Final Exam Flashcards
(123 cards)
1
Q
Eight critical characteristics of complaints
A
Location
Character of quality
Quantity or severity
Timing
Setting
Aggravating and relieving factors
Associated factors
Patient’s perception
2
Q
PQRSTU
A
Provocative or palliative
Quality or quantity
region or radiation
severity scale
timing
understanding patient’s perception
3
Q
Orientation phase of nurse-patient relationship
A
Introductions and an agreement between the nurse and patient about their mutual roles and responsibilities
4
Q
Working phase of the nurse-patient relationship
A
Exploring and developing solutions that are enacted and evaluated in subsequent interactions; advocating
5
Q
Termination phase of the nurse-patient relationship
A
Review of health changes and how the patient has dealt with physical and emotional responses; includes discharge planning
6
Q
Expressive (Broca’s) aphasia
A
Short but meaningful sentences
7
Q
Receptive (Wernicke’s) aphasia
A
Long but unmeaningful sentences
8
Q
Global aphasia
A
The worst. 1 word sentences and barely understood
9
Q
Dysarthria
A
Difficulty speaking caused by brain damage
10
Q
Avoid ecchymotic areas in which 2 meds
A
Warfarin and coumadin
11
Q
How does vasoconstriction regulate temperature
A
Warms the body up (shivering)
12
Q
How does vasodilation regulate temperature
A
Cools us down (sweating)
13
Q
What vitamin does skin synthesize
A
Vitamin D
14
Q
Ulcers come from
A
Venous insufficiency
15
Q
What does peripheral neuropathy do with wounds
A
Slow healing
16
Q
Acute wound
A
Injury such as a knife, gunshot, burn, or surgical incision; heals within 6 months
17
Q
Chronic wound
A
Wound that persists beyond usual healing time (>6 months) or occurs without new injury to the area
18
Q
Open wound
A
Break present in the skin; tissue damage present
19
Q
Closed wound
A
No break seen in the skin, but soft tissue damage evident
20
Q
Abrasion
A
Wound involving friction of the skin; superficial; dermatologic procedure for scar tissue removal
21
Q
Puncture
A
Intentional or unintentional penetrating trauma by sharp or pointed instrument that penetrated skin and underlying tissue
22
Q
Laceration
A
Cut in the skin; smooth or jagged; shallow or deep; object possibly contaminated; infection risk
23
Q
Contusion
A
Closed wound; bleeding in underlying tissues from blunt blow; bruising
24
Q
Clean wound
A
Closed surgical wound that did not enter GI, GU, or respiratory systems; low infection risk
25
Clean/contaminated wound
Wound entering the GI, GU, or respiratory systems; infection risk
26
Contaminated wound
Open, traumatic wound; surgical wound with break in asepsis; high infection risk
27
Infected wound
Wound site with pathogens present; signs of infection
28
Vascular injury color
Brown or shiny
29
Hemostasis
Chilling
30
Inflammatory phase
Control bleeding
Deliver O2, WBC, and nutrients
WBC engulfs cells
Prolonged when there is too little/much inflammation
3-6 days
31
Proliferative phase
Replace tissue with collagen and connective tissue. Resurface new epithelial cells
3-24 days
32
Maturation of a wound
Can take over a year depending on the extent of the wound
Makes the wound look back to normal
No granulation tissue, barely any scarring, low infection risk
21st day
33
Secondary intention healing
A pressure injury healing by indirect closure. Tissue heals from underneath. Open burns, pressure injuries. Gaping, irregular wound. Wound gets filled with granulation tissue. Heals internally, nothing on epidermis. Deeper, wire scar is common
34
Tertiary intention
widely separated, deep. Closure of wounds occurs when there is no infection or edema. Lots of drainage and closes later. Called delayed closure. Purposefully left open to let infections resolve
35
Obesity and wound healing
slow wound healing because of weak defense against vascular invasion. Potential for wound dehiscence or evisceration (sutures popping)
36
Smoking and wound healing
vasoconstriction, tissue oxygenation impaired, not good enough clotting
37
Medications and wound healing
corticosteroids, anti-inflammatory delays closure, NSAIDS, anticoagulants
38
Heat application 3 effects
Promotes healing and suppuration (consolidation of pus)
Decreases inflammation by accelerating inflammatory process
Decreases musculoskeletal discomfort
39
3 physiologic mechanisms of heat application
-Results in vasodilation leading to increased blood flow, this increasing oxygen and nutrients to the area and promoting removal of waste products
-Increases capillary wall permeability, increases leukocytes and antibody flow to the area and action of phagocytes
-Increases sensory nerve conduction, promotes muscle relaxation, and decreases viscosity of synovial fluid
40
Select uses of heat application
Surgical and infected wounds, hemorrhoids, and episiotomies
Phlebitis and IV infiltration
Low back pain, menstrual cramps, contractures, arthritis, and muscle spasms
41
3 effects of cold application
Controls bleeding
Decreases edema
Relieves pain
42
3 physiologic mechanisms of cold application
Vasoconstriction which decreases blood flow, metabolic tissue demand, and supply of oxygen and nutrients
Decreases capillary permeability
Decreases nerve conduction velocity, induces numbness or paresthesia
43
Selected uses of cold application
Fractures, trauma, superficial lacerations, and puncture wounds
Sprains, muscle strains, and sports injuries
Arthritis, trauma, and musculoskeletal injuries
44
what 2 system impairments affect operative positioning
Respiratory and CV
45
What does anesthesia do to 2 body functions
Can't regulate temp or do urinary stuff
46
Epidural anesthesia is for what and what is important
c section, catheterization because bladder becomes neurogenic, risk for CAUTI, catheter needs to be DC and patient needs to void
47
Bowel stuff after surgery and NPO status
Introduce foods back slowly
Delayed bowel movements
Flatulence then bowel movements
48
What 2 organ dysfunctions decrease tolerance of anesthesia or meds
Liver and kidneys
49
What are narcotics given with
Something to make you poop
50
Rationale of turning and getting out of bed
Improves post-op mobility to minimize impact of immobility
51
Rationale for deep breathing, coughing, incentive spirometer
Improves post-op gas exchange and prevents resp complications
Most important
52
Rationale of leg exercises and SCDs
Improves venous return and prevents deep venous thrombosis post-op
53
Rationale of using a PCA
Provides optimal pain control post-op
54
PCA
Continuous dose of meds. Bolus where you push button for meds
55
Atelectasis
Complete or partial lung collapse
56
Symptoms of pulmonary embolism (9)
Chest pain
Dyspnea
increased RR
Tachy
Increased anxiety
diaphoresis
Decreased orientation
decreased BP
blood gas changes
57
Symptoms of hypovolemic shock
decreased urine
decreased BP
Weak pulse
Cool and clammy
Restless
Increased bleeding
Increased thirst
decreased CVP
58
Symptoms of infection
Redness
Purulent drainage
Fever
Tachy
Leukocytosis
59
2 symptoms of evisceration
Evidence of bowel through incision
Pain
60
Symptoms of gastric dilation
Nausea and vomiting
abdominal distention
61
Symptoms of paralytic ileus
decreased bowel sounds
No stool or flatus
nausea
vomiting
abd distention
abd tenderness
62
Symptoms of atelectasis
Dyspnea
tachypnea
decreased breath sounds
asymmetrical chest movement
Tachy
Restlessness
63
Symptoms of pneumonia
Rapid respirations
shallow respirations
fever
wet breath sounds
asymmetrical chest movement
productive cough
hypoxia
tachy
leukocytosis
64
Symptoms of urinary retention
Unable to void 8-10 hrs post-op
Palpable bladder
frequent,small amount voiding
Pain in suprapubic area
65
Stage 1 pressure injury
intact skin with non-blanchable redness of a localized area over a bony prominence
66
Stage 2 pressure injury
partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
67
Stage 3 pressure ulcer
Full thickness tissue loss. Fat may be visible but not bone or muscle. Slough may be present and may include tunneling
68
Stage 4 pressure injury
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough and eschar may be present. Often include tunneling.
69
Unstageable pressure injury
Full thickness tissue loss covered in slough
MARSI
70
Mucosal membrane pressure injury (MMPI)
Caused by medical device, don't stage
71
Deep tissue injury (DTI)
Purple or maroon localized area of discolored intact skin or blood-filled blisters. May be preceded by tissue that is painful, firm, bushy, boggy, warm, or cool
72
Intertrigo
Friction between folds
73
What does lymph do
Made of WBC, attacks bacteria in tissues and blood
74
Where does the right lymphatic duct empty into
The right subclavian vein
75
What does the thoracic duct do
Drains the rest of the body and empties into the left subclav vein
76
Where does the right lymphatic duct drain (6)
Right side of:
Head and neck
Arm
Thorax
Lung and pleura
Heart
Upper right liver
77
Function of the lymphatic system (3)
Convert fluid and plasma protein that leak out of the capillaries
Form a major part of the immune system that defends the body against disease
Absorbs lipids from small intestine
78
What do lymph nodes do
Filters harmful microorganisms out of the bloodstream
79
Temporomandibular joint
Joint we use to open mouth, should be smooth
80
Cranial nerve V motor test
Clench teeth
81
Cranial nerve VII motor test
Puff cheeks, smile, frown
82
Normal lymph nodes palpation
Gentle circular motion
Shouldn't be able to palpate
>1cm is lymphadenopathy
83
Cranial nerve XI test
Push shoulders up
84
What are normal superficial cervical nodes in a young adult like
Palpable if small, moveable, discrete, soft, and non-tender
85
Acromegaly
Large face/head
86
Thyroid gland (3)
2 lobes fixed to trachea
Should not be visible
Moves up when you swallow
87
When can you auscultate a thyroid gland
When it's enlarged
88
When can you hear a bruit in a thyroid gland
When it's overactive (increased BF to area)
89
Enlarged parotid gland
Parotid gland=between jaw and ears
Could be from viruses (mumps, herpes, epstein-barr) or bacteria
90
Parotitis and treatment
From infected tooth, infects whole gland
Tx is water and warm compress
91
Bell's palsy patho
Clot in facial nerve
92
Normal hearing intensity and frequency
0-25 dB intensity
125-8,000 cycles per second
93
Camphoraceous smell
Like moth balls
94
Ethereal smells
Like detergent
95
Sight in older adults (5)
Decreased visual acuity
Decreased peripheral vision
Presbyopia (hard to read)
Hard to distinguish color
Delayed pupillary reaction
96
Macular degeneration
Blurs central vision (normally age-related, damages macula- part of retina that controls sharp vision)
97
2 types of macular degeneration
Dry- distorted and fuzzy
Wet- blind spot in the middle
98
What decreases in the eyes >40 (3 things)
Tear production
Power of accommodation
Adaptation to darkness
99
What increases in the eyes >40
floaters
100
Low vision vs legally blind
Low: 20/70
LB: 20/200
101
Presbycusis
Age-related hearing loss
102
What does the confrontation test examine
Peripheral vision
103
Exophthalmos
Swelling of eyes related to thyroid (eyes bulging out)
104
Sbismus
Cross-eyed
105
Red reflex
Reflection of light off retina
106
Sensorineural loss
signals pathology of CN VIII, inner ear or auditory area of cerebral cortex
May be presbycusis (nerve degeneration with aging) or ototoxic medications (affect hair cells in cochlea)
107
Should the weber test be + or -
(-)
108
How to assess ventral surface of tongue for lesions
Touch roof of mouth with tongue
109
What part of the tongue does the facial nerve control
Anterior
110
What part of the tongue do the glossopharyngeal and vagus nerves control
Posterior
111
Tympanic membrane in older adults
Thick
112
Saliva production in older adult
decreased
113
Alginate dressing
Provides a moist environment
Highly absorbent of exudate
Establishes hemostasis
Placed inside the wound
Good for treating wounds with lots of exudate/deep wounds
NOT used in dry or tunneling wounds
Contact with wound activates gel
Secondary dressing required
For moderately draining wounds
114
Hydrogel dressing
Mild absorption
Needs a secondary dressing
Used in wounds with necrosis, infection, and need for moisture
Rehydrates dry wound beds
Partial-thickness wounds (pressure ulcers II-IV with secure dressing and gauze)
Minor debridement, burns, something about grafts
115
Transparent film dressings
Thin layer of plastic that covers wound
No absorption, creates a barrier
Allows some oxygen exchange and a moist environment
Used for necrotic tissue or superficial skin tears
Removal can cause damage to underlying skin
Uniform application can cause maceration of wound edges
Can be used instead of tape over intact skin to secure a gauze or dressing in place
116
Hydrocolloid dressings
mild-moderate absorption
NOT recommended for infected wounds, but used for wounds that are VULNERABLE to infection
Partial-thickness wounds
Shallow, full-thickness wounds
Minor debridement
117
Gauze
Non Adhesive, allowing environmental oxygen to reach the wound surface
Absorbent
May be moistened with sterile saline to create a moist packing
Newly created surgical incisions or wounds acquiring pressure for hemostasis
Packing or filling of deep wounds
118
Foam dressings
Moderately absorbent depending on thickness
Provide moist environment
Used over bony prominence on partial-thickness wounds for protection
Also used for deep wounds that have been packed with primary dressing
119
Silver wound dressings
Contains ionic silver-immediate or controlled release of silver into the wound bed
Used for infected or highly colonized wounds
Can be used with nearly any other dressing
Slow-release dressings can stay for up to 7 days
120
Hydrofiber dressings
Consists of sodium carbsomethingsomething fibers
Forms a gel as it absorbs exudates
Moderately to heavily draining wounds
Needs less frequent changes because it's highly absorbent and maintains moist wound bed
121
What can patient's odor POSSIBLY mean (2)
Metabolic or kidney issues
122
What kind of sore could mean syphillis
Canker
123
Self-skin exam ABCDE
Asymmetry
Border
Color & change
Diameter (6mm)
Elevation & enlargement
