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B2 Roseman ABSN
B2 M1-7
| Question | Answer |
|---|---|
| Mental Status | Emotional and Cognitive Functioning |
| Organic Disorder | |
| Psychiatric Mental illness | |
| Full Mental Status Evaluation | Brain Lesions, Symptoms of Psych illness, Behavior Change, Aphasia |
| ABCT - main components of mental status | Appearance, Behavior, Cognition, Thought Process |
| subjective data | what person says about self |
| objective data | observation through physical assessment |
| diagnostic reasoning | process of analyzing data, and drawing conclusions for diagnosis |
| nursing process | assessement, diagnosis, outcome id, planning, implementation, evaluation |
| Critical thinking priorities | 1st (ABCVS), 2nd, 3rd level |
| cue | piece of info, sign symptom data |
| nursing diagnosis | clinical judgement about response to actual or potential health - actual vs risk diagnosis |
| wellness diagnosis | focus on strengths, transition to better health |
| EBP | Evidence Based Practice |
| 2nd level priorities | mental, medication problems, urinary, abnormal labs, infection |
| 3rd level priorities | long term, family coping, take time with these |
| development:1st year:physical | 3x birth weight 2x length, massive brain growth, lose certain reflexes |
| DVP:1st:Psychosocial | Trust vs Mistrust |
| DVP:1st:cognitive | sensorimotor skills |
| DVP:1st:Behavioral Development | sitting, standing, walking, grasping, babbling, talking |
| DVP:Toddler:Physical | gain 2.5 kg and 12 cm lengthp; toddler lordosis |
| DVP:Toddler:Psychosocial | Autonomy vs shame and doubt |
| DVP:toddler:cognitive | sensorimotor period continues |
| DVP:toddler:Behavioral | Locomotion improves, fine motor gains include throwing, retrieving, holding an dusing pencils, behavioral patterns include negativism and ritualism |
| DVP:Preschool:Physical | Growth slows, stature approaches more adult proportions |
| DVP:Preschool:Psychosocial | development of superego, gender role, initiative vs guilt |
| DVP:Preschool:cognitive | Preoperational stage |
| DVP:Preschool:behavioral | fine motor advances, hand preference clarifies, telegraphic speech progresses to grammatically correct sentences, interactions move away from negatavism toward cooperative play |
| DVP:School-Age:Physical | slow steady growth, facial features mature, primary teeth to permanent |
| DVP:School-Age:psychosocial | industry vs inferiority, peer approval becomes significant |
| DVP:School-Age:cognitive | concrete operational stage |
| DVP:preadolescence:physical | girls growth spurt 10, boys 12 |
| DVP:Preadolescence:psychosocial | peer group gains importance, as does best friend |
| DVP:Adolescence:Physical | puberty, poor judgment primary health risk |
| DVP:Adolescence:psychosocial | ego identity vs identity confusion |
| DVP:Adolescence:cognitive | formal operations |
| DVP:Adolescence:behavioral | close friendships, peer group and romantic relationships - develop identity outside family |
| DVP:Early Adult:physical | completing growth, reach peak physical health and ability |
| DVP:Early Adult:psychosocial | intimacy vs isolation |
| DVP:EArly adult: cognitive | focus on work and career development |
| DVP:Middle Adult:Physical | agingin begins to affect body negative |
| DVP:Middle adult:psychosocial | generativity vs stagnation |
| DVP:Middle adult:cognitive | IQ complement by experience and knowledge |
| DVP:Late adult:physical | range of physical decline |
| DVP:Late adult:psychosocial | ego integrity vs despair |
| DVP:Late adult:cognitive | decline reaction speed and complex decision speed |
| population us | 300 million |
| 2/3 population | single race non-hispanic white |
| Minority or emerging majority population | 98 million |
| order of fastest growing populations | hispanic, black, asian, american indiands and alaska natives, native hawaiians and pacific islanders |
| National Standards for culturally and linguistically appropraite services in health care | 2001: effective care, respectful care, cultural/linguistic competence |
| language other than english | 20% - 47 million over 5years |
| Title V1 civil rights act of 1964 | services cannot be denied to people of limited english proficiency |
| states require providers offer language assistance in health | california, Massachusetts, new york |
| culturally sensitive | basic knowledge, constructive attitude in setting practice |
| culturally appropriate | apply knowledge, for best possible healthcare |
| culturally competent | understand/attend total cultural context |
| culture | thoughts, communication, actions, beliefs, values, institutions of racial, ethinci, religious or social groups |
| characteristics of culture | learned, shared, adapted, dynamic |
| heritage consistency | degree to which a person's lifestyle reflects heritage |
| causes of illness theories | biomedical, naturalistic, magicoreligious |
| PQRST:P | Provocative or palliative - brings it on, makes better/worse |
| PQRST:Q | Quality or Quantity - look, feel, sound |
| PQRST:R | Region or radiation - where is it, does it radiate |
| PQRST:S | Severity Scale - 1-10 - better/worse/same |
| PQRST:T | Timing - onset,duration,frequency |
| PQRST:U | Understand patient's perception |
| CAGE | Cut down - Annoyed @ criticism - Guilty sobre drinking - Eye opener |
| Mini Mental state components | orientation, registration, attention and calculation, recall, language |
| lethargic | can be awakened/drowsy |
| obtunded | transitional lethargy to stupor |
| stupor or semicoma - | responds only to persistent/vigorous shakes |
| elation | overconfidence |
| euphoria | unusually cheerfull |
| anxiety | source unknown |
| depersonalization | lack of ego boundaries - loss of id |
| ambivalence | opposing emotion |
| lability | rapid shift of emotion |
| inappropriate affect | clearly discordant with speech |
| aphasia | lack of ability to speak or write coherenctly or understand |
| ABCT:B | Behavior - consciousness, facial expression, speech, mood, affect |
| ABCT:A | Appearance |
| ABCT:C | Cognitive Functions - orientation x3, attention, recent/remote memory (4 unrelated words), judgement |
| ABCT:T | Though Processes - thought content, precesses, perceptions, screen suicide risk |
| Neuroanatomic pathway | nociceptors, interneurons, anterolateral spinthalamic tract |
| nociception | transduction, transmission, perception, modulation |
| neuropathic, | abnormal processing, most difficult, neuro chemical |
| bimanual palpation | envelope/capture body organs |
| diurnal cycle | daily cycle |
| gender effect on BP | after puberty F < M; after menopause F > M |
| age effect on BP | rise through childhood |
| Race effect on BP | AA > White |
| weight effect on BP | Obese > Normal |
| emotion effect on BP | Higher with fear, anger, pain through sympathetic nervous system |
| diurnal rythm on BP | daily cycle peak high afternoon, trough early morning |
| exercise on BP | activity raise BP, 5 min rest return to normal |
| stress on BP | higher persons with continual tension |
| Cardiac output physiologic BP | heavy exercise raise BP, pump failure lowers |
| peripheral vascular resistance effect BP | vaso constriction raises BP, vasodilation lowers BP |
| volume of circulating blood effect BP | hemorhage lowers BP, NA, H2O retention raises BP |
| Viscocity on BP | increased hematocrit in polycythemia raise BP |
| Elesticity of vessel wall | rigidity, hardening, arterisoslcerosis raises BP |
| 104 F | 40 C |
| 98.6 F | 37 C |
| 95 F | 35 C |
| systolic pressure | max pressure on artery during Left ventricle contraction |
| diastolic pressure | elastic recoil or resting pressure blood exerts between each contraction |
| Pulse pressure | difference of S and D - reflects SV |
| MAP | pressure forcing blood into tissues averaged over cardiac cycle |
| decrease cuff size | increase BP |
| deep somatic pain | blood vessels, joints, tendons, muscles, bone |
| Initial pain assessment | 8 ?, duration, intensity, aggravate/relief |
| Brief Pain Inventory | 24 hour ratings, 1-10, mod, walk, ability to sleep |
| short-form McGill Pain Questionnaire | rank, descroptors, overall intensity |
| Pain Ratinign scale | unidimensional, reflect pain intensity |
| numeric pain rating scale | 1-10 |
| descriptor scale | no pain, moderate, severe |
| faces pain | 1 to 10 |
| oucher pain | boys faces 0 to 5 |
| nociceptors | pain sensors periphery to CNS (skin, connective, muscle, thoracic, abdominal, pelvic, viscera |
| nociceptors triggered | 1 - trauma 2 - chemical from site |
| Peripheral A fibers | mylenated with large diameter - rapid transmit of pain to CNS - sharp |
| Peripheral C fibers | unmylenated and small - transmit slowly - secondary, dull achy |
| anterolateral spinothalamic tract | spinal cord section transmit pain to brain |
| nociceptive pain | nerve functioning and intact 1. transduction 2. transmission 3. perception 4. modulation |
| nociceptive processing | protective |
| neuropathic pain | pain that does not adhere to typical nocioceptive - abnormal processing often long after injury site heals |
| visceral | interior organs - include ureteral colic, acute appendicitis, ulcer pain, cholecystitis - presents w autonomic responses, vomiting, naseua, pallor, diaphonesis |
| deep somatic | blood vessels, joints tendons, muscles, bone - pressure, trauma, ischemia |
| analgesia | no pain sensation |
| hyperdigesia | increased pain sensation |
| mini nutritional assessment | malnourishment for older adults - 6 questions |
| excess weight nutrition | diabetes, neport disease, hypertension, cancer |
| calorie intake after recent trauma, surgery, burns, infection | need 2-3 times greater than usual |
| chronic illnesses affecting nutrition | diabetes mellititus, pancreatitus, malabsorption |
| medications affecting nutrition | analgesics, antacids, anticonvulsants, antibiotics, diaretics, laxatives, antineoplasic drugs, steroids, oral contraceptives, digestion |
| family history affecting nutrition | heart disease, gout, osteoporosis, cancer, gi disorders, obesity, diabetes |
| Food pyramid grains | 6 oz |
| food pyramid veg | 2 1/2 c |
| food pyramid fruits | 2 c a day |
| food pyramid milk | 3 c |
| food pyramid meat and beans | 5 1/2 oz |
| waist circumfrence | >35 inches W, >40 inches M |
| waist hip ratio | >1.0 M, >.8 Women |
| effects over waist circumfrence or waist hip ratio | heart disease, diabetes type II, metabolic syndrome |
| Mid upper arm muscle circumference | estimates skeletal muscele reserves or amount of lean body mass |
| Mid arm muscle area | indicator of lean body mass, skeletal protein reserves |
| hemoglobin | detect Fe deficeiency, anemia, 14-18 g/dL |
| gycosylated hemoglobin | ave blood glucose 2-3 months, Hbalc 5-7% normally |
| hematocrit | cell volume, fe slates M:37% F:49% |
| cholesterol | fat metabolism risk cardiovascular - 120 - 200 mg/dL |
| tryglycerieds | serum tryglycerides - blood fats screen for hyperdipidermia and coronoary artery disease <150 mg/dL |
| Serum Albumin | visceral protein status, better long term than acute malnutrition 3.5-5.5 |
| serum transferrin | Fe transport protein, isceral protien status, more sensitive than albumin, 170-250 mg/dL |
| Pralbumin | thyroxine binding prealbumin - transport protein, thyroxine T4, retional binding protein, acute changes in protein status and sudden demand s on proitein syntehisis, shortest half life - 48 hours |
| marasmus | inadequate protein, calories or prolonged starvation |
| kwashiorkor | diet high calorie, low protien, low protien liquied, fat |
| marasmus/kwashiorkor mix | prolonged inadequate protienc calories, severe starvation or catabolic |
| pellagra | pigmented keratic scaling lesions |
| corutic gums | vitamin c deficiency - gums, swollen, ulcerated, bleeding |
| follucular hyperkeratosis | dry bumpy skin - vit a or linoleic acid deficiency |
| bitots spots | foamy plaques of conea - vit a deficiency - may result in dry |
| pale tongue | fe deficeincy |
| beefy red tongue | vit b complex deficiency |
| rickets | vit d ca deficiency, cartilage cell growth enlarged epiphyseal growthplates, adultes = osteomalacia |
| magenta tongue | riboflavin deficiency |
| HIV associated malnutrition | smaller |
| cathectic | fat and muscle wasting |
| android obesity | fat in upper body and abdomen |
| LDL | bad cholesterol <130 mg/dL |
| HDL | good protien M 35-65, W 35-80 |
| C reactive protien | plasma protien marker of infammatory status produced by liver to monitor metabolic stress (not usually present in healthy adults) |
| hypoventilation | CO2 buildup - low shallow breathing |
| hyperventilation | CO2 blown off - quick rapid breathing |
| breathing | inspiration = - pressure |
| fremitus | palpable vibration of human body |
| diaghragmatic excursion | diaghram border during expiration and inspiration |
| bronchial breath sounds | high pitch inspiration < expiration harsh, shallow, trachea larynx |
| bronchovesicular breath sounds | med = major bronchri between scapulae, 1st and 2nd intercosta |
| vesicular breath sounds | low, soft inspiration > expiration, rustling between aveoli |
| adventitious sounds | sounds not normally in lungs - super imposed |
| atelectatic crackles | not pathologic fine crackles limit to a few breaths |
| forced expiratory time | number of seconds it takes person to exhale total to residual < 4 seconds |
| Barrel chest | equal anterior posterior to transverse diameter - ribs noriz |
| pectus excavatum | markedly sunk sternum - 2nd rib - not symptomatic |
| pectus carinatum | forward protrusion of sternum |
| kyphosis | hunchback - cardiopulmonary function |
| tachypnea | rapid shallow breathing >24 minute, fever, exercise |
| bradypnea | slow breathing <10m drug induced, depression |
| cheyne stokes respiration | regular pattern of deep rate up then down |
| biots respiration | irregular changes in rate/pattern |
| chronic obstructive breathing | overcome increased airway resistence - normal/prolonged air trapping |
| increased tactile fremitus | increased density of lung tissue |
| decreased tactile fremitus | anything that obstructs transmission of vibration |
| ronchial fremitus | vibration of thick secretions in larger bronchi |
| pleural friction fremitus | inflammation decreases pleura lubricating aviola |
| fine crackles | not cleared when cough, discontinous, air collides |
| course crackles | loud, low pitched, start early in inspiration - velcro |
| atelectatic crackles | sounds liek fine crackles but don't last long, alveoli not aerated |
| pleural friction rub | superficial course low, inflamed pleurae - 2 pieces of leather |
| wheeze sibilant | high pitch multiple notes - expiration, swelling, secretion, collapsing |
| wheeze - sonorous rhonchi | low pitch 1 not may clear with cough airway obstruction - reed |
| stridor | high pitch monophonic crow - louder neck >chest, inspiration - swollen tissues, foriegn body |
| atelectasis | collapses section of lung |
| lobar pneumonia | infection lets blood cells in alveoli |
| bronchitis | mucus glands in passageway - excess secretion |
| emphysema | destruction pulmonary connective tissue - enlarge air sacs, rupture internal alveolar wall |
| asthma | allergic hypersensitivity to specific allergen |
| pleural effusion thickening | excess fluid in intrapleural space overlying lung tissue |
| congestive heart failure | pump failure, pulmonary congestion increase blood in capillaries |
| pneumothorax | air in pleural causes lung collapse, air in pleural neutralizes activity |
| pneumocytis carinii pneumonia | virulent pneumonia - aIDs, parasit, cysts in alveoli |
| tuberculosis | micro inflames - scar tissue and reactive healed - multiply air filled cavity |
| pulmonary embolism | undissolved material stuck in lngs |
| acute respiratory distress syndrome | acute pulmonary insult damage alveolar - pulmonary edema |
| orthopia | difficulty breathing in the morning |
| peroxinal nocturnal dyspnea | sob at night |
| manubriosternal angle - angle of Louis | articulation of manubrium - continuous w 2nd rib site of tracheal bufurcation into R and L bronchi, upper border of atria of heart, above 4th thooracic vertabra on back |
| hypoxemia | decrease 02 in blood increase respiration |
| hypercapnia | increase co2 (stimulus to breathe) |
| diaphoresis | excessive sweating |
| precordium | OVER heart |
| precardium | wall AT heart |
| s1 | closure av valves begin systole |
| s2 | close semilunar valves end systole |
| respiration and heart | during inspiration more to Right less to LEft |
| split s2 | is the aortic valve closing earlier to pulmonic - deep breathing |
| s3 | ventricle filling vibrations - ventricle resistent immediate after s2 |
| s4 | end of diastole atria contract push blood non compliant ventricle - just before s1 |
| murmers | turbulent or collision 1- velocity up 2- viscocity down 3 - structural defect valve |
| pumping ability | 4-6 L blood per min |
| cardiac output | CO = SVxR |
| preload | venous return that builds during systole |
| afterload | opposing pressure ventricle generates to open valve |
| bruit | turbulance due to local vascular cause |
| hepatojugular reflux | r hand on liver |
| sinus arrhythmia | pulse varies w breathing normal young adults and children |
| split s2 ausculate | only heard in 2nd L interspace |
| ejection click | open semilunar valves - short high pitched - loud at apex |
| aortic prosthetic valve sounds | ball in cage - begin systolic |
| midsystolic click | mitral valve prolapes - close balloon in L atrium - sudden tense and click |
| opening snap | av valve open - 3rd of 4th interspace sternal border |
| summation sound | pathologic s3 and s4 resulting in loud prolonged rapid x4 |
| pericardial friction rub | inflamation in pericardium - sand paper = apex lower sternal border |
| thrill at base | 2nd and 3rd R interpaces - severe aortic stenosis, systera hypertension |
| lift (heave at sternal border) | r ventricular hypertrophy |
| volume overload at apex | displaces apical pulse laterally |
| pressure overload at apex | aortic stenosis, systemic hypertension |
| murmur grades | i to vi - i - barely audible iii - mod loud, easy to hear, vi - loudest heard stethescope off wall |
| pathologic s3 | ventricular gallop - persists sitting up, indicates decreased compliance of ventrices, earlies sign of heart failure, volume overload, mitral regurgitation |
| physiolgic s3 | normal in children, young adults - usually disapears when sit up |
| physiologic s4 | adults older 40-50 no evidence cardio disease - after exercise |
| pathologic s4 | atrial gallop - decreased compliance ventricle, systolic overload (afterload), outflow obstruction, heard best at apex Le Lateral position |
| gynecomastia | Male breast tissue temporarily enlarge |
| fibroadenoma | benign tumor |
| mammary duct ectasia | paste like matter in ducts, sticky, purulent discharge |
| carcinoma | bloody nipple, unilateral |
| intraductal papilloma | serous or serosanguienous discharge, palpable in underlying duct |
| pagets disease | early lesion - unilateral - clear, yellow discharge, dry scaling crusts at nipple apex |
| plugged duct | clogged - common - nurse baby on plugged side to keep empty 1st |
| breast abscess | infection pus accumulates in one area, antibiotics |
| mastitis | inflammatory mass before abscess formation, 1 quadrant, hot, red, swollen, tender, hot , hard |
| recoil | causes pulse |
| weak thready pulse | 1+, hard to palpate, fades in and out |
| full, bounding puls | 3+, pounds under fingers |
| Water-Hammer (corrigan's pulse) | greater than normal, then collapeses |
| pulsus bigeminus | every other beat early |
| pulsus alternans | force varies every other |
| pulsus paradoxus | weak inspiration, strong exhale |
| pulsus bisferiens | 2 strong systolic, then dip |
| raynauds syndrome | tricolor hand due to cold/vibration/stress |
| lymphedema | removal of lymph nodes cause unilateral edema |
| arteriosclerosis-ischemic ulcer | build up fatty plaques on interna and calcifacation |
| venous stasis ulcer | deep vein trhombosis or chronic incompetent valves |
| superficial varicose veins | blood reflux - incompetent valve |
| deep vein thrombophlebitis | inflamation - vein occluded by thrombos-edema |
| occlusion | build of fatty streaks, fibroid plaque, calcification |
| aneurysms | balloon - sac |
| fasciculi | bundles of muscle fibers |
| glenohumoeral | hemerous and glenoid fossa of the scapula |
| subacromial bursa | abduction help with humerous under scapula |
| epicondyle | side of elbow |
| Activities of daily living | bathing, toileting, dressing, grooming, eating , mobility, communicating |
| myalgia | muscle pain |
| grade of muscle strength | 0 to 5 0 - none, 2 - no gravity, passive, 5 - full ROM |
| subluxation | bones stay in contact, but allignment off |
| contracture | shortening of a muscle leading to limit ROM of joint |
| ankylosis | stiffness or fixation of joint |
| phalens test | indicative of carpel tunnel - hands back to back fingers pointing down |
| tinels test | indicative of carpel tunnel - direct percussion of medin nerve at anterior wrist |
| bulge sign | confirms presence of fluid |
| ballotement of patella | fluid - patella should touch femur |
| McMurrays test | supine, hold heel, flex knee and hit - external click = meniscus |
| lasgue test | straight leg raising - supine, raise leg short of pain, dorsiflex - for sciatic pain, herniated nucleus pulposus |
| ankylosing spondylitis | chronic spine and pelvis - eventually fuse together |
| primary skin lesion | change in structure |
| secondary lesion | change over time or with scratching |
| accesible lymph nodes | head and neck, arms, axillae, inguinal region |
| cephalic | head |
| pagets disease of bone | increase bone resoption, and formation - soften , thicken, side forms bone |
| acromegaly | excessive secretion of growth hormone, enlarged skull, thickened cranial |
| torticollis (wryneck) | hematoma, sterno mastoid, uslce firm, discrete, nontender mass mid |
| thyroid - multiple nodules | inflamation of multinodule |
| lymph acute infection | acute onset <14 days, bilateral, enlarged, warm tender firm, moveable |
| chronic inflammation | nodes clumped |
| cancer | nodes hard, >3cm, unilateral, nontender, matted, fixed |
| HIV | nodes enlaged, firm, nontender, mobile (occipital node elargement common) |
| Neoplasm | in thorax or abdomen - single enlarged nontender hard left supraclavicular node - virchows node |
| hodgkins | painless, rubbery discrete nodes that gradually appear |
| neoplasm | abnormal growth of tissue |
| palpebral fissure | eliptical space between eyelids |
| limbus | border between cornea, sclera |
| cantulus | corner of eye |
| caruncle | small fleshy mass sebatceas glands |
| conjugate movement | eyes on same axis |
| cornea reflex | blinking when touching eye |
| macula | recieves and translates light in retina |
| pupillary light reflexes | normal restriction pupil - simultaneous reflex other |
| accommodation | adaptation of eye for convergence |
| cataracts | lens opacity |
| glaucoma | chronic open angle - optic nerve |
| scotoma | blind spot surrounded by an area of normal or decreased vision |
| corneal light reflex - hirschberg test | light symmetrical both eyes |
| cover test | cover eye and observe if focused when taken away |
| strabismus | disparity of eye axis |
| myopia | near sighted |
| hyperopia | farsighted |
| esotropia | cross eyed |
| exotropia | outward turning of eyes |
| weber test | tuning fork center head which ear louder |
| rinne test | when sound no longer heard |
| romberg test | close eyes note any swaying |
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