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exam 2 Flashcards

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1
Q

superficial pain, usually involves the skin or subcutaneous tissue

A

cutaneous pain

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2
Q

severe pain that resistant to relief measures – cancer, spinal cord injury

A

intractable pain

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3
Q

pain that involves nerves, peripheral nerves, legs and lower extremities, spinal cord injuries, shingles, diabetic neuropathy

A

neuropathic pain

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4
Q

poorly located, originating in body organs

A

visceral pain

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5
Q

tendons, ligaments, bone, sprains

A

somatic

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6
Q

perception of pain - involves peripheral and CNS

A

noxious stimuli

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7
Q

free nerve endings, respond to painful stimuli

A

nociceptors

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8
Q

neurologic transmission of pain impulses

A

nociception

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9
Q

chemicals that reduce/inhibit transmission/perception of pain – morphine like neurotransmitters

A

endorphins, enkephalins, dynorphins

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10
Q

ncreased  metabolic rate, insulin response, risk of physiological disorders.
 Pain can be harmful to patients whose health is already compromised by age, injury, or illness
 Effective pain relief results in faster recovery and improved outcomes

A

effects of pain on patient

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11
Q

 Intensity  pain scale (none, mild, severe)
 Influenced by pain threshold, and pain tolerance
 Location of pain
 Quality – words to describe the pain
 Nurses Role  assess past history and what analgesics have worked, provide education, relive pain with interventions, assess effectiveness of interventions, monitor for adverse effects, be an advocate for patient when interventions are ineffective

A

nurse assess pain the her role

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12
Q 
opioid analgesic agents
Morphine
	Oxycodone
	Meperidine (Demerol)
	Tramadol (Ultram)
	Codeine
	Propoxyphene (Darvan)
	Hydrocodone (Vicodin)
A

side effects

respiratory depression and sedation, N&V, constipation, pruritus (severe itching) , urinary retention

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13
Q

maximum pain the person can tolerate

A

tolerance

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14
Q

smallest stimulus a person can take before reporting pain

A

threshold

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15
Q

 Use of more than one form of analgesia concurrently to obstain more pain relief w/ fewer side effects

A

balanced analgesia

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16
Q

medications that can be used to supplement an opioid medication in pain management

A

NSAID
• Ibuprofen (Advil, Motrin), Celecoxib (Celebrex)
• NSAIDs use w/ Opioids (not taken together, but at fixed times) may be effective in managing moderate to severe cancer pain. NSAIDs may cause bruising, stomach irritation and GI bleeding
ANTIDEPRESSANT/ANTISEIZURE
• Used for neuralgia paint (intense burning or cutting type pain)
• Does are smaller than generally used for depression and seizures
• Amitriptyline (Elavil), Imipramine (Toframil) – antidepressants
• Phenytoin (Dilantin) carbamazepine (tegretol) antiseizure meds

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17
Q

 Numeric Pain Intensity Scale (0 no pain, 5 moderate pain, 10 worst possible pain)
 Simple Descriptive Pain Scale – (no pain, mild, moderate, severe, very severe, worst possible)
 Visual Analogues Scale

A

uses of a pain scale

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18
Q

who is at risk for skin integrity issues - why?

A 
	Very thin or very obese
	Fluid loss through fever, dehydration, diarrhea
	Excessive perspiration
	Jaundice (itching, dry)
	Diseases of skin (eczema, psoriasis) 
	Poor nutrition/hydration
	Problems with circulation
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19
Q

interventions for age related skin problems

A

 Try not to use tape to skin
 Check skin frequently for breakdown – skin assessments
 Pad bony prominences if needed
 No need for full bath daily; apply lotions
 Push fluids for hydration

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20
Q

Wound with a localized tissue necrosis
 Majority in older adults b/c of aging skin, chronis illnesses, immobility, malnutrition, fecal and urinary incontinence
 Spinal cord injuries, traumatic brain injuries, neuromuscular disorders
 Back of head, shoulder, base of spine, butt, heel, toes, hip, inner knee, ankle, elbow

A

pressure ulcer

areas that are prone to one

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21
Q

intact skin with nonblanchable redness (does not turn white when pressed)

A

stage 1 pressure ulcer

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22
Q

Partial thickness loss, shallow open ulcer with red pink wound bed, intact, open/rupture or intact fluid filled blister

A

stage 2 pressure ulcer

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23
Q

Full thickness tissue loss, subcutaneous tissue may be visible

A

stage 3 pressure ulcer

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24
Q

Full thickness with exposed bone, tendon or muscle

A

stage 4 pressure ulcer

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25
Q

unable to determine the depth, may have necrotic tissue

A

unstageable pressure ulcer

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26
Q

 Predicting pressures sore risk

A

braden scale

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27
Q

edges well approximated  surgical wounds w/ sutured edges

A

primary wound healing

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28
Q

edges are not approximated.  burns, large open wounds from trauma, take longer to heal, more scar tissue

A

secondary wound healing

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29
Q

those wounds left open due to infection, packed wounds

A

tertiary wound healing

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30
Q

exudate

A

hemorrhag

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31
Q

separation or splitting open layers of surgical wound

A

dehiscence

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32
Q

extrusion of viscera or intestine through a surgical wound

wound or organs coming out

A

evisceration

33
Q

fistula formation

A

abnormal

34
Q

clear and watery

A

serous drainage

35
Q

consists of RBC’s and blood

A

sanguineous drainage

36
Q

light pink to blood tinged

A

serosanguineous

37
Q

WBC, thick and foul odor

can be dark yellow or green

A

purulent drainage

38
Q

types of drains

A
  1. penrose
  2. hemovac
  3. JP
  4. t-tube
39
Q

take off dead tissue

A

debridment

40
Q

necrotic black tissue

A

eschar

41
Q

inadequate blood supply to organ or body

A

ischemia

42
Q

regulates ECF, maintain blood volume, transmit nerve impulse and contract muscles. 135-145 mEq/L

A

sodium

135-145 mEq/L

43
Q

8.5-10.5 mEq/L 99% is in bones, 1% in ECF – most abundant electrolyte. Forms bones/teeth, transmit nerve impulses, regulating muscle contractions, maintaining cardiac pacemaker

A

calcium

8.5-10.5

44
Q

1.3 – 2.1 mEq/L – intracellular metabolism, sodium potassium pump, relax muscle contractions, transmit nerve impulses

A

magnesium

1.3-2.1

45
Q

transmits nerve and other chemical impulses, regulates cardiac and muscle contraction. 3.5-5mEq/L

A

potassium

3.5-5

46
Q

molecules from higher to lower concentration

A

diffusion

47
Q

requires energy to move substances call pump mechanism

A

active transport

48
Q

dehydration, hypovolemia, decreased intake, third spacing

A

fluid volume deficit

49
Q

hypervolemia, edema, excessive sodium intake

A

fluid volume excess

50
Q

assessment of fluid electrolyte imbalance

A 
	Skin turgor
	Tongue
	Moisture and oral cavities
	Tearing and salvation
	Facial appearance
	Edema 
	Body temp
	Pulse (tachycardia = loss of fluid)
	Lung sounds (moist crackles – excess)
	Blood pressure (falls in fluid volume decrease)
51
Q

converted to glucose and put into blood stream to use for energy
 Protein – formation of all body structures

A

carb

52
Q

formation of all body structure

A

protein

53
Q

cholesterol, absorption of vitamins, insulation, temperature control

A

lipids/fats

54
Q

aides in digestion, absorption, circulation and excretion, regulates body temp, mucous secretions, movement of joints

A

water

55
Q

metabolism of carbs, proteins and fats

A

vitamins

56
Q

contract muscles, bone formation, nerve impulses, metabolism

A

minerals

57
Q

most important – pg 1206

o Calcium, phosphorus, magnesium, sulfur, sodium, potassium, chloride

A

macrominerals

58
Q

C and B vitamins
• C – collagen formation, antioxidant, enhances iron absorption
• B - produce energy, metabolism of carbs, protein, and fats,

A

water soluble

59
Q

A, D, E, K
• K  synthesis of certain proteins necessary for blood clotting
• A – visual activity in dim light, mucous membranes formation, immune function
• D – calcium and phosphorus metabolism, stimulates calcium absorption
• E – antioxidant, protects vitamin A, heme synthesis

A

fat soluble

60
Q

BMI

A

 >30 is obese

61
Q

science-based strategies – guidelines provide advice to promote health and reduce risk for major chronic diseases through diet and physical activity

A

dietary guidelines for americans

62
Q

clear, full, soft, pureed, mechanical diet

A

 Clear – see through liquids only
 Full – regular diet
 Soft – only soft food
 Pureed  all food must be pureed (in blender) – consistency of thick pudding
 Mechanical  can be blended, pureed, ground, or finely chopped

63
Q

NPO

A

nothing by mouth

64
Q

Feeding tube, can deliver total or supplemental nutrition

A

enteral nutrition

65
Q

types of feeding tubes

A

• Nasogastric tube (NG) – through nose into stomach
• Dabhoff (smaller diameter than NG) though nose into stomach
• Nasointestinal (NI) – through nose, into upper small intestine
All SHORT term interventions

66
Q

 PEG – percutaneous endoscopic gastrostomy tube
 J tub – directly into jejunum
 Both directly into stomach
 Both LONG term interventions

A

PED and J tube

67
Q

 X-ray to see placement is correct
 Measure tub length and mark – to make sure tube doesn’t move
 Take precautions to prevent infections
 Make sure all medications are crushed and liquefied

A

complications of enteral feeding

68
Q

 Elevated levels of glucose
 Effects eyes, kidney, heart, neuro, muscular skeletal
 Pancreas – secretes insulin, produces insulin, controls insulin/blood glucose. Insulin secreted by beta cells. Uses potassium (so lowers potassium) super high potassium level - can treat w/ insulin.
 Pancreas stops produces insulin  glucagon (alpha cells) and stimulates liver to release stored glucose which increases blood sugar. Liver stores it as glycogen and breaks it down to give off sugar.

A

patho of type 1 and type 2

69
Q

function of insulin

A

decrease serum potassium

70
Q

alpha cells make…

A

glucagon

71
Q

signs of type 1

A

 Three P’s  polyuria, polydipsia, polyphagia -> urination, thirst, hunger

72
Q 
	Family history
	Obese/overweight   BMI over 25
	Ethnicity  native Americans
	Over 45
	Previous impaired glucose tolerance
	Hypertension
	High HDL cholesterol, high triglycerides
	History of gestational diabetes or delivery of baby of 9 pounds
A

risks for type 2

73
Q

 Reflects average blood glucose levels over 2-3 months
 Normal 4-6%
 Used to diagnose diabetes, and check balance for diabetic patients

A

Hgb A1C and normal value

74
Q

Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) – onset 15 minutes, peak 1 hour, duration 3-5 hours

A

rapid acting insulin

75
Q

Regular (Humulin –R) (Novolin – R) Onset 30-60 minutes, peak 2-3 hours, duration 4-6 hours

A

short acting insulin

76
Q

NPH (Humulin N) (Novolin N) Onset 2-4 hours, peak 6-8 hours, duration 12-16 hours

A

intermediate acting insulin

77
Q

Glargine (Lantus) Detemir (levemir) Onset 2 hours. Absorbed very slowly do not have peak time of effect

A

long acting insulin

78
Q

signs and symptoms of hypoglycermia

A

 Shakiness, sweating, confusion, tremors, hunger, weakness
 Causes – too much insulin, exercise, not enough food
 Treat: 15gm carbs – then follow with snack of starch and protein

nursing 101 (4 decks)

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