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Nursing ch 31

Hyperopia Farsightedness
Myopia Nearsightedness
Presbyopia Near vision in middle aged and older adults Loss of elastity of lens
Retinopathy Changes in retinal blood vessels Leading cause if blindness
Cataracts Incr opacity of the lens
Glaucoma Intraocular pressure
Strabismus Both eyes do not focus Eyes appear crossed
Macular degeneration Aging and resulting in damage sharp and central vision
Exopthalmos Bulging eyes
Ptosis Dropping eyes
Erythematous Yellow lump or sty on follicle of an eyelash Indicates suppurative infection
Cage Cut down Annoyed Guilty Eye-opener
Asses skin tugor Fold of skin on the bk of hand Stern also area with fingertips and release
Lateral recumbent Heart Aids in heart murmurs Respiratory difficulties do not tolerate this position
Sims Rectal and vagina Flexion of hip &knee Joint deformities hinder p. Ability to bend hop &knee (elderly)
Dorsal recumbent Head neck lungs breast hears abdomen extremities pulse Abdomen assessment promote relaxation of abd. Muscles P. W painful disorder more comfortable w knee flexed
Supine Head neck breast heart axillary abdomen extremities pulse Most relax easy access to pulse site P becomes short of breath easy raise head of bed
Sweet and fruit y ketones Oral cavity Diabetic acido
Sweet heavy thick odor Draining wound Psedomonas (bacterial infection)
Musty odor Casted body part Infection inside
Ammonia Urine Uti, renal failure
Glosgow cons scale Eyes open Verbal Motor response
Abstract thinking A stitch in time saves nine Dont coubt your chickens before they hatch
SPLATT Symptoms Previous fall Location Activity during fall Time Trauma after fall
During seizure Stay w pt and call for help Do not lift pt from floor to bed. If standing guide to ground and cradle in lap Turn p on side Do not restraint Do not put objects in mouth Stay w pt Reorient and assure Head to toe assessment
Risk band Yellow- falls Red- allergies Purple- do not resuscitate
TUG Verbal instruction to stand up from a chair Walk 10 ft quickly Turn @ walk bk and sit down Pt rise from straight bk chair w/o using arms 4 support Begin counting Look for unsteadiness in gait Sit bk down w/o using arms
TUG 12 seconds or longer - at risk for falling
Five pt scale for TUG 1- normal 2very slightly 3-mildly normal 4- moderately 5-severely
RACE Rescue Activate Confine Extinguish
Fire extinguisher A- combustible/ wood cloth paper plastic B- flammable / gas grease paint anesthetic C- electrical equipment
Restraints Are not to be ordered prn
Pull Aim Squeeze Sweep
Lead poising is highest in what age group Infancy and toddler
In adolecent what clues r giving for drugs Blood spots on clthes
Mental or physical threat No actual contact is required Assault
Actual and intentional touching without consent Hitting, striking a client, Battery
Protects pt from unwanted intrusions Release pt medical record to a unauthorized person Public relations department Invasion of privacy
Publication of false statements that results in damage to a persons reputation Defamation of character
One speaks falsely about another Slander
Written defamation of character Charting false entries Libel
Person standing in for a parent w their parent rights Loco parentis
Peripheral edema Distended neck veins Weight gain Nausea Weakness Right sided heart failure
Crackles Dyspnea Cough Fatigue Left sided heart failure
HF Slows heart rate and conduction Digoxin
Antagonist: protamine sulfate Lab value: PTT or ApTT Heparin
Antagonist: vitamin K Lab: PT determine efficacy Warfarin (Coumadin)
Partial thromboplastin time PTT
Prothrombin time or INR Determine efficacy of coumadin
Erythematous Yellow lump( sty) Indicates acute suppurative inflammation
Koilonychia (spoon nails) Concave Iron deficiency anemia
Created by: Krystal.ross