Week 1-12 Flashcards
(193 cards)
1
Q
What is the acronym OLDCART stand for?
A
O= Onset
L= Location
D= Duration
C= Characteristics
A= Aggravating factors
R= Relieving
T= Treatment
2
Q
What is the questions
for pain assessment?
A
P= What Porvokes the pain?
T= What type of pain is it?
M= Dose the pain move?
R= How would you rate your pain
T= How long ago did the pain start
3
Q
What is a normal blood pressure?
A
120/80 mmHG
4
Q
What dose the first and last heart beat mean?
A
First= systalic
Last= Distalic
5
Q
Name the normal pulse rate for adults, children, and new borns
A
Adluts= 60-100 beats/min
Children= 80-110 beats/min
New borns=120-160 beats/min
6
Q
What is the normal respiratory rate for an adult?
A
10-20 breathes per/min
7
Q
What is a skill?
A
It is something you practice
8
Q
Name the 4 type of ways you can take a temp. E.g., oral
A
tempanic= ear
Rectal
Oral
Axillory=armpit
9
Q
Name the medical terms for these temps 41c°,37.5c°,37c°,34c°,28c°
A
Hyperthermia=temp above 41c°
Febrile= temp above 37.5c°
Afebrile= normal temp 37c°
Hypothermia= 34c°
Severe Hypothermia=28c°
10
Q
Name the 8 pulse points on the body from the head to ankles.
A
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis
Porsterial tiblial
11
Q
What is Bradycardia?
A
When the heart rate is to slow less then 60bpm
12
Q
What is Tachycardia?
A
When the heart rate is more then 100bpm
13
Q
Name the 4 force the heart can beat at. E.g., weak
A
Absent
Weak/thread
Normal
Full/blunding
14
Q
Finish this sentence.
Breathing should be….
A
Relaxed
Regular
Automatic
Silent
15
Q
What does the acronym IPPA stand for?
A
I= inspection
P= palpation
P= percussion
A= auscultation
16
Q
What is a desirable amount of fluid intake and loss for a healthy in 24 hrs?
A
1500 to 3500ml
17
Q
What objective data would you use to assess a patient fluid balance status?
A
Daily weight
Fluid intake/output
Skin turgor
18
Q
What does ABCDE stand for in skin assessment?
A
Asymmetric
Border
Colour
Diameter less then 6 mm
Evolution
19
Q
What are the 4 things to look for with skin?
A
The texture
The thickness
The vascularity
And oedema
20
Q
What should you look for when assessing lesions?
A
The colour
How elevated it is
The pattern or shape
The size
The location
Exudate
21
Q
When doing a assessment looking at hair what should you look for?
A
Colour
Texture
Distribution
Lesions
Infestation
22
Q
What are you looking for when carrying out a nail assessment?
A
Shape and contour of the nail
Consistency
Colour
23
Q
When carrying out a full skin assessment what questions should you ask them to get a health history?
A
Have you had any hair loss/gain?
Have you had any chance in your nails?
Have you been exposed to any hazards environment or any chemicals?
What medication do you take?
Can you tell me about you salf care practices?
24
Q
Define patient centred care.
A
Care that puts people/patients at the centre of care and their individual context, history, culture, family and that take in to a count their strengths and weakness
25
When you are asking Pam about her pain what factors about her pain need to be considered
Onset
Location
Duration
Characteristics
Aggravates
Relieving
Treatment
Scale.
26
Pam reports her pain to be 8 out of 10. What sort of data is a pain score?
Subjective
27
Pam’s temperature was 36.8oC this is classed as a normal body temperature it is also referred to as
Afebrile
28
As a Student nurse you are working under the supervision and delegation of a Registered nurse. You are asked to take the patients pulse. What is the most common place to feel the pulse
Radial pulse
29
What objective data would you use to assess Mr Lyman’s fluid balance status?
Daily weight
Fluid Intake/output
Skin mobility/ turgor
30
Which class of laxatives will promote peristalsis?
Stimulant laxatives
31
Which type of diet is recommended for healthy bowel function?
High fibre
32
What are the 5 A's?
1. Accessible
2. Affordable
3. Appropriate
4. Acceptable
5. Adaptable
33
Describe what primary health care is.
PHC is an approach to to health that try's to make it such that all groups in our society have a golden standard of of health care by providing measures.
E.g. Health education and free dental care for under 18's
34
What is primary prevention?
Aims at preventing the Onset of illness
35
What is secondary prevention?
Catching the illness early.
36
What is tertiary prevention?
Reduce severity/ prevent progression of illness.
37
Describe the epidermis layer
1.Epidermis layer is the top layer of the skin
2.It is the protective waterproof layer of keratin
3. It has no blood vessels and relies on the dermis and hypodermis for nourishment/ waste removal.
38
Describe the dermis layer of skin
The dermis is made up of strong connective tissue as well as nurse here follicles glands their ducks arteries veins and capillaries.
39
Describe the hypodermis layer
1.The hypodermis layer is a fatty subcutaneous layer of fat tissue.
2.Hypodermis anchors the skin layer and serves as a heat insulator and shock absorber for the body.
3. The skin layer contains blood vessels lymph vessels and nerves and fat cells.
40
What is a laceration
Tearing of tissue edges not in aligned
41
Name the 6 types of wounds
Incision
contusion
laceration
abrasion
penetrating wound
thermal wound
42
Describe an incision
A cut from a sharp object wound edges are aligned
43
Describe a contusion
Damage to vessels caused bleeding below skin surface EG bruise
44
Describe abrasion
Rubbing or scraping of surface level epidermis layer
45
Describe what a penetration at wound is
This is when a foreign object enter scan at high velocities.
46
Describe a thermal wound
A thermal wound can be low or high temperature Burns
47
Name the three types of ulcers
Pressure ulcers
diabetic ulcers
arterial ulcers
48
Describe what a pressure ulcers
It is injury to the skin and any underlying tissue as a result from prolonged pressure on that area
49
Describe a diabetic ulcer
This is an ulcer impacted by poor circulation and sensation due to their diabetes.
50
Describe an arterial ulcer
This wound is occurs in the area of the leg or ankle caused by abnormal or damaged blood vessels/arteries leading to poor circulation
51
What are the two types of wound classifications
Surgical and non-surgical/traumatic
52
Describe what a surgical wound is and give an example.
These words are made under sterile conditions
have clean lines and controlled bleeding
risk of infection is minimal and healings is facilitated
EG inclusions are example of this class of wood
53
Describe non surgical or traumatic wounds classification
These wounds occur in a non sterile environment
contamination is likely
wound edges are usually Jagged and bleeding is uncontrolled
there is a high risk of infection and longer time healing.
An example of this type of wound would be a laceration
54
Name the four phase and wound healing
Homeostasis
inflammatory
proliferative
remodelling or the maturation phase
55
Describe 4 stages of homeostasis in wound healing and how long after the injury this phase occurs
the homeostasis phase begins 0 to 24 hours after damage or injury
1. Ruptured cells release inflammatory factors that causes the blood vessel to vasoconstriction.
2.Platelets aggregate to form temporary platelet clot within 60 Seconds
3. these platelets release chemicals and activate the secondary fibrin clot and the clotting cascade.
4.These platelets release chemicals such as serotonin, prostaglandins and histamin which causes vasodilation and increased capillary permeability.
56
Describe the inflammatory phase and the 3 steps involved and when
disturbed occurs after injury
This stage can a curse 0 to 4 days after damage
1. Neutrophils are first to the site of injury in jesting bacteria and cell debris.
2.After 24hrs macrophages are released and enter the wound area they ingest debris and release growth factors that are needed for new epithelium cells blood vessels as well as attracting fibroblasts.
3.Blood plasma accumulates causing swelling and pain at site of wound.
57
Describe the 3 steps in the proliferation phase and the time period occurs in
It occurs between 3 days to 3 weeks of the injury.
1.Firbroblasts enter the wound site then granulated tissue begins to form and capillaries grow across the wound bringing nutrients to the wound for healing
2.epithelial tissue is light pink in colour and usually migrates inward from the wound margins but can appear in spots over the surface of the wound.
3. The final step in the proliferation phase is collagen synthesis and accumulation.
58
Describe the remodelling stage as well as the when it started and after injury (2 steps)
This is the final stage of wound healing collagen is remodelled strengthening wound.
New collagen continues to be deposited which compressors blood vessels in the wound so that scar tissue eventually becomes a flat and thin white line.
59
What are the three things needed for good wound healing
Water
good blood circulation
and nutrients
60
What is the difference between chronic and acute wounds
Acute wounds heal normally following the wound-healing process and skin is restored to normal within weeks
chronic wounds do not progressed normally through the wound healing process meaning they can take much longer to heal up to months.
61
Name of the three types of wound healing
Primary intention
secondary intention
tertiary intention
62
Describe the primary intention wound type
Best type of wound is a surgical incision or Papercut
63
Describe the secondary intention wound type
Best type of wound healing takes longer there is more debris and fluids to clean away before wound can heal.
64
Describe the tertiary intentions of wound healing.
This wound is delayed primary intention. Is usually contaminated left open and needs to be stitched closed to prevent further infection obviously after cleaning.
65
Name the 6 things that can go wrong with wound healing.
Hypergranulation
sloughing
necrosis
Dehiscence (dis-a-da-in-s)
Evisceration (e-ves-a-ray-tion)
Maceration
66
What does ISBAR stand for?
Identity of patients
Situation
Background
Assessment and action
Response and Rationale
67
What is your basal metabolic rate related to?
The energy requirement of a person during rest
68
When undertaking a musculoskeletal assessment you notice the patient has abdominal lateral curve of the thoracic and lumbar spine this is refers to as.........
Scoliosis
69
Implicit bias is defined as what?
This is bias that is unconscious and automatic achieved within an individual.
70
What is the difference between objective and subjective data
Subjective data is personal interpretation of data. E.g., patients description of their illness.
Objective data viewpoint is based on factual data. E.g., patients blood pressure records
71
The Glasgow Cama Scale (GCS) is divided into 3 areas name those three areas
Eye-opening, monitor response and verbal response
72
What does the right upper Quadrant of the abdomen contain
Liver
gallbladder
transverse colon
73
What does the upper left Quadrant of the abdomen contain
Spleen
stomach
pancreas
74
What does the lower left Quadrant of the abdomen contain
Descending colon
Sigmoid colon
75
What does the lower right quadrant of the abdomen contain
Small intestine
Ascending colon
The appendix
76
What is escherichia coli?
It is a bacteria most commonly found in undercooked ground beef.
Within 24hrs of Ingesting ecoli, you will become diuretic with bad stomach cramps pain and profuse vomiting
77
What are the droplet safety practises
Gowns, gloves, mask and covered shoes and glasses. An example of these kinds of illnesses are mumps and rubella.
78
What are the standard safety practises
Gloves and mask. Example of this type of illness HIV Hepatitis B and C
79
What are the contact safety practises
Gloves, gown, masks. An example of this kind of illnessi is lice and scabies.
80
What are the airborne safety practises
Gloves, special filter mask (N-95), gown covered shoes, glasses. EG full PPE
an example of this type of illness is chickenpox and measles.
81
What is the Waterlow Score
It is a calculation of the risk of pressure ulcers developing on individual based on it's system
E.g., 1 low risk 10 high risk
82
What is oliguria
A medical term for low urine output
83
What are Prion?
Infectious proteins
84
What are fungi?
These are your yeast and moulds with a eukaryotic cells
nuclei
unicellular yeast dividing asexualy
85
What is a parasite?
Eukayotes.
Maybe multicellular
ranged from protozoa to tapeworm.
86
What are viruses?
They are infectious particles with proteins coated in nucleic acid ( DNA or RNA).
Needs to infect host cells to replicate Make new nucleic acid and proteins for the virus particles.
87
What are bacteria?
They are prokaryotic unicellular organisms that replicate via asexual division.
They do not possess a nuclei, Golgi bodies, Or an endoplasmic reticulum.
Bacteria can also be classified by using a gram stain.
88
When applying the principles of pain management what is the first concern
Client must be believe about perceived levels of their pain
89
What is chronic pain characterised by
Exacerbation and remission
greater than 3 months duration and effects normal functions
90
What is used for respiratory assessment
The respiratory rate
patients use of accessory muscles
skin colour
O2 saturation
91
What term is used to describe rapid breathing?
Tachypnoea (tac-pi-ne-a)
92
When performing percussion over and abdominal cavity the expected sound is what?
Resonance
93
When conducting a general survey what is included
Measurements of Vital Signs
94
When auscultating the heart what order should you be listening to
Aortic, pulmonic, tricuspid, mitral
95
A patient is admitted and they have been vomiting and diarrhoea for 3 days what symptoms would you expect in their physical exam?
Trachycardia
96
Poor oxygenation of the blood will affect the pulse rate causing it to become what?
Slower-than-normal
97
A young woman has HIV as a result she will be increased risk of what?
Cervical cancer
98
The onset of drugs action is the time it takes for the drug to...
Produce a response in the patient
99
What effects does smoking have on wound healing
Decreased oxygen supply to wound bed related to vasodilation
100
What are the 9 fundamental of care?
1. Communication
2. Clinical monitoring/management
3. Care environment management
4. Comfort /pain
5. Respect/dignity
6. Nutrition/hydration
7. Personal care
8. Safety/prevention
9. Self-care
101
What is the assessment for stool (6)
1. Frequency
2. Colour
3. Consistency
4. Shape
5. Amount
6. Odour
102
Name stool type 1-7
1. Like little nuts
2. Looks a bit lumpy
3. Has a cracked surface
4. Normal
5. Blobs
6. Mushy
7. Not soild
103
Disease VS Illness
Disease is a medical term used to describe pathological changes that impact body function. And can be objectively measured.
Illness is the response of a person to a perseved illness. And is measured subjectively.
104
Name the words in English.
Taha Tinana=.....
Tana Wairua=.....
Tana Whanau=....
Tana Hinengaro=....
Physical health
Spiritual health
Family health
Mental health
105
What does EWS chart stand for?
Early
Warning
Score
106
The functional ability of the GI tract most severely affected by ageing is
Metabolism
107
Name the thing you should look for when conducting a neurovascluar assessment? {6}
Colour of the affected area
Temperature warm/could
Move conpaired to other side
Sensation can they feel that?
Pulses blood flow to that area
Capillary refill 3-5 seconds
108
What does ADPIE stand for?
Assessment
Diagnosis
Planning
Implementation
Evolution
109
What drug is given to patients who are having a severe asthma attack?
Ventolin (vent-a-line) or subutamol (sub-bu-t-a-mole) . This helps relax the muscles around the airway allowing them to breathe easier
110
How to correctly use/find a peak flow measurement
Make sure the patient has a new mouthpiece
Reset the peak flow metre back to 0.
They should be sitting up straight with shoulders back.
Get the patient to take the deepest breath and they can before blowing into the peak flow metre.
Repeat this process three more times to get them medium.
111
List the questions for a verbal respiratory assessment?
1.Any nasal discharge
2.Any sinus pain
3.Have you had any injuries or trauma to your nose.
4.any nose bleeds and how often?
5.any allergies. EG hay-fever
6.have your sense of smell changed
7.how does your throat feel?
8.do you smoke? If so how much
9.have you been coughing?
10. Any shotness of breath?
11.any chest pain?
12.do you have a past history of chest pain and chest infection?
13. Have you been exposed of any hazid environments?
14. What medication do you take?
112
What sounds should you heir over the tracheal?
A harsh high pitched sound.
113
What sounds should you heir over the bronchial?
A loud high pitched sound.
114
What sounds should you heir over the bronchovesicular?
A Medium in pitch and loud.
115
What sounds should you heir over the vesicular?
A soft low pitched sound.
116
Describe what resonance is
An air filled structure
117
Describe what hyper resonance?
Over inflated of a air fuelled space
118
Describe what dull is
Soild organs and bones.
119
Describe what tympany (bell like) is
A fluid and air filled area. EG., abdomen.
120
What is an open ended questions?
An open ended question require more than one word response, and encourages elaboration.
e.g., What concerns you most about the surgery?
121
What is an closed ended questions?
An closed ended questions is answered with one word or yes/no.
e.g., Have you been in hospital before?
122
what is a leading questions?
Leading questions are questions that are worded in a way that makes the patient feel like there is a right answer or an answer you expecting them to give.
e.g., You are phakia/white, right?
123
Define sleep Vs rest
Sleep; is a state of rest accomplished by low level the brain activity with lower sensitivity to external stimuli.
Rest; is a state where the body has decreased levels of activity but is still awake.
124
Name the two types of physiology of sleep.
Cyclical of naturl sleep {2 steps}
Circadian rhythm
125
Name the 2 system used to control the nature cyclical of sleep.
Reticular activaing system= RAS (wakefulness)
bulbar synchronising region= BSR (sleep)
126
What are the two stages of sleep?
Non rapid eye movement sleep= NREM
Rapid eye movement sleep=REM
127
What dose RAS and BSR stand for?
Reticular activaing system= RAS
bulbar synchronising region= BSR
128
What dose NREM and REM stand for?
Non rapid eye movement sleep= NREM
Rapid eye movement sleep=REM
129
Name the 4 stages of NREM sleep
Describe each stage
And their time frame.
NREM Stage 1= light sleep EG., dosing {1-5 min}
NREM Stage 2= Napping {10-20 min}
NREM Stage 3= normal sleep {15-30 min}
NREM Stage 4 = exhausted sleep {15-30 min}
130
Describe REM sleep
Usually Vivid full colour dreams occur in REM sleep and REM sleep usually begins 90 minutes after you fall asleep
131
What are normal sleep patterns for newborns.
Newborns and infants usually sleep 16 to 18 hours per day
132
What is a normal sleep pattern for a toddler
Toddlers have a normal sleep pattern of 8-10 hours with napping during the day
133
What is the normal sleep pattern for preschool children
Pre-school children usually have a sleep pattern of between 9 to 16 hours with with an average of 12 hours sleep
134
Describe the sleep patterns for school-aged children
School age children usually need between 10 and 12 hours of sleep
135
Describe the sleep patterns of adolescents
Adolescents usually only need 8 to 10 hours of sleep
136
Describe the sleep patterns of adults
Adults only need 6 to 8 hours of sleep
137
Describe the sleep patterns of elderly
Elderly only need 5 to 7 hours of sleep
138
What are the four major classifications of sleep disorders
Dissomnias
Parasomnias
sleep disorders
other disorders
139
Describe the Dyssomnias
They are characterised by insomnia or exclusive sleeplessness
140
Describe parasomnia
They are described as a pattern of walking behaviour that appears during sleep.
141
Describe sleep order classification
Sleep disorders associated with medical or psychiatric disorders
142
Name the 3 types of Parasomnias and describe what each are.
Somnambulism= sleep walking
Som-nam-b-ilz-im
Sleep taking
Bruxism= grinding of teeth during sleep
Br-ox_is_im
Enuresis= urinating while sleeping
N-u-re-sis
143
Name the 5 classes of Dyssomnias
Insomnia= difficulty sleeping and maintaining sleep.
Hypersomnia= extensive sleeping particularly during the day.
Narcolepsy= uncontrollable desire to fall asleep (asleep while standing)
Nar-co-lip-see
Sleep apnoea= does not breathe between the storing intervals 20 to 10 seconds up to 2 minutes
App-knee-a
Restless leg syndrome= cramping and crawling or tingling sensation in legs
144
Name the two classification for treatments of Dyssomnias
Pharmacologic therapy
nonpharmacologic therapy
145
Name two types of Pharmacologic therapy
Hypnosis
Sedatives
146
Name the 6 types of non pharmalogic therapy
Stimulant control
sleep restrictions
sleep hygiene
cognitive therapy
multiple-component therapy
relaxation therapy
147
Steps and sleep assessment?
1.Sleep history
1a. Normal sleeping patterns
1b. Does the patient feel rested
Does the patient get a sufficient amount of sleep (for their age).
2. Does the patient keep a sleep diary.
2a. What is their sleeping routine
3.Does the patient snore while asleep
3a. Does the patient experience periodic limb movement ( also known as myoclonus)
148
Name the three relevant classes of law descriptions for each.
Criminal law= criminal act 1961
Civil law= family industrial and common law
Law of Torts= a civil wrong that causes someone else to suffer loss or harm resulting in liability.
149
When was the end of life choice at written into law.
2019
150
What criteria must the patient met to be eligible for the end of life choice ACT (6 steps)
1.Must be a terminal illness
2.prided under lawful processes
3.The health professional is not under any obligations
4.Assisted dying must not suggested by the healthcare professional
5.Requires a first and second opinion by attending medical professionals and a third opinion via psychologist maybe needed
6.Documentation and records are kept
151
What does NFR stand for
Not For Resuscitation
152
Describe drug/medication
Any substance that modifies body function when taken into the body
153
Describe pharmacology
A study of chemicals that affect the body's function.
154
Describe what a genetic names for medications is.
The name associated by the manufacturer that first developed the drug
155
Describe what a trend name of the medication is/means
The brand name selected by the drug company that sells the drug
156
What are Class A drugs?
Very high risk of harm drugs
E. G., Cocaine
157
What are Class B drugs give an example of a Class B drug
High risk of harm E.g., Morphine
158
What are class C drugs give an example of a class c drug
Moderate risk of harm E.g., Codeine
159
Class D drugs eg4 schedule
This is a precursor substance such as methamphetamine
160
What are the 5 factors affecting drug absorption give examples each
Route of administration EG injection or oral
drug solubility e.g. liquid absorbs more rapidly than solid
pH EG acidic drugs well absorb into the stomach
location conditions at the site of administration EG food in the stomach can delay or enhance absorption
drug dosage EG loading Vs maintenance
161
Name the 8 rights of medication administration
The right patient
The right time
The right medication
The right dosage
The right route
The right reason
The right to refuse
The right documentation
162
Name the types of Orders (6)
Routine order ( low dose of aspirin)
PRN order ( take as needed)
Single of order ( once only at a specific time)
Stat order (immediately)
Verbal or telephone order
standing order ( O2 therapy
163
PRN Order is
Take as needed
164
Stat order stand for....
Immediately
165
What is the lub sound in the heart
Closing of the mitral valve and tricuspid valve.
166
What dose the dub sound in the heart?
The dub sound is the closing of aortic and pulmonary valve.
167
Normal pulse rate for 1-12 months
80-140bpm
168
12 months - 2 years normal pulse rate.
80-130bpm
169
2-6 years normal pulse rate.
75-120bpm
170
6-12 years normal pulse rate.
75-110bpm
171
12+ years normal pulse rate.
60-100 bpm
172
Normal blood pressure
120/80
173
Pre- hypertension blood pressure
139/89
174
Stage 1 hypertension blood pressure
140/90
175
Stage 2 hypotension blood pressure
<160/<100
176
Gals stands for.....
Gait
Arms
Legs
Spine
177
Orthostatic hypertension, venous thrombosis causes
Blood pressure drop when the patient stands up
178
What are the function of bones in the body?
They support and protect international oranges e. g., the skull protects the brain.
179
What are the function of the muscles in the body?
Muscles pull against bones to make movement.
180
What is the mean function of the joints in the body?
The area where two bones are attached for the purpose of permitting body parts to move.
181
TDS
Twice a day
182
OD
Once a day
183
Sloughing is what?
When the skin (wound) change from moist, yellow and stringy to dry and black.
184
Describe hypergranulation
This is the excess of granulated tissue the has filled and wound area and had gone beyond the high of the area of the wound.
185
Describe necrosis
Necrotic wouds are areas of tissue loss that occurs following the death of their component cells.
186
Describe Dehiscence wouds
Dehiscence wouds are where a surgical incision has gone wrong and the side of the wound are pulling apart
187
Describe Evisceration
This the simular to Dehiscence but the intra domainal contents of the abdominal cavity is OUTSIDE of the abdomen!
188
Describe Maceration
This occurs when skin has been exposed to moisture for to long. Skin can be soggy looking and appears to be whiter then usual.
189
Attributes of a nurse 6
Open minded
Self awareness
Moral responsibility
Motivation
Leadership
Bravery and question the system
190
What are the 3 main part of child hood development?
Physical
Cognitive
Psychological
191
What is Jean piaget theory on child hood development? Date?
The theory of cognitive development (1969)
192
What is Erik Erik's on theory on child hood development? Date?
The theory of psychosocial development (1963)
193
What is Sigmund Freud theory on child hood development? Date?
The theory of psychosexual instinctaul drive? (1923)
