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204 &202 > 204 > Flashcards

204 Flashcards

1
Q

Skin cancer ABCD rule

A

Asymmetry- normal moles are symmetricalBorder- jagged edgesColor- if it has more than one color or hue it is suspicious diameter- if it is larger than a pencil eraser 1/4 inch it should be examined elevation/evolving- if its raised and if it is changing

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2
Q

body mechaninks

A

feet apart, bend knees head erect and midlineabdomen tuckedhips and ankles flexed

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3
Q

body balance

A

bend down not forward to maintain a low center of gravity

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4
Q

friction

A

can cause shear. when rubbing or resistance caused when body meets a surface

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5
Q

atqxic belt

A

unbalanced gait

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6
Q

rom excercises

A

3-4 times a dayactive pt- they are able to move their own jointspassive pt- nurse moves pt. joints

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7
Q

immobilized patiet - will need moving - use body mechanics

A

dependent pt- assist pt to regain independence

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8
Q

activity toleranceintervention

A

bulid back muscle massmanage pain

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9
Q

respiratory interventions

A

turn, cough, deel breath every 1-2 hrs. \increase fluid intae to 2000 ml/day

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10
Q

metabolic/fluid.electrolyte intervention

A

increase protein- for healingmonitor I&Oincrease fats and carbs

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11
Q

cardiac interventions

A

orthostatic hypotension- assist movement slowly, before standup dangle pt feet 5-10 min. DVT- deep vein thrombosis- give TED stockings, give anticoagulants, ROM every 4 hrs.

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12
Q

skin interventions

A

assess skin every 2-4 hoursreposition every 1-2 hrs provide pressure relieving devices

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13
Q

dehiscene- happens after abdominal surgery, wound separates. get pt back in bed call surgeon

A

evisceration- happens after abdominal surgery- bowel comes out, if pt has weak conn. tissue

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14
Q

disuse

A

muscle contracted by imobility

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15
Q

tissues under nail

A

tissues under the nail are highly vascular and provide clues to oxygenation status and blood perfusion

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16
Q

To make sure blood circulation isnt impared

A

you check for capilary refil by pressing on nail (it turns from white to pink in 3 sec)

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17
Q

clubbing

A

a deformity of the fingers and fingernailsassociated with lung, heart or GI disordersdue to low oxugen

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18
Q

pruritus

A

itching

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19
Q

cellulitus

A

when tissue around sore gets inflamed

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20
Q

fluid in rashes

A

serosanguinis- mixture of clear and red fluidsanguinus _ bloody purulin- pusy drainage (yellow, tan)serous- clear watery plasma

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21
Q

skin (warm and dry)

A

xerosis- dry skinseborrhea- oily skinstriae- strech markscheck for skin turgor- skin when pulled returns to normal, it skin doesnt recoil it is called tenting (check in clavicle not in hand, because skin in hand is thinner)

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22
Q

skin color changes

A

jaundice- yellow tint (liver & gallbladder disease) -look at the whites of their eyes to chek for this, palms are not a good place to chek because some ethnic griups have yellowish tonesvitiligo- loss of pigmentation to the skin

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23
Q

wounds

A

granulating- healing woundeschar- black skin that forms on wound. needs to be cutt off

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24
Q

hair problems (shiny and soft)

A

hirsutism- too much hair (endocrine disorder)alopecia acredia- hair loss of unknown origin

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25
Q

milia

A

white dots, baby acne

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26
Q

erythema toxicum

A

rash

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27
Q

limited mobility

A

hemiplegia-paraliyzed on one side of bodyparaplegia- paralyzed waist downquadriplegia- paralyzed neck down

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28
Q

if skin does not blach

A

stage I pressure ulcer has developed

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29
Q

foliculitis

A

hair follicle infection

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30
Q

pediculosis

A

lice

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31
Q

hirutism

A

increase in growth in facial, body, or pubic hair

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32
Q

paronychia

A

chronic infection of cuticle

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33
Q

vitiligo

A

unpigmented skin

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34
Q

nevi

A

moles

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35
Q

cyanosis

A

blue tinge to skin or gray color in lips, may see with clubbing (look at gums)

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36
Q

pallor

A

pale

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37
Q

jaundice

A

yellow from increased bile pigment

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38
Q

erythema

A

red from increased cutaneous blood flow

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39
Q

edema

A

swelling

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40
Q

petecheae

A

red/purple pinpoints tht dont blanch

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41
Q

purpura

A

brown/red/purple discoloration due to hemmorrhage into tissue (does not blanch)

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42
Q

slough

A

stringy substance attached to wound bed

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43
Q

macule

A

flat patch, darker in color

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44
Q

papule/plaque

A

round elevated

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45
Q

wheal

A

irregularly shaped elevated area, (mosquito mite/ hives)

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46
Q

nodule/tumour

A

nodule- solid, raised bump deeper and firmer than papule, extends through subcutaneous tissue

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47
Q

vesicle

A

filled with serous fluid (chickenpox) starts like a blister then crusts

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48
Q

bulla

A

fluid filled large blister

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49
Q

pustule

A

elevated lesion like a vesicle but filled with purulen (pussy) fluid

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50
Q

cyst

A

fluid filled leasion

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51
Q

scale

A

many layers of keratin, flaking skin

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52
Q

keloid

A

growing scar

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53
Q

excoriation

A

abrasion

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54
Q

fissure

A

linear crack

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55
Q

erosion

A

larger loss of epidermis

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56
Q

abses

A

puss filled leason (usually iv drug users)

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57
Q

ulcer

A

deep loss of skin surface

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58
Q

atrophy

A

thinning of skin with loss of normal skin furrow,

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59
Q

Vertigo

A

Dizzynes

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60
Q

Synocope

A

Fainting

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61
Q

impedigo

A

crusted leasion

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62
Q

echymoses

A

red/purple/yellow/green BRUISE(from ruptered blood vessles)

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63
Q

pain PQRST (you want to prevent pain)quality of pain (aching, stabbing, tender, tiring, numb)

A

p provokingq qualityr reagions severityt timing

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64
Q

shivering

A

sometimes shivering is a warning for an infection before the temp. starts to spike, decrease temp- vasodialationincrease temp- vasoconstrictionwhen pt comes of of the OR and they are cold- if a blanket is not enough give a narcotic such as opiod (this increases the temp)

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65
Q

afebrile- no fever

A

febrile- fever

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66
Q

when you get an abnormal reading of vital signs

A

you first want to find info (such as look at charts)then you want to reases and then call physitioninforeasses physitian

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67
Q

check pulse before giving medication

A

because if the pulse is already too low the medication will make it worse

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68
Q

pule (60-100) normal adultnewborn (130-160)rhythm (regular / irregular)volumestrongweakthredy- (hard to feel ) for people in shock because the BP is so low that it doesnt have force to push against arterial wallbounding- very strong (heart failure with extra fluid)

A

pressure of blood pushing against wall of artery as heart beats and restshypotensive - low pulsehypertensive - high pulsenormotensive- normal pulse

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69
Q

tachycardia

A

high heart rate

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70
Q

bradychardia

A

low heart rate

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71
Q

IF CUFF IS TOO SMALL

A

will give a HIGH bp reading

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72
Q

IS CUFF IS TOO BIG

A

will give a LOW bp reading

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73
Q

respiration

A

12-20 Rhythm (regular / irregular )characteristics ( shallow, deep, labored)labored - SOB, when pt is in pain or accident

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74
Q

blood pressure

A

force of blood pushing against wall of arteries systolic- contractdiastolic- relax

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75
Q

BP readings

A

normal (120/80)prehypertension (120-139 / 80-89)Hypertensive (stage 1) 140-159 / 90-99hypertensive (stage 2) >160/100

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76
Q

core temp (rectal, tympanic)

A

surface (oral, axulary, temporal)

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77
Q

rectal

A

more accurate (dont use on cardiact pt)

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78
Q

celcius ferenheigt

A

C=(F-32) x 5/9

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79
Q

The average normal oral temperature is 98.6°F (37°C). An oral temperature is 0.5°F (0.3°C) to 1°F (0.6°C) lower than a rectal or ear (tympanic) temperature.A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.An ear (tympanic) temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.An armpit (axillary) temperature is usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature.

A

.

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80
Q

pesonal space

A

1 1/4 - 4 feet

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81
Q

SBAR

A

used for giving report or charting

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82
Q

leading question

A

direct pt to a specific part of the body

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83
Q

profalactive treatement

A

preventative treatment

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84
Q

medical asepsis

A

sanitation- reduces nr of microorganismsdisinfection- destroies infectious agentsseralization

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85
Q

surgical asepsis

A

sterle

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86
Q

iatrogenic infection

A

given to patient by proceadures

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87
Q

nonsocomial infection

A

hospital aquired infection

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88
Q

QSEN

A

organization for facutly to teach studentsabout safety

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89
Q

sentinal event

A

event that occurs from a hospital procedure that causes harm to a patient or even death

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90
Q

nearmiss event

A

event in which a disasterous thing happends but it is ether cought right away or it doesnt have any negative effets on the pt

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91
Q

levels of care

A

primaty- preventative- immunization excercice, diet, washing handssecondary- screening- mammogramstertiary- rehabilitiation

92
Q

light palpation 1 cm

A

deep palpation 4 cm

93
Q

5 percussion tones

A

tympany-high loud piched heard over abdomeresonace- over lungshyperresonance- overinflated lungsdullness- over liverflattness- over bones and muscle

94
Q

intrapersonal comm

A

self talk

95
Q

interperonal comm

A

2 or more ppl comm

96
Q

congruence

A

nonverbal behaviour matches verbal behaviour

97
Q

nurse-pt relationship

A
  1. preporatory phase2. orientation phase3. working phase4.. termination phase
98
Q

preporatory phase

A

pre interaction phasereview info about pt

99
Q

orientation phase (introductory phase)

A

introduce selfexplain procedureobserve behaviour

100
Q

working phase (maintenance phase)

A

encourage to express feelings

101
Q

termination phase

A

conclude

102
Q

vectors

A

living organisms can be insects or people

103
Q

fomites

A

inanimate objects such as clothing, water, food

104
Q

osteomyolitis

A

if infection goes to bone

105
Q

hirtuism

A

excessive hair on body

106
Q

pediculosis

A

lice

107
Q

alopecia

A

hair loss

108
Q

TED stocking

A

measure pt firstthe help to compress veins but not arteriesthey prevent blood clots, may be worn at times of ambulation to help with edema and blood clotts

109
Q

pulse deficit

A

apical rate - radial rate if its > 2 beats/min

110
Q

lymph nodes

A

-lymph nodes are in chains or clusters-they feel round, smooth, and rubbery-if they become enlarged or tender means that those are early signs of innflamation-if they are hard and irregular shaped they may be cancerous-you feel them in a circular manner

111
Q

if pt has a crocked smile

A

this may indicate a strokeSTROKE- difficulty with facial muscles

112
Q

dysphacia

A

difficuly speaing

113
Q

dysphagia

A

difficulty swallowing

114
Q

if pt complains of sore face

A

check sinuses

115
Q

transilumination

A

shine light in roof of mouth and it light is shown throught it is clear if not then there is sinuses

116
Q

thyroid

A

examine for symetry and lumpsif someone has an overenlagred thyroid you do not want to over examine bcuz this may cause an increase release of thyroid hormones

117
Q

snellen chart

A

testing vision20/100 what a normal person seen at 100 ft, this pt can only see in 20 feet

118
Q

testing eye muscle movements

A

pt. will watch your movng finger as it forms the letter H, this test for all 6 facial muscles

119
Q

glaucoma

A

blood vessles in eye may hemmoragehigh pressure of fluids in the eys

120
Q

pupil assesmentpreladirect light reflexaccomidationfacial nerves (H)

A

p.e.r.r.l.ap- pupilse-equalr-roundr-reactivel-light-accomidation - move finger from pt eye and away (pupils dialate at distand object and constrict at near object)

121
Q

direct light reflex

A

constriction of pupils when light is shined at them

122
Q

consensual light reflex

A

simultaneous constriction of other pupil

123
Q

unequal pupils

A

ALARMING- may indicate brain injury or stroke ask pt if they had if they have had any prior surgery

124
Q

respiratory system

A

change of o2 and co2 in the celular levelleft lung 2 lobesright lung 3 lobes

125
Q

inspiration- active

A

expiation- passive

126
Q

respiratory exam

A
  1. observe pt breathing, it its normal, labored2. asses a-p diameter (2-1) anterior/posterior3. asses pt. color (cyanosis)
127
Q

asthma

A

use of accesory musclesSOBwheezing/coughingmaybe cyanoses

128
Q

pulmonary embolii

A

blockage in lung by an embolism (blood clott)acute SOB ( dont give o2 for COPD)causes decrese/absent lung sounds

129
Q

trauma to chest

A

ribs crack, can puncture lungs

130
Q

COPD

A

chronic obstructive pulmonary desease\1. emphysema2. asthma3. chronic bronchitis-Chronic bronchitis, which involves a long-term cough with mucus;- Emphysema, which involves destruction of the lungs over time .

131
Q

flail chest

A

unsymetrical breathing

132
Q

dyspnea

A

difficulty breathing

133
Q

percution- helps to identify tissues are air, fluid or solid filled

A

resonance- spund between ribs, LUNGHYPERRESONANCE- EMPHYSEMA, WHERE THERE IS EXTRA AIR, COPDtympany- on belly, PUFFED CHEEK

134
Q

OXYGENATION

A

-look for change in level of councesness (pt is confused and anxious)SOB, skin color

135
Q

hypoxia

A

lack of o2 in tissues

136
Q

hypoxemia

A

lack of o2 in blood

137
Q

symptoms of hypoxia early signs

A

RATR- restlessA- anxietyT- tachycardia high HR

138
Q

symptoms of hypoxia late signs

A

BEDB- bradychardia low HRE- extreme restlessnessD- dyspnea

139
Q

why does pt become restless when oxygen drops

A

bcuz brain is effected and not getting enough oxygen

140
Q

why does pt become tachycardic when oxygen level drops

A

because high pulse rate causes high heart rate

141
Q

when pt SOB

A

instruct pt to take deep breaths(put pressure on diaphragm with pillow) and cough

142
Q

incentive spirometer

A

brethe in 10X hourexpands the lungs

143
Q

pursed lip breathing

A

makes breathing more effective. for COPD

144
Q

atelectasis

A

incomplete lung expansion or collapse

145
Q

perfusion

A

capillary blood presses through tissue

146
Q

peek flow meter

A

for pt with asthmayou establish a personal best level and measure and compare it 2X day

147
Q

sputumn collection

A

best in AM because mucous collects in throat pt can cought it upor if pt can not cought it by by themselves you can suction (when u suctin make sure to give o2 because u take the o2 out)

148
Q

artery- away from heart

A

vein- to heart

149
Q

myocardial infarction

A

artery getes blocked

150
Q

active percordium

A

heart pumping for hard you can see it under the skin

151
Q

cardicat cycle

A

systole- pumping phase, contractiondiastole- filling phase, relaxation

152
Q

decreased cardiac output

A

associated with a decrease in pheripheral pulse and causes FATIGUE

153
Q

pulse deficit

A

when heart beats are not all geting peripherallyradial pulse 80apical pulse 10020 pulse deficit

154
Q

first heart sound S1

A

accurs with closure of the two artrio-ventricular valves, when ventricles start to contract SYSTOLE

155
Q

second heart sound S2

A

PRODUCED BY CLOSURE OF AORTIC AND PULMONARY VALVES DIASTOLE

156
Q

MURMUR

A

soft swishing sounds in the heart. heard on chest wall due to turbulance, excercise, anemia, narrow valves

157
Q

erbs point

A

transition area from pulmonic to tricuspid valve, you can differentiate between murmors. because the murmors may overlap due to close proximety

158
Q

S3 and S4

A

both are heard during diastole

159
Q

ascultation of heart sounds

A

APETMaorticpulmonaryerbs pointtricuspidmitral

160
Q

regurgitation or insuficency

A

a valve that doesnt close efficently and results into the backflow of blood

161
Q

stenosis

A

a valve that doesnt open efficently may cause turbulent backflow secondary to obstruction or narrowing

162
Q

ascetis

A

fluid in belly

163
Q

pericardial friction rub

A

caused by fluid in the pericardial sackgrating sound

164
Q

pheripheral resistance (constricion of vessles)

A

squeeze of blood vessles, friction of blood as it passes through veins

165
Q

congestive heart failure

A

inability of heart to circulate blood effectively enough to meet bodys metabolic needshypertension is the main cause of this

166
Q

how to measure peripheral resistance (anchle brachial test) constriction of vessles

A

blood pressure taken in the ankle and arm. the ancle systolic pressure divided by arm systolic pressure. meaurment taken again after 5 min of waling on treadmillif there is a drop when pt walked on the treadmill that means that there may be PERIPHERAL ARTERIAL DESEASE CLOSER TO 1 THE BETTER

167
Q

distention

A

big veins from fluid overload

168
Q

if you can not feel the pulse

A

check with a doplar

169
Q

bruits- heard in carotid artery (only check one at a time)

A

A bruit is caused by turbulent blood flow in an artery which supplies blood to the brain

170
Q

allens test

A

to see if there is adequate perfusion in hand and to see if it is ok to pur an arterial line in that armASSESES BLOOD FLOW TO HAND PRIOR TO PLAING A-LINE

171
Q

HOMANS SIGNS

A

ASSESED FOR DVTif you dorsiflex the foot and they have pain they have DVT, you dont want to repedetly do it because it may dilodge the vlott

172
Q

holtor monitor

A

20 hour monitor to heart to find abnormalities

173
Q

peristalsis

A

intestines moving

174
Q

root work for liver

A

HEPATO-

175
Q

root word for bile or gallbladder

A

CHOLE-

176
Q

ROOT WORD FOR STOMACH

A

GASTRO-

177
Q

liver

A

produces bile, removes toxins from bloodalchohol, chemicals, drugs, tylenol and acetaminophen damages liverif there is a liver disorder jaundace occurs

178
Q

gallbladder

A

under liver, recieves bile from liver and forces it out of cystic duct to common bile duct

179
Q

cholithiasis

A

stones in gallbladder

180
Q

stool- lighterurine- darker

A

if there is a block in the gallbladder and bile doesnt spread efficently

181
Q

small intestine

A

digestion compleated there. and absorbtion

182
Q

large intestine

A

recieves and stored fluid waste

183
Q

ulcerative colities

A

ulcers in collon

184
Q

hernia

A

intestines comes through muslces

185
Q

hemmorroids

A

bleeding while passing stool

186
Q

diverticulosis

A

is the condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall

187
Q

obstipation

A

skinny ribbon stool

188
Q

aerophagia

A

swallowing air

189
Q

bobrogymus

A

rumbling stomach, hunger

190
Q

cachexia

A

pt is skeleton like, skinny

191
Q

cirrohsis

A

liver disease due to alchohol, liver cells can regenerate

192
Q

colic

A

irritated baby

193
Q

flatus

A

gas

194
Q

impactions

A

hard stool

195
Q

halitosis

A

bad breath

196
Q

melena

A

black stool, from stomach GI bleed, blood gets digested and turns black

197
Q

pyloric stenosis

A

narrowing of valve of stomach

198
Q

steatorrhea

A

fatty stools

199
Q

wounds (REEDA)

A

rednessedemaechymosesdrainageapproximation

200
Q

constipation

A

encourage fiber but with fluidsencourage ambulation

201
Q

garting

A

pt tightens muscles due to pain

202
Q

peritonitis

A

severe garting , board like bellyfe

203
Q

polyuria (diuresea)

A

production of abnormally large amounts of urine

204
Q

olguria

A

low urine output

205
Q

anuria

A

lack of urine production

206
Q

nocturia

A

voiding two or more times a night

207
Q

urgency

A

sudden strong desire to viod

208
Q

dyuria

A

painful or difficult voiding

209
Q

enuresis

A

involuntart urination in children

210
Q

normal urine outut

A

60 ml / hour1500 ml / day

211
Q

cystisis

A

UTIUrine is cloudy in cystitis because of bacterial and white cells.

212
Q

removal of foley cathater

A

If 4 hours after Foley removal have elapsed without voiding, it may be necessary to reinsert the Foley.

213
Q

credes method

A

With this method pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter. BY PRESSING HAND ON BLADDER

214
Q

crackles (RALES)

A

fluid (usually found on base of lungs)ASK PT TO COUGHT AND DEEP BREATHE TIMES EVERY HOURCOMMONLY WITH INSPIRATION

215
Q

WHEEZE

A

AIRWAY CONSTRICTIONCONTINUOUS, MUCSICAL, HIGH PITCHED

216
Q

RHONCHI

A

OBSTRUCTUON OF AIRWAY FROM SECRETIONSLIKE SNORINGLOW PITCHED

217
Q

STRIDOR

A

UPPER AIRWAY OBSTRUCTIONLOUDEST OVER TRACHEA (INHILATION OF FOREIGN BODY)

218
Q

Granulating

A

Healing wound

219
Q

PLEURAL RUB

A

BRUSHING SOUNDWHEN INFLAMED PLEURA RUBS ASSOCIATED WITH PNEUMONIA

220
Q

Eschar

A

Blac skim needs to be cutt ofDebreed

221
Q

Hemiplegia

A

Parylized on one side

222
Q

Parapalegia

A

Parulized waist down

223
Q

Quadriplegia

A

Paralyzed neck down

224
Q

Vessicles

A

Start like blosters then crustHicken pox

225
Q

If someone is an iv drug user

A

Abses- puss filed leasion

204 &202 (3 decks)

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