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Nurs 2212 > Exam > Flashcards

Exam Flashcards

1
Q

Adolescent Brain Development

A

-The corpus callosum, where fibres connect the brain’s left and right hemispheres, thickens in adolescence, and this improves adolescents’ ability to process information
-The prefrontal cortex doesn’t finish maturing until the emerging adult years, approximately 18 to 25 years of age or later = a lack of cognitive skills to effectively control their pleasure seeking
-The frontal lobe undergoes the most complex change during adolescence
-The frontal lobe is the last section of the brain to develop
-both the amygdala and hippocampus increase in volume during adolescence
- emotional control during adolescence is not fully developed until adulthood

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2
Q

oral contraceptives pills

A

-prevents the ovary from releasing egg
-thickens cervical mucus
-change the lining of the uterus

advantages
-highly effective
-reversible
-does not interfere with sex
-may reduce menstrual flow/cramps
-decreases PMS

disadvantages
-effectiveness can be reduced by other medications
-may cause irregular bleeding
-breast tenderness, nausea, headaches
-take everyday at same time
-increase risk of blood clots
-cardiovascular events

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3
Q

combined oral contraceptive (COC)

A

-contains estrogen and progestin

advantages
-decrease acne
-decrease body and facial hair
-reduces risk of endometrial, ovarian, and colon cancer
-reduce risk of ovarian cysts

disadvantages
-should not be used in those >35 who smoke

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4
Q

progestin only pill (POP)

A

-contains progestin only

advantages
-suitable for those who cannot take estrogen
-can be used during breastfeeding
-can be used in those >35 who smoke

disadvantages
-hormonal side effects: acne, headache, breast tenderness, mood issues, unwanted hair growth

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5
Q

contraceptive patch

A

-4 x 4 cm beige patch that sticks to the skin and continuously releases the hormones estrogen and progestin into the bloodstream
-prevents the ovary from releasing egg
-thickens cervical mucus
-change the lining of the uterus
-change patch q1w

advantages
-highly effective
-can reduce cramps and menstrual flow
-regulates menstrual cycle
-decrease PMS
-reduces risk of endometrial, ovarian, colon cancers
-reduces risk of ovarian cysts

disadvantages
-may cause irregular bleeding or spotting
-breast tenderness, nausea, headache
-skin irritation
-may be less effective in those who weight more than 90kg

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6
Q

vaginal ring

A

-small ring inserted in vagina, slowly releases hormones (estrogen and progestin) for 3 week
-stopping the ovaries from releasing an egg
-thicken the cervical mucus
-make the uterine lining thin

advantages
-highly effective
-may reduce menstrual flow, cramps, PMS
-reduces risk of endometrial, ovarian, colon cancers
-reduces risk of ovarian cysts
-does not have to be remembered each day

disadvantages
-may cause irregular bleeding or spotting
-cardiovascular events
-breast tenderness, nausea, headache
-vaginal discomfort
-requires remembering to change once a month

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7
Q

Intrauterine Contraception (IUC)

A

-hormonal IUC: the small cylinder on the IUC contains the hormone levonorgestrel, which is slowly released. The lining of the uterus becomes thinner and the cervical mucus becomes thicker which makes it harder for sperm to enter the uterus.

advantages
-highly effective
-long term (3-10y)
-cost effective
-suitable for those who cannot take estrogen
-can be used while breastfeeding
-reduces risk of endometrial cancer

disadvantages
-initial irregular bleeding
-ectopic pregnancy
-expensive
-pain/discomfort during insertion
-infection, perforation of uterus
-expulsion of IUC

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8
Q

injectable Contraception (Depo shot)

A

-injection contains progesterone only
-given 4x/year
-given in upper arm or buttock
-stops the ovaries from releasing an egg
-thicken the cervical mucus
-make the uterine lining thin

advantages
-highly effective
-good for people who have trouble remembering to take a pill every day
-good for those who can’t take estrogen
-can be used while breastfeeding
-can be used in those >35 who smoke
-may reduce menstrual flow, cramps, PMS
-reduces risk of endometrial cancer and cysts
-can improve symptoms of pelvic pain
-decrease seizures

disadvantages
-initial irregular bleeding
-venous thrombosis
-decrease in BMD
-change of appetite, weight gain
-hormonal side effects: acne, headache, breast tenderness, mood issues, unwanted hair growth
-6 to 10 months after the last injection for the ovaries to start releasing eggs again (delayed conception)

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9
Q

contraceptive implant

A

-sits just below the skin and continuously releases progestin
-lasts up to 3 years
-prevents ovaries from releasing egg
-thickens cervical mucous

advantages
-highly effective
-long term
-cost effective
-good for those who cannot take estrogen -can be used during breastfeeding
-suitable for those >35 who smoke
-may reduce cramps and PMS
-reduce/eliminate periods

disadvantages
-initial irregular bleeding
-hormonal side effects: acne, headache, breast tenderness, mood issues, unwanted hair growth
-pain, discomfort during insertion
-soreness at insertion site

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10
Q

male condom

A

-acts as a physical barrier preventing direct contact between the penis and the vagina. It prevents the exchange of body fluids and also traps the sperm in the condom so it cannot fertilize the egg
-only used water based, glycol, or silicone based lubes with latex condoms (no oil based lubes)
-synthetic condoms can be used with any kind of lube

advantages
-easily accessible
-inexpensive
-effective
-protects against STIs
-hormone free
-decrease risk of cervical cancer
-can be used with other contraception methods

disadvantages
-must be available at time of sexual activity
-must be stored and handled properly
-can expire
-can break or slip
-may reduce sensitivity
-latex allergy

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11
Q

female condom

A

-barrier contraception method, preventing contact between the sperm and the vagina.
-can be placed in the vagina up to 8 hours before sex

advantages
-prevent pregnancy and STIs
-can be used by people with latex allergies
-can be used with oil based lubes
-may be more comfortable than males condoms
-increase sexual stimulation

disadvantages
-trouble inserting it correctly
-more expensive than male condoms
-break or slip
-the ring may cause discomfort
-may be noisier than male condom

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12
Q

contraceptive sponge

A

-small sponge placed over the cervix to provide a physical barrier method to prevent sperm from entering
-contains spermicide
-sponge inserted into vagina up to 24 hours before sex
-protection begins immediately
-should be left in vagina for at least 6 hours after sex
-should not be in vagina for >30 hours total

advantages
-barrier method and spermicide in one
-no hormones
-easily accessible

disadvantages
-increases risk of vaginal and cervical irritation
-TSS
-increases risk of transmission of HIV
-trouble inserting
-does not prevent STIs
-high failure rate

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13
Q

cervical cap

A

-a deep silicone cap that fits against the cervix and prevents sperm and bacteria from entering
-physical barrier
-should always be used with spermicide gel
-gel forms a physical cellulose barrier in front of the cervix and lowers the pH of the vaginal fluid, thereby inhibiting sperm motility
-can be inserted up to 2 hours before sex
-gel should be reapplied for each repeated intercourse or after 2 hours
-should be left in vagina for at least 6 hours after sex
-should not stay in >48 hours total

advantages
-no hormones
-can be used while breastfeeding
-available in different sizes

disadvantages
-high failure rate
-increased risk of recurrent UTIs
-increased risk of TSS
-trouble inserting
-gel must be reapplied after each intercourse
-cannot be used in silicone allergy
-need a prescription

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14
Q

diaphragm

A

-a cap made of latex, silicone, nylon, that covers the cervix and prevents sperm from entering
-should always be used with spermicide gel
-gel forms a physical cellulose barrier in front of the cervix and lowers the pH of the vaginal fluid, thereby inhibiting sperm motility
-can be inserted up to 2 hours before sex
-should be left in vagina for at least 6 hours after sex
-should not remain in vagina for more than 24 hours total
-If there is repeated intercourse within the first 6 hours, more gel should be inserted with an application

advantages
-no hormones
-can be used while breastfeeding
-one size, fits most
-no prescription needed

disadvantages
-high failure rate
-increased risk of recurrent UTIs
-increased risk of TSS
-trouble inserting
-gel must be reapplied after each intercourse
-cannot be used with latex or silicone allergy

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15
Q

spermicides

A

-inserting spermicide in front of the cervix, destroys sperm on contact.
-should be used along with another method of contraception because alone they are not highly effective.
-must be inserted into the vagina at least 15 minutes before intercourse
-effective immediately and up to 1 hour after
-must be reapplied for each intercourse

advantages
-no hormones
-more effective when used with another barrier method
-can also protect against bacterial infections and PID

disadvantages
-not highly effective
-can be messy
-must be inserted right before sex
-may irritate penis and vagina
-may increase risk of HIV transmission

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16
Q

vasectomy

A

-a permanent surgical procedure to close or block the vas deferens
-another form of contraception is required until a semen analysis shows no sperm.

advantages
-safe and highly effective
-long lasting
-permanent
-simple procedure
-no hormones
-does not affect sexual function
-less invasive than tubal ligation
-no long term side effects

disadvantages
-permanent and irreversible
-risk of regret
-not effective immediately
-must use another contraception method for 3 months and do a follow-up sperm analysis that shows no sperm are present in the semen
-short term surgery related complications: pain, bleeding, vasovagal reaction, infection at the incision site, bruising and swelling of the scrotum

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17
Q

tube ligation and salpingectomy

A

-permanent surgical procedure where the two fallopian tubes get disconnected

advantages
-safe, highly effective
-long lasting (permanent)
-does not affect sexual function
-no hormones
-may reduce risk of ovarian cancer

disadvantages
-permanent and irreversible
-short-term surgery-related complications: pain, bleeding, infection at the incision site, trauma to adjacent organs or blood vessels in the abdomen
-risk of ectopic pregnancy if failure occurs

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18
Q

fertility awareness based contraception

A

-determine when ovulation occurs by:
-Measuring your basal body temperature every day
-Checking your urine with an ovulation kit to measure the LH hormone
-Observing changes in your cervical mucus
-Using an app to follow the calendar method and track your menstrual cycles and ovulation
-calculate your fertile window and avoid having sex during that time

advantages
-safe
-no side effects
-little cost
-natural
-no hormones

disadvantages
-least effective at preventing pregnancy
-requires practice to do correctly
-can be tricky (not all cycles are regular)
-must avoid sex at certain times

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19
Q

lactational amenorrhea method (LAM)

A

-used by women who have just given birth and are exclusively breastfeeding
-The hormones that trigger lactation interfere with the release of the hormones that trigger ovulation. The more you nurse your baby, the less likely you are to ovulate

advantages
-highly effective for first 6 months after birth (if the mother breastfeeds at least 4 hours/day and 6 hours/night
-natural way to prevent pregnancy after childbirth
-safe
-convenient
-no cost

disadvantages
-effectiveness is limited to 6 months after childbirth
-may be difficult to exclusively breastfeed

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20
Q

withdrawal (coitus interruptus)

A

-male withdraws his penis from the vagina and away from the external genitalia of the female partner prior to ejaculation

advantages
-natural
-safe
-convenient
-no cost
-no hormones

disadvantages
-not easy (requires self control)
-risky

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21
Q

abstinence

A

-not having sex

advantages
-most effective
-safe
-no cost
-no side effects

disadvantages
-can be challenging
-unprepared if you change your mind
-partners must be committed to this

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22
Q

chlamydia

A

symptoms
-vaginal bleeding
-discharge (clear, watery, milky)
-abdominal pain
-testicular pain/swelling
-itchy urethra
-pain/burning while voiding

treatment
-antibiotics
-sexual partners in the last 60 days require testing
-re-tested 6 months after treatment

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23
Q

gonorrhoea

A

symptoms
-most women don’t develop symptoms (men do)
-painful urination
-discharge (thick, yellow-green)
-itchiness
-testicular pain/swelling

treatment
-dual therapy antibiotics
-sexual partners in the last 60 days require testing
-re-tested 6 months after treatment
-should also be treated for chlamydia

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24
Q

syphilis

A

symptoms
-inc. prevalence
-4 stages
-a painless open sore on the genitals, anus, throat
-rash
-flu like symptoms
-swollen glands

treatment
-injectable penicillin
-sexual partners in the last 3 months require testing

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25
Q

trichomoniasis

A

symptoms
-most common non-viral STI
-men have less symptoms
-pain/burning while voiding
-pain during sex
-discharge from penis

treatment
-oral antibiotics
-get treated early

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26
Q

herpes

A

symptoms
-most common cause of genital ulcerations
-often no symptoms
-cold sores
-sores on genitals
-itchy genitals
-flu like symptoms
-pain while voiding

treatment
-no cure
-antivirals may help outbreaks

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27
Q

pubic lice

A

symptoms
-insects that nest in pubic hair
-skin irritation and inflammation
-itchy and red skin
-louse feces
-small blue spots on skin where lice have bitten

treatment
-All household contacts and recent sexual partners within the past month should be treated to prevent re-infestation
-antihistamines and steroid creams can control itchiness
-medical shampoos
-Clothing, bedding and other possible contaminated items should be washed or dry cleaned, or bagged for three days to one week. Items that cannot be washed or bagged should be vacuumed

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28
Q

scabies

A

symptoms
-parasitic mites that burrow below the skin
-lay eggs under skin to hatch
-intense nighttime itchiness and red rash
-the lesions are usually in the hands, wrists, armpits, waist, nipples, around the belly button, and in the male genitalia.

treatment
-skin scraping of the burrow to remove the mite
-burrow ink test
-medical creams and shampoos
-all household contacts and recent sexual partners within the past month should be treated to prevent re-infestation
-Clothing, bedding and other possible contaminated items should be washed or dry cleaned, or bagged for three days to one week. Items that cannot be washed or bagged should be vacuumed

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29
Q

lymphogranuloma venereum (LGV)

A

symptoms
-caused by variations of bacteria that cause chlamydia
-appear 30 days after infection
-painless sore or bump where bacteria entered
-flu like symptoms
-swollen lymph nodes
-deformity of genitals

treatment
-antibioticos

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30
Q

bacterial vaginosis

A

symptoms
-harmful bacteria outnumber good bacteria
-often no symptoms
-thin vaginal discharge (white or grey)
-fishy smell

treatment
-antibiotic pills, creams, ovules

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31
Q

yeast infection (vulvovaginal candidiasis)

A

symptoms
-too much yeast in vagina
-thick white clumpy vaginal discharge
-vaginal itching, pain, burning, redness
-pain during voiding and sex

treatment
-antifungal creams, ointment, oral pills or ovule

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32
Q

HPV

A

symptoms
-genital warts
-itchiness
-pain and bleeding during sex
-cervical cancer

treatment
-no cure
-can remove visible lesions and warts
-treatments for warts
-immune system can clear infection, but it can reoccur

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33
Q

HIV

A

symptoms
-may not have symptoms for years
-mild flu like symptoms
-fever, fatigue, weight loss, chronic diarrhea, dyspnea, cough, loss of vision, recurrent yeast infections, lesions, shingles, herpes, anemia
-causes your immune system to fail
-cancer, dementia, death

treatment
-antiretroviral therapy
-is a chronic disease
-NO CURE
-treatments can slow the progression of the disease
-partner notification!

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34
Q

young adult: biology & genetics

A

-18-34 years old
-major milestones: Completion of formal education, commencing full-time employment, getting married and parenthood
-Healthiest period, optimal muscle strength (age 25–30), peak manual dexterity.
-Developing behaviours to promote a healthy lifestyle.
-Decreasing incidence of accidents, injuries, violence.
-Self-help resources are very popular with young adults.

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35
Q

young adult: health perception & management

A
  • Young adults have the highest number of emergency department visits and lowest number of outpatient visits.
  • leading causes of death: unintentional injuries (accidents), homicide, suicide
  • Cholesterol, diabetes, smoking, hypertension, metabolic syndrome. So, necessary to screen for cardiovascular conditions after the age of 25 as well as provide education about risk factor modification
  • Prevention, screening, and modifying risk factors is key with young adults
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36
Q

young adult: nutritional metabolic pattern

A

-Caloric needs increase substantially, particularly in men.
Basal metabolic rate declines
- Assessment: BMI, waist circumference, blood pressure, & cholesterol
- Nutritional needs and common deficiencies: Iron, folic acid, calcium
-Variety of nutrition-dense foods, especially whole grains, fruits, vegetables, low fat or fat-free milk, lean meat, and protein sources
-Encourage iron, calcium and folic acid intake

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37
Q

young adult: elimination pattern

A
  • Well-established elimination pattern
  • Although eating disorders begin at an earlier stage of development, they can persist during young adulthood
  • Common complaints: Constipation, Hemorrhoids, Occasional diarrhea
    -Report changes in elimination patterns
    -Adequate fluids; eating fruit and vegetables
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38
Q

young adult: activity exercise pattern

A

Exercise recommendations
- Aerobic exercise of moderate intensity for 150 minutes per week in bouts of 10 minutes or more at least 2 days a week
- Muscle and bone strengthening 2 days per week
- Barriers: lack of time, access to facilities, safe environments
-Helmets for bicycles, motorcycles

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39
Q

young adult: cognitive perceptual

A
  • Visual acuity: highest at 20 years and begins to decline by 40 years, when farsightedness frequently develops.
  • Hearing: best at 20 years. The ability to distinguish high pitched tones decreases with age.
  • Other senses: Taste, smell, touch and awareness of temperature and pain remain stable until 40 to 50 years of age
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40
Q

young adult: Piaget

A

-Achievement of formal operational thinking allows young adults to analyze all combinations of possibilities and construct hypotheses. Young adult thought becomes more perceptive and insightful; issues can therefore be evaluated realistically and objectively.
-Although they tend to take greater risks, young adults typically demonstrate the use of appropriate reasoning, anticipation, and analytical approaches.

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41
Q

young adult: erikson

A

-intimacy versus isolation and loneliness.
-Young adults who are unsure of their identity may avoid intimate contact or engage in promiscuous behaviour lacking in true intimacy, which can result in isolation and consequent self-absorption

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42
Q

young adult: Kohlberg

A

-post conventional moral reasoning
-Define rights and morality in terms of self-chosen principles.
-the individual is able to differentiate the self from the rules and expectations of others and to define principles regarding rights in terms of self-chosen principles
-Doing for self Vs others/society

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43
Q

young adult: roles relationship patterns

A

-Formation of intimate relationships
-Decisions about life and career directions
-Formation of family units
-Multiple decisions related to child-bearing, finances, roles and relationships
-Depression common—supportive counselling and services
-(Assess for suicidal ideation)

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44
Q

young adult: sexuality-reproductive pattern

A

Infertility
-Affects 16% of couples; increased incidence greater than 30 years
-Assisted reproductive technologies (stressful, costly)
-Sterilization: choice increases with age

Unintended pregnancy (40% of all pregnancies)
-Half of unplanned pregnancies are caused by contraceptive failure
-Nurse’s role: help choose most appropriate method of contraception

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45
Q

young adult: environmental processes

A

-Injuries are the leading cause of death in young adults
-Alcohol intake/ binge drinking and Motor vehicle accidents cause more fatalities than all other causes of death combined.
-Occupational hazards and stressors (Young adults work in hazardous jobs): emphasis on protective clothing, equipment, instruments etc

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46
Q

middle aged adults: biology & genetics

A
  • age 35-64 years
    -Fat disposition, decreased muscle mass and bone density, osteoarthritis
  • Hormonal changes
  • Reduction of glomerular filtration by 50%
    -Leading causes: heart disease, cancer, and accidents
  • Heart disease: number one cause of death
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47
Q

middle aged adults: health perception & management

A

-acceptance of aging, the need to exercise, and weight control, decreasing or stopping cigarette smoking and alcohol consumption.
-The leading causes of death during middle adults are malignant diseases such heart disease, cancer, etc.
-Dietary factors and unhealthy weights are correlated with 5 of the 10 leading causes of death in Canada. Emphasis on diet and exercise.

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48
Q

middle aged adults: nutritional metabolic pattern

A

-The middle-aged adult typically leads a more sedentary lifestyle than does the young adult.
-Obesity risk increases with less education, low income, ethnicity
-alcohol abuse
- adults consume these agents for many reasons, including peer pressure, loneliness, alienation, frustration, anxiety, and low self-esteem.
- Women have a higher death rate related to alcoholism than men. More men than women are considered problem drinkers

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49
Q

middle aged adult: activity exercise pattern

A
  • Activities that focus on skill and coordination
  • Caution is recommended for adults nearing age 65 years to prevent muscle strains and/or falls.
    physical exercise should involve as many muscles as possible and be performed on a regular basis. - Adults should spend 30 minutes or more in brisk physical activity (e.g., walking, jogging, swimming, bicycling) every day for a total of 3 to 4 hours per week.

Initiating exercise program: Points to consider for better success
- Choose activities enjoyed in past (if appropriate)
- Activities that the person/group interested in
- Consider potential for injury, proper equipment
- Exercise testing if high risk

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50
Q

middle aged adults: cognitive perceptual pattern

A

-Helping children become responsible, happy adults
- Rediscovering or developing new satisfaction in the relationship with one’s spouse (for the single adult, this can occur in a relationship with a sibling or significant other)
- Developing an affectionate, but independent, relationship with aging parents
- Reaching the peak in one’s career
- Achieving mature social and civic responsibility
- Accepting and adapting to biological changes
- Maintaining or developing friendships
- Developing leisure-time activities
- Can process complex problems of reasoning
- Focus on involvement, absence of chronic disease, flexibility, family, complexity, favourable socioeconomic status, personal satisfaction, spouse with high cognitive function

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51
Q

middle aged adult: erikson

A

-generativity vs stagnation
-Generativity involves a sense of productivity, creativity, and the desire to help others, whereas stagnation involves a sense of isolation and focus on oneself.
-Middle age is a time of critical self-review. For some, this review may prompt sadness, disappointment, self-doubt, and regret if the desired and expected life goals have not been met.

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52
Q

middle aged adult: roles relationships pattern

A
  • Multiple responsibilities and stresses
  • Children, aging parents, job, and civic responsibilities
  • Single-parent families
  • Over-involvement with children’s activities
  • Caring for aging parents
  • Divorce: Children of divorced parents may have emotional effects lasting for decades.
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53
Q

middle aged adult: self perception

A

-Some people try to “hold on” to youth by dressing as more youthful counterparts dress, whereas others adapt their attire to their age and position in life.

Women (40s and 50s)
- Raising a family
- Helping parents as they age
- Coping with divorce or death of a spouse
- Retirement, and financial insecurity.
- Menopause

men
- The hormonal changes in men are gradual, typically beginning between 40 and 55 years of age. The symptoms are similar to those experienced by women with the emotional effects related to other life events, past coping patterns, and general feelings of self-esteem

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54
Q

middle aged adult: sexuality and reproduction

A

-Sexual arousal is slower, orgasms are less intense, and a return to pre-arousal levels is more rapid, with men having longer refractory periods between erection and ejaculation.
-Women can experience vaginal dryness, difficulty finding a partner, less interest in initiating sex, and longer times to reach orgasm

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55
Q

theories of aging

A

No single theory
Factors under study
Genetics: predict development of disease
Diet: calorie restriction
Antioxidants: binding free radicals

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56
Q

older adults: health perception & management

A
  • Motivation: Important for maintaining health
  • Nursing role: Help older persons understand the importance of health factors, to learn their goals, and what motivates them.
  • Not to underestimate their abilities.
  • Encourage active participation in care rather than performing care for them.
  • Activities to promote health and prevent frailty

Recommended clinical preventive services for older persons
- Immunizations (influenza and pneumococcal)
- Screenings for early detection
- Smoking-cessation counseling for those who smoke.

Health assessment screening
- Renal insufficiency
- Alcoholism
- Polypharmacy
- Substance/Illicit drugs

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57
Q

older adults: nutritional metabolic pattern

A
  • Adults aged 65 or older typically require fewer calories than younger adults.
  • Although fewer calories are needed, older people require more nutrition from these calories to promote and protect health.
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58
Q

older adults: obstacles to maintaining optimal nutrition

A

Access to food
Low income
Decline in GI absorption, metabolism, elimination
Deterioration of senses (taste, smell and vision)
High frequency of dental and swallowing problems
Cultural food preferences
Lifelong eating habits
Living environment (e.g., institutions)
Anorexia resulting from disease
Medications
Hospital stay

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59
Q

older adults: ways to improve nutrition

A
  • Encouraging family members to bring in special foods that the resident enjoys is helpful.
  • Assess the person’s food preferences and any difficulties in eating, followed by careful planning of an appropriate menu, to encourage healthy eating.
  • A pleasant setting with social interaction enhances the desire to eat.
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60
Q

older adults: elimination pattern

A
  • Bowel and bladder functions are altered by normal changes of aging.
  • Gastro-intestinal motility decreases as people age.
  • Diet plays a significant role in problems with intestinal motility and constipation.
  • Decreased intake of fluids and fibre contribute in large part to constipation.
  • Many medications taken by older persons also cause elimination concerns.
  • Lack of physical activity and changes in the environment that decrease privacy also contribute to elimination problems.
  • It is important to reassure them that through diet and exercise they can gain control of most elimination problems
  • Schedule regular times to void
  • Pelvic floor exercises
  • Avoid stimulant such as caffeine
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61
Q

stress incontinence

A

when someone coughs or sneezes

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62
Q

urge incontinence

A

once the urge to void is felt they cannot wait to void
inability to delay voiding once the bladder is full

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63
Q

functional incontinence

A

associated with environmental barriers, physical limitations, or cognitive impairment in which the care recipient is unable to reach the toilet.

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64
Q

acute incontinence

A

Last for less than 6 months
Secondary to another disease

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65
Q

chronic incontinence

A

Stress, urge, overflow, functional

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66
Q

older adults: activity-exercise pattern

A

-Recommended at least 150 min of moderate to vigorous exercise/week
-Goal- help maintain flexibility, strength, and balance
-Strength training improves balance and reduces the risk of falls, strengthen bones and reduces blood sugar levels
-Weight bearing – functional mobility, promoting independence, and prevent falls.

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67
Q

older adults: sleep rest pattern

A

Do’s
- Regular bedtime and waking schedule
- Plan activities during the day (eg. exercise)
- Bedtime rituals (reading, meditating, etc.)
- Comfortable and quiet sleep environment
- Use the bed only for sleep and sexual activity
- Check on medications that may interfere with sleep

Dont’s
- Avoid long daytime naps
- Vigorous activity right before bed
- Caffeine after mid morning
- Drinking alcohol before bed
- Sleep medications
- Tobacco
- Driving when tired

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68
Q

older adults: cognitive perceptual pattern

A
  • Brain weight decreases with aging. Shift occurs in the proportion of grey matter to white matter.
  • Affects memory, comprehension, problem-solving, and decision-making.
  • cognitive impairment is not a normal change of aging
    -Keep their minds active: Read, engage in stimulating conversation and entertainment, Scrabble and Bingo
  • Encourage to perform self-care activities, such as dressing, themselves.
    -Elderly patients like consistency in their environment and do not make abrupt changes. Change often fosters confusion. Familiar environments and consistent routines are encouraged.
69
Q

presbycusis

A

progressive sensorineural hearing loss associated with aging – difficulty filtering background noise and understanding high-pitched voices.

70
Q

older adults: taste and smell

A
  • Loss of taste buds
  • The flavors of sweet, sour, salty, and bitter become blurred.
  • Safe cooking and alternative seasoning
  • Inability to sense warning signal- smoke, rotten food
  • Teach- check dates on food packages frequently, be attentive while cooking and preparing meals
71
Q

older adults: Erikson

A
  • Ego integrity vs. despair (coming to terms with life)
  • Ego integrity: acceptance of life; feeling “at peace”
  • Fear of death and despair, feels life was “in vain”
    -Successfully navigating the stage of ego integrity versus despair requires that the individual accept normal bodily changes associated with aging, find meaning in life apart from work, accept the inevitability of death, and be at peace with his or her life.
72
Q

older adults: roles relationships pattern

A

Grandparenting: new role
- Frequently brings joy and happiness
- Grandparents raising children—stress issues
- Counselling, support groups, education—all help with coping

73
Q

older adults: depression

A

Older person is at highest risk
Medical conditions, losses, physical changes
Depression is also caused by physiological changes in the aging body.

74
Q

older adults: suicide

A

Risk factors for suicide include social isolation, alcohol and substance abuse, psychosis, bereavement, and serious medical illness.
Challenge: promote value in life, alleviate suffering

75
Q

older adults: falls

A
  • Leading cause of morbidity and mortality
  • Accounts for about 40% of admissions to long-term care
  • Result in decreased, mobility, decreased ability to live independently, and increased risk of an early death
  • Risk assessment and prevention are essential
  • Should be assessed after an injury or annually
  • Even if an older person isn’t injured after a fall , they may develop a fear of falling, and therefore limit their activities and increase their risk for future falls.
76
Q

older adults: 5 leading causes of death

A

Cancer, heart disease, unintentional injury, COPD, cerebrovascular diseases

77
Q

screening

A
  • A preliminary step to identify individuals who need more diagnostic workup to prevent further development of condition or disease or adverse disease outcome
  • Screening is secondary prevention
  • Not generally a diagnostic measure, nor it is curative
  • a step toward empowering individuals to make more informed choices about their health and health behaviors

Primary objective
- Detection of a disease in its early stages
- Treat disease and prevent progression of disease

78
Q

individual screening

A

One person is tested by a healthcare provider who has selected the individual as high risk (e.g., Hypertension)

79
Q

group or mass screening

A

A target population is selected on the basis of increased incidence of a condition or a recognized element of high risk within the identified group (e.g., Target population tested for selected disorders such as hypertension, elevated levels of lipids & cholesterol, elevated blood sugar)

80
Q

one test disease specific screening

A

Administration of a single test that searches for a characteristic that indicates a high risk of developing a disorder. (e.g., B.P monitoring to evaluate hypertension)

81
Q

multiple test screening

A

Administration of 2 or more tests to detect more than one disease. In some cases , one sample can be used to evaluate an individual for several conditions. (e.g blood sample for glucose, cholesterol etc.)

82
Q

advantages of screening

A
  • cost effective
  • The screening process can be applied to both individuals and larger populations
  • Some screenings mandated by law, e.g., PKU
  • Screening can be one-test disease-specific or multiple test screening.
  • Screening creates the opportunity for health teaching.
83
Q

disadvantages of screening

A
  • Uncertainty in scientific evidence—possibility of errors
  • Any margin of error can have serious consequences
  • False positive—anxiety, unnecessary interventions
  • False negatives—disease is overlooked; missed opportunity for early intervention
84
Q

morbidity

A

diseased state or disability from any cause
Includes range or degree of illness

85
Q

significance

A
  • level of priority of disease as public health concern
  • Determined by incidence and prevalence and by the quantity (severity) and quality of life affected by the disorder
  • Media
86
Q

prevalence

A

Prevalence is the proportion of a given population with the disease or condition at any one point in time. (all cases)
- generally existing
- chronic conditions

87
Q

incidence

A

is the rate of a new population problem and estimates the risk of an individual developing the specific disease or condition during a specific period or over a lifetime. (new cases)
- rate of occurrence
- acute conditions

88
Q

quality adjusted life year (QALY)

A

Perfect health minus the disability-adjusted life year (DALY)
1 year of excellent health = 1 QALY
1 year of of disease = 0.5 QALY

89
Q

disability adjusted life year (DALY)

A

Year spent in less than healthy life
Measure of the burden of disease
Measures gap between current health and excellent health status

90
Q

screening measures must be…

A
  • Must be available, easy to administer, safe, cost-effective, accurate
  • Screening tool must accurately distinguish those with and those without disease.
  • Reliability - the ability of different individuals to produce the same results (consistent, stable, results)
  • Validity - accuracy or truthfulness of the test (does the test actually measure what we are looking for)
91
Q

Implementing screening program is dependent on:

A

community resources (funds, health care workers, follow up services, referrals, treatment sources, administrative personnel)

92
Q

lead agency

A

oversee the development of a community health program

93
Q

stakeholders

A

individuals or groups with a genuine interest in the topic (hospitals, health and social services agencies, primary health centers, schools, etc)

94
Q

community assessment

A

systematic method of collecting data that provides a detailed account, first identifying need and subsequently determining the type, quantity, and quality of resources

95
Q

Controversies of screening results:

A
  • False positives, false negatives; duty to inform?
  • Cutoff points: determines whether person is “disease positive” or “disease negative”
  • Borderline cases—interpretation changes as guidelines change; when to refer or not refer
96
Q

cost benefit ratio

A
  • Performed first
  • Allow comparison of various outcomes in monetary terms
  • Cost of screening vs cost of long term care management
  • Example: BP screening for hypertension vs. cost of chronic care for stroke, CHF, etc.
  • Cost screening vs. cost of HPV vaccine for cervical cancer
  • This comparison is necessary in health planning when the initial consideration is dependent on whether the expected health outcome will be most beneficial to the community at the most reasonable cost
97
Q

cost effectiveness

A
  • Determines the optimal use of resources to reach a desired health outcome
  • Implementation of all screenings would be ideal, but limited resources means some choices are made among various screening options
98
Q

cost efficacy

A
  • Goal is to be efficient - budget limited funds toward optimizing goal
  • Funds (vs. health benefit) are the focus
  • When they are many goals and limited funds - must choose wisely
99
Q

person dependent factors

A

Age, gender, race and ethnicity, income level, and lifestyle (daily habits, nutrition, fitness, tobacco use, alcohol and drug use, stress management, risky behaviour, etc)

100
Q

environment dependent factors

A

Conditions: workplace, home, and community
Chemical, physical, and psychological forces

101
Q

health education

A
  • Any combination of learning experiences designed to help individuals and communities improve their health by increasing their knowledge or influencing their attitudes
  • Information alone does not change behaviour. Nurse educators must also focus on examining ways to prompt positive individual and community behavior change through policy and program development that address the social determinants of health, thereby reducing health inequities.
  • As population ages there is more need to shift from acute individualized interventions → community based interventions (health promotion, disease prevention)
  • One cannot assume that poor health is related only to a lack of information or education & that by providing this, recipients will experience improved health.
102
Q

goals of health education

A
  • Encourage positive, informed changes in lifestyle
  • Empower the individual
  • Help individuals, families, and communities achieve optimal health (via their own actions and initiative).
  • improve health literacy
  • People who believe they have autonomy and who are involved in decision making are more likely to experience improvement in mental and physical health outcomes
103
Q

functional literacy

A

More than a basic reading ability to include the understanding and use of printed information that is fundamental to daily life at work, at home, and in the community.

104
Q

health literacy

A

Building upon functional literacy, health literacy is the ability to apply these skills to health situations for the purpose of achieving healthier outcomes.

105
Q

Health Behaviour Change: ecological model

A

Health behaviour is viewed as a complex interaction of individuals with the environment—multiple influences (interpersonal group, community, etc)

106
Q

Health Behaviour Change: individual model

A

help explain factors influencing and interfering with positive health behaviors. In addition, they also contribute to understanding how educational intervention supports behavior change

107
Q

Health Behaviour Change: health promoting behaviours

A

activities which enhance health, support healthy environments, prevent disease, and detect and control symptoms

108
Q

protection motivation theory

A
  • Paradigm to predict and explain health behaviour
  • Focuses on how fear influences change
  • Marketing capitalizes on fear to get people to change their behaviour (eg, anti-smoking campaigns)

Engagement in health-promoting behaviour is based upon three factors:
- One’s beliefs about the severity of the illness
- Perceived benefits of change
- Barriers and confidence levels (self-efficacy) in creating change

109
Q

social cognitive theory: Bandura

A
  • Emphasizes the influence of self efficacy or efficacy beliefs on health behaviour

Describes 3 interacting factors
- Behaviour - role modeling
- Cognition - what we think and feel
- Environment - social influences

What should the nurse do?
- Modelling
- Provides opportunities for imitating behaviours
- Useful to demonstrate desired behaviours
- Example: parents model behaviour for their child

110
Q

transtheoretical model

A
  • Precontemplation: Not considering behaviour change
  • Contemplation: Seriously considering a specific behaviour change in next 6 months
  • Planning: Starting to change or seriously thinking about making change in next month
  • Action: Made behaviour change; change persisted for 6 months
  • Maintenance: 6 months after change; continues indefinitely
111
Q

social marketing

A

process which uses marketing principles and techniques (prompts, messaging, images) to influence behaviours (to benefit the individual and society)

112
Q

Teaching Plans for Groups

A
  • Desired behaviour change for health promotion
  • Plan written from learner’s perspective
  • The individual is an active participant
  • Plan should clarify learner outcomes
  • Specific actions or abilities desired during or at end of program
113
Q

most common nutrient deficiencies

A

iron and calcium, which results in anemia and osteoporosis

114
Q

Four leading diet-related causes of death

A
  • congenital heart disease
  • cancer
  • cerebrovascular accident (stroke)
  • diabetes mellitus
115
Q

Obesity or overweight

A

1 in 4 adults; 1 in 5 youths

116
Q

health canadas healthy eating strategies

A
  • Improving healthy eating information
  • Improving nutritional quality of foods
  • Protecting vulnerable populations
  • Supporting increased access to and availability of nutritious foods
117
Q

A Food Policy for Canada (Government of Canada) has four pillars:

A

1.Food security
2.Health
3.Environment
4.Sustainable growth of the agriculture and food sector

118
Q

dietary reference intakes (DRI)

A

DRI is used to plan and assess diets of healthy people.
May not account for genetic diversity or specific groups. It serves as an overall guideline for the population

119
Q

recommended dietary allowances (RDAs)

A

Form the basis for the DRIs

120
Q

Dietary Supplements and Herbal Medicines

A
  • The best way to obtain nutrients is by eating a variety of foods
  • Dietary supplements should be used cautiously so that excess amounts are not consumed, which could lead to possible adverse effects
  • It is important to be cautious when using any supplements.
121
Q

nutrition screening

A
  • Discover characteristics or risk factors associated with dietary and nutrition problems
  • Identify individuals who are potentially at risk
  • Older persons are at disproportionate risk
  • Canadian Nutrition Screening Tool (CNST)
  • Referred to a dietitian after screening
122
Q

BMI

A
  • Underweight: BMI less than 18.5 kg/m2
  • Healthy weight: BMI of 18.5 to 24.9 kg/m2
  • Overweight: BMI of 25 to 29.9 kg/m2
  • Class 1 obese: BMI of 30 to 34.9 kg/m2
  • Class 2 obese: BMI of 35 to 39.9 kg/m2
  • Class 3 obese (morbid obesity): BMI of 40 kg/m2 or higher
123
Q

obesity: LEARN acronym

A

L—Listen with sympathy and understanding to the person’s perception of the problem.
E—Explain personal perceptions of the problem.
A—Acknowledge and discuss differences and similarities.
R—Recommend treatment.
N—Negotiate an agreement.

124
Q

cross training

A

performing different types of exercise on different days of the week or performing different types of exercise within one session. The benefits of cross training include a decreased risk of musculoskeletal injury, an increased potential for total body conditioning, and improved long-term compliance because variety decreases boredom and eliminates the exercise barrier of limited choices.

125
Q

aerobic exercise

A
  • activity using large muscle groups in a repetitive, rhythmic fashion over an extended period to improve oxidative energy-producing system and improve cardiorespiratory status
  • fuel = adipose tissue
  • Examples: walking, jogging, swimming
126
Q

anaerobic exercise

A
  • high-intensity, short-duration activity results in improved muscle strength, power, and reactivity
  • fuel = glucose-glycogen and phosphagens
127
Q

Canadian Physical Activity Guidelines: 5-17 years old

A
  • 60 minutes of moderate- to vigorous-intensity physical activity every day
  • Vigorous activities at least 3 days per week
  • Activities to strengthen muscles and bones at least 3 days per week
128
Q

Canadian Physical Activity Guidelines: 18-64 years old

A
  • 150 minutes of moderate- to vigorous-intensity physical activity per week – in bouts of 10 minutes or more
  • Muscle and bone strengthening 2 days per week
129
Q

Canadian Physical Activity Guidelines: 65+ years old

A
  • 150 minutes of moderate- to vigorous-intensity physical activity per week – in bouts of 10 minutes or more
  • Muscle and bone strengthening activities 2 days per week
  • Those with mobility issues should include balance training to prevent falls
130
Q

exercise for Osteoarthritis

A
  • Aquatic exercise: improves function, decreases pain
  • Water activities are good exercise alternatives for people with musculoskeletal limitations who need some weight relief with exercise.
131
Q

exercises for rheumatoid arthritis

A
  • Tai chi: may improve lower extremity ROM
  • Aerobic exercise: increases aerobic capacity, muscle strength, joint mobility
  • Postpone exercise during exacerbations
132
Q

exercise prescription (FITT)

A

Frequency
- Aerobic exercise 3−5 times a week
- Resistance training 2−3 times a week
Intensity
- Moderate to rigorous
- Resistance exercise 8−12 repetitions
Time
- 20−60 minutes plus warm-up and cool-down
- 15−30 minutes to complete a series of resistance exercises
Type
- Aerobic
- Resistance training

133
Q

relaxation response

A
  • Inborn set of physiological changes which offset fight-or-flight response (stress response)
  • Physiological changes resulting in a “letting go” of physical, emotional, or mental tension
  • Common techniques to elicit RR: Controlled breathing, meditation, imagery, mindfulness, yoga, repetitive exercise
134
Q

for exercise to be successful the person must:

A

Feel competent doing the activity
Feel confident in overcoming barriers
Feel safe doing the activity
Can access activity on a regular basis
Perceives no negative social or financial cost
Is able to address competing time demands

135
Q

stressor

A

any psychological, social, environmental, physiological, or spiritual stimulus, that disrupts homeostasis, thereby necessitating change or adaptation

136
Q

extrinsic factor

A

no control (e.g., weather, death of spouse)

137
Q

modifiable factor

A

modify through changing their environment, interactions, behaviour

138
Q

intrinsic factor

A

created or exacerbated by individual response to stress (e.g., negative thinking, procrastination

139
Q

burnout consists of 3 things

A

Emotional exhaustion
Depersonalization
Diminished sense of accomplishment

140
Q

cognitive symptoms of stress

A

Trouble thinking clearly
Lack of creativity
Memory loss
Forgetfulness
Inability to make decisions
Thoughts of running away
Constant worry
Loss of sense of humour

141
Q

relational symptoms of stress

A

Isolation
Intolerance
Resentment
Loneliness
Lashing out
Hiding
Clamming up
Lowered sex drive
Nagging
Distrust
Lack of intimacy
Using people

142
Q

stress: primary appraisal

A
  • descriptions of perceived actual and potential positive and negative outcomes
  • Negative outcomes: Harm
  • Positive outcomes: challenges resulting from stressors that an individual perceives can be overcome
143
Q

stress: secondary appraisal

A

-follows primary appraisal. Individual’s identification of choices to cope with stress

144
Q

stress: self awareness

A
  • Recognize signs (muscle tension resulting in backache, headache)
  • Attend to cues to reduce negative mood states (anxiety symptoms) or symptoms (stretching for backache)
  • Recognizing warning signs
  • Nursing role: Assist people to identify stress signals, their response to stress change response (breathing and relaxation), break stress cycle
  • Mindfulness
145
Q

stress: relaxation

A

Two components
- Repetition of a word, thought, or activity
- Passive disregard of everyday thoughts

Mini-relaxations
- can be taught quickly and used throughout the day
- Individuals can be taught to monitor minor stress warning signs (jaw and shoulder tension) and to use a mini-relaxation exercise to keep these initial symptoms of stress from developing into an incapacitating tension headache.
- A mini-relaxation exercise can be anything from a few conscious, deep diaphragmatic breaths to several minutes of sitting quietly

146
Q

Cognitive-behavioural restructuring (4 steps)

A
  • Stop (break the cycle of escalating, negative thoughts).
  • Breathe deeply (elicit the relaxation response and release tension).
  • Reflect (ask “What is going on here? What am I thinking? Is the thought true? Is the thought helpful? Am I jumping to conclusions or magnifying the situation?”).
  • Choose a more realistic, rational response. Try out the alternative response in a future situation
147
Q

integrative health care

A

combines complementary and alternative health care practices with conventional medicine

148
Q

allopathic medicine

A
  • Focus is on identifying and treating disease (symptom & disease).
  • Conventional practice of science-based curative medicine
  • Care by physician or mid-level provider
  • Medications, surgery, and procedures to treat ailments
149
Q

salutogenic medicine

A
  • A new paradigm in health care
  • Incorporates positive psychology to pursue wellness, both mentally and physically.
  • No focus on pathogenesis
  • Goal is preventive health and overall well-being
150
Q

traditional Chinese medicine

A
  • Based on a wide-ranging collection of different philosophies and therapeutics, from acupuncture to demonology
  • multiple herbs and medicines are prescribed together by the practitioner
  • Many herbal TCM remedies do in fact work and, therefore, TCM should not be regarded as a completely supernatural framework
  • Balances yin and yang and the balance and harmony of a vital energy or life forces
151
Q

acupuncture

A
  • Acupuncture involves stimulating these energy points on the body by using needles that penetrate the skin to alleviate pain or to treat various health conditions.
  • Acupuncture points act as valves in meridians
  • Valve opens and closes, corrects imbalance in qi
  • Effective for treating substance abuse, depression, insomnia, nausea and vomiting, pain
152
Q

homeopathy

A
  • Homeopathy is based upon the philosophy of vitalism that interprets diseases and sickness as caused by disturbances in the body’s vital energy or life force.
  • practitioners treat patients by administering small amounts of dilute pathogenic substances believed to cause their symptoms to stimulate the body’s healing abilities
  • Homeopathic remedies are prepared from plants, animals, and minerals
153
Q

naturopathy

A
  • Naturopaths are recognized and regulated.
  • Blends modern scientific knowledge with traditional and natural forms of medicine.
  • Naturopathy supports prevention of disease through healthy living and positive mind–body–spirit strength, to enhance the body’s innate healing properties
  • Practitioners do not use prescription medications, injections, x-rays, or surgery, but instead use a variety of complementary and alternative medicine modalities, emphasizing healthy lifestyle, strengthening and cleansing the body, and noninvasive treatments.
  • The naturopathic philosophy is to stimulate the healing power of the body and treat the underlying cause of disease. Symptoms of disease are seen as warning signals of improper functioning of the body, and unfavourable lifestyle habits
154
Q

Ayurvedic medicine

A
  • Evolved over thousands of years
  • Uses herbs, massage, diet, medications based upon the “seasons of life”
  • The goals of Ayurveda are seen as the treatment of disease, prevention of disease, and improving a person’s quality of life, by balancing the body, mind, and spirit.
  • Belief - good health is achieved when one’s mind and body are in harmony.
155
Q

physical manipulation interventions

A

-chiropractic
-massage
-reflexology

156
Q

chiropractic

A

The theory of chiropractic rests on three theoretical assumptions, in that (1) spinal vertebrae become misplaced, (2) displacement of these vertebrae interferes with nerve action, and (3) manipulating the spine to realign the vertebrae removes the nerve interference, improving the flow of nervous stimulation

157
Q

massage

A
  • involves various techniques to treat body stress or pain through the manipulation of soft tissues by touch
  • Registered massage therapist—professional title that is recognized in Canada
  • Manipulation of muscle and soft tissue
    may be useful to help reduce stress, depression, and anxiety in clients, but other than that, there is no significant evidence that supports its use for other conditions
  • Considered an adjunct (rather than alternative) health promotion therapy
158
Q

reflexology

A
  • A reflexologist applies pressure with the thumbs to mapped points on the feet, hands, or both, by pressing deeply into the point to release tension and stimulate circulation of blood, lymph, and energy.
  • Reflexology is more than massage because practitioners believe that the points correspond to the organs of the body and that stimulating the points will stimulate the organs to heal.
159
Q

aromatherapy

A
  • Uses naturally extracted oils from plants to balance, harmonize, and promote the health of body, mind, and spirit.
  • The therapeutic use of the oils may be via inhalation, external application, or ingestion.
  • There is some evidence that it may be effective for combating postoperative nausea and vomiting
160
Q

movement based interventions

A

-Qigong
-Tai chi
-Yoga
-Dance

161
Q

Qigong

A

Qigong is combining relaxed movements with a meditative aspect and controlled breathing.

162
Q

tai chi

A
  • Combined physical movement, breath control, meditation
  • Sequence of poses flows in an unbroken rhythm to balance energy flow
  • Brings awareness of moment-to-moment state of body
  • Produces meditative state
163
Q

mind body interventions

A

-meditation
-mindfulness

164
Q

guided imagery

A
  • Focuses on calming thoughts or experiences
  • Promotes sense of well-being, relaxation
  • Visual or guided imagery encourages clients to relax by focusing on calming thoughts or experiences. Imagery is “a gentle but powerful technique that focuses and directs the imagination” in order to, among other things, promote a sense of well-being and to help people relax
165
Q

human energy field therapy

A
  • therapeutic touch
  • reiki
  • magnetic field therapy
166
Q

therapeutic touch

A
  • One of the goals of therapeutic touch is to reduce blockages
  • Human energy fields interact with environmental energy fields.
  • Involves no physical contact.
  • There is weak to no evidence for its efficacy.
167
Q

reiki

A
  • Universal energy of ki
  • A form of massage but rather a form of touch therapy intended to balance human energy. The therapist may not even touch the care recipient
  • Japanese Buddhist origin
  • No empirical evidence exists for its efficacy.
168
Q

touch therapy

A
  • In touch therapies such as therapeutic touch, healing touch, and reiki, among others, practitioners use their hands to direct life energies drawn from the environment to the individual in an effort to restore balance and harmony within the human energy system. During these therapies, the hands can be placed directly on the person’s body or at a distance from the body.
  • Touch therapy does not involve massage: either shiatsu, deep massage, or any other form of massage. In some forms of touch therapy, the therapist’s hands are placed on the care recipient’s body. With other forms of touch therapy, the therapist holds the hands near the care recipient’s body but does not actually touch the care recipient.

Nurs 2212 (2 decks)

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