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NUR-220 > Exam 1 NUR-202 > Flashcards

Exam 1 NUR-202 Flashcards

1
Q

What is the nursing process

A

(ADOPIE)

Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation

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2
Q

What is the first step in the nursing process?

A

Assessment

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3
Q

What is Assessment?

A

Collection of Data that is both Subjective and Objective.

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4
Q

How do you implement Diagnosis?

A

Comparing clinical findings with normal findings.

Interpreting data

Validating

Documenting

(CIVD)

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5
Q

How do you implement outcome identification?

A

Identify expected outcomes

Individualize to the person.

culturally appropriate

realistic and measurable

include a timeline

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6
Q

How do you implement Planning?

A

Establish priorities

develop outcomes

Set timelines for outcomes

identify interventions

integrate EBP

Document plan of care

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7
Q

How do you implement Implementation?

A

Implement in a safe and timely manner.

use EBP interventions

Collaborate with colleagues

Use community resources

Coordinate care delivery

health teaching

document

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8
Q

how do you implement Evaluation?

A

progress towards outcomes

Conduct systematic, ongoing criterion-based evaluation.

Include patients and significant others.

Use ongoing assessment to revise diagnoses, outcomes, and plans.

Disseminate results to patient and family

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9
Q

First level priorities are?

A

ABC

Airway

Breathing

Circulation

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10
Q

Second level priorities are?

A

ACI

Acute pain

Change in mental status

Infection

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11
Q

Third-level priorities are?

A

LFAR

Lack of knowledge

Family coping

Activity

Rest

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12
Q

Types of data?

A

Complete

Episodic

Follow-up

Emergency

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13
Q

What is a complete data base

A

describes current and past health state and forms a baseline.

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14
Q

What is episodic database

A

it is a mini database smaller in scope and more focused.

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15
Q

Follow up data base?

A

identified problems should be evaluated at regular intervals

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16
Q

Emergency database?

A

rapid collection of data often compiled concurrently with life saving measures.

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17
Q

What is EBP?

A

use of best evidence when practicing care.

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18
Q

5 steps to EBP?

A

ask the clinical questions

acquire sources of evidence

appraise and synthesize evidence

apply relevant evidence in practice

assess the outcomes

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19
Q

Dysarthria

A

Disorder of articulation: Distorted speech sounds; may sound unintelligible

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20
Q

Dysphonia

A

Disorder of voice: Difficulty or discomfort talking. With abnormal pitch or volume cause by laryngeal disease. Sounds hoarse or whispered, articulation and language are intact

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21
Q

Aphasia

A

Language comprehension and production secondary to brain damage: True language disturbance; a defect in word choice and grammar or comprehension. Language processing is disrupted.

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22
Q

Dysphagia

A
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23
Q

Dysphasia

A
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24
Q

Global aphasia

A

The most common and severe form of a large lesion of language areas

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25
Q

Expressive aphasia

A

Can understand language but can’t use language effectively

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26
Q

Receptive aphasia

A

can use language but cannot understand it very well.

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27
Q

What are the 4 components of general survey

A
  1. Physical appearance
  2. body structure
  3. Mobility
  4. Behavior

(PDMB)

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28
Q

Physical appearance?

A

Age, Sex, LOC, Skin color, facial features, overall appearance

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29
Q

Body structure?

A

Stature, Nutrition, Symmetry, posture, and position.

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30
Q

Mobility?

A

Gait and ROM

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31
Q

Behavior?

A

Facial expression, Mood and affect, speech, speech pattern, dress.

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32
Q

Abnormalities in Body Height and Proportion?

A

Dwarfism (Hypopituitary dwarfism, Achondroplastic dwarfism), Gigantism, acromegaly, anorexia, bulimia, Cushing’s Syndrome, Marfan Syndrome.

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33
Q

Hypopituitary dwarfism?

A

Lack of GH in childhood results in growth below the 3rd percentile (hypothyroidism and adrenal insufficiency. Infantile facial features and chubbiness.

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34
Q

Achondroplastic dwarfism?

A

normal trunk size, short arms and legs, and short stature. Large head with frontal bossing: midface hypoplasia (small) and thoracic kyphosis… ect.

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35
Q

Gigantism

A

Excessive secretion of GH delayed sexual development.

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36
Q

acromegaly

A

excessive secretion of GH in adulthood

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37
Q

bulimia nervosa

A

the Person has mental disorder where the person self purges. (dental issues)

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38
Q

Anorexia nervosa

A

Mental disorder where the person does not eat fanatic concern with weight.

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39
Q

Cushing’s Syndrome

A

Moon face, buffalo hump, weight gain, edema, excessive production of ACTH

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40
Q

Marfan syndrome

A

tall thin stature >95th percentile long thin fingers.

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41
Q

Vital signs

A

Temperature, Pulse, RR, BP

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42
Q

What type of data are vital signs

A

Objective data

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43
Q

what is normal temperature

A

35.8 to 37 degrees C

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44
Q

What is normal pulse

A

60-100 and 2+ normal force

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45
Q

what is normal respirations

A

12-20

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46
Q

what is normal BP

A

120/80

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47
Q

Force of pulse grading

A

0-3

0+ weak
1+ thready
2. normal
3+ bounding

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48
Q

bradycardia

A

<50 Beats/min

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49
Q

Tachycardia

A

> 95-100 beats/min

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50
Q

What may be affecting the pulse?

A

Fever, meds, anxiety, cardiac history, athlete, activity, ect.

51
Q

when you cant palpate the pulse what do you use?

A

doppler

52
Q

What situations can affect respirations?

A

Narcotics, head injury, HF, activity intolerance, Anesthesia, exercise, sleep.

53
Q

Note the position of the patient when they are breathing what are some positions that patients take to facilitate breathing

A

Orthopnea (breathing becomes better when sitting up), tripod, nocturnal dyspnea (labored breathing while asleep.

54
Q

SpO2 what should you know?

A

Typical range is 97-99%, should be taken. Every shift assessment. If abnormal have the patient cough/deep breath. check if it is a machine issue, if results are abnormal put on O2, it can also be monitored continuously or intermittently

55
Q

What situations could affect O2 saturation?

A

Anemia, Lung disease, Heart disease, Inadequate O2 given or method of delivery.

56
Q

what is the difference between systolic and diastolic

A

Systolic pressure: max pressure felt on artery during left ventricular contraction or systole.

Diastolic pressure: elastic recoil, or resting, pressure that blood exerts constantly between each contraction.

57
Q

Mean arterial pressure (MAP)

A

It is the pressure of blood forcing into tissue, averaged over the cardiac cycle. if less than 60 mmHg blood is shunted to major organs.

58
Q

What is the definition of orthostatic hypotension

A

Drop in the systolic BP > 20 mmHg and/or Drop in the diastolic BP > 10 mmHg

59
Q

What are some common causes of orthostatic changes in BP?

A

Fluid loss, aging and related vascular changes, bedrest, changes in BP meds.

60
Q

Korotkoff 1

A

(Systolic number) Is the first audible tapping sound

61
Q

Korotkoff 5

A

Is silence, diastolic pressure is the number which the last audible sound is heard before silence.

62
Q

transduction

A

Pain is felt in the periphery. (Distal)

63
Q

Transmission

A

Pain moves away from the spinal cord to the brain (moves toward the middle)

it is also important for a quick reaction

64
Q

Perception (pain)

A

becomes aware of the pain (me)

65
Q

Modulation

A

body tries to modify the pain through endogenous hormones (mod-ify)

66
Q

PQRST

A

Provocation: What causes the pain

Quality: what does the pain feel like

Radiates: where does the pain go

Severity: the pain on a scale from 1-10

Time: when did the pain start

67
Q

Visceral Pain

A

Pain that originates from the larger internal organs
(e.g., stomach, intestine, gallbladder, pancreas) symptoms of this pain are nausea, sweating, tachycardia, and hypertension.

68
Q

Somatic Pain

A

Originates from musculoskeletal tissues or the body surface. Symptoms of this pain are sharp or dull.

69
Q

Deep Somatic Pain

A

Pain that originates from sources such as the blood vessels, joints, tendons, muscles, and bones. Symptoms of this pain are aching and throbbing

70
Q

Cutaneous Pain

A

Pain that is derived from the skin’s surface as well as the Sub Q tissue. Symptoms of this pain are sharp and burning.

71
Q

Acute pain

A

Is pain that is new in onset. It is short-term and self-limiting and often follows a predictable trajectory. It is a protective measure.

72
Q

Chronic Pain

A

Which is pain that has lasted longer than expected or continues for six months or longer. This pain can be divided into malignant and nonmalignant. (malignant pain often parallels the pathology created by the tumor cells, i.e., organ stretching and necrosis.) and (nonmalignant pain is often associated with deep somatic pain like arthritis, fibromyalgia, and low back pain.

73
Q

Breakthrough Pain

A

In an otherwise controlled pain syndrome, it is a transient spike in pain level, moderate to severe intensity. It often results in end-of-dose failure or episodic pain.

74
Q

What are the pain scales

A

Numerical PS (0-10)

FLACC PS (infants/toddlers)

PAINAD (advanced dementia)

CRIES (neonatal postop care)

75
Q

Nociceptive Pain

A

Pain that is Somatic or Visceral

76
Q

Neuropathic Pain

A

HIV/AIDS, diabetes, and Herpes zoster.

77
Q

Cancer Pain

A

Bone metastases neuropathy

78
Q

Pressure Ulcers Stages

A

Stage 1: Intact non-blanchable (no capillary refill)

Stage 2: Shallow, Red wound (partial thickness)

Stage 3: Full thickness, no bone, tendon, or muscle

Stage 4: Full thickness, with bone, tendon, or muscle & slough/necrosis (debreeding and cleaning)

Unstageable: you can’t see red covered in eschar and slough.

If it is Red (protect) proliferative stage and requires moist dressings.

If it is Yellow (clean), drainage and slough

If it’s black (debride), remove eschar (necrotic tissue) with mechanical or chemical debridement.

79
Q

ABCDE Moles and freckles

A

Asymmetry

Border

Color

Diameter

Elevation/enlargement

80
Q

Macule/Patch

A

freckle, flat nevi, petechiae, measles, scarlet fever

81
Q

Nodule

A

Solid, elevated, hard, or soft, larger than 1cm

82
Q

Vesicle

A

Fluid-filled (blister) i.e., herpes simplex, zoster, varicella.

83
Q

Wheal

A

welts/hives, i.e., allergic reaction, mosquito bite, TB skin test.

84
Q

Cyst

A

An encapsulated fluid-filled cavity in the dermis of the subq layer, tensely elevating skin. I.e., subq cyst and wen.

85
Q

Pustule

A

A pus-filled cavity that is elevated. I.e., impetigo and acne.

86
Q

Annular/Circular

A

begins in the center and spreads

87
Q

Confluent

A

circles that runs together

88
Q

Discrete

A

separate i.e., acne

89
Q

Grouped

A

It looks like bubble wrap i.e., vesicles, contact dermatitis

89
Q

Gyrate

A

snake-like, twisted, coil

90
Q

Target

A

Looks like a bullseye

91
Q

Linear

A

straight like a scratch

92
Q

Polycyclic

A

annular growing together many circles getting closer
(beehive)

93
Q

Zosteriform

A

follows nerve path (herpes zoster)

94
Q

What factors contribute to pressure injury development

A

Compression of blood vessels, friction, and shear (that tear and injure blood vessels and damage the top layer of the skin.), Bony prominences, and moisture.

95
Q

What is assessed in the BRADEN SCALE

A

Sensory perception

Moisture

Activity

Mobility

Nutrition

Friction and shear

96
Q

Bruising

A

ecchymosis

97
Q

Pallor

A

cyanosis (blue/purple)

98
Q

Diaphoresis

A

sweating

99
Q

dehydration not definition what can happen to the skin.

A

increase in turgor (tenting)

100
Q

What to do if patient is Jaundiced

A

assess the sclera and mucous membrane

101
Q

What to do if patient presents with Inflammation

A

Palpate for edema and warmth.

102
Q

When gathering OBJECTIVE DATA on the skin what should be gathered?

A

Texture- is the skin smooth and firm

Thickness- observe for thickened areas

Edema- assess for fluid accumulation in the interstitial spaces using the rating scale of 0-4

Mobility and turgor- is the patient’s skin elastic

Vascularity and bruising (ecchymosis)

103
Q

Assessing hair

A

The patient’s hair is blonde, thin, full, with no lesions or inhabitants.

104
Q

Capillary refill

A

should be under 3 seconds if over 3 it is considered sluggish.

105
Q

Malignant Skin conditions

A

Basal cell carcinoma- pearly translucent top and overlying telangiectasia (broken blood vessel). Round pearly borders with central red ulcer.

106
Q

Squamous cell carcinoma

A

Arise from actinic keratoses or de novo—erythematous scaly patch with sharp margins, 1cm or more. de

107
Q

Malignant melanoma

A

Transformation of melanocytes is often cutaneous. 80% of cutaneous melanomas arise in sun/artificial UV-exposed areas: irregular borders, mixed pigmentation, flaking/oozing texture.

108
Q

Kaposi Sarcoma

A

Aids/HIV

109
Q

mental status assessment

A

ABCT

Appearance

Behavior

Cognition

Thought Process

(Person, Place, Time) ANOS X 4

110
Q

LOC

A

Awake, Alert, responds appropriately

111
Q

Facial Expressions

A

Appropriate to situation

112
Q

Speech

A

quality of speech, effortless, and appropriate

113
Q

Mood and affect

A

Body language, facial expression, and cooperative

114
Q

Orientation

A

Person, place, time

115
Q

Attention Span

A

Ability to concentrate

116
Q

recent memory

A

diet recall

117
Q

remote memory

A

ask about historical events

118
Q

new learning

A

4 unrelated words test at intervals of 5, 10, and 30 mins.

119
Q

PHQ-2

A

Asks 2 questions about depressed mood used as a screening tool for PHQ-9

120
Q

PHQ-9

A

Series of 9 questions requiring adding column totals that relate frequency of occurrence of symptoms.

The higher the score, the greater the likelihood of functional impairment or clinical diagnosis.

High score (bad)

121
Q

What is the difference between dementia and delirium?

A

Dementia is a chronic disturbance of consciousness and cognition. Long-term and short-term memory loss is more pronounced. (irreversible), Delirium is an acute disturbance of consciousness and cognition that develops over a short period of time. No history of dementia and may develop in addition to dementia during hospitalization. UTI is another example, and it is usually reversible.

122
Q

What is the difference between cognitive function and consciousness?

A

LOC is the patient’s level of awareness, which is determined by. We are starting with awake, Lethargic, Stuporous, Obtunded, and comatose.

123
Q
A

NUR-220 (2 decks)

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