knowledge assessment III Flashcards
(277 cards)
1
Q
skeletal structure
A
cranium is composed of 22 bones supporting the soft tissue structures of the head
2
Q
anatomy of head
A
contains:
- muscles
- blood supply
- nerve supply
- salivary glands
3
Q
blood supply to the head
A
- carotid arteries
- temporal artery
- internal and external jugular veins
4
Q
nerve supply to face
A
cranial nerve V - facial nerve
5
Q
salivary glands
A
parotid
submandibular
sublingual
6
Q
CN VIII can interfere with
A
vestibulocochlear nerve can interfere with balance
7
Q
facial nerve innervates ear which can
A
interfere with balance
8
Q
facial muscles are responsible for
A
all movement of the face
CN V responsible for movement
9
Q
any injury to ear
A
effects coordination and hearing
10
Q
brainstem injury
A
very disoriented and confused
11
Q
anatomy of the nose
A
- allows air to enter the respiratory tract
- primary organ for smell
- nerve and blood supply consits of CN 5, 7, 9, and 10, internal and external carotid arteries, and kiesselbach plexus
- lymphatic drainage
12
Q
kiesselbach plexus
A
blood supply to the nose, most common for nose bleeds
13
Q
ethmoid bone
A
only bone separating brain from nose
14
Q
if ethmoid bone breaks
A
risk for infection, leakage of cerebrospinal fluid
15
Q
sigmoid bone
A
helps protect against infection
16
Q
sinuses all come together to form
A
osteomeatal complex
17
Q
sinus anatomy
A
frontal sinus
maxillary sinus
ethmoid sinus
18
Q
most common site of anterior nose bleeds
A
kiesselbach
common in cases of trauma, should stop with pressure
19
Q
mouth
A
- eat, taste, chewing, speech
- very vascular tongue
- salivary glands
- teeth and gums
20
Q
vascularity of tongue allows for
A
sublingual meds
quick acting meds
21
Q
tongue
A
- muscle (most vascular muscle)
- front 2/3 should be covered in tastebuds
22
Q
salivary glands
A
- produce 2-4 L/day of saliva
- affected by aging and certain meds, xerostomia, chemo
23
Q
issues with salivary gland causes
A
harder to swallow food, and protection
24
Q
xerostomia
A
dry mouth
25
teeth and gums
- 32 full grown adult teeth
- dentures
- state insurance and medicate may not include dental care
26
C1-C7
helps support neck
27
C3, C4, C5 ...
keep lungs alive
will not be able to breathe on own if injured
28
neck is composed of
- vertebrae
- muscles
- trachea
- thyroid and parathyroid glands
- lymphatics
- throat
- tonsils and adenoids
29
neck muscles
sternocleidomastoid and trapezius contribute to use of accessory muscles for breathin
30
tracheal deviation
- should be midline
- should not be painful, or deviated
- if deviated s/o lung collapse
31
thyroid
should not be felt
should be sticking out
32
hypothyroidism
fatigue, high BP, increase in BW
33
hyperthyroidism
decrease wiehgt, increase BP, increase HR, increase metabolism
34
posterior auricular lymph nodes
behind ear
35
occipital lymph nodes
base of head posteriorly
36
superficial cervical lymph nodes
lower ear and parotid
37
deep cervical lymph nodes
other nodes of head and neck, occiptal scalp, ear, back of neck, tongue, trachea, nasopharynx, nasal cavities, palate, esophagous
38
posterior cervical lymph nodes
in between sternocliedomastoid and traps
39
supraclavicular lymph nodes
thorax and abdomen
40
preauricular lymph nodes
in front of ear
41
parotid lymph nodes
below ear, on parotid gland
42
tonsillar lymph nodes (jugulodiagastric)
at jawline
43
submental lymph nodes
lower lip, floor of mouth, apex of tongue
44
submandibular lymph nodes
cheek, side of nose, lower lip, gums, anterior tongue
45
if lymph nodes are palpable..
could be signs of infection or cancer
46
if lymph nodes arent draining
gets larger
47
tonsils
pain, breathing, swelling, infection
48
older adult considerations for H&N
- facial skin becomes less elastic
- bony structures are more pronounced causing alteration in facial appearance
- hair begins to thin (may be related to thyroid)
- spinal structure may become concave and reduced ROM in neck can appear
- hypothyroid is common in pts 60+, all older adults should be evaluated
- gustatory rhinitis (clear rhinorrhea stimulated by smell and taste of food)
- decreased olfactory sensory fibers
- thinning of soft tissues of oral cavity - increased risk of ulcer, infection, and oral CA
- decreased enamel on the teeth - gums beging to recede and teeth appear larger (increased bone resorption and teeth may loosen, brittle teeth, may break, may need implants or dentures, may need altered diet due to dentition change)
- smooth glossy tongue may result from deficiencies in different B vitamins
49
vitamin B impacts
brain function
50
cultural variations and health disparities for H&N
- shape and size of facial features, head and neck
- females have higher risk of both hypo and hyper thyroidism
- oropharyngeal cancer occurs more frequently in economically developed countries
- oral disease higher amongst those of low socioeconomic status
- congenital defects in children
- head and neck cancer (high risk with HPV infection)
- sleep disorderd breahthing (2x-4x more MI or stroke)
- cavities increase among decrease socioeconomic status
51
priority urgent assessment H&N
- acute head and neck injury (C-spine stabilization is priority, assess for neurologic changes)
- obtain H&P
- neck pain
- lymph node assessment
- thyroid assessment
52
c-spine stabilization
neck not stable, turning can sever spinal cord causing death
53
educate patients on
wearing helmet
54
full hx only when pt is
stable
55
lymph nodes concerns
> 1 cm
hard
rubbery
immobile
56
thyroid - BMR
increase in BMR is life threatening
called thyroid storm
57
priority urgent assessment mouth and nose
- epistaxis
- post-op bleeding after tonsillectomy
- ludwig angina
- aspiration risk
- ansomnia
- anaphylaxis and airway obstruction
58
epistaxis
- nosebleed
- posterior nose bleed, no pressure works, likely to swallow blood and experience n/v
- 3-5 days of tubing
59
tonsillectomy
increased risk of bleeding
hypotensive
tachycardic
60
ludwig angina
swelling of tongue
61
aspiration
food/fluid in lungs
increased risk after stroke (sit up, assess ANOx4)
silent aspiration is more dangerous
62
anosmia
loss of smell
signs of neuro issue (early sign of parkinson)
viral
63
anaphalyaxis
airway
!emergent!
64
subjective data collection for head and neck
- assess risk factors (health promotion and educational opportunity)
- past medical hx
- lifestyle and personal habits
- dental health
- substance use hx
- environmental exposure
- meds or allergies
- family hx
65
teaching and health promotion
- tobacco use (always assess interest in quitting)
- sleep disorders (insufficient sleep = poor brain development)
- cancer (risks)
- oral health
- hereditary hemorrhagic telangiectasia
- headache or facial pain
- limited ROM of neck
- lumps of masses
- hypo/hyperthyroidism
66
hereditary hemorrhagic telangiectasia
malformations of vessels in body causing increased risk of bleeding
nose bleeds is common sign (use humidifiers and saline)
67
objective data collection
- inspect head, neck, mouth, hair, and throat
- evaluate swallowing
- assess aspiration risk
- vision test
- hearing test
68
sinus cultures indicate
sinusitis
69
biopsies are done in
cases where lymph nodes can be palpated
70
lab values - cbc for wbc, thyroid levels
infection, TH levels
71
radioallergosorbent testing (rast) for allergies
skin testing
72
xray
observe bones
73
CT scan and MRI
observe soft tissue
74
xray ct scan and mri
observe structural abnormalities
75
sleep studies
sleep apnea
76
prioritize hypotheses and take action
- cluster data and ID patterns
- nose, sinus, mouth, throat (impaired airway clearance, impaired swallowing, sleep deprivation
- head and neck (activity intolerance, fatigue, chronic pain)
77
anatomy of neurological system
composed of central and peripheral nervous system
78
central nervous system
- composed of brain and spinal cord
79
peripheral nervous system
composed of cranial and spinal nerves
80
the cerebrum
- right and left hemisphere which control motion of opposite side of body
- composed of four lobes; frontal, parietal, occipital, temporal
81
frontal lobe
personality, behavior, emotions, intellectual function (broca's area- mediates speech)
82
parietal lobe
sensation
83
occipital lobe
visual reception
84
temporal lobe
auditory reception (hearing), taste, smell
wernicke's area - language comprehension
85
hypothalamus
- respiratory center, temperature regulation, appetite, sex drive, heart rate, BP regulation
- regulates anterior/posterior pituitary (hormone regulation)
86
traumatic injury to frontal lobe can lead to
impulsive changes in personality and sometimes memories
87
impaired hypothalamus causes
vital signs to be abnormal
88
cerebellum
motor coordination of voluntary movements, equilibrium muscle tone, walking, balance, ADLs
89
brainstem regulates
primitive reflexes (coughing, gagging, HR, BP)
90
neuro change =
cardiac change
91
ascending spinal cord
carries sensory information
92
descending spinal cord
sends motor information
93
neurons
- basic functional unit of nervous system
- receives/transmits electrochemical nerve impulses
- afferent and efferent neurons
94
afferent neurons
sensory neurons
carry impulses from the body to the CNS
95
efferent neurons
motor neurons
carry impulses from the CNS to the body
responds to afferent neuron stimulation
96
peripheral nervous system
- all the nerves outside the brain and spinal cord
- relays messages from brain to the rest of the body
- cranial nerves
- spinal nerves
97
cranial nerves
- 12 pairs that exit from the brain
- sensory, motor, or both
98
spinal nerves
- arise from spinal cord and innervate the rest of the body
- 31 pairs
99
c1-c6 contain
most of spinal nerves
100
if spinal cord injury to c1-6
pt may have difficult time breathing
101
cranial nerves responsible for eye movement
- CN II: optic (2)
- CN III: oculomotor (3)
- CN IV: trochlear (4)
- CN VI: abducens (6)
102
CN I
olfactory nerve
smell
sensory
103
what cranial nerve is responsible for sensory of face
CN V: trigeminal
104
what cranial nerve allows for movement of face and certain aspects of taste
CN VII: facial nerve
105
what cranial nerve is responsible for neck and shoulder movement
CN XI: accessory
106
CN II
optic nerve
sight
sensory
107
CN III
oculomotor
eyeball movement and movement of upper eyelid
motor
parasympathetic: pupillary light reflex
108
CN IV
trochlear
eyeball movement: superior oblique
motor
109
CN V
trigeminal
V1: opthalmic
facial sensation (S)
pupillary dilation (SM)
V2: maxillary
facial sensation (S)
V3: mandibular
chewing (M)
facial sensation (S)
110
CN VI
abducens
eyeball movement - lateral rectus (M)
111
CN VII
facial nerve
taste: anterior 2/3 of tongue (S)
facial expression, eyelid closing, stapedius muscle: dampens sounds (M)
lacrimation salvation - submandibular + sublingual glands (P)
112
CN VIII
vestibulocochlear nerve
hearing: cochlea (S)
balance: vestiublar apparatus (S)
113
CN IX
glossopharyngeal nerve
sensation from posterior 1/3 of tongue, tonsils, middle ear, pharynx, taste from posterior 1/3 of tongue (S)
stylopharyngess muscle elevates pharynx and larynx (M)
salivation - parotid gland (P)
114
CN X
vagus nerve
swallowing, elevation of palate, talking, coughing, gag reflex (M)
heart rate, GI peristalsis, sweating, vasovagal syncope (P)
peripheral chemoreceptors - hypoxemia (SM)
115
CN XI
accessory nerve
head turning: SCM (M)
shrugging: trapezius (M)
116
CN XII
hypoglossal nerve
most muscles of tongue (except palatoglossus) - tongue movement (M)
117
reflex arc
- basic defense mechanism (involuntary)
- stretch (deep tendon) - knee jerk response
- superficial - plantar reflex
- visceral (organ) - pupillary response
118
neurological system on aging adult
- loss of muscle bulk/tone (atrophy)
- delayed reaction time
- decreased ability to multitask or respond to multiple stimuli
- decreased cerebeal blood flow
- peripheral nervous system decline
119
loss of muscle/tone (atrophy) in older adults
- disuse
- loss of neural structures in brain and spinal cord
120
delayed reaction time in older adults
- velocity of nerve impulses is slowed
- motor system (movement) slows
121
decreased cerebral blood flow in older adults
- decreased gas exchange ability
- impaired BF (cardiac, vascular)
122
peripheral nervous system decline in older adults
- decreased balance
- postural hypotension
123
impact of culture and genetics on strokes
- 5th most common cause of death
- 1.3% Asian/Pacific Islanders
- 2.3% Hispanics
- 2.5% whites
- 4% African Americans
- 4.6% Amercian Indians
- decreased incidence with HTN/HLD screening and cholesterol and BP meds
- "stroke belt"
- functional status
124
health promotion for neuro assessment
- stroke prevention
- injury prevention (wear helmet, diet, drinking, sports, drugs, falls)
- chronic neurological conditions (alz. parkinsons)
125
basic neurological assessment
- chief complaint
- admitting diagnosis
- PMH
- if pt has concerns - focused assessment
126
focused assessment
- neurologic concenrs
- significant neurologic PMH
- basic neurological assessment reveals an abnormality
127
indicators of significant changes in neuro status
- acute change in mental status
- changes in consciousness not explained by known causes
- seizures
- onset of flexor or extensor posturing
- change in size and decreased reactivity to light in one or both pupils
- onset of conjugate or dysconjugate eye deviation
- progressing weakness (paresis) or paralysis of extremity or one side of body
- facial weakness
- significant changes in VS
- changes in BP, HR or heart rythm may threaten tissue oxygenation or result in direct injury from hemmorhage
- progressively rising BP leading to widening pulse pressure, decreasing pulse, and decreasing respirations, the classic signs of increased intracranial pressure (Cushing response); these are late signs of lower brainstem compression
- irregular breathing patterns may indicate progressing brainstem compression
128
sequence of neurological assessment
- mental status (cognition)
- subjective questions
- brain function (motor, sensory, reflexes)
129
headache
OLDCARTS
130
head injury
event hx, type and description
loc and recall of event
131
dizziness/vertigo
- OLDCARTS
- position changes, activity, meds
132
memory
OLDCARTS
decrease in mental function or confusion
133
time =
brain
134
seizures
- OLDCARTS
- associated clinical presentations
- postictal phase
- precipitating factors
- med therapy and coping strategies
135
tremors
- OLDCARTS
- precipitating and alleviating factors
136
weakness
- localized or generalized
- distal or proximal
- impact on mobility or ADLs
137
vision changes: sudden
- onset duration frequency
- loc and safety
138
incoordination
- problem with balance while standing or ambulating
- lateral drifting, stumbling, or falling
- legs giving way and/or clumsy movements
139
numbness or tingling
- OLDCARTS
- whether it occurs with activity
140
difficulty swallowing
with solids or liquids
drooling
141
difficulty speaking
- OLDCARTS
- clarity
- forming words or saying what you want to say
142
patient centered care
- information regarding past pertinent medical hx
- alcohol history
- substance abuse/drug history
143
mental status
- level of consciousness
- level of arousal
- orientation status
144
assessing brain function
- symmetry at rest
- speech
- pupillary response (PEERLA) (cardinal positions of gaze)
- strength
- sensation
145
level of consciousness
is the patient...
- alert
- confusion
- drowsiness, lethargic, obtunded
- stuporous
- comatose
146
level or arousal (eye opening)
- spontaneous: no stimuli needed
- normal verbal stimuli: name calling
- loud verbal stimuli: loud voice if no response to normal voice
- tactile: light touch, place hand on pt's arms or legs, gently rub/shake
- noxious stimuli: vigorous touch, shaking, sternal rub, nail bed pressure
147
orientation status
- person (name DOB)
- place (where are they)
- time (what day is it)
- situation (what is happening)
148
glasgow coma scale (GCS)
1. eye opening response
spontaneous - 4
to voice - 3
to pain -2
none - 1
2. best verbal response
oriented -5
confused -4
inappropriate words - 3
incomprehensible sounds - 2
none - 1
3. best motor response
- obeys command - 6
- localized pain - 5
- withdraws - 4
- flexion - 3
- extension - 2
- none - 1
total: 3-15
149
facial structures to observe for symmetry
- eyebrows
- eyese
- nose
- ears
- mouth
150
observe pt for (facial)
- size comparison if applicable
- placement (plane)
- drooping
151
judge the quality of persons speech
- pace - rate of speech (normal, abnormal - slowed, rapid)
- word choice - appropriateness
- clarity - understandibility of speech
152
aphasia
difficulty with language comprehension and production of speech
153
expressive aphasia
- understands spoken and written language
- cannot express oneself verbally or transcribed
154
receptive aphasia
- cannot understand written or spoken language (hears sounds/reads words but cannot relate these to any previous experience)
- can speak fluently and effortlessly with clear speech but they substitute wrong or made up words when speaking
155
global aphasia
experiences components of both expressive and receptive aphasia
156
PERRLA
pupillary assessment
equal - on both sides
round
reactive to
light
accommodation
157
strength
- where to test? (upper and lower extermities)
- how to rate (strong, moderate (average), weak, or absent)
158
sensation
- palpate arms, legs, and feet bilaterally
- determine if sensation is equal on both sides
159
ask pt to
smile
frown
close eyes
lift eyebrows
puff cheeks
stick out tongue
160
sternomastoid assessment
- rotation of head against resistance
- place hand on side of chin and apply resistance
- ask pt to rotate head forcibly against resistance
161
big pupils
non reactive
brain herniation
162
trapezius assessment
- also known as shoulder shrugs
- apply resistance against top of shoulders
163
DTRs
- evaluates reflex arc
- equipment: reflex hammer, used to strike tendon at muscle insertion site, two sides, pointed end - small target area (upper extremities), flat end - wider targets (lower extremities)
164
4 point reflex response grading
4+ = brisk/hyperactive
3+ = brisker than average
2+ = average (normal)
1+= diminished
0 = no response
165
optimize results
extremity should be relaxed
muscle partially stretched
swing hammer by moving wrist
excess force is not needed
166
clonus
rapid rhythmic contraction of muscle
seizures, rapid contraction and tremor happens
167
hyperreflexia
exaggerated reflex
168
hyporeflexia
diminished or absent reflex
169
knee pats
pat both knees with hands, flip hands, pat, flip hands, pat
170
finger thumb test
touch thumb with each finger starting with index finger
repeat in opposite direction
171
finger- nose finger
touch examiners index finger then their own nose, then back to examiners index finger
172
assess cerebrallar function through
rapid alternating movements
balance (heel-to-toe walking)
stationary balance (romberg's test)
173
superficial reflexes
elicited by stimulation of the skin
plantar resopnse
174
meningeal assessment
nucal rigidity
brudzinski sign
kernig sign
175
nuchal rugidity
associated with meningitis and intracranial hemorrhage
neck stiffness (flex head forward passively, would cause severe pain)
176
toes pointing up is not normal
+ babinski
babies do this and cannot walk until it goes away
177
brudziniski sign
body curls up
178
kernig sign
lay on back, life leg up and straight, pain in lower back
179
assessing unconscious patient
- urgent evaluation
- risk for life threatening condition
- client cannot participate
- perform GCS
- PERRLA
- brainstem assessment
- motor function
- patterns of progressive decline or brain herniation
180
lumbar puncture
used to observe meningitis (assess CSF), brain pressure
181
CT scan for neuro
staple, quickest easiet
182
MRI
spinal cord injuries
if patient is confused must be minfull
183
angiograph
look at vessels
184
EEG
sees brain activity
185
assessments include
1. admision, comprehensive assessment
2. shift or ongoing assessment
3. focused assessment (specific)
4. urgent assessment (emergency)
186
comprehensive assessment
- any pain?
- mind body soul past hx
- past surgeries, past illness, family hx
- can you tell me why you're here?
- allergies?
- do you drink, smoke, do drugs?
- meds?
187
assessment begins at
admission, continues until client is transitioned to next phase of care
188
nurses cannot delegate
main functions of assessment, planning, evaluation, and nursing judgement
189
RNs can delegate
- ADLs
- assistive devices
- nutrition and oral hydration
- mobility/immobility
- rest and sleep
- non pharmacological comfort interventions
190
RN responsible for delegation
- right task
- right circumstances
- right person
- right direction and communication
- right supervision
- right evaluation
191
older adults
- have special needs related to physiological changes of aging and diminished physiological reserve
- increased risks of falls w/ fractures, delirium, HAI, medication interactions
- may develop acute med problems within 30 days of last hospitalization causing rehabilitation
- 2x the risk of developing various complication: abscess, wound infection, emphysema, URI, pneumonia, thrombosis, pneumothorax, compartment syndrome
192
racial and ethnic minorities experience
lower quality of care, less likely to receive routine medical care, face higher rates of morbidity and mortality
193
urgent assessment
- occurs during any physiologic or psychological change in client
- nurses need to ID S/S of deteroiration based on knowledge of physiological compensatory mechanisms and correlation of pathophysiology of illness
- nurses ability to recognize and resopnd to signs and worsening client in timely manner plays a pivotal role in client outcomes
194
examples of urgent assessment
- vital signs outside normal parameters
- acute change in O2 sat, pupillary response, urine output
- threatened airway
- new onset chest pain
- acutely cold, cyanotic, or pulseless extremity
- confusion, agitation, or delirium, unexplained, lethargy, acute altered mental status
- signs of stroke, difficulty speaking
195
communicating the assessment
- use effective and appropraite communication of the changed or abnormal parameters
- clear, concise, timely reporting to provider is required
- SBAR format
- follow facility protocols
- RRT
196
comprehensive admitting assessment
- V.S.
- general survey
- neurological assessment
- head, face, eyes, ears, nose, mouth, throat, assessment
- anterior thorax assessment
- upper extremities assesment
- abdominal assessment
- posterior thorax assessment
- lower extremities assessment
- intake and elmination
- psychosocial assessment
197
general shift assessment
- head to toe
- client immediate conern
- immediate treatment/teaching/discharge planning
- care priorities
198
focused shift assessment
- integration into shift assesment
- clinical judgement: determine client priorities
199
specialized assessment for hospitalized patients
- injuries from falls
- immobility
- pressure injury
- DVT
- adverse drug events
- catheter-associated UTIs
- central line associated bloodstream infections
- surgical site infections
- ventricular associated penumonia
- sepsis
200
making clinical decisions
- analyze labs and diagnostic testing
- prioritize hypotheses and take action
- analyzing changing findings: progress notes
- interprofessional collaboration w/ discharge planning team
- plan the care
- evaluate outcomes
201
newborns and infants
circumcision
57% of males in US are circumcised
202
children and adolescents
tanner's stages of maturation
203
between 13-15...
the pubic hair and testicles and penis are still growing
204
around 14-17...
fll size and pubic hair grow triangular
205
older adults
- stool retention, incontinence
- declining testosterone levels
- testes drop lower in scrotum
- benign prostatic hyperplasia (BPH)
- erectile dysfunction
206
cultural considerations for male genitalia
- cultural beliefs, gender identity, sexual orientation
- piercings and tattoos
- transgender female
207
many meds can cause issues with ED and libido
- can cause isssues with ED and libido
- statins
- diuretics
- antidepressants
- beta-blockers (heart med assess hx of CV illness)
- anticonvulsants
208
older adults are more likely to experience
constipation with decrease in sensation isn't firing to brain
209
priority urgent assessment of male genitalia
- testicular torsion versus epididymitis
- fournier's gangrene
- cathether-acquierd urinary tract infection
- anorectal difficulties
- colorectal cancer
210
testicular torsion versus epididymitis
- penile pain
- scrotal pain
- twisting of spermatic cord cutting BF from area surrounding it
- surgical emergency
- epididymis inflammation
211
fournier's gangrene
- happens mostly to diabetics
- necrotizing bacteria of the perineum or around area causing gangrene
- can be from peripheral neuropathy due to diabetes
- presents as swelling pain, worsening
- surgical intervention
212
CAUTI
- high incidence of UTIs without proper cleaning and maintenance of catheter
- 75% of hospital admissions
213
colorectal cancers
- encourage people to have rectal exams as it is one of the most curable to without having proper precautions of self assessment, there will be a society with increase prevalence` of colorectal cancer
214
assessment of risk factors for male genitalia
- past med hx
- med and surgical hx
- life style and personal habits: 5Ps (partners, practices, protection, past hx of STIs; prevention or pregnancy)
- meds
- family history
215
health goals
testicular/prostate cancer; family planning, STIs
216
common symptoms of male genitalia issues
- pain
- difficulties with urination
- ED
- penile lesions, discharge, rash
- scrotal enlargement
- older adults
- cultural considerations
217
comprehensive male genitalia assessment
- utilize inspection and palpation as appropriate
- groin
- penis
- scrotum
- sacrococcygeal areas
- perineal area
- inguinal region and femoral aras
218
anterior pituitary gland
secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
219
hypothalamus
releases FSH and LH via gonadotropin-releasing hormones (GnRH) and luteinizing-releasing hormones (LnRH); inhibits prolactin release
220
ovaries
estrogen and progesterone
221
ectopic pregnancy
fertilized egg that has implanted other than uterus
usually fallopian tubes but can be anywhere
burst fallopian tube can cause death
222
significant vaginal bleeding is equivalent to
soiling a pad every 30 minutes
223
high HR due to low BP from significant bleeding from uterus causes
anemia
low iron
pale
dizziness
224
placenta previa
placenta blocking way of vaginal birth
225
placental abruptio
bursting of placenta
226
gestational hypertension
preclampsia - 140/90
check kidney function, urine output, BUN/creatinine - objective data for hypotension
227
preterm labor
contractions more than 6/hr before 37 weeks
228
ambiguous genitalia at birth
common for drainage and swelling but if it doesn't go down there may be a concern for hermaphrodites, congenital abnormality
229
puberty: tanner stages
when taking care of adolescents
230
menopause
12 consecutive months without menses
231
menopause causes
- changes related to lack of estrogen and progesterone production
- vaginal infections, UTIs, dyspareunia, diminished libido
- increased risk for endometrial, vaginal, and vulvar cancers; unexpected signs and symptoms
- intmacy difficulties and physiological changes
232
age of onset of puberty
5 mo prior in african americans compared to whites
233
cultural variations and health disparities female genitalia
- some with greater sexual fluency and candidiness about sexuality
- personal choice, unrelated to culture and responsibility
- latina females have highest rates of cervical cancer and are more likely to die as a result
- african americans 2x more likely to die from cervical cancers compared to whites
- female circumcision
234
priority urgent assessment for female genitalia
- severe pain
- excessive vaginal bleeding
235
severe pain of female genitalia
- acute infection (PID, UTI)
- appendicits
- pancreatitis
- cholescystitis
- strangulated hernia
- muskuloskeletal trauma (ruptured bladder, spleen, liver)
- ectopic pregnancy
- ovarian cyst
236
excessive vaginal bleeding
change from normal menstruation cycle occurring outside normal menses, during pregnancy, trauma
237
subjective data of female genitalia assessment
- past medical hx
- menstrual hx
- obstetrical hx: gravida; para; term; preterm; abortion; living
- menopause
- gynecological hx
- immunizations
- sexual history
- lifestyle (sexual activity, birth control)
- STIs
- obesity
- osteoporosis
- contraceptives
-meds
- family hx
238
teaching and health promotion of female gentialia
- prevention of STIs
- menopause changes
- prevention of HPV and cancer
- genital self-exam
- elimination of female genital circumcision
- appropriate screenings
- immunizations: HPV vaccine
239
common symptoms of female genitalia pain
- pelvic pain
- vaginal burning, discharge, itching
- menstrual disorders
- structural difficulties
- sexual dysfunction
- hemorrhoids
240
pap smear if for
cervical cancers not STDs
241
role of the nurse in mental health scenarios
- assessment is subtle and indirect
- sensitive issues
- allow sufficient time to provide therapuetic interventions
- need time, follow-up, and allow for closure
- requires advanced education
242
violence
many forms, each with unique risk factors and characteristics
243
family violence
- biologically or legally related to offender
- domestic violence, intimate partner violence, male violence against women, child abuse, sibling violence, elder abuse, abuse during pregnancy
- threatened or actual physical or sexual violence, physiological/emotional abuse, and/or abuse during pregnancy
- acceptable by some cultures
244
intimate partner violence/domestic violence
- poorer the household, higher rate DV
- 6x more likely if female in lower socioeconomic status
245
female immigrants have higher rates of
violence
246
sexual violence
- forced sex in dating and marital relationships, gang rape, sexual harassment, inappropriate touching, molestation, sex w. patient, forced prostitiution, forced exposure to sexually explicit behavior
- child sexual abuse: adult rape
- cultural differences
247
human trafficking
- form of slavery
- sexual exploitation, forced marriage, cheap labor for domestic or commericial purposes
248
child abuse and maltreatment
- "red flags": anxiety, depression, aggression, anger
- sibling violence
- punking and bullying
249
most common form of child abuse
sibling abuse
250
elder abuse
- neglect, financial exploitation, abdonment
- intentional actions by caregiver or other person
- elder assessment instrument
251
vulnerable adults
- more likely to have disabilities
- abuse and neglect
- physical, sexual, physiological, financial abuse, and neglect
252
hate crimes
- "acts of physical harm and specific criminal threats motivated by animus based on race, color, national origin, religion, gender, sexual orientation, gender identity, or disability"
- victims develop depression and physiological trauma
- affect other = families, communities, entire nation
253
misuse of drugs
not taking drugs as prescribed
"instead of taking 2 i take 3"
254
addiction
have craving/obession with drug
chronic relapsing brain disease that craves that high despite any consequence
255
dependence
tolerance to med
if it is stopped, withdrawals
256
common substances
- alcohol
- caffeine
- canabis
- hallucinogens
- inhalants
- opioid
- sedatives, hypnotics or anxiolytics
- stimulants
257
substance abuse is most notable among
women, racial/ethnic minorities, older age adults, and lower education level and socioeconomic class
258
stats for substance abuse
stress, caregiver role strain, depression, anxiety, binge drinking, heavy alcohol use
259
alcohol use disorder
- needs to meet certain criteria
- mild, moderate, severe
- clinical institue withdrawal assessment for alcohol (CIWA)
260
CIWA
done with 2 nurses
treatment during withdrawls, visual hallucinations, auditory hallucinations, headache, feeling sick
261
opioid crisis
- includes prescription opioids, heroin, synthetic opioids (fentanyl), animal sedatives (carfentanil)
- commonly results in overdose death
- requires immediate emergency interaction with multiple doses of naloxone
- nonfatal cases leave emotional ,physiological physical impacts on pt and family
262
priority urgent assessment of mental health
- includes questions about violence and harm to self or others: risk for injury w/ psychotic states, depression, dementia delirium, suspected violence, risk for harm requires urgent attention, homicidal or suicidal thoughts require urgent attention
- question safety first, presenting situation last
- prevents forgetting to ask critical questions about safety
- allows more time to focus on pressnting situation
263
subjective data collection for mental health
- includes what pt says directly to you, what you overhear pt say, and what family and friends report
- open-ended questions
- validate patient given information through family or friends
- must listen not only for what is said but what is unsaid
- nurse must be comfortable and deal with own feelings and beliefs to help pt
- pt may use diversionary tactics, avoid answering questions, be fearful
264
interviewing pt about violence
- key aspect: asking about personal experiences of violence
- universal rule: conduct patient interview in private, with no one else: pay attention to individual who comes with pt and does not want or refuses to leave pt with you
- assess violent experiences as normal and natural
- following listening principles
265
alcohol and drug use disorder interview
- occurs together in about half the population
- may be labeled "dual diagnosis"
- may be linked to personality disorders, PTSD, OCD, panic disorder, social phobias, seecific phobias, major depression, manic depression, schizophrenia
- often needs psych referral
- denial part of substance use disorder
- assess curent and past use of tobacco, alcohol, prescription, and OTC products
- CAGE assessment
266
risk factors for mental health conditions
- past med hx
- violence
- alcohol and drug use
- meds
- family hx
267
delirium, dementia, and depression assessment
onset:
- delirium: acute over few hours; lasting hours to weeks. occurs in context of medical illness, substance misuse, or withdrawal
- dementia: slow, lasting months to years
- depression: slow
description:
- delirium: impaired recent remote memory; fluctuating attention; thoughts disorganized; change in cognition; clouding of consciousness; perceptual disturbances; without mood components
- dementia: impaired remote memory; attention preserved; thoughts impoverished; global impairment of intellect; alert
- depression: impaired memory; aware; attention intact; impaired concentration; if psychosis present, usually systematized normal emotional responses; perceptual disturbances; sad effect or mood
268
DDD Assessment
- can be acute
- delirium can place patient at risk for injury
- risk of suicide increases with depression
- risk of suicide increases with depression
- effective treatment relies upon accurate assessment and diagnosis
269
teaching and health promotion: mental health
- current stressors and coping
- pervasive worry or anxiety
- altered mood or affect
- memory, concentration, and problem soliving abilities
270
general health goals for mental health
- decrease suicide risk
- increase # of individuals with co-occurring substance use and mental health disorders who receive treatment
- increase # of adults w/ serious mental illness to receive treatment
- reduce ED visits for harms from nonmedical use of prescription opioids
271
signs and symptoms of mental health issues
- suicidal ideation (SAD PERSONAS)
- homicidal ideation and aggressive behavior
- altered mood and affect (mood disorders)
- auditory or visual hallucinations
- olfactory and tactile hallucinations
272
older adults and mental health
geriatric depression scale
delrium, dementia and depression table
273
ABCT
- A: appearance (overall appearance, posture, movement, hygeine, grooming, dress)
- B: behavior (LOC, eye contact and facial expressions, speech)
- C: cognitive function (orientation, attention span, memory MMSE, minicog, judgement)
- T: thought processes and perceptions
274
drug and alcohol use test
CAGE
CAGE-AID
275
alcohol withdrawal test
CIWA
276
mini-cog
used to assess cognitive function in individuals presenting with signs of dementia
277
