaching a community education class about rest and sleep. Which concepts should the nurse include?
Bedtime routines are associated with an expectation of sleep
Sleep needs vary, even within the same stage of growth and development
Which of the following statements associated with rest and sleep must the nurse consider when planning care?
Sleep requirements increase during stress
Level of awareness decreases as a person progresses through the sleep cycle
Sleep needs
Neonate: 16 hrs/day
Infants: 15 hrs/day
Toddlers: 12 hrs/day
Preschoolers: 12 hrs/night
School-aged
6 years: 11-12 hrs/night
11 years: 9-10 hrs/night
Adolescents: 8-10 hrs/night (Avg. <7 hrs/night)
Adults: 7-9 hrs/night
Young: 6-8 ½ hrs/night
Older: sleep difficulty increases with age

Older adults need less sleep or tend to sleep less
Infants need the most sleep
Summary of a Holistic Nurse
A nurse who sees themself as an important part of the patient's healing process. One who uses many tools from the holistic, integral, and integrative models of care.

A nurse who strives to have a caring relationship with their patient and communicates with them in a therapeutic and compassionate manner.

A nurse who provides holistic caring, and who recognizes the need for self-reflection as an ongoing process of personal development.
Holistic Nursing Care
Self-assessment
8 areas of wellness
Incorporates client perspective
8 areas of wellness (holism)
Emotional
Financial
Social
Spiritual
Occupational
Physical
Intellectual
Environmental
Therapeutic Communication
Healthcare language
Professional nursing language
Holistic Communication
A caring-healing process that calls forth the full use of self in
interacting with another.
Centering
Grounding
Intention
Presence
Intuition
Categories of Communication
Verbal: Asking questions
Non-verbal: Smiling
Eye contact
Body language
Facial expressions
Context: The setting in which the communication is taking place
Let's be "CLEAR"
"C" - center yourself
"L" - listen wholeheartedly
"E" - empathize
"A" - Attention
"R" - Respect
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