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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
Created by: mojoshare