NRSG200 > 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
creatinine phosphokinase
CPT
chest physiotherapy
C&S
culture and sensitivity
CF
Cystic fibrosis
CP
Cerebral palsy
CSF
cerebral spinal fluid
CSM
circulatory, sensory, motor
CT
computerized tomography
CVA
cerebrovascular accident
CVP
central venous pressure
CX
culture
CXR
chest x-ray
Adventitious breath sounds
abnormal breath sounds. occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed. often superimposed over normal sounds. absence of breath sounds over some lung areas is also a significant finding that is associated with collapsed and surgically removed lobes or severe pneumonia
Ex: crackles (rales), gurgles (rhonchi), friction rub, wheeze
Angle of Louis
this is the starting point for locating the ribs anteriorly. it is the junction between the body of the sternum and the manubrium (the handle-like superior part of the sternum that joins with the clavicles).
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 of the cerebral cortex. can be categorized as sensory or receptive aphasia, and motor or expressive aphasia.
auscultation
the process of listening to sounds produced within the body. may direct (performed using the unaided ear ie to listen to a respiratory wheeze or the grating of a moving joint), or indirect auscultation which is performed using a stethoscope, transmitting sounds to a nurse’s ears.
Ex: indirect auscultation using steth to hear bowel sounds or valve sounds of heart and blood pressure
Blanch test
can be carried out to test capillary refill, that is, 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.
bruit
a blowing or swishing sound. it’s created by turbulence of blood flow due either to a narrowed arterial lumen ( a common development in older people), or to a condition such as anemia or hyperthyroidism, that elevates cardiac output. if bruit is found, the carotid artery is then palpated for a thrill.
clubbing
a 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.
cyanosis
(a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. in dark-skinned clients, close inspection of the palpebral conjunctiva (lining of the eyelids) and palms and soles may also show evidence of cyanosis.
diastole
the period in which the heart ventricles relax. starts with S2 and ends at the subsequent S1. normally no sounds are audible during these periods. experienced nurse may however perceive extra heart sounds (S3 and S4) during diastole. both sounds are low pitched and heart best at apex, with steth bell, and with client laying on left side. S3 occurs early in diastole right after S2 and sounds like lub-dub-ee (S1, S2, S3). often disappears when client sits up. S3 is normal in children and young adults. in older adults, it may indicate heart failure. S4 sounds (ventricular gallop) occur near the very end of diastole just before S1 and creates sound of dee-lub-dub. may be heard in older clients and can be sign of hypertension.
edema
the 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
the visual examination, which is assessing by using the sense of sight. should be deliberate, purposeful, systematic. nurse inspects with naked eye and with lighted instrument like otoscope to view ear. use visual, olfactory, and auditory cues. frequently uses vision to assess moisture, color, texture of body surfaces as well as shape, position, size, color, symmetry of body. lighting must be sufficient for nurse to see clearly (either natural or artificial light). when using auditory senses, it is important to have a quiet environment for accuracy. inspection can be combined with other assessment techniques.
jaundice
a yellowish tinge. may first be evident in the sclera of the eyes and then in the mucous membranes and the skin. nurses should take care not to confuse jaundice with the normal yellow pigmentation in the sclera of a dark-skinned client. if jaundice is suspected, the posterior part of the hard palate should also be inspected for a yellowish color tone.
palpation
examination of the body using the sense of touch. the pads of the fingers are used because their concentration of nerve endings makes them highly sensitive to tactile discrimination. palpation is used to determine a. texture (like of the hair) b. temperature( of skin area) c. vibration (ie of a joint) d. position, size consistency, and mobility of organs or masses e. distention (ie of bladder) f. pulsation g. tenderness or pain.
2 types: light (superficial) and deep palpation. light should always precede deep because heavy pressure on fingertips can dull sense of touch. light: dominant hand fingers move parallel to skin surface and press gently, moving in a circle. skin is slightly depressed. if necessary to determine the details of a mass, nurse presses lightly several times rather than holding pressure.
deep: done with 2 hands bimanually. extend dominant hand then place finger pads of nondominant hand on dorsal surface of distal interphalangeal joint of middle three fingers of dominant hand. top hand applies pressure while lower hand remains relaxed to perceive tactile sensations. for deep using one hand, finger pads of dominant hand press over area to be palpated. often other hand supports from below. use back of hand and fingers to determine skin temp. to test vibration, use palmar surface of hand.
percussion
act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. 2 types: direct (nurse strikes area to be percussed directly with pads of two, three, or four fingers or with pad of middle finger. strikes are rapid, movement is from wrist. not generally used to percuss thorax but is useful in percussing adult sinuses) or indirect (striking of an object ie a finger, held against the body area to be examined. middle finger of nondominant hand (aka the pleximeter) is placed firmly on pt skin. only distal phalanx and joint of this finger should touch skin. using tip of flexed middle finger of other hand (aka the plexor), nurse strikes pleximeter, usually at distal interphalangeal joint or a point between the distal and proximal joints. striking comes from wrist. forearm remains stationary. angle between plexor and pleximeter should be 90 degrees, blows must be firm, rapid, short to obtain clear sounds).
pallor
result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation. in clients with dark skin, usually characterized by absence of underlying red tones in skin and may be most readily seen in buccal mucosa. in brown skinned clients, pallor may appear yellowish brown tinge; in black skinned clients, skin may appear ashen gray. pallor in all people is usually most evident in areas with least pigmentation such as conjunctiva, oral mucous membranes, nail beds, palms of hands, soles of feet
precordium
area of chest overlying heart, inspected and palpated for presence of abnormal pulsations or lifts or heaves.
S1
first heart sound that occurs when the atrioventricular (AV) valves close. these valves close when the ventricles have been sufficiently filled. although they do not close simultaneously, the closure occurs closely enough to be heard as one sound. S1 is a dull, low pitch sound described as “lub”.
S2
after the ventricles empty the blood into the aorta and pulmonary arteries, the semilunar valves close, producing this second heart sound described as “dub”. has a higher pitch than s1 and is shorter in duration. occurs within 1 second or less of s1, depending on heart rate. s1 and s2 are both audible anywhere on the precordial area, but are best heard over aortic, pulmonic, tricuspid, and mitral areas.
systole
period in which the ventricles contract. begins with s1 and ends at s2. normally shorter than diastole.
thrill
frequently accompanies a bruit. a vibrating sensation like the purring of a cat or water running through a hose. it also indicates turbulent blood flow due to arterial obstruction.
vitiligo
seen as patches of hypopigmented skin. caused by the destruction of melanocytes in the area.
alarm reaction
initial reaction of the body which alerts the body’s defenses. divided into two parts: shock and countershock.
anger
emotional state consisting of subjective feeling of animosity or strong displeasure. verbal expression of anger can be signal to others of one’s internal psychological discomfort and a call for assistance to deal with perceived stress. verbally expressed anger differs from hostility, aggression, and violence, but it can lead to destructiveness and violence if the anger persists unabated. clearly expressed verbal communication of anger when angry person tells the other person and carefully identifies the source, is constructive. the other person can deal with it and help to alleviate it.
anxiety
common response to stress. state of mental uneasiness, apprehension, dread, foreboding, or feeling of helplessness related to impending or anticipated unidentified threat to self or significant relationships. can be experienced at conscious, subconscious, or unconscious level. anxiety disorders are very common although there are cultural differences. 4 levels:
- mild - slight arousal that enhances perception, learning, productive abilities
- moderate - increases arousal to point where person expresses feelings of tension, nervousness, concern. abilities narrowed.
- severe - consumes most of person’s energies and requires intervention. perception is further decreased. unable to focus on what is really happening.
- panic - overpowering, frightening level of anxiety causing person to lose control. less frequently experienced. perception affected to degree that the person distorts events.
burnout
nurses become overwhelmed and develop this complex syndrome of behaviors that can be likened to the exhaustion stage of the GAS. the nurse with burnout manifests physical and emotional depletion, a negative attitude and self-concept, and feelings of helplessness and hopelessness. prevent by using techniques to manage stress and become attuned to stress and personal reactions to stress (aka smoking, substance abuse). take steps to reduce stress ie antianxiety med, evaluating
caregiver burden
long-term stress seen in family members who undertake the care of a person in the home for a long period. produces responses such as chronic fatigue, sleeping difficulties, high blood pressure. in case of caregiver burden, caregiver also becomes nurse’s client and a care plan to intervene should be created. prolonged stress can also result in mental illness. individual may develop interpersonal problems, work difficulties, significant decrease in ability to meet basic human needs.
countershock phase
second part of alarm reaction. during this, changes produced in body during shock phase are reversed. person is best mobilized to react during shock phase.
crisis intervention
short term helping process of assisting clients to work through crisis to its resolution and restore their precrisis level of functioning. includes not only client in crisis but also various members of client’s support network. not the specialty of one professional or group: people who intervene come from fields of nursing, medicine, psychology, etc
defense mechanisms
ego defense mechanisms are unconscious psychological adaptive mechanisms, or according to Anna Freud, mental mechanisms that develop as the personality attempts to defend itself, establish compromises among conflicting impulses, and calm inner tensions. Defense mechanisms are unconscious mind working to protect the person from anxiety. they can be precursors to conscious cognitive coping mechanisms that will ultimately solve the problem. they release tension. examples: denial, dissociation, fantasy, projection, regression, rationalization, suppression
depression
an extreme feeling of sadness, despair, dejection, lack of worth, or emptiness, affects millions of Americans per year. signs and symptoms and severity vary with client and significance of precipitating event. emotional symptoms: feelings of tiredness, sadness, emptiness, numbness. behavior signs: irritability, inability to concentrate, difficulty making decisions, loss of sexual desire, crying, sleep disturbance, social withdrawal. physical signs: loss of appetite, weight loss, constipation, headache, dizziness. many experience short periods in response to overwhelming stressful events, such as death or loss of job. prolonged depression however is cause for concern and may require treatment.
fear
emotion or feeling of apprehension by impending or seeming danger, pain, or other perceived threat. the fear may be in response to something that has already occurred, in response to an immediate or current threat, or in response to something the person believes will happen.
object of fear may or may not be based in reality.
Ex: nursing student might be fearful in anticipation of first client care experience
general adaptation syndrome
selye’s stress response, aka stress syndrome. characterized by a chain or pattern of physiological events. to differentiate the cause of stress from response to stress, Selye used term stressor to denote any factor that produces stress and disturbs body’s equilibrium. stress can be observed only by changes it produces in body. response of the body (the GAS), occurs with release of certain adaptive hormones and subsequent changes in structure and chemical composition of body. parts of body affected by stress: GI tract, adrenal glands, lymphatic structures. prolonged stress: ulcers appear in stomach, adrenal glands enlarge, lymphatic structures such as thymus, spleen, lymph nodes atrophy.
3 stages: alarm reaction, resistance, exhaustion
shock phase
during this phase, the stressor may be perceived consciously or unconsciously by the person. stressors stimulate the SNS, which stimulates the hypothalamus. the hypothalamus releases corticotropin-releasing-hormone which stimulates the anterior pituitary gland to release adrenocorticotropic hormone. during times of stress, adrenal medulla secretes epinephrine and norepinephrine in response to sympathetic stimulation: increased heart contraction, increased cardiac output, bronchial dilation, increased cellular metabolism, etc.
stage of resistance
second stage in the GAS and LAS syndromes.
it’s when the body’s adaptation takes place. in other words, the body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it.
stage of exhaustion
third stage in GAS/LAS syndromes.
adaptation that the body made during second stage cannot be maintained. the ways used to cope with the stressor have been exhausted. if adaptation has not overcome the stressor, the stress effects may spread to entire body. at the end of this stage, body may either rest and return to normal, or death may be ultimate consequence. end of this stage depends largely on adaptive energy resources of the individual, severity of the stressor, and external adaptive resources provided, such as oxygen.
how anxiety and fear differ (4 ways)
- source of anxiety may not be identifiable: source of fear is.
- anxiety is related to future, anticipated event. fear is related to past, present, future.
- anxiety is vague; fear is definite.
- anxiety results from psychological or emotional conflict; fear results from specific physical or psychological entity.
