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IUPUIB244Week1
Chapters 3,7, and 8 Weber
| Question | Answer |
|---|---|
| When do you use the mnemonic device COLDSPA? | When assessing pain |
| What does the "C" in COLDSPA mean? | Character - Describe the sign or symptom (feeling, appearance, sound, smell, or taste) |
| What does the "O" in COLDSPA mean? | Onset - When did it begin? |
| What does the "L" in COLDSPA mean? | Location - Where is it? Does it radiate? Does it occur anywhere else? |
| What does the "D" in COLDSPA mean? | Duration - How long does it last? Does it recur? |
| What does the "S" in COLDSPA mean? | Severity - How bad is it? How much does it bother you? |
| What does the "P" in COLDSPA mean? | Pattern - What makes it better or worse? |
| What does the "A" in COLDSPA mean? | Associated factors/how Affects client - What other symptoms occur with it? How does it affect you? |
| Normal range of body temperature for an adult | 96.0 F to 99.9 F (36.5 C to 37.7 C) |
| Normal range of body temperature for the elderly | 95.0 F to 97.5 F |
| Amplitude of pulse = 1 | Thready or weak (easy to obliterate) |
| Amplitude of pulse = 2 | Normal pulse (obliterate with moderate pressure) |
| Amplitude of pulse = 3 | Increased pulse |
| What is difference between axillary temperature and oral? | -1 F |
| What is difference between rectal temperature and oral? | +0.7 - 1.0 F |
| How long do you take a temperature orally? | About 2 minutes |
| How long do you take an axillary temperature? | 10 minutes |
| How long do you take a rectal temperature? | 3 minutes |
| What is difference between tympanic temperature and oral? | +1.4 F |
| Normal pulse rate in adults | 60 to 100 beats per minute |
| Pulse rate for bradychardia? | Pulse lower than 60 beats/minute |
| Pulse rate for tachychardia? | Pulse greater than 100 beats/minute |
| Normal respiratory rate in adults | Between 12 and 20 breaths/minute |
| Normal respiratory rate in the elderly | Between 15 and 22 breaths/minute |
| Normal blood pressure | Less than 120/80 |
| What is Isolated systolic hypertension (usually older adults) | Systolic pressure over 140 but diastolic pressure under 90 |
| What is Orthostatic or postural hypotension? | A drop of 20 mmHg or more from the recorded sitting blood pressure |
| Korotkoff's sounds - Phase I | First appearance of faint, clear, repetitive tapping sounds. systolic pressure |
| Korotkoff's sounds - Phase II | Muffled or swishing sounds, may temporarily subside. Loss of sound is called auscultatory gap. |
| Korotkoff's sounds - Phase III | Return of distinct, crisp, louder sounds - blood flowing relatively freely through increasingly open artery |
| Korotkoff's sounds - Phase IV | Sounds that are muffled, less distinct, and softer (with a blowing quality) |
| Korotkoff's sounds - Phase V | All sounds disappear completely. Diastolic pressure |
| Prehypertension pressures | Systolic 120-139 Diastolic 80-89 |
| Stage 1 hypertension pressures | Systolic 140-159 Diastolic 90-99 |
| Stage 2 hypertension pressures | Systolic >160 Diastolic > 100 |
| What is pulse pressure? | Difference between Systolic and Diastolic blood pressure levels |
| What is normal pulse pressure for an adult? | 30 - 50 mmHg |
| Pain classification - name 4 categories | Duration, location, etiology, and severity |
| 3 classifications of pain for duration and etiology together | Acute pain, Chronic nonmalignant pain, Cancer pain |
| Pain location classifications - 3 | Cutaneous pain, Visceral pain, Deep somatic pain |
| QUESTT mnemonic for pain assessment in children, letters stand for: | Question the child Use pain-rating scales Evaluate behavior and physiological changes Secure parents' involvement Take cause of pain into account Take action and evaluate results |
| Amplitude of pulse = 4 | Bounding (unable to obliterate or requires very firm pressure) |
| Location of apical pulse | 5th intercostal space, left mid clavicular line |
| Assess respirations for: | Regularity, rhythm, depth, use of accessory muscles |
| Do not take blood pressure on arm with: | IV, shunt, or same side as mastectomy |
| What does oximetry measure? | Percentage of hemoglobin saturated with oxygen. |
| Pain transduction | Afferent nerves are stimulated by something |
| Pain transmission | Signal is sent to dorsal horn /spinal track |
| Pain Modulation | "Gate" in dorsal horn regulates passage of signal |
| Pain Perception | Combination of transduction, transmission, and modulation. Pain is whatever the patient says it is. |
| Acute pain is pain that lasts for: | < 1 month. Responds well to narcotics |
| Chronic pain is pain that lasts for: | > 6 months |
| Physiologic responses to pain: | Emotional, physical appearance, increased vital signs, decreased GI and urinary function, increased hormones (insulin), metabolic (blood gases), muscular dysfunction |
| Light palpation | depress 1 cm |
| Deep palpation | depress 2.5 to 5 cm |
| Percussion tones - Resonant | Heard over lung tissue |
| Percussion tones - tympany | Most of abdominal cavity |
| Percussion tones - dull | Solid organs |
| 5 steps in Nursing process | Assessment, Diagnosis, Planning, Implementation, Evaluation |
| 4 types of health history | Complete, Episodic, Interval, Emergency |
| Do not use "why" when interviewing for health history | Interview no-no |
| Pallor | Paleness of skin, especially face |
| Erythema | Abnormal redness of the skin due to capillary congestion, as in inflammation |
| Cyanosis | A bluish or purplish discoloration of the skin due to deficient oxygenation of the blood |
| Jaundice | A yellowish pigmentation of the skin caused by deposition of bile pigments or excessive breakdown of red blood cells |
| Urticaria | Hives |
| Ecchymosis | A black and blue or purple area caused by escape of blood into tissues from ruptured blood vessels |
| Petechiae | A minute reddish or purplish spot containing blood that appears in skin as a result of localized hemorrhage |
| Pruritis | Localized or generalized itching due to irritation of sensory nerve endings |
| Hematoma | Localized collection of blood that creates an elevated ecchymoses. Associated with trauma |
| 5 steps of melanoma assessment | Asymmetry, Border, Color, Diameter, Elevation or Evolving |
| Turgor | Hydration |
| Macule | Flat, non-palpable skin color change (freckle), <1cm diameter |
| Papule | Elevated, palpable, solid mass, circumscribed order (wart), <0.5 cm |
| Patch | Flat, non-palpable skin color change (port wine stain), >1 cm diam. |
| Plaque | elevated, palpable, solid mass, >0.5 cm |
| Nodule | Elevated, solid, palpable mass, deep into dermis,0.5-2cm |
| Tumor | Elevated, solid, palpable mass, deep into dermis, 1-2cm |
| Vesicle | Circumscribed, elevated, palpable mass containing serous fluid, <0.5 cm, (poison ivy) |
| Bulla | Circumscribed, elevated, palpable mass containing serous fluid, > 0.5 cm |
| Wheal | Elevated mass with transient borders (hives) |
| Pustule | Pus filled vesicle or bulla |
| Cyst | Encapsulated, fluid-filled, or semi-solid mass in subcataneous tissue or dermis |
| Erosion | Loss of superficial epidermis, does not extend to the dermis, depressed, moist |
| Ulcer | Skin loss extending past epidermis |
| Scar (Cicatrix) | Healed wound or incision |
| Fissure | Linear crack in skin, may extend to dermis |
| Vitiligo | chalk-white, non-scaling, macular patches |
| Telangiectasia | Fine, irregular redlines, does not blanche when touched |
| Scale | Heaped up, keratinized cells |
| Lichenification | Rough, thick epidermis, secondary to persistent itching or rubbing |
| Keloid | Irregular shaped, elevated progressively enlarging scar |
| Scar | Fibrous tissue that replaces normal skin following injury or laceration |
| Excoriation | Loss of the epidermis, scratch or abrasion |
| Fissure | Linear break from epidermis to dermis |
| Erosion | Loss of part of the epidermis, depressed, moist, glistening |
| Ulcer | Loss of epidermis and dermis, necrotic tissue loss, concave |
| Petechia | Round reddish, bluish macule, flat, non-palpable, 1-2 mm, associated with bleeding tendencies |
| Atrophy | Thinning of the skin surface, skin appears translucent and paper thin |
| 1st degree burn | Epidermis injured, skin is dry red, painful, no blisters |
| 2nd degree burn | Epidermis and dermis damaged, blisters present, very painful |
| 3rd degree burn | Epidermis, dermis, and squamous tissue, may involve muscles and bones, little or no pain (nerve endings are destroyed) |
Created by:
bjperkin
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