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Clinical > Phys Assessment > Flashcards

Phys Assessment Flashcards

1
Q

What does subjective mean?

A

What someone tells you (history)

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2
Q

What does objective mean?

A

measurment/reading (phys exam)

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3
Q

What are the 2 components of clinical reasoning?

A

Diagnostic & Critical Thinking

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4
Q

What is the diagnostics composed of

A

cues, info, signs, symptoms, lab data

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5
Q

what is the difference between a sign and symptom

A

sign= you can see it, symptoms= experiences

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6
Q

What are the 6 nursing processes

A

ADOPIE= Assess, diagnostic, outcome, planning, implementation, evaluation

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7
Q

Medicine Treats…

A

disease

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8
Q

Nursing…

A

how patient reacts

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9
Q

Diagnosis

A

Valid influences, compare “clusters”, identify related factors

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10
Q

Outcome

A

realistic, something that can be measured, TIME FRAME, unique to PT

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11
Q

Planning

A

establish priorities, refer back to outcomes, plan of care, interventions

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12
Q

Implementation

A

readiness, review interventions, collaborate team members, counseling, refer continuing care

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13
Q

Evaluation

A

meet or did not meet final outcome

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14
Q

What are the first priorties that are essential?

A

ABCs= Airway, breathing, circulation (brain)

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15
Q

What are some components of Critical Thinking

A

identify assumptions, validate, normal/abnormal, relevance, inconsistencies, patterns, missing info, actual & potential risk, setting priorities, patient centered, evaluate

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16
Q

4 Types of Data

A

1) Complete Health Data 2) Episodic/Problem Centered/Focus data 3) Follow-up data 4) Emergency data base (ABCs)

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17
Q

Expanding Concepts of Health…x5

A

1) Biomedical Model 2) Holistic Health (whole body, culture) 3) Health promotion/prevention 4) culture 5) genetics

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18
Q

High level assessmen

A

holism, life cycle, culture must not detract from importance, hands on expertise

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19
Q

Interview means

A

factors that may affect communication

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20
Q

3 Phases of Interview

A

1) Process of Communication 2) Internal 3) External Factors

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21
Q

Process of Communication means.

A

sending/receiving internal/external facotrs

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22
Q

Internal Factors composed of…

A

empathy, ability to LISTEN

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23
Q

External Factors composed of

A

privacy, refuse interruptions, phys envt, dress, note taking, recording, electronic health record

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24
Q

Techniques of Communication

A

open vs closed ended questions (case by case), nonverbal skills, eye contact, voice, touch, dress

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25
Q

What do adolescents prefer being around?

A

peer groups

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26
Q

What are you viewing in infants?

A

nonverbals

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27
Q

At what ages are parents involved in the interviewing?

A

Infant-school age

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28
Q

What should you watch for in communication with older people

A

slang words

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29
Q

What are some special need situations

A

acute illness, under the influence, anxious, crying, sexually aggressive, hearing impaired

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30
Q

What type of questions should you ask for special need situations

A

closed questions

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31
Q

What is the first thing you should do in cross cultural situations

A

identify your own biases

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32
Q

What does cross cultural communication entail?

A

etiquette, space & distance, cultural considerations on gender, sexual orientation

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33
Q

What are ways we overcome communication barriers

A

interpreters, vocal cues, action cues, object cues, space/touch

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34
Q

Are mental status assessments objective or subjective

A

always subjective

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35
Q

What does etiology mean

A

cause

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36
Q

What are 2 types of measuring mental disorders

A

organic & psychiatric

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37
Q

What is an example of an organic mental disorder

A

alzheimers, dementia, bc they are known causes

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38
Q

Alert & Oriented x 4 (behavior orientation)

A

1) person 2) place 3) time 4)situation (what brought you here)

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39
Q

What is recent memory?

A

short term

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40
Q

What is remote memory

A

long term

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41
Q

What does perception mean?

A

awareness of 5 senses

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42
Q

What are 4 components of mental health assessment

A

1) appearance 2) behavior 3) cognition 4) thought processes

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43
Q

What does aphasia mean

A

language impairment

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44
Q

QPR stands for

A

question, persuade, refer

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45
Q

Broca refers to

A

physical incapability to speak

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46
Q

Wernicke

A

not being able to speak correctly

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47
Q

presbycusis means

A

age related hearing loss

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48
Q

Define health

A

balance of person with one’s physical, mental, and environment

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49
Q

Illness

A

loss of balance with physical, mental and environment

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50
Q

What is ethnicity

A

a group having similar traits: common language, common heritage and cultural similarities

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51
Q

Race

A

relates more towards the appearance of a person. Biologically with inherited genetic traits.

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52
Q

Nationality

A

place where the person was born

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53
Q

Heritage

A

ancestors of a person

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54
Q

Culture

A

more of a microcosm; one trait or characteristic

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55
Q

What is a database?

A

Sub & Objective data gathered from a patient plus the results of any diagnostic studies completed

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56
Q

What is a nursing “diagnosis”

A

actual/potential health problems or of wellness strengths

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57
Q

Frequencies of visits…

A

varies depending on person’s illness and wellness needs

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58
Q

define cultural diversity

A

transcultural phenomenon. At least 2 people having diff cultural orientations

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59
Q

what does evidence based mean?

A

combining clinical expertise with the use of nursing research, while considered values of the PT

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60
Q

What is clustered data

A

patterns and relationships among the data

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61
Q

A good rule of an interviewer is to..

A

spend more time listening than talking

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62
Q

When a patient denies something but acts in the opposite

A

bring verbal and nonverbal behavior to PT attention

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63
Q

When should touch be used

A

if interviewer knows pt well

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64
Q

at what age should interviewer question child him/herself

A

age 7

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65
Q

What interviewing techniques should be avoided for an adolescent

A

silence and reflection

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66
Q

What is the proper distance for personal space

A

1.5-4 ft

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67
Q

Religion is defined as

A

belief in a divine or superhuman spirit to be obeyed or worshiped

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68
Q

Why is there a need for cultural care

A

demographic change

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69
Q

The imbalance of hot and cold is considered “illness” among…

A

Hispanic-American heritage

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70
Q

What is an amulet

A

the evil eye

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71
Q

What does empacho mean?

A

a culture-bound syndrome that ha no equivalent from a biomedical perspective

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72
Q

What does “review of systems” mean?

A

the evaluation of the past and present health state of each body system

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73
Q

What does PQRSTU Stand for

A

1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding

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74
Q

What 2 section of child’s health history become important to current health status

A

developmental and nutritional history

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75
Q

What is one way to detect dementia

A

mini-cog

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76
Q

A Major characteristic of dementia is

A

impairment of short & long term memory

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77
Q

Dysarthria

A

difficult or unclear articulation of speech that is otherwise linguistically normal.

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78
Q

What is echolalia

A

meaningless repetition of another person’s spoken words as a symptom of psychiatric disorder.

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79
Q

The part of the hand used for assessment of vibration are

A

ulnar surface of the hand

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80
Q

Performing indirect percussion, the stationary finger is struck where..?

A

at the middle joint

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81
Q

How would you describe the pitch of a sound wave obtained by a percussion

A

number of vibrations per second

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82
Q

The bell of the stethoscope is used for..

A

soft, low pitched sounds

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83
Q

Which aperture is used for a patient with undilated pupils

A

small

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84
Q

If an infant is asleep, where can you start with the examination

A

heart, lung, and abdomen

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85
Q

When does examination of a child change to head to toe

A

school age

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86
Q

When inspecting ear canal, which speculum is used for the otoscope

A

the largest that will fit

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87
Q

During gen survey what are the 4 areas of interest

A

1)Appearance 2)Body structure 3)Mobility 4)Behavior

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88
Q

What is gait

A

a person’s manner of walking

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89
Q

Measuring gait, the base is usually…

A

as wide as the shoulder width

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90
Q

What changes in head circumference measurements in relation to the chest will occur from infancy to early childhood

A

head will be 2 cm larger than the chest circumference. Between 6 months & 2 years they will be the same.

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91
Q

From 80 - 90 what happens to height and weight

A

both decrease

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92
Q

To accurately assess patients pulse what is the range?

A

start with zero to 30

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93
Q

A normal pulse for a patient is..

A

2+

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94
Q

How do you accurately assess a patient’s respiration?

A

count for 20 seconds

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95
Q

What is pulse pressure

A

the difference between systolic and diastolic pressure

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96
Q

What is coarctation?

A

narrowing of the aorta

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97
Q

If PT has coarctation the thigh pressure would be..

A

lower than in the arm

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98
Q

What is the mean arterial pressure

A

diastolic pressure plus one third pulse pressure

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99
Q

Why is sizing of a bp cuff important

A

too narrow will give false reading that is HIGH

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100
Q

Diastolic

A

when the heart refills with blood

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101
Q

systolic

A

when heart is contracting

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102
Q

what is nociception

A

pain receptors

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103
Q

neuropathic pain

A

burning painful sensation that moves around toes and bottoms of feet.

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104
Q

Diaphoretic means

A

inducing perspirations

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105
Q

visceral pain

A

sweating, pale, pain in abdomen

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106
Q

What is a pre-term baby more sensitive too

A

painful stimuli

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107
Q

What is the wong baker scale

A

visual facial expressions to define pain scale (ex broken arm)

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108
Q

analgesics

A

pain reliever

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109
Q

Complex Regional Pain I

A

chronic pain that usually affects an arm or a leg.

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110
Q

This is a pain problem expected with impaired older adult

A

peripheral vascular disease

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111
Q

What is a common physiologic change that occurs with pain

A

tachycardia

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112
Q

Assessing Pain Mnemonic

A

P- OLDCARTS

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113
Q

P-OLDCARTS

A

previous hx, onset, location, duration, character, aggravating, radiation, timing, severity

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114
Q

What are the 4 steps in a regular physical exam

A

1) inspection 2)Palpation 3)Percussion 4)Auscultation

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115
Q

What are the steps when examing the abdomen

A

1) Inspection 2)Auscultation 3) Palpation 4) Percussion

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116
Q

Gen Survey Application

A

1)Appearance 2)Body Structure (lordosis/kyphosis) 3)Gait (how they walk) 4)Behavior 5)Weight

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117
Q

What is the diurnal cycle

A

difference in temp in the morning vs afternoon (cooler in the morn)

118
Q

Ways to take temp

A

oral, electronic, axillary, rectal, tympanic membrane, temporal

119
Q

What is normal temperature in the mouth

A

98.6F or 37C

120
Q

What is normal temp in axillary

A

97.6F or 38.4C

121
Q

What is normal temp in rectum

A

99.6F or 37.6C

122
Q

What is normal temp in tympanic membrane?

A

98.6F

123
Q

What is the conversion Celsius to Fahrenheit

A

C= 5/9 (f-32)

124
Q

What is the conversion for Fahrenheit to Celsius

A

(9/5 x C) +32

125
Q

What is the formula for Cardiac Output

A

CO= SV x HR

126
Q

What is a normal amount of blood that gets pumped every heart beat?

A

2 ox or 70 mm

127
Q

Where do you place the stethoscope to listen to heart sounds

A

4-5 Intercostal

128
Q

What is normal for adults heart rate

A

50-100 beats/min (100+ is tachy)

129
Q

What i normal for infant heart rate

A

80-160

130
Q

What numeric is used for Force?

A

0-3+

131
Q

What is normal force

A

2+

132
Q

What is bounding or after a run

A

4+

133
Q

What is force is considered “weak”

A

1+

134
Q

What is respiration?

A

amount someone breaths in 1 iminute

135
Q

What is the ratio for pulse

A

4: 1

136
Q

When you see the ration for BP

A

Systolic is the higher # (top) Diastolic is lower #

137
Q

If the diastolic is high on the bottom is that concerning

A

yes

138
Q

Pulse Pressure =

A

Systolic - Diastolic

139
Q

Mean Arterial pressure

A

force that pushes blood into the tissues

140
Q

To hear Kortkoff sounds and you cant use the arm, what should you do?

A

use thigh

141
Q

What does the pulse oximeter do?

A

measure how much hemoglobin carries oxygen (95% or higher)

142
Q

What does a doppler do?

A

picks up changes in sound frequency as blood flows

143
Q

What is the best indicator of Pain

A

what they tell you

144
Q

What condition is hard to treat in terms of pain

A

Neuropathic pain, abnormal procession of pains messages

145
Q

Visceral means

A

organs

146
Q

Cutaneous means

A

skin

147
Q

What are signs of acute pain behavior

A

guarding, grimacing, moaning, restless, stillnes diaphoresis, vital signs change

148
Q

What type of palpation do you use for mobility and turgor?

A

Tenting

149
Q

When is mobility decreased

A

with edema

150
Q

When does tenting or turgor occur

A

severe dehydration or weight loss

151
Q

What does striae mean?

A

stretch marks

152
Q

What does sterile mean?

A
  • no life
  • using special gases
  • high heat
153
Q

For surgical apses how long do you wash your hands?

A

3 minutes

154
Q

When is surgical apses necessary?

A
  • intentional perforation of the skin
  • body cavity, not exposed to outside
155
Q

What are the golden rules of surgical apses

A
  • an object below the waist is contaminated, because it is out of range of vision
  • never turn your back on a sterile field
  • keep trashcan close by, or drop on ground
  • Both patient and provider wear mask
  • If you break sterile technique- START OVER
  • 1” border
156
Q

What makes a surface/ area contaminated

A
  • prolonged exposure to air
  • wet surfaces
  • 1” border is contaminated
157
Q

Are wrappers of sterile objects sterile?

A

NO

158
Q

Define a sterile field

A

room/space for handling sterile objects

159
Q

Name 5 types where patient needs surgical asepsis technique

A
  1. Open Body Cavity
  2. Catheter
  3. Burns
  4. Central Line
160
Q

Clean technique

A
  • removes majority of microorganisms, not everything
  • no autoclaving
161
Q

What is lipping

A
  • if you are using a solution more than once
    • pour some out before use
162
Q

When do you use sterile gloves for surgical asepsis?

A

once you’ve added everything to the sterile field

163
Q

What are the 4 things we asses for skin, hair , nails

A
  1. Structure/Function
  2. Subjective
  3. Objective
  4. Abnormal findings
164
Q

What is the largest organ and our bodies’ first line of defense?

A

the skin

165
Q
A
  • horny layer- shedding
  • basal layer on the bottom
166
Q

What is apocrine

A
  • sweat glands during puberty
  • smells bad
167
Q

What are eccrine glands

A
  • major sweat glands in all humans. Most dense in palms and soles
  • appears as dilute saline solution
168
Q

What are 4 major functions of the skin?

A
  1. keep fluid in/protect
  2. nonverbal communication
  3. wound repair
  4. vitamin D absorption
169
Q

In infants/children when does hair follicles start developing

A

3 months

170
Q

What is common in skin of pregnant women

A
  • stria grandorum
  • increase pigment
171
Q

What is xerosis

A

dry skin, mostly in older adults

172
Q

What happens to older adults nails?

A

thicken- due to fungus

173
Q

pruritus means?

A

itching

174
Q

Culture and genetics and skin

A

body odors vary by race

175
Q

Jaundice means

A

yellow

176
Q

Cyanosis means

A

blue

177
Q

What causes poor circulation in older adults

A

diabetes

peripheral vascular disease

178
Q

What are examples of subjective data for skin hair nails

A
  • mole inspection/palpation
  • rash/lesions
  • birth marks
  • hair loss
  • env’t hazards
  • self-care, wear sunscreen?
  • bruising
  • itching
179
Q

Objective Data examples for skin hair nails

A
  • skin color
  • use pen light
  • ruler
180
Q

Pallor means

A

pail

181
Q

What part of your hand do you use to palpate for temperature

A

dorsa (back)

182
Q

What are 6 maor things you want to palpate for in skin hair nails

A
  1. Temperature
  2. texture- use finger tips
  3. moisture
  4. diaphoresis (sweating)
  5. thickness
  6. Edema
183
Q

How is edema measured?

A
  • 4 point scale
  • 1+ = 2mm
  • 2+ = 4mm……
184
Q

What is pitting edema?

A
  • think memory foam, leaves a thumb print
185
Q

What is non pitting edema

A

The lack of indentation when fingertip pressure is applied to the skin, which classically occurs in hypothyroidism

186
Q

What does vascularity mean?

A

bruising

187
Q

3 Common types of birthmarks

A
  1. freckles
  2. junctional nevus
  3. compound nevus
188
Q
A

junctional nevus

189
Q
A

Compound Nevus

190
Q

What are the abnormal signs for pigmented lesions

A

ABCDE

191
Q

ABCDE stands for

A
  • Asymmetry
  • Border
  • Color variation
  • Diameter grater than 6mm
  • Elevation or Enlargement
192
Q

Hypothermia

A
  • high fever
  • localized coolness
193
Q

Hyperthermia

A
  • fever
  • area feels warn
  • trauma
  • infection/sunburn
194
Q

Uremia

A

renal failure

195
Q

Brown-tan coloration

A

example Addisons disease- increase melanin production

196
Q
A
  • Annular Lesion
  • circular (ringworm)
197
Q
A
  • Confluent Lesion
  • ex hives//uriticaria
198
Q
A
  • Discrete lesion
  • Skin tags//acne
199
Q
A

Gyrate Lesion

200
Q
A

grouped lesions

201
Q
A

linear lesion

202
Q
A

Target Lesion

203
Q
A
  • zosteriform
  • linear around unilateral nerve
  • ex: herpes
204
Q
A
  • Polycyclic
  • i.e. psoriasis
  • anular lesions grow together
205
Q

What are primary skin lesions x6

A
  • Macular/Patch
  • Papule/Plaque
  • Nodule/Tumor
  • Vesicle/bulla
  • Cyst
  • Postule
206
Q
A
  • Macule
    • Patch larger than 1 cm
  • flat not raised
207
Q
A
  • Papule
    • Plaque larger than 1 cm
  • can feel, slightly elevated
  • mole wart
208
Q
A
  • Nodule
    • tumor larger than 3 cm
209
Q
A
  • Wheal
    • Urticaria-hives
  • raised irregular shape due to edema
  • mosquito bites, allergies
210
Q
A
  • Vesicle
    • Bulla- larger than 1cm
  • a blister, herpes chicken pox, shingles
211
Q
A
  • Cyst
  • encapsulated fluid filled cavity
  • subcutaneous layer.
212
Q
A
  • Pustule
  • pus filled cavity
213
Q

What are some secondary Skin lesions?

A
  • Crust
  • Scale
  • fissure
  • erosion
  • ulcer
  • Excoriation
  • scar
  • atrophic scar
  • lichenfication
  • Keloid
214
Q
A
  • Crust
  • dried out when blisters burst
215
Q
A
  • Scale
  • compact flakes of skin
216
Q
A
  • Fissure
  • ex cracks at corner of mouth
217
Q
A
  • Erosion
  • shallow depression
  • moist but no bleeding
218
Q
A
  • Ulcer
  • irregular shape, may bleed
  • leaves scar
219
Q
A
  • Scar
  • replaced with connective tissue (collagen)
220
Q
A
  • Atrophic Scar
  • thinning of the epidermis
  • decreased visibility of normal skin markings
  • shiny
221
Q
A
  • Lichenification
    • when someone scratches an area excessively
222
Q
A
  • Keloid
    • hypertrophic scar
    • elevetated skin by excess scar tisue
223
Q
A
  • Pressure Ulcer Stage I
  • red but ubroken
  • will not blanch
224
Q
A
  • Stage 2 Ulcer
  • loss of epidermis
  • like open blister
225
Q
A
  • Stage 3 ulcer
  • extending into subcutaneous tissue
  • resembling a crater
226
Q
A
  • Stage IV Ulcer
  • breaks through all skin layers
  • visible bone or tendons
227
Q

What are some vascular lesions

A
  • petechiae
  • purpura
  • hematoma
  • contusion
228
Q

What is petechiae/purpura

A
  • small purple color
229
Q

What is hematoma

A
  • a bruise you can feel
230
Q

What is a contusion

A

another word for bruise

231
Q

What are the phase/coloration of bruises

A
  1. red
  2. blue-purple
  3. blue-green
  4. yellow
  5. brown-vanishing
232
Q

what is a “pattern” injury

A
  • a bruise or wound whose shape suggests instrument or weapon that caused it
    • belt buckle, broomstick, burning cig, pinch, bite, scalding hot liquid
233
Q

nevus is the medical term for…

A

mole

234
Q

where should you assess for early jaundice?

A
  • sclera and hard palate
235
Q

Normal angle between the nail base and the nail is…

A

160 degrees

236
Q

How long should it take the capillary beds to refil?

A

1-2 seconds

237
Q

What does flat brown macules on the hands mean?

A

Sun exposure, do not require treatment

238
Q

Flattening of the angle between the nail and its base…

A

clubbing

239
Q

Lyme disease is more prevalent during

A

May thru September

240
Q

What causes milia?

A

sebum occludes skin follicles

241
Q

Epidermis layer

A
  • basal layer,
  • thin,
  • stratum corneum
242
Q

Dermis Layer

A
  • collagen
  • elastic tissue
243
Q

Subcutaneous layer

A
  • adipose tissue
244
Q

This is when lower half of the body turns red, upper half blanches..

A

Harlequin

245
Q

This term is used when you notice mottling on trunk and extremities

A

Cutis Marmorata

246
Q

large round or oval patch of light brown usually present at birth

A

cafe au lait

247
Q

When irrigating a wound, how would the nurse know the right amount of pressure to apply?

A

between 5 and 15psi

248
Q

Which device is used for wound irrigation?

A

19 gauge needle attached to 35 mL syringe

249
Q

Elsevier:

What is the nursing action to set up suction for a hemovac drainage system?

A

the nurse should compress it firmly and replace the plug.

250
Q

Elsevier:

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?

A

Culture & sensitivity

251
Q

Elsevier:

What’s wrong with using a microwave for irrigating a wound?

A

can create hotspots

252
Q

Elsevier:

What is the proper method for cleansing the evacuation port of a wound drainage system?

A

Wipe it with an alcohol sponge.

253
Q

Braden Scale

A

Risk for skin breakdown/Pressure ulcer

254
Q

ABD

A

Abdominal

255
Q

What disease is a neurotic disorder?

A

MS, associating with neuro pain

256
Q

What is the goal of wound care?

A
  • to heal the wound
  • prevent infection
257
Q

What type of patient is at highest risk for suicide?

A

one that devises a plan

258
Q

This is when a wound ruptures along a surgical suture

A

dehiscence

259
Q

What is the primary intention for wound healing?

A
  • tissue surfaces have been approximated
  • low tissue loss
  • remove dressings after drainage
260
Q

What are 4 ways for debriefing a wound?

A
  1. Mechanical
  2. Chemical
  3. Auto
  4. Surgical
261
Q

What is autolytic debriefing?

A

takes advantage of the body’s own ability to dissolve dead tissue

262
Q

What is secondary intention for wound healing?

A
  • considerable tissue loss
  • edges cannot be drawn together
  • longer to heal
  • scarring is greater
  • infection risk
    • Pressure ulcers
  • continue dressings for moisture
  • assist debridement
263
Q

What is tertiary intention for wound healing?

A
  • “delayed”
  • require more connective tissue than wounds that heal by secondary intention
    • abdominal wound that is initially left open to allow for drainage but is later closed.
264
Q

What are the phases for a full thickness wound repair?

A
  1. Hemostasis (fibrin)
  2. Inflammatory phase
  3. Proliferative phase- epithelial
  4. Remodeling- can take years
265
Q

What are some complications for wound healing?

A
  • hemorrage
  • infection
  • dehiscence
  • avisceration
  • fistula
266
Q

What organ is 15% of our total body weight

A

Skin

267
Q

Black or brown tissue that must be removed

A

necrotic

268
Q

Yellow tissue in a wound that must be removed

A

slough

269
Q

What is evisceration?

A

A surgical wound that opens up (dihiscence) but is a medical emergency

270
Q

What are symptoms of wound Infections?

A
  • puss
  • odor
  • wolume
  • redness
  • fever
  • pain
271
Q

What could be the psychosocial component of wound healing?

A
  • body image
  • scars
  • odors
  • drains
  • temp prostetic
272
Q

What is a penrose drain?

A

soft rubber tube placed in a wound area, to prevent the build up of fluid.

273
Q

What is a Hydrocolloid dressing?

A
  • gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer.
  • protects from surface contaminants
274
Q

What is hydrogel dressing

A
  • provides moisture to a dry wound
  • dry or dehydrated wounds
  • partial or full-thickness lesions
  • abrasions or severe scrapes
  • minor burns
  • wounds with granulated tissue development
  • radiation skin damage
275
Q

What is a transparent film dressing used for?

A
  • to protect skin in pressure spots.
  • cover wounds with little or no drainage
276
Q

What are montgomery ties?

A
  • used for frequent dressing changes w/o having to remove and reapply tape.
  • Breathable, strong, and comfortable
  • help prevent skin trauma associated with frequent taping.
277
Q

How many grams of protein can a patient lose per day with an open wound?

A

50 grams

278
Q

Heat Therapy risks

A
  • vaso-constriction
  • damage epithelial cells
  • blistering
  • no longer than 1 hour
279
Q

Cold Therapy Risks

A
  • vaso dialation
  • risk is tissue ischemia (frost bite)
280
Q

What happens with negative pressure wound thearpy

A
  • granulation lines the surface
  • removes fluid and exudates to prevent infection
281
Q

What is required in the delivery of culturally congruent care?

A
  • knowledge
  • skills
  • attitudes
282
Q

What is an example of a nurse stereotyping a patient?

A

do you bathe and use deodorant more than one time a week?

283
Q

homelessness is an example of caring for a patient from a different..

A

culture

284
Q

What are appropriate questions to ask a native american?

A
  1. do you use folk remedies
  2. do you have a family physician
  3. do you use a shaman
285
Q

What is an example of data validation

A
  • comparing values with previous values
  • report to charge nurse
286
Q

What are the steps for a nursing diagnosis?

A
  1. review assessment data
  2. cluster
  3. diagnostic label
  4. contet of pt’s health probl and select related factor
287
Q

What could be indicated when a reddened area blances on fingertip touch?

A

blanching hyperemia. Body overcoming ischemic episode

288
Q

To determine wound infection, where should the specimen be taken?

A

wound, after it has been cleaned with normal saline

289
Q

After surgery a patient coughs and opens up a wound. What is the nurse’s first intervention?

A

cover with saline-soaked towels and notify surgical team.

Evisceration

290
Q

When do you use a warm compress?

A
  • to relieve edema
  • improve blood flow

Clinical (12 decks)

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