NURS263 exam 2

SBIRT

screening, brief, intervention, referral for treatment

CAGE

self assessment tool on alcohol DEPENDENCE

cut, annoyed, guilty, eye-opener

one yes= potential problem

more than one= highly likely problem

AUDIT

alcohol use DISORDERS identification test

8+ score indicates harmful alcohol use

depression screenings

PHQ-9 & PHQ-2

C-SSRS

columbia suicide severity ranking scale

SAD PERSONS

sex male

age

depression

previous history

excessive drug use

rational thinking lost

seperated

organized plan

no support

sickness

LOC

ask person, place, day, time

alert

lethargic

obtunded- need stimulation

stupor- need painful stimulation

coma

GCS

glasgow coma scale

eye, verbal, motor

4, 5, 6

GCS eye scale

4= spontaneous

3= speech

2= pain

1= none

GCS verbal scale

5= oriented

4= confused

3= inappropriate words

2= incoherent

1= none

GCS motor scale

6= obeys command

5= move to localized pain

4= flex to withdraw from pain

3= abnormal flexion

2= abnormal extension

1= none

types of delirium

hyperactive, hypoactive, mixed

CAM

confusion assessment method

tests DELIRIUM

SLUMS

exam for ALZEIMERS/ DEMENTIA

depends on level of education

20-30 & 27-30 (hs) are normal

common cause of dementia

alzheimers: gradual destruction of brain nerve cells

dysphonia

volume voice disorder

wernicke’s aphasia

difficulty comprehensing (receptive)

words dont make sense

broca’s aphasia

speech issue (cant move boca- mouth)

short phrases

dysarthria

defect in MUSCULAR control of speech

sternum

manubrium, body, xiphoid process

manubrium components

suprasternal notch

sternal angle (angle of louis)- articulation ebtween manubrium & body; location of 2nd ribs

costal angle

between right & left costal margins

normally less than 90 degrees

which ribs are connected to superior cartilages

7-10

anterior vertical reference lines

midsternal

L/R midclavicular

posterior vertical reference lines

vertebral/ midspinal lines

L/R scapular lines

mediastinum

central area in thoracic cavity

trachea bifurcates into BRONCHI at sternal angle

bronchi: RIGHT is shorter and more vertical than LEFT

bronchi bifurcates into BRONCHIOLES

bronchioles terminate into ALVEOLAR DUCTS > ALVEOLAR SACS (contain ALVEOLI)

alveoli

where o2 & co2 more freely between respiratory system & bloodstream

in alveolar sacs

lobes of the lung

right= 3 lobes

left= 2 lobes

parietal pleura

lines CHEST cavity

visceral pleura

lines EXTERNAL SURFACE of LUNGS

pleura space

between parietal and visceral pleura

mechanisms of breathing

ventilation, inspiration, expiration

ventilation

mechanical act of BREATHING through chest expansion

inspiration

inflow of air into lungs

slight negative pressure in lungs

expiration

passive relaxation of intercostal muscles & diaphragm

decrease in cavity size > positive pressure in lungs

breathing patterns

change according to CELLULAR DEMANDS

strongest stimulation to breath is CARBON DIOXIDE (hypercapnia)

orthopnea

difficulty when lying SUPINE— associated with heart failure

proxysmal nocturnal dyspnea

causes waking up

where are pain sensitive nerve endings located

in pleura and mucous

NOT in the lungs

pleurisy

inflammation of parietal pleura

types of sputum

white= VIRAL

yellow/green= BACTERIAL

5 A’s of smoking cessation

ask, advice, assess, assist, arrange

polycythemia

too many RBCs

clubbed nails are a result of

hypoxia (tissue)

crepitus

cracking and popping sound due to air in tissue

fremitus

vibrations of air transmitted to chest wall

check through ball/ ulnar hand edge

bronchial breath sounds

trachea and throat

high pitched, loud, short inspiration & long expiration

bronchovesicular breath sounds

around sternum and scapula

moderate pitch, equal inspiration & expiration

vesicular breath sounds

peripheral lung fields

low pitched, soft, long inspiration & short expiration

voice sounds

bronchophony (99)

egophony (e)

whispered pectoriology (one two three)

when are alveoli formed

8 years old

fine crackles

high pitched, short popping sounds heard on inspiration

coarse crackles

low pitched, bubbling sounds

pleural friction rub

low pitched dry grating sound

sibilant wheeze

high pitched musical sound

sonorous wheeze

low pitched snoring/moaning sound

stridor

harsh honking wheeze, sounds like a seal

tachypnea & bradypnea

greater than 24 bpm & less than 10 bpm

kussmual breathing

rapid deep labored breathing associated with diabetic ketoacidosis

cheyne stokes

alternating periods of deep/rapid breathing with APNEA

room air oxygen

21% liters per minute

low flow oxygen

room air blended with delivered oxygen & dilutes it (lower fiO2)

ex. nasal cannula

ex. non rebreather mask

high flow oxygen

precise amount of fiO2

ex. venturi-mask

flow meter

valve that regulates o2 flow

nasal cannula

by 4s

1L/min= 24%

2L/min= 28%

3L/min= 28&

4L/min=36%

5L/min=40%

6L/min= 44%

non rebreather

reservoir bag filled with o2 that enters mask on inspiration (ONE WAY VALVE)

delivers HIGHEST AMOUNT OF OXYGEN (80-95%)

minimum flow rate= 10L/min

venturi mask

uses ADAPTOR to ensure accurate flow rate

2-4= 24%

4-6= 28%

8-10= 35%

10-12=40%

12-15=60%

semi-fowlers position

head and torso raised 15-45 degrees

humidification

for greater than 4 L/min delivery or extreme dryness

DISTILLED or STERILE water

attached to flow meter

incentive spirometry

helps increase lung volume & alveoli inflation

GAUGE (goal marker) that allows patients to measure progress

at least 10x EVERY HOUR

atelectasis

lung collapse caused by blockage :(

pulmonary system

transport DEOXYGENATED blood from right ventricle to lungs & returns OXYGENATED blood to left atrium

systemic system

provides functional blood supply to ALL body tissue

carries oxygen and nutrients to cells & picks up carbon dioxide and waste products

portions of the heart

upper portion= base; left 2nd ICS

lower portion= apex; left 5th ICS

heart coverings

pericardium

epicardium

myocardium (thickest)

endocardium

sinoatrial (SA) node

“pacemaker of heart”

generate impulses 60-100 bpm

ATRIA contract simultaneously & send blood to ventricles

atrioventricular (AV) node

40-60 bpm

delays electrical impulses & relays signal to AV BUNDLE

AV bundle

20-40 bpm

bundle of his & purkinjie fibers > stimulates VENTRICLES

depolarization

positive charges, more active

repolarization

resting

P waves

ATRIAL depolarization

QRS complex

VENTRICULAR depolarization/ atrial repolarization

T wave

ventricular repolarization

QT interval

ventricular depolarization > repolarization

diastole

higher pressure in ATRIA

AV valves open & ventricles relaxed

systole

higher pressure in VENTRICLES

causes AV valves to CLOSE > S1 (beginning of systole, loudest at BASE) LUB

causes SV valves to CLOSE > S2 (end of systole & beginning of diastole) DUB

S3

caused by blood hitting VENTRICLE WALL

“ken-tuc-ky”

S4

caused by blood flowing rapidly into “stiff” ventricles after atrial contractions

“ten-nes-see”

midsystolic murmurs

aortic/pulmonic stenosis

pansystolic murmurs

mitral/tricuspid regurgitation

diastolic murmurs

aortic regurgitation, mitral stenosis

carotid artery

supplies neck/head with oxygenated blood

bifurcates into external & internal

jugular veins

return blood to the heart (vena cava)

stroke volume

amount of blood pumped from heart with each contraction

cardiac ischemia

Inadequate blood supply

ex. angina: myocardial ischemia

nocturia

urgent need to urinate at night (increased renal perfusion)

rheumatic fever

acute rheumatic fever & rheumatic heart disease

due to b-hemolytic strep

exercise recommendation

3x for 30min a week

murmurs

turbulent flow that creates swooshing/blowing sound

thrills

vibrations felt over 2nd/3rd intercostal space