NUR 200 Exam #2 - Bradley University

respiration

exchange of oxygen/carbon dioxide

ventilation

movement of air into/out of the lungs

the upper airway includes

- pharynx (throat)

- trachea

- epiglottis

the lower airway includes

- trachea

- bronchi

- bronchioles

apex

upper portion of the lungs

base

lower portion of the lung

rate

how fast you breathe

- hyperventilation: breathing fast and deep

- hypoventilation: shallow breathing

lung compliance

ease of lung inflation (how well they are able to breathe)

lung elasticity

ability to recoil, poor if stale air gets trapped

airway resistance

the resistance to airflow within the airways

external respiration

moving air through the blood/body

internal respiration

brings air back to the lungs, and out of the body

hypoxia

signs and symptoms include:

- RESTLESSNESS

- blue lips

- low SPO2

assessment of pulmonary function

- inspect

- palpate

- percuss

- auscultate

inspect

the respiratory pattern

palpate

pulses, skin temp, heart pulsations, and areas of tenderness

percuss

lung fields for consolidation or excess air pockets

auscultate

breath sounds, heart sounds, vascular sounds

normal sputum

clear, light yellow

what does pulse ox measure

oxygen carrying capacity on hemoglobin

chest tube

removes air from the pleural space

how to prevent healthcare-associated pneumonia

incentive spirometer, repositioning, coughing, deep breathing

incentive spirometer

expands the alveoli and lower lung base

oxygen therapy includes

- nasal cannula (least invasive, add a bubbler to humidify the air, use lubricant if necessary)

- mask

- transtracheal catheter (most invasive)

micronutrients

vitamins, minerals

macronutrients

carbs, proteins, fat

macro and micronutrients

allow for the growth, maintenance, and functioning

anabolism

formation of larger molecules from smaller ones

catabolism

the breakdown of larger molecules into smaller components

carbohydrates

primary energy source, supplies energy to muscles and organs

- give a feeling of fullness

- includes sugars (monosaccharides, disaccharides, and polysaccharides)

monosaccharides

simple sugars, goes through the body fast

- not good for diabetes patients

diasaccharides

2 sugars linked together

polysaccharides

complex sugars that take longer to break down

- ex: whole grains, veggies

- good for diabetes patients

proteins

secondary energy source that works with

- tissue building

- nitrogen balance

- builds amino acids

complete amino acids

comes from an animal source

incomplete amino acids

comes from nuts and plants

lipids (fats)

back-up energy source that taste good

- contributes to cholesterol

HDL

good cholesterol, found in omega-vitamins and fish

LDL

bad cholesterol, found in high saturated fat diets

tissue building occurs primarily with which type of nutrient?

proteins

fat soluble vitamins

A, D, E, K

vitamins

a type of micronutrient that is organic

- necessary for metabolism/preventing a specific deficiency disease

minerals

a type of micronutrient that is inorganic

- found in nature that occur naturally in foods

vitamin A

eggs, leafy green veggies, and milk

vitamin D

fish, milk, sunlight

vitamin E

vegetable oils, nuts, fish, and leafy green veggies

vitamin K

green leafy veggies and liver

calcium can be found in

dairy products, green leafy veggies, legumes, and nuts

magnesium can be found in

whole grains, nuts, legumes, green leafy veggies

potassium can be found in

fruits, veggies, meats, legumes, and shellfish

sodium can be found in

table salt, meat, baking soda

a patient arrives at the ED and is noted to be hypomagnesemic. which of these being eaten by the patient would suggest teaching was effective?

whole grain bread and almonds

basal metabolic rate

natural amount that an individual burns in a day

total energy needs

replacing calories used for BMR + physical activity

overweight

25.0-29.9

class I obesity

30.0-34.9

class II obesity

35.0-39.9

class III obesity

40.0 or higher

for a nutritional examination

assess wound healing, skin tugor, concave abdomen, change in muscle mass

interventions for a pt that is NPO

- glucose and electrolyte supplements for long term pts

- assist with oral hygiene

- provide other activities at meal time

glucose intolerance

- avoid concentrated sugars

- COMPLEX CARBOHYDRATES ARE BEST TOLERATED

- smaller, more nutritious meals

if a patient presents with a c/o of a dry mouth, which nursing interventions would be most appropriate?

- avoid caffeine

- offer chewing gum

- provide patient with fresh water

- avoid tobacco

enteral

ex: tube feeding via NG tube

- delivery of liquid nutrition in upper intestinal tract via tube

- short (NG) or long (g-tube) therapy

parenteral

ex: total parenteral nutrition

- delivery of nutrition IV into a large central vein

- can give nutrition based on labs (can change daily)

function of the kidneys

filter metabolic waste from blood stream as urine

process of urine elimination

- internal urethral sphincter closes to allow for bladder to fill

- signaling to the voiding reflex center the urge to void

- internal sphincter relaxes

- conscious relaxation of external urethral sphincter occurs

how much urine do the kidneys produce

50/60 mL/hr, around 1500 mL a day

specific gravity of urine

1.002 (light colored) to 1.030 (darker colored)

infants (urination)

- up to 1 year

- 15 to 65 mL per kg

- produces 8-10 wet diapers per day (education)

children (urination)

toilet training is highly variable and is influenced by family and culture

- requires control of external urethral sphincter

enuresis

occasional involuntary passage of urine

- normal up to school years

- occurs more often when they are involved in activity

nocturnal enuresis

nighttime bedwetting

- occurs in some children up to age 6-7

nocturia

frequent urination after going to bed

physical activity/dehydration (urination)

causes kidneys to hold water

bladder + kidney infections

inflammation of bladder, ureters, and kidneys

- s/s: frequent urination, dysuria, hematuria

hypertrophy of the prostate

enlarged tissues, interfere in flow from the bladder to the urethra

dysuria

painful/difficult urination

hematuria

blood in urine

assessment (urination)

- physical examination

- diagnostic procedures (BUN + creatinine)

- measure I&O

anuria

absence of urine

- seen with dialysis patients

oliguria

UO less than 400 mL/day

- seen in dehydrated patients

polyuria

excessive urination

- seen in patients with uncontrolled diabetes

functional incontinence

untimely loss of urine with no cause

- seen in children, confused people, and people who are immobile

transient incontinence

short term + resolves spontaneously

- ex: UTI

overflow incontinence

leakage of urine with distended bladder

- because of impaction or prostate enlargement

urinary retention assessment findings include

hesitancy, dribbling, weak urine stream, pain, frequency, and urge after urination

urinary incontinence assessment findings include

loss of urge or ability to hold urine

valsalvar maneuver

older people can pass out from ICP and rectal pressure, glaucoma, open surgical wounds

paralytic ileus

surgery can cause the ileum to paralyze, and have no bowel sounds

which statements made by the nurse indicate an understanding of factors that affect bowel elimination?

-immobility slows GI mobility

- an increase in hydration promotes peristalsis

- a decrease in nutrition slows peristalsis

- vegetables increase flatulence

ileostomy

liquid stool

colostomy

solid stool

focused physical assessment (bowel elimination)

1. inspect (contour of abdomen)

2. auscultate (bowel sounds)

3. palpate (4 quadrants of abdomen)

how much fiber is normal to intake every day

women: 25g

men: 38g

how much water is normal to intake every day

women: 2700mL

men: 3700mL