Fundamentals of Nursing, 9th Ed., Potter, Perry, Stockert & Hall, 2017 | Registered Nurse (RN) School Study Aid
Respiratory Anatomy
- Nasal Cavity
- Hair Filters
- Mucus Filters and Moistens
- Capillaries Warm
- Pharynx (Throat)
- Larynx (Voice Box)
- Cilia Expel Mucus and Dust
- Trachea
- Bronchi
- Alveoli
Alveolar Gas Exchange
- Pulmonary Artery Blood is O2-Poor, CO2-Rich
- Two-Cell Thick Air-Blood Barrier
- CO2 Diffuses Into Air
- O2 Diffuses Into Blood
- Gases Equilibrate
- Pulmonary Vein is O2-Rich, CO2-Poor
- Thermoregulation
Coronary Arteries
- Aortic Root
- Right Coronary Artery (RCA)
- Right (Acute) Marginal Artery
- Posterior Descending Artery (PDA)
- Left Coronary Artery (LCA)
- Left Anterior Descending (LAD) Artery
- Circumflex Artery
- Left Marginal Artery
Cardiac Cycle - Systole
- AV Node
- AV Node Conducts Signal to Bundle of His
- Bundle of His Signals Purkinje Fibers to Contract Ventricles
- Tricuspid Valve Closes
- Pulmonary Valve Opens
- Mitral Valve Closes
- Aortic Valve Opens
Cardiac Cycle - Diastole
- Aortic Valve Closes
- Pulmonary Valve Closes
- Ventricles Relax
- Mitral Valve Opens
- Tricuspid Valve Opens
- Ventricles Fill
- Sinoatrial (SA) Node Fires
- Atrial Contraction
ECG Interpretation
- Rate
- Rhythm
- P Waves
- Upright, Rounded, Before Every QRS
- PR Interval (< 0.20 seconds)
- Normal QRS (< 0.12 seconds)
Hypoxia (Early Symptoms)
- Diaphoresis
- Restlessness
- Tachypnea
- Dyspnea on Exertion
- Tachycardia
- Hypertension
- Arrhythmias
- Decreased Urine Output
- Unexplained Fatigue
Hypoxia (Late Symptoms)
- Cyanosis
- Cool, Clammy Skin
- Use of Accessory Muscles
- Retractions
- Hypotension
- Arrhythmias
Unstable Angina
- Chest Pain with Rest or Exertion
- Limits ADLs
- > 15 Minutes
- Less Likely Relieved by Nitroglycerin
- ST Depression
- Fatigue
- Acute Coronary Syndrome (ACS) Treatment
- Emergency Treatment
Right Heart Failure Assessment
- Jugular Venous Distention (JVD)
- Peripheral Edema
- Hepatosplenomegaly
- Nocturia
- Weight Gain
- Ascites
- Fatigue
Myocardial Infarction Interventions
- Morphine
- Oxygen
- Nitrates
- Aspirin
- Thrombolytics (tPA)
- Cardiac Catheterization
- Stent Placement
- Angioplasty
- Coronary Artery Bypass Grafting (CABG)
- Decrease Modifiable Risk Factors
- Resuming Activity (Physical, Sexual)
Types of Heart Failure
- Left Sided
- Pulmonary Congestion
- Right Sided
- Peripheral Edema
- High Output
- Unable to Meet Metabolic Needs
ECG: Atrial Fibrillation
- Variable Rate
- Irregular Rhythm
- No P Wave
- No PR Interval
- QRS < 0.12 Seconds
Left Heart Failure Assessment
- Pulmonary Congestion
- Pink Frothy Sputum
- Wheezing or Crackles
- Dyspnea with Exertion
- Cough
- Fatigue
- Tachycardia
- Weak Peripheral Pulse
- S3, S4 Heart Sounds
Myocardial Infarction Assessment
- Substernal Chest Pain
- Crushing or Dull Sensation
- Arm, Jaw, and Neck
- > 20 Minutes
- Unrelieved by Nitro
- Palpitations
- Diaphoresis
- Fear of Impending Doom
- Nausea and Vomiting
- Shortness of Breath
- Monitor for Arrhythmias
Tuberculosis Assessment
- Airborne Droplet
- 3 Week Productive Cough
- Night Sweats
- Chest Pain
- Fever
- Weight Loss
- Fatigue
- Chest X-Ray
- Blood Tests
- Mantoux Skin Test
- 3 Positive Sputum Tests
Myocardial Infarction Diagnosis
- 12 Lead ECG
- ST Elevation
- Q Wave
- T Wave Inversion
- Troponin T and I
- CK-MB
- Early ECG
- Cardiac Stress Test
Mitral Regurgitation
- Holosystolic
- Blowing Murmur
- Loudest at Apex
- Radiates toward Axilla
- Louder by Squatting
- Hand Grip
- Expiration
Tricuspid Regurgitation
- Holosystolic
- Blowing Murmur
- Radiates to Right Sternal Border
- Enhanced by Inspiration
Aortic Regurgitation
- Diastolic Murmur
- Immediate High-pitched
- Blowing Murmur
- Wide Pulse Pressure
- Water Hammer Pulse
- Head Bobbing
- Pulsating Nail Bed
- Can Cause Austin Flint Murmur
Stable Angina
- Chest Pain with Exertion
- Relieved within 15 Minutes
- ST Depression
- Nitroglycerin
- Up to 3 Doses q 5 Minutes
- Rest
- Antiplatelet Medication
- CABG
- Angioplasty
Substance Use Disorder Assessment (Formerly Substance Abuse Assessment)
- Changes in Mood
- Poor Hygiene
- Odd Sleep Patterns
- Frequent Injuries
- Relationship or Job Difficulty
- Poor Performance
- Anorexia OR Weight Loss
- Social Isolation
- Financial Problems
Lung Sounds - Wheezes
- Throughout Lung
- High Pitched
- Musical
- Air Moving through Narrowed Airways
Inhaled Anesthetics
- Unknown Mechanism
- HEISMN Drug Name Acronym
- Respiratory Depression
- Myocardial Depression
- Lower Metabolic Demand, Increased Cerebral Blood Flow
- Hepatotoxicity (Halothane)
- Nephrotoxicity (Methoxyflurane)
- Seizure (Enflurane)
- Malignant Hyperthermia
- Expansion of Trapped Gas
Warfarin (Coumadin)
- Inhibits Clotting Factors
- Atrial Fibrillation
- Venous Thrombosis
- Pulmonary Embolism
- PT/INR Levels
- Observe for Bleeding
- Pregnancy
- Vitamin K and Fresh Frozen Plasma
- Prolonged Therapeutic Onset
- Maintain Same Diet
Marijuana Intoxication Assessment
- Euphoria
- Slowed Reaction Time
- Conjunctival Injection
- Increased Appetite
- Anxiety
- Social Withdrawal
- Paranoid Delusions
Cocaine Intoxication Assessment
- Euphoria
- Delusions
- Mydriasis
- Hallucinations
- Agitation
- Hypertension
- Arrhythmias
- Hyperthermia
- Seizures
- Nasal Septum Perforation
Tuberculosis Skin Mantoux Test (PPD)
- Delayed Hypersensitivity (Cell Mediated Response)
- Intradermal Injection
- Read 48-72 hours
- ≥ 5 mm Induration
- Immunosuppressed
- ≥ 10 mm Induration
- High Risk Patients
- ≥ 15 mm Induration
- Chest X-Ray
Cardiac Enzyme Evaluation: Troponin
- Cardiac Muscle Injury
- Detection in Blood: 4 Hours
- Peak: 24 - 36 Hours
- Return to Normal: 5 - 14 Days
- Most Specific for Cardiac Muscle
- Treat Aggressively
Cardiac Enzyme Evaluation: Creatine Kinase CK-MB
- Skeletal or Cardiac Muscle Injury
- Onset: 4-8 Hours
- Peak: 12-24 Hours
- Return to Normal: 2-3 Days
Troponin Lab Values
- Troponin T (cTnT)
- < 0.1 ng/mL Normal
- Troponin I (cTnI)
- < 0.5 ng/mL Normal
- > 2.3 ng/mL Myocardial Injury
Cholesterol Lab Values
- LDL (Low Density Cholesterol)
- < 100 mg/dL
- HDL (High Density Cholesterol)
- > 40 mg/dL Males
- > 50 mg/dL Females
- Total Cholesterol
- < 200 mg/dL
Cardiac Catheterization
- Fluttering Sensation
- Contrast Media
- NPO 6-12 Hours
- Bed Rest
- Assess Circulation
- Assess for Bleeding
- Monitor Vital Signs
pH - Blood and Urine Lab Value
- Blood
- 7.35 - 7.45
- Urine
- 4.0 - 8.0
Pediatric Vaccinations - Age 4 Months
- DTaP - Diphtheria Tetanus acellular pertussis
- RV - Rotavirus
- HiB - Haemophilus Influenzae Type B
- IPV - Inactivated Polio Vaccine
- PCV - Pneumococcal
Pediatric Vaccinations - Age 6 Months
- Hepatitis B
- DTaP - Diphtheria Tetanus acellular pertussis
- RV - Rotavirus
- HiB - Haemophilus Influenzae Type B
- IPV - Inactivated Polio Vaccine
- PCV - Pneumococcal
- Influenza
Pediatric Vaccinations - Age 12 to 15 Months
- Varicella Zoster
- MMR
- Hepatitis A
- DTaP - Diphtheria Tetanus acellular pertussis
- HiB - Haemophilus Influenzae Type B
- IPV - Inactivated Polio Vaccine
- PCV - Pneumococcal
Tracheostomy Care
- Inner Cannula Removed and Cleaned
- Clean Q8 Hours Around Stoma
- One Finger Under Ties
- Speak with Deflated Cuff
- Can Eat with Tube in Place
- Keep Replacement Tube Nearby
- Immediately Replace if Dislodged
- Physician Does First Tube Change
Obstructive Sleep Apnea (OSA)
- Narrowed or Obstructed Air Passage
- Apnea
- Loud Snoring
- Startle Response
- Daytime Drowsiness
- Positional Therapy
- Oral Appliance
- Continuous Positive Airway Pressure (CPAP)
- Surgery
- Weight Loss
Pneumothorax
- Air Enters Pleural Space
- Sudden Dyspnea
- Absent or Restricted Movement on Affected Side
- Decreased or Absent Breath Sounds on Affected Side
- Chest Pain
- Tracheal Deviation
- Vital Sign Changes
- Crepitus
- High Fowler's Position With Oxygen
- Prepare For Chest Tube Placement
- Educate High Risk Patients
Chest Tubes: Management and Care
- Confirm suction order
- Crepitus
- Kinking
- Shortness of Breath (SOB)
- Infection
- Excessive bubbling
- If tube dislodges from patient, use petroleum gauze taped 3 ways
- If drainage system is damaged, place disconnected drainage tube in sterile water
Oxygen Delivery Methods
- Nasal Cannula
- Simple Face Mask
- Non-Rebreather Mask
- Venturi-Mask
- Oxygen In Use Sign
- No Electrical Sparks
- Six Feet Away from Open Flames
- Dry Nasal and Upper Airway Mucosa
- Skin Irritation
- Home Education