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204 Cards in this Set
- Front
- Back
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What are the two main concepts of oxygenation? |
Respiration and ventilation |
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What is ventilation? |
Movement of air into and out of the lungs. |
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What is respiration? |
The exchange of oxygen and carbon dioxide. Takes place in the alveolar capillary and capillary cell membrane. |
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What does oxygenation of the blood, organs and tissue depend on? |
Adequate ventilation |
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What is a surfactant? |
An agent than can reduce the surface tension of a liquid, such as soap. |
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Why are babies born before 33 weeks in particularly vulnerable? |
They lack the surfactant needed for their lungs. They are at higher risk for Respiratory Distress Syndrome. They do not develop surfactant until they are approximately 33 weeks gestation. |
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What is RDS? |
Respiratory Distress Syndrome - collapse of an infant's lungs due to insufficient surfactant. |
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What factors affect ventilation? |
- Respiratory rate - respiratory depth - hyperventilation - hypoventilation - hypoxia - hypoxemia - lung compliance - lung elasticity - airway resistance - rhythm |
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What is the respiratory rate? What is normal? |
How fast you breathe. 12-20 breaths per minute is normal. |
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What is the respiratory depth? |
How much the lungs expand to take in air |
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What is hyperventilation? |
Breathing too fast. Too much CO2 is taken in and cannot be removed by the alveoli. Can be caused by anxiety and stress. |
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What is hypoventilation? |
Decreased rate or shallow breathing. Can be caused by narcotics. |
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What is hypoxemia? |
Oxygen deficiency in the blood. Can become hypoxia. |
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What is lung compliance? |
Ease of lung inflation. |
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What is lung elasticity? |
Lungs to recoil with ease. |
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What is airway resistance? |
Resistance to airflow in the airways (can be caused by tumor or asthma). |
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What kinds of respiration are there? |
Two - internal - external |
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What is internal respiration? |
Occurs in the body organs and tissues when O2 and CO2 are exchanged between capillaries and tissue. |
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What is external respiration? |
Occurs at the alveolar capillary membrane where O2 and CO2 are exchanged by diffusion. |
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Where does the voluntary control of breathing come from? |
The motor cortex which can temporarily override the respiratory centers. |
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What controls involuntary breathing? |
The respiratory centers in the brain stem. If there is a brain injury, breathing can be affected. |
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What are the factors that can influence pulmonary function? |
- lifespan and development (RDS) - environment (air quality) - lifestyle (smoking, nutrition, exercise) - medications (opiates can depress respiration) - pathology (allergies, infections) - abnormalities (trauma) |
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What is eupnoea? |
Free easy normal resting breathing (12 - 20 breaths/ min for an adult) |
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What is tachypnea? |
Rapid breathing - more than 24 breaths/min. |
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What is Bradypnea? |
Slow breathing - less than 10 breaths/ min |
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What is apnea? |
Absence of breath - stopping as in sleep apnea |
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What is kussmaul? |
Deep breathing, labored breathing associated with severe metabolic acidosis like diabetic ketoacidosis (hyperventilation) |
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What is Biot's breathing? |
Irregular, shallow breathing with periods of apnea. |
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What is Cheyne - Stokes breathing pattern? |
A gradual increase of respirations than apnea. A cycle that runs from 30 seconds to 2 minutes. (The respirations gradually increase to hyperventilation, reducing the CO2, which causes apnea - the apnea then causes a drop in CO2, which then causes hyperventilation) |
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What is displayed by someone making a respiratory effort? |
- Nasal Flaring - Retractions (visibly pulling in - using the body to breathe) - Using accessory muscles to breathe (like the neck and abdominal muscles) - Grunting (making noises while breathing) - Body position like orthopnea - Paroxysmal Nocturnal Dyspnea - waking from sleep due to shortness of breath - Conversational Dyspnea - stopping talking to breathe - Stridor - high pitched, harsh crowing inspiratory sound that can be heard without a stethoscope, cause is in the larynx/ trachea area - Wheezing - high squeak on inspiration or expiration (more in the lungs)
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Assess a cough accompanied by nasal congestion, sneezing, watery eyes, and nose drainage. How do you treat? |
It's an allergy. Treat with OTC allergy meds |
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Assess a cough accompanied by fever, chest congestion and sputum. How do you treat? |
It's an upper respiratory infection. Treat with antibiotics. |
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Assess a cough accompanied by dyspnea, chest tightness & wheezing. How do you treat? |
May be an airway obstruction like asthma. Treat with corticosteroids and bronchodilators. |
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What is a productive cough? |
One that raises sputum (mucus or debris) up from the airways. |
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What are the 7 different colors of sputum and what do they mean? |
- white/ clear means a virus or common cold - yellow or green means infection - black is coal, dust or soot - rust colored mean pneumonia - hemoptysis (coughing up blood) could mean cancer - pink and frothy means pulmonary edema - foul-smelling means bacterial infection like pneumonia or lung abscess. |
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Describe sputum with regard to amount and timing. |
- Sputum can vary from a teaspoon to a pint. - increases with the severity of the underlying condition - limited sputum does not mean minor problem - a smoker may cough more in the morning - a person with URI may cough all day |
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With regards to oxygenation status, what does diagnostic testing tell us? |
Sputum sample, TB test or allergy test, may reveal the cause of the impaired O2 level. Spirometry, Arterial Blood Gases (ABG), peak flow monitoring and pulse oximetry may tell us how severe the impaired O2 levels are. |
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What does a peak flow monitor measure? |
A patient with asthma uses a peak flow monitor to monitor the peak expiratory flow rate (PEFR) - the output of the lungs. |
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How is an O2 saturation monitor used? |
It is placed on the finger. Check to make sure there is proper circulation in the location to be used (check pulse on the arm of that finger) |
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What are alternative (to the finger) locations to place a sensor of an O2 saturation monitor? |
Toe, earlobe and bridge of nose (uses different kinds of sensors) |
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What diagnostic test would best be used to measure a clients level of hypoxemia? A. Chest X-ray B. Pulse Oximeter reading C. ABG D. Peak expiratory flow rate |
C. Arterial Blood Gases is the most direct way in which the level of oxygen in the blood can be measured |
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The term "Kussmaul" refers to a high pitched, harsh, crowing expiratory sound that occurs due to an obstruction of the larynx. A. True B. False |
B. False. Stridor is the term for the high pitched, harsh, crowing expiratory sound. |
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What are the nursing interventions for optimal oxygenation? |
- promoting respiratory function - mobilizing secretions - oxygen therapy - use of a mechanical ventilator - use of chest tube drainage systems - administering respiratory meds |
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What are the ways for promoting respiratory function? |
- immunizations (preventing URI's by getting pneumonia & flu shots) - positioning in bed - high Fowler's - incentive spirometry - aspiration precautions - TB screening - teach method of preventing respiratory infections - correct positioning and suctioning - O2 therapy, artificial airways if needed |
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What are the ways to mobilize secretions? |
- deep breathing and coughing - hydration - chest physiotherapy (clapping patient's back to help move the sputum out) |
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What are the ways to deliver oxygen therapy? |
- Nasal Cannula - Mask - Face tents - Trans-tracheal catheter - Venturi Mask - Non-rebreathing mask |
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Safety teaching to a mother of a toddler you would include in your teaching regarding high risk for the following factors that influence oxygenation. Select all that apply. A. Frequent serious respiratory infections B. Airway obstruction from aspiration of small objects C. Drowning in small amounts of water around the home |
B. airway obstruction on small objects C. drowning in small amounts of water |
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The nurse gives IV morphine to a patient for pain control. What is the priority to monitor after giving this medication? A. Decrease heart rate B. Muscle Weakness C. Decreased urine output D. Respiratory Depression |
D. Respiratory Depression |
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Chose all the factors that influence normal lung volumes? Choose all. A. Age B. Race C. Body size D. Activity level |
A. Age D. Activity level |
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A patient has a massive head injury. During assessment the nurse notices the patient respirations following a cycle of progressively increased depth, then progressively decreased depth, followed by a period of apnea. What respiratory pattern is this? |
Cheyne-Stokes respiration |
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What patient would it be appropriate to give chest PT to? A. Congestive heart failure B. pulmonary edema C. pneumonia D. pulmonary embolus |
C. pneumonia - chest PT is the treatments generally performed by physical therapist and respiratory therapists whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient. |
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What is chest physiotherapy? |
Includes: 1. postural drainage (patient's position) 2. chest percussion (done with cupped hands) 3. Chest vibrations (like the vibrating vest) |
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What is a good physical position for someone having trouble breathing? Why? |
Tripod position. Sitting up and leaning over a table or arms braced against the legs. Allows the abdominal organs to sit low with gravity. |
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What kind of person does better with a face mask for delivering oxygen? |
A mouth breather. |
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What does a non-rebreather mask do? |
Allows for higher concentrations of oxygen to be delivered to the patient as opposed to a regular face mask. |
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What is used in conjunction with oxygen cannula or face masks? |
A humidifier to prevent drying. |
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What is an oropharyngeal airway? |
A C-shaped tube inserted into the mouth and into the pharynx of an unconscious patient that cannot maintain an airway. |
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What is a nasopharyngeal airway? |
A flexible rubber tube that is inserted into the nose and down to the pharynx of a semi-conscious patient that cannot maintain an airway. |
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When performing a trachea dressing change, what is necessary? Why? |
A trachea dressing kit because you cannot cut a normal bandage gauze because pieces of the gauze may get into the airway. |
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If you're suctioning a trachea (or any other patient), what is important to remember? |
To hold down the suction valve and not to suction until fully in or pulling out. Only suction during withdrawal!! |
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When suctioning a patient, what needs to be done before, after and possibly during the procedure? |
Hyper oxygenate! When suctioning, the patient cannot breathe! Give a few extra breaths with the ambu before and after suctioning. Also give a minute between suctioning with a 3-cycle. |
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What are some clear signs that a patient needs suction? |
- gurgling sounds during breathing - restlessness - labored breathing - decreased O2 saturation - increased heart rate - when auscultating the lungs, they sound "junky" |
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What does a chest tube do? |
Removes air or fluid from the pleural space so lungs can fully expand. |
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What is a pleural vac system? |
A three chamber system that chest tubes are attached to drain the fluid from the pleural space. |
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What are the three chambers that make up the pleural vac system? |
1. A suction control chamber 2. water seal chamber 3. drainage collection chamber |
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Describe the 1st chamber of the pleural vac system. |
- It should bubble, but not vigorously. - it should be filled with 20ml of water (there is a line) - it should always be bubbling and if not, it should be checked to see if it's on, if it's connected to wall or possibly standing on the tube. |
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Describe the 2nd chamber of the pleural vac system. |
The water seal chamber should not bubble, but it tidal and should go up and down with the patient's breathing. If it is not, check the patient then check if there is a kink. |
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Describe the 3rd chamber of the pleural vac system. |
The drainage collection chamber collects all the drainage from the pleural space. If over 100 cc/hr is collected then it is significant. |
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What kind of dressing should be used with a chest tube and why? |
A petroleum jelly dressing to prevent air leaking from around the site. |
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In caring for a patient with a tracheostomy, the nurse would give priority to the nursing diagnosis of A. Risk for ineffective airway clearance B. Anxiety related suctioning C. Social Isolation related to altered body image D. Impaired tissue integrity |
A. Maintaining a patent airway by tending to excessive secretions is the priority. |
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What is the primary body fluid? |
Water and solutes (electrolytes and non-electrolytes) |
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What does water content of the human body vary with? |
- age - sex - adipose tissue (obese people have less body fluid than leaner people) |
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What does body fluid consist of? |
- water - electrolytes - nonelectrolytes |
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What are electrolytes? Give examples. |
Solutes that develop an electric charge when dissolved in water. Potassium and sodium are examples. |
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What are nonelectrolytes? Give examples. |
Solutes that do not develop an electric charge when dissolved in water. Glucose and urea are examples. |
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What is the difference between intracellular and extracellular fluid? |
Intracellular fluid is inside the cells and accounts for about 40% of bodily fluid. Extracellular fluid is outside the cells and accounts for about 20% of bodily fluid, like interstitial, intravascular and trans-cellular. |
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What is the function of bodily fluid? |
To carry water, nutrients, and oxygen to cells and remove waste. |
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What is interstitial fluid? |
It is in the space between the cells. It is the fluid that makes up edema - excess interstitial fluid. |
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What is intravascular fluid? |
It is the plasma in the blood. |
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What is trans-cellular fluid? |
It is specialized fluid, like CSF, pleural fluid, peritoneal fluid, digestive juices and synovial fluid. |
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What are the body fluid compartments? |
- intracellular - extracellular - third spacing |
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What is third spacing? |
Occurs when body fluids move from one space to another in which it is no longer available to the body. An example is when fluid fills a blister, pleural effusion or pericardial effusion. |
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What does intracellular fluid consist of? |
- magnesium - potassium - phosphate |
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What does extracellular fluid consist of? |
- sodium - chloride - bicarbonate - albumin - a protein |
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What happens if an electrolyte finds it's way into a bodily fluid that it does not normally occupy, or their concentration is not within a physiologic range? |
Severe imbalances occur. |
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How do fluids and electrolytes move throughout the body? |
- osmosis - diffusion - filtration - active transport |
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What is osmosis? |
The movement of water through a semipermeable membrane from an area of higher concentration (of water) to an area of lower concentration (of water). Trying to equalize the solvent concentrations. |
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What is diffusion? |
Passive transport of solutes across a semipermeable membrane from an area of high concentration to an area of low concentration in an effort to equalize both sides. |
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What is filtration? |
Movement of both water and smaller particles from an area of high pressure to an area of low pressure. |
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What is active transport? |
Molecules that move from a lower concentration to a higher concentration. It requires ATP. |
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About how much of fluid intake comes from food? |
About 20% |
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What is fluid intake regulated by? |
Changes in plasma osmolality signal the thirst center in the hypothalamus and causes the urge to drink. |
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What is the thirst mechanism inhibited by? |
- high fluid intake - fluid retention - excessive IV fluid infusion of hypotonic solutions - low sodium intake |
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What is sensible fluid loss? |
Measurable and perceived, such as in urine or diarrhea. |
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What is insensible fluid loss? |
Immeasurable and not perceived such as evaporation from the skin and through respiration. Accounts for about 900mL /day. Increases with open wounds and burns. |
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What accounts for the greatest amount of fluid loss and what should it remain at? |
Urine should remain at least 30-50 mL/ hour |
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What is the principal regulator of fluid and electrolyte balance and how does it do it? |
The kidneys. With the use of hormones: - Antidiuretic hormone (ADH) - Renin-Angiotensin system - Aldosterone - Thyroid hormone - Brain naturetic factor |
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In a healthy adult, all of the following regulate body fluids. Select all that apply. 1. Hormone levels 2. Fluid intake 3. Oxygen saturation 4. Kidney Function |
1. Hormone levels 2. Fluid Intake 4. Kidney Function |
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What is hypovolemia? |
Loss of fluid and electrolytes from extracellular fluid. Causes low blood volume. |
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What causes dehydration? |
- too little intake - too much loss (bleeding, diarrhea, emesis, NG suction - fluid shifts (as leaking into tissues or loss at burns) |
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What are the signs of dehydration? |
- dry skin and mucus membranes - nonelastic skin turgor (pinch and skin stays up) - decreased urine output - hypotension - tachycardia - rise in temperature - weight loss - muscle weakness - fatigue |
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If a patient has hypovolemia and dehydration and fluid balance isn't restored, what will happen? |
Patient will enter hypovolemic shock with a rapid thready pulse and orthostatic hypotension |
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Describe weight loss and dehydration. |
Weight loss is sensitive indicator of fluid loss. A sudden 5% loss in body mass is clinically important. 8% loss is severe and a 15% is usually fatal. |
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Who is more at risk for dehydration? |
- older patients - children - individuals with conditions associated with fluid loss (emesis, diarrhea, etc.) |
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What is hypervolemia and what causes it? |
Too much sodium retention and water in the extracellular fluid. - too much sodium intake - disease of the kidney or liver - poor pumping efficiency of the heart |
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What are the signs of hypervolemia? |
- elevated BP - Pale, cool skin - edema, ascites (serous fluid in the peritoneal cavity) - crackles |
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How does a nurse prevent hypervolemia? |
- monitor input and output - careful with IV fluids |
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What are the major electrolytes? |
- sodium - potassium - calcium - magnesium - chloride - phosphate - bicarbonate |
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Describe sodium. |
- is the major positively charged electrolyte in the extracellular fluid (ECF) - it's primary function is to regulate body fluid - is reabsorbed (along with potassium) in the kidneys - healthy adults should limit intake to 2300mg/day and everyone else to 1400 mg/day - needs to be between 135 mEq/L and 145 mEq/L |
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Describe potassium. |
- is the major electrolyte in the intracellular fluid (ICF) - helps with muscle contraction and cardiac conduction - is eliminated in the kidneys - is a key electrolyte in cellular metabolism - should eat about 4700 mg/day but most adults eat about half - moderate deficiency is linked with increased BP, risk of bone turnover and kidney stones - needs to be between 3.5 mEq/L and 5 mEq/L |
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Describe calcium. |
- is required for bone health, neuromuscular function and blood clotting - 99% is found in bones and teeth - blood levels are closely monitored and when serum levels drop, is taken from the bones - insufficiency leads to osteoporosis - normal levels are between 8.5 and 10.5 mg/dL |
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When is calcium requirements at the highest? |
- during childhood - during adolescents - during pregnancy - during breastfeeding |
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Why are older adults at risk of calcium insufficiency? |
- there are changes in absorption as part of the aging process - chronic medical conditions |
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Describe magnesium. |
- 99% is in ICF and bone and 1% is in ECF - used in biochemical reactions in the body - low levels can be seen in patients with high alcohol intake |
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Describe chloride. |
- it is the most abundant anion (negatively charged) in ECF - is usually bound with other ions - is found in table salt |
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Describe phosphate. |
- is an anion found in ICF - mostly bound in with calcium in teeth and bones - has an inverse relationship with calcium (as calcium increases, phosphate decreases and as phosphate increases, calcium decreases) |
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Describe bicarbonate. |
- is found in both ICF and ECF - levels are regulated by the kidneys to help maintain acid/ base balance (if needed it is conserved, if too much it is excreted) |
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What is hyponatremia and what are the symptoms? |
- When sodium (Na+) is below 135 mEq/L - appetite loss - nausea - vomiting - weakness - lethargy - confusion - muscle cramps or twitching - seizures |
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What is hypernatremia and what are the symptoms? |
- When sodium (Na+) is above 145 mEq/L - thirst - increased temperature - dry mouth - sticky mucus membranes - when severe: hallucinations, irritability, lethargy and seizures |
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What is hypokalemia and what are the symptoms? |
- When potassium is below 3.5 mEq/L - fatigue - appetite loss - nausea - vomiting - muscle weakness - dysrhythmias - decreased GI motility - paresthesias (pins & needles feeling) - EKG changes (flat 'T' waves) |
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What is hyperkalemia and what are the symptoms? |
- When potassium is above 5 mEq/L - muscle weakness - dysrhythmias - flaccid paralysis (floppy but can't move) - EKG changes (peaked 'T' waves) |
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What causes hyponatremia? |
- diuretic use - GI fluid loss (diarrhea, emesis, suctioning) - too much free water |
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What causes hypernatremia? |
- too much sodium intake - water deprivation - increased water loss - hypertonic tube feed |
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What causes hypokalemia? |
- use of non-potassium sparing diuretics - GI fluid loss (vomiting or suctioning) - steroids - anorexia and bulimia |
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What causes hyperkalemia? |
- renal failure - potassium sparing diuretics - high potassium intake with renal insufficiency - acidosis - major trauma clotting in a blood sample, hemolysis, may cause a false hyperkalemia test result and must be redrawn |
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What is hypocalcemia and what are the symptoms? |
- calcium below 8.5 mg/dL - diarrhea - paresthesia (tingling in the extremities) - muscle cramps - tetany - cardiac irritability - positive trousseau's & chovostenk's signs (tetany of the masseter muscle and of the hand) |
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What causes hypocalcemia? |
- hyperparathoidism - poor absorption - alkalosis - vitamin D deficiency |
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What is hypercalcemia and what are the symptoms? |
- Calcium above 10.5 mg/dL - muscle weakness - constipation - kidney stones - bradycardia - bizarre behavior |
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What causes hypercalcemia? |
- hyperparathyroidism - bone cancer - excess supplementation - thiazide diuretics (they lower calcium excretion in the kidneys) |
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What is normal oxygen saturation? |
95%-100% (below 94% is considered abnormal in healthy people) |
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When inserting a catheter for suctioning, should the catheter be moistened and how? |
Yes, it should be moistened with normal sterile saline. |
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When inserting a catheter for suctioning, how far in should a nurse go? |
4 to 5 inches or until coughing or met with resistance. |
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What kind of technique is used for suctioning. |
Sterile technique |
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When are the only two times that a chest tube can be clamped? |
- when the collection chamber is full or broken - when it needs to be clamped to check for an air leak - clamp only with a rubber nose tip clamp |
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If a chest tube attached to a patient water seal chest drainage system disconnects, what should a nurse do? |
Place the disconnected end in a bottle of sterile water. It serves as a temporary water seal until a new system can be set up. |
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Name some foods high in potassium. |
- potatoes - fish - green leafy spinach - bananas - pistachios - beet greens |
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What is hypomagnesemia and what are the symptoms? |
- magnesium below 1.3 mEq/L - neuromuscular irritability - disorientation - mood changes - dysrhythmias |
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What causes hypomagnesemia? |
- chronic alcoholism - malabsorption - diabetic ketoacidosis - prolonged gastric suctioning |
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What is hypermagnesemia and what are the symptoms? |
- magnesium over 2.1 mEq/L - flushing warm skin - hypoactive reflexes - depressed respiration - hypotension |
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What causes hypermagnesemia? |
- renal failure - adrenal insufficiency - excess replacement |
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What is hypophosphatemia and what are the symptoms? |
- phosphate levels below .7 mEq/L - paresthesia - joint stiffness - seizures - cardiomyopathy - impaired tissue oxygenation |
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What causes hypophosphatemia? |
- refeeding after starvation - alcohol withdrawal - diabetic ketoacidosis - respiratory acidosis |
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What is hyperphosphatemia and what are the symptoms? |
- phosphate level over 2.6 mEq/L short term symptoms - tetany - paresthesia - cramping long term symptom - calcification of soft tissue |
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What are the causes of hyperphosphatemia? |
- renal failure - hyperthyroidism - chemo - excessive use of phosphate based laxatives |
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What is an acid? |
A compound that contains hydrogen ions (H+) that can be released. pH below 7 |
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What is a base? |
A compound that accepts free hydrogen ions (H+). pH above 7 (blood serum is slightly basic) |
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What is pH? |
The acid/ base balance of a solution |
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What is the acceptable pH range for blood? |
- 7.35 - 7.45 - below 7.3 or above 7.52 changes how enzymes work and causes the heart muscle to be irritable - below 6.9 or above 7.8 is usually fatal |
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What is pH measured by? |
Arterial Blood gases |
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What does an ABG test for? |
- blood is taken from an artery (as opposed from a vein like most blood tests) - tests for pH (normal is 7.35-7.45) - tests partial pressure of CO2, or PCO2 (normal is 35mmHg - 45 mmHg) - tests saturation of O2 (95-100 is normal) - tests bicarbonate levels HCO3 (normal is 22 to 26 mEq/L) |
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What is a respiratory cause of acidosis? |
Too slowed breathing (hypoventilation). Too much carbonic acid is made from too much carbon dioxide causing acidosis. |
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What is a metabolic cause of acidosis? |
Too much diarrhea. Loss of bicarbonate. (Ass-idosis) |
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What is a respiratory cause of alkalosis? |
Hyperventilation - not enough carbonic acid because not enough carbon dioxide. |
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What is a metabolic cause of alkalosis? |
Vomiting. Losing gastric acid, so an increase of bicarbonate. |
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What are the steps to reading ABGs? |
1. look at the pH 2. look to see if it's respiratory or metabolic |
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If checking ABGs and the PCO2 is normal but the HCO3 is off, is it respiratory or metabolic? |
Metabolic because it refers to the bicarbonate levels being off. |
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If checking ABGs and the PCO2 is off but the HCO3 is normal, is it respiratory or metabolic? |
Respiratory because it refers to the carbon dioxide levels being off. |
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pH of 7.25 PCO2 of 55 PO2 of 60 HCO3 of 25 What is wrong with this patient? |
pH of 7.25 is acidosis PCO2 of 55 is elevated HCO3 is normal Too much carbon dioxide means this patient has respiratory acidosis |
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pH of 7.55 PCO2 of 30 PO2 is 63 HCO3 is 22 What is wrong with this patient? |
pH of 7.55 is alkalosis PCO2 of 30 is too low HCO3 is normal Too little carbon dioxide means this patient has respiratory alkalosis |
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What is a good way to remember the norms for ABG? |
- 7.35 - 7.45 is normal for serum pH (just try to memorize this part) - for PCO2 the 35-45 is the 2nd part of the pH - for HCO3, 22-26 seems like the perfect ages to be (can go anywhere and do anything and not yet in your 30s)
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What are the clinical manifestations of acute respiratory acidosis? |
- increased pulse and respiratory rate - headache, dizziness - confusion and decreased level of consciousness - muscle twitching |
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What are the clinical manifestations of acute respiratory alkylosis? |
- confusion, difficulty focusing - headache - tingling - palpitations - tremors |
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What are the clinical manifestations of metabolic acidosis? |
- headache - confusion, drowsiness - weakness - peripheral vasodilation - nausea and vomiting - Kussmaul breathing (rapid and deep) - often associated with kyperkalemia |
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What are the clinical manifestations of metabolic alkylosis? |
- dizziness - tingling - hypertonic muscles - decreased respiratory rate and depth |
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If we have metabolic alkylosis, what will our respiratory system do? |
In this situation, our pH is too high, which means it's too basic, which means we need more CO2 and carbonic acid (too much is acidosis), so we slow down our breathing to try and compensate. |
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If we have metabolic acidosis, what will our respiratory system do? |
In this situation, our pH is too low, which means it's too acidic, which means we need more O2 and bicarbonate (too much causes alkylosis), so we speed up our breathing to try and compensate. |
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If we have metabolic alkylosis, and our respiratory system fails to compensate, what will our urinary system do? |
With alkylosis, the serum is too basic, meaning there is too much bicarbonate in the blood. The kidneys will excrete bicarbonate. |
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If we have metabolic acidosis, and our respiratory system fails to compensate, what will our urinary system do? |
With acidosis, the serum is too acidic, meaning there is too much carbonic acid in the blood. The kidneys will conserve bicarbonate to neutralize the acid. |
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What is the SA node? |
The sinoatrial node of the heart, commonly known as the primary pacemaker of the heart. |
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Damage to the SA node would cause which of the following and why? A. Shortness of Breath B. A slowed heart rate C. Elevated heart rate D. No symptoms |
B. A slowed heart rate because the SA node is the primary pacemaker. If the AV node had to take over, it would beat at a slower pace. If the AV node then failed, another area would have to take over at an even slower pace. The SA node has the fastest regular pace. |
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What is the AV node? |
The atrioventricular node. Electrical activity passes through the AV node from the SA node into the right and left bundles of HIS and into the Purkinje fibers to the ventricles. |
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What are catecholamines? |
In the human body, the most abundant catecholamines are epinephrine, norepinephrine and dopamine. When released, are part of the fight or flight response in the body (vasoconstriction, increased BP, increased HR, etc.) |
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What is part of the aging process regarding cardiac health? |
- heart muscles lose contractile strength - heart valves become thicker and more rigid - peripheral vessels become less elastic |
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What is the result of the normal aging process of the heart? |
The aging heart is less able to respond to increased oxygen demand (such as in exercise). Thus, the aging adult has a lower tolerance to exercise and needs longer to recover and is more prone to orthostatic hypotension. |
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What is a U wave on an ECG? |
A blip after the T wave indicating hypokalemia (low potassium). |
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What are the steps to attaching a patient to a cardiac monitor? |
- attach leads to the machine - clean placement sites with washcloth until red - may have to clip or shave hair - clean area again with alcohol pad to remove oil - attach lead wires to electrodes - remove electrode backing and apply to skin pressing firmly |
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What is infiltration? |
Fluid seeping out of the vessel into surrounding tissue at the IV site. |
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What is extravasation? |
When an irritating fluid seeps out of the vessel into surrounding tissue at the IV site. |
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What is a thrombus? |
A clot forming at an IV site due to the vessel being punctured. Complications can occur such as erythema, pain, warmth. May palpate a cord (vessel turning hard). |
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What is thrombophlebitis? |
Clot plus inflammation at the IV site. Will see tender cordlike veins and edema. |
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What are some nursing interventions for electrolyte imbalances? |
- Dietary teaching (such as low sodium, high potassium foods) - Oral electrolyte supplements if diet isn't enough - limiting, or facilitating, oral fluid intake - parenteral replacement of fluids and/ or electrolytes |
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What is the first thing a nurse does if a complication happens with the IV (such as thrombus, extravasation, etc.)? |
Stop the IV. |
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What is dyspnea? |
Shortness of breath |
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What is cyanosis? |
Looking at lips and conjunctiva, there is a bluish discoloration. It is a late sign of hypoxia. |
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What is hypoxia? |
Low oxygen in the tissues. |
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What is DOE? |
Dyspnea on exertion |
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What can interfere with a pulse oximeter? |
- nail polish - fake nails - cold extremities - poor circulation |
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What is retraction? |
When a person is visibly pulling in muscles. Using the body to breathe. |
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What is orthopnea? |
Difficulty breathing in a lying position. |
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What is wheezing? |
High pitched squeek or musical note on inspiration or expiration. |
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What kind of oxygen mask is typically used for a COPD patient? |
Venturi mask that delivers 24%-50%. Gives precise F102. |
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When a patient has a chest tube, where does the other end of the tube have to be? |
Below lung level. |
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Who is the universal blood recipient and why? |
AB+. A person with A can donate, a person with B can donate and a person with O can donate, whether they are positive or negative. |
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Who is the universal blood donor and why? |
O-. There are no antigens at all on the O and no Rh factor as well. |
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What is DVT? |
Deep vein thrombosis. A clot that forms in a deep vein often in a leg. Can develop in patients that have a condition that affects how their blood clots. Can also happen after trauma or after long periods of bed rest. |
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What is rate and depth regarding respiration? |
- rate is how fast or slow you breathe - depth is how much your lungs must expand to take in air (deep or shallow) |
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What is the difference between hypoxia and hypoxemia? |
Hypoxemia is low oxygen in the blood and hypoxia is low oxygen in the tissues. Hypoxemia can lead to hypoxia. |
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What are the advantages of a central line? |
- can administer highly irritating meds because of the quick mixing of blood - accessible even in severe fluid depletion - some may be used for invasive, continuous monitoring of cardiac indicators - can be used for parenteral nutrition - can be used for blood draws |
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What are the disadvantages of a central line? |
- specially trained personnel must insert them and consent is required - placement must be confirmed by radiology - dressing changes require sterile technique - there is an increased risk of trauma; pneumothorax or infection - may increase risk of dysrhythmias - cost is higher |
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What is the equipment needed for changing IV solutions and tubing? |
- nonsterile gloves - administration set - IV solution - IV pole - antiseptic swabs - 1 inch nonallergenic tape - time tape - watch with a second hand |
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What are the pre-procedure assessments for changing IV solutions and tubing? |
- assess the IV catheter for patency before changing the solution container or administration set - assess the IV site for signs of phlebitis, infiltration, infection or inflammation - check IV catheter insertion date |
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What are the steps for changing an IV solution? |
1. following the "rights", prepare and label the next container of IV solution at least 1 hour before the present infusion is scheduled to finish. 2. close the roller clamp on the admin. set 3. wearing clean, nonsterile gloves, remove the old IV solution from the IV pole. Remove the spike from the bag, keeping the spike sterile. 4. remove the protective cover from the new IV solution 5. place the spike into the port of the new container 6. hang the IV solution on the pole 7. inspect the tubing to be sure that it is free of air bubbles and that the drip chamber remains half filled 8. open the roller clamp and adjust drip rate 9. affix time tape to new IV solution container 10. dispose of used supplies appropriately |
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What are some nursing interventions to lower the risk of DVT? |
- antiembolism socks - anticoagulant therapy - warm compresses if currently have one |
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What does histamine do? |
During an allergic reaction histamine is released causing blood vessels to become leaky allowing fluid to enter the tissues causing edema, which can hamper cardiac function. |
