Module 2 Flashcards
Describe the decorticate posture
Client with lesions of the corticospinal tract and draws hands up to chest
Describe the decerebrate posture
Client with lesions of the diencephalon (midbrain) or pons extends arms and legs, arches back, and rotates hands and arms internally
What assessment questionnaire is used to determine if an alcohol assessment is needed
CAGE
Cut/Annoyed/Guilt/Eye-opener
What assessment guide is used to assess the likelihood of a suicide attempt
SAD PERSONS
(Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, Sickness)
Questions to ask to assess the patient’s LOC
Name, address, phone number, where they are currently, the day, appropriate time of the day
What is the Glasgow Coma Scale (GCS) used for
To assess which clients are at a high risk for rapid deterioration of the nervous system
(Scale of 14 indicates an optimal LOC)
In Erikson’s stages of psychological development, describe the infant stage
Basic trust vs mistrust
Describe the toddler stage in Erikson’s psychosocial development
Autonomy vs shame and doubt
Describe the preschooler stage in Erikson’s psychosocial development
Initiative vs guilt
Describe the school-ager stage in Erikson’s psychosocial development
Industry vs. inferiority
Define acute pain (2)
Rapid onset and a short course
Usually associated with an recent injury
Define chronic (nonmalignant) pain (2)
Usually associated with a specific cause of injury
Constant pain that persists for more than 6 months
Define cancer pain (2)
Compression of peripheral nerves
Damage to these structures following surgery, chemo, radiation, tumor growth filtration
3 types of cancer pain
Somatic
Visceral
Neuropathic
Many clients with cancer experience ___ pain (brief severe pain that occurs in spite of pain meds)
Breakthrough
Cancer pain can result from (7)
Blocked blood vessels causing poor circulation Bone fracture from metastasis Infection Inflammation Psychological/emotional problems Side effects from cancer treatments Tumor exerting pressure of a nerve
What does the sympathetic nervous system do to the body? (4)
Heart rate
Constricts blood vessels
Raises the BP
“Fight or flight”
Physiologic response to pain (5)
Anxiety Fear Hopelessness Sleeplessness Thoughts of suicide
Patient expresses these when in pain (5)
Reports of pain Cries Moans Frowns Facial grimaces
What hormones are elevated when the SNS is activated? (5)
Antidiuretic Epinephrine Norepinephrine Aldosterone Glucagons
7 dimensions to pain
- Physical (patients perception of pain)
- Sensory (quality of the pain)
- Behavioral (patient demonstrates pain)
- Sociocultural (cultural background)
- Cognitive (beliefs, attitudes, intentions, motivating related to pain)
- Affective (feelings, sentiments, emotions)
- Spiritual (attributes to pain, self, others, and the divine)
Define COLDSPA
- Character (description in patients words)
- Onset (when did it start)
- Location (where is it?/radiate)
- Duration (how long does it last?)
- Severity (identify precipitating factors)
- Pattern (continuous/intermittent)
- Associated factors (what factors relieve/increase pain)
Describe FLACC pain assessment for children
Face Legs Activities Cry Consolability
4 abnormal LOC
- Lethargy - client eyes open, answers questions, falls back asleep
- Obtunded - client opens eyes to loud voice, responds slowly with confusion, seems unaware of environment
- Stupor - client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
- Coma - client remains unresponsive to all stimuli; eyes stay closed
What do you assess using the GCS? (3)
Eye opening
Verbal response
Motor response
15 symptoms of depression
Falling asleep frequently Ability to sleep through night Waking up too early Sleeping too much Feeling sad Decreased appetite Increased appetite Decreased weight Increased weight Concentration/decision making View of oneself Thoughts of death/suicide General interest Energy level Feeling slowed down
Actual RN Dx with impaired verbal communication R/T….(4)
- international language barrier
- hearing loss
- inability to clearly express self or understand others
- aphasia, psychological impairment, organic brain disorder
Actual RN Dx regarding mental status and substance abuse (7)
- Anxiety R/T awareness of increasing memory loss
- acute or chronic confusion R/T dementia, head injury, stroke, alcohol or drug abuse
- impaired memory R/T dementia, stroke, head injury, alcohol or drug abuse
- dressing/grooming self-care deficit R/T confusion and lack of resources/support from caregivers
- disturbed thought process R/T alcohol or drug abuse, psychotic disorder, or organic dysfunctional
- social isolation R/T inability to relate/communicate effectively with others
- complicated grieving R/T suicide of child and increasing isolation from support systems
What types of data is included in the RN history (3)
Psychosocial
Cognitive
Moral developments
What subjective data is included in the RN history (5)
Biographical data Hx of present health concerns Personal health Hx Family Hx Life and health practices
8 pain assessment tools
- Visual analog scale (VAS)
- Numeric Rating scale (NRS)
- Numeric pain intensity scale (NPI)
- Verbal descriptor scale
- Simple descriptive pain intensity scale
- Graphic rating scale
- Verbal rating scale
- Faces pain scales (FPS)
Barriers to pain assessment with people with cultural background (6)
- Asian and Asian American - pain is honorable
- African American - God and prayer will help more than medicine
- Hindu - pain endured in the preparing for the next life in the cycle of reincarnation
- Native American - metaphors and images from nature are used to describe pain
- Hispanic - pain is often very expressive
- Jewish - pain is expressed openly, with much complaining, pain must be shared, recognized, and validated by others so the experience is affirmed
What do you inspect when you assess for pain (4)
Posture
Facial expressions
Joints and muscles
Skin for scars, lesions, rashes, changes, or discoloration
Protocol for pain management (3)
Get analgesic ordered
RN observe for changes in self-report
Follow up
QUESTT principals for pain in children
Question the child Use pain rating scales Evaluate behavior and physiologic changes Secure parent's involvement Take cause of pain into account Take action and evaluate results
Describe melanoma (2)
Malignant - most serious skin cancer
Most rapidly increasing form of cancer in US
Define macule and 7 examples
Small flat nonpalpable skin color change. Less than 1 cm with a circumscribed border
Freckles, flat miles, petechiae, rubella, vitiligo, port wine stains, ecchymosis
Mnemonic for assessing suspicious lesions
Asymmetry Border Color Diameter Elevation
What tool is used to assess for fungal infections
Wood’s light
What scale is used to detect pressure sore risk
Braden
Describe vesicles and 5 examples
Circumcised elevated palpable mass containing serious fluid. Less than 0.5 cm
Herpes simplex/zoster, varicella (chicken pox), poison ivy, 2nd degree burn, shingles
Describe bulla and give 5 examples
Circumcised elevated palpable mass containing serious fluid. Larger than 0.5 cm
Pemphigus, contact dermatitis, large blister burns, poison ivy, billows impetigo
Describe papule and give 3 examples
Elevated palpable solid mass. Circumscribed border less than 0.5 cm.
Nevi, warts, lichen planus
Describe each pressure ulcer stage
Stage 1- nonblanchable redness of a localized area, painful
Stage 2- partial thickness loss of dermis, shallow open ulcer, red-pink wound bed without slough
Stage 3- full thickness tissue loss, bone, tendon, or muscle NOT exposed
Stage 4- full thickness tissue loss, exposed bone, tendon, or muscle. Slough or eschar may be present
Unstageable- full thickness tissue loss, covered by slough and/or eschar in the wound bed
2 RN Dx with impaired skin integrity R/T…
- Poor nutritional intake and/or bowel/bladder incontinence
- Immobility and deceased circulation
RN Dx when analyzing data from a skin, hair and nail assessment (4)
- Ineffective health maintenance R/T lack of hygienic care of the skin, hair, and nails
- disturbed body image R/T scarring, rash, or other skin condition that alters skin appearance
- deficient fluid volume R/T excessive diaphoresis secondary to excessive exersise and high environmental temps
- disturbed sleep pattern R/T persistent itching of the skin
What is a useful landmark in the cervical area to determine other vertebrae
Cervical vertebrae C7
Purpose of lymph nodes
Filter lymph before it returns to the vascular system
10 lymph nodes
- Preauricular
- Posterior auricular
- Occipital
- Superficial cervical
- Deep cervical chain
- Posterior cervical
- Supra clavicular
- Tonsillar
- Submental
- Submandibular
Leading cause of brain injuries
Falling (35.2%)
3 risks for a TBI for infants and toddlers
- Environmental risks for falls
- Lack of parental knowledge of shaken baby syndrome
- Caregivers risk of shaken baby syndrome
2 risks for TBI for children and teens
- Knowledge and use of protective equipment in sports and bicycle use
- Knowledge and use of safety practices when driving
3 risks for TBI for adults and older adults
- Knowledge and use of safety practices when driving
- Impairment of physical/mental activity
- Potential for maltreatment or domestic violence
What kinds of questions would you ask if you were obtaining lifestyle and health practices (5)
Do you smoke or chew tobacco?
Do you drink alcohol?
Do you wear a hardhat for hazardous occupations?
What recreational activities do your participate?
What is your typical posture when relaxing, sleeping, and working?
How to palpate the thyroid gland
Use a posterior approach
Stand behind client
Client lowers chin to chest and turn neck slightly
Place thumbs on nape of neck with other fingers on either side of the trachea below cricoid cartilage
Use fingers to push trachea
5 different types of headaches
Sinus Cluster Tension Migraine Tumor related
Characteristics of sinus headache
Occurs with or after a cold or acute sinusitis or acute febrile illness with purulent discharge from nose.
Occurs in 1 area of face along eyebrow ridge and below cheek bone.
Lasts until associated condition is improved.
Moderately severe.
Pain is worse with sudden movements of head
Characteristics of cluster headache
Sudden onset may be precipitated by ingesting alcohol.
In the eye and orbit and radiating to the facial and temporal regions.
Occurs in late evening or night.
Intense pain.
Movement or walking back and forth may relieve the discomfort.
Characteristics of tension headache
No prodromal stage may occur with stress anxiety or depression.
In the frontal temporal or occipital region.
Lasts days, months, or years.
Aching pain.
Symptomatic relief may be given by local heat, massage, analgesics, antidepressants, and muscle relaxants
Characteristics of migraine headache
May have prodromal stage (visual disturbances, vertigo, tinnitus, numbness or tingling of fingers or toes) may be precipitated by emotional disturbances, anxiety, or ingestion of alcohol cheese chocolate or other foods.
Around eyes, temples, cheeks, forehead may affect only 1 side of face.
Lasts up to 3 days.
Throbbing severe pain.
Usually subsides later in day.
Characteristics of tumor related headaches
No prodromal stage may be aggravated by coughing sneezing or sudden movements of the head.
Location depends on tumor.
Occurs in morning and lasts for several hours.
Variable in intensity of pain.
Usually subsides later in day.
RN Dx with ineffective health maintenance R/T…(2)
- refusing to wear protective gear during contact sports or seat belt while driving or riding as a passenger
- disregard for the effects and dangers associated with smoking and using dip
RN Dx with imbalanced nutrition R/T…(3)
- less than body’s requirements R/T increased metabolism secondary to hyperthyroidism
- more than body’s requirements R/T decreased metabolism secondary to hypothyroidism
- less than body’s requirements R/T difficulty swallowing which limits consumption of food
RN Dx with analyzing data from a head and neck assessment (7)
- ineffective tissue perfusion R/T cerebral R/T impaired circulation to brain
- activity intolerance R/T fatigue and weakness secondary finalized metabolic rate secondary to hypothyroidism or to surgery of head neck or face
- constipation R/T hyperthyroidism or hypothyroidism
- chronic pain sinus headache R/T inflammation of sinuses secondary to seasonal allergies
- disturbed body image R/T head injury
- impaired swallowing R/T mechanical obstruction of the head and neck secondary to tissue swelling tracheostomy or abnormal growth
- impaired swallowing R/T lack of gag reflex paralysis of facial muscles or decreased cognition
