Week 1-12 Flashcards
What is the acronym OLDCART stand for?
O= Onset
L= Location
D= Duration
C= Characteristics
A= Aggravating factors
R= Relieving
T= Treatment
What is the questions
for pain assessment?
P= What Porvokes the pain?
T= What type of pain is it?
M= Dose the pain move?
R= How would you rate your pain
T= How long ago did the pain start
What is a normal blood pressure?
120/80 mmHG
What dose the first and last heart beat mean?
First= systalic
Last= Distalic
Name the normal pulse rate for adults, children, and new borns
Adluts= 60-100 beats/min
Children= 80-110 beats/min
New borns=120-160 beats/min
What is the normal respiratory rate for an adult?
10-20 breathes per/min
What is a skill?
It is something you practice
Name the 4 type of ways you can take a temp. E.g., oral
tempanic= ear
Rectal
Oral
Axillory=armpit
Name the medical terms for these temps 41c°,37.5c°,37c°,34c°,28c°
Hyperthermia=temp above 41c°
Febrile= temp above 37.5c°
Afebrile= normal temp 37c°
Hypothermia= 34c°
Severe Hypothermia=28c°
Name the 8 pulse points on the body from the head to ankles.
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis
Porsterial tiblial
What is Bradycardia?
When the heart rate is to slow less then 60bpm
What is Tachycardia?
When the heart rate is more then 100bpm
Name the 4 force the heart can beat at. E.g., weak
Absent
Weak/thread
Normal
Full/blunding
Finish this sentence.
Breathing should be….
Relaxed
Regular
Automatic
Silent
What does the acronym IPPA stand for?
I= inspection
P= palpation
P= percussion
A= auscultation
What is a desirable amount of fluid intake and loss for a healthy in 24 hrs?
1500 to 3500ml
What objective data would you use to assess a patient fluid balance status?
Daily weight
Fluid intake/output
Skin turgor
What does ABCDE stand for in skin assessment?
Asymmetric
Border
Colour
Diameter less then 6 mm
Evolution
What are the 4 things to look for with skin?
The texture
The thickness
The vascularity
And oedema
What should you look for when assessing lesions?
The colour
How elevated it is
The pattern or shape
The size
The location
Exudate
When doing a assessment looking at hair what should you look for?
Colour
Texture
Distribution
Lesions
Infestation
What are you looking for when carrying out a nail assessment?
Shape and contour of the nail
Consistency
Colour
When carrying out a full skin assessment what questions should you ask them to get a health history?
Have you had any hair loss/gain?
Have you had any chance in your nails?
Have you been exposed to any hazards environment or any chemicals?
What medication do you take?
Can you tell me about you salf care practices?
Define patient centred care.
Care that puts people/patients at the centre of care and their individual context, history, culture, family and that take in to a count their strengths and weakness
When you are asking Pamabout her pain what factors about her pain need to be considered
Onset
Location
Duration
Characteristics
Aggravates
Relieving
Treatment
Scale.
Pamreports her pain to be 8 out of 10. What sort of data is a pain score?
Subjective
Pam’s temperature was 36.8oC this is classed as a normal body temperature it is also referred to as
Afebrile
As a Student nurse you are working under the supervision and delegation of a Registered nurse. You are asked to take the patients pulse. What is the most common place to feel the pulse
Radial pulse
What objective data would you use to assess Mr Lyman’s fluid balance status?
Daily weight
Fluid Intake/output
Skin mobility/ turgor
Which class of laxatives will promote peristalsis?
Stimulant laxatives
Which type of diet is recommended for healthy bowel function?
High fibre
What are the 5 A’s?
- Accessible
- Affordable
- Appropriate
- Acceptable
- Adaptable
Describe what primary health care is.
PHC is an approach to to health that try’s to make it such that all groups in our society have a golden standard of of health care by providing measures.
E.g. Health education and free dental care for under 18’s
What is primary prevention?
Aims at preventing the Onset of illness
What is secondary prevention?
Catching the illness early.
What is tertiary prevention?
Reduce severity/ prevent progression of illness.
Describe the epidermis layer
1.Epidermis layer is the top layer of the skin
2.It is the protective waterproof layer of keratin
3. It has no blood vessels and relies on the dermis and hypodermis for nourishment/ waste removal.
Describe the dermis layer of skin
The dermis is made up of strong connective tissue as well as nurse here follicles glands their ducks arteries veins and capillaries.
Describe the hypodermis layer
1.The hypodermis layer is a fatty subcutaneous layer of fat tissue.
2.Hypodermis anchors the skin layer and serves as a heat insulator and shock absorber for the body.
3. The skin layer contains blood vessels lymph vessels and nerves and fat cells.
What is a laceration
Tearing of tissue edges not in aligned
Name the 6 types of wounds
Incision
contusion
laceration
abrasion
penetrating wound
thermal wound
Describe an incision
A cut from a sharp object wound edges are aligned
Describe a contusion
Damage to vessels caused bleeding below skin surface EG bruise
Describe abrasion
Rubbing or scraping of surface level epidermis layer
Describe what a penetration at wound is
This is when a foreign object enter scan at high velocities.
Describe a thermal wound
A thermal wound can be low or high temperature Burns
Name the three types of ulcers
Pressure ulcers
diabetic ulcers
arterial ulcers
Describe what a pressure ulcers
It is injury to the skin and any underlying tissue as a result from prolonged pressure on that area
Describe a diabetic ulcer
This is an ulcer impacted by poor circulation and sensation due to their diabetes.
Describe an arterial ulcer
This wound is occurs in the area of the leg or ankle caused by abnormal or damaged blood vessels/arteries leading to poor circulation
What are the two types of wound classifications
Surgical and non-surgical/traumatic
Describe what a surgical wound is and give an example.
These words are made under sterile conditions
have clean lines and controlled bleeding
risk of infection is minimal and healings is facilitated
EG inclusions are example of this class of wood
Describe non surgical or traumatic wounds classification
These wounds occur in a non sterile environment
contamination is likely
wound edges are usually Jagged and bleeding is uncontrolled
there is a high risk of infection and longer time healing.
An example of this type of wound would be a laceration
Name the four phase and wound healing
Homeostasis
inflammatory
proliferative
remodelling or the maturation phase
Describe 4 stages of homeostasis in wound healing and how long after the injury this phase occurs
the homeostasis phase begins 0 to 24 hours after damage or injury
- Ruptured cells release inflammatory factors that causes the blood vessel to vasoconstriction.
2.Platelets aggregate to form temporary platelet clot within 60 Seconds
- these platelets release chemicals and activate the secondary fibrin clot and the clotting cascade.
4.These platelets release chemicals such as serotonin, prostaglandins and histamin which causes vasodilation and increased capillary permeability.
Describe the inflammatory phase and the 3 steps involved and when
disturbed occurs after injury
This stage can a curse 0 to 4 days after damage
- Neutrophils are first to the site of injury in jesting bacteria and cell debris.
2.After 24hrs macrophages are released and enter the wound area they ingest debris and release growth factors that are needed for new epithelium cells blood vessels as well as attracting fibroblasts.
3.Blood plasma accumulates causing swelling and pain at site of wound.
Describe the 3 steps in the proliferation phase and the time period occurs in
It occurs between 3 days to 3 weeks of the injury.
1.Firbroblasts enter the wound site then granulated tissue begins to form and capillaries grow across the wound bringing nutrients to the wound for healing
2.epithelial tissue is light pink in colour and usually migrates inward from the wound margins but can appear in spots over the surface of the wound.
- The final step in the proliferation phase is collagen synthesis and accumulation.
Describe the remodelling stage as well as the when it started and after injury (2 steps)
This is the final stage of wound healing collagen is remodelled strengthening wound.
New collagen continues to be deposited which compressors blood vessels in the wound so that scar tissue eventually becomes a flat and thin white line.
What are the three things needed for good wound healing
Water
good blood circulation
and nutrients
What is the difference between chronic and acute wounds
Acute wounds heal normally following the wound-healing process and skin is restored to normal within weeks
chronic wounds do not progressed normally through the wound healing process meaning they can take much longer to heal up to months.
Name of the three types of wound healing
Primary intention
secondary intention
tertiary intention
Describe the primary intention wound type
Best type of wound is a surgical incision or Papercut
Describe the secondary intention wound type
Best type of wound healing takes longer there is more debris and fluids to clean away before wound can heal.
Describe the tertiary intentions of wound healing.
This wound is delayed primary intention. Is usually contaminated left open and needs to be stitched closed to prevent further infection obviously after cleaning.
Name the 6 things that can go wrong with wound healing.
Hypergranulation
sloughing
necrosis
Dehiscence (dis-a-da-in-s)
Evisceration (e-ves-a-ray-tion)
Maceration
What does ISBAR stand for?
Identity of patients
Situation
Background
Assessment and action
Response and Rationale
What is your basal metabolic rate related to?
The energy requirement of a person during rest
When undertaking a musculoskeletal assessment you notice the patient has abdominal lateral curve of the thoracic and lumbar spine this is refers to as………
Scoliosis
Implicit bias is defined as what?
This is bias that is unconscious and automatic achieved within an individual.
What is the difference between objective and subjective data
Subjective data is personal interpretation of data. E.g., patients description of their illness.
Objective data viewpoint is based on factual data. E.g., patients blood pressure records
The Glasgow Cama Scale (GCS) is divided into 3 areas name those three areas
Eye-opening, monitor response and verbal response
What does the right upper Quadrant of the abdomen contain
Liver
gallbladder
transverse colon
What does the upper left Quadrant of the abdomen contain
Spleen
stomach
pancreas
What does the lower left Quadrant of the abdomen contain
Descending colon
Sigmoid colon
What does the lower right quadrant of the abdomen contain
Small intestine
Ascending colon
The appendix
What is escherichia coli?
It is a bacteria most commonly found in undercooked ground beef.
Within 24hrs of Ingesting ecoli, you will become diuretic with bad stomach cramps pain and profuse vomiting
What are the droplet safety practises
Gowns, gloves, mask and covered shoes and glasses. An example of these kinds of illnesses are mumps and rubella.