EXAM 1 NUR-220 Flashcards
Alopecia
hair loss or baldness
Caries
Cavities of the teeth
Cerumen
wax in the external ear canals, consisting of a heavy oil and brown pigment
Cheilosis
Ulcerations of the lips
Gingivitis
inflammation of the gingivae or gums
Glossitis
inflammation of the tongue
halitosis
offensive breath
pediculosis
infestation with lice
periodontitis
extensive inflammation of the gums and alveolar tissues; synonym for periodontitis
plaque
invisible, destructive, bacterial film that builds up on teeth and eventually leads to the destruction of tooth enamel
stomatitis
inflammation of the oral mucosa
tartar
hard deposit on the teeth near the gum line formed by plaque buildup and dead bacteria
Tier 1 Precautions are and require what?
Tier 2 Precautions are/ and require what?
Droplet Precautions are/ and require what?
What is the difference between airborne and droplet precautions? (more than just one answer)
Airborne precautions are/ and require what?
What is normal blood pressure
120/80
In regards to blood pressure when should lifestyle changes be implemented?
When the BP is 130/80
In regards to BP stage 1 indicates?
a systolic (S) of 130-139 OR diastolic (D) of 80-89 mmHg
In regards to BP stage 2 indicates?
(S) >140 OR (D) >90 mmHg
In regards to BP Hypertensive crisis is?
(S) >180 AND OR (D) > 120
Hypertension
120-129/<80
Hypotension
<90/60 mmHg with S&S
Orthostatic hypotension
(pooling of blood) When you go from lying down to sitting/standing there is a decrease in pressure. Decrease in (S) of 20 and a decrease in (D) of 10.
Primary hypertension
Primary hypotension
Symptoms of Orthostatic Hypotension?
Lightheaded, dizziness, and blurred vision
testing for Orthostatic Hypotension?
Involves lying the person down for 5 minutes. then grabbing BP and pulse, Then sitting that person down for 3 minutes then re-checking BP and pulse. Then (IF ABLE) finally bring that person to the standing position for another 3 minutes then check BP and Pulse
PS: Everyone has a drop but only a little bit & doesn’t last as long as 3-5 minutes
What is (MAP) & what is the minimum range?
(MAP) stands for mean arterial pressure, which is the indication of perfusion of blood to vital organs. A minimum MAP of 60mm Hg is required in order to perfuse vital organs however normal is 70-100.
PS: the equation to get this number is 2 X (D) + (S) over 3
Numerical Pain Scale?
Mild (1-3) Moderate (4-6), Intense (7-10)
FLACC Pain Scale What does it mean and who is it used for?
Face, Legs, Activity, Cry, and Consolability (FLACC) Is for people who cannot communicate.
PAINAD Pain Scale. What does it mean and who is it used for?
PAINAD is used to figure out the level of PAIN in patients with advanced dementia (AD)
Important things to know when assessing pain in patients?
Onset, Location, Functional limitations (e.g., can’t eat or sleep), Pain Interventions (e.g., pharm/non-pharm), and the Patient’s Functional Goals (e.g., chronic pain 10/10 to a 3/10).
After intervention of pain, what should be done?
Reassess the patient in 4 hours or sooner (evaluation)
PS: Intervention —> evaluation
Is pain a normal part of aging?
NO! Pain is not a part of aging.
How do you handle a patient who fears addiction to pain meds?
A. Tell them that they are okay and that it never actually happens.
B Educate the patient.
C re-evaluated the idea of giving pain meds to the patient.
D Sneakily put the opioids in their drink.
The answer is B
PS: If you answered D you are a bad person and should never be a nurse
Is everyone’s pain the same?
No. everyones pain is different and personal biases should not interfere with compassionate care.
What is SPO2?
measures the amount of hemoglobin saturated with oxygen in ARTERIAL BLOOD
Normal SPO2?
> 95% also adults with a disease can have >92%. However <92% indicates that O2 to the tissues is inadequate.
LESS THAN 85% IS ABNORMAL IN EVERYONE!
PS: Another thing to note is patients >80 y.o and with lung disease 85% - 89% SpO2 levels may be their acceptable norm.
What is FIO2?
The fraction of inspired O2 and the amount of O2 breathed. (e.g., room air –> 21% air/ Oxygen –> 80%)
PS: 88% on room air is WAY different than 88% on oxygen. (One is an emergency)
If the patient is sleeping and SpO2 is decreased what should be done?
- raise the head of the bed (HOB) THIS IS THE FIRST THING TO BE DONE!
- ask them to take deep breaths.
With pulse OX readings what interferes with light transmission?
Outside light, Carbon monoxide, patient motion, Dark skin.
With pulse OX readings what interferes with arterial pulsations?
Peripheral Vascular disease (PVD), Hypothermia at the assessment site (cold hands), Low cardiac output, hypotension, peripheral edema, tight probe, Arrhythmias.
Normal Temperature (T)
35.8 - 37.5
Normal Pulse (P)
60 - 100
Respirations (R)
12-20
Normal Blood Pressure (BP)
< 120/<80
SpO2
95% - 100% be aware of Hgb
HAI?
Healthcare-associated infection
What are the TOP 4 HAI’s
- UTI
- Surgical Site Infections
- Blood Steam Infections
- Pneumonia
Nosocomial?
Something that originated or occurred inside a hospital setting
Bloodborne pathogens?
Infections or microorganisms in blood that can cause disease in humans.
Iatrogenic?
Something that wasn’t supposed to happen that happened under the our care that resulted in an infection.
Factors predisposing patients to Nosocomial infections? (3 things)
- Use of invasive medical devices
- Antibiotic-resistant Organisms
- Poor compliance with hand washing
what is the bodies first line of defense
intact skin
Infectious agents?
- Bacterial- most significant and most prevalent in hospital settings.
- Virus- smallest of all microorganisms.
- Fungi- plant-like organisms in air, soil, and water.
Microorganism reservoirs? (5 answers)
- Other humans (e.g., TB)
- Animals, insects (Vectors) (e.g., malaria, zicka, and rabies.
- Soil (e.g., tetanuss)
- Food, water, milk (e.g., listeria, salmonellala
- Inanimate Objects (Fomite)
Incubation period
Organisms growing and multiplying (NO SYMPTOMS)
Prodromal period
person is most infectious, vague and nonspecific signs of disease.
Full stage of Illness
presence of specific signs and symptoms (S&S) of disease
Convalescent period
recovery
Elevated WBC is ?
> 10,000/mm3
Neutrophils?
Produce (Bands- immature) increased in acute bacterial infections (should be less than 10%) Increased 10% indicates shift to the left.
Lymphocytes?
elevated in chronic bacterial (TB) and viral infections
eosinophils?
elevated in parasitic infections, fungus (cocci), and allergic reactions.
C-reactive protein?
Non-specific and indicates inflammation. presence of pathogens in urine, blood, and sputum or drainage cultures.
What are some diagnostic tests for infections?
CXR and Lumbar puncture
Blood-borne pathogens (BBP)
HEP A, E (Bowels), B, C, and HIV
What precautions do you use with BBP?
Standard precautions
what do standard precautions indicate?
- Treat all body fluids as if they are infected.
- Treat potentially contaminated materials as if they are infected.
- Have an essential role in preventing transmission.
When do we use hand hygiene?
- Before we enter or leave the room
- Before contact with patients
- After direct contact with patient skin
- After contact with body fluids
- Before putting on sterile gloves
- AFTER REMOVING STERILE GLOVES
- After touching patient surroundings
When is soap and water better over alcohol?
With spore (Cdiff)
What is all of the PPE equipment
- Gloves
- Gowns
- Masks
- Protective eye gear
- Surgical caps and shoe covers
Is PPE sterile?
NO PPE is NOT sterile
Is it appropriate to wear gloves when a patient is not a risk or body secretions
NO do not do this professor Filos told us that it was rude and could make the patient uncomfortable.
Transmission-based precautions (Tier 2) Include?
- Contact- Cdiff, MRSA, chickenpox
- Droplet- Influenza, Pertussiss
- Airborne- COVID-19, TB, Measles, Chickenpox
Tier 2 precautions are used in addition to what?
Tier 1 precautions (standard)
Contact precautions and droplet precautions? (environment)
do not require the door to be closed
Airborne precautions required?
an N95 mask, the door to be closed, and a NEGATIVE PRESSURE.
When transporting Airborne precaution patients what do you do?
Limit to essential purposes. and instruct the patient to wear a surgical mask.
Surgical asepsis are required for?
Invasive procedures, sterile dressings, central line dressings, and Urinary catheter insertion.
PS: Anytime you are penetrating skin
(Passive ROM Exercises): How should the nurse move each joint and in doing (blank) which results in?
each joint is moved to the point of resistance, resulting in exercise to full limitation of the area.
what is required for the use of logrolling?
a drawsheet or a friction reducing sheet to allow for smooth movements.
If a patient requests to move on to the stretcher without help. How should the nurse respond?
“You are free to move on to the stretcher yourself but I will supervise for your safety.”
trochanter rolls are required in?
instances that patients have hip fractures or injuries to the base of the femur.
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?
Sims’ position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.
Patients with dementia giving instructions?
instructions should be given in clear, short sentences that offer simple, step-by-step instructions.