foundations of nursing > quiz 3 > Flashcards
quiz 3 Flashcards
c
with
C
centigrade
c/o
complains of
C&DB
cough and deep breath
C1 to C6
cervical vertebrae, one to six
CABG
coronary artery bypass graft
CAD
coronary artery disease
CBC
complete blood count
CC
chief complaint
CDC
Centers for Disease Control
CHF
congestive heart failure
cm
centimeter
CMV
Cytomegalovirus
CO
cardiac output
COPD
chronic obstructive pulmonary disease
CPK
creatine phosphokinase
CPT
chest physiotherapy
C&S
culture and sensitivity
CF
Cystic fibrosis
CP
Cerebral palsy
CSF
cerebral spinal fluid
CSM
circulation, sensory, motor
CT
computerized tomography
CVA
cerebrovascular accident
CVP
central venous pressure
CX
culture
CXR
chest x-ray
alarm reaction
the initial reaction of the body to stress, which alerts the body’s defenses
- divided into shock phase (stressor is perceived consciously or unconsciously by the individual - sympathetic nervous system) and countershock phase (changes produced in the body during the shock phase are reversed)
anger
emotional state consisting of a subjective feeling of animosity or strong displeasure
- verbal expression of anger can be a signal to others of one’s internal psychologic discomfort and a call for assistance to deal w/ perceived stress
anxiety
a common reaction to stress; a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of hopelessness related to an impeding or anticipated unidentified threat to self or significant relationships
- can be experienced at the conscious, unconscious, or subconscious level
- 4 levels: mild anxiety (slight arousal that enhances learning and productivity), moderate anxiety (individual expresses feelings of tension, nervousness, concern), severe anxiety (requires intervention), panic (loss of control)
burnout
complex syndrome of behaviors that can be likened to the exhaustion stage of the general adaptation syndrome
- physical and emotional depletion, negative attitude and self-concept, and feelings of helplessness/hopelessness
- how to manage stress: exercise, accept failures, seek counseling, daily relaxation program, collegial support groups
caregiver burden
reaction to long-term stress seen in family members who undertake the care of an individual in the home for a long period
- produces responses such as chronic fatigue, sleeping difficulties, high BP
countershock phase
changes produced in the body during the shock phase are reversed
crisis intervention
short-term helping process of assisting clients to work through a crisis to its resolution and restore their precrisis level of functioning
- includes client in crisis and client’s support network (healthcare professionals, psychologists, social workers, police officers, teachers)
- working w/ another individual inc. likelihood that individual in crisis will resolve it positively
- crisis counseling, home crisis visits
defense mechanisms (adaptive mechanisms)
result of conflicts between the id’s impulses and the anxiety caused by the conflicts due to social and environmental restrictions
- the methods the ego uses to fulfill the needs of the id in a socially acceptable manner are defense mechanisms
ex. denial, projection, repression, substitution
depression
an extreme feeling of sadness, despair, dejection, lack of worth, or emptiness
- affects millions of Americans
- tiredness, sadness, emptiness, numbness (emotional)
- irritability, inability to concentrate, difficulty making decisions, loss of sexual desire, crying, sleep disturbance, social withdrawal (behavioral)
- loss of appetite, weight loss, constipation, headache, dizziness (physical)
- individuals can develop short periods of depression
fear
an emotion or feeling of apprehension aroused by impending or seeming danger, pain, or another perceived threat
- response to an immediate or current threat, to something the individual believes will happen
differences between anxiety and fear:
1. source of anxiety = unidentifiable, source of fear = identifiable
2. anxiety = future, fear = past, present, future
3. anxiety = vague, fear = definite
4. anxiety = psychologic/emotional conflict, fear = specific physical/psychologic entity
general adaptation syndrome (stress syndrome)
(Selye) a general arousal response of the body to a stressor characterized by certain physiologic events and dominated by the sympathetic nervous system
- stressor: any factor that produces stress and disturbs the body’s equilibrium
- occurs w/ the release of certain adaptive hormones and subsequent changes in the structure and chemical composition of the body
- parts of the body affected by stress: GI tract, adrenal glands, lymphatic structures, deep ulcers in stomach, adrenal glands enlarge, lymphatic structures (thymus, spleen, lymph nodes) atrophy and shrink
shock phase
stressor may be perceived consciously or unconsciously by the individual
- stressors -> stimulate sympathetic nervous system -> stimulates hypothalamus -> corticotropin-releasing hormone -> anterior pituitary gland -> adrenocorticotropic hormone
- adrenal medulla -> epinephrine and norepinephrine in response to sympathetic stimulation
- epinephrine: inc. myocardial contractility (inc. blood flow/cardiac output), bronchial dilation (inc. oxygen intake), inc. blood clotting, inc. cellular metabolism, inc. fat mobilization to provide energy
- norepinephrine: dec. blood to kidneys, inc. secretion of renin (-> angiotension -> inc. bp)
stage of resistance
when the body’s adaptation takes place
- body attempts to cope w/ stressor and limits the stressor to smallest area of the body that can deal w/ it
- second stage in the GAS and LAS syndromes
stage of exhaustion
adaptation that the body made during the second stage cannot be maintained
- ways used to cope w/ stressor have been exhausted
- third stage of GAS syndrome
- if adaptation has not overcome the stressor, stress effects may spread to entire body
- end of this stage depends on adaptive energy resources of individual, severity of stressor, and external adaptive resources provided
adventitious breath sounds
abnormal breath sounds; occur when air passes through narrowed airways or airways filled w/ fluid or mucus, or when pleural linings are inflamed (or moisture)
- extra sounds
- crackles/rales, wheezes, rhonchi/gurgles
angle of louis
junction between the body of the sternum (breastbone) and the manubrium (handle-like superior part of the sternum that joins w/ the clavicles)
- starting point for locating ribs anteriorly
- superior border of the second rib attaches to the sternum at this manubrio-sternal junction
aphasia
any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury
- can be categorized as sensory or receptive aphasia (loss of ability to comprehend written/spoken words), and motor or expressive aphasia (loss of power to express oneself by writing, making signs, or speaking)
- sensory aphasia -> auditory aphasia (lost ability to understand printed/written figures) + visual aphasia (lost ability to understand printed/written figures)
auscultation
process of listening to sounds produced within the body
- can be direct or indirect
- direct auscultation: performed using unaided ear ex. respiratory wheeze, grating of moving joint
- indirect auscultation: performed using stethoscope, which transmits sounds within body to ears ex. bowel sounds, valve sounds of heart
- most body sounds are soft and must be heard through a stethoscope
- auscultated sounds are described according to their pitch, intensity, duration, and quality
blanch test
carried out to test the capillary refill (peripheral circulation)
- normal nail bed capillaries blanch when pressed, but quickly turn pink or their usual color when pressure is released
- slow rate of capillary refill may indicate circulatory problems
- nails should be smooth, pink and convex curvature
bruit
a blowing or swishing sound created by turbulence of blood flow due either to a narrowed arterial lumen (common development in older people) or to a condition, such as anemia or hyperthyroidism, that elevates cardiac output
- carotid is auscultated for a bruit and if a bruit is found, then carotid artery is palpated for a thrill
clubbing
condition in which the angle between the nail and the nail bed is 180 degrees or greater
- may be caused by a long-term lack of oxygen
- softening of nail bed
cyanosis
a bluish tinge that is most evident in the nail beds, lips, and buccal mucosa
- in dark-skinned clients, close inspection of the palpebral conjunctiva (lining of eyelids) and palms and soles may also show evidence of cyanosis
diastole
period in which the ventricles relax
- starts with s2 and ends at subsequent s1
- no sounds are audible
- experienced nurses may perceive extra heart sounds (s3 and s4) low in pitch and heard best at the apex, with the bell of stethoscope and w/ the client lying on the left side
edema
presence of excess interstitial fluid
- area of edema appears swollen, shiny, and taut and tends to blanch the skin color or, if accompanied by inflammation, may redden the skin
- generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction or venous abnormalities
erythema
skin redness associated with a variety of rashes and other conditions
inspection
visual examination, which is assessing by using sense of sight
- deliberate, purposeful, systematic
- uses naked eye, olfactory (smell), auditory (hearing), otoscope (used to view the ear)
- use visual inspection to assess moisture, color, and texture of body surfaces, as well as shape, position, size, color, and symmetry of the body
jaundice
yellowish tinge that may first be evident in the sclera of the eyes and then in the mucous membranes and the skin
- if suspected, posterior part of the hard palate should also be inspected for a yellowish color tone
- don’t confuse jaundice with the normal yellow pigmentation in sclera of dark-skinned patient
palpation
examination of the body using the sense of touch
- pads of fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination
- determine texture, temperature, vibration, position/size/consistency/mobility, distention, pulsation, tenderness/pain
- palpate for temperature, turgor, moisture, edema
- light palpation: precedes deep; skin is slightly depressed (1cm); warm hands/short nails
- deep palpation: heavy pressure on fingertips can dull sense of touch/damage organs; indicated in clients who have acute abdominal pain/pain not yet diagnosed
- effectiveness of palpation depends on client’s relaxation
percussion
act of striking the body surface to elicit that can be heard or vibrations that can be felt
- direct percussion: striking area to be percussed w/ pads of 2/3/4 fingers or w/ middle finger; strikes are rapid/from wrist, useful in percussing adult’s sinuses
- indirect percussion: striking of object (such as a finger) held against body area to be examined; middle finger of nondominant hand is placed firmly on the client’s skin (pleximeter); plexor (middle finger of other hand) strikes pleximeter at the joint
pallor
result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation
- in clients w/ dark skin, usually characterized by absence of underlying red tones in the skin and may be most readily seen in buccal mucosa
- in brown-skinned clients, may appear as yellowish brown tinge, and in black-skinned clients, may appear ashen gray
- most evident in areas w/ least pigmentation such as conjunctiva, oral mucous membranes, nail beds, palms of hand, and soles of feet
precordium
area of the chest overlying the heart
- inspected and palpated for presence of abnormal pulsations/lifts/heaves
- lift and heave: a rising along the sternal border with each heartbeat
S1
first heart sound that occurs when atrioventricular valves close (when ventricles have been sufficiently filled)
- valves do not close simultaneously but occur closely enough to be heard as one sound
- dull, low-pitched sound described as “lub”
- less aortic/pulmonic intensity
- louder than or equal to tricuspid/mitral of s2
- beginning of systole
S2
after the ventricles empty the blood into the aorta and pulmonary arteries, semilunar valves close which produce the second heart sound “dub”
- higher pitch than s1 and shorter duration
- louder aortic and pulmonic than s1; less intensity/equal to mitral and tricuspid of s1
- end of systole
systole
period in which ventricles contract
- begins w/ s1 and ends w/ s2
- shorter than diastole
thrill
frequently accompanies a bruit; is a vibrating sensation like the purring of a cat or water running through a hose
- indicates turbulent blood flow due to arterial obstruction
vitiligo
patches of hypopigmented skin caused by the destruction of melanocytes in the area
albinism: complete/partial lack of melanin in the hair, skin and eyes
- other localized color changes may indicate problem such as edema or localized infection
- dark-skinned clients have area of lighter pigmentation such as palms, lips, and nail beds
