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Nursing 161; Fall 2013 > Exam 3- Tissue Integrity > Flashcards

Exam 3- Tissue Integrity Flashcards

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1
Q

Integumentary:

Initial reaction to a problem that alters one of the structural components of the skin

A

Primary

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2
Q

Integumentary:
Changes in the appearance of the primary lesion with progression of an underlying disease or in response to a topical or systemic therapeutic intervention

A

Secondary

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3
Q

Integumentary:

Related to blood vessel integrity

A

Vascular

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4
Q

Protects tissues from physical, chemical & biologic damage. Prevents water loss, serves as a water-repellent layer. Stores melanin, converts cholesterol to vitamin D when exposed to sunlight. Contains phagocytes, which prevent bacteria from penetrating skin.

A

Epidermis

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5
Q

Regulates body temp. by dilating & constricting capillaries.Transmits messages via nerve endings to CNS.

A

Dermis

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6
Q

Secretes sebum, which lubricates skin & hair & plays role in killing bacteria.

A

Sebaceous (oil) glands

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7
Q

Regulate body heat by excretion of perspiration.

A

Eccrine sweat glands.

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8
Q

Remnants of sexual scent gland

A

Apocrine sweat glands.

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9
Q

A reddening of the skin. May occur during fever, hypertension, inflammation. May also result from sunburns, drug reactions, acne rosacea etc.

A

Erythema

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10
Q

A bluish discoloration of the skin and mucous membranes.

A

Cyanosis

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11
Q

Why does cyanosis occur?

A

Results from poor oxygenation of hemoglobin.

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12
Q

Paleness of skin, may occur with shock, anger, fear, anemia & hypoxia.

A

Pallor

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13
Q

An abnormal loss of melanin in patches. Typically occurs over the face, hands or groin.

A

Vitiligo

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14
Q

Appears as patches of pale, itchy wheals in an erythematous area.

A

Urticaria (hives)

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15
Q

Raised bluish or yellowish vascular lesions.

A

Bruises (Ecchymosis)

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16
Q

An accumulation of fluid in the body’s tissues.

A

Edema

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17
Q

How is edema graded?

A

Depress patient’s skin.
1+ Slight pitting - no obvious distortion
2+ Deeper pit, no obvious distortion
3+ Pit is obvious; extremities are swollen
4+ Pit remains with obvious distortion

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18
Q

When/why is edema commonly found? (think health reasons, not time of day) (5)

A
  • Cardiovascular
  • Renal failure
  • Trauma
  • Cirrhosis of liver
  • Side effect of drugs
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19
Q

Hair loss - may be related to hormones, chemical or drug treatments (radiation).

A

Alopecia

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20
Q

Flat, nonpalpable change in skin color. Usually a circumscribed border. Smaller than 1 cm.
Ex. freckles, measles, petechiae.

A

Macule

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21
Q

Flat, nonpalpable change in skin color. May have irregular border. Larger than 1 cm.
Ex. Mongolian spots, port-wine stain, vitiligo.

A

Patch

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22
Q

Elevated, fluid-filled, round or oval shaped, palpable mass with thin translucent walls & circumscribed borders. SMALLER than 0.5cm.
Ex. herpes, early chickenpox, poison ivy.

A

Vesicles

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23
Q

Elevated, fluid-filled, round or oval shaped, palpable mass with thin translucent walls & circumscribed borders. LARGER than 0.5cm.
Ex. Contact dermatitis, friction blisters, large burn blisters.

A

Bulla

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24
Q

Elevated solid, palpable mass with circumscribed border. SMALLER than 0.5 cm.
Ex. Elevated moles, warts.

A

Papule

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25
Q

Elevated solid, palpable mass with circumscribed border. LARGER than 0.5 cm.
Ex. Psoriasis, actinic keratosis.

A

Plaque

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26
Q

Elevated, often reddish area with irregular border caused by diffuse fluid in tissues rather than free fluid in a cavity. Size varies.
Ex. insect bites, hives.

A

Wheals.

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27
Q

Elevated, solid, hard or soft palpable mass extending deeper into the dermis than a papule. Measure 0.5 to 2 cm.
Ex. small lipoma, intradermal nevi, fibroma.

A

Nodule

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28
Q

Elevated, solid, hard or soft palpable mass extending deeper into the dermis than a papule. Measures LARGER than 2 cm.
Ex. Large lipoma, hemangioma, carcinoma.

A

Tumor

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29
Q

Elevated, pus-filled vesicle or bulla with circumscribed border. Size varies.
Ex. Acne, impetigo, carbuncles.

A

Pustule

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30
Q

Elevated, encapsulated, fluid-filled or semisolid mass originating from the sub-q tissue or dermis, usually larger than 1 cm.
Ex. sebaceous cyst, epidermoid cyst.

A

Cyst.

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31
Q

Translucent, dry, paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen & elastin.
Ex. Striae, aged skin

A

Atrophy

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32
Q

Deep, irregularly shaped area of skin loss extending into the dermis or sub-q tissue. May bleed.

A

Ulcer

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33
Q

Wearing away of the superficial epidermis causing a moist, shallow depression.
Ex. scratch marks, ruptured vesicles.

A

Erosion

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34
Q

Linear crack with sharp edges, extending into the dermis.

Ex. cracks at corner of mouth, on hands.

A

Fissure

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35
Q

Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing.

A

Lichenification

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36
Q

Flat, irregular area of connective tissue left after a lesion or wound has healed.

A

Scar

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37
Q

Shedding flakes of greasy, keratinized skjn tissue.

Ex. dandruff, dry skin, psoriasis, eczema.

A

Scales

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38
Q

Elevated, irregular, darkened area of excess scar tissue caused by collagen formation during healing. Extends beyond the site of the original injury.

A

Keloid

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39
Q

Dry blood, serum, or pus left on the skin surface when vesicles or pustules burst.

A

Crust

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40
Q

Benign vascular tumors, come in different forms. Ex. Port wine stain.

A

Angioma

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41
Q

Raised, reddened round circumscribed plaques covered by silvery white scales.

A

Psoriasis

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42
Q

Epidermal skin lesion directly related to chronic sun exposure & photodamage.

A

Actinic keratosis - AKA senile or solar keratosis.

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43
Q

Physical Assessment of Integumentary Includes:

A

Skin, Hair, Nails

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44
Q

Assessing the skin:

A

Inspect: Moisture, Vascular changes/markings, Skin Integrity, Hygiene

Palpate: Lesions, Moisture, Temperature, Texture, Turgor

Document lesions: Color, Size, Location, Shape, Texture, Distribution, Drainage, Related findings.

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45
Q

premalignant skin changes related to sun exposure and chronic skin changes

A

Actinic Keratosis

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46
Q

Most common type of skin cancer but least aggressive, appears on sun-exposed areas of body and incidence increases with age

A

Basal Cell Carcinomas

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47
Q
  • Malignant proliferation of the epidermis, may occur on sun-damaged skin or normal skin
  • Can metastasize by blood or lymphatic system, so need to evaluate lymph nodes
  • Typically appears as rough, thickened, scaly tumor, common sites are head and face, and upper extremities, may also be nodular
  • Treatment – excision, cryosurgery, radiotherapy
A

Squamous Cell carcinoma

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48
Q

cancerous neoplasm arising from melanocytes, 10 times more likely in fair-skinned individuals, can originate anywhere there is pigment, but 1/3 originate in existing nevi

A

Malignant Melanoma

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49
Q

Usually > than 6 mm in diameter, are asymmetric, develop within the epidermis over a long period of time ( in-situ)
When they penetrate the dermis  can metastasize

A

Malignant Melanoma

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50
Q

ABCD (and E)rule for assessing suspicious nevi

A

A – asymmetry (one half of the nevi does not match the other half of the nevi)
B – border irregularity (edges are ragged, blurred, or notched)
C – color variation or dark black color
D – diameter greater than pencil eraser (6 mm)
E – evolving (change in size, shape, color, etc)

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51
Q

The immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psychospiritual, social and environmental); much more than the absence of pain

A

Comfort

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52
Q

Subjective Comfort

A

Must understand normal for that client. Client’s expression of contentment & ease.

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53
Q

Objective Comfort

A

Neurological, medical functions, processes typically associated with comfort. Nurse may note vital signs in normal range, calmness in facial expressions.

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54
Q
  • The fifth vital sign.
  • Unpleasant sensory, emotional experience
  • Associated with actual or potential tissue damage
  • Described in terms of damage
  • Plays protective role
  • Relief of pain is a client right
A

Pain

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55
Q

The most common reason for seeking health care?

A

Pain

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56
Q

“Whatever the person experiencing it says it is, and existing whenever the person says it does.”

A

Pain

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57
Q

4 ways to describe pain:

A

1-location
2-intensity
3-etiology
4-duration

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58
Q

Duration of pain

A

Establishes difference between acute and chronic pain.

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59
Q

What is used to measure intensity of pain?

A

A 0-10 pain scale.

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60
Q

Pain scale range:
1-3=
4-6=
7-10=

A 
1-3= mild pain
4-6= moderate pain
7-10= severe pain
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61
Q

Prolonged pain that is constant or recurring for longer than 6 months. May be mild to severe, involves parasympathetic nervous system response.

A

Chronic pain

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62
Q

Pain that lasts only through the expected recovery period. May be mild to severe, has sympathetic nervous system response.

A

Acute pain

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63
Q

Pain that may result from direct effects of treatment of this disease…

A

Cancer pain.

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64
Q

Lack of energy and motivation that may/may not be accompanied by drowsiness

A

Fatigue

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65
Q

Common causes of fatigue

A
  • anemia
  • sleep disorders
  • depression or grief
  • pregnancy
  • respiratory disorders
  • hypothyroidism
  • use of alcohol or drugs
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66
Q

Chronic disorder characterized by widespread musculoskeletal pain, fatigue & multiple tender points.

A

Fibromyalgia

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67
Q

Insomnia

A

inability to fall asleep or remain asleep.

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68
Q

Hypersomnia

A

cannot stay awake during the day.

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69
Q

Narcolepsy

A

sleep attacks or excessive daytime sleepiness.

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70
Q

Sleep apnea

A

frequent short breathing pauses during sleep.

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71
Q

A term referring to interventions used to promote sleep.

A

Sleep hygiene

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72
Q

Properly functioning nervous system sends signals that tissues are damaged, requiring attention and proper care.

A

Physiological pain

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73
Q

Damaged or malfunctioning nerves due to injury, illness or undetermined reasons cause “this” pain.

A

Neuropathic pain

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74
Q

Sharp and localized or dull & diffuse - pain originating from nerve receptors in the skin or close to body surface.

A

Somatic pain

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75
Q

Pain that arises from body organs - often radiates or is referred. May be described as cramping, intermittent or colicky pain. Dull achy pain.

A

Visceral pain

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76
Q

Pain perceived in an area distant from the site of stimuli.

A

Referred pain

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77
Q

Gate Pain Theory

A
  • Pain impulses can be modified at spinal cord level before reaching the brain
  • Gates at dorsal horn synapses in spinal cord
78
Q

Pain Experience:

  • Perceives pain
  • physiological indicators may vary so behavioral observation is recommended for pain assessment.
  • responds to pain w/ increased sensitivity.
A

Infant pain

79
Q

Pain Experience:

  • ability to describe pain & its intensity & location
  • may consider pain a punishment
  • tends to hold someone accountable for pain
  • perceives pain a threat to security
A

Toddler & preschooler pain

80
Q

Pain Experience:

  • tries to be brave when facing pain
  • responsive to explanations
  • identify location & describe the pain
  • may regress to earlier stage of development with persistent pain
A

School-age child

81
Q

Pain Experience:

  • may be slow to acknowledge pain
  • giving in to pain may be considered a weakness
  • wants to appear brave in front of peers and not report pain
A

Adolescent

82
Q

Pain Experience:

  • exhibiting pain behaviors may be gender based
  • may ignore pain b/c perceived as sign of weakness or failure
  • fear of what pain means may prevent some from taking action
A

Adults

83
Q

Pain Experience:

  • decreased sensation or perceptions of pain.
  • lethargy, anorexia, fatigue may be indicators of pain.
  • multiple conditions with vague symptoms
  • may withhold complaint in fear of treatment or lifestyle changes
A

Older adult

84
Q

The nurse is aware that the A-delta fibers conduct which of the following types of pain?

A

Sharp, shooting pain impulses

85
Q

Pain that exceeds baseline.

A

Breakthrough pain

86
Q

Pain that is experienced in high frequency bursts

A

Central pain

87
Q

Pain that has an Absence of any diagnosed cause or event

A

Psychogenic pain

88
Q

-Mild pain step 1
Nonopioid analgesics (with/without coanalgesic)
-Persists, moderate pain step 2
Weak opioid, combination of opioid and nonopioid, (with/without coanalgesic)
-Persists, severe pain step 3
Strong opiates administered around the clock
Titrated until pain relieved, respiratory effects

A

WHO Three step approach

89
Q

Does not affect platelet function
Rarely causes GI distress, renal, skin, CV
Hepatotoxicity with high dose, long-term use

A

Acetaminophen

90
Q

Vary in anti-inflammatory properties
Metabolism, excretion, side effects
Narrow therapeutic index

A

Acetaminophen, ibuprofen, aspirin

91
Q

Pure opioid drugs bind tightly to mu receptors
Found throughout the body
Morphine, oxycodone, hydromorphone

A

Full agonists

92
Q

Name 3 Full agonist opioid drugs

A

Morphine
Oxycodone
Hydromorphone

93
Q

Have ceiling effect
Block mu receptor or neutral
Buprenorphine
Alternative to methadone

A

Partial agonists

94
Q

Name one partial agonist

A

Buprenorphine

95
Q

Act like opioids and relieve pain (agonist effect)
Works only if client has not taken any pure opioids (antagonist effect)
Blocks, inactivates other opioid analgesics
Includes dezocine, pentazocine, butorphanol tartrate, nalbuphine hydrochloride

A

Mixed agonist-antagonists

96
Q

Weak opioid analgesics

mixed opioid analgesics

A 
Weak opiods (codeine, tramadol)
Mixed agonist-antagonist drugs (Stadol, Nubain)
97
Q 
Strong opioid analgesics
Most potent class of pain relievers
A

Opium derivitives morphine, methadone, hydromorphone, oxycodone, fentanyl,

98
Q

Chemical interruption of nerve pathway

Injection of local anesthetic into nerve

A

Nerve block

99
Q

COLDERR

Pain Assessment

A 
C = character
O = onset
L = location
D = duration
E = exacerbation
R = relief 
R = radiation
100
Q 
What are these examples of:
Acute Pain
Chronic Pain
Hopelessness  
Anxiety  
Ineffective Coping
Ineffective Health Maintenance
A

Examples of Pain Nursing Diagnosis

101
Q

What is this an example of:
Client will
Report reduction in pain to allow for comfort
Be able to contribute to self-care activities
Obtain adequate pain relief to allow for mobility
Obtain adequate pain relief to allow for sleep

A

Nursing Plan

102
Q 
What is this an example of:
Assess client’s pain
Time for pain relief highly dependent on
Route of administration
Nonpharmacological intervention
Client’s pain level prior to initiation of therapy
Evaluate vital signs
Objective data may validate/conflict with subjective data
A

Nursing evaluation

103
Q 
What is this an example of:
Teaching of client and family includes
Specific drugs to be taken
How to take or administer drugs
Importance of taking pain medications before the pain becomes severe
Explain risk of addiction very small
Importance of scheduling rest and sleep
Suggest resources
A

Community based care

104
Q

Occurs when the structures of the pharynx or oral cavity block the flow of air. Begins with snorting, then breathing ceases.

A

Obstructive apnea

105
Q

Is thought to involve a defect in the respiratory center of the brain.

A

central apnea

106
Q

A combination of obstructive apnea and central apnea

A

Mixed apnea

107
Q

Behavior that may interfere with sleep and may even occur during sleep. Example: sleepwalking

A

Parasomnia

108
Q

Two risk factors of insomnia:

A
  • older age

- female

109
Q

Risk factors for sleep apnea

A
  • male
  • increasing age
  • obesity
  • large neck circumference
110
Q

Mental health problems associated with poor sleep:

A
  • anxiety
  • depression
  • substance abuse disorders
111
Q

Alternative sleep therapies

A
  • Melatonin
  • herbal chamomile tea
  • lemon balm
  • valerian
  • Cognitive-behavioral therapy
  • guided imagery
112
Q

What is this an example of:

  • sleep history
  • talk to the client and their sleep partner
  • sleep assessment scales
  • obtain objective data - pallor, dark circles under eye, level of consciousness, reflexes, vital signs…
A

Nursing assessment

113
Q

What is this an example of:

  • disturbed sleep pattern
  • impaired gas exchange
  • anxiety related to diagnosis of a sleep disorder
  • fatigue
  • risk for injury related to somnambulism
A

Nursing diagnosis

114
Q 
What is this an example of:
The client will 
-sleep through the night
-use good sleep hygiene
-remove distractions from the bedroom
A

Nursing Plan

115
Q

A client is going to have a sleep study done and wants to know what type of tests to anticipate. The nurse’s best answer is:

A

Electroencephalography - electrodes placed on the scalp to record brain waves

116
Q

What is this an example of:
Healthy individuals obtain less sleep than needed
19 hours awake produces same impairments as blood alcohol level of 0.05
Nurses with reduced hours of sleep more likely to make errors

A

Insufficient sleep

117
Q

Diagnostic studies for sleep disorders

A 
Polysomnography (PSG)
Electroencephalogram (EEG)
Electromyogram (EMG)
Electro-oculogram (EOG)
O2 saturation
Electrocardiogram (ECG)
118
Q

What is this an example of:
Data collection
Observations of duration of client’s sleep
Questions about how client feels upon awakening
Observations of client’s level of alertness during day

A

Nursing evaluation

119
Q

Refers to physical change, increase in size

A

Growth

120
Q

Refers to increase in complexity of function
Skill progression
Capacity, skill to adapt to environment

A

Development

121
Q

Erikson’s 8 stages of development:

Infancy

A
  • Birth to 18 months

- Trust vs. Mistrust

122
Q

Which Erikson stage:

Learning to trust others vs. mistrust, withdrawal, estrangement…

A

Infancy

Trust vs. Mistrust

123
Q

Erikson’s 8 stages of development:

Early Childhood

A
  • 18 months to 3 years

- Autonomy vs. shame and doubt

124
Q

Which Erikson stage:

Self-control w/o loss of self-esteem vs. compulsive self-restraint or compliance

A

Early childhood

-Autonomy vs. shame and doubt

125
Q

Erikson’s 8 stages of development:

Late Childhood

A

3 - 5 years

Initiative vs. guilt

126
Q

Which Erikson stage:
Learning the degree to which assertiveness & purpose influence the environment vs. lack of self-confidence; pessimism, fear of wrongdoing.

A

Late childhood

Initiative vs. guilt

127
Q

Erikson’s 8 stages of development:

School Age

A

6-12 years

Industry vs. inferiority

128
Q

Which Erikson stage:

Beginning to create, develop, & manipulate vs. loss of hope, sense of being mediocre.

A

School Age

Industry vs. inferiority

129
Q

Erikson’s 8 stages of development:

Adolescence

A

12-20 years

Identity vs. role confusion

130
Q

Which Erikson stage:

Coherent sense of self vs. feelings of confusion, indecisiveness and possible antisocial behavior.

A

Adolescence

Identity vs. role confusion

131
Q

Erikson’s 8 stages of development:

Young adulthood

A

18-25 years

Intimacy vs. isolation

132
Q

Which Erikson stage:
Intimate relationship with another person, commitment to work vs. impersonal relationships, avoidance of relationship, career or lifestyle commitments.

A

Young adulthood

Intimacy vs. isolation

133
Q

Erikson’s 8 stages of development:

Adulthood

A

25 - 65 years

Generativity vs. stagnation

134
Q

Which Erikson stage:

Creativity, productivity, concern for others vs. self-indulgence, self-concern, lack of interests and commitments.

A

Adulthood

Generativity vs stagnation

135
Q

Erikson’s 8 stages of development:

Maturity

A

65 to death

Integrity vs. despair

136
Q

Which Erikson stage:

Acceptance of worth & uniqueness of one’s own life; acceptance of death VS. Sense of loss, contempt of others.

A

Maturity

Integrity vs. despair

137
Q

A Factors that influence Development

Genetics:

A

Remains unchained throughout life – physical characteristics, gender, temperament.

138
Q

A Factors that influence Development

Chromosomes and genes:

A
  • Carry messages that encode for characteristics, diseases.

- Sex chromosomes and autosomal chromosomes

139
Q

A Factors that influence Development

Prenatal influences –

A

mothers nutrition, maternal smoking, maternal alcohol consumption

140
Q

A Factors that influence Development

Family & parenting

A
  • Profile of family characteristics

- Families influence children profoundly

141
Q

A Factors that influence Development

Cultural influences –

A
  • Traditional practices
  • Genetic variations
  • Rules regarding patterns of social interaction
  • Genetic traits
142
Q

A Factors that influence Development

Nutrition –

A

-Essential to growth and development
-Poorly nourished= More likely to get infections
& Not attain full height potential
-Prenatal nutrition

143
Q

A Factors that influence Development

Environment – living conditions

A
  • Living conditions
  • Socioeconomic status
  • Climate
  • Community
144
Q

A Factors that influence Development

Health – injury, illness

A
  • Injury, illness

- Prolonged, chronic illness

145
Q

Nine Parameter of Personality:

Activity Level

A
  • Degree of motion during eating, playing, sleeping, bathing.
  • Score: high, medium, low
146
Q

Nine Parameter of Personality:

Rhythmicity

A
  • Regularity of schedule maintained for sleep, hunger, elimination
  • Score: regular, variable, irregular
147
Q

Nine Parameter of Personality:

Approach or withdrawal

A
  • Response to new stimulus such as a food, person or activity
  • Score: approachable, variable, withdrawn
148
Q

Nine Parameter of Personality:

Adaptability

A
  • Degree of adaptation to new situations

- Score: adaptive, variable, nonadaptive

149
Q

Nine Parameter of Personality:

Threshold or responsiveness

A
  • intensity of stimulation needed to elicit a response to sensory input, objects in the environment or people.
  • Score: High, medium, low
150
Q

Nine Parameter of Personality:

Intensity or reaction

A
  • Degree of response to situations

- Score: Positive, variable, negative

151
Q

Nine Parameter of Personality:

Quality of mood

A

-Predominant mood during daily activity & response to stimuli
Score: positive, variable, negative

152
Q

Nine Parameter of Personality:

Distractibility

A
  • ability of environmental stimuli to interfere with the child’s activity.
  • Score: distractible, variable, nondistractible
153
Q

Nine Parameter of Personality:

Attention span & persistence

A
  • amount of time devoted to activities & the degree of ability to stick with an activity in spite of obstacles
  • Score: persistent, variable, nonpersistent
154
Q

developmentally inappropriate behaviors involving inattention

A

ADD

155
Q

hyperactivity, impulsivity accompany inattention

A

ADHD

156
Q

Risk factors for ADD &/or ADHD

A
  • Interaction of genetic, biologic, environmental
  • Prenatal exposures
  • No single gene located at this time
157
Q

Clinical manifestations for ADD / ADHD

A
  • Decreased attention span
  • Impulsiveness
  • And/or increased motor activity
158
Q

Diagnoses ADD / ADHD

-History

A
  • Family history
  • Birth history
  • Growth and developmental milestones
159
Q

Diagnoses ADD / ADHD

Behaviors

A
  • Sleep, eating patterns

- Progression, behaviors in school

160
Q

Diagnoses ADD / ADHD

Social, environmental conditions

A

Reports from parents, teachers

161
Q

Frequently diagnosed after beginning school
Often brought in when behaviors interfere with daily functioning of teachers, parents
Diagnostic criteria
Inattention
Hyperactivity
impulsivity

A

ADD / ADHD

162
Q

Medications for moderate to severe ADD/ADHD

A

Ritalin
Adderall
Strattera

163
Q

Environmental Support for ADD / ADHD kids

A
  • Decreasing stimulation
  • Orderly environment
  • Behavioral support
  • Reward child for desired behaviors
  • Applying consequences for undesirable behaviors
164
Q

What is this an example of:
Family and birth history
Developmental testing
Observation of child

A

Nursing Assessment

165
Q 
What is this an example of:
Impaired Verbal Communication
Impaired Social Interaction
Chronic Low Self-Esteem
Risk for Injury
Risk for Caregiver Role Strain
A

Nursing Diagnosis

166
Q 
What is this an example of:
-Discourage regular television, encourage physical activity for young children
-Hospitalized child
Administering medications
Manage environment
Implementing behavioral management plan
Emotional support
Promoting self-esteem
Ensuring ongoing care
A

Nursing Plan

167
Q 
What is this an example of: 
Administer medications
Minimize environmental distractions
Implement behavioral management plans
Provide emotional support
Promote self-esteem
A

Nursing Implementation

168
Q

What is this an example of:
Parents, child demonstrate understanding
Family accurately, safely manages medication administration
Child demonstrates increased attentiveness, decreasing hyperactivity
Child displays formation of positive self-image

A

Nursing Evaluation

169
Q

Autistic Spectrum Disorders (ASDs)

Autism, Asperger syndrome & PDD (pervasive developmental disorder).

A

-impairments in language, cognition & social skills that make them seem different than others.

170
Q

Risk factors for ASDs

A
  • Fetal Alcohol Syndrome (FAS)
  • Fragile X syndrome
  • Phenylketonuria (PKU)
  • Down syndrome
  • Environmental factors
171
Q

Pervasive developmental disorders (PDDs)

A

-Impaired social interactions & communication - -restricted interests, activities & behaviors

172
Q

Clinical Manifestations

A
  • Impairments in social interactions
  • Communication
  • Difficulties and delays
  • Abnormal communication patterns
173
Q

What nursing stage is this an example of:

  • No babbling or communication gestures by 12 months
  • No single word by 16 months
  • No spontaneous two words by 24 months
  • Loss of language or social skills previously achieved
  • History
A

Nursing Assessment

174
Q 
What nursing stage is this an example of:
Child will 
Remain free of injury
Acquire communication strategies
Perform self-care
Demonstrate developmental progress
Participate in small group activities
A

Nursing Plan

175
Q 
What nursing stage is this an example of:
Stabilize environmental stimuli
Provide supportive care
Enhance communication
Maintain a safe environment
Provide anticipatory guidance
A

Nursing Implementation

176
Q

Stereotypy

A

rigid, obsessive behavior. Repetitive behaviors include: head banging, biting themselves, twirling in circles.
This is often self-stimulating or self-distructive.

177
Q

Echolalia

A

compulsive parroting of a word or phrase just spoken by another.

178
Q

A syndrome in which an infant falls below the fifth percentile for wight and height on a standard growth chart or is falling in percentiles on a growth chart.

A

Failure to Thrive

179
Q

Risk factors for failure to thrive:

A
  • Infants deprived of mothering
  • Parental depression
  • Substance abuse
  • Mental retardation
180
Q

Clinical Manifestations of failure to thrive:

A
  • Persistent failure to eat adequately

- No weight gain/weight loss in child < 6 years

181
Q

Collaboration for failure to thrive

A
  • Thorough history

- Physical examination

182
Q

Nursing assessment for failure to thrive

A
  • Physical assessment: Measurements, Percentiles
  • History: Stressors in parents lives, Ask about pregnancy and birth
  • Observe behaviors when parents feed child
183
Q

Flat, macule, vascular lesion, non-blanchable, hemorraged tissue, emboli (trauma to long bone, fatty stuff released into system and causes fatty pulmonary emboli) - may see if someone has low platelet count, meningial, Rocky Mountain spotted fever.

A

Petichiae

184
Q

tumor, soft & yellow, lipoprotiens and cholestrol in them.

A

Xanthoma

185
Q
  • Benign - Fatty tumor.
A

Lipoma

186
Q

Lesions

  • Primary
  • Secondary
  • Vascular
A
  • Primary - original skin issue.
  • Secondary - happens after the primary stage.
  • Vascular - related to blood vessel integrity.
187
Q

medication caused scar, at IV site. Under the skin.

A

Extravasation

188
Q

Related to severe illness, then grows out and leaves a ridge, is on multiple fingers.

A

Beau’s Line

189
Q

Club nail -

A

finger has club like appearance r/t COPD - hypoxia caused.

190
Q

Phases of healing:

A
  1. Hemostasis - vasoconstrict, platelet release, clot formation
  2. Inflammation
  3. Proliferation
  4. Maturation

Nursing 161; Fall 2013 (4 decks)

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