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NUR 204 Fundamentals > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

presbyopia

A

age-related loss of the eyes ability to focus on close objects due to decreased elasticity of the lens

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2
Q

cataracts

A

opacity of the lens which blocks the entry of light rays into the eye

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3
Q

glaucoma

A

structural eye disorder which causes an increase in intraocular pressure, can lead to blindness

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4
Q

diabetic retinopathy

A

leakage and blockage of retinal blood vessels, can lead to retinal hypoxia, retinal hemorrhages, blindness

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5
Q

macular degeneration

A

loss of central vision from deterioration of the center of the retina

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6
Q

conductive hearing loss

A

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
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7
Q

sensorineural hearing loss

A

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
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8
Q

mixed hearing loss

A

combination of conductive and sensorineural hearing loss

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9
Q

risk factors of hearing loss

A 
advancing age, ototoxic meds 
- antibiotics- gentamicin, metronidazole
diuretics- furosemide
-NSAIDS- aspirin, ibuprofen
Chemotherapeutic agents- cisplatin
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10
Q

caring for a client with aphasia(loss of ability to understand or express speech)

A
  • make sure only 1 person speaks at a time
  • allow plenty of time for pt to respond
  • use brief sentences with simple words
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11
Q

stages of wound healing

A

inflammatory
proliferative
maturation/remodeling

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12
Q

inflammatory stage of healing

A
  • begins with injury

- lasts 3 to 6 days

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13
Q

proliferative stage of wound healing

A

-lasts next 3 to 24 days
-replacing lost tissue with connective or granulated tissue and collagen
- contracting wounds edges
resurfacing new epithelial cells

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14
Q

maturation/remodeling stage of wound healing

A
  • 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
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15
Q

serous drainage

A

portion of the blood that is watery and clear or slightly yellow
-EX: fluid in blisters

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16
Q

sanguineous drainage

A
  • contains serum and red blood cells

- thick and reddish

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17
Q

serosanguineous drainage

A
  • contains both serum and blood
  • watery
  • pale and pink
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18
Q

purulent drainage

A
  • result of infection
  • thick and contains white blood cells, tissue debris, bacteria
  • may have foul odor
  • yellow, tan, green, brown
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19
Q

purosanguineous drainage

A

mixed drainage of pus and blood = newly infected

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20
Q

nursing interventions for wounds

A
  • 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
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21
Q

woven gauze (sponges)

A

absorbs exudate from the wound

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22
Q

nonadherent dressing (Telfa)

A

does not stick to wound bed

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23
Q

damp to damp dressing

A

mechnically debride a wound until granulation tissue starts to form in the wound bed
-must be kept moist at all times

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24
Q

self adhesive, transparent film (tegaderm)

A

temporary “second skin”

-for small superficial wounds

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25
Q

hydrocolloid dressing

A
  • 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
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26
Q

hydrogel dressing

A
  • 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
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27
Q

alginate dressing

A
  • nonadherent
  • conform to the wounds shape and absorb exudate
  • provides moist wound bed
  • packs wounds
  • supports debridement
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28
Q

collagen dressing

A
  • powders
  • pastes
  • granules
  • sheets
  • gels
  • pastes
  • helps stop bleeding and promotes healing
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29
Q

stage 1 pressure injury treatment

A
  • relieve pressure
  • frequent turning
  • pressure relieving devices
  • keep dry, clean, well nourished and hydrated
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30
Q

stage 2 pressure injury treatment

A
  • moist healing environment = saline or occlusive dressing= HYDROCOLLOID DRESSING)
  • nutritional supplements
  • analgesics
31
Q

stage 3 pressure injury treatments

A
  • clean/debride
  • nutritional supplements
  • analgesics
  • antimicrobials
32
Q

stage 4 pressure injury treatment

A

-clean/debride
-nonadherent dressing changes every 12 hr.
rest same as 3.

33
Q

indications for NG tube

A
  • 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
34
Q

enteral feedings

A

provide nutrients to clients who cannot consume foods orally but whose GI tract is functioning

35
Q

Standard (polymeric) enteral formula

A
  • milk based products
  • blenderized foods
  • whole nutrient formulas
36
Q

modular enteral formulas

A
  • single macronutrient preperation
  • not nutritionally complete
  • supplement to other foods
37
Q

elemental enteral formulas

A
  • predigested nutrients
  • not nutritionally complete
  • easier for a partially dysfunctional GI tract to absorb
38
Q

Specialty enteral formulas

A
  • meeting specific nutritional needs
  • not nutritionally complete
  • for clients who have hepatic failure, respiratory disease, HIV
39
Q

types of enteral tubes

A 
-Nasogastric or nasointestinal
       short term, inserted via nose
-gastrostomy or jejunostomy
       longer than 6 weeks
       inserted surgically
-percutaneous endoscopic gastrostomy or jejunostomy
40
Q

Sodium Lab Values

A

136-145

41
Q

Potassium Lab Values

A

3.5-5

42
Q

Calcium Lab Values

A

9-10.5

43
Q

Chloride lab values

A

98-106

44
Q

magnesium lab values

A

1.8-2.6

45
Q

phosphate lab values

A

3-4.5

46
Q

carbon dioxide lab values

A

23-30

47
Q

Glucose lab values

A

74-106

48
Q

BUN lab values

A

10-20

49
Q

Creatinine lab values

A

(female) 0.5-1.1

(male) 0.6-1.2

50
Q

GFR lab values

A

> 90

51
Q

WBC lab values

A

5-10

52
Q

RBC lab values

A

(female) 4.2-5.4

(male) 4.7-6.1

53
Q

hemoglobin lab values (Hmg)

A 
F = 12-16
M = 14-18
54
Q

hematocrit lab values (hct)

A

f= 37-47%

m=42-52%

55
Q

platelets lab values

A

150-400 10^3

56
Q

pH lab value

A

7.35-7.45

57
Q

Albumin lab value

A

3.5-5

58
Q

preallbumin lab value

A

15-36

59
Q

cholesterol lab value

A

<200

60
Q

triglycerides lab value

A

f=35-135

m=40-160

61
Q

Prothrombin time lab value (PT

A

11-12.5 seconds

62
Q

INR(no anticoagulation)

A

0.8-1.1

63
Q

INR(afib, dvt, PE)

A

2-3

64
Q

INR(prosthetic heart valve)

A

3-4

65
Q

aPTT

A

30-40 seconds

66
Q

types of cells found in blood

A

erythrocytes
thrombocytes
leukocytes

67
Q

RBC

A

oxygen and CO2 carrier

actual count of red corpuscles

68
Q

HDL:LDL

A

3:1
HDL=good cholesterol
LDL=bad cholesterol

69
Q

hemoglobin

A

direct meausre of oxygen carrying capacity of the blood
decrease=anemia
increase=hemoconcentration, polycythemia

70
Q

hematocrit

A

-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

71
Q

mean cell volume (MCV)

A

=hct/RBC
Large cells= macrocytic=b-12 or folate deficiency
small cells= microcytic= iron deficiency

72
Q

Hypokalemia

A
  • 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

73
Q

hyperkalemia

A

-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

NUR 204 Fundamentals (2 decks)

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