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263 FINAL
| Question | Answer |
|---|---|
| assesment | subjective and objective data |
| diagnosis | analyzing subjective and objective data to make a professional judgment |
| planning | determining outcome criteria and developing a plan |
| implementation | carrying out the plan |
| evaluation | assessing whether outcome criteria have been met and revising the plan |
| initial comprehensive | collection of subjective data about the client's perception of their health, health history, family history and lifestyle as well as objective data |
| ongoing or partial assessment | data collection after comprehensive database is established |
| focused or problem oriented assessment | specific health concern, specific body systems |
| emergency assessment | life threatening, immediate |
| documentation of data | provides database for nursing process, promoted effective communication |
| what needs to be validated | gaps between subjective and objective data, differences in what the patient says, highly abnormal findings |
| ways to validate | recheck own data, clarify with questions, verify with another nurse, compare subjective and objective |
| identify abnormal data and strengths | used to formulate diagnoses to minimize potential weakness |
| cluster data | consider if additional data is needed, look for related cues from identified strengths |
| draw inferences | infer, determine if collaborative problem or need a referral |
| collaborative problem | certain complications that nurse monitor to detect changes in status |
| propose possible nursing diagnoses | hypothesize and generate |
| data analysis | diagnostic phase because the end result or purpose is to identify a nursing diagnosis |
| wellness diagnosis | client has motivation and well being to follow care |
| risk diagnosis | client is vulnerable to developing complication |
| actual diagnosis | client is experiencing problem |
| syndrome | group of signs and symptoms |
| check defining characteristics | most accurate, delete invalid |
| confirm, rule out diagnosis | verify diagnoses with client |
| pitfalls | too much or little data, unreliable, invalid, insufficient cues to support diagnosis, cues clustered are unrelated, quick diagnosis, incorrect wording |
| alert | eyes are open, able to answer questions and maintains eye contact |
| lethargic | opens eyes, answers questions falls back asleep quickly |
| obtunded | opens eyes to loud voices, responds slowly |
| stupor | awakens to painful stimuli, returns to sleep |
| coma | unresponsive to painful, noxious stimuli |
| glasgow coma scale | records conscious state of a person, 3 is coma, 15 is fully awake |
| alzheimer's | poor judgment and decision making, inability to manage budget, losing track of date, misplacing items |
| AUDIT | alcohol use disorders identification test |
| SAD persons | suicide risk assessment, sex, age, depression, previous attempt, ethanol abuse, rational thinking, lack social support, organized plan |
| CAM | confusion assessment method |
| SLUMS | mental status exam (dementia or alzheimer), orientation, memory, speech, cognitive |
| PHQ9 | depression scale |
| older adult BP | arteries more rigid, increased systolic BP |
| acute pain | recent injury |
| visceral pain | abdominal, thorax, cranium |
| somatic pain | ligaments, tendons, bones and nerves |
| phantom pain | nerves, missing limb |
| FLACC | face, legs, activity, cry, consolability |
| walker's cycle of violence | tension building, acute battering stage, honeymoon |
| domestic violence | a pattern of abusive behavior where one partner gains or maintains control |
| violence interview | confidentiality, develop trust, simple, direct questions, listen, discuss legal, mandatory report |
| violence observe | appearance and body build, children may look underdeveloped, older client thin, frail, malnourished |
| violence observed hygeine | neglect poor hygiene, soiled clothing, long sleeve and pants in warm weather |
| assess violence mental status | anxious, depressed, suicidal, withdrawn, difficult concentration, poor eye contact, soft speech, unable to recall past events |
| violence vital signs | prolonged stress leads to hypertension, elevated heart rate and respiratory rate |
| cultural awareness | knowledgable about thoughts, feelings, sensations and how it affects interactions with others |
| purpose of cultural assessment | learn beliefs and behaviors, compare to Western health care, compare to those of similar background, assess prevalent diseases |
| culture bound latin | mal de ojo |
| culture bound african | high blood |
| culture bound native american | ghost sickness |
| ideal body weight female | 100 pound for 5ft plus 5lb for every inch over 5 ft |
| ideal body weight male | 106 pound for 5ft plus 6lb for every inch over 5ft |
| normal BMI | 18.5 to 24.9 |
| obese BMI | 30 - 39 |
| IDDSI framework | how thick food is getting, drinks 0 foods until 7 |
| hemoglobin | 13 - 16/18 |
| hematocrit | 40 - 52 |
| serum albumin | 3.5 - 5 |
| prealbumin | 17 - 40 |
| BUN | 5 -25 |
| vitamin A deficiency | dry, rough, scaly skin, night blindness |
| vitamin B deficiency | flaky skin, beefy red tongue, paresthesia, decreased mental status |
| vitamin C deficiency | spongy, bleeding gums, petechiae, sores |
| vitamin K deficiency | petechiae, ecchymoses |
| riboflavin deficiency | red conjunctiva, mouth cracks, magenta tongue |
| protein deficiency | thin hair, ascites, edema, poor wound healing |
| iodine deficiency | swollen neck, goiter |
| iron deficiency | brittle nails |
| zinc deficiency | unhealing sores |
| thiamin deficiency | altered mental status |
| dehydration | orthostatic hypotension |
| overhydration | crackles in lungs, pale yellow urine |
| diabetes | excessive weight loss despite adequate intake |
| older adult skin | decreased perspiration, decreased flexibility and motility lead to improper hygiene, paleness, dryness, skin lesions |
| older adult nails | thick, yellow, brittle |
| freckles | flat, small macules of pigment following sun exposure |
| mole | nevus, flat or raised tan marking |
| stage 1 pressure ulcer | intact skin, nonblanchable redness over a bony prominence, painful, firm, soft, warm or cool |
| stage 2 pressure ulcer | partial thickness loss of dermis, shallow open ulcer with a red pink wound bed, without slow, shiny or dry ulcer, skin tears |
| stage 3 pressure ulcer | full thickness tissue loss, subcutaneous fat loss with visible bone, tendon or muscle not exposed, may undermine or tunnel, visible adipose tissue |
| stage 4 pressure ulcer | full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar |
| braden scale | risk for skin breakdown, sensory perception, moisture, activity, mobility, nutrition, friction |
| macule and patch | flat, small, non palpable skin color change (macule - circumscribed), patch is a freckle |
| papule and plaque | elevated, palpable, solid mass (papule circumscribed) |
| plaque | psoriasis |
| nodule and tumor | elevated, solid, palpable extends into dermis |
| vesicle and bullae | circumscribed elevated |
| wheal | elevated mass with transient borders |
| pustule | pus filled vesicle or bullae, acne or impetigo |
| cyst | encapsulated fluid filled or semisolid mass in subcutaneous or dermis |
| erosion | loss of superficial epidermis |
| scar | cicatrix, skin mark left after healing, connective tissue |
| ulcer | skin loss past epidermis, necrotic tissue loss |
| fissure | linear crack |
| petechiae | pinpoint red dots, red or purple maculae |
| ecchymosis | round, irregular macular lesions, color varies yellow and green hues, bruising |
| hematoma | collection of blood under the skin |
| angioma | bright red spot on skin |
| clubbing nails | distorted, raised nail bed, due to hypoxia or long term oxygenation issues |
| psoriasis | yellow, nail pitting |
| yeast infection nails | white color, separation of nail and bed |
| bacterial infection nails | green, black or brown |
| fungal infection nails | yellow, thick, crumbling |
| concave or spoon nails | iron deficiency |
| thickened nails | decreased circulation |
| skin cancer | Asymmetry, border, color variation, diameter, evolving |
| phases of wound healing | hemostasis, inflammatory, proliferation, remodeling |
| hemostasis | blood vessels constrict, blood clot |
| inflammatory phase | WBC locate to wound, temperature increases as growth factor builds blood vessels |
| proliferation | regeneration, fibroblasts fill wound |
| remodeling | 3 weeks after injury |
| inspecting a wound | landmarks, size, edges, drainage |
| serous drainage | clear, no infection |
| sanguineous drainage | bloody |
| serosanguineous drainage | light pink |
| purulent drainage | pus, thick and odor |
| debridement | removal of devitalized tissue and foreign material, promoted healing, decreases infection |
| 3 main dressings | add, absorb, maintain moisture |
| autolytic debridement | own enzymes |
| enzymatic debridement | applies enzymatic to speed autolytic process |
| mechanical debridement | external force to dislodge and remove debris and necrotic tisse |
| eschar | dead tissue, black and leathery |
| shearing forces | pulled rather than lifted |
| dehiscence | partial or total separation of wound layers |
| sterile technique | surgical wounds |
| clean technique | pressure ulcers and chronic wounds |
| wound culture | taken after wound is cleaned to identify organism |
| irrigation of a wound | 1 inch above a wound |
| cranium | 8 bones, ethmoidal and sphenoidal not accessible |
| face | 14 bones, mandible is only movable (jaw) |
| sternomastoid muscle | rotates and flexes head |
| trapezius | extends head, moves shoulders |
| cranial nerve XI | shrug shoulders, turn against resistance |
| use of trapezius and sternomastoid | accessory muscle use, acute airway obstruction |
| sinus headache | constant throbbing, pressure like pain with a cold, eye brow or cheek |
| cluster headache | stabbing, sudden onset, alcohol induced, eye orbit, facial and temporal |
| tension headache | dull, tight, diffuse, with stress and anxiety, frontal, temporal, occipital, lasts days months, years and mostly women |
| migraine headache | nausea, vomiting, photophobia, phono phobia, may be one sided, eyes, temples, cheeks, forehead |
| hypothyroidism | sleepiness, cold intolerant, weight gain, muscle aches, dry skin, brittle nails, bradycardia, constipation |
| hyperthyroidism | nervousness, fatigue, weakness, palpitations, heat intolerance, dyspnea, diarrhea, weight loss, tachycardia, insomnia, brain fog |
| scleroderma | tightened hard face, thin skin |
| parkinson's | expressionless face, tremors, rigidity, akinesia, postural, instability |
| bell's palsy | one sided facial paralysis, sudden onset peak by 48 hours, affect cranial nerve VII |
| stroke cerebrovascular accident | neurologic damage, decrease vision, balance, numbness |
| impending stroke | visual disturbances, loss of balance, trouble walking, sudden weakness |
| diabetic ketoacidosis | fruity or acetone breath |
| small bowel obstruction | fecal odor breath |
| end stage liver | sulfur odor breath |
| older adult thyroid | fibrotic changes, weak temporal artery pulse |
| sclera | dense protective covering |
| retina rods | regulate black and white |
| retina cones | sensitive to bright color |
| visual fields | what a person sees with one eye |
| visual perception | nerve impulses conducted to brain |
| visual pathways | information from right is conveyed to left |
| anisocoria | pupils of different size |
| miosis | constricted pupils, pinpoint |
| mydriasis | dilated pupils, fixed |
| ectropion | outward lid |
| entropion | inward lid |
| ptosis | drooping eyelid |
| hordeolum | stye |
| strabismus | eyes inward or outward, tropia |
| papilledema | swelling of optic disk, lack physiologic cup, blurred margins |
| glaucoma | high pressure damaging optic nerve, painful, age over 40, high BP |
| open angle glaucoma | tunnel vision |
| acute angle glaucoma | halos, eye pain, headache |
| diplopia | double vision, intracranial pressure |
| presbyopia | impaired near vision, decreased accomodation |
| myopia | impaired far vision |
| visual fields peripheral vision | confrontation test, see finger at same time |
| near visual acuity | jagger card, snellen card |
| cover test | deviation, alignment or strength, uncovered eye remains fixed ahead |
| corneal light reflex | test for strabismus |
| pupillary light reflex | pupils constrict when exposed to bright light |
| consensual reflex | exposure in one eye leads to reaction of other eye |
| middle ear | transmits vibrations through ossicles |
| inner ear | labyrinth |
| presbycusis | gradual sensorineural hearing loss, whispered sounds |
| newborn auditory canal | curves upward, short and straight |
| conductive hearing | external and middle ear |
| conductive hearing loss due to | earwax, otitis media, perforated eardrum |
| sensorineural hearing | inner ear |
| sensorineural hearing loss due to | dysfunction of inner ear, cranial nerve VIII, gradual nerve degeneration |
| weber test | distinguished conductive and sensorineural hearing loss, tuning fork in middle forehead |
| rinne test | compares air and bone conduction, tuning fork on mastoid process |
| acute otitis media | red bulging membrane |
| otitis externa | swimmer's ear, pain in pinna and tragus, otorrhea (drainage), itching |
| tinnitus | ringing |
| oral cancer | under tongue |
| tongue cancer | side of tongue |
| sinuses | air filled, lined with ciliated mucous membranes, easily blocked |
| acute tonsilitis | enlarged, erythema and large gray white patches |
| 1 tonsils | visible |
| 2 tonsils | midway between tonsillar pillar and uvula |
| 3 tonsils | touch uvula |
| 4 tonsils | touch each other |
| childbearing women sinuses | epistaxis, bleeding gums, nasal congestion |
| right lung | 3 lobes |
| xiphoid process | above costal angle, 90 degrees, increases during hyperventilation and emphysema |
| landmark for lung and thorax assessment | costal angle, for people who retain oxygen, COPD angle changes |
| suprasternal notch | U shaped |
| resonance | percussed over normal lung tissue |
| hyper resonance | COPD, more air, pneumothorax |
| crepitus | crackling when air passes through subcutaneous tissue |
| increased fremitus | pneumonia |
| decreased fremitus | pneumothorax, pleural effusion |
| bronchial breath sound | high pitch, trachea area, short inspiration, long exhalation |
| broncho vesicular breath sound | bronchi, scapulae, sternum |
| vesicular breath sound | peripheral lung field |
| crackles sound | bronchitis, asthma, emphysema |
| coarse crackles | low pitch bubbling, pneumonia, pulmonary edema, velcro rales |
| pleural friction rub | grating sound, pleuritis, severe dehydration |
| stridor | harsh, honking wheeze, medical emergency, airway blockage |
| wheeze | airway obstruct |
| sibilant wheeze | asthma and emphysema |
| sonorous wheeze | bronchitis, sleep apnea |
| pectus excavaum | funnel chest |
| pectus carinatum | pigeon chest |
| carbon dioxide | strongest thing to regulate breathing pattern |
| hypercapnia | strongest stimulus to breath |
| tachypnea | more than 24 breaths per minute, not able to perfuse, trying to compensate |
| bradypnea | less than 10 breaths per minute, can be medication induced |
| hypoventilation | decreased rate, irregular pattern, drug overdose |
| dyspnea | difficulty breathing |
| kussamul | rapid, deep, labored, diabetic ketoacidosis |
| cheyne stokes | increased intracranial pressure, congestive heart failure, deep rapid breathing followed by period of apnea |
| chronic bronchitis | labored and noisy, occasional coughing |
| rust colored sputum | tuberculosis |
| breast function | produce and store milk, aid in sexual stimulation |
| glandular tissue | milk production |
| fibrous tissue | supports glandular tissue |
| fatty tissue | size and shape |
| lymph nodes | filter debris and return water and protein |
| anterior lymph node | chest wall and breasts |
| posterior lymph node | chest wall, part of arm |
| central lymph node | receive drainage, most palpated (high in axillae at top of ribs) |
| lateral lymph node | drain most of arms, brachial |
| peau d orange | orange peal appearance, associated with cancer |
| suggest malignancy of breast | dimpling, restricted breast tissue, retracted nipple |
| paget disease | redness and flaking of nipple, eczema scaly skin around areola |
| mastitis | red, painful, warm |
| cancerous tumor | irregular, firm, hard, fixed |
| fibroadenomas | lobular, ovoid, round and seldom tender, between puberty and menopause |
| benign breast disease | round, elastic, defined, tender and mobile cysts |
| asymmetrical breasts | benign |
| fibrocystic breast disease | premenstrual breast lumpiness and soreness subside after end of menstrual cycle |
| child breast | occurs in 5 stages, starts at puberty |
| breast cancer | lump, thickening of breast, discharge, bleeding, size change, BRCA1 or 2 |
| increases risk for breast cancer | high fat diet |
| SNS stimulation | increased cardiac output, increased blood pressure, increased heart rate |
| AV valves | tricuspid and bicuspid , first heart sound s1 at closure |
| SV valves | pulmonic, aortic |
| electrical conduction | SA node, AV node, bundle of His, bundle branches, purkinje fibers |
| SA node | 60 - 100, pacemaker of the heart |
| AV node | intrinsic rate of 40 - 60 |
| preload | amount of blood in ventricles at end of diastole, stretch |
| systole | blood in ventricles, pressure causes AV valves to close, SV open and blood is ejected |
| diastole | AV valves open, ventricles relax, takes two thirds of cardiac cycle |
| afterload | pressure against blood ejection during contraction |
| murmurs | increased blood viscosity, valve disorder, malfunction, abnormal chamber opening |
| thrills | vibration turbulence |
| stenosis | narrowing |
| sinus arrythmia | rate speeds with inspiration, slows with exhalation |
| dizziness | fall risk |
| smoking cessation | ask, advise, assess, assist, arrange |
| carotid | auscultate then palpate, use bell of stethoscope, client hold breath |
| apical pulse | best heard at apex if not left lateral |
| pulsus alternans | changes in strength and amplitude |
| paradoxical pulse | decreased amplitude, pericardial tamponade, obstructive lung disease |
| orthostatic hypotension | assess lying, sitting, standing, blood pressure decrease when standing |
| veins | carry deoxygenated blood back to heart |
| deep veins | femoral and popliteal |
| right side of the heart | pumps blood to lungs for gas exchange |
| left side of the heart | receives oxygenated rich blood and pumps systemically |
| allen test | patency of radial and ulnar arteries |
| arterial insufficiency | pain, pulselessness, paralyze, paresthesia, pallor, poikilothermy, cool to cold, dry and shiny |
| arterial insufficiency ulcers | tips of toes, heels, very painful, circular deep black and gangrene |
| venous insufficiency | aching, cramping, present pulse, edema, thick and tough skin reddish to blue |
| venous insufficiency ulcers | medial malleolus, anterior tibial, irregular border superficial, beefy red to yellow fibrinous |
| peripheral artery disease | atherosclerosis |
| atherosclerosis | narrowing arteries due to plaque buildup, reduces blood flow |
| lymphadema | damaged or blocked lymphatic circulation, buildup of lymph fluid |
| edema | increased capillary blood pressure, venous insufficiency, decreased plasma proteins, decreased colloid osmotic pressure |
| raynaud | vascular disorder, constriction or spasms |
| thrombophlebitis | infection, inflamed, warm |
| RUQ | liver, dullness percussed |
| RLQ | colon, large intestine, appendix |
| LUQ | spleen |
| LLQ | sigmoid colon, left kidney |
| suprapubic region | hypogastric, bladder pain |
| visceral pain | hollow abdominal organs become distended or contract forcefully |
| parietal pain | appendicitis, peritonitis; sharp and severe |
| diarrhea | frequency of bowel movements |
| blood and mucus stool | inflammatory bowel disease |
| clay colored stool | fatty, malabsorption |
| hyperactive bowel sounds | rapid mobility, diarrhea, borborygmus (growling) |
| hypoactive | diminished bowel activity, paralytic ileus, late bowel obstruction |
| abdomen assesment | empty bladder, begins in RLQ, inspect, auscultate, percuss, palpate |
| kidney percussion | costa vertebral angle |
| crohn's disease | cramping, diarrhea, nausea and vomitting, weight loss |
| psoas sign | pain in RLQ when leg hyperextended, appendicitis |
| obturator sign | pain in RLQ when hip and knee flexed and leg rotated |
| murphy sign | pain when pressure applied at liver border, inflamed gallbladder |
| rovsing sign | pressure in LLQ causes pain in RLQ |
| blumberg sign | rebound tenderness |
| cullen sign | discolored umbilical, bluish purple |
| grey turner | blue abdominal flanks |
| scaphoid | sunken abdomen |
| cirrhosis | liver edge firmness |
| stomach emptying post op | 24 - 48 hours |
| large intestine emptying | 3 to 4 days |
| scoliosis | lateral curvature of spine, convexity increase on one side |
| kyphosis | rounded thoracic cavity, hunchback |
| decline in height | 5th decade of life, thinning intervertebral discs |
| lordosis | J curve, pregnancy, lumbar curve |
| non weight bearing | no weight on affected limb |
| toe touch bearing | limb affected can be used for balance |
| partial weight bearing | small % of weight on affected limb |
| tolerated weight | client level of comfort |
| full weight bearing | no restriction |
| cerebellar ataxia | wide base, staggering, unsteady |
| spastic hemiparesis | flexed arm held close while toe drags |
| stereognosis | identify objects placed in hand |
| graphesthesia | correctly identify number traced on skin |
| cranial nerve 5 | sensory and motor, clenching jaw |
| swallowing cranial nerves | IX and X |
| brudinski sign | flex neck and knees flex |
| kernig sign | flex hip and knee then straighten |
| penis inspection | skin, shaft, foreskin, scrotum, lift scrotal area and assess skin |
| hypospadias | urethral meatus underneath glans |
| epispadias | urethral meatus on top of glans (dorsal) |
| hyrdocele | collection of serous fluid in scrotum, transillumination |
| testicular tumor | small, firm, non tender nodule, heavy feeling |
| scrotal hernia | loop of bowel protrudes into scrotum |
| epididymitis | infection, scrotum enlarged, red and tender |
| vaicocele | dilation of veins on the spermatic cord, discomfort, bag of worms |
| spermatocele | sperm filled cysts, mass on epididymis, movable above testes |
| hemorrhoid | painless papules caused by varicose veins, bleed with bowel movement |
| perianal abcess | cavity of pus, infected skin around anal opening, throbbing pain and red |
| anal fissure | splits in tissue, pain, itching, bleeding |
| rectal prolapse | rectum protrudes out anal opening, doughnut like |
| rectal polyps | pedunculate on stalk, sessile on mucosa |
| prostate cancer | 2nd most common, hard and fixed, median sulcus not palpable |
| colorectal cancer | 3rd most common, colonoscopy at age 45, african american high risk |
| colorectal cancer signs | abdominal pain, blood in stool, bowel habit change, weight loss, fatigue |
| vagina | acidic environment prevents infection |
| bartholian's glands | lubricate |
| cervix | seperates vagina and uterus, firm and soft, pink |
| red cervix | inflammation |
| blue cervix | pregnant (chadwick's) |
| pale cervix | anemia, post menopause |
| uterus | round, firm, smooth |
| corpus | bosy, muscular |
| hemorrhoid education | high fiber diet, hydration |
| trichomonas vaginalis | frothy yellow, green discharge |
| bacterial vaginosis | thin, white, fishy odor |
| candidal vaginitis | white cottage cheese discharge, yeast infection |
| mucopurulent cervicitis | yellow discoloration |
| uterine prolapse | uterus and cervix come out together descending into vaginal cavity |
| cystocele | bladder prolapses through vagina |
| rectocele | rectum into vagin |
| cervical polyps | polyps of endometrial cells arising from either uterus or cervix |
| retroversion | posteriorly turned |
| anteflexion | turned anterior |
| retroflexion | fundus bends posteriorly |
| cervical cancer diagnosis | PAP smear, treatable |
| cervical cancer risk factors | HPV, smoking, pregnancy, younger than 17, family, multiple partners |
| cervical cancer signs | pelvic pain, vaginal bleeding, discharge, cauliflower lesions |
| general survey information | appearance, vital signs, body measurements |
| mental status exam | LOC, orientation, cognitive |
| IV assesment | needed, working, pain, dressed, infected |
| complications of IV | phlebitis, infiltration, extravasation, dislodgment |
| room air | 21% |
| nasal cannula | low flow, low concentration |
| non rebreather | low flow, minimum rate of 10 L/min, one way valve |
| non rebreather disadvantage | malfunction cause suffocation because of increased CO2 level |
| venturi | high flow, specific amount of oxygen without drying mucus membranes |
| hypoxia | inadequate amount of oxygen available to perfuse cells |
| coughing | removes mucus and secretions |
| deep breathing | inflates alveoli, improves lung expansion, oxygenation of tissues |
| incentive spirometry | increases lung volume and inflation of alveoli |
| humidification | distilled water |
| breast self exam | monthly, right after menstrual cycle |
| amennorhea | absence of menses |
| menopause | 48 - 52 |
| upper outer quadrant | most common area of breast tumors |
Created by:
ahommel
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