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NUR 111 Stud guide 4
NUR 111 Study guide for test 4
| CN I | Olfactory. sense of smell: nostril patency |
| CN II | Optic visual acuity, visual fields |
| CN III | Oculomotor extraoculor movement, pupillary reaction to light and accommodation |
| CN IV | Trochlear see III |
| CN V | Trigeminal mastication strength, sensation of face/neck, corneal reflex |
| CN VI | Abducens see III |
| CN VII | Facial motor function of facial muscles, taste on anterior tongue |
| CN VIII | Acoustic hearing |
| CN IX | Glossopharyngeal (throat) symmetrical rise of uvula, swallowing, gag reflex, taste on posterior tongue |
| CN X | Vagus ability to speak and swallow |
| CN XI | Accessory muscle strength of neck |
| CN XII | Hypoglossal mobility/strength of tongue |
| Pressure Ulcer: Stage I | Skin intact; redness or blanching |
| Pressure Ulcer: Stage II | Partial thickness; loss of dermis and epidermis |
| Pressure Ulcer: Stage III | Full thickness without bone, muscle, or tendon exposed |
| Pressure Ulcer: Stage IV | Full thickness with bone, muscle, or tendon exposed |
| RYB | Red=granulation, Yellow=slough, Black=necrosis |
| Pressure Ulcer: unstageable | A wound full of eschar or necrotic tisue |
| Wound classification | Intentional vs unintentional. Open vs closed. Acute vs chronic. Partial thickness vs. full thickness vs complex. |
| Phases of wound healing: Hemostasis | Immediately after injury; vasoconstriction and clotting then vasodilation and release of exudate (serous, sanguineous, serosanguineous, purulent) |
| Phases of wound healing: Inflammatory | Lasts 4-6 days; WBCs move to site |
| Phases of wound healing: Proliferative | Lasts <3 wk. fibroblastic, regenerative, or connective tissue phase |
| Phases of wound healing: Maturation | Lasts <6 mo. formation of scar |
| Wound repair: primary intent | Surgical wounds |
| Wound repair: secondary intent | Does not have well approximated edges |
| Wound repair: tertiary intent | A wound left open for several days then closed up |
| Wound complications: Infection Hemorrhage Dehiscence Evisceration Fistula | Invasion of microorganisms |
| Wound complications: Hemorrhage | Excessive bleeding |
| Wound complications: Dehiscence | Partial-total separation of wound layers |
| Wound complications: Evisceration | Total separation of wound layers with protrusion of viscera |
| Wound complications: Fistula | Abnormal passage from organ-organ or organ-exterior of body |
| Effects of heat on local tissues | Dilation of peripheral blood vessels, increases tissue metabolism and capillary permeability, decreases muscle tension and blood viscosity, helps relieve pain |
| Effects of heat: systemic | Increases cardiac output and rate, sweating, decreases blood pressure |
| Effects of cold: systemic | Constricts peripheral blood vessels, decreases muscle spasms, promotes comfort Increases blood pressure, shivering, goose bumps |
| Effects of cold on local tissues | Constricts peripheral blood vessels, decreases muscle spasms, promotes comfort |
| Define: Cyanosis | Blue coloration of skin |
| Define: Pallor | Pale skin |
| Define: Jaundice | Yellow discoloration of skin and sclera of eyes |
| Define: Circumoral Cyanosis | Blue around the mouth |
| Define: Tenting | When skin remains elevated after being pinched up; tests turgor |
| Define: Petechiae | Small red dots on the skin <1 cm; don’t itch |
| Define: Purpura | Larger red dots on skin >1 cm; don’t itch |
| Define: Milia | Little white bumps seen on the faces of infants |
| Define: Hirsutism | Excessive body hair; usually indicative of an endocrine disorder |
| Define: Vitiligo | Hypopigmentation; white patchy areas |
| Define: Lentigo | Hyperpigmentation; brown spots; “liver spots”, “age spots” |
| Define: Onychylosis | Loosening or detachment of nail from nail bed |
| Define: Lanugo | Fine, downy hairs covering the body, esp. in premature babies |
| Define: Impetigo | Scabby eruption on the skin. Honey crusted lesons |
| Define: Echymosis | Bruising of the skin |
| Define: Macule | Lesion; ≤1cm; E.G. petechiae, freckle, etc. |
| Define: Patch | Lesion; >1cm; E.G. vitiligo |
| Define: Papule | Mass; ≤0.5cm; E.G. mole |
| Define: Plaque | Mass; > 0.5cm; E.G. coalesced papules |
| Define: Nodule | Mass; 0.5-2cm, firmer than a papule; E.G. wart |
| Define: Tumor | Mass; > 2cm; lipoma |
| Define: Wheal | Irregular, superficial area of localized skin edema |
| Define: Vesicle | Filled with serous fluid; ≤0.5cm; E.G. herpes simplex |
| Define: Bulla | Filled with serous fluid; > 0.5cm; E.G. second degree burn, blister, etc. |
| Define: Pustule | Filled with pus; E.G. acne, impetigo |
| Lab value: CBC | Complete Blood Count; “shift to the left” increase in neutrophils in inflammation |
| Lab value: WBC | White Blood Cell Count; 4,000-10,000 µ/L of blood; elevated in inflammation |
| Lab value: CRP | C-Reactive Protein; produced by liver; < 0.8mg/dL; elevated in inflammation |
| Lab value: ESR | Erythrocyte Sedimentation Rate; elevated during inflammation; Male= 0-20mm/hr. Female= 0-30mm/hr |
| Lab value: Albumin | 3.5-5.5 mg/dL; assess acute malnutrition |
| Lab value: Prealbumin | 23-43 mg/dL; assess chronic malnutrition Desirable <200mg/dL, Moderate risk 200-240mg/dL, High risk >240mg/dL |
| Lab value: Cholesterol | Desirable <200mg/dL, Moderate risk 200-240mg/dL, High risk >240mg/dL |
| Pitting edema stages: +1 | 2mm; slight pitting, no obvious distortion |
| Pitting edema stages: +2 | 4mm; deeper pit; no obvious distortion |
| Pitting edema stages: +3 | 6mm; pit obvious, extremities swollen |
| Pitting edema stages: +4 | 8mm; pit remains, obvious distortion |
| Define: Anasarca | Generalized edema; esp. head and trunk |
| Define: Dependent edema | Edema in lower or dependent extremities or parts of the body |
| Stages of inflammation: Stage I | Blood vessels constrict, Chemical mediators released, Increased capillary permeability fluids leak swelling and pain, blood flows slowly (increased viscosity) to allow escape of WBCs, Leukocytosis |
| Stages of inflammation: Stage II | Exudate production |
| Stages of inflammation: Stage III | Reparative phase: regeneration, formation of scar |
| Chain of infection: Infectious Agent | Pathogen (bacteria, virus, fungi, parasite) |
| Chain of infection: Reservoir | Where the pathogen lives |
| Chain of infection: Portal of Exit | Anywhere the pathogen can exit the reservoir |
| Chain of infection: Transmission | Transport of pathogen from reservoir to portal of entry (animal, person, etc) |
| Chain of infection: Portal of Entry | Any body opening |
| Chain of infection: Susceptible Host | A host with an acceptable environment for the pathogen |
| Changes associated with infection: Card 1/5 | Injury, ischemic changes, immune reaction: all cause inflammatory response |
| Changes associated with infection: Card 2/5. Vascular changes | Vascular Changes: vasodilation, increased capillary permeability, increased blood flow, local congestion |
| Changes associated with infection: Card 3/5. Cellular changes | Cellular Changes: phagocytosis, increased leukocystes (granulocytes and monocytes), release of chemical mediators (mast cells and macrophages) |
| Changes associated with infection: Card 4/5. Body's local respone = PRISH | Local Effects (PRISH) Pain, Redness, Impaired functioning, Swelling, Heat |
| Changes associated with infection: Card 5/5. Body's systemic response | Systemic Effects: fever (>101.4⁰F), leukocytosis, malaise, anorexia, increased HR, RR |
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