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Fundamentals Test 2 > Chap 22, 28, 39 > Flashcards

Chap 22, 28, 39 Flashcards

1
Q

This type of assesment is accomplished when first admitted to hospital

A

Initial assesment/ admission assesment
Gathering hx, demographic, physical exam, questions smoking drinking past surgeries occupation food preferences. What brought on admission

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2
Q

Type of assesmeent involved every beginning of shift, inspect/observation, appearance, skin color, clean disheverled, afdect(mood) c9ntours body color, rashes, ease of respirations, sob?

A

Shift assesment/head to toe

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3
Q

Exam accomplished 9n 9ne body system or area

A

Focused exam

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4
Q

Focused exam questions- what body area?

Headaches, dizzy, visual, cols allergies, sore throat dental, how sleeping?

A

Head and neck

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5
Q

Focused exam, questions what body area
Leg pain or cramps when walking
Tb exposure
Angina chest pain htn, mammo coughoccupational resp exposure

A

Chest

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6
Q

Focused exam, what body area

Indigestion, thirst hunger, rectal bleeds, hemorrhoids, gallbladder liver

A

Abdominal

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7
Q

Focused exam body area?

Urinating urgency, kidney stones sexually active , herpes, last papsmear

A

Genitourinary

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8
Q

Focused exam body area

Joint pain stiffness, full rom, circulation leg and arms, bruise easy, fx phlebitis

A

Extremitis musculskeletal

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9
Q

Focused exam body parts

Thyroid, dm 1 or 2

A

Endocrine

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10
Q

Aphysical exam techniques how many types paplation

A

Light and deep

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11
Q

Purpose of palpation

A 
Sense of touch =great deal clinical info. Detect size shape position of body parts. Texture temp, moisture on skin. 
Muscle spasm, rigidity
Pain swelling growth
Restriction movement
Turgor edema
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12
Q

Type of palpation checks for muscle spasm, rigidity, pain,swelling growth, restrictions in movement, pain, masses abnormal collection fluid,
PADS of FINGERS.
1/2- 3/4 inches

A

Light

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13
Q

Type of palpation used to check turgor moisture of skin @1/2 to 3/4

A

Light

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14
Q

Involved in physical exam technique, helps determine size, shape location density of organ and any AIR or FLUID there

A

Percussion- we dont do this.

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15
Q

Type of percussion

A

Tympany

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16
Q

Rules standing scale

A

No shoes, stand erect, bar placed flat on head

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17
Q

Where and how to listen to abnormal heart sounds

A

With the bell of the stethoscooe, lightly, in all 4 valve areas
Aortic, pulmonic. Tricuspid, mitral always use bell

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18
Q

What body system ?

A

Gen apoearance, skin. Stuffy nose, drainage, teeth, eye exam. Does thinking seem logical? Neck nornal? Lymph nodes?visual acuity, hearing check.

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19
Q

Chest, heart, lungs what to look for

A

Rise fall, symmetry, spine view from rear, should be midline w gentle concave and convex curves

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20
Q

Exaggerated lumbar curves (chest heart lungs)

A

Lordosis, l and l

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21
Q

Increased curve in thoracic area

A

Kyphosis(hunchbak) quasimodo

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22
Q

Pronounced lateral curvature of spine

A

(scoliosis)

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23
Q

Whistle musical high pitched sound air being forced throughnarrow partially obstructed airway

A

Wheeze

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24
Q

Course low pitched sonorous rattling caused by secretions in larger air passages

A

Gurgle /low pitched wheeze, rhonchi

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25
Q

Fine/course non musical sounds. Fine=high in pitch
Course=louder and low in pitch
Rubbing hairs between fingers

A

Crackles

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26
Q

Snoring sound produced by inability to cough up secretions from trachea or bronchi

A

Stertor

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27
Q

Croaking crowing partial obstruction of upper air passages

A

Stridor

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28
Q

Grating scratchy sound similar to creaking shoe leather, opening squeaky door, caused by irritated pleural membranes rub over each other

A

Pleural friction rub

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29
Q

When insoecting the anterior chest to see if there is a point of maximal impulse. (PMI) what should u see

A

Hopefully nothing as seeing pmi is bad!

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30
Q

Whichnis better way of checking skin turgor in olde adult?

A

Mucous membranes better that skin turgor

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31
Q

How shoukd u check for generalized edema?

A

Weight gain over short time

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32
Q

How to check for dependent edema

A

Press fingers into tissue overtibia just above ankle, if indentation remains, PITTING is present

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33
Q

How to describe edema ..what terms to use?

A

Taut, tight, puffy, indented, pitting. If pitting present classify according to depth

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34
Q

How many types of skin lesions?

A

6

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35
Q

Flat area w change to color smaller than 0.5cm

If larger than0.5, it is a patch

A

Macule (mac has a c so does color)

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36
Q

Elevated solid lesionsmaller than 0.5cm if larger it is a nodule

A

Papule think papas are elevated

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37
Q

Circumscribed, superficial collection serous fluid, smaller that 0.5 varicella, herpes zostersecond degree burn

A

Vesicle think shingles .. vesicle sounds like sick

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38
Q

Circumscribed elevated SOLID lesion psoriases, seborrheic actinic keratosis.

A

Plaque is solid

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39
Q

Firm edematous irregularly shaped area insect bite urticaria

A

Wheal.

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40
Q

Elevated superficial lesion filled w purulent fluid acne impetigo

A

Purulent=pustule

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41
Q

What do skin sensations do over time?

A

Diminish / decrease

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42
Q

When classifying pitting edema what are the numbers?

A

1-4 with 1 being minimum and 4 being most

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43
Q

How are nursing diagnosis formed?

A

Deoendent on problems discovered during assesment, the data is analyzed and problems identified. Rn ids nursing dx lvn may choose dx from nanda if no rn during shift.

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44
Q

What is planning?

A

Appropriate goals or expected outcomes are written for each nursing dx identified. Set priorities of care based on most urgent needs of each assigned pt.

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45
Q

What is implementation?

A

?

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46
Q

What is rnshope?

A 
Rest activity
Nutrition fluids electrolytes
Safety security
Hygiene, grooming
Oxygenation and circulation needs
Psychosocial and learning elimination
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47
Q

What is involved in initial observation head to toe assesment?

A

Skin color, appearance, affect, ease respiration, how pr feeling.

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48
Q

Why is an older adult prone to chilling?

A

Less subcutaneous tissue make sure to drape them

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49
Q

How to help older adult to not become stiff

A

Slowly help them to seated position and dangle for few minutes

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50
Q

What is a knee chest position used for

A

Rectal exams

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51
Q

What positions do you drape the whole body?

A

Sims and supine

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52
Q

Why use draping?

A

Prevent unexessary exposure also provides warmth

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53
Q

What should u do before bladder exam

A

Empty bladder

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54
Q

What is the weber test

A

Striking a tuning fork place on ots head then u should hear equally on both sides

55
Q

What is a rinne test?

A

Air vs bone conduction. After striking tuning fork place place in front of ear for air then bone. Think rino have bones

56
Q

What is consensual refkex

A

Grade when constricted. 2 consenting adukts, both eyes should react if u shine light on 1.

57
Q

What is the functional unit of respiratry system

A

Alveoli

58
Q

How many lobes lung

A

Left 2 lobes

Right 3 lobes

59
Q

Cns - rate /depth chemoreceptors in aorta and carotid send feedback to brain

A

True

60
Q

What is decreased 02in blood determined by spo2

A

Hypoxemia

61
Q

Decreased 02 @ cellular level

A

Hypoxia

62
Q

Retaining carbon dioxide is called what

A

Hypercapnia

63
Q

What happens during hypoxia

A
  1. Airway obstructed
  2. Restricted thoracic cage/ obesity pneumo, chest tube
  3. Neuromuscular-feedback to brain. Ms,mg ms, guiilian barre cva, brain,
64
Q

What are some disturbabces 8n diffusion of gas

A 
Emohysema 
Trauma 
Embolism
Tumors
Resp distress syndrome
65
Q

Early hypoxia symptoms

A 
Irritable
Restless
Confusion
Tachypnea
Anxiety
Abn lung sounds 
Angry bird air hungry
66
Q

Late signs hypoxia

A

Retractions
Cyanosis
Dysrhytmias

67
Q

What is a major complicationnof immobility

A

Hypostatic pneumonia

68
Q

What to do for hypostatic pneumonia bedridden due to immobility

A

Rom cough deep breathing turn q 2 hoain managament

69
Q

For gi tract effects problems

A

Increase fluid to 3000 cc increase fiber

70
Q

Brain psychological effects immobility what u can do

A

Active listening, communication

71
Q

Pulling force maintain body alignement maintain fracture alignment.
Relieve pain

A

Traction

72
Q

How many types traction

A

3.

Manual skin and skeletal

73
Q

Skin traction how many lbs

A

10-15

Aka buck traction

74
Q

Do we want to use traction on elderly pts

A

Not really skin and bones

75
Q

Rules traction

A
  1. Ropes and wts free of friction(hanging freely)not on floor
  2. Maintain alignment. Keep straight
  3. Wt hanging freely not touching bed ir floor
    4.
76
Q

Counter traction rules

A

Head of be should be no higher than 20 degrees

77
Q

What tyoe of traction is invasive

A

Skeletal traction

78
Q

Max weight for skeletal traction

A

30lbs/ 14kg

79
Q

Pin care

A

Sterile swabs circular motion

80
Q

What type drainage

A

Clear fluid drainage expected initially

But if persists and changes colors is a problem

81
Q

Pin care

A

Antimicrobial only.if ordered

82
Q

External fixator is invasive but pt can still move leg around

A

True

83
Q

Casting points to remember

A

Assses fir breakdown
Pad edge with dressings w moleskin
Chafing

84
Q

Hip spica cast

A

Never grab by middle

85
Q

What hapoens if cast dries too fast

A

Will compromise circulation so bivalve

86
Q

How to handle cast during drying

A

Use palm and flat parts of fingers rather than fingertios, dents in cast can lead to impairment pressure injuries

87
Q

Continuius laterak rotational beds

A

80 degrees can be set tonpause on either side for up to 30 mins

88
Q

Circolectric bed

A

Turns whole 360 degrees allowing change of position fir bed

89
Q

Air fluidized bed

A

Tx of 3 , 4 and unstageable pressure injuries fresh grafts flap repair

90
Q

Cpm care includes what

A

Assess opposite bleeding evaluate aignment every 2-4 hrs

91
Q

Cpm care

A

Assess skin condition over bony prominences provide sin care every 2 hours

92
Q

Neurovascular assesment

Every pt who has fx, cast traction

A 
Skin,
 movement,
 sensation, 
pulses, 
cap refill, 
pain
93
Q

Age changes affecting respiration

A 
Decreased elasticity thorax resp tissues
Water decreases 50 % dry mucous
Loss elastic recoil
Thick alveolar membrane - efficient gas excha
O2 sat 75-80
Less reso reserve
94
Q

Ways to distinguish hypoxia and hypoxemia

A

Hypoxia=disease illness-abg-cell level

Hypoxemia detected w spo2

95
Q

Common causes hypoxia

A

Obstruction airway-

Rettictes mvmnt thiracuc cage-obesity

96
Q

How many compressions per mi

A

100-120
Ensure full recoil
Cab

97
Q

Main ways to clear rspiratory secretions

A

Deep brthng-sit up, inhale, hld brth,3-5 brth out mth

Coughing
Objective to make sure lungs stay inflated

98
Q

When best to obtain sputum sample

A

1st morning
After nebulizer tx
1/2 tsp needed
Deep brthng cough help

99
Q

Postural drainage positions when best

A

45-60 mins before meal

In the a.m

100
Q

What to set suction pressure at

A

80-120mm hg
No more than 10 seconds
Trach= only til meet resistance

101
Q

Size suction catheters to use

A

8-12 french thin secretions

14-16 tenacious thick secretions

102
Q

Main concerns bc o2

A

Skin breakdown, nares ears cheeks ears

103
Q

Nc rules

A

Up to 6 but over 3 need humidification

104
Q

Which o2 dont require humidity

A

?

105
Q

When how to use incentive spirometer

A

Every hr while awake. 10 slow deep breaths

106
Q

What shiukd do before taking cuff off

A

Suction

107
Q

Shallow brthbg what should u do?

A

Cough/deep breathing

108
Q

When hear gurgling from trach

A

Suction, but first suction, pre oxygenate

109
Q

Chest tube takeaways

A

Below chest level
No kinks
Do not milk or strip bc can dislodg
If exceed 100 ml per hr report to doc

110
Q

How many cm for no suctioning

A

6-8

111
Q

Walker how to fit

A

Ht of hip joint elbows 15-30

112
Q

How fit crutches

A

Lay down- tip 6 in-pad 3-4 finger under axilla no shoe

Stand- shoes on 4-6 in pads 1/2-2 in

113
Q

Fit cane

A

Hand grip hip level 15-30

114
Q

Gait

A

4pt-slow r crutch left crutch
3pt 0 wt bear restr. 2 crutches 1 good leg
2 pt-leg crutch as 1opposite lef crutch same ti.e
Swing through-

115
Q

Walk up stairs

Down stairs

A

Strong leg upstairs first

Crutch down first

116
Q

Spiral bandage

A

Part is uniform

117
Q

Circular

A

Begins or ends bandage 2-3 times

118
Q

Spiral reverse

A

Reverse at one point not uniform areas lower leg forearm

119
Q

Figure 8

A

Ankle foot

120
Q

Recureent turn bandage for

A

Amputated leg stump or head

121
Q

Neurovascular checks on casting. Splints etc

A

Every hiur 24 hrs then 4-8 hours

Check skin, movement, sensation, pulses

122
Q

Cpm machine assses what?

A

Bleeding, evaluate alignment every 2-4 hours

Assess skin conditions every 2

123
Q

Air fluidized bed

A

Stage 3 4 and unstageable sores must still turn q 2

124
Q

Continuius lateral rotational bed

A

80 degrees, either side 30 mins

125
Q

Isometric exercises for

A

Musculoskeletal

126
Q

Passive rom

A

For respiratory,

127
Q

How many cm catheter for suction

A

6-8

128
Q

Airway airway used unconcious pts

A

Et,

129
Q

Which mask muffles voice , cant eat drink

A

Simple face mask

130
Q

Which mask delivers fi02 regardless of breathing pattern/ copd patients

A

Venturi mask

131
Q

External pin is it attached to traction?

A

No but still need to do pin care

132
Q

Soft rustling sounds

A

Vehicular

133
Q

When oatient slaps hand away what reaction

A

Localized to pain

134
Q

Pt complains chest pain

A

Ask prior heart attack
Ask sob
Describe pain type

Fundamentals Test 2 (3 decks)

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