Nur 155 Exam 3 questions and answers verified for accuracy

Describe Venous insufficiency Swelling of legs & ankles, leg cramps, shallow wounds, varicose veins, normal pedal pulses, increase edema, normal skin temp., skin dry & flaky, pain is mild to moderate, elevation lessens pain Describe the face tent mask Used when a standard type mask is not tolerated well by patient varying O2 concentrations; Delivers 4-8 L/min Describe the venture mask Allows for precise O2 concentration & liter flow delivers 4-10 L/min Describe the simple face mask Standard face mask; delivers 5-8 L/min Describe the partial rebreather mask Simple face mask w/ O2 reservoir bag attached allows pt to rebreathe the first 1/3 of exhaled O2 Define Eupnea normal respirations quiet, rhythmic, effortless Define Tachypnea rapid respirations seen w/ fever, hypoxemia, metabolic acidosis Define Apnea Absence of breathing Define Hyperventilation Increased air movement more CO2 is eliminated than produced Define Kussmaul's breathing Metabolic acidosis, body attempts to compensate for increased metabolic acid in form of CO2 Define Bradypnea Abnormally slow respiratory rate seen in pt who took morphine or sedatives, pt w/ metabolic acidosis, pt w/ increased inter-cranial pressure from TBI Define hypoventilation Inadequate alveolar ventilation caused by slow or shallow breathing, may occur due to disease of respiratory muscle, drugs or anesthesia How do we implement care for cardia patients? Positioning, ambulation, exercise, I/O, medications, prevent venous stasis Define Orthopnea Inability to breathe easily unless sitting upright or standing Define cheyne stokes respirations Marked rhythmic waxing & waning of respirations from deep to very shallow w/ short periods of apnea commonly caused by chronic disease, TBI or overdose What is the risk assessment tool for skin impairment? Braden Scale for predicting pressure sore risk Pressure area risk assessment form scale Define non-modifiable risk factos Cannot be reduced; heredity, age, gender What do we do for patients in respiratory distress? Assess, administer meds(inhalers), monitor vitals, place in high flowers, place O2 on patient, call provider Define modifiable risk factors Can be reduced; smoking, diabetes, obesity, elevated serum lipids, hypertension, sedentary lifestyle Describe mustache reservoir cannula looks like mustache, O2 conserving, delivers 100% O2 bolus Labs that are altered during acute problems Troponin, CMP, hemoglobin, Creatine Kinase (CK) Describe the non-rebreather mask Delivers highest O2 concentration possible, 95-100% delivers 10-15 L/min Implementing of promoting oxygenation Position high fowlers, deep breathing exercise, use O2 incentive spirometer, ambulation, percussion, clear secretions S/S of decreased oxygen rapid pulse, rapid or shallow respirations and dyspnea, increased restlessness, light headedness, flaring nostrils, intercostal retractions cyanosis, irritability What effect does ROM have on the respiratory system? Strengthens lungs Define dyspnea Difficulty breathing or feeling of being short of breath, flared nostrils, labored breathing, cyanosis, increased heart rate Describe chronic confusion Dementia Never try to reorient we step into their world What is sensory overload? Too much stimuli, EX: ICU patients, anxiety and other issues can occur Describe Acute confusion From TBI or illness Always try to reorient to reality What effect does ROM have on the cardiovascular system? Strengthens heart muscle What do we teach patients about ROM? Position, move and turn while in bed, ambulate, prevent complications of immobility What is sensory deprivation? Decrease/lack of stimuli fatigue, drowsiness, yawning What are the 3 stages of GAS? 1. Initial Stage 2. Resistance Stage 3. Exhaustion or Recovery Stage Describe benefits of ROM Relieves stress, increases stamina, helps sleep, strengthens heart/lungs, increase metabolism, helps peristalsis, strengthens joints, prevents venous stasis How to assess for circulation BP, palpate peripheral pulses for strength and equality, osculate carotid for bruits, osculate lungs, assess skin for color, edema, temp, hair distribution, lesions, cap refills, numbness Describe arterial insufficency Ulcers on lower 1/3 of leg, toes or web spaces, lack of granulation tissue, severe pain, pedal pulses diminished, edema, decreased skin temp., tissue thin and shiny, hair loss, yellow nails, elevation increases pain Define stage 1 pressure ulcer Red area, burns a little Define purosanguineous wound exudate Bloody pus Define Serous wound exudate plasma/serum Describe the nasal cannula nasal prongs, most common, least expensive, delivers 2-6 L/min Describe the proliferative phase scarring beings, scabs form days 6-21 Describe coping mechanism: Compensation making up for perceived inadequacy by developing another desirable trait Describe coping mechanism: Intellectualizations Cognitive feelings used to block or avoid feelings about painful incident Define stage 4 pressure ulcer Must be packed and unpacked, usually "tunnels", does not hurt b/c it goes past sensory layer Describe Resistance phase of GAS Body attempts to maintain homeostasis usually exhaused at this point from SNS Describe Fear Feeling/Emotion Apprehension, the IS identifiable source related to past, present or future Describe the coping mechanism: Displacement Transfer emotion to another object or person, rarely adaptive Describe the coping mechanism: Identification Person takes on ideas, personality or characteristics of another Describe coping mechanism: Denial Failure to ignore reality by refusing to acknowledge, temporarily decreases stress Describe exhaustion or recovery phase of GAS If you stay here a long time, depression and long term health problems occur. Ex: Alcoholism Describe Anxiety State Mild sleeplessness, worry, questioning, moderate-shakiness, tremors, twitches, impaired cognitive fx Cant identify source What are the nursing diagnosis to go along with skin wounds? Impaired skin integrity, risk for infection, immobility, poor nutrition, tissue perfusion