Exam 1 Flashcards
(187 cards)
1
Q
Nursing Intervention during:
Pre-trajectory health
A
Prevention, changing modifiable risks
2
Q
Nursing Intervention during:
Trajectory onset
A
Explain testing, emotional support to pt and family
3
Q
Nursing Intervention during:
Stable
A
Reinforce positive behaviors
4
Q
Nursing Intervention during:
Acute
A
Direct care, emotional support
5
Q
Nursing Intervention during:
Comeback
A
Rehab and PT to increase strength, gain lifestyle back
6
Q
Nursing Intervention during:
Crisis
A
Direct pt care, collaborate with team members to stabilize pt
7
Q
Nursing Intervention during:
Unstable
A
Education, emotional support
8
Q
Nursing Intervention during:
Downward
A
Home care or community-based care, end of life planning
9
Q
Nursing Intervention during:
Dying
A
Direct and supportive care
10
Q
Primary prevention
A
Prevent disease before it happens;
alter unhealthy lifestyle, education, immunization
11
Q
Secondary prevention
A
Reduce the impact of disease;
exam and screening (mammography, colonoscopy), early detection, modified work
12
Q
Tertiary prevention
A
Soften impact of ongoing illness/disease;
chronic disease management programs, rehab programs, support groups
13
Q
Apraxia
A
Inability to use words correctly
14
Q
Aphasia
A
Inability to speak or understand
15
Q
Delirium
A
A hallucination, delusions, or fear and anxiety
Causes: Infection, alcohol, medication toxicity, dehydration, impaction
16
Q
Alzheimer’s disease
A
Chronic, progressive, and degenerative
17
Q
Medicare
A
Health insurance for 65+ or disabled; does not cover long term care (hearing aides, glasses, dentures)
18
Q
Medicaid
A
State-based, need-based health insurance
19
Q
Developmental disability
A
Occurs from birth to age 22;
ex. Down Syndrome
20
Q
Acquired disability
A
Occurs from an acute injury
ex. Stroke, TBI
21
Q
Age-related disability
A
Progression from chronic illness
ex. Arthritis, dementia
22
Q
Outermost parts of the eye
A
Cornea and sclera
23
Q
Middle portion of eye contains
A
Iris, choroid, and ciliary body
Also aqueous humor, lens, and vitreous humor/body
24
Q
Innermost layer of eye contains
A
Retina, macula, and photoreceptors (rods and cones)
25
Cranial nerves, GO!
1 - Olfactory
2 - Optic
3 - Oculomotor
4 - Trochlear
5 - Trigeminal
6 - Abducens
7 - Facial
8 - Vestibulocochlear
9 - Glossopharyngeal
10 - Vagus
11 - Spinal Accessory
12 - Hypoglossal
26
Aqueous humor
Clear liquid in front of the lens, continuously produced and replaced
27
Lens
Behind the iris, bends light that enters the pupil, constricts and widens light (PERRLA)
28
Vitreous humor/body
Contains clear gel-like plasma, helps maintain eyeball shape (along with sclera)
Shrinks with age and can develop floaters (normal aging)
29
Retina
Extension of optic nerve, contains photoreceptors (rods and cones)
30
Rods
Provide peripheral light and low light (night vision)
31
Cones
Provide bright light and color
32
4 Eye functions
Pupil constriction
Accomodation
Convergence
Refraction
33
Pupil convergence
adjusting to light
34
Accomodation
allows eye to adjust image to retina no matter where it is
35
Convergence
ability of eyes to turn something seen between two eyes into one object
36
Refraction
bending light from outside the eye to meet the retina
Refraction errors are how we get poor eyesight/acuity
37
Ectropion
Eyelid turns outward
38
Entropion
Lower eyelid turns inwards
39
Trichiasis
Eyelashes grow inwards
40
Nystagmus
Involuntary eye movements
41
Impaired vision
20/40 or worse
42
Blindness visual acuity
20/200 and worse
43
Amsler grid
Tests for macular degeneration
Curvy lines = macular degeneration
44
Jaeger test
Tests reading visual acuity
45
Ishihara
Tests color vision; numbers hidden in colored circle
46
Pinhole test
Physician looks for cataracts with shield with pinholes to eliminate glare from direct light
47
Tonometry
Test intraocular pressure; screening for glaucoma
48
Confrontation test
Tests peripheral vision; stand across and cover mirrored eyes; indicates retina health
49
Fluorescein Angiography
Evaluates macular edema or abnormal blood vessels/perfusion
50
Nursing consideration for Fluorescein angiography
Check for iodine or shellfish allergy; check labs for BUN/Creatinine (kidney function), increase hydration to excrete dye
51
Eye ultrasonography
Looks for tumors, retinal detachment, hemorrhage, cataracts
52
OD
Oculus Dexter; right eye
53
OS
Oculus Sinister; left eye
54
OU
Oculus Uterque; both eyes
55
Myopia
Nearsightedness
Dx with Snellen chart
56
Hyperopia
Farsightedness
Dx with Jaeger chart
57
Presbyopia
Age-related farsightedness
58
Hordeolum
Stye; infected sebaceous gland
Tx: Topical antibiotic and warm soak
59
Seborrheic Blepharitis
Inflammation of eyelid edges; reduced tear production increased risk for bacterial infections
Tx: Wash eyes with baby shampoo
60
Staphylococcal Blepharitis
Can develop from severe seborrheic blepharitis
Tx: Antibiotics
61
Conjunctivitis
"pink eye", inflammation of the conjunctiva
Causes: allergic reaction (dander, pollen, pools), viral, or bacterial
Tx: According to cause, allergic meds or antibiotic
62
Chlamydia Trachomatis
Major cause of worldwide blindness, r/t STI
Tx: Antibiotics
63
Keratitis
Infection/inflammation of the cornea; bacterial, viral, fungal, or parasitic
Tx: (in order) IV/topical antibiotic, acyclovir, antifungal
64
Uveitis
Severe inflammation characterized by redness, pain, and photophobia
Tx: Steroid eye drops, dark sunglasses
65
Corneal dystrophies
Inherited; characterized by deposits that lead to irregular surface and blurred vision
S/sx: Edema, blisters, pain
66
Keratoconus
Inherited; cornea thins and protrudes, can have astigmatism (corrected with glasses)
67
Corneal ulceration
Tissue loss from an infection (EMERGENCY); Can develop from corneal abrasion (trauma)
S/sx: Pain, tearing, purulent/bloody drainage, loss of vision
Dx: Fluoresein dye
Tx: Antibiotic or antifungal, possible cornea transplant
68
Cataracts
Lens opacity that distorts the image directed onto the retina
69
Cataracts risk factors
Smoking, diabetes, obesity, trauma, steroid use
70
Cataracts s/sx
Blurred vision, decreased color perception, vision worse in bright lights (halo), possible double vision, decreased peripheral vision, H/A, arched eyebrow
71
Cataracts pathology
Lens proteins dry out and form crystals
72
Cataracts Tx
Surgery (one eye at a time)
- Steroids, antibiotics, eye patch, sunglasses, avoid increasing IOP
Without treatment it will lead to blindness
73
Cataracts surgery nursing consideration
Itchiness/scratching, mild blurry vision, and drainage is normal, pain is NOT normal
74
Retinopathy
Microvascular damage that can be slow or rapid
75
Retinal holes, tears, or detachment s/sx
Sudden pain, floating dark spots, curtain covering visual field, cobweb, bright flashing light
76
Retinal holes, tears, or detachment dx
Ophthalmoscope
77
Retinal holes, tears, or detachment tx
Emergent tx: Surgery, Cryotherapy, insert air bubble to reattach retina (positioning)
Conservative tx: Restrict activity, eye patch to reduce eye movement
78
Macular degeneration pathology
Waste material and debris collects to create drusen - yellow plaques
- Retina may show yellow spots on exam
79
Macular degeneration risk factors
Smoking, hypertension, female, short, long term diet poor in carotene and Vit. E
80
Types of macular degeneration and tx
Dry macular degeneration: More common; caused by gradual blockage of retinal capillaries, retinal cells become necrotic (faster in smokers), rods and cones can dye; no cure;
- Tx: reduce progression
Wet macular degeneration: Abrupt onset
- Tx: laser surgery to stop leaking vessels
81
Normal IOP range
10-21 mmHg (22-32 = glaucoma dx)
82
Glaucoma pathology
IOP leads to ischemia and damage to the optic nerve; causes peripheral vision loss
83
Chronic Open-Angle Glaucoma pathology
Most common type; blockage in trabecular mesh work impairs aqueous humor flow
84
Chronic Open-Angle Glaucoma s/sx
None besides decreased peripheral vision/poor visual field
85
Chronic Open-Angle Glaucoma tx
Eye drops that reduce IOP
86
Acute Angle-Closure Glaucoma pathology
Retina bends and blocks aqueous humor flow; usually sudden onset, emergency
87
Acute Angle-Closure Glaucoma s/sx
Sudden H/A, brow pain, N/V
88
Acute Angle-Closure Glaucoma tx
Surgery, laser, or medication (or combination) to reduce IOP
Long term: Beta blockers or cholinergics that dilate blood vessels
89
Topical anesthetics (eyes) use
For eye pain
90
Mydriatic use for eyes
dilate the pupil
91
Cycloplegic use for eyes
paralyze the iris
92
Glaucoma meds do what for eyes
Lower IOP by decreasing aqueous production or increase aqueous outflow
93
Nursing consideration for eye drops
1. Use eye drops before ointments
2. Wait 5 minutes between 2 different eye drops
94
External ear is called
pinna/auricle
95
Middle ear contains
Tympanic membrane and ossicles (malleus, incus, and stapes)
96
Failure in outer/middle ear causes what kind of hearing loss
Conductive hearing loss
97
Inner ear contains
Cochlea and cochlea nerves (facial, auditory, vestibulocochlear), eustachian tube (opens and closes with yawning and swallowing)
98
Failure in inner ear leads to what kind of hearing loss
Sensorineural hearing loss; also disturbance of balance and orientation
99
Where is cone of light located on tympanic membrane
Lower right
100
Presbycusis
Age-related hearing loss
101
Subjective data for hearing assessment
History of mumps or scarlet fever, aspirin use (ototoxic), pain, hearing changes
102
Audiometry
Tests pitch and intensity with beeps in headphone
103
Weber test
Tuning fork placed on top of head, sound should be heard equally in both ears
Sound is heard louder on damaged side with conductive hearing loss (outer/middle ear damage)
Sound is heard worse in effected ear with sensorineural hearing loss (inner ear damage)
104
Rinne test
Tuning fork placed on bone behind ear until it isn't heard, then placed beside ear until it is no longer heard
Distinguishes between air and conduction hearing loss
Air conduction is 2-3x longer than bone conduction
105
What happens if there is conductive hearing loss with Rinne test
Sound is heard longer and louder during bone conduction
106
What happens if there is sensorineural loss with Rinne test
Air conduction and bone conduction can be diminished
107
Auditory Evoked Potential
Electrodes are used to test the cranial nerves
108
Electronystagmography (ENG)
Records nystagmus (goes along with vertigo)
109
Caloric testing
Evaluates the inner ear; warm water is infused into the ear, nystagmus is a normal response within 20-30 seconds
110
Epley Maneuver
For vertigo; turn head towards side with vertigo then quickly lay down with head over edge; look for nystagmus, HELPS with vertigo by correcting displaced crystals in the ear
111
Dix-Hallpike maneuver
Turn head 45 degrees and lay back; dizziness will occur on side with vertigo; use to DIAGNOSE vertigo
112
Endoscopy
Looks for new onset hearing loss or fistulas
113
CT Scan (for ears)
Looks at ear structures for tumors
114
MRI (for ears)
Notes any soft tissue changes (tumors)
115
External otitis
Irritation of the auditory canal, bacterial, fungal, allergic
Otalgia = ear pain
Tx: Topical antibiotics, antifungals, steroids, and pain control
116
Cerumen impaction
S/sx: Otalgia or sensation of fullness, hearing loss
Tx: Irrigation with warm water, suction
116
Earwick
Used to instill antibiotics into the external canal; can be used for edema/inflammation
116
Trauma/perforation (ears)
Most heal in 1-2 weeks, may require aspiration of hematoma or surgery if it doesn't heal
116
Foreign body (ears)
Do not use irrigation - bugs and vegetables can swell and further impact ear
Can use mineral oil for bugs
116
Tympanoplasty
Grommet (tube) inserted into tympanic membrane to release pressure and fluid
- Watch for facial nerve changes, signs of infection, vertigo, tinnitus, balance issues, educate on avoiding water in ears, avoid planes
116
Malignant external otitis
More virulent form of external otitis
Usually caused by pseudomonas aeruginosa
Tx: Antibiotics, sometimes need an earwick if swelling is close to canal entrance
116
Motion sickness tx
Antivert, Dramamine
116
Mastoiditis
Infection of the mastoid air cells
S/sx: Pain not relieved by tubes, fever, malaise, hearing loss, vertigo, can lead to meningitis
Tx: IV antibiotics, mastoidectomy
Unsuccessful tx: Cranial nerve damage to 6&7 - facial drooping, inability to look sideways
116
Otosclerosis
Hereditary; most common cause of hearing loss, abnormal bone growth in middle ear that causes progressive hearing loss
S/sx: Vascular and bony changes, good bone conduction but poor air conduction
Tx: Calcium, Tympanoplasty
116
Meniere's disease
Excess endolymphatic fluid in the ear,
S/sx: Tinnitus, fullness in ear, one sided hearing loss, vertigo episodes that last 3-4 hours, hearing loss is eventually irreversible
Cause: Unknown
116
Malignancy (ears)
Most commonly basal squamous cell skin cancer due to sun exposure
S/sx: Sandpaper feeling on auricle edge
116
Otitis media
Types: Acute, Chronic, or Serous (involves fluid w/o active infection)
Infection of middle ear that causes inflammation and build-up of fluid behind the eardrum
116
Meniere's disease tx
Low sodium, low sugar diet, fresh/unprocessed foods (Furstenberg/Neutral Ash diet)
Limit alcohol, Avoid aspirin -> increase dizziness
Meds: Diuretics, Antivert, Dramamine, antihistamines, N/V meds
Surgery: Endolymphatic shunt
117
Benign Paroxysmal Positional Vertigo (BPPV)
Cause: debris particles in the ear
S/sx: Dizziness, N/V, falling, nystagmus
Tx: Meclizine, Epley maneuver
118
Acoustic Neuroma
Benign tumor where cranial nerve 8 enters the canal
S/sx: hearing loss and vertigo
Tx: surgical removal of tumor
- Educate pt to report clear drainage from nose (may be CSF)
119
Labyrinthitis
Infection of inner ear/labyrinth; sudden onset
Rare complication of otitis media
S/sx: Vertigo, N/V, hearing loss, tinnitus
120
Ototoxicity
Medications can cause hearing loss
Tx: D/C drug
121
Nociceptive pain pathway
1. Transduction
2. Transmission
3. Perception
4. Modulation
122
Neuropathic pain characteristics
Stabbing, electric shock
123
Non opioid examples
Acetaminophen, Aspirin, ibuprofen (NSAID's), Salicylates
124
Ceiling effect of non opioids
Increasing the dose above a certain level will not give more pain relief
- Opioids do not have ceiling effect
- Mixed opioids DO have ceiling effect (cannot exceed dose of non-opioid in the mix)
125
Where does the opioid react to the mu agonist receptor?
The dorsal horn (of the vertebrae)
- Dorsal side of vertebrae brings in sensory information, ventral side sends out motor information
126
NSAID AE
GI bleeding, peptic ulcer
- give with food
- assess for bleeding (bruising, coffee ground emesis, tarry stool)
127
Adjunctive examples
Local anesthetic - Lidocaine
Anticonvulsants - Neurontin, Lyrica
Antidepressants - Cymbalta, Effexor
Ketamine
128
Layers of the skin
Epidermis - no vasculature, Vit D activated here
Dermis - hair follicles, sebaceous gland, sweat gland
Subcutaneous tissue
129
Skin assessment for moles/lesions
A: Asymmetry of shape
B: Border irregularity
C: Color variation
D: Diameter
E: Evolving or changing in any feature
130
Macule
Flat, discolored spot on skin with sharp borders
- Ex. Freckle
131
Papule
Solid elevations without fluid with sharp borders
- Ex. Mole
132
Nodule, tumor
Palpable, solid, elevated mass
Nodules with distinct borders
Tumors extend deep into dermis
- Ex. Wart (nodule), large lipoma (tumor)
133
Vesicle
Small distinct elevation with fluid
- Ex. Blister from herpes simplex
134
Bulla
Large distinct elevation with fluid
- Ex. Friction burn or burn blister
135
Pustule
Vesicle or bulla filled with purulent drainage
- Ex. Acne, carbuncles
136
Wheal
Localized area of edema, irregular and variable in size and color
- Ex. Hive, insect bite
137
Plaque
Larger, flat, elevated, solid surface
- Ex. Psoriasis
138
Scale
Thin or thick flake, varying in color
- Ex. Dandruff
139
Crust
Dried residue of exudates
- Ex. Residue of impetigo
140
Fissure
Linear crack in the skin
- Ex. Athlete's foot
141
Ulcer
Opening in skin caused by sloughing of necrotic tissue
- Ex. Pressure ulcer, stasis ulcer
142
Tzanck smear
Blistering condition observed under glass slide
- Used for herpes
143
Wood's light
UV light shows hyperpigmentation of lesions
144
Actinic Keratosis
Rough, scaly patch from overexposure to the sun
Premalignant (turns into squamous cell carcinoma)
- Tx: Efudix cream (Fluorouracil)
145
Squamous cell carcinoma
Rough, thick, scaly tumor
Local or metastatic
- Tx: Surgical excision, cryosurgery, Efudix cream (Fluorouracil)
146
Basal cell carcinoma
Most common; sun exposure
Rarely metastatic
Small, waxy nodule with pearly border
- Tx: Mohs surgery or curettage (excision), cryosurgery
147
Malignant melanoma
Variation in color, grows radially (wide) and vertically (deep)
Seen in ages 20-45
Highly metastatic to bone, liver, and spleen
- Tx: Surgical excision
148
Cellulitis
Generalized infection
Tx: Oral or IV antibiotic
149
Carbuncle
Cluster of boils
Usually staphylococcus
Tx: Oral or IV antibiotic
150
Furuncle
Boil
Usually staphylococcus
Tx: Oral or IV antibiotic
151
Impetigo
Superficial infection caused by staph. or strep.
Contagious
152
Herpes 1
Cold sore
Flair ups and remissions, but always remains in nerve ganglia
Spread by direct contact
153
Herpes 2
Genital warts
Flair ups and remissions, but always remains in nerve ganglia
Spread by direct contact
154
Herpes zoster
Shingle
Dormant chicken pox
155
Plantar wart
HPV (human papillomavirus) infection
156
Tinea pedis
Athlete's foot; fungal infection
157
Tinea capitis
Fungal infection of scalp
158
Tinea corporis
Ringworm; fungal infection
159
Pediculosis capitis
Head lice
160
Pediculosis corporis
Body lice
161
Pediculosis pubis
Genital lice; crabs
162
Scabies
Mites under skin
Severe itching, burrows, straight lines
- Tx: Scabicide left on for 12-24 hours and repeated a week later
163
Atopic dermatitis
Eczema
- Tx: Steroid creams, light therapy (sunlight)
164
Uticaria
Hives
165
Psoriasis
Autoimmune disorder; epithelial cells divide too quickly
Lifelong
Exacerbation and remission
- Tx: Corticosteroid, UV light
166
Koebner's phenomenon
Skin that was previously damaged is at risk for further complications and even cancer
167
Lentigo
Melanocytes related to sun exposure and aging
AKA liver spots or age spots
168
Seborrheic keratosis
Neoplasm that occurs during middle age
Itching and scaly spot
Hereditary
Removed for cosmetic reasons; benign
169
Hidradenitis suppurativa
Abscess in axilla from blockage or infection in sweat glands
Tx: Warm compress and antibiotics
170
Seborrheic dermatosis
Excessive oil production
Leads to chronic inflammation
Can lead to secondary yeast infection
- Tx: (wet form) topical corticosteroid, (dry form) dandruff shampoo
171
Keloid
Overgrowth of scar tissue
172
Purpura
Blood spots under the skin
173
Petechiae
Broken capillaries
Seen with venous insufficiency or liver disease
174
Vitamin C role in healing
Promotes collagen synthesis
175
Vitamin A role in healing
Stimulates epithelial cells, stimulates immune system
