301 Test 2 part 2 Flashcards
a related factor to acute confusion is being over the age of
60
a few of the precipitating factors of acute confusion:
use of restraints
indwelling catheter
hospital admission for fractures of hip surgery
male gender
foul smelling sputum and fever can be signs of
risk for aspiration
moles that are greater than __ mm are cause for concern
6 mm
most reliable site to exam color change in dark skinned people
under tongue, buccal mucosa, palpebral conjunctiva, sclera
localized hypothermia occurs in peripheral arterial insufficiency and in ___ disease because of vasospasm
Raynauds disease
warm, moist, velvet skin is associated with
hyperthyroidism
rough, dry skin is associated with
hypothyroidism
arterial insufficiency makes the skin very
thin and shiny
a deep pitting edema would get a rating of
+4
unilateral edema suggests a peripheral problem where as bilateral suggests a central such as __ or __ failure
heart of kidney
poor turgor can indicate severe
dehydration
small red dots on adults
cherry (senile) angiomas (they’re not significant)
seborrhea is aka
dandruff
spoon shape nails may occur with
iron deficiency anemia
inflammation of the base of the nail
paronychia
a normal angle for a nail is
160 degrees
thick and ridged nails can be caused by arterial
insufficiency
brown linear streaks along the nail are abnormal for
light skinned people
a sluggish capillary refill is slower that
1 to 2 seconds
in pregnant women, on the abdomen the linea __ appears as a brownish-black line
nigra
an irregular brown patch on the face (normal finding)
chloasma
lesions in pregnant women with tiny red centers and radiating branches
vascular spiders
liver spots are aka senile
lentigines
“skin tags” are overgrowths of normal skin in older adults
acrochordons
abnormal lung sound that occurs with pneumonia and pulmonary edema
crackles
abnormal lung sound that occurs from asthma and emphysema
wheezes
a coarse crackling sensation palpable over the skin surface
crepitus
jaundice, mongolian spots, and hemaniomas may be normal in
infants
to check for cyanosis, definitely check the
tongue
cool skin might be a sign of compromised __ or dehydration
circulation
for older adults, check skin turgor near the
clavicle or sternum
decreased turgor is a normal finding for
older adults
turgor is seen with normal aging and
dehydration
dry and flakey skin may be normal for
older adults
to check for edema, press with your finger for how many seconds
5
milia (tiny collections of sebum on the face) are normal in
infants
acrochordons are normal in
adults
flat or inverted nipples are ___ finding
abnormal
visible thyroid is a ___ finding
abnormal
an enlarged thyroid may indicate a
goiter
a tender thyroid may indicate
inflammation
sternal and intercostal retractions are seen in severe
hypoxia
touching the back and chest to feel for vibrations while the person says “99”
tactile fremitus
being unable to hear tactile fremitus is the midthorax is ___ finding
normal
children and thin adults may have ___ed fremitus
increased
increased fremitus means the lungs are more dense, such as in
edema
decreased fremitus means the lungs are less dense, such as in __ or __
emphysema or asthma
percuss over the intercostal spaces rather than over the
ribs
when percussing the chest, dullness indicates
fluid or masses in the lungs
when percussing the chest, hyper resonance indicates air trapping, such as in
emphysema
the movement of the diaphragm during breathing
diaphragmatic excursion
normal distance for diaphragmatic excursion
3 to 6 cm
decrease diaphragmatic excursion may indicate
paralysis, atelectasis, or COPD
bronchial breath sounds are heard over the
trachea
bronchovesicular breath sounds are heard over the __ and between the __
sternum and between scapulae
vesicular breath sounds are heard over
most of the lung fields
crackles are aka
rales
abnormal breath sound, bubbling, popping, very brief and heard during inspiration
crackling
abnormal breath sound, snoring, continuous low pitched. May clear with coughing
rhonchi
abnormal breath sound, musical or squeaking
wheezes
abnormal breath sound, honking
stridor
abnormal breath sound, grating
friction rub
abnormal breath sound, high pitched tubular sound
grunting
nurse needs to be notified is PO falls below
95%
postural drainage should not be done for at least 2 hours after
eating
ulcer that has irregular wound pattern
venous
type of ulcer- surrounding skin it thin, shiny, dry, cool, loss of hiar
arterial
type of ulcer, patients complain of increasing pain with activity
arterial
between arterial and venous, which has a pale base and which is “ruddy/beef”
arterial pale
venous “ruddy/beefy”
cane size: with patient standing, place the cane 4 inches from her foot. It should come up to the __ of the hip joint
top
walker size: should extend from the floor to the hip joint so that the patient can hold the walker with __ degree flexion of the elbow
30
crutch size: while the pt is wearing shoes, measure from the heal to the axilla then add
1 inch (2.5 cm)
crutches: have pt stand and place crutches 4 to 6 inches (10 to 15 cm) from his
heel
crutches: adjust the axillary pad __ fingerbreadths below the axilla
3
the pt should hold the cane on his __ side
strong
cane: distribute weight __ between feet and cane
evenly
advance the cane and __ leg at the same time.
weaker
where do you stand with a walker?
between the back legs
pick up the walker and advance it as you
step ahead
similar to using a cane, when you advance the walker also advance the ___er leg
weaker
3 factors used in the Braden score of pressure ulcers
mobility
nutrition/hydration
moisture
__ cream is used to treat incontinence dermatitis
barrier
which abnormal findings should be escalated?
all
if someone’s at risk for pressure ulcers check their nutrition status, specifically __ level
albumin
if someone’s at risk for pressure ulcers, besides albumin check their __ and __
BUN and hemoglobin
skin redness can be a stage 1 pressure ulcer or
DTI
__ gel is used for keeping the wound moist
hydrogel
you have to wound so that it doesn’t form an
abscess
use of heat and cold requires an
order
type of wound healing: when a wound involves minimal or no tissue loss and has edges that are well approximated (closed)
primary intention healing
type of wound healing: occurs when a wound involves extensive tissue loss, which prevents wound edges from approximating
secondary intention healing
type of wound healing: occurs when a wound should not be closed (e.g. because it’s infected)
secondary intention healing
type of wound healing: occurs when 2 surfaces of granulation tissue are brought together
tertiary intention healing
type of wound healing: requires strict aseptic technique
tertiary intention healing
clean wounds typically drain __ exudate
serous
exudate: watery, straw colored
serous
exudate often seen with deep wounds or wounds or wounds in highly vascular areas
sanguineous
exudate that indicates damage to capillaries
sanguineous
exudate in new wounds
serosanguineous
malodorous exudate
purulent
exudate seen with infected wounds
purulent
red pus exudate
purosanguineous
between venous and arterial ulcers, which has drainage
venous
if the tissue was compressed for 1 hour, reactive hyperemia should not last longer that
30 minutes (if it lasts longer than 30 minutes, there’s been tissue damage)
adequate intake of calories, protein, vitamin C, and zinc and cholesterol, copper are need to promote
healing
fever can be a risk factor for
skin breakdown
6 rights
patient medication dose route time documentation
