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Nursing > Fundamentals Exam 2 > Flashcards

Fundamentals Exam 2 Flashcards

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0
Q

Slough

A

Liquified or wet dead tissue. White, yellow, light tan

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1
Q

Eschar

A

Dried dead tissue, cornified, tan brown, black

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2
Q

Undermining

A

Bigger wound than opening. Extends under the edge

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3
Q

Tunneling

A

Tracts extend out from the wound

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4
Q

Exudate

A

Drainage of pus, yellow fluid

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5
Q

Stage 1

A

Intact skin, no blanching red area usually over bony prominence

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6
Q

Stage 2

A

Shallow open ulcer with redor pink wound bed w/o slough. Partial thickness, shiny, dry, shallow ulcer. No slough or bruising.

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7
Q

Stage 3

A

SubQ fat may be seen. Slough, no exposed bone, muscle, or tendon. May have undermining or tunneling

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8
Q

Stage 4

A

Exposed bone , tendon, or muscle. May have slough, eschar, undermining or tunneling

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9
Q

Unstageable

A

Full thickness, base or wound bed covered by slough or eschar. Often includes tunneling and/or undermining

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10
Q

Deep tissue injury

A

Purple/maroon localized area of discolored skin

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11
Q

Moisture wound

A

Partial thickness, shallow craters, linear denuded skin in creases. From moisture

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12
Q

Wound Measurement orientation

A

Like clock
Length 12-6
Width 3-9
Depth- deepest from wound edge to bottom. Unable if eschar or slough

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13
Q

Serous Drainage

A

Clear fluid like in blister

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14
Q

Sanguineous drainage

A

Contains RBC’s

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15
Q

Serosanguineous

A

Combo clear with blood tint

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16
Q

Purulent

A

Contains wbc’s

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17
Q

Heat therapy

A

Dilates peripheral blood vessels
muscle tension
>pain

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18
Q

Cold therapy

A

Constricts peripheral blood vessels
>muscle spasm
Promotes numbness
Promotes comfort

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19
Q

HIPAA

A

1996 Health Insurance Portability Accountability Act

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20
Q

SBAR

A

Situation-concise statement of problem
Background-brief, pertinent info.
Assessment-what found/thought
Recommendation-action requested

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21
Q

Acute pain

A

Rapid onset

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22
Q

Chronic pain

A

Longer can have breaks and exacerbations

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23
Q

Cutaneous pain

A

Superficial pain close to surface

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24
Q

Somatic pain

A

Originates in tendon, bone , muscle, ligament, blood vessel, nerves

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25
Q

Visceral pain

A

Poorly localized. Originates in thorax, cranium, abdomen

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26
Q

Mode of transmission- pain

Referred pain

A

Pain perceived in different site than origination

27
Q

Neuropathic pain

A

Damage/abnormal fxn of peripheral nerves or CNS

28
Q

Intractable pain

A

Therapy resistant despite multiple intervention

29
Q

Phantom pain

A

Pain experienced in lost limb/body part

30
Q

FLACC pain scale

A 
Faces
Legs
Activity
Cry
Consolability
31
Q

Numerical sedation scale

A

1=awake/alert
2=drowsy occasionally, but easily aroused.
3=drowsy frequently, falls asleep in conversation. Reduce Dose
4=somnolent, minimal response. Discontinue opioid try naloxone

32
Q

% of brain is water

A

75

33
Q

% of blood is water

A

83

34
Q

%of muscles is water

A

75

35
Q

Extracellular

A

Outside cells

36
Q

Interstitial

A

Between cells and outside blood vessels

37
Q

Intravascular

A

Blood plasma

38
Q

Transcellular

A

Cerebrospinal, pleural, peritoneal, and synovial

39
Q

Intracellular

A

Within cells

40
Q

Desired adult fluid intakes n 24 hr

A

1500-3500 ml in 24hr

41
Q

Amt. Most adults average of water

A

2500-2600ml/day

42
Q

Sensible losses

A

Are fluid losses from urination, defecation, and wound. these can be measured

43
Q

Insensible losses

A

Are losses via skin and lungs about 28%

44
Q

Sodium

A

Regulates extra cellular fluid

135-145 mEq/L

45
Q

Potassium

A

Plays a vital role in electrical impulses

3.5-5.0 mEq/L

46
Q

Calcium

A

Plays major role in transmission of nerve impulses

9.0-10.5 mg/dL

47
Q

Magnesium

A

Acts on cardiovascular system

1.2-2.0 mEq/L

48
Q

Chloride

A

Major component of interstitial and lymph fluid

97-107 mEq/L

49
Q

Hyponatremia

A

Na+ <135mEq/L
Symp: tachycardia, hypotension, mu. cramps, weakness, lethargy,HA
Causes=GI losses, diuretics, excess h20 intake, burns, kidney disease.
Tx based on cause

50
Q

Hypernatremia

A

Na+ >145mEq/L
Symp: irritable, thirst, fever, dry &. Flushed skin, dry tongue & mucus membrane, muscle twitch
Causes=<intake Na+
Tx based o cause

51
Q

Potassium

A

Fx= cardiac, skeletal, & smooth muscle fx.
Maintains fluid volume w/I cell
Metabolism of CHO & Pro-

52
Q

Hypokalemia

A

muscle tone, paresthesias
Causes=diuretics, GI losses, Diaphoresis,
Tx= K+ replacement

53
Q

Hyperkalemia

A

> 5.0mEq/L
Symp: cardiac arrhythmia, hypotension, anxiety, muscle weak
Causes=renal failure, diabetic ketoacidosis.
Tx=Kayexelate

54
Q

Calcium

A 
Most abundant mineral
Development of teeth & bones
Req. for transmission of nerve impulses
Skeletal and cardiac muscle contraction
Regulates heart beat & BP
Vit D required for absorption
55
Q

Hypocalcemia

A

<9.0mg/dL
Symptoms: numbness, tingling in fingers and toes, muscle twitch, seizures, laryngeal spasm.
Causes=Vit D deficiency, pancreatitis .
Tx= Ca2+ supplement w/VitD

56
Q

Hypercalcemia

A

> 10.5mg/dL
Symp: lethargy, muscle weak, kidney stones, > memory
Causes=hyperparathyroidism, excess Vit D intake,
Tx = identify underlying cause

57
Q

Magnesium

A

Fx= activates co-factor in over 300 enzymes. Affects neuromuscular irritability & contractions, contributes to cardiovascular regulation, stabilizes excitable membranes Ca2+

58
Q

Total water volume in body

A

50-60% intracellular has 70% of total body water

59
Q

Water content variations

A

Age, body fat, gender

Infants have more total body fluid. More prone to deficit

60
Q

Hypomagnesemia

A

<reflexes and muscle tremor, tachycardia, confusion
Causes-malnutrition, alcoholism, D, NG suction
Tx give Magnesium

61
Q

Hypermagnesemia

A

> 2.0mEq/dL
HTN, flushing, skin warmth, >R
Causes=renal failure
Tx symptomatic

62
Q

Hypovolemia/hypervolemia

A

H2O and electrolyte loss/retention

63
Q

Body systems that have a role in fluid/electrolyte homeostasis

A

Kidney, CVSystem, adrenal glands, pituitary gland, nervous system, thyroid/parathyroid gland, GI, hypothalamus.
Fluid balance is threatened with any organ/system failure

64
Q

Acidosis

A

PH below 7.35

Death at 6.80-

65
Q

Alkalosis

A

PH above 7.45

Death at 7.80+

66
Q

Homeostatic PH regulators

A

•chemical buffer system
**•respiratory mechanism
•renal mechanism
Effectiveness varies with development infant & AA less eff.

Nursing (7 decks)

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