Final Study Guide NR 200 Respiratory, Cardiac, Reproductive, Cultural & Spiritual
ABG - CORRECT ANSWER normal Arterial Blood gas
pH: 7.35-7.45
... [Show More] (balance of acid/base)
PaO2: 80-95
SaO2: 95-100
PaCO2: 35-45 (acid)
HCO3: 22-26 (base)
Kidneys - CORRECT ANSWER Gas exchange info:
Metabolic is when___________________________ are envolved
Bicarb - CORRECT ANSWER Gas exchange info:
_____________________ is based in the kidneys
Respiratory Acidosis causes - CORRECT ANSWER 1. Cardiac Arrest
2. Respiratory Depression (drugs)
3. Foreign Body Obstruction
4. Asthma
Respiratory Acidosis Symptoms - CORRECT ANSWER 1. Confusion
2. Easy Fatigue
3. Lethargy
4. Shortness of breath
5. Sleepiness
Respiratory Alkalosis sign - CORRECT ANSWER When around your mouth is white, fingers, and toes are hard to move.
Respiratory Alkalosis causes - CORRECT ANSWER Hyperventilation (psych)
Conditions that increase respiratory rate:
Pulmonary Edema
Asthma (can do either or)
Pulmonary embolism (trying to get breaths in)
Respiratory Alkalosis Symptoms - CORRECT ANSWER Dizziness
Hand tremors
Numb lips/extremities
Anxiety
Nausea
Metabolic Acidosis - CORRECT ANSWER Occurs after a few days of respiratory acidosis
METABOLIC Acidosis - CORRECT ANSWER It is a ___________________________ __________________________ when HCO3 (bicarbonate) is involved
METABOLIC Alkalosis - CORRECT ANSWER It is a _________________________ ____________________________ when HCO3 (bicarboate) is involved.
"Blowing off" CO2 (hyperventilation)
ABG examples:
pH: 7.55 high
PCO2: 30 low
HCO3: 22 normal
**Hyperventaliting** - CORRECT ANSWER Respiratory Alkalosis
Kidneys cannot keep up with excreting acid
ABG examples:
pH: 7.25 low
PCO2 28 low
HCO3 15 low
**Cardiac Arrest** - CORRECT ANSWER Metabolic Acidosis
We are not getting O2 to the tissue
Ventilation inadequate (CO2) build up
ABG examples:
pH: 7.25 low
PCO2 55 high
HCO3 25 normal
**Respiratory Depression** - CORRECT ANSWER Respiratory Acidosis
Body loses too much acid OR retains too much base (HCO3)
ABG example:
pH: 7.51 high
PCO2 39 normal
HCO3 30.4 high
**Diuretic** - CORRECT ANSWER Metabolic Alkalosis
Signs and Symptoms of Respiratory distress - CORRECT ANSWER Inspect the chest front and back
Size and shape (anteroposterior diameter compared with the lateral diameter)
1. Symmetry
2. Color
3. Superficial venous patterns
4. Prominence of ribs
5. Spinal deviation
6. Sternal protrusion
**BONUS QUESTION**
If patient came in with a barrel chest, what should we predict the patient has? - CORRECT ANSWER COPD
Inspection of the chest: - CORRECT ANSWER 1. Wall movements
2. Use of accessory muscles
Evaluate Respirations by: - CORRECT ANSWER 1. Rate
2. Rhythm or pattern (listen without stethoscope)
** Note any audible sounds with respiration**
Pulmonary and cardiac difficulties - CORRECT ANSWER Fingers: Clubbing
Breath: Odor (ex: strep)
Skin, nails, and lips: cyanosis (blue) or pallor
Lips: pursing
Nostrils: flaring/sniffing
Tripod position: trying to get breaths by leaning forward.
Crepitus - CORRECT ANSWER Crackly or crinkly sensation, can be both palpated and heard.
Crackles (Formerly called rales) - CORRECT ANSWER Abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinuous sounds
Fine - CORRECT ANSWER High pitched, and relatively short in duration
Coarse - CORRECT ANSWER Low pitched, and relatively longer in duration
Rhonchi - CORRECT ANSWER Deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuous, and less discrete than crackles
Rhonchi - CORRECT ANSWER caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure
Wheeze - CORRECT ANSWER Continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration
Wheeze - CORRECT ANSWER Caused by a relatively high-velocity airflow through a narrowed or obstructed airway. May be caused by the bronchospasm of asthma (reactive airway disease) or acute or chronic bronchitis.
Friction rub - CORRECT ANSWER Occurs outside the respiratory tree. Dry, crackly, GRATING, low-pitched sound and is heard in both expiration and inspiration. Caused by inflamed, roughened surfaces RUBBING together.
Mediastinal Crunch (Hamman sign) - CORRECT ANSWER Found with mediastinal emphysema
Variety of sounds-loud crackles, clicking and gurgling sounds are synchronous with the heartbeat and not particularly so with respiration.
Respiratory Differences in Pediatrics - CORRECT ANSWER -Fetal lungs contain NO air; has exchange is through
placenta
-At birth, lungs adapt to postnatal functions. Infants <1 year have the most anatomic differences from adults
1. Infants obligatory (nose breathers)
2. By age 10, respiratory system more like adults
Potential for Air Way Obstruction in Pediatrics - CORRECT ANSWER 1. Larger tongue
2. Larynx (small radius, swelling can cause obstruction)
3. Large adenoids/tonsils
Potential for airway compression in Pediatrics - CORRECT ANSWER Trachea, larynx, bronchi cartilage more compliant
More at risk for respiratory distress in Pediatrics - CORRECT ANSWER Less alveoli
Smaller lung volume (250cc at birth, 6000cc adult)
Ribs of the Pediatrics - CORRECT ANSWER Chest wall not as stable/more compliant than adults
-Less strength to lift ribs
-Developed by school-age
Diaphragm of Pediatrics - CORRECT ANSWER Decreased lung volume due to abdominal organs large against diaphragm
Children have normally high respiratory rates - CORRECT ANSWER -Faster metabolic rate than adults
-Higher oxygen demand (40-60)/min
**BONUS QUESTION**
Periodic breathing, a sequence of relatively vigorous respiratory efforts followed by apnea of as long as ________ to _____________ seconds, but is more like ________________ seconds. - CORRECT ANSWER 10 to 15 seconds,
20 seconds
**BONUS QUESTION**
If there is chest pain and you can push on the chest to help relieve the pain, then its probably what? - CORRECT ANSWER Muscle related.
Chest circumference of children - CORRECT ANSWER 2-3 cm smaller than the head circumference.
The five symptoms of respiratory disease:
1. C
2. S
3. S
4. W
5. P - CORRECT ANSWER 1. Cough
2. Sputum
3. Shortness of breath
4. Wheezing
5. Pain
Systole - CORRECT ANSWER 1.Ventricles contract-Blood is ejected from the left ventricle into the aorta and from the right ventricle into the pulmonary artery.
2.Mitral and tricuspid valves CLOSE (first heart sound) S1 "lub'
3. Aortic and pulmonic valves OPEN -Blood ejected into arteries
4. Aortic and pulmonic valves CLOSE (second heart sound) S2 "dub"
Diastole - CORRECT ANSWER 1.Mitral and tricuspid valve OPEN
2. Blood moves from atria to ventricles (third heart sound) S3
3. Ventricles dilate, blood drawn into the ventricles as the atria contract, so blood moves from the atria to the ventricles
4. Atria contract as ventricles almost filled
5. Causes complete EMPTYING of atria (Fourth heart sound) S4
** Bonus Question**
What extra heart sounds "Gallops" does the "S3" sound like? - CORRECT ANSWER "Kentucky"
**Bonus Question**
What extra heart sounds "Gallops" does the "S4" sound like? - CORRECT ANSWER "Tennessee"
Electrical Activity (Electrocardiogram) ECG - CORRECT ANSWER is a graphic recording of electrical activity during the cardiac cycle
P Wave - CORRECT ANSWER The sequential activation (depolarization) of the right and left atria
QRS Complex - CORRECT ANSWER Right and left ventricular depolarization (normally the ventricles are activated simultaneously)
ST-T Wave - CORRECT ANSWER Ventricular repolarization
U Wave - CORRECT ANSWER Origin for this wave is not clear-but probably represents "afterdepolarizations" in the ventricles
PR interval - CORRECT ANSWER Time interval from onset of atrial depolarization (P wave) to onset of ventricular depolarization (QRS complex)
QRS Duration - CORRECT ANSWER Duration of ventricular muscle depolarization
QT Interval - CORRECT ANSWER Duration of ventricular depolarization and repolarization
Pregnancy Women cardiac changes - CORRECT ANSWER 1. Maternal blood volume increases 40% to 50% over prepregnancy level. Heart works harder to accommodate the expanded blood volume.
2. Left ventricle increases in both wall thickness and mass
3. Heart shifts to more horizontal position. Uterus enlarges and the diaphragm moves upward.
Pregnancy Women Cardiac change continue - CORRECT ANSWER 4. Heart rate gradually increases during pregnancy
5. Pulse is 10% to 30% faster by end of their trimester
6. Heart position shifts as a size and position of uterus changes
7. Apical impulse shifts up and laterally
Older Adults Cardiac change - CORRECT ANSWER 1. Heart size may decrease
2. Left ventricular wall thickens
3. Valves fibrose and calcify
4. Heart rate slows
5. Stroke volume decreases
6. Cardiac output during exercise declines by 30% to 40%
7. Endocardium thickens
8. Myocardium becomes less elastic
9. Electrical irritability may be enhanced with EKC changes.
The examination of the heart includes the following - CORRECT ANSWER 1. Inspecting
2. Palpating
3. Auscultating the heart
**BONUS QUESTION**
In assessing cardiac functions, what is the most common ERROR to listen to first? - CORRECT ANSWER the Heart! You should INSPECT FIRST, PALPATE SECOND, AND THIRD AUSCULTATE!
Inspection of the Apical Impulse - CORRECT ANSWER Should be VISIBLE at about the midclavicular line in the fifth left intercostal space.
should NOT be seen in more than one space if the heart is healthy.
Palpation of the Apical Impulse - CORRECT ANSWER Point of Maximal Impulse (PMI) Point at which the apical impulse is MOST readily seen or felt.
Thrill - CORRECT ANSWER A fine, palpable, rushing vibration, a palpable murmur
Palpation of the Peripheral arteries - CORRECT ANSWER 1. Carotid
2. Brachial
3. Radial
4. Femoral
5. Popliteal
6. Dorsalis Pedis
7. Posterior tibial
Peripheral Artery Disease - CORRECT ANSWER Arteries in any location can become stenotic (narrowed)
Peripheral Artery Disease:
The 3 P's occulusion - CORRECT ANSWER 1. Pain
2. Pallor
3. Pulselessness
Peripheral Artery Disease Signs - CORRECT ANSWER 1. Bruits
2. Loss of body warmth
3. Pallor or cyanosis
4. Collapsed superficial veins
5. Atrophied skin and loss of hair
Stenotic - CORRECT ANSWER Narrowed
Peripheral Artery Disease: Diminished circulation to the tissues will lead to signs and symptoms that are related to .... - CORRECT ANSWER 1. Site
2. Degree of stenosis
3. Ability of collateral channels to compensate
4. Rapidity with which the problem develops
Peripheral Edema - CORRECT ANSWER Venous obstruction and insufficiency
Swelling
Grading 1+ through 4+
Lymphatic System consists of - CORRECT ANSWER 1. Lymph fluid/collecting ducts
2. Lymph nodes
3. Spleen
4. Thymus
5. Tonsils and adenoids
6. Peyer patches
Lymphatic Nodes - CORRECT ANSWER 1.Oval-shaped
2.Part of immune system
-Filters harmful agents out of body
-Attacks those that manage to enter
-Distributed widely throughout the body
-Linked by lymph vessels
Inspection and Palpation Disorders of the lymph system have three physical signs to inspect - CORRECT ANSWER 1. Enlarged lymph nodes (lymphadenopathy) "sore throat"
2. Red streaks in the skin (Lymphangitis) "track infection"
3. Lymphedema (one leg is bigger than the other)
Breast Examination is typically performed when - CORRECT ANSWER The patient has a specific breast complaint as part of an overall annual well person examination
Examination of the breasts includes - CORRECT ANSWER 1. Examination of the axillae
2. Relevant lymph node chains
MAJOR focus of the examination in adults is - CORRECT ANSWER Identification of breast masses, skin, or vascular changes that could indicate malignancy.
Male breast consist of - CORRECT ANSWER 1. Small nipple and areola
2. Thin layer of breast tissue
Breast Self-Examination (BSE) - CORRECT ANSWER remains an IMPORTANT toll in the detection of breast cancer. 20yr olds+ **Every woman should be familiar with her own breasts and report any breast changes to her health care provider**
Pregnant women inspection - CORRECT ANSWER 1. Increase in size
2. Tenderness and tingling
3. Enlarged erect nipples
4. Vascular spider sand striae
Pregnant women Palpation - CORRECT ANSWER 1. Colostrum
2. Coarse nodularity of breast tissue
3. Dilated subcutaneous veins
Lactating women Palpate and examine - CORRECT ANSWER Palpate breast.
1. Engorgement
2. Clogged milk ducts
Examine nipples.
1. Irritation or blisters
2. Petechiae
3. Cracking
Older Adults Breast changes Inspection - CORRECT ANSWER 1. Elongation or flattening
2. Hanging tissue
3. Smaller nipple size
Older Adults Breast changes Palpation - CORRECT ANSWER 1. Fine granular glandular tissue
2. Thickened inframammary ridge
3. Fluid-filled cysts
Tanner's Five Stages of Breast Development (sexual maturity) - CORRECT ANSWER 1. Tanner 1 (preadolescent): Only the nipple is raised above the level of the breast, as in the child.
2. Tanner 2: Budding stage, bud-shaped elevation of the areola
3. Tanner 3: Breast and areola enlarged, No contour separation
4. Tanner 4: Increase fat deposits; Areola forms a secondary elevation above that of the breast. Occurs in approximately half of all girls and in some cases persists in adulthood.
5. Tanner 5 (Adult stage): Areola is (usually) part of general breast contour and is strongly pigmented. Nipple projects.
Nipple and Areola -The 5 D's - CORRECT ANSWER 1. Discharge
2. Depression or inversion
3. Discoloration
4. Dermatologic changes (Breast feeding, breast cracking)
5. Deviation
Menstrual cycle - CORRECT ANSWER 1. Menstrual phase (bleeding)
2. Postmenstrual phase (stop)
3. Ovulation (Happens when the egg comes out ready for fertilization)
4. Secretory phase
5. Premenstrual (luteal) phase
Talking with Adolescents about sexual intercourse - CORRECT ANSWER Same questions as an adult female, talk with teen in PRIVATE. Should NOT assume that youthful age precludes sexual activity or any of the related concerns. Questions should be posed in a gentle, matter-of-fact, and nonjudgmental manner.
**BONUS QUESTIONS** At what age should young women who are NOT sexually active have their first examination? - CORRECT ANSWER by age 21.
Special techniques for reproductive exam for adolescents - CORRECT ANSWER 1. Allay anxiety for what may be first examination
2. Same examination and positioning as for adult
3. Appropriate-size speculum
4. Maturational changes of sexual development:
-Just before menarche, there is a physiologic increase in vaginal secretions.
-Hymen may or may not be stretched across the vaginal opening.
-By menarche, the vaginal opening should be at least 1 cm wide.
Sexual abuse signs and symptoms-Children - CORRECT ANSWER 1. Medical complaints
2. Behavioral manifestations
3. Behavioral manifestations (sexually)
Medical Complaints -Children - CORRECT ANSWER Sexual abuse:
-Evidence of general physical abuse or neglect
-Evidence of trauma and/or scarring in genital, anal, and perianal areas
-Unusual changes in skin color or pigmentation in genital or anal area
-Presence of sexually transmitted infection
-Anorectal problems such as itching, bleeding, pain, fecal incontinence, poor anal sphincter tone
-Genitourinary problems (rash, sores in genital area, vaginal odor, pain)
Behavioral manifestations-Children - CORRECT ANSWER Sexual abuse:
-Problem with school
-Dramatic weight changes or eating disturbances
-Depression
-Sleep problems or nightmares
-Sudden change in personality or behavior
-Aggression or destructiveness
-Sudden avoidance of certain people or places
-Use of sexually provocative mannerisms
Behavioral manifestations (sexually)-Children - CORRECT ANSWER - Excessive masturbation or sexual behavior
- Age-inappropriate sexual knowledge or experience
-Repeated object insertion into vagina and/or anus
-Child asking to be touched/kissed in genital area
-Sex play between children with 4 years or more age difference
-Sex play that involves the use of force, threats, or bribes.
Spirituality - CORRECT ANSWER Expression of meaning and purpose in life; expression of innermost self
Spirit (our spirit gives us our spirituality) - CORRECT ANSWER is the dimension of self that: thinks, contemplates, explores meaning and purpose in life
Transcendence - CORRECT ANSWER Moving beyond who one is in the moment.. to who the person will become in the future
Faith (our own definition of our God) - CORRECT ANSWER Belief based on trust and life experience, not science
Hope (having outcome that is "okay") - CORRECT ANSWER Confident expectation of positive outcome in face of adversity
Reflection - CORRECT ANSWER Contemplating life experiences and searching for meaning in them.
Ex: Many nursing students choose to enter nursing school because they have had a "life experience" that called them into nursing (Car accident, family death, observation of nurse in action, desire to help people, etc.)
Prayer - CORRECT ANSWER Spoken or unspoken communication with a higher power.
Belief in Health Care AMISH - CORRECT ANSWER 1. No belief in modern conveniences and technology
2. Believe that hard work "worldliness" keep them close to God
3. School up to grade 8
4. No insurance (their community helps pay for it)
5. Use folk remedies/tradition/personal experience (ask about this)
6. Less prevention of disease
7. Tend to wait until VERY sick to obtain care
Belief in Health Care JEHOVAH'S WITNESS - CORRECT ANSWER 1. NO BLOOD PRODUCTS!!
2. May accept blood fractions for diseases such as hemophilia (lack of blood clots)
3. Do not believe in immediate afterlife
4. Do not believe in faith healing
Belief in Health Care JUDAISM - CORRECT ANSWER 1. NO ELECTRICITY, NO WORK, etc. from sundown Friday to Sundown Saturday (however, saving life trumps Sabbath)
2. Kosher diet
3. Like to consult with rabbi for end of life issues
4. Burial happens quickly (puts body on floor, closer to the ground the better...)
Belief in Health Care MUSLIMS - CORRECT ANSWER 1. Modesty
2. Diet Restrictions
3. Wash hands prior to and after meals, before prayers (PRAYS 5X/DAY.....)
4. "Suffer in silence"
5. Discourages withdrawal of life support (consult Imam)
6. Burial ASAP/no autopsies
7. Ramadon: is the ninth month of the Islamic lunar calendar. Every day during this month, Muslims around the world spend the daylight hours in a complete fast.
Belief in Health Care CATHOLICS - CORRECT ANSWER 1. Sacraments/blessings
-Anointing of the sick (last rites)
-Holy Communion
-Confession
2. Baptism for babies
3. Religious objects
4. Holy Communion prior to surgery
Spiritual Health Assessment Questions - CORRECT ANSWER 1. Do you have family in the area?
2. How are you handling this hospitalization or illness?
3. What faith practices or beliefs will help you cope with this illness or hospitalization?
Do you belong to a faith community? Do you want them to be notified?
Spiritual Health assessment-Pt. Cue Category -VERBAL - CORRECT ANSWER Asks for prayer or chaplain; ask if the nurse has time to talk; talks about topics related to life, death, or purpose
Spiritual Health Assessment-Pt. Cue Category-Nonverbal - CORRECT ANSWER Exhibits neediness; is angry or noncompliant; seems depressed or withdrawn
Spiritual Health Assessment-Pt. Cue Category-Environmental - CORRECT ANSWER Has religious books, jewelry, or symbols. Displays family pictures
Spiritual Health Assessment-Pt. Cue Category-Situational - CORRECT ANSWER Has a life-threatening diagnosis or life-changing condition; is facing death
Spiritual Care - CORRECT ANSWER Mutual, purposeful, interactive process between a nurse and a patient (with family) to promote the patient's spiritual health.
Signs of Spiritual distress - CORRECT ANSWER Belief or value system disruption; certain health situations that threaten their meaning and sense of purpose in life. Patients may have spiritual needs when learning of a life-changing diagnosis or experiencing a health crisis. [Show Less]