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nur101 exam2

QuestionAnswer
Jaundice yellow (sclera) r/t impaired bilirubin
cyanosis blue (mouth, nailbeds)decreased oxygen
erythema redness (local or widespread)
Edema excess fluid in tissue
trace edema 1+ edema 2+ edema 3+ edema 4+ edema brawny not measurable 2mm 4mm 6mm 8mm warm, weeping, shiny, tight
turgor elasticity (dehydration)
brisk turgor normal
sluggish turgor tenting of skin
symptom analysis "Old Carts" onset, location, duration, characteristics, aggravating/alleviating systems, related symptoms, treatment, severity
Symptoms analysis "coldspa" character (feel, sounds, smell, etc), onset, location, duration, severity, pattern, associated factors
Importance of nutrition and metabolic health pattern deficiencies may explain other problems, fluid intake important, problems related to underweight/obesity, skin is line of 1st defense against infection, HC treatment may interfere with cellmatabolism,
essential nutrients water, electrolytes, minerals, vitamins & protein for tissue building
daily calorie requirement for men/women 2800/2000
carbohydrates, fats, proteins & alcohol help provide energy and support metabolic processes
nutrients supply the body with necessary elements for growth, maintenance, and repair
macronutrients carbohydrates, protein, fats
metabolism process of producing and using energy within body cells
plays major role in metabolism thyroid hormones
ways energy is used in the body breathing, circulation, nervous system function
Basal Metabolic Rate (BMR) the amount of energy required for essential life processes
BMR is measured by when the body is physically, metabolically and emotionally at rest
BMR is influenced by these factors activity, hormonal imbalance, temperature, stress, and illness
Metabolic processes Anabolism, catabolism
anabolism cell building, fat(adipose tissue),
catabolism breaking down of cells and tissues
normal body mass index (BMI) 18.5-24.9
Nutritional processes Ingestion, digestion, absorption, transport, metabolism
ingestion nutrients taken into the gastrointestinal (GI) tract
digestion breakdown of ingested nutrients to be absorbed by the body.
digestion process begins in mouth (chewing saliva), peristalsis to stomach, to small intestines.
major digestive area stomach
absorption passage of digested food from gi tract to the blood or lymph circulation
place where most nutrients and electrolytes are absorbed small intestines
transport movement of nutrients across the cell membrane
metabolism final process of nutrition. energy is produced and used in the body cells
Lab assessment for metabolism positive balance more consumed than excreted
lab assessment for metabolism negative balance intake less than output
lab tests 24 hour urine. bun blood test (albumin and protein)
1st line of defense skin
functions of skin protects underlying tissues and organs. also plays a role in maintaining temp, fluid/electrolyte balance, absorption, excretion, immunity, vit D synthesis, id of one's appearance.
layers of skin epidermis, dermis, subcutaneous
epidermis outer layer of skin
dermis connective tissue and blood vessels
subcutaneous connective tissue infiltrated with fat, blood vessels, nerves, and glands
Decubitus ulcers pressure sores
stage 1 pressure sore redness, blood stasis, warm to touch
stage 2 pressure sore epidermal loss, possible damage to dermis
stage 3 pressure sore fullthickness skin loss, sero-sanguinous or purulent drainage common
stage 4 pressure sore full thickness, deep into connective tissue, muscle, bone. may have necrosis. may need debridement.
factors affecting wound healing need adequate proteins, normal albumin, hemoglobin, hematocrit and transferrin levels
s/s of impaired wound healing increased redness & swelling, pus formation, dehiscence (wound edges break loose), wound color changes, decreased granulation tissue
Lymphatic system/lymph nodes act as filters of lymph fluid
location of lymph nodes head, neck, breast, axilla, inguinal, clavicle & popliteal areas
lymphadenitis inflammation of lymph nodes (painful)
lymphangitis inflammation along the course of lymphatic vessel
lymphedema lymph tissue swelling
largest endocrine gland thyroid gland
thyroid gland controls metabolic rate hormone production and secretion
hormones secreted by thyroid gland t3(thyronine), t4, calcitonin
T3 hormone increases BMR, increases chemical reaction rates, increase heat production, stimulates metabolism of essential nutrients, promotes human growth, short life span
T4 hormone same function as T3, can be converted to T3, secreted in greater amounts, longer life span than T3
calcitonin calcium metabolism
daily requirement of iodine 100-200 mcg from bread, salt, seafood, milk, eggs
parathyroid glands are located posterior surface of thyroid gland
parathyroid glands regulate calcium, phosphorus metabolism
signs of hyperthyroidism exopthalmus (big eyes), weakness, fatigue, diaphoresis, tachycardia, chest pains, dysrhythmias, increased blood pressure, weight loss, increased appetite, diarrhea, or constipation, restless, nervous, insomnia, irritable, hyperactivity
signs of hypothyroidism myxedema, decreased cardiac output and conduction, enlarged heart, decreased blood pressure, atherosclerosis (fat in blood vessels), increased cholesterol, lethargy, fatigue, slow speech, thick tongue, deep voice, weight gain, decreased appetite, constipa
other skin related problems diabetes, liver, renal, cancer, fluid imbalance, impaired O2, peripheral vascular disease, skin infections
oral cavity mucus mucosa, salivary glands, tongue, gums/teeth, palate
mucus mucosa keeps mouth hydrated, aids in digestion, chemical barrier to trauma and infectious organisms
salivary glands secrete up to 1500 ml/day, provides moisture, initiates starch breakdown
tongue taste buds, moves food with saliva, initiates swallowing
palate forms the roof of the mouth (hard and soft)
oropharnyx moves food into the esophagus
questions for interviewing diet, weight problems, ingestion problems, food and fluid intake nausea and vomiting, preferences, activity levels, psychosocial, cultural and personal influences, nutrition knowledge, physical changes
Physical Assessment - assess for: subcutaneous fat, muscle mass, height, weight, skin integrity, hair, nails, oral cavity, abdomen, thyroid gland, body temp
skin assessment color, pigment, moisture, temp, texture, thickness, turgor, mobility, hygiene, lesions
hair assessment color, pigment, quantity, texture,distribution, hygiene
nail assessment shape,configuration, color, lesions, thickness, cap refill
normal shape of nail 160 degree angle
abnormal findings of nails clubbing, spooning, cyanosis
normal cap refill of nails <3 seconds
Created by: 526128021