Nursing State Flash Cards

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1503 Terms

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PQRST pain assessment

P - provocations (what brings pain on),

Q - quality or quantity of pain (how long it lasts),

R - region, radiation,

S - severity,

T - timing (when it started, how long it lasts, does anything cause it)

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COLDSPA pain assessment

C - character,

O - onset (when did it begin?),

L - location (where is it?),

D - duration (how long does it last?),

S - severity (how bad is it?),

P - pattern (what makes it better or worse?),

A - associated factors (what makes symptoms occur)

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FLACC

Face, Legs, Activity, Cry, Consolability

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FLACC pain assessment usage

Used for paediatric patients

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FLACC score of 1-3

Indicates mild discomfort

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FLACC score of 4-6

Indicates moderate pain

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FLACC score of 7-10

Indicates severe discomfort/pain

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Integumentary assessment

Assesses rashes, skin turgor, warmth, dryness, colour

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Neurological assessment

Assesses AVPU, GCS, behaviour changes, slurred speech, facial drooping/palsy

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Cardiovascular assessment

Assesses heart rate and rhythm, blood pressure, swollen legs/arms, skin signs of CVS concern (i.e. cyanosis), peripheral pulses

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Respiratory assessment

Assesses work of breathing, accessory muscle use, respiratory rate, equal chest rise and fall

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Gastrointestinal assessment

Assesses bowel sounds, bowel movements, abdomen distended, painful/tender abdomen

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Genitourinary assessment

Assesses urinary concerns, hydration, urination frequency, pain

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Musculoskeletal assessment

Assesses muscle wastage, weakness, mobility issues

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A-E assessment

A - airway, B - breathing, C - circulation, D - disability, E - exposure

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IPPA approach

I - inspection (what can we see?),

P - palpitation (what can we feel?),

P - percussion (what can we hear through listening and feeling?),

A - auscultation (what can we hear?)

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Target range for pH

7.35-7.45

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Target range for HC03 (bicarbonate)

22-26mmol/L

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Target range for sodium

135-145mmol/L

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Target range for potassium

3.5-5.2mmol/L

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Target range for Pa02 (partial pressure of oxygen)

70-100mmHg

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Target range for PaC02 (partial pressure of carbon dioxide)

35-45mmHg

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Characteristics of acids

Hydrogen containing compounds that release H+ ions when dissolved in water. The higher the concentration of H+, the lower the pH = fluid becomes more acidic

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Characteristics of bases

Compounds that pick up/bind H+ ions.

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Basicity and pH relationship

The lower the concentration of H+, the higher the pH, making the fluid more basic (alkaline).

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Most abundant electrolyte in extracellular fluid

Sodium (Na+).

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Most abundant electrolyte in intracellular fluid

Potassium (K+).

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Impact of sodium on the body

  • The greatest influence on ECF osmolarity and water level in body fluid

  • Blood pressure/volume

  • Cell transportation

  • Neuronal signaling

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Impact of potassium on the body

  • The greatest influence on ICF osmolarity

  • Maintains resting cell membrane

  • Pumping heart and muscles

  • Controlling acid-base balance

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Water and electrolyte balance in the blood

Aldosterone stimulates sodium (Na+) reabsorption/retention and potassium (K+) secretion at the renal tubules.

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Acid-base balance in the blood

Achieved through regulating excretion of acid/bases as necessary;

lungs can excrete or conserve acids via ventilation; kidneys can excrete or conserve acids or bases in the urine.

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Kidneys role in acid-base maintenance

Bicarbonate is conserved by being reabsorbed while acids are expelled in urine.

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Lungs role in acid-base maintenance

Can only regulate acid excretion via ventilation through CO2 excretion

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Causes of hypernatremia

Water loss or excessive sodium gain in the ECF leading to an increase in plasma osmolarity which can lead to a fluid shift and cellular dysfunction.

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Signs and symptoms of hypernatremia

  • Increased thirst (polydipsia)

  • Dry mucus membranes

  • CNS symptoms (i.e. lethargy, irritability, muscle twitching).

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Causes of hyponatremia

Sodium loss or water gain in the ECF, decreasing ECF osmolarity meaning water will move into cells causing them to swell and leads to cellular dysfunction.

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Signs and symptoms of hyponatremia

  • Muscle twitching and weakness,

  • hypervolemia,

  • oedema,

  • decreased urine output,

  • confusion,

  • seizures.

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Causes of hyperkalemia

Caused by increased intake, cell damage from trauma, burns, hypoxia or acidosis, or decreased renal excretion.

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Signs and symptoms of hyperkalemia

  • Muscle weakness or cramps,

  • fatigue,

  • decreased GI motility,

  • arrhythmias,

  • ECG changes,

  • cardiac arrest,

  • bradycardia.

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Causes of hypokalemia

Caused by reduced dietary intake or increased loss of K+ from increased renal secretion.

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Signs and symptoms of hypokalemia

  • Muscle weakness,

  • arrhythmias,

  • ECG changes,

  • cardiac arrest,

  • respiratory depression,

  • decreased GI motility.

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Causes of respiratory acidosis

Buildup of CO2 in the blood leading to excess H+ from depression of brainstem respiration or failure of ventilation (i.e. pneumonia, COPD, airway resistance).

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Signs and symptoms of respiratory acidosis

  • Headache,

  • blurred vision,

  • SOB,

  • lethargy,

  • disorientation,

  • muscle twitching,

  • convulsions.

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Causes of respiratory alkalosis

Lowered H+ in blood from too much CO2 being expelled due to hyperventilation, pain, anxiety, sepsis, fever, or hypoxemia (low oxygen in tissues).

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Signs and symptoms of respiratory alkalosis

  • Dizziness

  • confusion,

  • convulsions,

  • muscle spasms in fingers or toes.

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Metabolic acidosis

Increased acid production when too much bicarbonate is excreted from renal loss (i.e. renal failure) or GI loss (i.e. diarrhoea), or increased acid production from ketoacidosis, medications such as Paracetamol or Aspirin, increased lactic acid production, or exposure to certain toxins.

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Signs and symptoms of metabolic acidosis

• Headache

• Lethargy

• Confusion

• Coma

• Hyperventilation

• Nausea/vomiting

• Hypotension.

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Metabolic alkalosis

Too much hydrogen/acids are lost or too much bicarbonate is retained from GI loss,

increased renal loss (i.e. diuretics, Cushing's syndrome),

dehydration or increased bicarbonate retention from IV solutions.

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Signs and symptoms of metabolic alkalosis

• Weakness

• Muscle cramps

• Hyper-reflexia

• Hypoventilation

• Confusion

• Convulsions.

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Red blood

Corrects anaemia and oxygenates tissues.

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Gold blood

Restores haemostasias, either platelet plug or fibrin net.

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Bottles in blood transfusions

Specialised support and replacement, sourced from plasma.

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Timeframes for blood administration

• 4 hours from issue

• 4 hours from spiking the bottle

• 3 hours from reconstitution

• 1 hour from issue.

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Post administration guidelines after blood transfusion

• Stay with the patient for the first 15 minutes

• TPR (temp, pulse, respiration) every 30 minutes

• BP every hour

• TPR/BP at completion.

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Blood pressure regulation

• Blood volume, overall compliance, cardiac output, peripheral resistance

• Parasympathetic NS releases acetylcholine which slows the heart

• Sympathetic NS releases catecholamines, epinephrine and norepinephrine to increase heart rate.

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RAAS system regulation of blood pressure

• BP drops and is detected by the renin-angiotensin aldosterone system (RAAS)

• Sympathetic NS stimulates and releases renin • Angiotensinogen is activated by the liver

• Angiotensin 1 is created

• Angiotensin-converting enzyme (ACE) converts angiotensin 1 to angiotensin 2

• Angiotensin 2 constricts vessels and increases blood volume.

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Cardiac output regulation

• Changes in stroke volume and heart rate.

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Caring for someone with a cardiac event

• ABCs (airways, breathing, circulation)

• Vitals - pain assessment

• Medications (morphine, GTN, aspirin), consider other medications and allergies

• Reassurance.

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Focused cardiovascular assessment

• Inspection - jugular veins (?distended), extremities, CAP refill, redness, pitting oedema

• Auscultation - heart sounds, murmurs

• Palpitation - radial, neck, inner knee, pedal, femoral pulses.

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Thickest layer of the heart

Myocardium.

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Order of blood flow

• Starts in the superior and inferior vena cavae

• Moves to the right atrium • Into the right ventricle

• Blood goes through the pulmonary trunk and enters pulmonary circulation

• Blood reenters the heart through the left atrium

• Moves into the left ventricle

• Enters systemic circulation via the aorta.

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Intrinsic conduction system

Sets the basic rhythm of the heart by generating impulses that stimulate the heart to contract.

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Cycle of the intrinsic conduction system

• Starts with atrial contraction

• Ventricular contraction closes AV valves and opens semilunar valves

• Semilunar valves then close and the chambers relax

• Blood fills the ventricles.

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P-wave on an ECG

Atria depolarization.

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QRS complex on an ECG

Ventricle depolarization.

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T-wave on an ECG

Ventricle repolarization.

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First heart sound (S1)

Sound from mitral and tricuspid valve closing.

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Second heart sound (S2)

Sound from the aortic and pulmonic valves closing.

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Murmur

Abnormal heart sound of blowing/swishing from blood turbulence.

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Grade 1 murmur

Hard to hear.

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Grade 2 murmur

Easily heard but faint.

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Grade 3 murmur

Easy to hear

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Grade 4 murmur

Loud with chest thrill

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Grade 5 murmur

Very loud, can hear when corner of the chest piece is lifted off the chest

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Grade 6 murmur

Can hear when whole chest piece is lifted off the chest

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Angina

Chest pain that occurs when the oxygen demand of the myocardium outweighs the available supply

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Causes of angina

Caused by physical exertion or stress

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Stable angina

Predictable and resolves with rest or GTN

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Unstable angina

Unpredictable and can occur at rest.

Increases in severity, length and/or frequency

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Angina treatment

Smoking cessation,

Control HTN,

Improve diet,

Weight loss,

Lower cholesterol,

GTN (nitroglycerine),

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Coronary artery disease

Narrowing, stiffening and/or blockage of coronary arteries usually caused by atherosclerosis

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Coronary artery disease treatment

Coronary bypass graft (CABG), stents/balloons

Antiplatelets (i.e. aspirin),

Statins (lowers cholesterol),

Beta blockers (lowers HR and BP),

ACE inhibitors (lowers BP)

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Blood test indicating myocardial infarction

Increased troponin T

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ECG changes indicating myocardial infarction

T wave inversion, ST elevation or depression

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Signs and symptoms of myocardial infarction

Prolonged pain or tightness in the chest,

Shoulder, arm, neck, or jaw pain,

Diaphoresis,

Pallor,

Nausea/vomiting,

Anxiety,

SOB,

Fatigue

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NSTEMI on ECG

Non S-T elevation,

involves subendocardial infarction (partial occlusion)

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STEMI on ECG

Elevation of the S-T segment. Complete and sustained blockage resulting in transmural infarction

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Myocardial infarction treatment

Morphine,

Oxygen,

Nitroglycerine,

Aspirin,

Thrombolytics,

Percutaneous coronary intervention (PCI)

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Atrial fibrillation

Irregular and typically rapid heart rate that can cause a stroke or PE

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Ventricular tachycardia

Abnormal and rapid discharge of electrical signals in the ventricles (150-200 bpm)

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Signs and symptoms of ventricular tachycardia

Palpitations,

SOB,

Chest pain,

Dizziness,

Loss of consciousness

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Ventricular tachycardia treatment

Can cause cardiac arrest.

Treated with radiofrequency ablation,

implantable cardioverter defibrillator (ICD) or antiarrhythmics (i.e. Sotolol, Amiodarone)

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Ventricular fibrillation

Ventricles quiver instead of contracting, caused by lack of cardiac output in ventricles

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Ventricular fibrillation treatment

CPR, Defibrillation,

Implantable cardioverter defibrillation (ICD),

Medications (i.e. epinephrine, amiodarone)

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Pulmonic stenosis

Narrowing of the pulmonary valve

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Causes of pulmonic stenosis

Rubella in mothers,

Rheumatic fever,

Carcinoid syndrome

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Signs and symptoms of pulmonic stenosis

Fatigue,

SOB,

Chest pain,

Fainting,

Cyanosis,

Poor appetite,

Abdominal distension

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Pulmonic stenosis treatment

Balloon valvuloplasty,

Pulmonary valve replacement

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Aortic stenosis

Narrowing of the aortic valve preventing blood from flowing properly

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Causes of aortic stenosis

Calcium buildup in the valve cusp, Rheumatic fever, Bicuspid aortic valve (birth defect)