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348 Cards in this Set
- Front
- Back
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(Components of the Communication Process)
Medium thru which the messsage is being sent |
channel
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distance from 0 to 18 in.
reserved for people who feel close. Tone of voice is louder with increased sensation of body heat. |
Intimate distance
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(1.5-4 ft.)usually friends, vision is clear, voice tone is moderate, sensations of body heat & smell are lessened, better to read nonverbal (client/nurse conversation usually held here, 1 to 1 teaching, counseling)
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Personal distance
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(more than 4 ft.) formal communication, increased eye contact (making rounds, leading a group, teaching a class)
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social or public distance
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Messages one sends to oneself “self-talk”
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Intrapersonal
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communication that occurs between two people
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Interpersonal
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Relationship aspect of communication
Refers to all factors that influence how message is received Focuses on the communication process, not just the content |
Metacommunication
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“I’ll sit with you”, “Go on”, “Uh-huh” head nodding
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Offering self
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- “What would you like to talk about today?” “Can you tell me more about that” “How have things been going”
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Broad openings
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Therapeutic Approaches that allows client to set pace
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silence
broad openings offering self |
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Therapeutic Approaches that Responding to verbal/nonverbal cues
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exploring
recognition focusing directing |
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Therapeutic Approaches that Encourage spontaneity
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open- ended
reflection restating |
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Therapeutic Approaches that allows Encourage expression of feelings
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verbalizing the implied
making observations clarifying |
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Therapeutic Approaches that Encourage client to make some changes
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confronting
limit setting |
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“Tell me more about the pain”, Tell me about your family”
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Open-ended
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-“What do you think about that” “You sound a bit agitated by now”
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reflection
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"Sounds like you are pretty angry at him”, “You are having problem sleeping”
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Restating
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“Tell me more about how you feel when you do not take your meds.” “Tell me about one of those time you felt upset”
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Exploring
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“I noticed…..” I see…..”
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Recognition
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“You mention that you had a problem with…” “You say you feel upset a lot.”
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Focusing
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“What made them say that to you” “When were you told this”
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Directing
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“You are worried about the med bills”
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Verbalizing the implied
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“You seem sad today” “Your limping as if your leg hurts”
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Making observations
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“Tell me what you meant by upset”, “Who told you this”
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Clarifying
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“You say your angry, yet you are smiling”
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Confronting
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"Why?"
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Probing
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Quantitative changes in physical size of the body and its parts are measurable
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Growth
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Behavioral changes in functional abilities and skills qualitative
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Development
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Becoming fully grown and developed
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Maturation
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Assimilation of info w/ resultant change in behavior
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Learning
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Principles of Growth and Development
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1. Occurs head to toe
2. Proximodistal pattern 3. Simple to complex 4. Continuous, orderly, predictable 5. Consistent development process 6. Individual rates of progression 7. Specific characteristics for each stage 8. Certain tasks at each stage 9. Stages vary in critical nature |
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Theoretical Perspectives of Human Development in which:
Growth is influenced by interaction of: Genetic predisposition Central nervous system Endocrine system Maturation |
Physiological dimension
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Theoretical Perspectives of Human Dev.
Based on subjective feeling and interpersonal relationships |
Psychosocial dimension
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Focus on an individual’s unconscious process
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Intrapsychic (psychodynamic) theory
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Trust vs. Mistrust
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Birth to 18 months
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Autonomy vs.
Shame/Doubt |
18 months
to 3years |
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Initiative vs.
Guilt |
3 to 6 years
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Industry vs. Inferiority
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6 to 12 years
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Identity vs. Role Diffusion
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12 to 20 years
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Intimacy vs.
Isolation |
18 to 25 years
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Generativity vs. Stagnation
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21-45 years
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Integrity vs. Despair
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45+ years
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Sullivan's theory that Focused that relationships w/ others influence how one’s personality develops
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Interpersonal theory
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Theorists of the Cognitive dimension
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Piaget and Inhelder
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taking in new info or experiences.
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Assimulation
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allows for readjustment of mind set to take in new info, thus understanding is increased
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Accommodation
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changes that occur due to accommodation and assimilation.
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Adaptation
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• Person’s value system that helps to differentiate right and wrong
• Theorists: Kohlberg, Gilligan |
Moral dimension
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• Relation with self, others, and a higher power or divine source
• Spirituality does not refer to a specific religious affiliation. • Theorist: Fowler |
Spiritual dimension
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Nursing implications
1. Physical exams and screenings 2. Teaching relaxation techniques |
Prenatal -------Conception to birth
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Neonatal nursing implications
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1. Complete and thorough assessment
2. Teaching 3. Bonding 4. Basic care needs 5. Car safety |
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Neonatal safety considerations
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1. Accidents are main cause of mortality
Car seats 2. Infections Skin breakdown from diaper rash, ect |
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Safety considerations are choking on objects in environment, car accedendent & incorporating child into family
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Infancy
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Age st which Play is vital, there are accidents w/ toys, and accidental poisoning.
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Toddler walker-3 years
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Age age which there are many accidents due to curiousity. Accident prevention would be role modeling. Communication at child's level is emphasized
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Preschooler 3- 6 years
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Age at which adequate rest and sleep are vital, and accidents during play such as traffic, bikes, & strangers
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school age 6 -12 years
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Age at which safety considerations are
1. Violence 2. substance abuse 3. sex education 4. unhealthy lifestyles |
Preadolescent- Ages 10 to 12 years
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Age in which Safety considerations are
1. Accidents 2. Homicide 3. suicide |
Adolescent Ages 13 to 20 years
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Age in which Nursing implications are
1. Avoidance of accident, injury, violence 2. Development of health-promoting behaviors ( healthiest time) o Safety considerations 1. Car accidents 2. Sun bathing |
Young Adult Ages 21 to 40 years
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Age in which Safety considerations are
1. Cancer- smoking, alcohol abuse 2. Increased leisure accidents |
Middle Adult--- Ages 40 to 65 years
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Body’s physiological reaction to any stimulus that evokes a change
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Stress
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• Subjective response
• Occurs during a threat to well-being • Pervasive feeling of dread |
Anxiety
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Subjective stress
↓perception & attention |
Moderate anxiety
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↑ subjective stress, selective attention, distorted perception
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Severe anxiety
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Major perception distortion
immobilization & function impairment impaired communication |
Panic anxiety
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Increased degree of alertness;
increased vigilance |
mild anxiety
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Process to adjust to stressors
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Adaptation
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• Inherent part of life
• Behavior is altered in response to stressor |
Change
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General adaptation syndrome (GAS)
Stage 1 |
Alarm- perceived threat
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General adaptation syndrome (GAS)
Stage 2 |
Resistance- fight or flight
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General adaptation syndrome (GAS)
Stage 3 |
Exhaustion- after long-term coping; breakdown to illness or disease
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Physiological response to a stressor affecting a specific part of body.
Redness, warmth, swelling |
Local adaptation syndrome (LAS)
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coping ineffectively w/ stress
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Maladaptation
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Stressor exceeds the person’s abilty to cope.
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Crisis
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Identifiable precipitating event
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Crisis
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Unresolved with usual coping skills
Intervention required |
Crisis
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Balancing factors of a crisis
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Perception Coping mechanism
Situational support |
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Type of crisis in which Occurs as age or move to next developmental stage
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Developmental or maturational
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Type of crisis in which are
Unpredictable Not experienced by everyone When change in role or function. |
Situational
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Type of crisis in which are
Upredictable rare |
Adventitious
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• Unconscious operations
• Protect the mind from anxiety |
Defense mechanisms
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Type of change
Physical & emotional changes that occur at different stages of the life cycle • Predictable & gradual |
Developmental
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Type of change
• Adaptive response to external stimuli • Change imposed by others |
Reactive
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Type of change that Occurs w/ person’s conscience
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Covert
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Type of change where One is aware, but not usually in direct control.
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Overt
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Lewin’s theory of change
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1. Unfreezing- recognize need for change
2. Moving- the actual changing implementation 3. Refreezing- new changes incorporated into behavior |
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Lippitt’s theory of change
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1. Diagnose problem
2. Assess change target motivation & capability 3. Assess change agent’s motivation & capability 4. Make objectives 5. Determine role of change agent 6. Maintain change 7. Terminate role of change agent |
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o Intentionally initiates and creates change
o Constantly seeks ways to make improvements o Empowers the client to initiate change in order to adapt more successfully |
Nurse as a change agent
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Observe for signs of distress
Labored breathing, pallor, cyanosis, protection of a painful part, sweating or cold moist palms, anxious face Observe state of health, statureWeight, height, and vital signs are measured during the survey Note posture (erect, slumped) Observe motor activity: gait and body movements should be smooth and effortless Abnormal: unsteady, slow gait, tremors |
General survey assessment
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Normal sequence of physical assessment
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Inspection
Palpation Percussion Auscultation |
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Percussion Sounds - Characteristics
Normal in muscle or bone Abnormal in Lungs (severe pneumonia) |
flatness
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Percussion Sounds - Characteristics
Normal in organs (liver) Abnormal in lungs (atelectasis) |
Dullness
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Percussion Sounds - Characteristics
quality "thud" |
dullness
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Percussion Sounds - Characteristics
quality "hollow" |
resonance
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Percussion Sounds - Characteristics
Normal in lungs No abnormal sites |
resonance
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Percussion Sounds - Characteristics
quality "boom" |
hyperresonance
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Percussion Sounds - Characteristics
normal in children's lungs Abnormal in adult lungs (emphysemia) |
Hyperresonance
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Percussion Sounds - Characteristics
quality "drum" |
tympany
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Percussion Sounds - Characteristics
normal as gastric air bubble Abnormal in lungs (large pneumothorax) |
tympany
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respirations above 24
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tachypnea
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volume elements during assessment
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normal
shallow deep |
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difficulty breathing
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dyspnea
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periods of appnea followed by periods of increasing and decreasing breathing
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kussmaul breathing
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lung assessment reveals
A/P 1:1 indicating..... |
Barrel chest
(COPD, emphysema) |
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Normal Breath sounds:
High/loud pitch hollow quality heard more during experation |
bronchial
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normal breath sounds:
moderate pitch blowing quality |
bronchialvesicular
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normal breath sounds:
sound located in the trachea |
bronchial
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normal breath sounds:
sound located b/t 1st & 2nd Intercostal spaces |
brobhivesicular
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normal breath sounds:
low pitch soft/ breezy quality |
vesicular
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normal breath sounds:
sound located in peripheral lung |
vesicular
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abnormal assessment sound during inspiration simulated by roling a strand of hair as in CHF, pneumonia, & pulmonary edema
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crackles
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abnormal assessment sound predominantly during expiration phase of low-pitched course rattling, musical
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rhonchi
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abnormal assessment sound predominantly during expiration of a high-pitch whistling, creaking
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wheezes
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abnormal assessment sound
predominantly on inspiration of grating on inspiration and expiration |
pleural friction rub
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S1, is heard loudest at....
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apex of heart (PMI) mitreal area
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phase at which the ventricle contract to eject blood
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systole (S1)
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phase in which ventricles are relaxed and no blood is being ejected
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diastole (S2)
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S2 is heard loudest....
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at the base of heart
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Assessment of carotid pulse
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inspect
palpate ausculatate |
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bruit may indicate
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arterial narrowing
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abdominal assessment order
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inspect
auscultate percuss palpate |
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Which normal breathsound is the result of air moving thru the smaller airways over the lungs.
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vesicular
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Which positions are contraindicated in clients with cardiopulmonmary alterations
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supine & prone
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which sound during percussion of abdomen indicates dullness
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high-pitch sound of short duration
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which sound during percussion of abdomen indicates tympany
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low-pitch sound of lond duration
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Specimen collection done where ever client current is
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Point of care testing
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causes of inaccurate venipuncture results
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1. hemoconcentration
2. hemolysis 3. when drawn from above IV site |
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reduced water in plasma w/ increased blood cells
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hemoconcentration
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Hemoconcentration can be prevented by
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reducing risk of prolonged standing
checkiong tourniquet regularly |
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the breakdown of red blood cell & release of hemoglobin
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hemolysis
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Do not perform a ABG test if........
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1. Client is hyperthermic
2. Right after breathing & suctioning therapies 3. Changes in ventilator settings |
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ABG testing is Contraindicated by:
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1. Anticoagulant therapy
2. Clotting disorder 3. Symptomatic peripheral vascular disease 4. Neg. Allen Test- measure collateral circulation in radial artery |
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• Impaired circulation signs:
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1. Numbness
2. Bluish color 3. Absence of peripheral pulse |
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• Skin punctures when there are poor veins
• Commonly used for blood-glucose analysis |
Capillary puncture
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Capillary puncture sites
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1. Heel-(neonates & infants)
2. Fingertip- palmar tip for children & adults 3. Earlobe-shock or edema in extremities |
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used to collect specimen from a client w/ an indwelling catheter. (drainage bag grow bacteria)
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Closed drainage system-
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RBC count
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4 million – 6 million
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Hemoglobin Count
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12 - 16 (times 3, usual reading of HCT)
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Hemocrit count
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36-48
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WBC count
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5,000-10,000
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platelet count
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150,000 - 450,000
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erythrocytes
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red blood cells
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red blood cells function to...
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Transporting oxygen carrying hemoglobin
transportingCO2 in form of sodium bicarbonate being an acid-base buffer for whole blood |
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decreased RBC count
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anemia, hypothyroidism, leukemia
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increased RBCs
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dehydration, hypoxia, polycyhemia
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increased hemoglobin
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COPD, polycythemia, high altitudes, burns, shock
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decreased hemocrit
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leukemia, hemorrhage
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increased hemocrit
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dehydration, polycythemia
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decreased hemoglobin
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anemia, severe hemorrhage
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are the most numerous circulating WBC. They respond more rapidly to the inflammatory & tissue injury sites than other types of WBC. During an acute infection, the body’s first line of defense
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neutrophils
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increases in viral infections; increases with chronic lymphocytic leukemia
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Lymphocytes
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increased with chronic inflammatory diseases
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monocytes
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increases with allergies, parasites (worms, wheezes and other diseases)
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Eosinophils
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mainly functions as body’s immune system
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plasma & Lymphocytes
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is a plasma protein, found in liver that requires vitamin K for synthesis
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Prothrombin (factor II
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is the most frequently requested laboratory coagulation measurement; used routinely to monitor therapy with the anticoagulant warfarin (coumarin); assesses extrinsic pathway of coagulation, particularly fibrinogen (factor I) and prothrombin (factor II); some drugs and foods either increase of decrease the PT.
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Prothrombin time
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used to monitor therapy with anticoagulant heparin; assesses intrinsic pathway of coagulation; hemophilia is an intrinsic deficiency
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Partial thromboplastin time (PTT)
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is a disease in which your body produces abnormally shaped red blood cells; sickle cells don't last as long as normal, round red blood cells, which leads to anemia. The sickle cells also get stuck in blood vessels, blocking blood flow. This can cause pain and organ damage.
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SICKLE CELL ANEMIA
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The 2-hour postprandial blood sugar is drawn 2 hrs after the pt eats a meal. Normal result is
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less than 120 mg/dl.
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needed to transport glucose into cells
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Insulin
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normal glucose results
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normal fasting= 70 to 115 mg/dl & less than 120 postprandial
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major cholesterol carrier in the blood
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LDL (low-density lipoproteins
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carries cholesterol away from the arteries and back to the liver where it is removed from the blood
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HDL (high-density lipoproteins
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Chemical form in most fat in foods & insoluble in water
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Triglycerides
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Nurses should prepare for lipid testing by teaching client to:
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1. Eat regular diet for 3 -7 days before test
2. No vigorous exercise for 24 before test 3. No caffeine 24 hrs before test 4. May have to withhold meds. 24 hrs. 5. Be aware that repeated test may be done to tell elevation |
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A microorganism smaller than a bacteria, which cannot grow or reproduce apart from a living cell (influenza)
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Viruses
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can live on the skin. They can live on the dead tissues of the hair, nails, and outer skin layers
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Fungi
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Parasites are living things that use other living things - like your body - for food and a place to live.
You can get them from contaminated food or water, a bug bite, or sexual contact |
protozoa
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the degree of pathogenicity (ability of a microorganism to reproduce) of an infectious microorganism (pathogen
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Virulence
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Invasion and multiplication of microorganisms without infection
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Colonization
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Microorganisms that are always present, usually without altering pt’s health
Handwashing with soap and water alone is not sufficient to remove Example: staphylococci To remove, need friction (most essential element of handwashing |
Resident flora
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Attach for a brief time
Do not continually live on the skin Example: E. Coli Hand washing with soap and water is effective in removing transient |
Transient flora
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direct physical transfer from infected person to host (ie. STD)
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Contact
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a susceptible host contacts droplet nuclei or dust particles suspended in the air (influenza
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Air-born
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Protein molecule having a configuration that allows it to combine with a specific antigen resulting in agglutination, precipitation, neutralization or increased susceptibility to phagocytosis.
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Antibodies
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an agent is transferred to a susceptible host by animate means such as mosquitoes, fleas, ticks, lice, and other animals
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Vectorborne
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an agent is transferred to a susceptible host by contaminated inanimate objects (water food, milk)
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Vehicle
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Purpose of immune response
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to neutralize or destroy antigens
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The first interaction between an antigen and antibody
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primary immune response
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antibody-antigen reaction due to release of histamine from injured cells.
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Allergic Reaction
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stage in inflammation process in which there is a release of histamine, bradykinin, serotonin and Lymphokins
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stage 1
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stage in inflammation process in which there is (erythema) redness due to ↑ blood flow into area
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stage 2
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stage in inflammation process in which there is an ↑ capillary permeability w/ leakage of plasma out of capillaries into the damaged tissue.
• Tissue space & lymphatic are blocked by fibrogen clots |
stage 3
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stage in inflammation process in which there is Damaged tissue infiltrated by leukocytes which engulf bacteria & necrotic tissue. They eventually die and form a cavity of necrotic tissue & dead leukocytes, mainly neutrophils & macrophages.
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stage 4
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stage in inflammation process in which Destroyed tissue cells are replaced w/ identical o similar structural & functional cells or scar tissue.
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stage 5
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stage in inflammation process in which Activates inflammatory process
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stage 1
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stage in inflammation process in which Produces redness & warmth
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stage 2
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stage in inflammation process in which Initiates the inflammatory process;
Infection is walled off & nonpitting edema occurs |
stage 3
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stage in inflammation process in which Produces purulent exudates
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stage 4
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stage in inflammation process in which Promotes tissue healing or the formation of scar tissue
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stage 5
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Limited to a defined area or single organ
Symptoms include pain and tenderness, redness, warmth, and swelling, purulent drainage |
localized infection
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Affects entire body and involves multiple organs
Symptoms include malaise, anorexia, nausea & vomiting, fever, increased pulse and respirations, increased WBC, lymph node enlargement |
systemic infection
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interval between entrance of pathogen into body and appearance of first symptoms
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Incubation period
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interval from onset of nonspecific s/s (fatigue) to more specific S&S; during this phase, microorganisms multiply, spreading disease more likely
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Prodromal stage
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interval when pt manifests S&S specific to type of infection (febrile, WBCs, jaundice)
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Illness stage
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acute symptoms disappear, pt returns to the previous state of health
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Convalescence
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antigenic preparation or gram-positive exotoxin that is detoxified with chemicals or heat
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toxoids
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Laboratory indicators for an infection:
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• ↑ Leukocytes (white blood cells)…WBCs
• ↑Neutrophils: in acute, severe inflammation • ↑ Lymphocytes: chronic bacterial/viral infections • ↑ Monocytes: some protozoan, rickettsial infections and tuberculosis • ↑ Eosinophils & basophils: unaltered in an infectious process • ↑ Erythrocyte sedimentation rate (ESR): presence of inflammation |
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• Reduces number, growth, and spread of microorganisms
• Clean technique • Hand hygiene |
medical asepsis:
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The passage of a drug from site of administration into the bloodstream
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Absorption
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The movement of drugs from the blood into various body fluids and tissues.
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distribution
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Physical & chemical processing of the drug
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metabolism
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Process in which drugs are eliminated from body
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excretion
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Precise description of drug’s composition (chemical formula)
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Chemical name
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Given by the U.S. Adopted Names Council to the manufactures who 1st made the drug.
• Official name is given to this drug when the drug is approved |
Generic name (nonproprietary)
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• Given by pharmaceutical companies when marketing the drug
• One generic drug may have several trade name based on the number of companies marketing the drug. |
Trade or brand name (proprietary
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what is Half-life
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The time it takes the body to eliminate half of the blood concentration levels of the original dose (50% of original dose is still present in blood other 50% is gone)
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Time it takes body to respond to drug
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Onset of action
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what is Peak plasma level
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Highest blood concentration of a single dose
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What is Trough
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Lowest blood concentration of a drug
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When is trough measured?
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Measured immediately before next scheduled dose
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Time drug remains in the system great enough to have a therapeutic effect
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Duration
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Maintenance of certain levels
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Plateau
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Preparation
Safest and most convenient Slower to absorb than others and route: |
Oral
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Preparation and route:
used when small amount of med is needed Acts quickly b/c oral mucosa is very vascular |
Buccal
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Hydrocortisone eardrops are contraindicated in clients
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w/ fungal or viral infection as herpes.
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When giving Vaginal meds you should instruct client;
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Discharge may smell
Wear a pad Not to use tampon Suppositories should be held for 15 min in Sims position |
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Delivery through gastrointestinal tube
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Enteral
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Mild
Predictable nontherapeutic |
Side effects
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Unexpected
potentially hazardous |
Adverse effects
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Person develop antibodies against drug
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Drug allergy (hypersensitivity)
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One is accustomed to a specific drug that a larger dose is needed (Cancer patients)
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Drug tolerance
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When body can’t metabolize a drug, causing the drug to build up in blood
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Toxic Effect
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Highly unpredictable response that may be manipulated by overresponse, or atypical response.
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Idiosyncratic reaction
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Single dose of med to be given immediately
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Stat orders
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Either one time meds, or may need drops or tabs over short period of time
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Single-dose orders
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Given routinely until order is cancelled
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Standing orders
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System of Weight and Measure
based on units of 10 |
Metric system
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System of Weight and Measure
Basic units of weight is grain (gr.) Expressed in fraction (1/4) |
Apothecary system
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System of Weight and Measure
Units of liquid measurement is drops (gtts) |
Household system
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is tsp, tbsp, cup, & glass
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Household system
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Pediatric dosages are based on
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weight, age, & body surface area
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System of packaging & labeling each dose of meds by pharmacy often to supply within 24 hrs.
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Unit dose form
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Dispensed in large quantities
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Stock supplied drugs
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Physiological or psychological dependence on a substance or behavior
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Addiction
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The delivery of oxygen to the body’s cells is a process that depends upon the interplay of the following systems:
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Oxygenation
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Movement of air into (inhalation) and out (exhalation) of lungs to deliver fresh air to the alveoli
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Ventilation
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An increase in CO2 in the blood or decrease in ph in body fluids will
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stimulate faster and deeper ventilation.
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Once fresh air reaches the lung’s alveoli, oxygen uptake takes place (the exchange of oxygen from the alveolar space into the pulmonary capillary blood.)
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Alveolar Gas Exchange
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oxygen dissolved in plasma is partial pressure.
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(PaO2)-
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Normal PaO2 in blood
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is 80 to 100 mmHg
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oxygen bound to hemoglobin
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SaO2
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Normal SaO2 in blood
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96%to 98%
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the process of chamber filling
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Diastole
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Occurs as the right and left atria relax and blood flows into both atria chambers from venae cavac & pulmonary veins.
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Diastole
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process of chamber emptying.
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Systole
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Represents pathologies that impair the ability of the chest wall and lungs to expand during the inspiratory stage of ventilation.
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Restrictive Pulmonary Disease
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Caused by:
1) pneumonia 2) Pulmonary scarring. 3) Traumatic injury to thorax |
Restrictive Pulmonary Disease
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Occurs when airways become partially or completely blocked, while trapping stale air that should be exhaled.
Impaired exhalation & air trapping |
Obstructive Pulmonary Disease
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Most common:
• Asthma • Emphysema • Chronis bronchitis |
Obstructive Pulmonary Disease
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alveolar collapse
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Atelectasis
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Causes of Atelectasis
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Tumor
Occlusion of the small airways by secretions Failure of a client to breathe deeply after abdominal surgery. |
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This is an infection in the lung caused by bacteria or viruses or by swallowing your food "the wrong way".
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Pneumonia
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o you will have pus in your lungs, just as you would if a skin wound was infected
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Pneumonia
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Collection of fluid b/t the pleural layers. May consist of serous fluid (hydrothorax), purulent fluid (emphysema), or chyle (chylothorax).
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Pleural Effusion
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Collection of blood b/t pleural layers. (increase in B/P)
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Hemothorax
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A collections of air b/t the pleural layers caused by a hole in one or both layers of membrane. May be open (communicating w/ chest wall) or closed (no exterior wound)
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Pneumothorax
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A decrease in the efficiency of gas diffusion from alveolar space into the pulmonary capillary blood
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Diffusion Defects
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May be caused by:
Thickening of alveolar-capillary basement membrane o Marked increase in the speed of the blood flow thru capillary beds, which reduce contact time w/ alveoli. Are uncommon, but can coexist w/ emphysema, pulmonary edema, etc |
Diffusion Defects
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The amount of fresh air entering the alveoli (alveolar ventilation) and the amount of blood flow to regions of the pulmonary network are not uniformed throughout the lungs.
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Diffusion Defects
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areas may be well ventilated, but poorly perfused
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deadspace
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areas are well perfused, but poorly ventilated
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shunting
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Generalized decreases in pulmonary circulation may cause.....
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right-sided heart failure or pulmonary hypertension, or pulmonary artery sclerosis.
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Regional decreases in pulmonary circulation may be related
|
to blockage of pulmonary artery by embolus or regional vasoconstriction.
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Characterized by narrowing and eventual occlusion of the lumen (opening to arteries) by deposits of lipids, fibrin, and calcium.
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Atherosclerosis
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deprivation of blood flow
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Ischemia
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death of a tissue
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Infarction
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Typically accompanied w/ a back up in the blood in the venous circuit (pulmonary and systemic veins
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heart failure
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decreased hemoglobin causes a decrease in the oxygen-carrying capacity in the blood
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Anemia
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mimics anemia b/c it reduces oxygenation by competing with oxygen for binding sites w/ the hemoglobin.
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Carbon monoxide poisoning
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........impairs mitochondrial functioning, render the oxygen in the arterial blood useless to cells.
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Cyanide poisoning and severe sepsis
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a natural by product of glucose metabolism
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Carbon dioxide
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Signs of hypoxia
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Regular or irregular
Restlessness Apprehension Anxiety Dizziness Confusion Agitation ↑ pulse rate ↑ respiration rate & depth ↑ blood pressure (unless hypoxia is caused by shock) |
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Flattened angle of the nail bed and a rounding of the fingertips may
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Clubbing of fingers
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Clubbing of fingers may indicate
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chronic hypoxia.
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Mucoid sputum
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Tracheobronchitis, asthma
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Decreased cardiac output findings
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Low B/P
Cool clammy skin Weak thread pulse Low urine output Diminished level of consciousness |
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pain caused by myocardial ischemia
Defined as crushing or squeezing |
Angina pectoris
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ischemia to the extremities usually brought on by exercise and relieved by rest.
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Intermittent claudication
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Provide shape and form to cells
o Regulate body temperature |
water
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Important regulator of ECF volume & osmolarity
Influences acid-base balance Controls H20 distribution between ECF and ICF Key component in transmission of nerve and muscle impulses |
Na+
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Salt, cheese, processed foods, ham bacon shellfish
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Na+
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results in decreased serum osmolarity
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Hyponatremia
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Cognition & Sensory (headaches, lethargy, confusion, depression) Monitor LOC, institute safety measures
Muscle Weakness Assist with ROM Nutrition & metabolism (nausea, vomiting, diarrhea, abd cramps) Monitor intake of Na and water Skin & mucous membranes (dry and pale) Administer IVF Oxygenation and ECG (tachycardia and hypotension) Monitor hourly vital signs, and I & O |
Hyponatremia
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This causes fluid to move out of cells
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Hypernatremia
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Cognition & Sensory (Restless, agitated, twitching, →coma) Monitor LOC, institute safety measures
Activity/mobility ( muscle tone, hyperreflexia) Maintain body alignment & asst w/ movement Nutrition & metabolism (nausea, vomiting, anorexia) Monitor oral fluids or a hypotonic solution Skin & mucous membranes (flushed, dry skin) Administer oral hygiene Oxygenation and ECG (tachycardia) Monitor hourly vital signs, and I & O |
Hypernatremia
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Regulates ICF osmolarity
Promotes transmission of nerve impulses & muscles Promotes enzymatic action for (carbs to energy; amino acids to proteins) Regulates acid-base through exchanges of hydrogen ions |
Potassium (K+)
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Fruits, especially bananas, oranges, dried fruits; vegetables, meats, nuts
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Potassium (K+)
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amount of Potassium (K+)
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3.5-5
meq/L 150-155 |
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Nutrition & metabolism (↓bowel sounds, abd distention, N&V) Admin K replacement, as ordered; never bolus IV K, dilute in IV fluids
Muscle Weakness & ↓reflexia Protect from injury Cognitive and sensory malaise, confusion, coma Monitor pt’s level of consciousness Elimination constipation & polyuria Monitor I&O Resp & ECG ↓breath sounds, ↓ cardia, ↓tension, arrhythmias Monitor hourly VS; monitor Heart R & R |
hypokalemia
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Nutrition & metabolism (abd cramps, nausea & diarrhea) Restrict K intake; Kayexalate; IV glucose & insulin move K into cells
Muscle Weakness, cramps & pain Assess for pain and provide comfort measures Elimination oliguria and anuria Monitor I&O Oxygenation and ECG bradycardia, can cause cardiac arrest Monitor hourly vital signs; ECG changes; draw blood away from IV infusion |
Hyperkalemia
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Promotes transmission of nerve impulses.
Provides strong teeth & bones. Essential for blood clotting Promotes absorption of vitamin B |
Calcium (Ca2+)
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Milk, cheese, yogurt, sardines, whole grains and green leafy vegetables
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Calcium (Ca2+)
|
|
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amount of calcium
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4.5-5.5
mEq/L |
|
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(anxiety, irritability, tingling & numbness of fingers) Abd & muscle cramps; + Trousseau’s; + Chvostek’s Admin IV calcium; teach a diet high in calcium with vitamin D supplement
Oxygenation and ECG changes ↓Calcium results in ↓phosphate |
Hypocalcaemia
|
|
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Tap the facial nerve 2 cm anterior to the earlobe, unilateral twitching of facial muscles indicates a positive response
|
Chvostek’s sign:
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|
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Cognitive & sensory (depression and lethargy) Monitor pt’s state of sensorium for safety
Activity and Mobility ↓ muscle tone and deep tendon reflexes osteoporosis, osteomalacia Encourage pt movement and exercise; asst pt w/ movement to ↓ pain Oxygenation and ECG; heart block, arrest Monitor vital signs; ECG changes Flank pain from calculi, polyuria ↓calcium salts Nutrition & Metabolism N&V, anorexia, constipation Teach pt to ↓calcium and increase fiber |
Hypercalcemia
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molecules move from greater concentration to lesser concentration
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Diffusion
|
|
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• Controls the carbon dioxide in extracellular fluid
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Respiratory regulation (several minutes)
|
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Hypoventilation: COPD (chronic obstructive lung disease), lung edema, brainstem injury
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Respiratory acidosis:
|
|
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Hyperventilation: high altitude, anxiety
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Respiratory alkalosis:
|
|
|
– Excessive bicarbonate, excessive vomiting
|
Metabolic alkalosis:
|
|
|
• Insufficient metabolism of carbohydrates, high intake of fat, excessive ASA, severe diarrhea (lose pancreatic & intestinal secretion which tend to be alkaline)
|
Metabolic acidosis
|
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water-soluble vitamins
|
B-complex & C
|
|
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increased pulse rate w/ weak pulse volume
|
• FVD (fluid volume deficit
|
|
|
increased pulse volume & 3rd heart sound
|
FVE
|
|
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fat soluble VITAMINS
|
A,D, E, K
|
|
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catabolism exceed anabolism
|
negative nitrogen balance
|
|
|
vitamin neede for blood clotting
|
vitamin K
|
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|
vitamin act as antioxidant
|
vitamin e
|
|
|
vitamin needed to absorb calcium; sunlight
|
vitamin D
|
|
|
vitamin needed for bone growth, vision, skin
|
vitamin A
|
|
|
vitamin antioxidant; needed for wound healing
|
vitamin c
|
|
|
well localized, burning sensation
|
cutaneuos pain
|
|
|
well localized "burning" or "prickling" sensation
|
cutaneous pain
|
|
|
nonlocalized pain and originates in areas such as tendons, ligaments, or nerves
|
somatic pain
|
|
|
deep pain
|
somatic pain
|
|
|
discomfort in organs and less localized than somatic pain
|
visceral pain
|
|
|
pain felt in an area of an organ, but not a specific organ
|
reffered pain
|
|
|
the changing of noxious stimuli in sensory nerve endings to energy impulses
|
transduction
|
|
|
movement of impulses from site of origin to the brain
|
transmission
|
|
|
developing conscious awareness of pain
|
perception
|
|
|
the changing of pain impulses
|
modulation
|
|
|
somatic & visceral pain
|
nociceptic pain
|
|
|
phantom pain, spine injury
|
neuropathic pain
|
|
|
pain occuring when blood supply of an area is restricted
|
ischemia pain
|
|
|
based on a premise that pain impulses travel thru either a small-diameter or large diameter nerve cell
|
gate control theory
|
|
|
• Useful in treating mild to moderate pain
• Relieves pain by acting on peripheral nerve endings to the injury site to decrease inflammation ceiling effect |
Nonopioid Analgesics
|
|
|
• Useful in treating moderate to severe pain
• Relieves pain by acting on several sites in the central nervous system (CNS) |
Opioid Analgesics (narcotics)
|
|
|
• Advantages: multiple drug choices, sedative and anxiolytic properties useful in some acute treatment settings; some are inexpensive; long-acting controlled-release forms are available
• Disadvantages: Regulated by prescriptions; stigma and fear are associated with use; many side effects. |
Opioid Analgesics (narcotics):
|
|
|
drugs that were developed for use other than pain, but have been found to enhance the effects of analgesics.
|
Adjuvant Analgesics:
|
|
|
Class of adjuvant drugs
|
Antidepressants: Tricyclics and serotonin, reuptake inhibitors
Anti-epileptic drugs Anxiolytic drugs Steroids |
|
|
Provides continuous, mild electric current via electrodes placed on the skin near a painful site
|
Transcutaneous electrical nerve stimulation (TENS)
|
|
|
sleep in which there is rapid eye movement
|
REM
|
|
|
What is the sleep cycle
|
the 4 stages of NREM, with a return to stage 3, then 2, then into first stage of REM
|
|
|
somnabulism
|
sleepwalking, sleeptalking
|
|
|
wounds with extensive tissue loss and wounds in which the edges cannot be proximated
|
secondary intention healing
|
|
|
suturing is delayed until problems resolve
|
tetiary intention healing
|
|
|
exudate of clear water texture
|
serous exudate
|
|
|
maintainance of red wounds (normal)
|
must be protected and kept moist and clean
|
|
|
maintainace of yellow wounds
(bacteria in wound) |
cleaned of prudent exudate
|
|
|
maintanance of black wounds
(eschar) |
debridement
|
|
|
stage of pressure ulcer:
nonblanchable erythema of intact skin |
stage 1
|
|
|
stage of pressure ulcer:
partial thickness of skin is lost involving epidermis or dermis |
Stage 2
|
|
|
stage of pressure ulcer:
full thickness of skin with damage to the bone. |
stage 4
|
|
|
stage of pressure ulcer:
skin loss involving subcutanous tissue |
stage 3
|
|
|
one main cause of hypokalemia
|
crash diets
|
|
|
stage of sleep with slightly slowed heart and respiration rate
|
NREM
|
