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Fundamentals Test 2 > Chap 22, 28, 39 > Flashcards

Chap 22, 28, 39 Flashcards

(134 cards)

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1
Q

This type of assesment is accomplished when first admitted to hospital

A

Initial assesment/ admission assesment
Gathering hx, demographic, physical exam, questions smoking drinking past surgeries occupation food preferences. What brought on admission

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2
Q

Type of assesmeent involved every beginning of shift, inspect/observation, appearance, skin color, clean disheverled, afdect(mood) c9ntours body color, rashes, ease of respirations, sob?

A

Shift assesment/head to toe

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3
Q

Exam accomplished 9n 9ne body system or area

A

Focused exam

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4
Q

Focused exam questions- what body area?

Headaches, dizzy, visual, cols allergies, sore throat dental, how sleeping?

A

Head and neck

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5
Q

Focused exam, questions what body area
Leg pain or cramps when walking
Tb exposure
Angina chest pain htn, mammo coughoccupational resp exposure

A

Chest

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6
Q

Focused exam, what body area

Indigestion, thirst hunger, rectal bleeds, hemorrhoids, gallbladder liver

A

Abdominal

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7
Q

Focused exam body area?

Urinating urgency, kidney stones sexually active , herpes, last papsmear

A

Genitourinary

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8
Q

Focused exam body area

Joint pain stiffness, full rom, circulation leg and arms, bruise easy, fx phlebitis

A

Extremitis musculskeletal

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9
Q

Focused exam body parts

Thyroid, dm 1 or 2

A

Endocrine

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10
Q

Aphysical exam techniques how many types paplation

A

Light and deep

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11
Q

Purpose of palpation

A 
Sense of touch =great deal clinical info. Detect size shape position of body parts. Texture temp, moisture on skin. 
Muscle spasm, rigidity
Pain swelling growth
Restriction movement
Turgor edema
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12
Q

Type of palpation checks for muscle spasm, rigidity, pain,swelling growth, restrictions in movement, pain, masses abnormal collection fluid,
PADS of FINGERS.
1/2- 3/4 inches

A

Light

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13
Q

Type of palpation used to check turgor moisture of skin @1/2 to 3/4

A

Light

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14
Q

Involved in physical exam technique, helps determine size, shape location density of organ and any AIR or FLUID there

A

Percussion- we dont do this.

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15
Q

Type of percussion

A

Tympany

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16
Q

Rules standing scale

A

No shoes, stand erect, bar placed flat on head

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17
Q

Where and how to listen to abnormal heart sounds

A

With the bell of the stethoscooe, lightly, in all 4 valve areas
Aortic, pulmonic. Tricuspid, mitral always use bell

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18
Q

What body system ?

A

Gen apoearance, skin. Stuffy nose, drainage, teeth, eye exam. Does thinking seem logical? Neck nornal? Lymph nodes?visual acuity, hearing check.

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19
Q

Chest, heart, lungs what to look for

A

Rise fall, symmetry, spine view from rear, should be midline w gentle concave and convex curves

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20
Q

Exaggerated lumbar curves (chest heart lungs)

A

Lordosis, l and l

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21
Q

Increased curve in thoracic area

A

Kyphosis(hunchbak) quasimodo

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22
Q

Pronounced lateral curvature of spine

A

(scoliosis)

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23
Q

Whistle musical high pitched sound air being forced throughnarrow partially obstructed airway

A

Wheeze

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24
Q

Course low pitched sonorous rattling caused by secretions in larger air passages

A

Gurgle /low pitched wheeze, rhonchi

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25
Fine/course non musical sounds. Fine=high in pitch Course=louder and low in pitch Rubbing hairs between fingers
Crackles
26
Snoring sound produced by inability to cough up secretions from trachea or bronchi
Stertor
27
Croaking crowing partial obstruction of upper air passages
Stridor
28
Grating scratchy sound similar to creaking shoe leather, opening squeaky door, caused by irritated pleural membranes rub over each other
Pleural friction rub
29
When insoecting the anterior chest to see if there is a point of maximal impulse. (PMI) what should u see
Hopefully nothing as seeing pmi is bad!
30
Whichnis better way of checking skin turgor in olde adult?
Mucous membranes better that skin turgor
31
How shoukd u check for generalized edema?
Weight gain over short time
32
How to check for dependent edema
Press fingers into tissue overtibia just above ankle, if indentation remains, PITTING is present
33
How to describe edema ..what terms to use?
Taut, tight, puffy, indented, pitting. If pitting present classify according to depth
34
How many types of skin lesions?
6
35
Flat area w change to color smaller than 0.5cm | If larger than0.5, it is a patch
Macule (mac has a c so does color)
36
Elevated solid lesionsmaller than 0.5cm if larger it is a nodule
Papule think papas are elevated
37
Circumscribed, superficial collection serous fluid, smaller that 0.5 varicella, herpes zostersecond degree burn
Vesicle think shingles .. vesicle sounds like sick
38
Circumscribed elevated SOLID lesion psoriases, seborrheic actinic keratosis.
Plaque is solid
39
Firm edematous irregularly shaped area insect bite urticaria
Wheal.
40
Elevated superficial lesion filled w purulent fluid acne impetigo
Purulent=pustule
41
What do skin sensations do over time?
Diminish / decrease
42
When classifying pitting edema what are the numbers?
1-4 with 1 being minimum and 4 being most
43
How are nursing diagnosis formed?
Deoendent on problems discovered during assesment, the data is analyzed and problems identified. Rn ids nursing dx lvn may choose dx from nanda if no rn during shift.
44
What is planning?
Appropriate goals or expected outcomes are written for each nursing dx identified. Set priorities of care based on most urgent needs of each assigned pt.
45
What is implementation?
?
46
What is rnshope?
``` Rest activity Nutrition fluids electrolytes Safety security Hygiene, grooming Oxygenation and circulation needs Psychosocial and learning elimination ```
47
What is involved in initial observation head to toe assesment?
Skin color, appearance, affect, ease respiration, how pr feeling.
48
Why is an older adult prone to chilling?
Less subcutaneous tissue make sure to drape them
49
How to help older adult to not become stiff
Slowly help them to seated position and dangle for few minutes
50
What is a knee chest position used for
Rectal exams
51
What positions do you drape the whole body?
Sims and supine
52
Why use draping?
Prevent unexessary exposure also provides warmth
53
What should u do before bladder exam
Empty bladder
54
What is the weber test
Striking a tuning fork place on ots head then u should hear equally on both sides
55
What is a rinne test?
Air vs bone conduction. After striking tuning fork place place in front of ear for air then bone. Think rino have bones
56
What is consensual refkex
Grade when constricted. 2 consenting adukts, both eyes should react if u shine light on 1.
57
What is the functional unit of respiratry system
Alveoli
58
How many lobes lung
Left 2 lobes | Right 3 lobes
59
Cns - rate /depth chemoreceptors in aorta and carotid send feedback to brain
True
60
What is decreased 02in blood determined by spo2
Hypoxemia
61
Decreased 02 @ cellular level
Hypoxia
62
Retaining carbon dioxide is called what
Hypercapnia
63
What happens during hypoxia
1. Airway obstructed 2. Restricted thoracic cage/ obesity pneumo, chest tube 3. Neuromuscular-feedback to brain. Ms,mg ms, guiilian barre cva, brain,
64
What are some disturbabces 8n diffusion of gas
``` Emohysema Trauma Embolism Tumors Resp distress syndrome ```
65
Early hypoxia symptoms
``` Irritable Restless Confusion Tachypnea Anxiety Abn lung sounds Angry bird air hungry ```
66
Late signs hypoxia
Retractions Cyanosis Dysrhytmias
67
What is a major complicationnof immobility
Hypostatic pneumonia
68
What to do for hypostatic pneumonia bedridden due to immobility
Rom cough deep breathing turn q 2 hoain managament
69
For gi tract effects problems
Increase fluid to 3000 cc increase fiber
70
Brain psychological effects immobility what u can do
Active listening, communication
71
Pulling force maintain body alignement maintain fracture alignment. Relieve pain
Traction
72
How many types traction
3. | Manual skin and skeletal
73
Skin traction how many lbs
10-15 | Aka buck traction
74
Do we want to use traction on elderly pts
Not really skin and bones
75
Rules traction
1. Ropes and wts free of friction(hanging freely)not on floor 2. Maintain alignment. Keep straight 3. Wt hanging freely not touching bed ir floor 4.
76
Counter traction rules
Head of be should be no higher than 20 degrees
77
What tyoe of traction is invasive
Skeletal traction
78
Max weight for skeletal traction
30lbs/ 14kg
79
Pin care
Sterile swabs circular motion
80
What type drainage
Clear fluid drainage expected initially | But if persists and changes colors is a problem
81
Pin care
Antimicrobial only.if ordered
82
External fixator is invasive but pt can still move leg around
True
83
Casting points to remember
Assses fir breakdown Pad edge with dressings w moleskin Chafing
84
Hip spica cast
Never grab by middle
85
What hapoens if cast dries too fast
Will compromise circulation so bivalve
86
How to handle cast during drying
Use palm and flat parts of fingers rather than fingertios, dents in cast can lead to impairment pressure injuries
87
Continuius laterak rotational beds
80 degrees can be set tonpause on either side for up to 30 mins
88
Circolectric bed
Turns whole 360 degrees allowing change of position fir bed
89
Air fluidized bed
Tx of 3 , 4 and unstageable pressure injuries fresh grafts flap repair
90
Cpm care includes what
Assess opposite bleeding evaluate aignment every 2-4 hrs
91
Cpm care
Assess skin condition over bony prominences provide sin care every 2 hours
92
Neurovascular assesment | Every pt who has fx, cast traction
``` Skin, movement, sensation, pulses, cap refill, pain ```
93
Age changes affecting respiration
``` Decreased elasticity thorax resp tissues Water decreases 50 % dry mucous Loss elastic recoil Thick alveolar membrane - efficient gas excha O2 sat 75-80 Less reso reserve ```
94
Ways to distinguish hypoxia and hypoxemia
Hypoxia=disease illness-abg-cell level | Hypoxemia detected w spo2
95
Common causes hypoxia
Obstruction airway- | Rettictes mvmnt thiracuc cage-obesity
96
How many compressions per mi
100-120 Ensure full recoil Cab
97
Main ways to clear rspiratory secretions
Deep brthng-sit up, inhale, hld brth,3-5 brth out mth Coughing Objective to make sure lungs stay inflated
98
When best to obtain sputum sample
1st morning After nebulizer tx 1/2 tsp needed Deep brthng cough help
99
Postural drainage positions when best
45-60 mins before meal | In the a.m
100
What to set suction pressure at
80-120mm hg No more than 10 seconds Trach= only til meet resistance
101
Size suction catheters to use
8-12 french thin secretions | 14-16 tenacious thick secretions
102
Main concerns bc o2
Skin breakdown, nares ears cheeks ears
103
Nc rules
Up to 6 but over 3 need humidification
104
Which o2 dont require humidity
?
105
When how to use incentive spirometer
Every hr while awake. 10 slow deep breaths
106
What shiukd do before taking cuff off
Suction
107
Shallow brthbg what should u do?
Cough/deep breathing
108
When hear gurgling from trach
Suction, but first suction, pre oxygenate
109
Chest tube takeaways
Below chest level No kinks Do not milk or strip bc can dislodg If exceed 100 ml per hr report to doc
110
How many cm for no suctioning
6-8
111
Walker how to fit
Ht of hip joint elbows 15-30
112
How fit crutches
Lay down- tip 6 in-pad 3-4 finger under axilla no shoe Stand- shoes on 4-6 in pads 1/2-2 in
113
Fit cane
Hand grip hip level 15-30
114
Gait
4pt-slow r crutch left crutch 3pt 0 wt bear restr. 2 crutches 1 good leg 2 pt-leg crutch as 1opposite lef crutch same ti.e Swing through-
115
Walk up stairs | Down stairs
Strong leg upstairs first | Crutch down first
116
Spiral bandage
Part is uniform
117
Circular
Begins or ends bandage 2-3 times
118
Spiral reverse
Reverse at one point not uniform areas lower leg forearm
119
Figure 8
Ankle foot
120
Recureent turn bandage for
Amputated leg stump or head
121
Neurovascular checks on casting. Splints etc
Every hiur 24 hrs then 4-8 hours | Check skin, movement, sensation, pulses
122
Cpm machine assses what?
Bleeding, evaluate alignment every 2-4 hours | Assess skin conditions every 2
123
Air fluidized bed
Stage 3 4 and unstageable sores must still turn q 2
124
Continuius lateral rotational bed
80 degrees, either side 30 mins
125
Isometric exercises for
Musculoskeletal
126
Passive rom
For respiratory,
127
How many cm catheter for suction
6-8
128
Airway airway used unconcious pts
Et,
129
Which mask muffles voice , cant eat drink
Simple face mask
130
Which mask delivers fi02 regardless of breathing pattern/ copd patients
Venturi mask
131
External pin is it attached to traction?
No but still need to do pin care
132
Soft rustling sounds
Vehicular
133
When oatient slaps hand away what reaction
Localized to pain
134
Pt complains chest pain
Ask prior heart attack Ask sob Describe pain type

Fundamentals Test 2 (3 decks)

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