click below
click below
Normal Size Small Size show me how
MEPN SciOfNsg1
MEPN Med/Surg
Question | Answer |
---|---|
CN I | Olfactory |
CN I assessment | eyes closed, ask patient to identify familiar odors; test ea. nostril separately |
CN II | Optic |
CN II assessment | Snellen Eye Chart |
CN III | Oculomotor |
CN IV | Trochlear |
CN VI | Abducens |
CN III, IV, & VI assessment | EOM (6 directions) and pupillary reflexes |
CN V | Trigeminal |
CN V assessment | eyes closed facial site idenfication/sharp/dull/jaw mvt./eye tearing |
CN VII | Facial |
CN VII assessment | symmetry, smile/frown, eyebrow mvt., mouth mvt (open/close) |
CN VIII | Acoustic |
CN VIII assessment | whisper, Weber (top), Rinne (bone vs. air conduction) |
CN IX | Glossopharyngeal |
CN IX assessment | swallow, sugar vs. salt identification |
CN X | Vagus |
CN X assessment | gag reflex, swallow, "ah" uvula mvt. |
CN XI | Spinal Accessory |
CN XI assessment | should shrug, rotate head |
CN XII | Hypoglossal |
CN XII assessment | tongue out/against sides of mouth (resistance) |
Maslow's hierarchy of needs | Physiologic needs Safety and Security Belongingness and affection Esteem and self-respect Self-actualization |
Nursing Process | Assessment Diagnosis Planning Implementation Evaluation |
Autonomy | self rule/free choice |
Beneficence | do good |
Nonmaleficence | do no harm |
Confidentiality | privacy barring mandatory reporting |
Double Effect | 1.Action is morally good/neutral 2.Good intention 3.Good not achieved through bad means 4.Balance of good over evil |
Fidelity | promise-keeping in all respects |
Justice | all cases treated alike |
Distributive Justice | equality, societal contribution, individual need/effort/merit, legal entitlement |
Retributive Justice | retribution, punishment distribution |
Paternalism | intentional autonomy limitation for harm prevention |
Sanctity of Life | life is highest good regardless of quality |
Veracity | truth obligation |
NANDA-NIC-NOC | Diagnosis-Intervention-Outcome |
transplanted kidney placement | anterior abdomen |
How long can a kidney be artificially perfused before it is unable to be transplanted? | 24 hours |
decrease in the likelihood of rejection | younger kidney or from a relative |
Organ Transplantation Criteria | 1.Endstage disease 2.Other tx failure 3.Progression 4.Not infected 5.Disease 6.Surgical Survival |
Renal Diet | >carbs, <phosphorus, <potassium, <protein, <fluids, <sodium |
Treatment of choice for Barbiturate OD | Hemodialysis |
central line catheter solely used for dialysis | Ash split: subclavian vein catheter |
Must check for thrill, bruit, and hand circulation periodically throughout the day. | AV fistulae |
CAPD | Continuous Ambulatory Peritoneal Dialysis |
CAPD process | dialysate, cyclic, dwell: peritoneal membrane is the artificial kidney |
Dialysis goals | 1.Remove end products of metabolism 2.Maintain electrolytes 3.Correct acidosis 4.Replenish bicarb levels 5.Remove excess fluid |
Increased BUN and creatinine | ESRD: end-stage renal disease |
ESRD | end-stage renal disease |
azotemia | presence of increased amts of nitrogenous waste products, esp. urea, in the blood |
nocturia | increased noc urinary output |
anemia s/s | fatigue, weakness, cold tolerance, listless, <ADL ability, <willpower |
ARF | acute renal failure |
ARF prognosis | reversible if intervened early |
CRF | chronic renal failure |
CRF prognosis | progressive and irreversible |
shrimp allergy | also allergic to iodine; allergic to dye in contrast tests |
Mild pain analgesics | ASA, NSAIDs, Acetaminophen |
Moderate pain analgesics | A/ -codeine, -hydrocodone, -oxycodone, and -dihydrocodone, or tramadol |
Severe pain analgesics | Morphine, Hydromorphone, Methadone, Levorphanol, Fentanyl, Oxycodone |
Acute Pain Physiological responses | >BP, >PR, >RR, dilated pupils, perspiration |
Chronic Pain Physiological adaptation | normal VS and pupils, dry skin |
Acute Pain Behaviors | focuses on pain, reports pain, cries and moan, rubs painful part, >muscle tension, frowns and grimaces |
Chronic Pain Behaviors | quiet, no report of pain unless questioned, physical inactivity of immobility, turns attention to things other than pain, blank or normal facial expression |
pain | what patient reports it to be |
pain assessment | location, intensity, quality, onset, duration, variation |
uncontrolled pain in the elderly may lead to | depression, decreased socialization, impaired ambulation, increased healthcare utilization |
tolerance | decreasing effect to continued use of the same dose of a drug |
nonpharmacologic pain management | distraction, relaxation, guided imagery, positive self talk, thought stopping, cutaneous stimulation |
RICE | rest, ice, compression, elevation |
fixation | frame connected to pins |
ORIF | open reduction internal fixation |
amputation | partial or total removal of extremity |
cast care | keep dry, do not cover with plastic, do not stick anything down it |
casting material choices | nonplaster (fiberglass), plaster |
closed reduction | numb and move bones into place |
open reduction | surgical incision to align bones c/s fixation; tetanus infection risk |
hypovolemia | loss of 1-2L of blood |
possible result of multiple rib fractures | flail chest; respiratory compromise |
two types of pelvic fracture | stable, unstable |
common fracture of the wrist/hand that can cause nonunion and decreased function | scaphoid |
complications of fractures | DVT, PE, Fat embolis syndrome |
Fat embolis syndrome s/s | neurological changes, confusion, pulmonary insufficiency, petechial rash to chest, axilla, and upper arms |
compartment syndrome | pressure in ltd space constricts structures within compartment; pain beyond expected response; 2days-1week post-injury |
Autonomic Dysreflexia | exaggerated response of SNS; aka Complex Regional Pain or Reflex Sympathetic Dystrophy |
trochanter rolls | prevent external rotation of the hip |
maintains hip abduction | foam triangle |
Buck's traction | control muscle spasms and immobilize leg to proper alignment before surgery |
mobility complications | pneumonia, UTI, constipation, urinary stasis, atelectasis |
6 P's of physical assessment | pulselessness, pain, paresthesias, poikilothermia, paralysis, pallor |
fracture | disruption of bone continuity |
stress-fracture | overuse and constant stress leading to bone deterioration |
avulsion | piece broken away; pulled off by ligament or tendon |
communited | many pieces |
impacted | crushed together |
angulation | direction of displacement |
contusion | blunt trauma |
hematoma | large amt of bleeding in soft tissues |
sprains | ligament stretch/tear; bruising |
strains | tendons and muscle unit insult |
Grade 1 sprain/strain | stretch, no tear; ~2 weeks |
Grade 2 sprain/strain | partial tear with some instability; loose/lax; ~3-4 weeks |
Grade 3 sprain/strain | complete tear with complete opening of joint on stress; ~3-4 weeks |
Carpal Tunnel Syndrome | inflammation of sheath; pinches median nerve that innervates the thumb, pointer, and middle fingers |
bursitis | inflammation of the bursa of the joint |
epicondylitis | inflammation of the tendon at its origin; ex. tennis/golfer's elbow from rotation mvts of the forearm |
Primary injury | initial trauma |
Secondary injury | secondary unsatisfactory responses; ex. ischemia, hypoxia, febrile |
normal ICP level | 0-15 |
ICP | intracranial pressure |
CPP | cerebral perfusion pressure |
CPP = MAP - ICP norm | 70-100 mmHg |
CPP < 50 mmHg | assoc with ischemia and neuronal death |
Cushing's Triad | HTN, Bradycardia, Change in respiratory pattern |
decorticate | hyperflexion posturing |
decerebrate | hyperextention posturing |
Battle's Sign | post-auricular ecchymosis |
Raccoon eyes | peri-aural fracture; bruising around eyes |
Halo sign | blood on paper pools in center with yellow ring around droplet; bleeding from ear |
ABC's | airway, breathing, circulation |
ARDS | adult respiratory distress syndrome; lungs stiff and less-compliant |
site of wounds that bleed most heavily | scalp |
post concussion syndrome | vague s/s; mild HA that lasts months |
concussion | sudden transient mechanical injury with disruption of neural activity |
Glasgow Coma Scale brain injury severity | severe 3-8 moderate 9-12 mild 13-15 |
open brain injury | penetration; skull open to air |
closed brain injury | blunt trauma; acceleration/deceleration injury; contusions |
epidural hematoma | arterial hematoma between dura and inner surface of skull |
epidural hematoma s/s | brief LOC, lucid, then deterioration, bleeding |
subdural hematoma | venous hematoma between dura and arachnoid layer |
acute | < 2 days |
subacute | 2 days to 2 weeks |
chronic | > 2 weeks |
most common type of seizure | tonic-clonic |
tonic phase | muscle contractions |
clonic phase | jerky movements |
Prodromal Phase | activity before seizure; tick/twitch |
Aural Phase | warning sign/feeling of impending doom |
Ictal Phase | actual seizure activity |
Postictal Phase | relaxing post-seizure |
Type of meningitis with highest mortality rate | bacterial |
Hallmark of meningitis | Nuchal rigidity |
lab diagnostic of meningitis | lumbar puncture (CSF analysis) |
CVA | cerebral vascular accident |
CVA Primary Prevention Procedure | carotid endarterectomy |
CVA Secondary Prevention | statin, anti-HTN meds, anti-coag. therapy, anti-platelet therapy |
anti-coag therapy | warfarin |
anti-platelet therapy | ASA, plavix, Persantine, Ticlid |
tPA | transplasminogen activator |
tPA result | produces localized fibrinolysis |
window for tPA administration from onset of ischemic stroke s/s | 3 hours |
tPA inclusion critera | 18+, <3h s/s, no recent sx/MI/GI bleed, rule out/no prior hemorrhagic stroke, no acute trauma/injury |
loss of vision in one eye | hemianopia |
inability to carry out learned, sequential movements | apraxia |
unable to recognize familiar objects | agnosia |
neglect affected side of CVA | neglect syndrome |
receptive aphasia | understand deficit |
expressive aphasia | understands, but unable to express |
R-sided CVA | L hemiplegia, impatient, impulsive, poor judgment, emotional instability |
L-sided CVA | R hemiplegia, aphasias, cautious, slow, careful, memory loss |
Stroke Test: FAST | facial droop, arm drift, speech, time of onset |
Smile Stroke Test | 1. Smile 2. Raise both arms 3. Repeat a sentence |
90-day stroke risk following TIA | 3-17.3% (greatest <30 days) |
TIA | Transient Ischemic Attack |
Male stroke risk | thrombotic, better chance of survival |
Female stroke risk | hemorrhagic, higher mortality rate |
Nonmodifiable Disease Risks | age, gender, race, family history |
Modifiable Disease Risks | obesity, smoking, ETOH use, inactivity, diet, lifestyle |
2-3 times higher risk of stroke than Caucasians | African Americans |
CNS | Central Nervous System: brain and spinal cord |
3 major regions of the brain | cerebrum, brainstem, cerebellum |
serves as center for conducting messages to and from the brain and as a reflex center | spinal cord |
spinal nerves | 31 pairs |
cranial nerves | 12 pairs |
ANS | autonomic nervous system |
ANS branches | Sympathetic, Parasympathetic |
Identifies intracerebral hemorrhage, tumors, cysts, aneurysms, edema, ischemia, atrophy and tissue necrosis, shift in intracranial contents | CT scan |
CT scan | with and without contrast, noninvasive, painless |
provides information about blood vessels of the brain and identify vascular lesions | MRI/MRA |
MRI/MRA | screen for metal implants, ability to lie still, and claustrophobia |
Positron Emission Tomography | assess normal brain function and cerebral blood flow and volume; differentiate types of dementia, stage brain tumors |
uses radionuclide and requires no coffee/ETOH/smoking 24h prior to test | PET scan |
used to evaluate aneurysms, AV malformations, blood vessel patency and stenosis, thrombosis, vasospasm, space occupying lesions by way of contrast | Cerebral Angiogram |
evaluates the velocity of blood flow through the carotid arteries and identifies occlusive disease | Carotid Duplex Study |
EEG | Electroencephalogram |
measures the electrical activity of the brain, diagnoses brain disease and brain death | EEG |
measure CSF pressure and obtain sample | lumbar puncture |
Stage 1 Alzheimer's | 2-4 yrs; subtle deterioration in memory, restless, forgetful, subtle personality changes |
Stage 2 Alzheimer's | 2-12 yrs; confusion, wandering, personality changes: agitation, hallucination; language deficits, motor apraxia |
Stage 3 Alzheimer's | 2-4 yrs; inability to communicate, incontinence, may require total care |
aphasia in which meaningless or inappropriate word or syllable substituted for the correct spoken word or word combinations | paraphasia |
involuntary repetition of words spoken by others | echolalia |
evening/bedtime agitation to point of verbal outbursts, wandering, or acts of violence | sundowning |
sundowning interventions | calm, quiet environment, music, sitter, limit naps during the day, maximize daylight exposure, provide for patient safety |
A deficiency of dopamine in the central nervous system's motor control pathways | Parkinson's Disease |
Parkinson's Manifestations | TRAP: tremor, rigidity, (brady)akinesia, postural instability |
impairments of speech due to diseases that affect facial muscles; hard to understand speech without aphasia | dysarthria |
small amount of tissue destroyed with a needle | thalamotomy |
affected area located and tissue destroyed | pallidotomy |
4D's of hospital patients/POW's | Debility, Dependency, Dread, Depersonalization |
agitation, excitability, irritability, distractable | hyperactive behavior |
lethargy, somnolence, apathy, decreased activity | hypoactive behavior |
Cardinal sign of UTI in elderly | confusion |
Cardiac Conduction Pathway | SA node, AV node, Bundle of His, Bundle Branches (Right/Left), Purkinje Fibers |
the amount of blood ejected with each heartbeat | stroke volume |
the percent of end-diastolic volume ejected with each heartbeat | ejection fraction |
amount of blood pumped by the ventricle in liters per minute | cardiac output; CO = HR x SV |
degree of stretch of the cardiac muscle fibers at the end of diastole | Preload |
ability of the cardiac muscle to shorten in response to an electrical impulse | Contractility |
the resistance to ejection of blood from the ventricle | Afterload |
hunchback posture that alters chest landmarks for palpation and auscultation | Kyphosis |
normal BP values | <120/80 mmHg |
Prehypertension | 120-139/80-89 mmHg |
Stage 1 HTN | 140-159/90-99 |
Stage 2 HTN | >160/100 |
stages of atherosclerosis | fatty streak, fibrous plaque, complicated lesion |
Healthy Lipid Level | <200 |
HDL goal | >35 |
LDL goal | <100 |
pain or discomfort | angina |
predictable pain that subsides when precipitating factors resolved | Stable Angina |
unpredictable artery spasm; chest pain usually precipitating at night | Prinzmetal's Angina |
unrecognized angina pectoris | Silent ischemia |
inflammation of the pericardium | pericarditis |
Major Cations | Na+, K+, Ca++, Mg++ |
Major Anions | Cl-, PO4-, HCO3- |
Na+ | 135-134 mg/L |
Major ECF cation; primary determinant of ECF volume/concentration; controls flow of water | Na+ |
anorexia, N/V, fatigue, dyspnea, orthostatic hypotension, flushed skin, decreased skin turgor due to loss of sodium or gain of water | Hyponatremia |
thirst, dry red swollen tongue, increased temperature due to loss of water or increase in sodium intake | Hypernatremia |
K+ | 3.5-4.5 mEq/L |
Major ICF cation; controls cellular osmotic pressure | K+ |
decreased muscle activity, decreased membrane action potential, decreased bowel motility, confusion, irritability, lethargy, weakness, cramping, tetany, dysrhythmias, decreased ST segment, T wave | Hypokalemia |
ventricular dysrhythmias, depressed ST, peaked T wave, cardiac arrest, N/V, diarrhea | Hyperkalemia |
Mg++ | 1.5-2.5 mEq/L |
2nd most abundant ICF cation; transmission/conduction of nerve impulses, contraction of muscles, enzymatic reactions (esp. with ATP) | Mg++ |
neuromuscular weakness, tingling, cramps, Chvostek/Trousseau sign, decreased potassium, calcium, and phosphate | Hypomagnesium |
tetany with BP (hand contraction on BP cuff inflation) | Chvostek/Trousseau sign |
peripheral vasodilation, facial flushing, hypotension, N/V, muscle weakness, drowsiness, respiratory depression, cardiac arrest | Hypermagnesium |
water moves from low solute to high solute | osmosis |
number of particles per liter | osmolarity |
solute moves from high solute to low solute | diffusion |
water moves from high hydrostatic to low | filtration |
move against a concentration gradient | active transport |
controls concentration (osmolality) of body fluids | ADH: Antidiuretic Hormone |
insensible, unmeasurable fluid loss | ventilation, diaphoresis, stool |
urine output <400 ml/day | oliguria |