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Nursing > Fundamentals Exam 2 > Flashcards

Fundamentals Exam 2 Flashcards

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0
Q

Slough

A

Liquified or wet dead tissue. White, yellow, light tan

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1
Q

Eschar

A

Dried dead tissue, cornified, tan brown, black

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2
Q

Undermining

A

Bigger wound than opening. Extends under the edge

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3
Q

Tunneling

A

Tracts extend out from the wound

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4
Q

Exudate

A

Drainage of pus, yellow fluid

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5
Q

Stage 1

A

Intact skin, no blanching red area usually over bony prominence

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6
Q

Stage 2

A

Shallow open ulcer with redor pink wound bed w/o slough. Partial thickness, shiny, dry, shallow ulcer. No slough or bruising.

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7
Q

Stage 3

A

SubQ fat may be seen. Slough, no exposed bone, muscle, or tendon. May have undermining or tunneling

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8
Q

Stage 4

A

Exposed bone , tendon, or muscle. May have slough, eschar, undermining or tunneling

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9
Q

Unstageable

A

Full thickness, base or wound bed covered by slough or eschar. Often includes tunneling and/or undermining

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10
Q

Deep tissue injury

A

Purple/maroon localized area of discolored skin

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11
Q

Moisture wound

A

Partial thickness, shallow craters, linear denuded skin in creases. From moisture

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12
Q

Wound Measurement orientation

A

Like clock
Length 12-6
Width 3-9
Depth- deepest from wound edge to bottom. Unable if eschar or slough

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13
Q

Serous Drainage

A

Clear fluid like in blister

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14
Q

Sanguineous drainage

A

Contains RBC’s

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15
Q

Serosanguineous

A

Combo clear with blood tint

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16
Q

Purulent

A

Contains wbc’s

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17
Q

Heat therapy

A

Dilates peripheral blood vessels
muscle tension
>pain

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18
Q

Cold therapy

A

Constricts peripheral blood vessels
>muscle spasm
Promotes numbness
Promotes comfort

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19
Q

HIPAA

A

1996 Health Insurance Portability Accountability Act

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20
Q

SBAR

A

Situation-concise statement of problem
Background-brief, pertinent info.
Assessment-what found/thought
Recommendation-action requested

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21
Q

Acute pain

A

Rapid onset

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22
Q

Chronic pain

A

Longer can have breaks and exacerbations

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23
Q

Cutaneous pain

A

Superficial pain close to surface

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24
Somatic pain
Originates in tendon, bone , muscle, ligament, blood vessel, nerves
25
Visceral pain
Poorly localized. Originates in thorax, cranium, abdomen
26
Mode of transmission- pain | Referred pain
Pain perceived in different site than origination
27
Neuropathic pain
Damage/abnormal fxn of peripheral nerves or CNS
28
Intractable pain
Therapy resistant despite multiple intervention
29
Phantom pain
Pain experienced in lost limb/body part
30
FLACC pain scale
``` Faces Legs Activity Cry Consolability ```
31
Numerical sedation scale
1=awake/alert 2=drowsy occasionally, but easily aroused. 3=drowsy frequently, falls asleep in conversation. Reduce Dose 4=somnolent, minimal response. Discontinue opioid try naloxone
32
% of brain is water
75
33
% of blood is water
83
34
%of muscles is water
75
35
Extracellular
Outside cells
36
Interstitial
Between cells and outside blood vessels
37
Intravascular
Blood plasma
38
Transcellular
Cerebrospinal, pleural, peritoneal, and synovial
39
Intracellular
Within cells
40
Desired adult fluid intakes n 24 hr
1500-3500 ml in 24hr
41
Amt. Most adults average of water
2500-2600ml/day
42
Sensible losses
Are fluid losses from urination, defecation, and wound. these can be measured
43
Insensible losses
Are losses via skin and lungs about 28%
44
Sodium
Regulates extra cellular fluid 135-145 mEq/L
45
Potassium
Plays a vital role in electrical impulses 3.5-5.0 mEq/L
46
Calcium
Plays major role in transmission of nerve impulses 9.0-10.5 mg/dL
47
Magnesium
Acts on cardiovascular system 1.2-2.0 mEq/L
48
Chloride
Major component of interstitial and lymph fluid 97-107 mEq/L
49
Hyponatremia
Na+ <135mEq/L Symp: tachycardia, hypotension, mu. cramps, weakness, lethargy,HA Causes=GI losses, diuretics, excess h20 intake, burns, kidney disease. Tx based on cause
50
Hypernatremia
Na+ >145mEq/L Symp: irritable, thirst, fever, dry &. Flushed skin, dry tongue & mucus membrane, muscle twitch Causes=
51
Potassium
Fx= cardiac, skeletal, & smooth muscle fx. Maintains fluid volume w/I cell Metabolism of CHO & Pro-
52
Hypokalemia
muscle tone, paresthesias Causes=diuretics, GI losses, Diaphoresis, Tx= K+ replacement
53
Hyperkalemia
>5.0mEq/L Symp: cardiac arrhythmia, hypotension, anxiety, muscle weak Causes=renal failure, diabetic ketoacidosis. Tx=Kayexelate
54
Calcium
``` Most abundant mineral Development of teeth & bones Req. for transmission of nerve impulses Skeletal and cardiac muscle contraction Regulates heart beat & BP Vit D required for absorption ```
55
Hypocalcemia
<9.0mg/dL Symptoms: numbness, tingling in fingers and toes, muscle twitch, seizures, laryngeal spasm. Causes=Vit D deficiency, pancreatitis . Tx= Ca2+ supplement w/VitD
56
Hypercalcemia
>10.5mg/dL Symp: lethargy, muscle weak, kidney stones, > memory Causes=hyperparathyroidism, excess Vit D intake, Tx = identify underlying cause
57
Magnesium
Fx= activates co-factor in over 300 enzymes. Affects neuromuscular irritability & contractions, contributes to cardiovascular regulation, stabilizes excitable membranes Ca2+
58
Total water volume in body
50-60% intracellular has 70% of total body water
59
Water content variations
Age, body fat, gender | Infants have more total body fluid. More prone to deficit
60
Hypomagnesemia
61
Hypermagnesemia
>2.0mEq/dL HTN, flushing, skin warmth, >R Causes=renal failure Tx symptomatic
62
Hypovolemia/hypervolemia
H2O and electrolyte loss/retention
63
Body systems that have a role in fluid/electrolyte homeostasis
Kidney, CVSystem, adrenal glands, pituitary gland, nervous system, thyroid/parathyroid gland, GI, hypothalamus. Fluid balance is threatened with any organ/system failure
64
Acidosis
PH below 7.35 | Death at 6.80-
65
Alkalosis
PH above 7.45 | Death at 7.80+
66
Homeostatic PH regulators
•chemical buffer system **•respiratory mechanism •renal mechanism Effectiveness varies with development infant & AA less eff.

Nursing (7 decks)

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