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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 |
Created by:
jjannett
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