NUR 111 Test 4 review
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| Brain areas and function | Cerebrum - reasoning, judgement, concentration, sensory and speech. Cerebellum (cblm) - coordination.
Brainstem - CN, respiratory, and CV center.
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| Age related sensory changes - neonate | Visual acuity (VA) 20/100 - 20/400, rectus muscles uncoordinated, transient nystagmus, esotropia (stabismus) common, corneal larger% of orbit, eustacian tubes shorter/wider, fetus begins hearing ~20w.
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| Age related sensory changes - adults | Changes in accomodation (change in focal length, ability to focus on near and far; hence reading glasses). Greatest decline is 45-55yo. Hearing loss. Normal changes limit functional ability.
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| Define hypogeusia. Define hyposmia. | Hypogeusia: loss of taste.
Hyposmia: loss of smell.
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| Age related sensory changes - older adults | Decreased senses. With >=1 impairment, may be at incr risk for falls.
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| Define cataract | Opacification of lens.
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| Glaucoma | "Hypertension" of the eye. Increase intraocular pressure (IOP). Causes optic neuropathy. Gradual loss of peripheral vision "tunnel vision".
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| Macular degeneration | Leading cause of legal blindness. Loss of central, most vital, vision.
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| Define legal blindness. Define impaired vision. | Legal blindness: best corrected vision of 20/200 or less.
Impaired vision: Best corrected vision of 20/40 or less.
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| Conductive vs sensorineural hearing loss | Conductive - problem with transmission of sound. Sensorineural - problem with inner ear or nerve portion of hearing (tumor, degenerative disease, trauma, vascular disease)
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| Ototoxic drugs | ASA, furosemide, aminoglycosides, vancomycin
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| Presbycusis | Loss of hearing: hair cells of cochlea degenerate with aging, Loose high pitched sounds of speech first. Can hear men better than women.
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| Risk factors for hearing loss | 25% environmental - around time of birth. 50% of loss in children is genetic. Certain infections, craniofacial abnorm., low birth weight, hyperbilirubinemia (>16), aminoglycosides, low APGAR, meningitis, vent >5d, syndromes assoc w hearing loss (Down)
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| Manifestations of conductive,sensorineural hearing loss, presbycusis | Conductive - loss of all freq. Sensorineural - loss of hi pitched freq, difficult to discriminate speech. Presbycusis - gradual in onset, unsociable and paranoid.
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| Tinnitis | Ringing in ears. Associated with hearing loss. (perception only. there is no actual sound)
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| Ear surgeries for hearing | Cochlear implant. Stapedectomy - removal of stapes, it is replaced with prosthesis. Tympanoplasty - repair of TM.
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| Cognition | Reasoning, thinking, learning, interpreting language, problem solving, communication, storing, retrieving and using information.
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| States of awareness: conscious state | Delirium (abrupt)- altered mental status - not psychiatric.
Dementia (gradual and irreversible).
Confusion.
Normal Consciousness.
Somnolence - drowsy.
Minimally conscious.
Locked-in Syndrome.
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| States of awareness: unconscious state | Asleep. Stupor - almost entirely unresponsive & only responds to base stimuli such as pain. Coma -a person: cannot be awakened; fails to respond normally to painful stimuli, light, or sound, vegetative state - sleep/wake cycles, moves lids, no cognition
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| FH taking: inherited diseases | Tay-Sachs.
Huntington’s chorea.
Muscular dystrophy.
Neurofibromatosis.
Alcoholism.
Mental Retardation.
Epilepsy/seizure disorder.
Alzheimer’s disease.
Learning disorders.
Weakness or gait disorders.
Thyroid disease.
Diabetes.
Hypertension.
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| SH taking: elements | Environmental or occupational hazards
Hand, eye, foot dominance
ADL
Sleeping patterns
Use of alcohol and tobacco
Use of mood-altering drugs
Anxiety
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| 6 components of neurophysical exam | 1 - Muscle tone/strenth. 2 - Proprioception/cerebellar function (assess balance, coordination, fine motor [these are drunk driving tests]). 4 - cerebral function (gross motor and cognitive). 5 - Cranial nerves. 6 - sensory/taste/smell. 7 - reflexes
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| Cranial nerve I - Olfactory nerve | Sense of smell/taste. Test with test tube of coffee.
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| Cranial nerve II - Optic nerve | Sense of sight. Test with visual acuity, or visual fields.
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| Cranial nerve III - Oculomotor nerve | Test III, IV, & VI together by with extra ocular movements. All EOM except for IV and VI are CN III. CN III also raises eyelids & constricts pupils
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| Cranial nerve IV - Trochlear nerve | Test III, IV, & VI together by with extra ocular movements. All EOM except for IV and VI are CN III. Superior oblique: test by having patient look inferior and lateral. If patient has difficulty, may be CN IV deficeit: "SO4"
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| Cranial nerve V - Trigeminal nerve | Trigeminal nerve is nerve of facial sensation. Corneal, facial, and motor portion (muscles of mastication).
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| Cranial nerve VI - Abducens nerve | Test III, IV, & VI together by with extra ocular movements. All EOM except for IV and VI are CN III. Lateral rectus deviates eye laterally. Patient cannot gaze laterally if this nerve is impaired. "LR6"
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| Cranial nerve VII - Facial nerve | Innervates muscles of facial expression. Test by asking patient to wrinkle forehead, raise eyebrows, puff out cheeks, smile and show teeth. Test sweet, sour, salty taste on anterior tongue.
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| Cranial nerve VIII - Vestibulocochlear nerve | (May also be called auditory nerve). Innervates inner ear (hearing). Test with speech, soft sounds, Weber and Rhine.
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| Cranial nerve IX - Glosopharyngeal nerve | Test IX and X to together. IX innervates posterior portion of tongue, and pharynx, ability to raise soft palate and to swallow. Gag reflex.
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| Cranial nerve X - Vagus nerve | Test IX and X to together. Test ability to raise soft palate and to swallow/speak. Gag reflex.
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| Cranial nerve XI - Accessory nerve. Also called spinal accessory nerve. | Test: have patient shrug shoulders against resistance. Turn head from side to side against resistance.
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| Cranial nerve XII - Hypoglossal | Below the tongue. It controls tongue movements of speech, food manipulation, and swallowing. Say " D L N T"
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| Oh, Oh , Oh, To, Touch, And, Feel, Very, Good, Velvet, Such, Heaven!!! | CN I-XII mnemonic.
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| Some, Say, Marry, Money, But, My, Brother, Says, Big, Brains, Matter, More | CN mnemonic for Mixed, Sensory, or Both.
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| Babinski reflex | "Key" test. Scribe a key along the plantar surface of the foot. Toes go upward. May indicate a high spinal cord injury or upper motor neuron injury. Also called plantar reflex. Toes upgoing = positive. Infants have Babinski, normal adults do not.
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| Weber test. Rinne test. | Negative Weber is normal (hearing equal at center or on both sides).
Positive Rinne is normal (AC>BC).
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| New Por (t) | Negative Weber. Positive Rinne. These are normals.
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| Integumentary System Includes: | Skin, mucous membranes, hair, nails, sebaceous, sweat, & mammary glands.
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| Functions of the skin: | Protect underlying tissues. Body temp regulation. Sensation (nerves, touch, pain, pressure, heat/cold). Vitamin D. Immunological. Absorption. Elimination.
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| 3 Skin Layers | Epidermis. Dermis. Subcutaneous.
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| Define: Milia | Small white heads on babies. "Milk bumps"
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| Define: Lanugo | Fine hairs on a newborn that go away within 2wks after birth.
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| Define: Lesion | Any abnormality of the tissue of an organism. Wound or injury. Infected or diseased patch of skin.
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| Define: Macule | Circumscribed, flat, nonpalpable. Lesion <=1cm. (Petechiae, freckle.)
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| Define: Petechia | Small macule. 1-2mm red spots on the skin.
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| Define: Patch | Circumscribed, flat, nonpalpable. Lesion >1cm. (Vitiligo, birthmark.)
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| Define: Vitiligo | A loss of brown color (pigment) from areas of skin, resulting in irregular white patches that feel like normal skin.
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| Define: Papule | Palpable, elevated, solid. Mass <=0.5cm. (Mole)
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| Define: Plaque | Palpable, elevated, solid. Mass >0.5cm. (Psoriasis)
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| Define: Psoriasis | Skin condition that causes skin redness and irritation. Thick, red skin with flaky, silver-white patches called scales.
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| Define: Nodule | Palpable, elevated, solid. Mass 0.5-2cm; firmer than a papule. (Nevus, wart)
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| Define: Nevus | Dark colored, often hairy patch of skin. Often termed, birthmark or beauty mark. 50% of malignant melanomas (a skin cancer) arise from pre-existing nevi.
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| Define: Tumor | Palpable, elevated, solid. Mass >2cm. (Lipoma)
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| Define: Lipoma | A growth of fat cells in a thin fibrous capsule just under the skin. (Benign tumor)
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| Define: Wheal | Palpable, elevated, solid, irregular, superficial area of localized skin edema. (Hives, misquito bite)
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| Define: Vesicle | Circumscribed, superficial skin elevation, filled w/ serous fluid. <=5cm. (Herpes simplex)
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| Define: Bulla | Circumscribed, superficial skin elevation, filled w/ serous fluid. >5cm. (2nd degree burns)
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| Define: Pustule | Circumscribed, superficial skin elevation, filled w/ pus. (Acne, impetigo)
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| Define: Impetigo | A contagious skin infection that produces blisters & sores on the face, hands, neck, & diaper area. (Honey crusted lesions)
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| Define: Ecchymosis | Bruising
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| Define: Beau's Lines | Deep grooved lines that run from side to side on the fingernail or toenails. Indicates acute illness.
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| Define: Fissure | Deep crack in dermis. (Athlete's foot)
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| Define: Erosion | Loss of superficial epidermis. Forms crater in the skin.
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| Define: Lichenification | Thicken or roughened epidermis.
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| Define: Atrophy | (Tissue wasting) Thining of skin, loss of skin furrows, shiny appearance.
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| Define: Excoriation | To scratch, tear skin.
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| Define: Keloid | Excessive scar growth. (Hypertrophied scar)
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| ABCDE Inspection of Skin lesions | A- asymmetrical. B- borders. C- color. D- diameter. E- elevation.
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| Skin assessment. "4 T's & ME" | Tissue integrity. Temp. Texture. Thickness. Moisture. Edema.
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| Define: Anasarca | Bull frog swelling. Whole body edema.
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| Define: Hirsutism | Excessive hair. Secondary male characteristics in women. (Mustache, sideburns, beard, deep voice, balding)
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| Define: Neoplastic | Tumor or abnormal growth of tissue.
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| Wound Repair by Primary Intention | Surgical repair.
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| Wound Repair by Secondary Intention | Allowed to heal on its on & scar in.
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| Wound Repair by Tertiary Intention | Delayed surgical repair.
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| Phases of Wound Healing | Hemostasis, Inflammatory, Proliferation, Maturation.
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| Types of Exudates | Serous - clear fluid. Sanguinous - bloody fluid. Serosanguinous - clear & bloody. Purulent - pus discharge.
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| Define: Desiccation | Drying up
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| Define: Maceration | Over-hydration
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| Define: Fistula | Abnormal formation of tube (tract) through scar tissue or from one organ to another or to the skin surface.
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| Define: Ischemia | Inadequate oxygen delivered to tissue.
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| Stages of Pressure Ulcers | Stage I- Intact, reddened. Stage II- epidermis & dermis. Stage III- Full thickness, subcutaneous, fat may be visible, bone & tendons NOT visible. Stage IV- Full thickness to the bone, tendon, muscle. Unstageable- Dead tissue.
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| Dimensions of Wound Measurement | L x W x D in cm.
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| Effects of Applying Heat. | Dilates peripheral vessles, increases metabolism, reduces blood viscosity & capillary permeability, reduces muscle tension and pain.
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| Effects of Applying Cold. | Constricts peripheral vessels, reduces muscle spasms, promote comfort.
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| Tzanck smear | Used to determine if lesion is a Herpes lesion
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| Woods lamp | hand held magnified ultraviolet lamp.
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| Contact dermatitis | Prototype: poison ivy. Skin reaction from allergin/irritant exposure to the affected skin.
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| Allergic contact dermatitis | Redness, swelling, and itching; vesicles and bullae. (erythema, edema, pruritis)
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| Solid skin lesions by size | Papule (<0.5mm), nodlue (0.5mm-2cm), tumor (>2cm)
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| Fluid:vesicle as pus:? | Pustule
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| Burns by degree | 1st: sunburn. 2nd: partial thickness burn - has blisters. 3rd - full thickness burn - skin is now dead - no sensation.
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| Inflammation: acute vs chronic | Acute - protective- stimulates healing - protects from further damage.
Chronic - can be debilitating.
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| Systemic inflammatory response | Temp, WBC, Inflam, HR, RR - all increased. Malaise and anorexia.
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| Local inflammation - PRISH | Pain, Redness, Impaired function, Swelling, Heat (warm to touch).
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| Stages of inflammation (3 stages): STAGE 1 | STAGE 1: Vessels constrict.
Tissues rel chemical mediators to dilate vessels - hyperemia.
Incr vasc permeability > fluids leak > swelling & pain.
Blood flow slows in dilated vessels to allow more WBCs to arrive > increased WBC production & release.
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| Stages of inflammation (3 stages): STAGE 2 | STAGE 2: Exudate production. (fluid leaks from vessels)
Serous (clear fluid)
Purulent (pus filled fluid).
Hemorrhagic
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| Stages of inflammation (3 stages): STAGE 3 | STAGE 3: Reparative phase
Regeneration
Scar (fibrous tissue) formation
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| Common inflammatory diseases | Alterations in inflammatory cascade
Inflammation can occur in any tissue.
Common diseases:
Appendicitis.
Crohn’s disease (IBD).
Arthritis.
Nephritis - dmg to basement membrane - albuminuria/hematuria.
Peptic ulcers.
SLE (Lupus)
RA
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| Common lab tests for inflammation | Erythrocyte sedimentation rate (ESR) "sed rate"
Normal = 0–20 mm/h.
CBC: Leukocytosis OR a "left shift" (elevated neutrophil count) could mean inflammation.
C-reactive protein (CRP)
Normal < 0.8 mg/dl or < 8.0 mg/L.
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| Complete blood count (CBC): Normal lab values | WBC 4-10,000. Differential "dif": neutrophils (granulocytes) 67% (2/3), lymphocytes 33% (1/3), eosinophils, basophils, monocytes. Leukoenia=low WBC. Leukocytosis = hi WBC.
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| Nursing interventions for inflammation | RICE.
Rest, Ice, Compression, Elevation. Corticosteriods, NSAIDs. Antibiotics (abx), surgery, nutrition, prevent further injury, maintain dietary intake.
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| Define: subclinical infection | Infection that is below the limit of clinical detection. "asymptomatic" infection. NO SYMPTOMS.
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| Define: infection disease | contagious disease, communicable disease. Caused by microorganism.
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| Pathogen, parasite, opportunist. | Pathogen = disease causing organism.
Parasite - organism that lives at the expense of the host.
Opportunist - organism not normally a human pathogen, but can be if the right situation exists.
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| Define: asepsis, sterile, clean. | Asepsis - free from disease causing microbes.
Sterile - a theoretical organism free state.
Clean - limits amount of organisms.
Surgical - sterile.
Medical - clean.
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| Classes of microbes | Bacteria, Fungi, Viruses, Parasites (often means intestinal parasites)
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| Colonization vs infection | Colonization - microbe present and reproducing.
Infection - microbe present, reproduction, and is causing disease.
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| Types of infection | Local - local tissues only.
Systemic -spread to distant sites, away from local infection.
Bacteremia - able to grow microbe from blood - bacteria in blood.
Septicemia - able to grow microbe from blood - causes sepsis
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| Sepsis | Severe inflammatory whole body response to infection. Low BP, hi HR, hi RR, hi temp may have decreased perfusion / ischemia to vital organs,
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| Chain of infection - six links | Infectious agent
Reservoir
Portal of exit
Means of transmission:
Direct
Indirect
Vehicle or Vector
Airborne
Portals of entry
Susceptible host
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| Disinfectant/antiseptic agent | Disinfection – interrupts agent and reservoir.
Disinfectant - used 4 inanimate objects.
Antiseptic - used 4 skin, tissue.
Bactericidal - destroys bacteria.
Bacteriostatic - prevents growth.
Commonly used antiseptics, disinfectants
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| Sterilizing methods | Steam / moist heat -autoclave
Boiling water
Dry heat
Radiation
Gas – autoclave
Chemical
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| Define: sterile. Define: sanitized. | Sterile - "free" from microbes.
“Sanitized” = safe level of microbes
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| Stages of the infectious process | Incubation - time from inoculation to onset of symptoms.
Prodromal - early symptoms of infection.
Full stage of illness (acute) - full blown symptoms.
Convalescent - recovering stage of infection.
Carrier - asymptomatic state, still carry microbe.
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| Sources of microbes | Endogenous - host gets it from self (opportunistic organism) - normal flora.
Exogenous - get from someone else.
Iatrogenic - caused by medical treatment.
Nosecominal - iatrogenic infection acquired in a hospital or ambulatory treatment setting.
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| Tests associated with infection | Procalcitonin,C-reactive protein (CRP). WBC count, and "left shift" (neutrophil %) - all of these increase with infection.
Serologic testing (titers)
Antibiotic peak and trough levels
X-rays, ultrasound
Lumbar puncture
Urinalysis
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| Common health care abx resistance problems | MRSA methicillin-resistant Staphylococcus aureus.
VRE vancomycin-resistant enterococcus.
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| Antibiotic Resistance Risk Factors | Severity of illness
Previous abx
Underlying conditions:
CRI, IDDM, PVD, dermatitis.
Invasive procedures:
dialysis
invasive devices
Foley
Repeated use healthcare system
Previous colonization of resistant organisms
Advanced age
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| VRE risk factors | Previous trt w vancomycin or other abx for long periods.
Hospitalization.
Weakened immune system (ICU, oncology, transplant).
Surgery.
Medical devices that stay in for some time such as Foley's or central lines.
Colonization with VRE .
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| VRE transmission / diagnosis | Transmission
Contact with skin or contaminated surfaces
Diagnosis
Culture anal area, stool, urine, wound, blood
VRE Treatment
Usu no treatment if colonized only
Linezolid (Zyvox)
Quinupristin-dalfopristin (Synercid)
Remove Foley if VRE UTI
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| Define Clostritiuim difficile (C. dif) | A bacteria that causes diarrhea and more serious conditions such as
pseudomembranous colitis (PMC)
toxic megacolon
perforations of the colon
sepsis
death (rarely)
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| C. Diff Risk Factors | Antibiotic exposure
Gastrointestinal surgery/manipulation
Long length of stay in healthcare settings
Serious underlying illness
Immunocompromising conditions
Advanced age
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| C. Diff Clinical Manifestations | May be colonized with no symptoms
If C. Diff associated disease:
Watery diarrhea
Fever
Loss of appetite
Nausea
Abdominal pain/tenderness
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| C. Diff Diagnosis / transmission | C. Diff Diagnosis
C. Diff stool toxin.
Stool culture – most sensitive
C. Diff Transmission
Any surface, device, or material contaminated with feces
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| C. Diff Treatment | Discontinue antibiotic to which previously exposed
Antibiotics (about 10 days) – metronidazole or vancomycin orally
Repeat testing not recommended if symptoms resolve – may remain colonized
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| C. Diff Precautions in Healthcare | Judicious abx
Contact precautions for suspected disease:
pvt room
soap and water hand hygiene - alcohol rubs not as effective. clean gloves for pt care
gowns if soiling is likely
dedicate equipment when possible
CONTINUE UNTIL DIARRHEA CEASES
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