306 exam 2 Flashcards
1
Q
Eye Disorders
A
Cataracts-
A clouding of the lens of the eye that causes vision to be blurry, hazy, or less colorful.
Glaucoma-
An increase in intraocular pressure due to the buildup of fluid, or aqueous humor, that causes compression of the optic nerve.
Open Angle: Tunnel Vision, Gradual loss of vision
Closed Angle: Severe pain, sudden onset of decreased vision
Eye Exams: Increased Ocular pressure
Treatment: Eye drops, Laser eye surgery
Acute Macular Degeneration-
An irreversible degeneration of the macula that leads to a loss of central vision as clients age.
Diabetic Retinopathy-
affects blood vessels in the retina causing blindness.
Astigmatism-
A defect that causes both nearby and faraway objects to appear blurry
2
Q
Acute Macular Degeneration
A
An irreversible degeneration of the macula that leads to a loss of central vision as clients age.
2
Q
Cataracts
A
A clouding of the lens of the eye that causes vision to be blurry, hazy, or less colorful.
3
Q
Glaucoma
A
An increase in intraocular pressure due to the buildup of fluid, or aqueous humor, that causes compression of the optic nerve.
Open Angle: Tunnel Vision, Gradual loss of vision
Closed Angle: Severe pain, sudden onset of decreased vision
Eye Exams: Increased Ocular pressure
Treatment: Eye drops, Laser eye surgery
3
Q
Diabetic Retinopathy
A
affects blood vessels in the retina causing blindness.
4
Q
Astigmatism
A
A defect that causes both nearby and faraway objects to appear blurry
5
Q
Eye exams as early as
A
6 months old
6
Q
Comprehensive eye exam at
A
40
With no comorbidities
2-4 years ages 40-54
1-3 years 44-64
1-2 years 65+
7
Q
Children ages _______ screened at least once
A
3-5
8
Q
Eye Safety
A
Wear goggles or safety glasses in an environment that is dangerous
9
Q
Hyperopia
A
Inability to see nearby objects clearly, also referred to as farsightedness.
10
Q
Myopia
A
Inability to see faraway objects clearly, also referred to as nearsightedness.
11
Q
Astigmatism
A
A defect in the eye making objects nearby and faraway look blurry or distorted
12
Q
Presbyopia
A
Age-related farsightedness, or a gradual decrease in the ability to clearly see nearby caused by the loss of flexibility of the lens of the eye.
13
Q
Sensorineural Hearing Deficit
A
Effects inner ear, nerve pathway
Could be associated with tinnitus and vertigo
Age related presbycusis, followed by noise-induced hearing loss
Congenital, genetic or acquired
14
Q
Noise-induced hearing loss
A
Associated with prolonged exposure to sounds greeted than 85 dB including loud music
Can be caused by single exposure to intense sound over 120dB
Wear ear protection, avoid loud situations
Warning signs are inability to hear from 3 feet away
14
Q
Conductive Hearing loss
A
Loss of hearing at all frequencies
Most common cause: Obstruction of external ear canal
Impacted cerumen
Perforated tympanic membrane
15
Q
Otosclerosis
A
Abnormal growth of bone in the middle ear.
15
Q
Otitis Media
A
Inflammation in or the accumulation of fluid in the middle ear that can result in conductive hearing loss
16
Q
Occupational Risks for hearing loss
A
Machinery, Planes, other loud environments
17
Q
Presbycusis
A
Age-related hearing loss.
18
Q
Hair cells of cochlea ______ With aging
A
degenerate
19
Q
______ pitched tones, conversational speech lost initiaially
A
High
20
Q
Sensorineural hearing loss
A
Hearing loss that occurs from problems either in the inner ear or on the vestibulocochlear (auditory) nerve (cranial nerve VIII).
21
Conductive Hearing loss
Inability of sound to travel from the outer ear to the eardrum and middle ear.
Blockage in ear canal
21
Tinnitus
Hearing sound when no external sound is present, such as ringing, buzzing, roaring, clicking, hissing, or humming noises.
22
Vertigo
a sensation of motion or spinning that is often described as dizziness
23
TORCH
Toxoplasmosis, Rubella, Cytomegalovirus, Syphilis, Herpes
24
Idiopathic neuropathy
Neuropathy due to nerve damage of an unknown cause.
24
Peripheral Neuropathy
Conditions that occur when nerves in the central nervous system become damaged resulting in numbness, pain, and weakness to the extremities.
25
Diabetic neuropathy
Nerve damage that occurs in clients who have diabetes mellitus due to high blood glucose levels and high levels of triglycerides, which cause damage to the nerves and to the small blood vessels supplying blood to the nerves.
26
Rinne test
Tuning fork on mastoid bone, when client cannot hear it place it outside auditory canal
27
Weber Test
Place the tuning fork on the middle of forehead, detect if the client hears the sound equally. Can detect sensorineural issues
28
Sensory processing disorder
When a client appropriately detects sensory stimuli, but their brain has difficulty interpreting and responding appropriately to the stimuli.
28
Sensory Deficit
A deficit in the expected function of one or more of the five senses.
29
Sensory Deprivation
A reduction in or absence of stimuli to one or more of the five senses.
30
Sensory Overload
Receiving stimuli at a rate and intensity beyond the brain’s ability to process the stimuli in a meaningful way.
31
Ototoxicity
Causing damage to or dysfunction of the cochlea or vestibule.
32
Aphasia
A disorder that affects a client s ability to articulate and understand speech and written language due to damage in the brain (National Institute on Deafness and Other Communication Disorders).
33
Tactile Hypersensitivity
Being overly sensitive to tactile stimulilation.
34
Tactile Defensiveness
A severe sensitivity to touch that most people would find acceptable that often causes physical pain.
35
Tactile Hyposentivity
Under-responsiveness to tactile stimulation.
36
Gustatory Cells
Taste cells that contain specific receptors that allow for differentiation between sweet, sour, bitter, salty, or savory flavors.
37
Hypogeusia
A decreased ability to taste.
37
Dysgusia
A persistent salty, rancid, or metallic taste is said to have dysgeusia.
38
Aguesia
The inability to taste anything.
39
Phantom taste perception
A persistent, foul taste when the mouth is empty.
39
Hyposmia
A reduction in the ability to perceive odors.
39
Anosmia
The inability to smell anything.
40
Phantosmia
The sensation of an odor that isn't there.
40
Parosmia
a distortion in smells, such as when a previously pleasant smell becomes unpleasant.
40
Delirium
confused thinking and reduced awareness of the environment.
41
Vulnerable Populations
Socioeconomic
Different primary language compared to health care site
Sexual Orientation
Sensory Deficits
Demographics
41
Socioeconomic
Education level
Employment status
Household income
Poverty status
42
Sexual Orientation
Clients who identify as lesbian, gay, or bisexual, and can also include those clients who are questioning their sexual orientation or sex identity.
42
Emic knowledge
An insider's viewpoint of a culture.
43
Cultural Competence
Being able to incorporate effective nursing care with emic and etic knowledge including appreciating, accepting, and respecting all individual s cultural influences, beliefs, customs, and values.
43
Demographics
Age
English language proficiency
Household type
Population density
Race and ethnicity
Sex
44
Health Disparities
Preventable differences in incidence and prevalence of disease, injury, or violence among populations, based on race, ethnicity, gender, gender identity, LGBT, age, or socioeconomic status
44
Etic knowledge
An outsider's viewpoint of a culture.
44
Culture
The learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guide their thinking, decisions, and actions in patterned ways.
45
Cultural Humility
Being aware of power imbalances and biases and respecting other peoples values
Not one culture is better than another
46
Implicit Bias
The involuntary attitudes or associations that affect our perceptions, actions, decisions, and interactions with others, unconsciously.
47
Explicit Bias
Bias that's derived from our conscious thoughts and beliefs that can be reported.
48
Health Equity
Valuing all individuals equally and removing obstacles to optimal health and health care across different populations.
49
Health Equality
The distribution of the same resources, including opportunities, to all individuals within a population.
50
Personal Health Literacy
The extent to which an individual can obtain, process, and comprehend basic health information.
51
Organizational Health literacy
The extent to which organizations equitably assist individuals with understanding, finding, and using information and services to make informed health-related decisions for themselves and others.
52
Intrapersonal:
“Intrapersonal cultural humility occurs when nurses and nurse faculty are actively engaged in examining and critiquing their beliefs and motives.” (Hughes, et. al. 2020)
52
Cultural Health Assessment
Assessments that can be conducted to gather information regarding the client's culture and how it can affect their health.
52
Interpersonal:
“Interpersonal humility happens when individuals critically engage in questioning and understanding the values and cultures of their patients, families and colleagues” (Hughes, et. al. 2020)
53
Musculoskeletal system:
Muscular system
Skeletal System
54
Muscular system
Muscles and Tendons, ligaments, cartilage
54
Skeletal system
Bones, joints of skeletal system
55
Muscular system and skeletal system work together to...
Support body weight, control movements, provide stability, some provide protection for heart, lungs, and brain.
56
Muscle types
Smooth, Cardiac, Skeletal
57
Ligaments
Connect bones to other bones
58
Tendons
Connects muscles to bones
59
Cartilage
Flexible connective tissue
60
Acute injury treatment
RICE
Rest, Ice, Compress, Elevate
POLICE
Protection, Optimal, Load, Ice, Compression, Elevation
60
Pregnancy complications
Back pain due to weight
Postural fixing, physical therapy to strengthen back muscles
Caution on meds
61
Alteration in muscles, bones, and joints link a variety of health problems
Arthritis
Fractures
Neurological disorders
Traumatic Injuries
Parkinsons
Spinal cord injuries
Back problems
Multiple sclerosis
62
Childhood complications
Growing pains
Presents as pain in arms and legs
63
Adolescents complication
Most common time to see scoliosis
64
Back Pain – Herniated Disc
Perforation on vertebrae leading to escaping fluid to compress nerve root, extremely painful
64
Lumbar Herniated Disc
Hip pain, Lower back pain
65
Adult Complications
Back pain
66
Cervical Herniated Disc
Upper extremity pain, Shoulder pain, Neck pain
67
Herniated Disk interventions
Pharmacologic- Meds
Nonpharmacologic- Accupuncture
Surgery
68
Effects of Aging on the body
Loss of bone mass
Decrease lean body mass
Increased rigidity in tendons and ligaments
Foot problems
Muscle atrophy
Decreased height
Decreased range of motion
69
Good body mechanics
Wide Base
Look at patients
Straight back, no bending at the waist
Life with the legs
70
Clients with Fall Risks
Diagnoses
Abnormal lab values (Potassium)
Vital signs
Cognition
Medication (Pain, diuretics)
71
Consequences of immobility
Moving is healing
Hospital acquired pressure injuries, DVTs, pneumonia, Falls, Cognition/Delirium, Readmissions, Length of stay, Discharge disposition, Appropriate rehab utilization
Closer we get to a zero fall environment, the further away we get from a culture of mobility
72
Concepts related to mobility
Collaboration, Comfort, Health, Wellness, Injury, Illness, Mood and Affect, Safety, Stress and coping
73
The 5+ Senses
- Visual
- Olfactory
- Gustatory
-Tactile
- Auditory
- Kinesthetic: Position in time and space
- Stereognosis: Use of tactile and memory to identify object
- Visceral: Sensation of knowing something is happening in body
74
Modifiable Risk Factors for Alterations of Sensory Perception
- Environment (UV light exposure, loud sounds)
- Lifestyle (stress, smoking)
- Injury
- Medications
75
Non-Modifiable Risk Factors for Alterations of Sensory Perception
- Genetics
- Aging
76
Impacts of Sensory Alteration
- Communication (deaf -> hard to talk/hear)
- Psychosocial (can't hear, don't want to do social things)
- Independence (challenges independence, confidence, self-esteem)
76
Modifiable and Non-Modifiable Risk Factors for Alterations of Sensory Perception
- Disease/Illness
77
Cataracts
- Lenses get cloudy and yellow
- 60-70yrs old becomes a problem
78
Glaucoma
- Gradual loss of peripheral vision
- Aqueous Humor flow is compromised
- Open Angle: Tunnel vision
- Closed Angle: Severe pain, sudden vision loss
- Treatment: Eye drops, laser eye surgery
79
Acute Macular Degeneration
- Dark area and distortion
- Treatment: Antioxidants and zinc
80
Diabetic Retinopathy
- Bleeding in eye and occludes vision
81
Refractive Errors
- Presbyopia: Aging of the eye, close objects become blurry
- Myopia: Nearsighted, distant objects appear blurry
- Astigmatism: Blurry/distorted vision
82
Nursing Interventions for Visually Impaired
- Clear pathways
- Ensure good lighting
- Call light, glasses, assistive devices all in reach
- Prevent Sensory overload
- Print materials in larger font
83
Tactile Sense
- Access: Touch different texture and temperature objects on patient's skin with their eyes closed
- Impairment: Decreased mobility, falls, weak grasp, pressure sores
84
Tactile Impairment Through Lifespan
- Older adults have decreased sensitivity to touch
- Uncontrolled diabetes causing peripheral neuropathy
- Polyneuropathy: Damage to multiple body parts
85
Symptoms of Peripheral Neuropathy
- Aching, shooting, tingling, burning pain and weakness
86
Tactile Nursing Care
- Address contributing conditions
- Change position often to avoid sores
- Promote effective coping
87
Olfactory Sense
Smell
Often not adequately tested
Can use swabs with vanilla
Electro-olfactography
88
Olfactory and Gustatory Nursing Care
- Danger cleaning with some chemicals
- Gas appliances in good working order
- Inspect food for freshness
- Suggest healthy way to add flavor besides salting
- Maintain good oral care (brush twice, floss once, visit dentist every 6)
88
Olfactory and gustatory Impairment Through Lifespan
- Pregnancy: increase sense of smell, leading to nausea and vomiting or food cravings
- Older adults: senses diminish
- May be affected by cold, flu, coronavirus, sinusitis
- MS and Parkinson's can affect them as well
89
Hearing Screenings
- Newborns screened regularly
- Preschool and school age screened at school
- Adults every 10yrs until 50, every 3yrs after 50
90
Rinne Test
- Place vibrating tuning fork on mastoid bone, remove when can't hear, place outside ear
- Air conduction should be twice as long as bone conduction
91
Weber Test
- Place tuning fork on top of head
- Should hear equally in both ears
92
Auditory Alterations
Hearing Deficits May:
- Be partial or total
- Be congenital or acquired
- Affect one or both ears
- Affect specific frequencies or all frequencies
93
Conductive Hearing Loss
Equal loss of hearing at all frequencies
Causes
-Obstruction of external ear canal
- Wax buildup
- Perforated ear drum
- Disruption or fixation of ossicles
- Chronic and untreated ear infections
94
Sensorineural Hearing Loss
-Effects inner ear, auditory nerve pathway
- May be associated with tinnitus and vertigo
- Most common cause is age related presbycusis (degeneration of hair cells of cochlea)
94
TORCH
T: Toxoplasmosis
O: Other (syphilis, varicella, mumps, parvovirus, HIV)
R: Rubella
C: Cytomegalovirus
H: Herpes simplex
95
Non-pharmacological Auditory Therapies
-Hearing aids
-Assistive listening devices
-White or pink noise-masking device
-TD/TTY telephones
-Internet accessibility
-Lip Reading
-Flashing/vibrating safety alarms
96
Pharmacological Auditory Therapies
-Decongestants
-Steroids
-Antibiotics
(Used to treat cause of temporary hearing alterations)
97
Auditory Health Promotion
- Earplugs
- Use email or text instead of call
- Use written materials
- Closed captions
- ASL or Lip reading classes
98
What Components Make Up Muscular System?
- Ligaments
- Tendons
- Cartilage-
- Muscles
99
What Components Make Up Skeletal System?
- Bones
- Joints
100
Ligaments
Connect bones to other bones
101
Tendons
Connects bones to muscles
102
Types of Musculoskeletal Alterations
-Back problems
-Fractures
-Multiple Sclerosis
-Osteoarthritis
-Parkinson's
-Spinal Cord Injuries (SCI)
103
RICE
R: Rest
I: Ice
C: Compress
E: Elevate
104
POLICE
P: Protection
O: Optimal
L: Load
I: Ice
C: Compression
E: Elevation
105
Concepts Related to Mobility
-Collaboration
-Comfort
-Health, Wellness, Illness, and Injury
-Mood and Affect
-Safety
-Stress and Coping
106
Lifespan Considerations: Children
-Massive bone growth
-Growing pains in legs/arms
107
Lifespan Considerations: Infants
-Flexible
-Unfused cartilaginous joints
108
Lifespan Considerations: Adolescents
-Injuries from sports
-Continued muscle and bone growth/development
109
Lifespan Considerations: Pregnancy
-Increase weight
-Increase stress on muscles and bone
110
Lifespan Considerations: Older Adults
-Compressed Spine
-Decrease muscle mass
-Stiffer joints
111
Pharmacological Interventions For Back Pain
-Drugs
111
Herniated Disc Description
-Anulus fibrosis ruptures
-Nucleus pulposus herniates
-Nerve gets compresses
112
Non-pharmacological Interventions for Back Pain
-Acupuncture
-RICE/POLICE
-Low impact exercise
113
Fall Risks
-Abnormal lab values (low potassium causes muscle weakness)
-Vitals out of range
-Cognition
-Meds (diuretics make you pee, get up to go to bathroom, fall)
114
BMAT
-Bedside Motility Assessment Tool
1. Assess use of assistive device
2. Have patient reach across body to shake your hand
2. Stretch foot out and point toe (with at least one leg)
3. Bear weight on leg for 5 seconds
4. March in place
5. Step forward and back with each leg
115
immobility
An inability to reposition or move self
116
Synovial Joints
Fluid-filled capsules that connect bones and enable movement.
117
proprioception
Feedback from sensory receptors to coordinate, balance, and fine-tune body positioning and movement.
118
Peripheral Nervous System
Nervous system outside of the brain and spinal cord, which regulates the responses of the body to external stimuli.
119
Ergonomics
Study of body mechanics in relation to the demand and design of the work environment and the equipment used.
120
Mobility
Moving from one position to another.
121
Atrophy
Become smaller and weaker often from disuse.
122
Sarcopenia
Loss of lean muscle caused by immobility.
123
Foot Drop
A type of joint contracture that results in the foot and toes permanently pointing downward.
123
Joint Contractures
An abnormal fixation of a joint due to changes in muscles and connective tissue.
124
Activity Intolerance
Inadequate amount of physical or psychological energy to undergo or complete a necessary activity.
125
Kyphosis
Excessive outward curvature of the upper area of the spine.
126
Passive Range of Motion
The movement of a joint by another individual.
127
Active Range of Motion
Voluntary movement of a joint.
128
BMAT Stages
Safety Screen.
Level 1 - Sit and Shake Assessment.
Level 2 - Stretch and Point Assessment.
Level 3 - Stand Assessment.
Level 4 - Walk.
