Foundations In Nursing Exam 2 Review PDF

Foundations In Nursing: Exam 2 Review Respiratory System: ○ Stimulus for breathing: As CO2 levels increase, chemoreceptors are stimulated→depth and rate of respirations increases=compensation Considerations for older adults: decreased lung elasticity/cilia...

Foundations In Nursing: Exam 2 Review Respiratory System: ○ Stimulus for breathing: As CO2 levels increase, chemoreceptors are stimulated→depth and rate of respirations increases=compensation Considerations for older adults: decreased lung elasticity/ciliary action/muscle strength Children/Infants: increased BMR=increased RR, immature lungs ○ Airway negatively impacted by: air pollution, allergens, smoking/drugs/alcohol Increased WOB (work of breathing). 1. Restricted lung movement 2. Airway obstruction Results in decreased expansion of lungs, decreased lung volume and capacity, causes lungs to stiffen and lung tissue to swell, reduces diameter of airway ○ Ex: pneumonia, atelectasis, foreign body aspiration, toxins (asbestos/radiation) ○ Airway Obstruction: any process that decreases the diameter of airways and increases airway resistance Asthma: Sx: SOB, bronchoconstriction, inflammation, mucous production Pneumonia: build-up of mucous/fluid. Can lead to collapse (atelectasis) COPD (Chronic Obstructive Pulmonary Disease): airway obstruction, airway resistance, decreased gas exchange and CO2 retention. **Worsens over time, rarely reversible. Air gets trapped in alveoli and lose ability to rebuild and stretch=CO2 retention Sx: SOB, cough with mucus production, fatigue, frequent lung infections Barrel Chest: causes changes in diameter to chest over time due to air trapping Tripod Position: lean forward to expand rib cage and improve breathing ○ Altered Respiratory Function: Cough: response to irritation in the air ways: acute or chronic (weak/strong, dry/wet) Sputum production: nose, throat, or lungs (color, consistency, amount) Hemoptysis: bloody mucous Dyspnea: shortness of breath (SOB) Bradypnea: slowed RR (22 breaths per min) Cheyne-Stokes: increased rate and depth of respiration followed by a period of apnea (no breathing, 15-20 seconds) in a cyclic pattern Common at end stage of illness Chest Pain: pain caused by inflammatory mediators that stimulate nerve endings Adventitious Breath Sounds: abnormal breath sounds Crackles: popping, bubbling, not cleared by cough. Rhonchi: rumbling, coarse sounds (sounds like snore) Wheezes: high-pitched musical noises. Air trying to pass through constricted passages Stridor: upper airway obstruction. hi-pitched audible on inspiration (common in infants) Retractions: accessory muscle use Characterized by pt leaning forward to breathe. Can see movement between the ribs, at the sternum and straining in neck or shoulders. Nasal flaring present, can be agitated and alter LOC. Cyanosis:blue/gray skin discolo (central-lips/mucous membranes, peripheral-nails/fingers/toes) Caused by poor O2 saturation Clubbing: nail beds elongated, narrowed and bulbar due to vasodilation and increased blood flow to extremities. Compensatory mechanism Caused by conditions that result in poor oxygenation and perfusion (respiratory/cardiac disease, severe or chronic hypoxia) ○ Diagnostic Procedures: Pulse oximetry: infrared sensory, noninvasive. % of Hgb carrying oxygen (>94% =normal) Patient baseline may be lower due to underlying condition (COPD) Oxyhemoglobin Curve: the % Hgb saturated with oxygen to the PaO2 (pressure of oxygen in the blood). ○ RAPID PaO2 drop when SPO2 drops below 90% Chest X Ray: fluid, air, tumors (atelectasis, pneumonia, lung collapse) Bronchoscopy: visualize airway directly via scope in trachea and bronchi Sputum culture: gram stain to detect infection and sensitivity (tx with abx) Arterial blood gas: O2, CO2, blood pH Pulmonary function test: lung volume and capacity (severity and tx efficacy) ○ Nursing Interventions: Hydration: encourage fluids. Avoid caffeine and alcohol (diuretics-cause dehydration) Clear fluids best (don't give milk/thick fluids →do not help thin secretions) Positioning: Semi-fowlers, raise HOB, change positions (Q2H turns), “good side down” Drain secretions and promote expansion Ambulation: upright, OOB, walking Deep breathing: expands alveoli, promote cough, inhale slowly through nose Coughing: deep cough/splinting ○ stacked cough (deep breath, cough slightly, deep breath, cough slightly) ○ low flow or “huff” cough (in deep, out pursed lip, say “huff” or cough @ end) Pursed lip breathing: clients with COPD. increases airway pressure in bronchi, helps airways stay open longer and allows more air to escape. Minimizes alveolar collapse and air trapping. Aerosol/nebulizer meds:suspended liquid droplets in air or O2 (mist) delivered directly to lungs Incentive Spirometry: breathe deeply (forcefully inhale) and visually measure progress Metered Dose Inhaler (MDI): measure dose of medication (powdered or gas) Spacer: Increases delivery of medication to lungs and decreases bad taste in mouth Peak Flow Meter: measure peak expiratory flow rate and tells us about changes in pt airway diameter. Record every day in am/pm and before/after tx *forcefully breathe OUT* Green, red, yellow zones based on personal best. Chest Physiotherapy: Percussion: produce mechanical waves by clapping to remove secretions Postural drainage: positioning in order to drain secretions (lower lobes=head down) Vibration: loosen secretions (flutter valve/acapella, high frequency pulsator vest) ○ Types of Oxygen Delivery Systems: Maintain SPO2 >93%, PaO2 >60 mmHg Use LOWEST concentration for SHORTEST amount of time **Anything higher than 3LPM must be humidified** FILL bag BEFORE placing on pt face!!! Low-flow: Mix with RA (DO NOT meet pt inspiratory demand) Nasal Cannula (NC): 1-6LPM (24-60% O2) *comfortable and convenient Simple Face Mask: 5-10 LPM (40-60% O2) *covers mouth and nose Partial Rebreather Face Mask: 10-15 LPM (30-60% O2) *pt needs to re-breathe 1/3 of their CO2 (hyperventilating, anxious, stab wound) Non-Rebreather Mask (NRB): 10-15 LPM (55-90% O2) *one way valve that prevents pt from rebreathing CO2 (hypoxia, acute respiratory distress *pure O2*)  High-flow: Entire ventilatory demand of pt is met (fixed-precise concentration of O2) ○ Pre-mixes ratio of O2 to air before delivery to pt ○ Delivers gas at flow rates that exceed pt inspiratory demand High Flow Nasal Cannula: up to 60 LPM. placed by respiratory therapist (premie infants) ○ Reduces dead space, heated and humidified Venturi Mask: 24-60% O2 *colored valves to control concentration ○ Used in pts with low O2 that need humidification. COPD (limits amount of O2 so pt does not lose stimulus to breathe). Tracheostomy Collar: 28-98%, high humidity Oxygen Hood: >60%. High humidity ○ Weaning off of O2: done incrementally Reduce slightly, monitor pt for distress, SPO2, WOB, RR then lower again when stable ○ Tracheal Suctioning: removal of secretions through a tube placed in surgical opening (stoma) Indications: audible upper airway noise/gurgling, adventitious breath sounds (crackles/rhonchi), cyanosis, decreased pulse ox/PaO2, hypoxia (restlessness/anxiety), increased work of breathing (WOB) (retractions, nasal flaring, tachypnea, SOB). Principles: Suction to end of tracheostomy and 1 cm beyond MAX Suction on the way OUT only. Intermittently or continuously (do not damage mucus membrane) Rotate catheter in circular motion as you suction DO NOT suction more than 10-15 seconds in adults, or 5-10 seconds in infants/children (airway is occluded and they are not being oxygenated during that time) Hyperoxygenate the pt before and between passes NO MORE than 3 passes in one session Always keep extra trachs (1 same size + 1 smaller), a kelly clamp, trach insertion kit, suction and an ambu bag at bedside Complications: edema, obstruction (secretions or foreign body), hypoxia/bronchospasm, infection, hemorrhage, skin breakdown, expulsion of trach/decannulation Cardiac System: ○ Heart Disease: vessels, valves, heart itself Cardiovascular disease: organs, body RF: age, sex, race, high cholesterol, diabetes, HTN, family hx Lifestyle: poor diet, sedentary, obesity, smoking, drug use, excessive alcohol, high stress/anger ○ Altered Cardiac System: lead to heart disease Congestive Heart Failure (CHF): insufficient pumping of heart Sx: SOB, fatigue, weakness, BLE edema, weight gain, tachycardia, dysrhythmias, persistent cough/wheeze Arrhythmia: improper beating of heart Sx: fluttering in chest, tachy/bradycardia, chest pain, SOB, dizziness, fainting Stroke: damage to brain from interruption of blood flow Sx: numbness, difficulty with balance, speech and understanding, blurred vision, facial drooping, difficulty swallowing Myocardial infarction (MI): lack of blood flow to heart Sx: chest pain, numbness/pain in left arm, jaw or back pain Cardiac Arrest: heart suddenly stops. May occur without warning. Hypertension (HTN): force of blood against artery walls Sx: headache, fatigue, vision problems, chest pain, dyspnea, dysrhythmia ○ Medications: Cardiac glycosides: increase cardiac contractility, decrease HR Antihypertensives: decrease BP Vasopressors: increase BP Antiarrhythmics: regulate HR Nitrates: relieve angina (chest pain) Antilipids: decrease cholesterol levels Diuretics: reduce fluid volume Anticoagulants: prevent/resolve blood clots ○ EKG lead placement: artifact=movement 5 lead: Telemetry Clouds over Grass ○ RA (white) ○ RL (green) Smoke over Fire ○ LA (black) ○ LL (red) Chocolate is good for the heart ○ V1: 5th ICS, Right side 12 lead: + RA, LA, RL, LL V1: 4th ICS Right side V2: 4th ICS Left side V3: between V2/V4 not on bone V4: 5th ICS Midclavicular, Left side V5: between V4/V6 not on bone V6: 5th ICS Midaxillary, Left side ○ Nursing Interventions: EKG, Telemetry Leg exercises, positioning TEDS/SCIDS Medications; anticoag., diuretics Assessment and Education ○ Cardiac Rhythm Strips: Normal Sinus Rhythm (NSR): 60-100 bpm NSR bradycardia: 100 bpm P: atrial depolarization QRS: ventricular depolarization ST: complete depolarization of ventricles T: ventricular repolarization ○ Cardiac Rhythms: Ventricular Tachycardia (V-Tach): foci in ventricles take over and beat too fast to count Tx: cardioversion, CPR, antiarrhythmic drugs (sawtooth) *SHOCKABLE* Ventricular Fibrillation (V-Fib): rapid, disorganized depolarization of ventricles. NO palpable pulse. *SHOCKABLE* Tx: Defib the Vfib (defibrillation & CPR) Long-term implantable cardioverter-defibrillator (LT ICD)  Ventricular Dysrhythmia: ectopic foci in walls of ventricles (impulses from places there shouldn't be), decreased cardiac output (not able to fill before contracting again), ventricular rate is only 20-40 bpm (cannot sustain life) Premature Ventricular Contraction: ONE-OFF Beat. NOT rhythm. (more in bradycardia) Pulseless Electrical Activity (PEA): electricity works but no contraction. If no pulse then no cardiac output→no tissue perfusion→death Tx: start CPR, hope heart starts contracting Asystole: no electrical activity-immediate loss of O2 to brain/heart/tissues Tx: CPR (hopefully get some rhythm back then shock) ○ Cardiac Tests/Monitoring: Duplex Ultrasound: how blood moves through arteries and veins (US + doppler) Stress test: monitor and record heart activity during physical activity Echocardiogram: visualize how heart is pumping and valves work through ultrasound (detects structural abnormalities) Holter Monitor: worn 1-3 days at home, records activity of heart during ADLs Angiogram/angiography: dye to look for blockage or narrowing Percutaneous transluminal coronary angioplasty (PTCA): catheter in arm/neck/groin Uses a balloon to inflate and compress blockage. Sometimes coronary artery stent is placed to hold vessel open Coronary artery stent: placed with balloon catheter, locks open to hold vessel open Monitor dysrhythmias and admin anticoagulants Coronary artery bypass graft (CABG): uses another vessel to bypass a damaged vessel LIMA (left internal mammary artery): best moved over, live vessel, no valves LAD (left anterior descending) artery: “widow maker” Greater saphenous vein: veins are not built to handle the pressure INTERVENTIONS: Monitor VS (watch for dysrhythmias) Monitor for bleeding at insertion site Check peripheral pulses Immobilize limb for 6 hours (dye-kidney function) and maintain pressure dressing ○ IF bleeding through dressing DO NOT remove old, apply another on top Monitor I&O (urinate within 6 hours of procedure), Administer fluids ○ Cardiac Rhythm Devices: Pacemaker: augments or replaces natural pacemaker of heart Indications: bradycardia, tachycardia, damage to heart from MI, CHF DO NOT put AED pads directly over pacemaker Implantable Cardiac Defibrillator (ICD): Indications: tx V Tach and V fib (feels like being kicked in chest) ○ Life-sustaining Orders: DNR: do not resuscitate DNI: do not intubate MOLST: medical orders for life-sustaining treatment ○ Cardiovascular Access Device : Peripheral IV (PIV): short term, placed at bedside by nurse in peripheral vein Peripherally Inserted Central Catheter (PICC): long term, typically used for abx, terminates at superior vena cava (SVC) or subclavian artery. Placed at bedside by specialized nurse Checked by X Ray before use  Central Line: Central Venous Access Device (CVAD) *Internal Jugular* confirm by X Ray Triple lumen: short term, multiple lumens that terminate in different places to admin non-compatible meds at same time, Placed in neck by provider at bedside ○ Increases risk of pneumothorax or air embolism Hickman Central Line:triple lumen, long term, placed in OR in SVC *Internal Jugular* ○ Tunnels through subq tissue from arm ○ Decron Sheath: plug for tissue to grow around Groshong: double lumen *rare* used when pt is allergic to heparin Mediport: long term, placed in OR, terminated in SVC ○ Self healing: Huber needle used to access Enteral: nutrition delivered via the GI system. (Includes nutrition through gastric tube) ○ Diets: NPO: nothing per os/nothing by mouth Clear Liquid: tea, soda (ginger ale), light-color Jell-O, clear broth Pre- and Post-op and/or first day after being NPO Full-liquid: clear liquid/liquid at room temp (ice cream and sherbert) Soft-diet: puree diet/mechanical soft As tolerated: indicated by pt Restrictive: cardiac, diabetic ○ Nasogastric Tube (NG Tube): MUST be checked by X Ray before use. MD order OK to use. Future placement verification: insert air into tube and listen over stomach, aspirate pH During insertion have pt sip water to help advance tube Infants with cleft lip/palate cannot such=heart/lung problems because they're too tired Interventions: HOB 30-45 degrees at all time Check placement Admin tube feeds Check residual (GRV) and replace Flush tube to maintain patency Assess (is it in place? Markings on the tube. Is pt tolerating well?) Salem Sump: two lumens/pigtail. Short term. Suction. *should not be used for feeding* Blue pigtain helps suction from sticking to membranes and allows air exchange. ○ DO NOT tie a knot in pigtail, use a chucks if leaking Levin: one lumen. Short term. Primarily for feeding (can be used to suction) ○ Gastric Decompression: drain fluid or air from stomach via suction ○ Gastric Lavage: irrigation of the stomach (poison/overdose) ○ PEG (Percutaneous Endoscopic Gastronomy): long term (many years). For bolus or continuous feeds PEG/MIC Key: enders through the abdominal wall into the stomach held in place by a balloon (PEG). (MIC key-flatter version with special piece to snap on) Pt often able to use on their own at home. Gastrojejunostomy (G-J) Tube and Jejunostomy (J) Tube: long-term J-tube: bypasses stomach and goes directly into intestine G-J tube: G port=suction in stomach, J-port=feeds/meds in jejunum Enters via jejunum-decreases the risk of aspiration Flush with 30-50 cc according to order. Q4H, between feeds and meds Three ports: G-port, J-port, balloon port  ○ Kangaroo/Patrol Pump: control rate at which feeding is delivered *NO MEDS* Bag EXPIRES after 24 hours-throw remaining feed away HOB 30-45 degrees (decrease aspiration and vomiting) Flush to keep patent If you aspirated 1.2-2.5x hourly rate, hold feed 1 hour and check again. Hypertonic solutions: feeds shift fluid into the intestines and may cause diarrhea. ○ Bolus Feed: gravity feed. No pump. Check residual (250-500 cc =HOLD) ○ Stopcock/Lopez Valve: do not have to remove feeding tube to check for residual or give meds Parenteral: delivered intravenously ○ Indications: For pts who cannot get nutrition via GI tract Nutritional support: proteins, carbs, fats, electrolytes (K, P), vitamins, minerals Mediation admin ○ IV Solutions: (Banana Bag/Osler bag: vitamins and minerals (alcoholics)) Isotonic: normal saline (NS) (0.9% NaCl)/(0.9% sodium chloride) Iso=equal, same osmolarity as blood=replacement fluid Ex: lactated ringers (LR) Who? Pts bleeding, vomiting, diarrhea *Replace lost fluid* Hypotonic: ½ NS (0.45% sodium chloride) hypo=lower, osmotic pressure is LESS than in cells=fluid shifts INTO cells=cells swell MONITOR CAREFULLY. *dangerous* can cause intravascular fluid depletion and cardiovascular collapse (decrease BP) NEVER GIVE TO: pts with increased intracranial pressure (ICP) Hypertonic: 3% sodium chloride, 5% sodium chloride Hyper=higher, osmotic pressure is GREATER than in cells=fluid shifts OUT of cells=increased pressure in intravascular space (increase BP, edema, circulatory overload) ONLY given in ICU, requires intense monitoring *MOST DANGEROUS* Contraindication: hypernatremia ○ IV Access: Butterfly needle: needle remains Angiocath: hollow tubes for contrast dye Medlock/heplock/saline lock: needle removed, catheter remains ○ Administration sets: Primary admin set: spike + tube to IV Piggyback/secondary set: electrolytes/meds Extension set: makes peripheral IV longer Clave connector: end of tubing to stop fluid (cork) *clean clean clean* Roller clamp: adjusts rate of flow **CHANGE tubing every 96 hours for continuous. (Q24H for abx/short term) ○ IV Flow rates: KVO (keep vein open): 10/20 cc per hour Bolus: wide open “999” in pump Maintenance: continuous ○ Interventions: Infusion rate and amount (pump/gtt factor) I&Os (at least Q4H) Lab values (double check everything) Common sense (if ambulatory, make it easy to get to BR) ○ IV Complications: Infiltration: fluid enters surrounding tissues. Sx: pain/burning/blister, skin is pale, cool, swollen/taught Tx: STOP infusion, remove IV→new insertion site. Fluid should be absorbed naturally by body Phlebitis: inflammation of vein Sx: pain, swelling, itchiness, tenderness Tx: remove IV Thrombophlebitis: blood clot in vein Infection: Sx: warmth, pain, redness, swelling Tx: remove IV, culture site ( possible abx) Fluid overload: infusing fluid too fast or too much (very young or very old) Air Embolism: air in tubing goes into patient Sx: chest pain, dyspnea, SOB, hypotension, cardiac arrest (C.A.) Catheter breaks/damage: ensure whole piece is attached to hub CLABSI: central line associated bloodstream infection (abx) ○ Complete/Total Parenteral Nutrition (CPN/TPN): >10% dextrose and/or >5% protein =more concentration ONLY infused via central line HYPERtonic solution Increased risk of infection due to dextrose (sugar bacteria can eat) ○ Partial/Peripheral Parenteral Nutrition (PPN):