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NUR101 > Nur 101 Unit 2 > Flashcards

Nur 101 Unit 2 Flashcards

1
Q

Conversions

5ml =

A

1tsp

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2
Q

Conversions

1tbs =

A

3tsp = 15ml

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3
Q

Conversions

2 tbs =

A

1oz

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4
Q

Conversions

1oz =

A

30ml

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5
Q

Conversions

8oz =

A

1 cup

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6
Q

Conversions

16oz =

A

1pint = 2cups

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7
Q

Conversions

32oz =

A

1qt = 2 pints

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8
Q

Conversions

4qts =

A

1 gal

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9
Q

Conversions

1000ml =

A

1L = 1qt

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10
Q

Conversions

1000 mcg =

A

1mg

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11
Q

Conversions

1000mg =

A

1 gm

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12
Q

Conversions

1000 gm =

A

1 kg

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13
Q

Conversions

60mg =

A

1 gr (grain)

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14
Q

Conversions

1kg =

A

2.2 lbs

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15
Q

Conversions

1 lbs =

A

454gm = 0.454 kg

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16
Q

Conversions

1lb =

A

16 oz

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17
Q

Conversions

28.4gm =

A

1oz

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18
Q

Conversions

1in =

A

2.54 cm

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19
Q

Factors to assess in evaluating nutrition and metabolism

A

Nutrition is Influenced by: ethnic heritage, experiences (+/-), media and community resources

Differences may explain other problems
Fluid intake
Problems r/t underweight/ obesity
Skin is the first defense against infection
HC treatment may interfere with cell metabolism

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20
Q

Nutrients

A

Supply the body with necessary elements for growth, maintenance, and repair.
- most nutrients and electrolytes are absorbed in the sm. intestine

Carbs, fats, proteins, and alcohol help provide energy and support metabolic processes

Essential nutrients, water, electrolyte, minerals, vitamins, and protein for tissue building.

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21
Q

Macronutrients

A

Carbohydrates

Protine

Fats

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22
Q

Macronutrients

Carbohydrates

A

Main energy source

Sources of CHO:
Fruits, veggies, grains, milk

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23
Q

Macronutrients

Protein

A

Essential in growth and repair of tissues

20 amino acids exist
10 essential amino acids
-not synthesized by body
-a compound protein food has all 10

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24
Q

Macronutrients

Fats

A

Main source of fatty acids

Essential for growth and development

Other functions:
Hormones, tissue structure, nerve impulse trans, insulation, protection

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25
Q

Macronutrients

Vitamins

Pg.W81

A

Water soluble

Fat soluble

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26
Q

Macronutrients

Minerals

Pg. W 81

A

Major

Essential

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27
Q

Metabolism

A

Process of producing and using energy within the body’s cells. The final process of nutrition

Fueled by nutrients :

  • Energy produced
  • energy used
  • needs to be balanced for health

Thyroid hormone players a major role

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28
Q

Why is energy used in the body

A

To maintain essential life processes (BMR)
- breathing, circulation, NS function

To support non essential life activities
- running, working, handling stress, some energy is used for digestion and absorption

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29
Q

Basal Metabolic Rate

BMR

A

The amount of energy required for essential life processes

It’s measures when the body is physically, metabolically, and emotionally at rest

Influenced by activity, hormonal imbalance, temp. Stress, illness

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30
Q

Metabolic processes

A

Blood channeled to the liver is where metabolic process occur

Anabolism

Catabolism

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31
Q

Metabolic processes

Anabolism

A
  • cell building
  • excess stored as fat and can be used for body needs if nutritional intake isn’t sufficient
  • fat excess= weight gain

(Lab assessment = positive balance )

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32
Q

Metabolic processes

Catabolism

A
  • break down of cells and tissues
  • necessary for a constant source of energy
  • excess= decreased weight
    -cont. excess = muscle wasting (ex diarrhea)
    (Lab assessment = negative balance )
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33
Q

Lab assessment for metabolism

Positive balance

A

More consumed than excreted

  • increased demand during pregnancy, growing, kids
  • anabolic state
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34
Q

Lab assessment for metabolism

Negative balance

A

Intake less than output
-loss of protein in the form of muscle and other tissue.
- metabolic demands are not met
( catabolic state)

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35
Q

Lab assessment for metabolism

Lab test

A

24 hr urine
24 hr calorie counting, looking at the protein and nitrogen intake.
BUN blood test
Albumin and protein blood test to ck for deficiencies ( nessary for wound healing)

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36
Q

4 stages Pressure ulcers
-Skin deprived of oxygen

Stage 1

A
  • Blood stasis
  • Redness not relieved by massage or pressure relief
  • warm to touch
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37
Q

4 stages Pressure ulcers
-skin deprived of oxygen

Stage 2

A
  • Epidermal loss, possible damage to the dermis
  • moist and depressed skin, erosion, abrasions, blister, shallow crater
  • can heal ok R/t no blood vessel damage
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38
Q

4 stages Pressure ulcers
-skin deprived of oxygen

Stage 3

A
  • full thickness skin loss
  • ulcer can extend to subcutaneous layer
  • drainage is common( suro-sanguinous or purulent)
  • healing time is longer and needs regranulation
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39
Q

4 stages Pressure ulcers
-skin deprived of oxygen

Stage 4

A
  • full thickness deep into CT, muscle, bone.
  • may have necrosis
  • need adequate protein and albumin levels for healing( attn nutrition. Pt put on special diet)
  • healing time is longer
  • may need debridement
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40
Q

Debridement

2 types

A

Cut away necrotic tissue

Wet to dry dressing changes

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41
Q

Conversions

1ml =

A

15 drops

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42
Q

Lymphatic system

Lymph node examination

A

Palpation: roll up and down b/t fingers. Only visible if inflamed

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43
Q

Lymphatic system

Lymphadenitis

A
  • Inflammation of lymph nodes

- painful

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44
Q

Lymphatic system

Lymphangitis

A

Inflammation along the course of the lymph vessel

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45
Q

Lymphatic system

Lymphadema

A

Tissue swelling

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46
Q

Thyroid gland

Secretes 3 hormones

A

T3
T4
Calcitonin

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47
Q

Thyroid gland hormone

T3

A

Increases BMR with increase oxygen consumption
Increases chem rxn rates
Stimulates metabolism of essential nutrients
Promotes human growth
Short lifespan

48
Q

Thyroid gland hormone

T4

A

Same functions as T3
Can be converted into T3
Secreted in larger amounts
Longer life span than T3

49
Q

Thyroid gland hormone

Calcitonin

A

Calcium metabolism

50
Q

ParaThyroid glands

A

Located on the posterior surface of the thyroid gland

Regulates calcium phosphorus metabolism

51
Q

Hyperthyroidism

A
  • Exophthalmos
    • weakness, fatigue
    • diaphoresis(sweating)
    • tachycardia, chest pain, dysrhythmias, increased BP
    • weight loss, increases appetite, diarrhea or constipation
    • restlessness, nervousness, insomnia, irritable, hyperactivity
52
Q

Hypothyroidism

A

Myxedema

  • decreased cardiac output and condition, enlarged heart, decreased BP
  • atherosclerosis, increased colesterol
  • lethargy, fatigue, slow speech, thick tongue, deep voice
  • weight gain, decreased appetite, decreased peristalsis, constipation
  • dry brittle hair
  • facial edema
  • memory impairment
  • cold tolerance, cold extremities
53
Q

Skin assessment tips

A 
Use inspection and palpitation
Good lighting
Evaluate areas at risk(pressure points)
Inspect all wounds, under skin folds
Compare right to left
Investigate any abn new finding and describe throughly
54
Q

Other skin related problems:

• Diabetes:

A

chronic skin infections with ulcerations (especially on the feet), poor wound healing, yeast infection under breasts, between fingers and toes, axilla and genital area

55
Q

Other skin related problems:

• Liver Disease:

A

jaundice, edema, ascites (fluid in abdomen), impaired protein metabolism with ETOH (alcohol), red palms and spider veins all over.

56
Q

Other skin related problems:

• Renal Disease:

A

pallor (pale), platelet disfunction, jaundice, edema

57
Q

Other skin related problems:

• Cancer:

A

of the skin

58
Q

Other skin related problems:

• Fluid imbalance:

A

edema if excess; decreased turgor, dryness, wrinkles, brittle skin and nails if fluid intake inadequate.

59
Q

Other skin related problems:

• Impaired O2:

A

pallor, cyanosis (blue lips, mouth, fingertips, toes), flushing, mottling (patches of blue/black areas), cold, clammy

60
Q

Other skin related problems:

• Peripheral Vascular Disease (PVD):

A

not enough blood and O2; pale, mottling, necrosis, cold, ulcerations

61
Q

Other skin related problems:

• Skin Infections:

A

fungal vs viral, herpes, cold sores, ringworms, scales, scabies, flaking, eggs, lice, nits, vesicles (blisters)

62
Q

Interview questions regarding

A 
Diet
Weight problems 
Ingestion problems
Food and fluid intake
N/V
Preferences
Activity level
Psychosocial, cultural and personal influence 
Nutrition knowledge (can they read food lables)
Physical change
63
Q

Physical assessment

Assess for…

A 
Subcutaneous fat (palpitation) 
Muscle mass
Hight and weight
Skin integrity
Hair
Nails
Oral cavity
Abdomen (palpitation) 
Thyroid gland(palpitation) 
Body temperature (palpitation)
64
Q

Skin assessment

A 
Color 
pigment 
moisture
Temp
Thickness
Texture
Turgor
Mobility
Hygiene
Lesions
65
Q

Hair assessment

A 
Color
Pigment
Quantity
Texture
Distribution
Hygiene
66
Q

Nail assessment

A 
Shape 
Configuration
Color
Lesions
Thickness 
Capillary refill
-160 degree angle
-clubbing( lack of O2)
-spooning(illness and sickness)
-cyanosis
67
Q

Skin deviations

Edema

A 
Excess fluid in tissue.
Assess for pitting and timing to return back to normal positioning.
Assessment and documentation of edema
-trace
-1+ =2mm
-2+ =4mm
-3+ =6mm
-4+ =8mm
Brawny = warm, shiney, tight, weeping
68
Q

Skin deviations

Turgor

A

Elasticity(dehydration)

  • brisk
  • sluggish(ck for tenting of the skin)
69
Q

Cognitive-perceptual

Describes the :

A

Ability to collect and use information

Decision making and other cognitive processes

70
Q

Neurological system

A

Major biological support system

- neuro pathology affects this system

71
Q

Cognition

A 
The process of knowledge 
Involves:
Intellectual function 
Learning
Motivation 
Thinking
Thought processes
Problem solving
72
Q

Perception

A

The process of acquiring info
Involves:
Using senses
Meaningful interpretation

73
Q

Goals for assessing cognitive perception

A

Note status of all senses

Note awareness of self-surroundings

ID risk factors

Note ability and knowledge to manage health

74
Q

Perception of pain /severe discomfort signals

A

Possible tissue damage

75
Q

Pain

A

Is whatever the client says it is and exist wherever they say it is(subjective)
Interferes with life activities
Results in stress and anxiety
Need to be documented per TJC
Identification and tx is important criterion of quality of care

76
Q

Perception

A

Is a protective mechanism
-Vision hearing and touch contributes to
Enjoyment of people
Relationships
Appreciation of the world
-provides information used in higher cognitive processes

77
Q

Mental health status assessment

LOC

A

Degree of
wakefulness
Arousability

78
Q

Mental health status assessment

Awareness

A

Ability to
Understand
Think
Feel emotions

79
Q

Mental health status assessment

Thought process

A 
Abstract thinking
Problem solving
Insight 
Memory
Judgment
Attn span
Understanding language 
Ability to follow directions
80
Q

Mental health status assessment

Communication ability

A 
Speech
Comprehension of language 
Ability to
Hear
Answer simple questions
Follow simple commands
81
Q

Individual assessment includes

A

Adequate senses( hearing, taste, touch, smell, vision)
Compensation( glasses, hearing aids)
Pain management
Cognitive functional abilities (orientation, memory, reasoning, judgment, decision making)

82
Q

Glascow coma scale

A 
Standardized assessment tool for assessing 
LOC
Cerebral dysfunction 
-assess eyes opening
-Motor and verbal responses 
Burton p.430
83
Q

Levels of consciousness

LOC

A 
Fully awake
Alert
Lethargic
Obtuned
Stuporous/ semicomatose
Comatose
84
Q

Levels of consciousness
LOC

Fully awake

A

Highest level

85
Q

Levels of consciousness
LOC

Alert

A

Awake and oriented

Responds to verbal commands

86
Q

Levels of consciousness
LOC

Lethargic

A 
Not fully alert
Drowsy/sleepy
Arousable
Looses train of thought( disoriented )
Spontaneous movements
87
Q

Levels of consciousness
LOC

Obtuned

A

Sleep most of the time
Few spontaneous movements
More rigorous stimulation to arouse
Decrease in appropriate responses to verbal commands

88
Q

Levels of consciousness
LOC

Stuporous/ semicomatose

A 
Unconscious most of the time
No spontaneous motor activity
Strong stimuli to arouse(pain)
Verbal responses limited or absent( moans and groans) 
Rarely awake or oriented
89
Q

Levels of consciousness
LOC

Comatose

A

Unable to arouse with painful stimuli
+ gag reflex
+ cough
If no reflexes, in deep coma

90
Q

3 types of Posturing

A

Decorticate Flexor
Decerebrate Extension
Flaccid

91
Q

3 types of Posturing

Decorticate Flexor posturing

A

Abn FLEXION posturing
May be in response to pain or may me spontaneous

Brain damage above the brainstem

92
Q

3 types of posturing

Decerebrate extension posturing

A

Abn EXTENSION posturing

To stimulus or spontaneous
Damage IN brainstem

Ominous sign

93
Q

3 types of posturing

Flacid

A

Limp

without muscle tone

94
Q

Increased intracranial pressure

IICP

A

Decreased LOC and reflexes
HA, restless
Change in respiratory status

Increase or decrease in pulse
Increase in BP
Widening pulse pressure

95
Q

Communication

Aphasia

A

Inability to express oneself properly thru speech
2 kinds
Expressive- can’t form words
Receptive- confused with words coming out.

96
Q

Neuro assessment

PERRLA

A 
Puples
Equal
Round
React to 
Light
Accommodation
97
Q

Neuro assessment

Accommodation

A

Pupils constrict as objects come closer

98
Q

Neuro assessment

Convergence

A

Eye cross as objects come close

99
Q

Pain thershold

A

Point at which pain is felt

100
Q

Pain tolerance

A

Pain endurance

101
Q

Acute pain

A

Significant, severe
Recent onset
Damage or injury has occurred

102
Q

Chronic pain

A

Consistent or intermittent
Persistent beyond expected healing time
Poorly defined
Problematic

103
Q

Pain types

A 
Somatic
Visceral
Phantom
Neuralgia
Causalgia
104
Q

Pain types

Somatic

A

Can be localized originates in trunk, skin, or bone(external)

105
Q

Pain types

Visceral

A

Internal organs ( ischemia, spasms, radiates from origin like with chest pain(referred) can’t be sharply localized( internal)

106
Q

Pain types

Causalgia

A

Intense pain after trauma that involves peripheral nerves of an extremity

107
Q

Diagnostic test

Sensory perception

A 
Traumatic injury
CVA
fluid and electrolyte Imbalance 
Hypoxia 
Medications
108
Q

Diagnostic test

Blood test

A 
Blood sugar
Blood urea nitrogen (BUN)
Arterial blood gases (ABG's)
Electrolytes
Calcium
Toxic substances (drug, ETOH)
109
Q

Diagnostic test

X- Ray

A

Fractures
Motor dysfunction
Degenerative joint disease (DJD)

110
Q

Diagnostic test

MRI

A

Trauma
Meligancy
Cerebral / spinal cord
Infractions

111
Q

Diagnostic test

CT

A

Lesions

Malignancies

112
Q

Diagnostic test

Cerebral angiogram

A

Dye test for blood vessel evaluation

113
Q

Diagnostic test

Electromyography (EMG)

A

Assess nurse and muscle response to electrical stimulation

114
Q

Diagnostic test

Electroencephalogram (EEG)

A

Recording of brain activity to do brain death or epilepsy

115
Q

COGNITIVE -PERCEPTION Nursing DX

A 
Acute pain
Chronic pain
Disturbed sensory perception 
Unilateral neglect
Deficient knowledge 
Disturbed thought process
Acute confusion
Readiness for enhanced decision making
Impaired environmental interpretation syndrome( common in CVA pt)
Chronic confusion
Readiness for enhanced knowledge
Decision all conflict
Impaired memory
116
Q

Nutrition- metabolism nursing DX

A 
Failure to thrive(adult)
Imbalance nutrition: less than/ more than
Breastfeeding 
- interrupted
-ineffective
-effective
Impaired swallowing
Nausea

NUR101 (4 decks)

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