Exam 2 Flashcards
presbyopia
age-related loss of the eyes ability to focus on close objects due to decreased elasticity of the lens
cataracts
opacity of the lens which blocks the entry of light rays into the eye
glaucoma
structural eye disorder which causes an increase in intraocular pressure, can lead to blindness
diabetic retinopathy
leakage and blockage of retinal blood vessels, can lead to retinal hypoxia, retinal hemorrhages, blindness
macular degeneration
loss of central vision from deterioration of the center of the retina
conductive hearing loss
alteration in the middle ear that blocks sound waves before they reach the cochlea of the inner ear
- hears better in noisy environment
- speaks softly
- obstruction in external canal(packed cerumen)
- holes, scarring in tympanic membrane
sensorineural hearing loss
alteration in the inner ear, auditory nerve, or hearing center of the brain
- tinnitus
- dizziness
- speaks loudly
- no otoscopic findings
- weber test lateralizing to other ear
mixed hearing loss
combination of conductive and sensorineural hearing loss
risk factors of hearing loss
advancing age, ototoxic meds - antibiotics- gentamicin, metronidazole diuretics- furosemide -NSAIDS- aspirin, ibuprofen Chemotherapeutic agents- cisplatin
caring for a client with aphasia(loss of ability to understand or express speech)
- make sure only 1 person speaks at a time
- allow plenty of time for pt to respond
- use brief sentences with simple words
stages of wound healing
inflammatory
proliferative
maturation/remodeling
inflammatory stage of healing
- begins with injury
- lasts 3 to 6 days
proliferative stage of wound healing
-lasts next 3 to 24 days
-replacing lost tissue with connective or granulated tissue and collagen
- contracting wounds edges
resurfacing new epithelial cells
maturation/remodeling stage of wound healing
- occurs on or about day 21
- strengthening of the collagen scar
- restoration of a more normal appearance
- can take more than 1 year to complete
serous drainage
portion of the blood that is watery and clear or slightly yellow
-EX: fluid in blisters
sanguineous drainage
- contains serum and red blood cells
- thick and reddish
serosanguineous drainage
- contains both serum and blood
- watery
- pale and pink
purulent drainage
- result of infection
- thick and contains white blood cells, tissue debris, bacteria
- may have foul odor
- yellow, tan, green, brown
purosanguineous drainage
mixed drainage of pus and blood = newly infected
nursing interventions for wounds
- provide hydration
- meet protein and calorie needs
- perform wound cleaning and irrigation
- administer analgesics and monitor for effective pain management
- administer antimicrobials
- document location and type of wound, status, type of drainage, type of dressing and materials, client teaching, how client tolerated procedure
woven gauze (sponges)
absorbs exudate from the wound
nonadherent dressing (Telfa)
does not stick to wound bed
damp to damp dressing
mechnically debride a wound until granulation tissue starts to form in the wound bed
-must be kept moist at all times
self adhesive, transparent film (tegaderm)
temporary “second skin”
-for small superficial wounds
hydrocolloid dressing
- occlusive dressing that swells in presence of exudate
- composed of gelatin and pectin
- forms a seal at the wounds surface to prevent evaporation moisture from skin
- can stay in place 3 to 5 days
hydrogel dressing
- mostly water
- gels after contact with exudate
- promotes autolytic debridement and cooling
- rehydrates and fills dead space
- for infected deep wounds, necrotic tissue
- not for heavy draining wounds
- provides moist wound bed
alginate dressing
- nonadherent
- conform to the wounds shape and absorb exudate
- provides moist wound bed
- packs wounds
- supports debridement
collagen dressing
- powders
- pastes
- granules
- sheets
- gels
- pastes
- helps stop bleeding and promotes healing
stage 1 pressure injury treatment
- relieve pressure
- frequent turning
- pressure relieving devices
- keep dry, clean, well nourished and hydrated
stage 2 pressure injury treatment
- moist healing environment = saline or occlusive dressing= HYDROCOLLOID DRESSING)
- nutritional supplements
- analgesics
stage 3 pressure injury treatments
- clean/debride
- nutritional supplements
- analgesics
- antimicrobials
stage 4 pressure injury treatment
-clean/debride
-nonadherent dressing changes every 12 hr.
rest same as 3.
indications for NG tube
- decompression= removal of gas or stomach contents to prevent or relieve distention, nausea, vomiting
- feeding
- lavage= washing out stomach to treat active bleeding, ingestion of poison
- compression= internal balloon to apply pressure for preventing GI or esophageal hemorrhage
enteral feedings
provide nutrients to clients who cannot consume foods orally but whose GI tract is functioning
Standard (polymeric) enteral formula
- milk based products
- blenderized foods
- whole nutrient formulas
modular enteral formulas
- single macronutrient preperation
- not nutritionally complete
- supplement to other foods
elemental enteral formulas
- predigested nutrients
- not nutritionally complete
- easier for a partially dysfunctional GI tract to absorb
Specialty enteral formulas
- meeting specific nutritional needs
- not nutritionally complete
- for clients who have hepatic failure, respiratory disease, HIV
types of enteral tubes
-Nasogastric or nasointestinal
short term, inserted via nose
-gastrostomy or jejunostomy
longer than 6 weeks
inserted surgically
-percutaneous endoscopic gastrostomy or jejunostomySodium Lab Values
136-145
Potassium Lab Values
3.5-5
Calcium Lab Values
9-10.5
Chloride lab values
98-106
magnesium lab values
1.8-2.6
phosphate lab values
3-4.5
carbon dioxide lab values
23-30
Glucose lab values
74-106
BUN lab values
10-20
Creatinine lab values
(female) 0.5-1.1
(male) 0.6-1.2
GFR lab values
> 90
WBC lab values
5-10
RBC lab values
(female) 4.2-5.4
(male) 4.7-6.1
hemoglobin lab values (Hmg)
F = 12-16 M = 14-18
hematocrit lab values (hct)
f= 37-47%
m=42-52%
platelets lab values
150-400 10^3
pH lab value
7.35-7.45
Albumin lab value
3.5-5
preallbumin lab value
15-36
cholesterol lab value
<200
triglycerides lab value
f=35-135
m=40-160
Prothrombin time lab value (PT
11-12.5 seconds
INR(no anticoagulation)
0.8-1.1
INR(afib, dvt, PE)
2-3
INR(prosthetic heart valve)
3-4
aPTT
30-40 seconds
types of cells found in blood
erythrocytes
thrombocytes
leukocytes
RBC
oxygen and CO2 carrier
actual count of red corpuscles
HDL:LDL
3:1
HDL=good cholesterol
LDL=bad cholesterol
hemoglobin
direct meausre of oxygen carrying capacity of the blood
decrease=anemia
increase=hemoconcentration, polycythemia
hematocrit
-packed cell volume
-% of blood that is composed of erythoctytes
=RBC x MCV
low= anemics or after acute heavy bleeding
high= pt has thick and sludgy blood
mean cell volume (MCV)
=hct/RBC
Large cells= macrocytic=b-12 or folate deficiency
small cells= microcytic= iron deficiency
Hypokalemia
- true depletion of K
- decreased intake( bulimia, alcholism)
- increased output (vomiting, diarrhea, laxative)
- increased renal output( steroids, diruretics, cushings syndrome)
Symptoms = hypotension, rhythm disturbances, decreased aldosterone release, decreased insulin release, cramps, weakness
hyperkalemia
-excess of K
-increased intake(salt subs, drugs)
endogenous(rhabdomyolysis, hemolysis, muscle crush injuries, burns)
decreased output (renal failure, NSAIDS, ACE, Heparin
symptoms = cardiac rhythm distrubances, bradycardia, hypotension, cardiac arrest, severe muscle weakness
