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66 Cards in this Set
- Front
- Back
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Acute pain |
present for 6 months, sudden onset |
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Chronic pain |
present longer than 6 months |
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Intractable pain |
pain that is not responsive to any intervention, no matter what nurse does - what pt.'s are most afraid of |
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Progressing pain |
pain that gets worse over time |
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Somatic pain |
-isolated to skin and a musculoskeletal system - bones, crushed tissue, burns. Sharp pain that's localized. -->responds well to analgesics -->can have swelling, bleeding, cramping along with it
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Visceral pain |
-Coming from organs specifically. -Dull. -Tends to radiate - goes from site of injury and radiates/goes to another site ex: heart pain goes down left arm |
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Referred pain |
pain shows up in site different from where problem is ex: kidney infections = back pain |
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Rebounding pain |
upon removal of pressure rather than application -typically acute |
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Breakthrough pain |
pain level breaks through medication/treatment |
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Neuropathic pain |
damage or disease that affects somatosensory system "pins and needles" or "tingling" |
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Apnea |
movement of no air --> 15-20secs. |
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Bradypnea |
less than 10 breaths per minute -same volume, slower |
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Normal breathing pattern |
12-20 breaths per minute (adult) |
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Tachypnea |
more than 20 breaths per minute -Same volume, faster |
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Hyperventilation |
faster, more volume - takes more work -->Kussmaul respirations when it is from diabetic ketacidosis (DKA) |
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Hypoventilation |
slower, less volume |
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Cheyne stoke |
hypoventilation - hyperventilation - hypoventilation - apnea - restart |
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Biots |
no pattern or rhythym |
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Agonal |
signs of relief "agony" |
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Compliance of lungs |
how much the lungs can stretch |
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Gas exchange |
exchange of CO2 and O2 at alveolar level when exhaling |
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Perfusion |
supply an organ, tissue, body with fluid (blood) by circulating it through blood vessels or other natural channels |
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Local infection |
limited to the specific part of the body where microorganisms remain |
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Disseminated infection |
spread to other ares beyond initial site of infection |
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Systemic infection |
(Septic) spread throughout the entire body, often via blood |
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Bacteremia |
Culture of blood shows bacteria |
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Septicemia |
When bacteremia results in a systemic infection |
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Classic signs a systemic inflammatory response (5): |
1. Fever: >38C or 100.4F 2. Increased pulse and respiratory rate if fever is high 3. Malaise (feeling discomfort, illness, or uneasiness) and loss of energy 4. Loss of appetite, some nausea + vomiting 5. Enlargement and tenderness of lymph nodes that drain the area of infection |
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Addiction: |
when person takes medication other than reason prescribed Ex: vicodin to get high instead of for pain |
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Behaviors indicating pain: |
1. Fist clenching 2. Pale color 3. Facial expressions 4. Protecting area/holding area where pain is 5. Noises (grunting, whaling, etc.) 6. Sweating 7. Respiratory distress 8. Withdrawal (not moving at all) 9. Movements - pacing, rhythmic distraction |
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Distractions/interventions with no meds: |
1. Manipulate the condition to promote comfort and decrease pain ex: loosen clothing, change position, pillows, etc. 2. Music 3. Guided imagery 4. Heath and cold therapy
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Threats to airways: |
1. smoking 2. Pregnancy 3. Obesity 4. Age 5. Environmental factors 6. Medications 7. Infections |
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Nursing interventions for people who are having a hard time breathing: |
1. Positioning: a. Improves chest expansion b. Postural drainage: different positions can drain lungs but can ONLY do with those who have stable vital signs 2. Pursed lip breathing 3. Use incentive inspirometer -increases/forces expansion of lungs - opens all alveoli, gets better gas exchange 4. Diaphragmatic breathing: clears 5. Huff coughing: helps loosen secretions so they can be removed 6. Comfortable position 7. Administer medications as ordered 8. Percussion: cup-shaped hand - used to loosen and dislodge secretions from lungs 9. Last thing can do: give oxygen - considered a drug so need an order for it. |
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Nasal Cannula |
1. 1-6 LPM - can't give more because pt. could swallow air 2. Humidification is required if high flow (3-6 LPM) for more than 1 hours 3. Assess nostrils and ears for pressure 4. Pt. must breathe through nose 5. Oral temp is not affected |
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Simple face mask |
1. Must be above 5 LPM - if below, will retain too much CO2 and decrease respiration rate 2. FiO2: 40-60% 3. Pt. can't eat or drink with mask on - must order NC 4. Pt must leave mask on ALL the time |
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Non-rebreather with O2 reservoir bag |
1. LPM = 6-15 2. FiO2 = 70-100% 3. Has on way valve 4. Bag must be inflated at least 1/3 of way during inhalation - or else not delivering 100% O2 5. Pt. must keep mask on at all times |
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Face tent |
giving little supplemental oxygen, makes working of breathing easier |
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Pneuomothorax |
collapsed lung - FREE AIR in chest cavity presses on lung and doesn't allow it to inflate -->air released via chest tube |
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Hemothorax |
collapsed lung - BLOOD in chest cavity presses on lung and doesn't allow it to inflate -->chest tube will rain blood |
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Pneumonia |
Lung inflammation - air sacs fill with pus/fluid and may become solid -->causes ineffective airway clearance, impaired gas exchange |
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Emphysema |
condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness |
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Interventions for body position: |
1. Put in bed body position, small pillow under lumbar area of back 2. Move pt. = ROM and dangling 3. Slowly raise HOB 4. Pallor (pale) = 1st sign of oxygen problems 5. Watch for increase in respiratory rate and sweat |
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Cyanosis |
bluish discoloration of skin resulting from poor circulation or inadequate oxygenation of blood -->assessed in conjuctiva, lips, fingers, and toes |
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Jaundice |
medical condition with yellowing of skin or eyes, arising form excess pigment bilirubin and typically caused by obstruction of bile duct, by liver disease, or by excessive breakdown of RBC's --->assessed in eyes and skin |
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Pallor |
an unhealthy pale appearance ---->assessed on hands and conductive
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Xerosis |
dermatosis exhibited as dry scaly skin with or without erythema (Redness), itching, and skin cracking ---> most common on scalp, lower legs, arms, hands, knuckles, sides of abdomen, and thighs |
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Nursing interventions to prevent pressure ulcers |
1. Minimize pressure by: a. turn client q2h b. padding (egg crates, hell protectors, special mattress) c. trapeze bar d. body alignment e. avoid high fowlers position when possible 2. Avoid shearing forces: draw sheets 3. Hydration + good nutrition (low salt) 4. Keep linens and bed clothing dry 5. Lotion not alcohol 6. Massage to increase circulation from distal to proximal 7. Inspect skin daily during hygiene 8. Barrier moisture creams to protect perianal skin area from urine or stool
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Nursing interventions for this with edema |
1. Low salt diet 2. Elevate legs UNLESS pt. has heart problem 3. Place pillow under legs when lying down 4. Wear support or compression stockings to improve flow of blood through veins 5. Move ankles for exercise and to improve circulation |
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Mottling |
due to vascular constriction and dilation and is normal response of skin to cold |
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Mongolian spots |
congenital birthmark with way borders and irregular shape -fades after a couple years, usually gone by adolescent age **don't confuse with bruising** |
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Places to take temp: (7) |
1. oral 2. temporal 3. axillary 4. tympanic 5. rectal 6. arterial 7. bladder |
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How to take orthostatic hypotension: |
1. pt supine: take BP + P 2. pt sits feet flat on ground: -wait 2 mins: <65 years old -wait 3 mins: >65 years old then take BP + P again...compare to supine ***if systolic decreased 20 mmhg or diastolic decreased 10 mmhg OR HR increased 40 bpm then they have orthostatic hypotension (stop) IF NOT...continue 3. pt. to standing, wait # of minutes, retake BP + P 4. compare to supines #'s
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Bradycardia |
<60 |
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Tachycardia |
>100 |
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Adult normal pulse rate |
60-100 bpm |
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Pulse sites (8) |
1. radial 2. femoral 3. brachial 4. temporal 5. apical 6. anterior tibial 7. pedal 8. carotid
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Restraints: medical surgical reasons |
-Used when pt is interfering with self-care/harming self (must document this action) -RN can request restrains w/o physician order BUT just start with least restrictive -Must be observed every 30 minutes and documented -RN must re-assess pt. if needs restraint by taking restrain off every 2 hours -Renew order every 24 hours |
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Restraints: behavioral health reason |
-Used when pt is harming self or others? -Every 15 minute observation...can be via camera or audio -Perform face to face assessment: every 4 hours for adult and every 2 hours for child 17 and younger -Must rewrite order every 4 hours |
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Airborne:
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-Apply standard precautions -Negative pressure room, keep door closed -All visitors and HCP wear special respirator -Limit movement of client outside of room. Client must wear surgical mask outside room |
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Droplet |
-Apply standard precautions -Private room -Wear mask if working within 3 feet of client -Wear gloves when working in room so don't touch surfaces with droplets on it and then touch face -Limit movement of client outside of room, client wears surgical mask |
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Contact |
-Apply standard precautions -Private room -Wear gown if contact infected surfaces or items, if client is incontinent, has diarrhea, colostomy, or wound drainage, etc. -Limit client movement outside room -Dedicate noncritical client care equipment to a single client |
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Protective Isolation |
-Purpose is to protect client who is severely immunocompromised with really low neutrophil counts -Staff with upper respiratory tract infection or ill should NOT enter room -Everyone who enters room wears full PPE including hair, foot covers, etc. -No standing water or flowers allowed -Hand hygiene antimicrobial soap |
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Supine Low fowler Semi fowler Fowler High fowler
Which is best for respiratory illness? |
flat 15-30 30-45 45-80* 90 |
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What do you do during a fire |
RACE remove alarm contain extinguish |
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5 signs of inflammation |
1. pain 2. swelling 3. redness 4. heat 5. impaired function of part |
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Signs of pediatric respiratory distress (5) |
1. tachypnea 2. abdominal breathing 3. intercostal and subcostal retractions 4. cyanosis (fast breathing=less O2 exchange) 5. Head bobbing (means total respiratory distress) |
