Test 1 and Test 2 Review Flashcards
Referred Pain
pain can originate in part of the body but be perceived in a distant organ
Gate Theory of pain
recognizers the relationship between pain and emotions
ex. stub toe- won’t grab toe you will grab foot
Phantom pain
may occur in someone who has lost a limb - may feel burning, crushing, cramping or twisted
Psychogenic pain
physical pain that cannot be identified
Ex. Sex abuse
Intractable pain
persistant pain that is resistant to therapy
Nociceptive pain
only respond to tissue damage or other intense chemical, mechanical, or thermal stimulation:
3 types
Somatic - deep pain ligaments, bones, tendons
Cutaneous - skin/subcutaneous
Visceral - organ pain
What does NIPS assess?
Neonatal
Infant
Pain
Scale
Newborn babies - rates babies on a scale of 0-1 with regard to breathing pattern, arms and leg movement, state of arousal, and crying (0-2) Higher the score can indicate problems
Mechanisms of pain
Transduction
Transmission
Perception
Modulation of Pain
What are things to remember when lifting?
Avoid twisting the thoracic spite and avoid flexion of the back; want to use the longest and strongest muscles (legs and arms) Tighten your abdominals and keep the object your going to life close to you/in your center of gravity
What are the 4 Ps to prevent fall
Every 2 hours assess:
Pain, Potty, Positiong, (IV) Pump Safety
Where is S2 best heard
at the base of the heart
**remember the base is at the top of the heart
SL closure
beginning of diastole
Where is S1 best heard?
at the Apex of the heart
** apex is at the 5th ICS below the base
AV closure
beginning of systole
Dextrocardia
when the heart is on the right side of the body and not the left
Bruits
abnormal sounds that can indicate a murmur or build up of plaque in the carotid artery (should normally sound like the ocean)
During percussion flatness is heard over
muscle/bone
During percussion tympanic is heard over
abdominals
During percussion resonance is heard over
lungs
During percussion dullness is heard over
a full bladder, lungs that might have fluid or mass in them
normal in spleen and liver
All People Eat Turkey Meat
Apical Pulmonic (2nd ICS) Erbs Point (3rd ICS) Tricuspid 4th/5th ICS (4th in kids) Mitral/Apex (5th ICS)
How long would you want to listen to an apical pulse for
60 seconds
xanthelasma
fat deposits above eye lids (cardiac assessment)
**means they have an elevated lipid level
arcus senilis
whitish round color around the eye (typically normal in older adults)
What are the normal respiratory rates
12-20 breaths
What are the 6 vital signs
Temp, Pulse, BP, Respiration, O2 Sat
Paaaaiiiiinnnnn
What are the sources of heat loss
Skin
Evaporation of Sweat
Warming and Humidfying inspired air
Eliminating Urine and Feces
When is your core temp the highest/lowest
highest between 4-7pm and lowest in the morning
What and where is your best core temperature
Esophageal
Contraindications of using a rectal thermometer
hemmorhoids diarrhea newborns rectal bleeding/surgery steriods cardiac
Normal pulse rates
newborns/babies 120-160bpm
adults 60-100bpm
What are 2 places to assess rate in peripheral pulses
radial and apical
pulse deficit
difference between apical and radial pulses
Kussamal breathing
shallow, rapid breathing often associated with metabolic acidosis
Contraindications for taking BP?
tremors breast removal vasectomy av shunt IV in that arm stroke
ausculatory gap
temporary disappearance of korotkoff sounds - typically between 1st and 2nd sounds
** Document and and let the provider know
Dx of Hypertension
3 readings greater than 140/90
orthostatic hypertension
postural hypertension - increase in BP when a person stands up — this increases peoples risk for falls
PQRST
PRECIPITATION FACTORS QUALITY/QUANTITY REGION/RADIATION/RELATED SYMPTOMS SEVERITY TIMING
What is the review of systems
2 types -focused or complete health history
Includes systematic head to toe assessment
Use open ended questions
Psychosocial assessment would include
preferences for food (vegan/kosher) activity and exercise recreation - pets, hobbies, stress relief practices personal habits fears/concerns religion sexuality patterns occupational/socioeconomic status
What are the steps in the Nursing process
Assessment (Nursing) Dx Planning Implementation Evaluation Revision of care
***ADPIE
Pitfalls to data recording
omitting date interpretation of data assuming/hastely interpreting data (think someone automatically smokes since they smell like it) Failure to follow up Poor communication
Respiratory Landmarks anterior and posterior
ICS 2,4,6,6
T 1,4,7,10, (9 and 5 laterally)
Lungs bifurcate at
ICS 2
T 4
Bronchial sounds
heard above bifurcation and expiratory> inspiratory
Bronchialvesicular
heard at the bifurcation E=I
Vesicular
heard below the bifurcation I>E
hyper-resonant
very loud/very low - may indicate abnormal air trapping in the lungs (overinflated
croup
seal like arching cough which is indicative of a narrowing of the passageway through the larynx - often in children; tx - breathing in cold air to decrease swelling (children 3months - 6 years)
Rhonchi
rattling sound caused by excessive mucus
heard in the upper part of the lungs because they occur in the bronchi!
Crackles
fine and course - means filled with fluid and typically heard in the lower portion of the lungs
Shunting
imbalance in V/Q ratio = diversion (Ventilation fails
**if one part of the lung isn’t working properly it is going to tax the other part of the lungs for gas exchange
pneumothorax
collapsed lung
stridor
high pitched breath sound - typically associated with people who have croup
Clubbing of nails could be indicative of
COPD or chronic smokers
Meconium
first stool
what is the proper order of assessment for the abdomen
Inspection
Auscultatioin
Percussion
Palpation
What are the 4 types of abdominal distensions
flat
scaphoid (caved in) (thin patients)
rounded (infants and toddlers)
protuberant - pregnant women/otherwise an indication that something may be wrong
Where is kidney and renal tenderness assessed
costovertebral angle
oliguria
low output of urine
anuria
no output of urine
torticollis
lateral deviation of the neck
cheiliosis
painful inflammation and cracking of the corners of the mouth
Cognitive development during the 1st year of life is also called the ___________phase and includes what 3 major tasks
sensorimotor
separation (realize that self is separate from other objects)
object permanence
mental representation (recognizing symbols)
Apgar Scale
HR Respirations Muscle tone Reflex Irritability Color
**rated on a scale of 0-2 - assessed 1 and 5 minutes after birth
score of 8-10 is excellent 4-7 is guarded + 0-2 is critical
What is the normal head circumference
33-35cm
microcephaly - congenital malformation/infectioin
macrocephaly - hydrocephalis (90% of normal body)
measurement of the crow to the rump should be about equal to the head circumference
When do tears begin in a newborn
after 2 months
Epstein’s pearls
small white pearl-like epithelia cysts on the palate are normal for newborns and disappear within a few weeks
At what age would expect the anterior fontanels to close
between 12-18 months
At what age would you expect the posterior fontanelles to close
3 months
Magnet reflex
flexing the newborns legs and applying pressure to the soles of the feet - normal response should be extension of legs
What type of breath sounds is normally heard in newborns
Bronchial
Which vision change is frequently seen in adolescents?
myopia (nearsightedness)
HEENT assessment of an adolescent what maybe be palpable owing to hormonal changes associated with puberty?
Thyroid
According to Erikson what is the developmental task for the school-age children 6-12? and 12-18?
Industry vs Inferiority
Identity vs. Role Diffusion
Percocious menarche
less than 8 years old
**normal age between 10 and 12; ovulating more = increased risk
BRCA test
+ BRCA1 = 80% chance of BC
+ BRCA2 = 45% chance of BC
