NURS 203: Final Exam Review (Didn't add unit 9 because it's literally a summary of everything, as well as urinalysis and pregnancy because I heard it's not going to be tested)

Nursing Process

A problem solving approach to identifying and treating client problems (ADPIE)

3 Main Goals of the Nursing Process

- Determine response to human problems, level of wellness, and need for assistance

- Provide care, teaching, guidance, and counselling

- Implement interventions for prevention, assisting the client to meet own needs and health-related goals

ADPIE

- Assessment

- Diagnosis

- Planning

- Implementation

- Evaluation

Assessment

The first phase of the nursing process; to gather and analyze information about the patient from their perspective

"Patient's Story"

A term used to describe the objective and subjective information about the client

Open-Ended Questions

Questions that allow respondents to answer however they want; used in assessments (Ex. What does your pain feel like?)

Close-Ended Questions

Questions that can be answered in short or single word responses (Ex. Are you hurting?)

Diagnosis

The second phase of the nursing process; to make a nursing diagnosis

4 Types of Nursing Diagnosis

- Problem-focused

- Risk

- Health

- Syndrome

Problem-Focused Diagnosis

A nursing diagnosis that describes an existing problem (Ex. Dizziness (r/t) Lack of hydration)

Risk Diagnosis

A nursing diagnosis that describes a potential problem that the client is vulnerable to (Ex. Risk for seizures (r/t) Can cause injury if they fall)

Health Promotion Diagnosis

A nursing diagnosis that describes a desire to realize human health potential; focus is on being as healthy as possible, and not preventing illness

Syndrome Diagnosis

A nursing diagnosis that is based on a group of signs and symptoms that occur together

Nursing Diagnosis Creation Process

- Underline the relevant symptoms

- Make a list of the symptoms

- Cluster similar symptoms

- Analyze the symptoms

- Select a nursing diagnosis label

(UMCAS)

Etiology

Cause of disease; appears as r/t (related to)

AEB

as evidenced by

3 multiple choice options

Three-Part System (PES System)

A naming system used in nursing diagnosis that uses a problem, etiology, and symptom to make a diagnosis (Ex. Diarrhea r/t lack of fibre in diet aeb watery stool)

Planning

The third phase of the nursing process that includes the identification of priorities and determination of appropriate outcomes and interventions

SMART

- Specific

- Measurable

- Attainable

- Realistic

- Timed

3 Parts of Planning

- Goal

- Outcome

- Criteria

(Ex. Patient will demonstrate better physical outcomes aeb the ability to walk up a flight of stairs without shortness of breath over 1 week)

Implementation

The fourth phase of the nursing process where the interventions are carried out with rationale

Evaluation

The fifth and final phase in the nursing process that involves evaluating the intervention to assess if it need to be altered or not

Artery

A blood vessel that carries blood Away from the heart

Vein

A blood vessel that carries blood back to the heart

Precordium

The area on the anterior chest overlying the heart and great vessels

Mediastinum

The space located between the lungs where the heart is found

Apex (Heart)

The bottom part of the heart which points down to the left

Base (Heart)

The top broader part of the heart

Right Cardiac Border

An area formed by the right atrium

Left Cardiac Border

An area formed by the left ventricle

3 Layers of the Heart Wall

- Pericardium

- Myocardium

- Endocardium

Pericardium

Membrane surrounding the heart

Anatomy of the Heart

Myocardium

The muscular wall of the heart; does the pumping

Endocardium

The thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

2 Types of Chambers in the Heart

- Atrium

- Ventricles

Atrium (2)

A thin-walled reservoir for holding blood, located at the upper chamber of the heart

Ventricle (2)

The thick walled muscular pumping chamber of the heart located at the bottom chamber of the heart

2 Main Types of Valves of the Heart

- Atrioventicular

- Semilunar

Atrioventricular Valves (AV) (2)

The valves that separate the atria and the ventricles

The 2 Atrioventicular Valves of the Heart

- Tricuspid

- Mitral

Tricuspid Valve

- The right AV valve separating the right atrium from the right ventricle

- Connected by 3 chordae tendinae

Mitral (Bicuspid) Valve

- The left AV valve separating the left atrium from the left ventricle

- Connected by 2 chordae tendinae

Chordae Tendinae

Fibers (heart strings) attatched to the tricuspid and mitral valve which pull it closed when papillary muscles contract, preventing back flow of blood

Semilunar Valves (SV) (2)

Valves located between the ventricles and the pulmonary arteries and aorta

The 2 Semilunar Valves of the Heart

- Pulmonic

- Aortic

Pulmonic Valve

The SV valve of the right side of the heart

Aortic Valve

The SV valve of the left side of the heart

The 4 Great Vessels of the Heart

- Superior/inferior venae cavae

- Pulmonary artery

- Pulmonary veins

- Aorta

Superior/Inferior Venae Cavae

The large veins that empty into the right atrium of the heart and return unoxygenated venous blood to the right side of the heart

Pulmonary Artery

Artery carrying oxygen-poor blood from the heart to the lungs

Pulmonary Veins

Veins carrying oxygenated blood from the lungs to the heart

Aorta

The largest artery in the body which carries oxygenated blood from the heart throughout the body

Blood Flow

Cardiac Cycle

A complete heartbeat consisting of contraction and relaxation of both atria and both ventricles

2 Phases of the Cardiac Cycle

- Diastole

- Systole

Diastole

The phase of the cardiac cycle where the ventricles relax and fill with blood (relaxation)

Systole

The phase of the cardiac cycle where blood is pumped from the ventricles and fills the pulmonary and systemic arteries (contraction)

Steps of Diastole

1.) Ventricles relax

2.) AV valves open

3.) Higher atrial pressure causes passive ventricular filling (early/protodiastolic filling)

4.) The atria contracts and pushes the last amount of blood into the ventricles (atrial systole)

Steps of Systole

1.) High ventricular pressure causes AV valves to close

2.) Ventricles contract, increasing ventricular pressure

3.) SV valves suddenly open, resulting in a quick ejection of blood

4.) SV valves close once ventricular pressure falls below aortic pressure

The 4 Heart Sounds

- S1

- S2

- S3

- S4

3 multiple choice options

S1

The first heart sound that occurs with the closure of the AV valves, beginning systole

S2

The second heart sound that occurs with the closure of the SV valves, ending systole

S3

The third heart sound that sometimes occur when the ventricles are resistant to filling during protodiastole

S4

The fourth heart sound that sometimes occur when the ventricles are resistant to filling during the end of diastole (presystole/atrial systole)

Rule with Stroke Volume Regarding Respiration

moRe to the Right

Less to the Left

3 multiple choice options

Murmurs

Blowing or swooshing sound from turbulent blood flow

Causes of Murmurs

- Increased velocity

- Decreased viscosity

- Structural defect

4 Characteristics of Heart Sounds

- Frequency (Pitch)

- Intensity (Loudness)

- Duration

- Timing

4 Parts of the Heart's Conduction System

- Sinoatrial (SA) node

- Atrioventricular (AV) node

- Bundle of His

- Purkinje fibers

Sinoatrial (SA) Node

Pacemaker of the heart conduction system, located at the right atrium (light blue)

Atrioventricular (AV) Node

The part that relays electrical impulses from atria into the bundle of his in the heart's conduction system; delayed slightly (yellow)

Bundle of His

Part of the heart's conduction system that transmits the cardiac impulse from the atrioventricular node to the purkinje fibers (red)

Purkinje Fibers

Fibers in the ventricles that transmit impulses to the right and left ventricles, causing them to contract

ECG Waves

- P wave

- P-R interval

- QRS complex

- Q-T interval

- T wave

P Wave

Atrial depolarization

P-R Interval

Atrial contraction

QRS Complex

Ventricular depolarization

Q-T Interval

Ventricular contraction

T Wave

Repolarization of ventricles

Stroke Volume

The volume of blood pumped out of the heart's left ventricle during each systolic cardiac contraction

Cardiac Output

Stroke volume x heart rate

Preload

The stretch at the end of diastole

Afterload

The ventricular pressure needed to overcome the high pressure in the aorta and open the aortic valve

2 Main Neck Vessels

- Jugular veins

- Carotid arteries

Jugular Veins

- One of the main neck vessels; carries unoxygenated blood to the superior vena cava

- Has 2 parts

- Provides information about activity of right side of heart

2 Parts of the Jugular Veins

- External

- Internal

External Jugular Veins

The more superficial jugular vein that lies lateral to the sternocleidomastoid and above the clavicle

Internal Jugular Veins

The deeper jugular vein that lies medial to the sternocleidomastoid

Carotid Arteries

The major neck vessel that carries oxygenated blood from the heart to the head

Main Differences Between Internal Jugular Veins and Carotid Arteries

- Internal jugular pulse more lower and lateral to sternocleidomastoid than the carotid pulse, which is higher and more medial

- Internal jugular pulse is more undulant and diffuse, while carotid pulse is more brisk and localized

- Internal jugular pulse varies with respiration

- Carotid pulse can be palpated

- Palpating internal jugular pulse will obliterate it

- Internal jugular pulse drops/disappears as the patient is brough to a sitting position

Developmental Heart Considerations for Infants and Children

- Heart is more horizontal until 7

- Lower BP and higher heart rate

- Innocent heart murmurs

Developmental Heart Considerations for Older Adults

- Arteries stiffen, increasing systolic pressure

- Risk for cardiovascular diseases

- Orthostatic hypotension

Foramen Ovale

A hole that connects the two atria in the fetal heart

Ductus Arteriosus

A blood vessel in a fetus that bypasses pulmonary circulation by connecting the pulmonary artery directly to the ascending aorta

Developmental Heart Considerations for Pregnant Women

- Increase in blood volume

- Increase in stroke volume

- Increase in cardiac output

3 multiple choice options

Subjective Data to Assess for the Heart

1.) Chest pain

2.) Dyspnea

3.) Orthopnea

4.) Cough

5.) Fatigue

6.) Cyanosis or pallor

7.) Edema

8.) Nocturia

9.) Cardiac history

10.) Family cardiac history

11.) Personal habits (cardiac risk factors)

Major Risk Factors for Heart Disease

- Stroke

- High blood pressure

- Smoking

- High cholesterol levels

- Obesity

- Physical inactivity

- Diabetes

Orthopnea

The need to assume a more upright position to breathe

OLD CARTS

- Onset

- Location

- Duration

- Character

- Alleviating/aggravating factors

- Radiation

- Treatment

- Severity