204 Flashcards
(225 cards)
1
Q
Skin cancer ABCD rule
A
Asymmetry- normal moles are symmetricalBorder- jagged edgesColor- if it has more than one color or hue it is suspicious diameter- if it is larger than a pencil eraser 1/4 inch it should be examined elevation/evolving- if its raised and if it is changing
2
Q
body mechaninks
A
feet apart, bend knees head erect and midlineabdomen tuckedhips and ankles flexed
3
Q
body balance
A
bend down not forward to maintain a low center of gravity
4
Q
friction
A
can cause shear. when rubbing or resistance caused when body meets a surface
5
Q
atqxic belt
A
unbalanced gait
6
Q
rom excercises
A
3-4 times a dayactive pt- they are able to move their own jointspassive pt- nurse moves pt. joints
7
Q
immobilized patiet - will need moving - use body mechanics
A
dependent pt- assist pt to regain independence
8
Q
activity toleranceintervention
A
bulid back muscle massmanage pain
9
Q
respiratory interventions
A
turn, cough, deel breath every 1-2 hrs. \increase fluid intae to 2000 ml/day
10
Q
metabolic/fluid.electrolyte intervention
A
increase protein- for healingmonitor I&Oincrease fats and carbs
11
Q
cardiac interventions
A
orthostatic hypotension- assist movement slowly, before standup dangle pt feet 5-10 min. DVT- deep vein thrombosis- give TED stockings, give anticoagulants, ROM every 4 hrs.
12
Q
skin interventions
A
assess skin every 2-4 hoursreposition every 1-2 hrs provide pressure relieving devices
13
Q
dehiscene- happens after abdominal surgery, wound separates. get pt back in bed call surgeon
A
evisceration- happens after abdominal surgery- bowel comes out, if pt has weak conn. tissue
14
Q
disuse
A
muscle contracted by imobility
15
Q
tissues under nail
A
tissues under the nail are highly vascular and provide clues to oxygenation status and blood perfusion
16
Q
To make sure blood circulation isnt impared
A
you check for capilary refil by pressing on nail (it turns from white to pink in 3 sec)
17
Q
clubbing
A
a deformity of the fingers and fingernailsassociated with lung, heart or GI disordersdue to low oxugen
18
Q
pruritus
A
itching
19
Q
cellulitus
A
when tissue around sore gets inflamed
20
Q
fluid in rashes
A
serosanguinis- mixture of clear and red fluidsanguinus _ bloody purulin- pusy drainage (yellow, tan)serous- clear watery plasma
21
Q
skin (warm and dry)
A
xerosis- dry skinseborrhea- oily skinstriae- strech markscheck for skin turgor- skin when pulled returns to normal, it skin doesnt recoil it is called tenting (check in clavicle not in hand, because skin in hand is thinner)
22
Q
skin color changes
A
jaundice- yellow tint (liver & gallbladder disease) -look at the whites of their eyes to chek for this, palms are not a good place to chek because some ethnic griups have yellowish tonesvitiligo- loss of pigmentation to the skin
23
Q
wounds
A
granulating- healing woundeschar- black skin that forms on wound. needs to be cutt off
24
Q
hair problems (shiny and soft)
A
hirsutism- too much hair (endocrine disorder)alopecia acredia- hair loss of unknown origin
25
milia
white dots, baby acne
26
erythema toxicum
rash
27
limited mobility
hemiplegia-paraliyzed on one side of bodyparaplegia- paralyzed waist downquadriplegia- paralyzed neck down
28
if skin does not blach
stage I pressure ulcer has developed
29
foliculitis
hair follicle infection
30
pediculosis
lice
31
hirutism
increase in growth in facial, body, or pubic hair
32
paronychia
chronic infection of cuticle
33
vitiligo
unpigmented skin
34
nevi
moles
35
cyanosis
blue tinge to skin or gray color in lips, may see with clubbing (look at gums)
36
pallor
pale
37
jaundice
yellow from increased bile pigment
38
erythema
red from increased cutaneous blood flow
39
edema
swelling
40
petecheae
red/purple pinpoints tht dont blanch
41
purpura
brown/red/purple discoloration due to hemmorrhage into tissue (does not blanch)
42
slough
stringy substance attached to wound bed
43
macule
flat patch, darker in color
44
papule/plaque
round elevated
45
wheal
irregularly shaped elevated area, (mosquito mite/ hives)
46
nodule/tumour
nodule- solid, raised bump deeper and firmer than papule, extends through subcutaneous tissue
47
vesicle
filled with serous fluid (chickenpox) starts like a blister then crusts
48
bulla
fluid filled large blister
49
pustule
elevated lesion like a vesicle but filled with purulen (pussy) fluid
50
cyst
fluid filled leasion
51
scale
many layers of keratin, flaking skin
52
keloid
growing scar
53
excoriation
abrasion
54
fissure
linear crack
55
erosion
larger loss of epidermis
56
abses
puss filled leason (usually iv drug users)
57
ulcer
deep loss of skin surface
58
atrophy
thinning of skin with loss of normal skin furrow,
59
Vertigo
Dizzynes
60
Synocope
Fainting
61
impedigo
crusted leasion
62
echymoses
red/purple/yellow/green BRUISE(from ruptered blood vessles)
63
pain PQRST (you want to prevent pain)quality of pain (aching, stabbing, tender, tiring, numb)
p provokingq qualityr reagions severityt timing
64
shivering
sometimes shivering is a warning for an infection before the temp. starts to spike, decrease temp- vasodialationincrease temp- vasoconstrictionwhen pt comes of of the OR and they are cold- if a blanket is not enough give a narcotic such as opiod (this increases the temp)
65
afebrile- no fever
febrile- fever
66
when you get an abnormal reading of vital signs
you first want to find info (such as look at charts)then you want to reases and then call physitioninforeasses physitian
67
check pulse before giving medication
because if the pulse is already too low the medication will make it worse
68
pule (60-100) normal adultnewborn (130-160)rhythm (regular / irregular)volumestrongweakthredy- (hard to feel ) for people in shock because the BP is so low that it doesnt have force to push against arterial wallbounding- very strong (heart failure with extra fluid)
pressure of blood pushing against wall of artery as heart beats and restshypotensive - low pulsehypertensive - high pulsenormotensive- normal pulse
69
tachycardia
high heart rate
70
bradychardia
low heart rate
71
IF CUFF IS TOO SMALL
will give a HIGH bp reading
72
IS CUFF IS TOO BIG
will give a LOW bp reading
73
respiration
12-20 Rhythm (regular / irregular )characteristics ( shallow, deep, labored)labored - SOB, when pt is in pain or accident
74
blood pressure
force of blood pushing against wall of arteries systolic- contractdiastolic- relax
75
BP readings
normal (120/80)prehypertension (120-139 / 80-89)Hypertensive (stage 1) 140-159 / 90-99hypertensive (stage 2) >160/100
76
core temp (rectal, tympanic)
surface (oral, axulary, temporal)
77
rectal
more accurate (dont use on cardiact pt)
78
celcius ferenheigt
C=(F-32) x 5/9
79
The average normal oral temperature is 98.6°F (37°C). An oral temperature is 0.5°F (0.3°C) to 1°F (0.6°C) lower than a rectal or ear (tympanic) temperature.A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.An ear (tympanic) temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.An armpit (axillary) temperature is usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature.
.
80
pesonal space
1 1/4 - 4 feet
81
SBAR
used for giving report or charting
82
leading question
direct pt to a specific part of the body
83
profalactive treatement
preventative treatment
84
medical asepsis
sanitation- reduces nr of microorganismsdisinfection- destroies infectious agentsseralization
85
surgical asepsis
sterle
86
iatrogenic infection
given to patient by proceadures
87
nonsocomial infection
hospital aquired infection
88
QSEN
organization for facutly to teach studentsabout safety
89
sentinal event
event that occurs from a hospital procedure that causes harm to a patient or even death
90
nearmiss event
event in which a disasterous thing happends but it is ether cought right away or it doesnt have any negative effets on the pt
91
levels of care
primaty- preventative- immunization excercice, diet, washing handssecondary- screening- mammogramstertiary- rehabilitiation
92
light palpation 1 cm
deep palpation 4 cm
93
5 percussion tones
tympany-high loud piched heard over abdomeresonace- over lungshyperresonance- overinflated lungsdullness- over liverflattness- over bones and muscle
94
intrapersonal comm
self talk
95
interperonal comm
2 or more ppl comm
96
congruence
nonverbal behaviour matches verbal behaviour
97
nurse-pt relationship
1. preporatory phase2. orientation phase3. working phase4.. termination phase
98
preporatory phase
pre interaction phasereview info about pt
99
orientation phase (introductory phase)
introduce selfexplain procedureobserve behaviour
100
working phase (maintenance phase)
encourage to express feelings
101
termination phase
conclude
102
vectors
living organisms can be insects or people
103
fomites
inanimate objects such as clothing, water, food
104
osteomyolitis
if infection goes to bone
105
hirtuism
excessive hair on body
106
pediculosis
lice
107
alopecia
hair loss
108
TED stocking
measure pt firstthe help to compress veins but not arteriesthey prevent blood clots, may be worn at times of ambulation to help with edema and blood clotts
109
pulse deficit
apical rate - radial rate if its > 2 beats/min
110
lymph nodes
-lymph nodes are in chains or clusters-they feel round, smooth, and rubbery-if they become enlarged or tender means that those are early signs of innflamation-if they are hard and irregular shaped they may be cancerous-you feel them in a circular manner
111
if pt has a crocked smile
this may indicate a strokeSTROKE- difficulty with facial muscles
112
dysphacia
difficuly speaing
113
dysphagia
difficulty swallowing
114
if pt complains of sore face
check sinuses
115
transilumination
shine light in roof of mouth and it light is shown throught it is clear if not then there is sinuses
116
thyroid
examine for symetry and lumpsif someone has an overenlagred thyroid you do not want to over examine bcuz this may cause an increase release of thyroid hormones
117
snellen chart
testing vision20/100 what a normal person seen at 100 ft, this pt can only see in 20 feet
118
testing eye muscle movements
pt. will watch your movng finger as it forms the letter H, this test for all 6 facial muscles
119
glaucoma
blood vessles in eye may hemmoragehigh pressure of fluids in the eys
120
pupil assesmentpreladirect light reflexaccomidationfacial nerves (H)
p.e.r.r.l.ap- pupilse-equalr-roundr-reactivel-light-accomidation - move finger from pt eye and away (pupils dialate at distand object and constrict at near object)
121
direct light reflex
constriction of pupils when light is shined at them
122
consensual light reflex
simultaneous constriction of other pupil
123
unequal pupils
ALARMING- may indicate brain injury or stroke ask pt if they had if they have had any prior surgery
124
respiratory system
change of o2 and co2 in the celular levelleft lung 2 lobesright lung 3 lobes
125
inspiration- active
expiation- passive
126
respiratory exam
1. observe pt breathing, it its normal, labored2. asses a-p diameter (2-1) anterior/posterior3. asses pt. color (cyanosis)
127
asthma
use of accesory musclesSOBwheezing/coughingmaybe cyanoses
128
pulmonary embolii
blockage in lung by an embolism (blood clott)acute SOB ( dont give o2 for COPD)causes decrese/absent lung sounds
129
trauma to chest
ribs crack, can puncture lungs
130
COPD
chronic obstructive pulmonary desease\1. emphysema2. asthma3. chronic bronchitis-Chronic bronchitis, which involves a long-term cough with mucus;- Emphysema, which involves destruction of the lungs over time .
131
flail chest
unsymetrical breathing
132
dyspnea
difficulty breathing
133
percution- helps to identify tissues are air, fluid or solid filled
resonance- spund between ribs, LUNGHYPERRESONANCE- EMPHYSEMA, WHERE THERE IS EXTRA AIR, COPDtympany- on belly, PUFFED CHEEK
134
OXYGENATION
-look for change in level of councesness (pt is confused and anxious)SOB, skin color
135
hypoxia
lack of o2 in tissues
136
hypoxemia
lack of o2 in blood
137
symptoms of hypoxia early signs
RATR- restlessA- anxietyT- tachycardia high HR
138
symptoms of hypoxia late signs
BEDB- bradychardia low HRE- extreme restlessnessD- dyspnea
139
why does pt become restless when oxygen drops
bcuz brain is effected and not getting enough oxygen
140
why does pt become tachycardic when oxygen level drops
because high pulse rate causes high heart rate
141
when pt SOB
instruct pt to take deep breaths(put pressure on diaphragm with pillow) and cough
142
incentive spirometer
brethe in 10X hourexpands the lungs
143
pursed lip breathing
makes breathing more effective. for COPD
144
atelectasis
incomplete lung expansion or collapse
145
perfusion
capillary blood presses through tissue
146
peek flow meter
for pt with asthmayou establish a personal best level and measure and compare it 2X day
147
sputumn collection
best in AM because mucous collects in throat pt can cought it upor if pt can not cought it by by themselves you can suction (when u suctin make sure to give o2 because u take the o2 out)
148
artery- away from heart
vein- to heart
149
myocardial infarction
artery getes blocked
150
active percordium
heart pumping for hard you can see it under the skin
151
cardicat cycle
systole- pumping phase, contractiondiastole- filling phase, relaxation
152
decreased cardiac output
associated with a decrease in pheripheral pulse and causes FATIGUE
153
pulse deficit
when heart beats are not all geting peripherallyradial pulse 80apical pulse 10020 pulse deficit
154
first heart sound S1
accurs with closure of the two artrio-ventricular valves, when ventricles start to contract SYSTOLE
155
second heart sound S2
PRODUCED BY CLOSURE OF AORTIC AND PULMONARY VALVES DIASTOLE
156
MURMUR
soft swishing sounds in the heart. heard on chest wall due to turbulance, excercise, anemia, narrow valves
157
erbs point
transition area from pulmonic to tricuspid valve, you can differentiate between murmors. because the murmors may overlap due to close proximety
158
S3 and S4
both are heard during diastole
159
ascultation of heart sounds
APETMaorticpulmonaryerbs pointtricuspidmitral
160
regurgitation or insuficency
a valve that doesnt close efficently and results into the backflow of blood
161
stenosis
a valve that doesnt open efficently may cause turbulent backflow secondary to obstruction or narrowing
162
ascetis
fluid in belly
163
pericardial friction rub
caused by fluid in the pericardial sackgrating sound
164
pheripheral resistance (constricion of vessles)
squeeze of blood vessles, friction of blood as it passes through veins
165
congestive heart failure
inability of heart to circulate blood effectively enough to meet bodys metabolic needshypertension is the main cause of this
166
how to measure peripheral resistance (anchle brachial test) constriction of vessles
blood pressure taken in the ankle and arm. the ancle systolic pressure divided by arm systolic pressure. meaurment taken again after 5 min of waling on treadmillif there is a drop when pt walked on the treadmill that means that there may be PERIPHERAL ARTERIAL DESEASE CLOSER TO 1 THE BETTER
167
distention
big veins from fluid overload
168
if you can not feel the pulse
check with a doplar
169
bruits- heard in carotid artery (only check one at a time)
A bruit is caused by turbulent blood flow in an artery which supplies blood to the brain
170
allens test
to see if there is adequate perfusion in hand and to see if it is ok to pur an arterial line in that armASSESES BLOOD FLOW TO HAND PRIOR TO PLAING A-LINE
171
HOMANS SIGNS
ASSESED FOR DVTif you dorsiflex the foot and they have pain they have DVT, you dont want to repedetly do it because it may dilodge the vlott
172
holtor monitor
20 hour monitor to heart to find abnormalities
173
peristalsis
intestines moving
174
root work for liver
HEPATO-
175
root word for bile or gallbladder
CHOLE-
176
ROOT WORD FOR STOMACH
GASTRO-
177
liver
produces bile, removes toxins from bloodalchohol, chemicals, drugs, tylenol and acetaminophen damages liverif there is a liver disorder jaundace occurs
178
gallbladder
under liver, recieves bile from liver and forces it out of cystic duct to common bile duct
179
cholithiasis
stones in gallbladder
180
stool- lighterurine- darker
if there is a block in the gallbladder and bile doesnt spread efficently
181
small intestine
digestion compleated there. and absorbtion
182
large intestine
recieves and stored fluid waste
183
ulcerative colities
ulcers in collon
184
hernia
intestines comes through muslces
185
hemmorroids
bleeding while passing stool
186
diverticulosis
is the condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall
187
obstipation
skinny ribbon stool
188
aerophagia
swallowing air
189
bobrogymus
rumbling stomach, hunger
190
cachexia
pt is skeleton like, skinny
191
cirrohsis
liver disease due to alchohol, liver cells can regenerate
192
colic
irritated baby
193
flatus
gas
194
impactions
hard stool
195
halitosis
bad breath
196
melena
black stool, from stomach GI bleed, blood gets digested and turns black
197
pyloric stenosis
narrowing of valve of stomach
198
steatorrhea
fatty stools
199
wounds (REEDA)
rednessedemaechymosesdrainageapproximation
200
constipation
encourage fiber but with fluidsencourage ambulation
201
garting
pt tightens muscles due to pain
202
peritonitis
severe garting , board like bellyfe
203
polyuria (diuresea)
production of abnormally large amounts of urine
204
olguria
low urine output
205
anuria
lack of urine production
206
nocturia
voiding two or more times a night
207
urgency
sudden strong desire to viod
208
dyuria
painful or difficult voiding
209
enuresis
involuntart urination in children
210
normal urine outut
60 ml / hour1500 ml / day
211
cystisis
UTIUrine is cloudy in cystitis because of bacterial and white cells.
212
removal of foley cathater
If 4 hours after Foley removal have elapsed without voiding, it may be necessary to reinsert the Foley.
213
credes method
With this method pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter. BY PRESSING HAND ON BLADDER
214
crackles (RALES)
fluid (usually found on base of lungs)ASK PT TO COUGHT AND DEEP BREATHE TIMES EVERY HOURCOMMONLY WITH INSPIRATION
215
WHEEZE
AIRWAY CONSTRICTIONCONTINUOUS, MUCSICAL, HIGH PITCHED
216
RHONCHI
OBSTRUCTUON OF AIRWAY FROM SECRETIONSLIKE SNORINGLOW PITCHED
217
STRIDOR
UPPER AIRWAY OBSTRUCTIONLOUDEST OVER TRACHEA (INHILATION OF FOREIGN BODY)
218
Granulating
Healing wound
219
PLEURAL RUB
BRUSHING SOUNDWHEN INFLAMED PLEURA RUBS ASSOCIATED WITH PNEUMONIA
220
Eschar
Blac skim needs to be cutt ofDebreed
221
Hemiplegia
Parylized on one side
222
Parapalegia
Parulized waist down
223
Quadriplegia
Paralyzed neck down
224
Vessicles
Start like blosters then crustHicken pox
225
If someone is an iv drug user
Abses- puss filed leasion
