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Nursing ch 31
| Term | Definition |
|---|---|
| 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 | |
| PASS | |
| Erythematous Yellow lump( sty) | Indicates acute suppurative inflammation |
| Koilonychia (spoon nails) | Concave Iron deficiency anemia |
Created by:
Krystal.ross
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