Exam 1: NR 414 Flashcards
What are the 4 components of Diagnostics
- cues,
- info,
- signs,
- symptoms,
- lab data
Diagnosis
Valid influences, compare “clusters”, identify related factors
What are some components of Critical Thinking
identify assumptions, validate, normal/abnormal, relevance, inconsistencies, patterns, missing info, actual & potential risk, setting priorities, patient centered, evaluate
4 Types of Data
- Complete Health Data
- Episodic/Problem Centered/Focus data
- Follow-up data
- Emergency data base (ABCs)
3 Phases of Interview
1) Process of Communication 2) Internal 3) External Factors
Process of Communication means.
sending/receiving internal/external facotrs
Techniques of Communication x6
- open vs closed ended questions
- nonverbal skills,
- eye contact,
- voice,
- touch,
- dress
What are ways we overcome communication barriers
interpreters, vocal cues, action cues, object cues, space/touch
What are 2 types of measuring mental disorders
organic & psychiatric
Alert & Oriented x 4 (behavior orientation)
1) person 2) place 3) time 4)situation (what brought you here)
What are 4 components of mental health assessment
1) appearance 2) behavior 3) cognition 4) thought processes
QPR stands for
question, persuade, refer
Broca refers to
physical incapability to speak
Wernicke
not being able to speak correctly
What is ethnicity
a group having similar traits: common language, common heritage and cultural similarities
Race
relates more towards the appearance of a person. Biologically with inherited genetic traits.
Heritage
ancestors of a person
What is a database?
Sub & Objective data gathered from a patient plus the results of any diagnostic studies completed
What does PQRSTU Stand for
1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding
How would you describe the pitch of a sound wave obtained by a percussion
number of vibrations per second
Which aperture is used for a patient with undilated pupils
small
During gen survey what are the 4 areas of interest
1)Appearance 2)Body structure 3)Mobility 4)Behavior
A normal pulse for a patient is..
2+
What is pulse pressure
the difference between systolic and diastolic pressure
What is the mean arterial pressure
diastolic pressure plus one third pulse pressure
what is nociception
pain receptors
neuropathic pain
burning painful sensation that moves around toes and bottoms of feet.
Complex Regional Pain I
chronic pain that usually affects an arm or a leg.
P-OLDCARTS
previous hx, onset, location, duration, character, aggravating, radiation, timing, severity
What are the 4 steps in a regular physical exam
1) inspection 2)Palpation 3)Percussion 4)Auscultation
What is normal temp in axillary
97.6F or 38.4C
What is normal temp in tympanic membrane?
98.6F
What is the conversion Celsius to Fahrenheit
C= 5/9 (f-32)
What is the conversion for Fahrenheit to Celsius
(9/5 x C) +32
What does a doppler do?
picks up changes in sound frequency as blood flows
When is mobility decreased
with edema
What does sterile mean?
- no life
- using special gases
- high heat
When is surgical apses necessary?
- intentional perforation of the skin
- body cavity, not exposed to outside
What are the golden rules of surgical apses
- an object below the waist is contaminated, because it is out of range of vision
- never turn your back on a sterile field
- keep trashcan close by, or drop on ground
- Both patient and provider wear mask
- If you break sterile technique- START OVER
- 1” border
Name 5 types where patient needs surgical asepsis technique
- Open Body Cavity
- Catheter
- Burns
- Central Line
What are 6 maor things you want to palpate for in skin hair nails
- Temperature
- texture- use finger tips
- moisture
- diaphoresis (sweating)
- thickness
- Edema
How is edema measured?
- 4 point scale
- 1+ = 2mm
- 2+ = 4mm……
3 Common types of birthmarks
- freckles
- junctional nevus
- compound nevus
junctional nevus
Compound Nevus
What are the abnormal signs for pigmented lesions
ABCDE
ABCDE stands for
- Asymmetry
- Border
- Color variation
- Diameter grater than 6mm
- Elevation or Enlargement
- Confluent Lesion
- ex hives//uriticaria
- Discrete lesion
- Skin tags//acne
Gyrate Lesion
- zosteriform
- linear around unilateral nerve
- ex: herpes
- Polycyclic
- i.e. psoriasis
- anular lesions grow together
What are primary skin lesions x6
- Macular/Patch
- Papule/Plaque
- Nodule/Tumor
- Vesicle/bulla
- Cyst
- Postule
- Macule
- Patch larger than 1 cm
- flat not raised
-
Papule
- Plaque larger than 1 cm
- can feel, slightly elevated
- mole wart
- Nodule
- tumor larger than 3 cm
-
Wheal
- Urticaria-hives
- raised irregular shape due to edema
- mosquito bites, allergies
-
Vesicle
- Bulla- larger than 1cm
- a blister, herpes chicken pox, shingles
What are some secondary Skin lesions?
- Crust
- Scale
- fissure
- erosion
- ulcer
- Excoriation
- scar
- atrophic scar
- lichenfication
- Keloid
- Scale
- compact flakes of skin
- Keloid
- hypertrophic scar
- elevetated skin by excess scar tisue
- Pressure Ulcer Stage I
- red but ubroken
- will not blanch
- Stage 3 ulcer
- extending into subcutaneous tissue
- resembling a crater
- Stage IV Ulcer
- breaks through all skin layers
- visible bone or tendons
What are some vascular lesions
- petechiae
- purpura
- hematoma
- contusion
Epidermis layer
- basal layer,
- thin,
- stratum corneum
Dermis Layer
- collagen
- elastic tissue
Subcutaneous layer
- adipose tissue
When irrigating a wound, how would the nurse know the right amount of pressure to apply?
between 5 and 15psi
Which device is used for wound irrigation?
19 gauge needle attached to 35 mL syringe
Elsevier:
What is the nursing action to set up suction for a hemovac drainage system?
the nurse should compress it firmly and replace the plug.
Elsevier:
Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?
Culture & sensitivity
Elsevier:
What is the proper method for cleansing the evacuation port of a wound drainage system?
Wipe it with an alcohol sponge.
Braden Scale
Risk for skin breakdown/Pressure ulcer
What is the primary intention for wound healing?
- tissue surfaces have been approximated
- low tissue loss
- remove dressings after drainage
What is secondary intention for wound healing?
- considerable tissue loss
- edges cannot be drawn together
- longer to heal
- scarring is greater
- infection risk
- Pressure ulcers
- continue dressings for moisture
- assist debridement
What are the phases for a full thickness wound repair?
- Hemostasis (fibrin)
- Inflammatory phase
- Proliferative phase- epithelial
- Remodeling- can take years
What is required in the delivery of culturally congruent care?
- knowledge
- skills
- attitudes
What is an example of a nurse stereotyping a patient?
do you bathe and use deodorant more than one time a week?
What are appropriate questions to ask a native american?
- do you use folk remedies
- do you have a family physician
- do you use a shaman
What is an example of data validation
- comparing values with previous values
- report to charge nurse
What are the steps for a nursing diagnosis?
- review assessment data
- cluster
- diagnostic label
- contet of pt’s health probl and select related factor
What could be indicated when a reddened area blances on fingertip touch?
blanching hyperemia. Body overcoming ischemic episode
To determine wound infection, where should the specimen be taken?
wound, after it has been cleaned with normal saline
After surgery a patient coughs and opens up a wound. What is the nurse’s first intervention?
cover with saline-soaked towels and notify surgical team.
Evisceration
