Term
| Adventitious Breath Sounds |
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Definition
| Abnormal breath sounds that occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed. |
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Term
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Definition
| A complete absence of respirations. |
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Term
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Definition
| Collapse of the air sacs. |
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Term
| Biot's (cluster) Respirations |
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Definition
| Shallow breaths interrupted by apnea. |
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Term
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Definition
| Abnormally slow respiratory rate, usually less than 10 respirations per minute. |
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Term
| Cheyne-Stokes Respirations |
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Definition
| Rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage. |
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Definition
| A bluish tinge of skin color. |
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Definition
| The mixing of molecules or ions of two or more substances as a result of random motion. |
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Definition
| Difficult or labored breathing. |
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Term
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Definition
| A chronic pulmonary condition in which the alveoli are dilated and distended. |
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| The proportion of red blood cells (erythrocytes) to the total blood volume. |
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Term
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Definition
| (Hg) The red pigment in red blood cells that carries oxygen. |
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Definition
| The accumulation of blood in the pleural cavity. |
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Term
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Definition
| A device that adds water vapor to inspired air. |
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Term
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Definition
| A condition in which carbon dioxide accumulates in the blood. |
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Term
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Definition
| (hypercapnia) Accumulation of carbon dioxide in the blood. |
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Term
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Definition
| Giving the client breaths that are greater than the client's normal tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag. |
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Definition
| Increasing the oxygen flow before suctioning and between suction attempts to avoid suction-related hypoxemia. |
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Term
| Mucus Clearance Device (MCD) |
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Definition
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Definition
- it acts as the major transportation system of the body.
- brings oxygen and nutrients to the cells
- removes waste for disposal from the body |
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Term
| What valve separates the right atrium from the right ventricle? |
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Definition
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Term
| What valve separates the left atrium from the left ventricle? |
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Definition
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Term
| What is the membrane that envelopes the heart? |
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Definition
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Term
| What is the outermost layer of the pericardium referred to as? |
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Definition
| The parietal pericardium. |
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Term
| What does the parietal pericardium do? |
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Definition
| Anchor the heart to surrounding structures and protects the heart. |
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Term
| What is the inner most layer of the pericardium? |
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Definition
| The visceral pericardium. |
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Term
| What does the visceral pericardium do? |
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Definition
Adheres to the surface of the heart and acts to protect the heart.
Forms the epicardium. |
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Term
| What are they two layers of the heart wall? |
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Definition
- myocardium
- endocardium |
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Term
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Definition
| - Cardiac muscle cells that form the bulk of the heart and contract with each beat. |
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Term
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Definition
| - Lines the inside of the heart's chambers and great vessels. |
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Term
| What separates the left and right side of the heart? |
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Definition
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Term
| What are the atrioventricular (AV) valves? |
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Definition
| The tricuspid valve on the right and the bicuspid valve on the left. |
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Term
| What are the semilunar valves? |
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Definition
| The pulmonic valve on the right and the aortic valve on the left. |
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Term
| What is the purpose of valves in the heart? |
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Definition
| To direct the flow of blood and prevent backflow. |
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Term
| Where does deoxygenated blood enter the heart? |
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Definition
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Term
| Where does oxygenated blood enter the heart? |
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Definition
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Term
| What are coronary arteries? |
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Definition
(aka coronary circulation)
- Encircle and penetrate the myocardium
- Replenish the heart during ventricular relaxation. |
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Term
| What happens if the coronary arteries are clogged? |
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Definition
| This deprives the heart of blood and oxygen and can cause chest pain, a myocardial infarction (heart attack), or death of the heart tissue. |
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Term
| What are the phases of of the cardiac cycle (heartbeat)? |
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Definition
- Contraction (systole)
- Relaxation (diastole) |
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Term
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Definition
| When the heart ejects (propels) the blood into pulmonary and systemic circulation. |
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Term
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Definition
| When the ventricles fill with blood. |
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Term
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Definition
- The first sound of a heartbeat.
- Beginning of ventricular systole; the second is caused by closure of the atrioventricular valves - the tricuspid and the mitral. |
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Term
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Definition
- The second sound
- Beginning of ventricular dystole; the sound is caused by closure of the semilunar valves - the aortic and pulmonic. |
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Term
| What is one quality of cardiac muscle that makes it unique? |
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Definition
| It has the capacity to generate electrical impulses and contractions independently of the nervous system (automaticity). |
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Term
| What is considered the pacemaker of the heart? |
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Definition
| The Sinoatrial node (SA or Sinus node). |
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Term
| What is are the affects of poor cardiac output? |
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Definition
- Oxygen and nutrients do not reach cells
- Impaired tissue perfusion |
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Term
| What influences heart rate? |
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Definition
- autonomic nervous system
- blood pressure
- hormones (thyroid hormone)
- medications |
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Term
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Definition
| The degree to which muscle fibers in the ventricle are stretched at the end of the relaxation period (dyastole). |
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Term
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Definition
| The resistance that the ventricle must overcome during systole to eject blood into circulation. |
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Term
| Where does deoxygenated blood enter the heart? |
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Definition
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Term
| When are pulse rates highest and most variable? |
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Definition
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Term
| What is the resting heart rate for neonates? |
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Definition
| 100 to 180 beats per minute immediately after birth and stabilizes at 100 to 150. |
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Term
| What is the heart rate of an infant to 2 year old? |
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Definition
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Term
| What is the adult heart rate and when is it reached? |
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Definition
- 60 to 95 beats per minute.
- obtained at 10 years old. |
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Term
| What is a sinus arrythmia? |
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Definition
| Heart rate that increases and decreases with each breath. |
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Term
| How does arteriosclerosis affect blood pressure? |
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Definition
| It causes BP to increase because of the narrowing diameter (lumen) and decrease in ability to dilate of blood vessels. |
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Term
| What is the primary contributor to cardiovascular disease? |
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Definition
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Term
| What is the leading cause of death in North America? |
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Definition
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Term
| What are the nonmodifiable risk factors for cardiovascular disease (CVD)? |
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Definition
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Term
| How does heredity affect the risk of CVD? |
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Definition
- Genes
- If a pt. has a parent with CVD the pt. is at greater risk for developing it.
- Certain racial and ethnic groups (ex. African Americans) are at a higher risk of developing CVD. |
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Term
| How does age influence the risk of developing CVD? |
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Definition
- CVD mostly affects those 60 years and older.
- Lifestype behaviors associated with CVD (patterns of diet, physical activity, and tobacco use) are established in early childhood and influence the development of CVD risk factors later in life. |
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Term
| How does gender influence the risk of developing CVD? |
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Definition
- In women estrogen slows the progression of atherosclerosis and reduces the risk of CVD. This is lost after menopause and women have the same risk for CVD as men from this point forward.
- Men are at a greater risk for developing CVD. |
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Term
| What are the modifiable risks of coronary heart disease (CVD)? |
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Definition
- elevated serum lipid levels
- hypertension
- cigarette smoking
- diabetes
- obesity
- sedentary lifestyle |
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Term
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Definition
| Lipid disorders characterized by abnormalities of lipoprotein metabolism and include elevations of total cholesterol, LDL cholesterol, or triglycerides; or deficiencies of HDL cholesterol. |
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Term
| How does hypertension increase the risk of coronary heart disease (CVD)? |
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Definition
- increases the workload of the heart, increasing oxygen demand and coronary blood flow, causing hypertrophy of ventricles causing heart failure over time.
- causes endothelial damage to blood vessels, stimulating the development of atherosclerosis. |
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Term
| How does cigarette smoking increase the risk of coronary heart disease (CVD)? |
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Definition
Nicotine increases heart rate, blood pressure, and peripheral vascular resistance, increasing the heart's workload.
- Causes vasoconstriction which can lead to a decrease in oxygen in areas of the body when combined with atherosclerosis. |
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Term
| How does diabetes increase the risk of coronary heart disease (CVD)? |
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Definition
| - high glucose levels are associated with accelerated development of atherosclerosis and levels of serum lipids and triglycerides. |
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Term
| How does obesity increase the risk of coronary heart disease (CVD)? |
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Definition
- Obesity is often accompanied with elevated serum lipid levels, hypertension, and diabetes.
- Obesity places an increased workload on the heart, which increases oxygen demand. |
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Term
| How does a sedentary lifestyle increase the risk of coronary heart disease (CVD)? |
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Definition
- Regular activity increases the heart rate and supply of oxygen to the body.
- Regular activity encourages the heart muscle to become more powerful and efficient and reduces the atherosclerotic process, risk of coronary heart disease, obesity, and diabetes. |
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Term
| What are 3 nontraditional risk factors for developing coronary heart disease (CVD)? |
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Definition
- Metabolic syndrome (Met-S)
- C-Reactive Protein
- Elevated Homocycteine Level |
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Term
| What are other risk factors for developing coronary heart disease? |
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Definition
- Heat and cold
- previous health status
- stress and coping
- dietary factors
- alcohol intake
- elevated homocysteine level |
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Term
| What are the 5 risk factors for developing metabolic syndrome? |
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Definition
- Central obesity (excess fat around stomach)
- Increased triglycerides
- Low HDL cholesterol
- Hypertension
- Elevated Fasting glucose levels |
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Term
| How does C-reactive protein (CRP) increase the risk of coronary heart disease (CVD)? |
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Definition
| - CRP signals an increase in the inflammatory process which puts a pt. at greater risk of MI. |
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Term
| How does Homocysteine increase the risk of coronary heart disease (CVD)? |
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Definition
- homocysteine is an amino acid that has been shown to be elevated in people with atheroclerosis.
- By knowing the level of this protein a pt. can reduce their risk of MI and CVD by changing their lifestyle. |
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Term
| Cardiovascular function can be altered by conditions affecting what 3 things? |
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Definition
- The function of the heart as a pump.
- Blood flow to organs and peripheral tissues
- The composition of the blood and its ability to transport oxygen and carbon dioxide. |
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Term
| What are three major alterations in cardiovascular function? |
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Definition
- Decreased cardiac output
- Impaired tissue perfusion
- Disorders that affect the composition or amount of blood available for transport of gases. |
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Term
| What are the signs and symptoms of a MI? |
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Definition
- Chest pain; substernal and/or radiating to the left arm, jaw
- Nausea
- Shortness of breath
- Diaphoresis |
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Term
| What are the signs and symptoms of heart failure? |
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Definition
- Pulmonary congestion; adventitious lung sounds
- Shortness of breath
- Dyspnea on exertion (DOE)
- Increased heart rate
- S3 heart sounds
- Increased respiratory rate
- Nocturia
- Orthopnea
- Distended neck veins
- Cold, pale extremities |
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Term
| What causes a decrease in cardiac output? |
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Definition
- Myocardial Infarction (MI)
- Heart Failure
- Irregular heart rhythms
- Structural heart conditions |
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Term
| What are examples of conditions that may precipitate heart failure? |
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Definition
- Conditions that increase preload
* Hypervolemia, Valvular Disorders, Congenital defects.
- Conditions that increase afterload
* Hypertension, atherosclerosis
- Conditions that affect myocardial function
* MI, Cardiomyopathy, Coronary Artery Disease |
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Term
| What are the signs of impaired circulation in the legs and feet? |
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Definition
- Decreased peripheral pulses
- Pain or paresthesias
- Pale skin color
- Cool extremities
- Decreased hair distribution |
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Term
| What are the risk factors for peripheral atherosclerosis? |
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Definition
- cigarette smoking
- high fat intake
- obesity
- sedentary lifestyle
- hypertension
- diabetes |
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Term
| what are less frequent factors increasing the risk for atherosclerosis? |
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Definition
- Vascular inflammation
- Arterial spasm
- Blood clots occluding blood vessels
- Tissue edema
- Incompetent valves in veins |
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Term
| What can be caused by incompetent valves? |
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Definition
- blood pooling in veins
- edema
- decreasing venous return to the heart
- inflammation
- clots (thrombi) |
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Term
| What are the signs and symptoms of an acute pulmonary embolism? |
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Definition
- Sudden onset of shortness of breath
- Pleuritic chest pain |
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Term
| What are the signs and symptoms of anemia? |
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Definition
- Chronic fatigue
- Pallor
- Shortness of breath
- Hypotension |
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Term
| What is a risk of anemia? |
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Definition
| Not enough oxygen being circulated by the blood. |
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Term
| What causes hypovolemia and are risks associated with it? |
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Definition
Causes are hemorrhage or severe dehydration, blood pressure and cardiac output fall.
Can lead to tissue becoming ischemic. |
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Term
| What causes hypervolemia and are the risks associated with it? |
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Definition
Causes are from excessive fluid retention from kidney failure.
Risks are the development of heart failure, peripheral edema, and tissue ischemia. |
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Term
| What should a comprehensive nursing history include for cardiovascular health? |
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Definition
- Current and past cardiovascular problems
- Family history of cardiovascular problems
- Medical history
- Exercise and activity level
- History of Tobacco use
- Diet
- Presence of symptoms
- Medications
- Lifestyle |
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Term
| What is the first step in examining the cardiovascular system? |
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Definition
Taking blood pressure in both arms and takes pulse in both arms.
Check apical pulse to peripheral pulses.
Listen for bruits in carotid arteries.
Listen to lungs for adventitious sounds. |
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Term
| What two enzymes are released into the blood during a heart attack? |
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Definition
- creatine kinase
- troponin |
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Term
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Definition
The study of the forces or pressures involved in blood circulation.
- used to evaluate the fluid status and cardiovascular function |
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Term
| Ineffective Peripheral Tissue Perfusion |
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Definition
| Decrease in blood circulation to the periphery that may compromise health |
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Term
| Risk for Decreased Cardiac Tissue Perfusion |
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Definition
| Risk for a decrease in cardiac (coronary) circulation |
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Term
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Definition
| Inadequate blood pumped by the heart to meet metabolic (demands) of the body |
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Term
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Definition
| Insufficient physiological or psychological energy to endure or complete required or desired daily activities. |
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Term
| Three ways to help maintain adequate cardiovascular functioning. |
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Definition
- changing position frequently
- ambulating
- exercising |
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Term
| Nursing interventions can be divided into two categories |
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Definition
- cardiac function
- vascular function |
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Term
| Vascular Nursing Interventions |
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Definition
- Elevate the legs to promote venous return
- Avoid pillows under the knees or more than 15 degrees of knee flexion
- Encourage leg exercises
- Encourage or provide frequent position changes |
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Term
| Cardiac Nursing Interventions |
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Definition
- position the client in high Fowler's position to decrease preload and reduce pulmonary congestion
- Monitor intake and output |
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Term
| What drugs reduce the workload of the heart and prevent vasoconstriction? |
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Definition
- nitrates
- calcium channel blockers
- angiotensin-converting enzyme (ACE) inhibitors |
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Term
| What drugs cause the contractile strength of the heart to increase? |
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Definition
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Term
| What methods are used to prevent venous stasis? |
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Definition
- exercises
- position changes
- antiemboli stockings
- sequential compression devices |
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Term
| What would most likely be included in the evaluation of the client goal of "demonstrates adequate tissue perfusion" |
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Definition
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Term
| Would a client who has a sustained heart rate of 150 beats/minute experience poor cardiac output? True or False. |
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Definition
| True. A fast heart rate doesn't allow for the ventricles to refill. |
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Term
| Your client has a Braden scale score of 17. The appropriate nursing action is |
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Definition
| Implement a turning schedule; the client is at increased risk of skin breakdown. |
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Term
| Proper technique for performing a wound culture includes which of the following? |
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Definition
Cleansing the wound prior to obtaining the specimen.
Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. |
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Term
| A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which of the following dressings? |
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Definition
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Term
| What type of dressings are used for wounds with significant drainage? |
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Definition
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Term
| Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that |
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Definition
Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired (dilation).
Rationale: The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat—dry or moist—will not prevent the rebound effect. The visual appearance of the site on inspection does not indicate if rebound is occurring. |
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Term
| Which statement, if made by the client or family member, would indicate the need for further teaching? |
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Definition
If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours.
Rationale: Immobile and dependent persons should be repositioned at least every 2 hours, not every 4 |
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Term
| An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is |
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Definition
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Term
| Which of the following are primary risk factors for pressure ulcers? Select all that apply. |
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Definition
-Low-protein diet
-Lengthy surgical procedures
-Fever |
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Term
| Which of the following items are used to perform wound irrigation? Select all that apply. |
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Definition
Clean gloves
Sterile gloves
60-mL syringe |
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Term
| Which of the following indicates proper use of a triangle arm sling? |
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Definition
| The knot is placed on either side of the vertebrae of the neck. |
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Term
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Definition
| growing only in the presence of oxygen |
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Term
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Definition
| growing only in the absence of oxygen |
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Term
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Definition
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Term
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Definition
| a strip of cloth used to wrap some part of the body |
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Term
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Definition
| a type of bandage applied to large body areas (abdomen or chest) that are designed for a specific body part (arm sling); used to provide support |
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Term
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Definition
| a protein found in connective tissue; a whitish protein substance that adds tensile strength to a wound |
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Term
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Definition
| a moist gauze dressing applied frequently to an open wound, sometimes medicated |
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Term
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Definition
| removal of infected and necrotic material |
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Term
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Definition
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Term
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Definition
| the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate |
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Term
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Definition
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Term
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Definition
| extrusion of the internal organs |
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Term
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Definition
| loss of the superficial layers of the skin |
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Term
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Definition
|
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Term
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Definition
| an insoluble protein formed from fibrinogen during the clotting of blood |
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Term
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Definition
| rubbing; the force that opposes motion |
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Term
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Definition
| young connective tissue with new capillaries formed in the wound healing process |
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Term
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Definition
| a contusion or "black eye" resulting from injury |
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Term
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Definition
| excessive loss of blood from the vascular system |
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Term
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Definition
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Term
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Definition
| prescribed or unavoidable restriction of movement in any area of a person's life |
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Term
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Definition
| deficiency of blood supply caused by obstruction of circulation to the body part |
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Term
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Definition
| a hypertrophic scar containing an abnormal amount of collagen |
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Term
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Definition
| the wasting away or softening of a solid as if by the action of soaking; often used to describe degenerative changes and eventual disintegration |
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Term
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Definition
| filling an open wound or cavity with a material such as gauze |
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Term
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Definition
| reddened areas, sores, or ulcers of the skin occurring over bony prominences |
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Term
| Primary Intention Healing |
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Definition
| tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring |
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Term
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Definition
| an exudate consisting of leukocytes, liquefied dead tissue debris, and dead and living bacteria |
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Term
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Definition
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Term
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Definition
| a bright red flush on the skin occurring after pressure is relieved |
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Term
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Definition
| renewal, regrowth, the replacement of destroyed tissue cells by cells that are identical or similar in structure and function |
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Term
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Definition
| an exudate containing large amounts of red blood cells |
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Term
| Secondary Intention Healing |
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Definition
| wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring |
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Term
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Definition
| inflammatory material consisting of a combination of clear and blood-tinged drainage |
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Term
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Definition
| inflammatory material composed of serum (clear portion of blood) derived from the blood and serous membranes of the body such as the peritoneum, pleura, pericardium, and meninges; watery in appearance and has few cells |
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Term
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Definition
| a combination of friction and pressure that, when applied to the skin, results in damage to the blood vessels and tissues |
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Term
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Definition
| a bath in which the client sits in warm water to help soothe and heal the perineum |
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Term
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Definition
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Term
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Definition
| healing that occurs in wounds left open for 3 to 5 days and then closed with sutures, staples, or adhesive skin closures |
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Term
|
Definition
| constricted blood vessels |
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Term
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Definition
| an increase in the diameter of blood vessels |
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Term
| An adolescent client who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet well. He has ambulated successfully around the unit with assistance and requests pain medication every 6-8 hr while reporting pain at 2 on a scale of 0 to 10 after the medication is given. his incision is approximated and free of redness with scant serous drainage noted on the dressing. Which of the following risk factors for poor healing does this client have (select all) |
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Definition
impaired circulation
impaired/suppressed immune system |
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Term
| an entry in a clients chart states that the wound drainage is "sanguineous". this means it is what? |
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Definition
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Term
| what is an example of a wound or injury healing by secondary intention? |
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Definition
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Term
Scenario: an older adult woman is 6 days postoperative following surgery for a bowel obstruction. during the last 24 hours she has reported nausea and she vomited small amounts of clear liquid 3 times in the last 8 hours. currently, her incision is well approximated and free of redness, tenderness and swelling.
which finding would indicate development of a wound infection? |
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Definition
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Term
Scenario: an older adult woman is 6 days postoperative following surgery for a bowel obstruction. during the last 24 hours she has reported nausea and she vomited small amounts of clear liquid 3 times in the last 8 hours. currently, her incision is well approximated and free of redness, tenderness and swelling.
later that day, the client becomes confused and pulls off her surgical dressing. The nurse enters the room and finds the clients wound separated with viscera protruding. which of the following nursing interventions are most appropriate? (select all) |
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Definition
-call for help
-cover the wound with a sterile dressing moistened with .9% sodium chloride
-stay with the client
-DO NOT attempt to repack wound or reinsert organs.
-The nurse should have the client lie supine with her hips and knees bent |
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Term
Scenario: An older adult client who has diabetes mellitus must now use a wheelchair after a cerebrovascular accident (CVA) 2 years ago that affected her right side. She doesn't respond to pain on the right side of her body. Her fluid and food intake is good, but she needs help with eating.
Which risk factors for developing pressure ulcers does this client have? |
|
Definition
|
|
Term
Scenario: An older adult client who has diabetes mellitus must now use a wheelchair after a cerebrovascular accident (CVA) 2 years ago that affected her right side. She doesn't respond to pain on the right side of her body. Her fluid and food intake is good, but she needs help with eating.
What can the nurse to to prevent skin breakdown? |
|
Definition
| Encourage repositioning every 15 minutes while the client is in the wheelchair. |
|
|
Term
| True or false: the skin is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual from injury. |
|
Definition
|
|
Term
| true or False: hypoproteinemia is an abnormally high protein content in the blood |
|
Definition
False.
It is an abnormally low level of protein in the blood |
|
|
Term
| What can hypoproteinemia indicate? |
|
Definition
| Can indicate inadequate diet or intestinal or renal disorders |
|
|
Term
| True or False: Wound beds that are too dry or disturbed too often fail to heal |
|
Definition
|
|
Term
| Should nutritional supplements be considered for nutritionally compromised wound care clients? |
|
Definition
| Yes, an inadequate intake of calories, protein, vitamins and iron is believe to be a risk factor for pressure ulcer development. |
|
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Term
| the nurse is assessing a wound and notes that the exudate is puruent. What would you expect the exudate to look like? |
|
Definition
| The exudate is thick with the presence of pus and is yellow in color. |
|
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Term
| During Discharge planning, the nurse is teaching a client how to apply an electric heat pad to his back. What is important for the nurse to know? |
|
Definition
-Do not insert sharp objects into pad as this may damage wiring and cause an electric shock
-ensure body area is dry unless there is a waterproof cover on pad
-use pads with a preset switch so clients can cant turn up the heat
-do not place the pad under the client. Heat will not dissipate and client may be burned. |
|
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Term
| what action taken by a client while administering a hot water bottle would indicate a need for further teaching? |
|
Definition
| The client fills the bag with water at a temp of 135F |
|
|
Term
| What water bad temps are considered safe for normal adults and children over 2 years? |
|
Definition
|
|
Term
| What water bad temps are considered safe for debilitated or unconscious adults and children under 2 years? |
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Definition
|
|
Term
|
Definition
| Sharp instrument ''open, deep or shallow'‘. |
|
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Term
|
Definition
| blow from a blunt instrument '' closed, skin appears ecchymosed (bruised)''. |
|
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Term
|
Definition
| Surface scrape ''open, involving the skin''. |
|
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Term
|
Definition
| penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional ''open wounds''. |
|
|
Term
|
Definition
| tissue torn apart, often from accident ''open, edges are often jagged''. |
|
|
Term
| Describe a penetrating wound |
|
Definition
| penetrating the skin and underlying tissues. '' Open wound ''. |
|
|
Term
| What are the risk factors for pressure ulcers? |
|
Definition
-Friction and shearing
-immobility
-inadequate nutrition
-fecal and urinary incontinence
-decreased mental status
-diminished sensation
-excessive body heat
-advanced age
-chronic medical conditions |
|
|
Term
| Describe stage I of Pressure ulcers |
|
Definition
| red color and the skin don’t return to normal color even the pressure is released. |
|
|
Term
| Describe stage II of Pressure ulcers |
|
Definition
| redness accompanied by blisters or shallow break in the skin |
|
|
Term
| Describe stage III of Pressure ulcers |
|
Definition
| break in the skin extending to the subcutaneous tissue |
|
|
Term
| Describe stage IV of Pressure ulcers |
|
Definition
| ulcer involves loss of all skin layers exposing muscle and bone. |
|
|
Term
| what are effects of wounds? |
|
Definition
Loss of all or part of organ functioning
Sympathetic stress response
Hemorrhage and blood clotting
Bacterial contamination
Death of cells |
|
|
Term
| when is a wound considered "open"? |
|
Definition
| when the skin or mucous membrane surface is broken. |
|
|
Term
| What is intentional trauma? |
|
Definition
| trauma occurring during therapy e.g., operations or venipuncture, removing tumor. |
|
|
Term
| what is unintentional trauma? |
|
Definition
| accidental; e.g. a person may fracture an arm in an automobile collision. If the tissues are traumatized without a break in the skin, the wound is closed. The wound is open when the skin or mucous membrane surface is broken. |
|
|
Term
| When can Shearing forces occur? |
|
Definition
| when a patient is moved carelessly or slides down in bed. |
|
|
Term
| what is reactive hyperthermia? |
|
Definition
| the bright red flush the skin takes on after pressure is relieved. |
|
|
Term
| what is the cause of pressure ulcers? |
|
Definition
| localized ischemia, a deficiency in the blood supply to the tissue |
|
|
Term
| What is the physiology behind pressure ulcer occurrence? |
|
Definition
| The tissue is compressed between two hard surfaces, usually the surface between the bed and the skeleton, when the blood cannot reach the tissue, the cells are deprived of oxygen and nutrients, waste products of metabolism accumulate in the cells, and the tissue consequently dies. Prolonged, unrelieved pressure also damages the small blood vessels. |
|
|
Term
| what are other names for pressure ulcers? |
|
Definition
| decubitus ulcers, pressure sores, or bedsores |
|
|
Term
|
Definition
| uninfected wounds in which minimal inflammation is encountered. |
|
|
Term
| what is a clean-contaminated wound? |
|
Definition
| surgical wounds in which the respiratory, alimentary, genital or urinary tract has been entered. No evidence of infection. |
|
|
Term
| What is a Contaminated wound? |
|
Definition
| open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Show evidence of inflammation. |
|
|
Term
| What is a Dirty or infected wound? |
|
Definition
| containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage. |
|
|
Term
| What is Primary intention healing |
|
Definition
| Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. It is also called primary union or first intention healing.e.g. closed surgical incision |
|
|
Term
| What is Secondary intention healing |
|
Definition
| It is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated. e.g., pressure ulcer. |
|
|
Term
| How does secondary intention healing differ from primary intention healing? |
|
Definition
1- The repair time is longer
2- Scarring is greater
3- Susceptibility to infection is greater |
|
|
Term
|
Definition
is initiated immediately after injury and last 3 to 6 days. This phase include mildly elevated temperature, leukocytosis, and generalized malaise. Two major processes occur during this phase:
Hemostasis
Phagocytosis |
|
|
Term
|
Definition
| extends from day 3 or 4 to about day 21 postinjury. Fibroblasts (connective tissue cells), which migrate into the wound begin to synthesize collagen (whitish protein), these substance adds tensile strength, this decreases the chance that wound open again. Capillaries grow across the wound, ↑ the blood supply. Fibroblasts move from the bloodstream into wound, depositing fibrin , the tissue becomes a translucent red color. This tissue , called granulation tissues , is fragile and bleeds easily |
|
|
Term
| Maturation (Remodeling phase) |
|
Definition
| begins about day 21 and can extend 1 or 2 years after the injury. During maturation, the wound is remodeled and contracted. The scar becomes stronger but the repaired area is never as strong as the original tissue. |
|
|
Term
| Time of Inflammatory Phase |
|
Definition
| initiated immediately after injury and last 3 to 6 days |
|
|
Term
| Time of Proliferative Phase |
|
Definition
| day 3 or 4 to about day 21 postinjury. |
|
|
Term
|
Definition
| day 21 and can extend 1 or 2 years after the injury. |
|
|
Term
|
Definition
| bacteria that produce pus |
|
|
Term
|
Definition
| consisting of pus and blood |
|
|
Term
|
Definition
| consisting of clear and blood tinged drainage |
|
|
Term
|
Definition
| abnormal massive bleeding; internal hemorrhage may be detected by swelling or distention in the wound |
|
|
Term
|
Definition
| The temperature and pulse increase, wound become tender, swollen, and warm. |
|
|
Term
| when is wound dehiscence most likely to occur? |
|
Definition
| 4 to 5 days postoperatively |
|
|
Term
| what are factors affecting wound healing? |
|
Definition
-Developmental considerations
-Nutrition
-Wound condition
-Lifestyle
-Medications |
|
|
Term
| Nursing intervention for maintaining skin integrity and wound care involve: |
|
Definition
1- Supporting wound healing
2- Preventing pressure ulcers
3- Treating Pressure ulcers
4- Dressing and cleaning wounds
5- Supporting and immobilizing wounds
6- Heat and cold applications |
|
|
Term
| Nursing intervention: Moist wound healing |
|
Definition
| The dressing and frequency of change should support moist wound bed conditions. Wound beds that are too dry or disturbed too often fail to heal. |
|
|
Term
| Nursing intervention: nutrition and fluids |
|
Definition
| Clients should be assisted to take in at least 2500ml of fluids a day unless it is contraindication, also the nurse should ensure that clients receive sufficient protein, vitamins C,A,B1 and B5, and Zinc. |
|
|
Term
|
Definition
| a scalpel or scissors is used to separate and remove dead tissue. |
|
|
Term
|
Definition
| scrubbing force or moist to moist dressings. |
|
|
Term
|
Definition
| collagenase enzyme agents such as papain – urea |
|
|
Term
|
Definition
| dressing that contain wound moisture, such as hydrocolloid and clear absorbent dressings. |
|
|
Term
|
Definition
-Sedative effect to relief pain and aches
-Vasodilatation and increase blood flow to the affected area
-Bringing oxygen and nutrients, antibodies, and leukocytes
-Promote soft tissue healing
-It is often used for clients with musculoskeletal problems such as arthritis. |
|
|
Term
|
Definition
Disadvantages:
Increase capillary permeability which cause edema |
|
|
Term
|
Definition
Vasoconstriction, which decrease the blood supply and nutrients to the affected area.
Decrease cellular metabolism
Decrease removal of wastes
Prolonged exposure to cold results impaired circulation, cell deprivation, and subsequent cell damage |
|
|
Term
|
Definition
| to flush out the wound, remove foreign particles |
|
|
Term
|
Definition
type of healing that occurs with wounds that are left open for 3-5 days to allow for edema or infection to resolve or exudate to drain. They are then closed.
Also called delayed primary intervention |
|
|
Term
| How do you know when healing has occurred? |
|
Definition
wound site is smaller
exudates are decreasing, no fresh blood |
|
|
Term
| Meaning of Braden scale score 18-23 |
|
Definition
| no risk for pressure ulcers |
|
|
Term
| Meaning of Braden scale score 15-16 |
|
Definition
| low risk, but implement preventative measures |
|
|
Term
| Meaning of Braden scale score 13-14 |
|
Definition
moderate risk
likely showing stage I signs if not sate II |
|
|
Term
| Meaning of Braden scale score 12 or less |
|
Definition
| high risk- likely has stage III or IV |
|
|
Term
|
Definition
| confined to the skin, that is, the dermis and epidermis; heal by regeneration |
|
|
Term
|
Definition
| involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone; requires connective tissue repair |
|
|
Term
| A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s condition? |
|
Definition
| A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes. |
|
|
Term
| To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the following? |
|
Definition
Huff coughing every 2 hours or as needed.
Rationale: Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (e.g., postoperatively). Deep breathing and coughing should be performed at the same time. |
|
|
Term
| The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action? |
|
Definition
Tells the client to raise two fingers to indicate pain or distress.
Rationale: Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. |
|
|
Term
| Which action by the nurse represents proper nasopharyngeal/nasotracheal suction technique? |
|
Definition
Rotate the catheter while applying suction.
Rationale: Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and side. |
|
|
Term
| Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective? |
|
Definition
“I should inhale slowly and steadily to keep the balls up.”
Rationale: Proper use of an SMI requires the client to take slow, steady inhalations, every hour or two, 5 to 10 breaths each time. |
|
|
Term
| While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate? |
|
Definition
Reconnect the tube to the water seal
.
Rationale: The tube should be reconnected to the water seal as quickly as possible |
|
|
Term
| The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has |
|
Definition
Anemia.
Rationale: Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. |
|
|
Term
| Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively? |
|
Definition
Orthopnea
Rationale: Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea. |
|
|
Term
| A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following? |
|
Definition
Decrease inflammation in the airways.
Rationale: Glucocorticoids are prescribed because of their anti-inflammatory effect. |
|
|
Term
| The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care? |
|
Definition
Percussion and postural drainage should be done before lunch.
Rationale: Postural drainage results in expectoration of large amounts of mucus. Clients sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort. |
|
|
Term
| Adventitious breath sounds |
|
Definition
| abnormal breath sounds that occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed |
|
|
Term
|
Definition
| a complete absence of respirations |
|
|
Term
|
Definition
|
|
Term
|
Definition
| shallow breaths interrupted by apnea |
|
|
Term
|
Definition
| abnormally slow respiratory rate, usually less than 10 respirations per minute |
|
|
Term
| Cheyne-Stokes respirations |
|
Definition
| rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage |
|
|
Term
|
Definition
| a method for suctioning an endotracheal tube or tracheostomy in which the suction catheter, enclosed in a plastic sheath, attaches to the ventilator tubing, and the client does not need to be disconnected from the ventilator |
|
|
Term
|
Definition
| a bluish tinge of skin color |
|
|
Term
|
Definition
| the mixing of molecules or ions of two or more substances as a result of random motion |
|
|
Term
|
Definition
| difficult or labored breathing |
|
|
Term
|
Definition
| a chronic pulmonary condition in which the alveoli are dilated and distended |
|
|
Term
|
Definition
| red blood cells, or RBC's |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| the portion of red blood cells (erythrocytes) to the total blood volume |
|
|
Term
|
Definition
| the accumulation of blood in the pleural cavity |
|
|
Term
|
Definition
| a device that adds water vapor to inspired air |
|
|
Term
|
Definition
| a condition in which carbon dioxide accumulates in the blood |
|
|
Term
| Hypercarbia (hypercapnia) |
|
Definition
| accumulation of carbon dioxide in the blood |
|
|
Term
|
Definition
| giving the client breaths that are greater than the client's normal tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag |
|
|
Term
|
Definition
| increasing the oxygen flow before suctioning and between suction attempts to avoid suction-related hypoxemia |
|
|
Term
|
Definition
| very deep, rapid respirations |
|
|
Term
|
Definition
| low partial pressure of oxygen or low saturation of oxyhemoglobin in the arterial blood |
|
|
Term
|
Definition
| insufficient oxygen anywhere in the body |
|
|
Term
| Incentive spirometer (sustained maximal inspiration device, SMI) |
|
Definition
| a device that measures the flow of air inhaled through a mouthpiece |
|
|
Term
|
Definition
| pressure in the pleural cavity surrounding the lungs |
|
|
Term
|
Definition
| pressure within the lungs |
|
|
Term
|
Definition
| hyperventilation that accompanies metabolic acidosis in which the body attempts to compensate (give off excess body acids) by blowing off carbon dioxide through deep and rapid breathing |
|
|
Term
|
Definition
| expansibility of the lung |
|
|
Term
|
Definition
| the tendency of lungs to collapse away from the chest wall |
|
|
Term
|
Definition
| ability to breathe only when in an upright position (sitting or standing) |
|
|
Term
|
Definition
| the compound of oxygen and hemoglobin |
|
|
Term
|
Definition
| the pressure exerted by each individual gas in a mixture according to its percentage concentration in the mixture |
|
|
Term
|
Definition
| accumulation of air in the pleural space |
|
|
Term
|
Definition
| positioning of a client to allow the drainage, by gravity, of secretions from the lungs |
|
|
Term
|
Definition
| where gas exchange occurs between the air on the alveolar side and the blood on the capillary side; the alveolar and capillary walls form the respiratory membrane |
|
|
Term
|
Definition
| the mucous secretion from the lungs, bronchi, and trachea |
|
|
Term
|
Definition
| a harsh, crowing sound made on inhalation caused by constriction of the upper airway |
|
|
Term
|
Definition
| the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet |
|
|
Term
|
Definition
| a surface-active agent (e.g., soap or a synthetic detergent); in pulmonary physiology, a mixture of phospholipids secreted by alveolar cells into the alveoli and respiratory air passages that reduces the surface tension of pulmonary fluids and thus contributes to the elastic properties of pulmonary tissue |
|
|
Term
|
Definition
| abnormally fast respirations; usually more than 24 respirations per minute |
|
|
Term
|
Definition
| the volume of air that is normally inhaled and exhaled |
|
|
Term
|
Definition
|
|
Term
|
Definition
| a series of vigorous quiverings produced by hands that are placed flat against the chest wall to loosen thick secretions |
|
|
Term
|
Definition
| delivers FiO2 of 24 - 44% with flowrates for 1 - 6 liters per minute via tubing with two small prongs for insertion into the nares |
|
|
Term
|
Definition
| delivers FiO2 of 40 - 60% with liter flows of 5 - 8 LPM for short term oxygen therapy |
|
|
Term
|
Definition
| delivers FiO2 of 80-95% at flow rates of 10-15 LPM to keep the reservoir bad two-thirds full during inspiration and expiration |
|
|
Term
|
Definition
| delivers FiO2 of 24 - 55% at flow rates of 2-10 LPM via different size adaptors |
|
|
Term
|
Definition
| delivers FiO2 of 24-100% at flow rates of at least 10 LPM and requires high humidification of oxygen |
|
|
Term
| what can cause a low oximetry reading? |
|
Definition
-nail polish
-inadequate peripheral circulation
-edema
-hypothermia
-decreased hemoglobin level |
|
|
Term
|
Definition
-tachypnea
-tachycardia
-restlessness
-pale skin and mucous membranes
-elevated blood pressure
-symptoms of respiratory distress of accessory muscles (nasal flaring, tracheal tugging, adventitious lung sounds |
|
|
Term
|
Definition
-confusion and stupor
-cyanotic skin and mucous membranes
-bradypnea
-bradycardia
-hypotension
-cardiac dysrhythmias |
|
|
Term
| a nurse is caring for a client who is having trouble breathing. What position should the nurse place the client in? |
|
Definition
|
|
Term
| which oxygen delivery system should be used when a precise amount of oxygen needs to be delivered? |
|
Definition
|
|
Term
| a nurse is preparing to perform endotracheal suctioning for a client. What are appropriate guidelines to be followed? |
|
Definition
-apply suction while withdrawing the catheter
-only perform suction when indicated NOT on a routine basis
-use a new tube each time suctioning is performed
-limit suctioning to two or three attempts
-maintain surgical asepsis |
|
|
Term
| which intervention is appropriate when caring for a client who has a tracheostomy tube? |
|
Definition
-keep cuff pressure between 14 and 20 mmHg
-use surgical asepsis
-ties are changed only when soiled
-use half-strangth hydrogen peroxide and normal saline solution to clean stoma site |
|
|
Term
|
Definition
| the drainage by gravity of secretions from various lung segments |
|
|
Term
|
Definition
| aspirating secretions through a catheter connected to a suction machine or wall suction outlet |
|
|
Term
| clear odorless gas that makes up 21% of the air we breathe |
|
Definition
|
|
Term
|
Definition
| collapse of a portion of the lung |
|
|
Term
|
Definition
| a series of vigorous quiverings produced by hands that are placed flat against the clients chest wall |
|
|
Term
| what does adequate ventilation depend on? |
|
Definition
-clear airways
-intact nervous system and respiratory center
-intact thoracic cavity capable of expanding and contracting
-adequate pulmonary compliance and recoil |
|
|
Term
|
Definition
| the amount of air remaining in the lungs after maximal exhalation |
|
|
Term
|
Definition
| total volume of lungs at maximal inflation |
|
|
Term
|
Definition
| total amount of air that can exhaled after a maximal inspiration |
|
|
Term
| what does the cough reflex consist of? |
|
Definition
-nerve impulses sent through the vagus nerve to the medulla
-a large inspiration of approx. 2.5 L occurs
-the epiglottis and glottis(vocal cords)close
-a strong contraction of abdominal and internal intercostl muscles dramatically raises the pressure in the lungs
-the epiglottis and glottis(vocal cords)open suddenly
-air rushes outward with great velocity
-mucus and any foreign particles are dislodged from the lower respiratory tract and are propelled up and out |
|
|
Term
| what is a risk of giving oxygen to clients with chronic obstructive pulmonary disease? |
|
Definition
| with two much oxygen they stop breathing |
|
|
Term
| expiratory reserve volume |
|
Definition
| maximum amount of air that can be exhaled following a normal exhalation |
|
|
Term
| what may be present with hypoxemia or hypoxia |
|
Definition
|
|
Term
|
Definition
| combined with hemoglobin and carried as oxyhemoglobin |
|
|
Term
| how long can the cerebral cortex tolerate hypoxia before permanent damage occurs |
|
Definition
|
|
Term
| what does the nurse assessment of oxygenation status include |
|
Definition
| history, physical examination, and review of relevant diagnostic data |
|
|
Term
| how much air for an adult is usually inspired and expired with each breath |
|
Definition
|
|
Term
| assumes a sitting position, often leaning forward slightly to permit greater expansion of the thoracic cavity is signs of what |
|
Definition
|
|
Term
| lung compliance is necessary for__________ and lung recoil is necessary for_____________ |
|
Definition
|
|
Term
| fingers and toes clubbed would be a sign of |
|
Definition
|
|
Term
| hyperventilation what happens to the CO2 level |
|
Definition
| respirations increase and more CO2 is eliminated than is produced |
|
|
Term
|
Definition
| forced expirations and may impair the body's ability to expel CO2 |
|
|
Term
| name the four processes of the respiratory system |
|
Definition
| pulmonary ventilation, alveolar gas exchange, transport of oxygen and carbon dioxide, and systemic diffusion |
|
|
Term
| hypoventilation may be caused by what |
|
Definition
(inadequate alveolar ventilation)
slow or shallow breathing, or both |
|
|
Term
| anxious, tired, and drawn are all signs of what |
|
Definition
|
|
Term
| what is the purpose for the nose in the respiratory system |
|
Definition
| warm, humidify, and filter |
|
|
Term
| what is the partial pressure of oxygen in the venous blood of the pulmonary arteries |
|
Definition
|
|
Term
| what makes up the lower respiratory system |
|
Definition
| trachea and lungs, with the bronchi, bronchioles, alveoli, pulmonary capillary network, and pleural membranes |
|
|
Term
| what are the accessory muscles of respiration |
|
Definition
| anterior neck muscles, intercostal muscles, and muscles of the abdomen |
|
|
Term
| hypoventilation may lead to what |
|
Definition
increased levels of carbon dioxide
or low leveles of oxygen (hypoxemia) |
|
|
Term
| a client who has been taking drugs such as morphine or sedatives, who have metabolic alkalosis, or who have increased intracranial pressure would have what type of breathing |
|
Definition
|
|
Term
| hypoventilation may occur because |
|
Definition
| diseases of the respiratory muscles, drugs, or anesthesia |
|
|
Term
| signs a client has dyspnea |
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Definition
| flaring of the nostrils, labored-appearing breathing, increased heart rate, cyanosis, and diaphoresis |
|
|
Term
| what is the normal hematocrit for men and for women |
|
Definition
|
|
Term
| what can affect the rate of oxygen transport from the lungs to the tissues |
|
Definition
cardiac output
number of erythrocytes and blood hematocrit
exercise |
|
|
Term
| hypoxemia may be caused by |
|
Definition
| conditions that impair diffusion at the alveolar-capillary level such as pulmonary edema or atelectasis (collapsed alveoli) or by low hemoglobin levels |
|
|
Term
| excessive increases in the blood hematocrit raises what |
|
Definition
|
|
Term
| what are the three ways carbon dioxide is transported from the cells to the lungs |
|
Definition
1. 65% inside RBCs as bicarbonate
2. 30% combines with hemoglobin as carbhemoglobin
3. 5% in solution in the plasma and as carbonic acid |
|
|
Term
|
Definition
type of hyperventilation that accompanies metabolic acidosis
the body attempts to compensate for increased metabolic acids by blowing off acid in the form of CO2 |
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|
Term
| what makes up the upper respiratory system |
|
Definition
| mouth, nose, pharynx, and larynx |
|
|
Term
| signs client has chronic hypoxemia |
|
Definition
| client feels fatigued and is lethargic |
|
|
Term
| Cheyne-Stokes respirations |
|
Definition
| marked rhythmic waxing and waning of respirations from very deep to very shallow with short periods of apnea commonly caused by chronic diseases, increased intracranial pressure, and drug overdose |
|
|
Term
| the absense of oxygen can lead to what |
|
Definition
| marked rhythmic waxing and waning of respirations from very deep to very shallow with short periods of apnea commonly caused by chronic diseases, increased intracranial pressure, and drug overdose |
|
|
Term
| insufficient oxygen anywhere in the body is what |
|
Definition
|
|
Term
|
Definition
many
most stem from cardiac or respiratory disorders |
|
|
Term
| what is one risk of a humidity tent? |
|
Definition
|
|
Term
|
Definition
also known as crackles, heard in the base of lower lungs
short in duration, crackling sound |
|
|
Term
|
Definition
also known as gurgles, heard over most lung areas
continuous, harsh gurgling sound |
|
|
Term
|
Definition
| heard all over continuous high pitched musical sound, best heard on expiration |
|
|
Term
|
Definition
heard in areas of greatest expansion (lower anterior and lateral chest)
grating or creaking sound |
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