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What are the types of pupillary responses to light?
- -consensual response
- -speed & degree of constriction
- -degree of
- constriction (before/after)
- -speed (brisk/sluggish)
Assessment of extraocular eye function?
-parallel gaze/corneal light reflex
-coordinated eye movement
Assessment of visual fields?
-cover one eye
-bring a raised object between yourself and pt. from several different points into the right periphery into visual field
-tell the pt. to say "NOW" when it comes into view
What is astigmatism?
uneven curvature of cornea, retina can't focus horizontal/vertical at same time
What is dipolthia?
What is hemianopia?
blind or decrease vision in half of each eye
What is microcephalic?
circumference of the head is more than two standard deviations smaller than average for person's age and sex
Assessment of ROM for tempromandibular joint?
-check for swelling or tenderness
-check for snapping or popping when mouth opens
-palpate pt.'s face in front of the tragi of ears
-have pt. open mouth
Assessment of external ear & meatus?
-alignment, shape, symmetry, skin color
-smoothness, free movement, no pain, or tenderness
-no redness, welling, discharge or presence of foreign body
Assessment of head?
-look at size
-facial movment & expressions
Assessment of the neck?
-corotid artery & jugular vein
What are the different types of headaches?
When should eye exams be done?
**more frequently done if there is a history of HTN, diabetes...
What test is performed for a near vision assessment?
What is normocephalic?
head and all major organs of the head are in normal condition w/o significan abnormalities
What is macrocephalic?
head is abnormally large, this includes the scalp, the cranial bone and the contents of the cranium
Assessment of the outer eye?
- -position of the eyelid
- -eye drooping, swelling, redness,
- discharge, even disrtibution of eye
-conjunctiva: clear, pink
-sclera: smooth, moist
-iris: similar in shape
-pupils: 3-5mm (PERRLA)
What is a papule?
small firm elevated lesion, under 1cm
ex: wart, mole
What is necrotizing facitis?
-caused by strep and other bacteria
-usually after trauma to area
-begins with pain in area, red, swollen, hot becomes violet with blisters, necrosis
-treatment: debride, penicillin, vancomycin
What is a angioma?
-benign tumor of small blood vessels
-check for neuro fibroma, motor weakness in thoraci cervical regions
What is cellulitis?
-localized area of infection of skin caused by staph or strep
-causes: red, warm, tender, pain, is solid
-treament: rest, elevate, warm compress, antibiotics if streaks
What is a furuncle?
-big pustule, hot, tender
What is seborrheic dermatitis?
-scaly white plaques
-eyebrows, ears, axillae
What is herpes simplex 1?
-virus lies dormant until stress, ultraviolet light, febrile, illness
-oral cold sore: vesicle, crust
What is herpes simplex 2?
-genital herpes caused by different virus, latent infection
-reddened patch and blisters
-complication: childbirth, encephalitis
What is candiasis?
-appears as a scalding red rash
-common below breast and genetalia
What is herpes zoster?
-follow nerve path
-dormant chickenpox virus in root ganglia of sensory, cranial or spinal nerves
-can only get shingles if already had chicken pox
What is a stage 1 pressure ulcer?
-skin intact, red, does not blanch, warm, soggy
-dark skin: red, blue or purple hues
What is a stage 2 pressure ucler?
-skin gone, loss of epidermis and dermis
-abrasion, blister, crater
What is atrophy?
thin skin surface with loss of skin markings
es: straie (stretch marks)
What is erosion?
wide fissue, only involves epidermis after vesicles, bullae or pustules
ex: varicella, herpes simplex
What is lichenification?
thickened areas of epidermis caused by chronic rubbing and scratching, rough thick
ex: chronic dermatitis
What are pustules?
vesicles filled with cloudy or purulent fluid
What are crusts?
dried serum or pus, may have some liquid, usually broken vesicle or pustules
What is a bullae?
large vesicles/blisters with clear fluid
ex: second degree burn
What is wheal?
elevated, irregular, transient area on dermis
ex: insect bite, TB skin test
What is a scale?
visible thickened stratum corneum, that is dry, whitish, looks like a "snake shedding skin"
ex: psoriasis, eczema
What is a fissure?
linear cracks in epidermis
ex: atheletes foot
What is a cysts?
encapsulated nodules filled with liquid or semisolid material that can be expressed
es: sebaceous cysts
What is a nodule?
raised and solid, extends 1-2cm into dermis, marble like, more then 1cm wide
What is a vesicle?
blisters filled with clear fluid, less than 1cm
ex: chicken pox, dermatitis
What is melanoma?
-asymmetry not round or oval
-border is irregular
-color is uneven
-diameter is greater thatn 6mm
-elevation, a change from flat
-feeling change, itch, tingle or stine
What is a macule?
flat, less thatn1 cm in diameter
What is a patch?
large macules, over 1 cm in diameter, may scale or wrinkle
ex: cafe au lait spots
What is respiratory acidosis?
Ph < 7.35
PCO2 > 45
bicarb and base excess are the same
indicates COPD, enphysemia, bronchitis, severe asthma
result of hypoventilation
What are the different lesion shape characteristics?
-annular: round with clear center (ringworm)
-iris: pink macule with purple ring
-gyrate: snake like
-polycyclic: annular come in contact with eachother
-group or cluster: like grapes lesions in groups
What is peripheral cyanosis?
-decreased blood flow to peripheral vessels
-poor tissue perfusion
-loss of red tone
-cyanosis in african american: lips, tounge, mucous membranes are grayish
What is color pallor?
-decreased hemoglobin or blood flow
-look: conjunctiva, mucous membrane, palms, soles, lips
-conditions: anemia, shock, blood loss, emotional upest
What is color jaundice?
-cause: increased serum bilirubin level or serum carotene level
-look: sclera, mucus memebrane
-condition: hemolysis, liver diseases, renal failure
What is ecchymosis bruise?
-reddish blue discoloration caused by broken blood vessels
-cause: trauma, anticogulants, decreased platelets
-check for coumadin, ASA, heparin
-check PT and PTT
What is central cyanosis?
-decreased oxygenation of arterial blood in lungs, impaired lung function
-tachycardia, hypotension, increased RR
-change in LOC
-drastic change in oxygenation will cause LOC change and restlessness also pt. because tachy
What is a stage 4 pressure ulcer?
-full thickness, necrosis, damage to muscle, bone, undermining
-can get osteomylitis and septic
What is stasis dermatitis?
-inflammatin of skin on lower leg, brown pigment R/T chronic edema, poor peripheral circulation
-melanin and hemosiderin deposits cause a stain/chronic venous stasis or insufficency result in distal lower extremity discoloration
-poor perpherial circulation poor blood supply from heart to get down to LE and if veins can't pump back up then RBC's stay in LE and break apart providing a red stain
-red stain specific line and bilateral
What is folliculitis?
pustule around hair follicule
What are plaques?
elevated more thatn 1cm in diameter
What is contact dermatitis?
usually from jewelry or detergents, cosmetics
What is petechiae?
-small reddish purple lesion under 0.5mm, do not fade or blanch
-cause: capillary fragility, decreased platelets, decreased clotting ability
-scattered all over body
What is color brown?
-increased melanin production/cafe au lait spots
-also called mongolian spots
-local okay, if generalized could be neurofibromatosis (scattered cancer througout)
-irregular shape, usually seen on sacral or buttock area
-more common on African American, Hispanic, Native American and Asian
What is vascular dementia?
blood supply is cut off to parts of the brain causing loss of function to cells in the brain "miny strokes"
What are the sensor deficit medications?
-antibotics: vancomyacin-balance, hearing
-diuretics: lasix-hearing loss
-analgesics: ASA-tinnitus, hearing loss
-chemo: hearing loss, taste
-OTC: nasal spray, cocaine
What is metabolic alkolosis?
Ph > 7.45
base excess >+2
indicates severe vomiting, peptic ulcer, hepatic failure, cystic fibrosis
What is metabolic acidosis?
- Ph <7.35
- PCO2 normal
- bicarb <24
base excess <-2
indicates DKA, severe diarrhea, kidney failure, acute MI
What is respiratory alkolosis?
bicarb and base excess are normal
indicates anxiety, fever, hyperthyroidism, pregnancy
results of hyperventilation
What are S3 heart sounds?
vibrations are produced by rapid ventricular filling (heard early in diastole, dull, low- pitched) may be normal in chidren and young adults
What are S4 heart sounds?
resistance to ventricular filling after contraction of atria, low pitched, considered abnormal
What are S1 heart sounds?
mitral and tricuspid calces are forced closed at the beginning of systole (lub) contraction, longer and lower pitched than S2, closure of valves
What are S2 heart sounds?
aortic and pulmonic valves are forced cloesed at the beginning of diastole (dub) relaxation
What are heart murmurs?
-caused when there is a reflux of blood through a valve
-caused by stenosis or insfficiency of a valve
-categories: grade 1-6, grade 1 being faint and grade 6 being loudest possiable sound
What are coarse crackles?
more common on expiration or early inspiration, coarse, rattling sounds caused by secretions in large airways
What are fine crackles?
heard at the end of inspiration, a popping sound caused by air moving into previously deflated airways, alveoli popping open
What is alkalosis?
-CO2 acid is decreased, Ph is increased, normal HCO3
-triggers: anxiety, stress, fever, chemical stimulation
-signs/symptoms: SOA, tachy, CP, dizzy, numbness
-treatment: breath in a paper bag
What is acidosis?
-causes: drugs, trauma, atelectasis
-results: increased acid is not removed when ventilation decreased, CO2 increased, Ph decreased, HCO3 normals tries to buffer acid
-signs: dizzy, HA, disoriented, CP
-treatment: encourage TCDB, position changes or exercise
***not blowing off enough O2
What are kussmaul breathing patterns?
-rate & depth increased, a compensatory mechanism to eliminate excess CO2
-associated with diabetis (acid/base balance), sweet smell associated with DKA
What are the first sign/symptoms of hypoxia?
What are the normal lab values for an ABG?
What are the normal lab values for HCT and HGB in males and females?
- male: 40-54%
- female: 37-47%
- male: 13-17
- female: 12-16
What is hematacrit?
percentage of blood volume that is RBC
What regulates respirations?
-neural controls the rate & depth
-automatic control is in the medulla oblongata
What is atelectasis?
incomplete lung expansion
What does effective respiratory functioning require?
- 1. ventilation
- -getting air into lungs
- 2. diffusion
- -exchange of O2 & CO2 between
- alveolar sacs and capillaries
- 3. perfusion
- -functioning cardiovascular system
What are the functions of the lower airway?
1. conduction of air
2. mucociliary clearance
3. production of surfactant
4. gas exchange in the alveoli
What is surfactant?
reduces surface tension, maintains alveolar distension & stability
What are the 4 classifications of heart failure?
- 1. asymptomatic (EF 45-50%)
- -can maintain daily activity
- 2. some difficulty with activity
- -can do some activity but may need
- to take a break
- 3. more distress with activity
- -can do some activities
- 4. most severe, needs O2 suppliment
- -must do activities with O2
What is ejection fraction?
fraction of blood contained in the ventricle at the end of diastole that is expelled during its contraction
**EF <50% than pt. is in heart failure
What need to be done to optimize stroke volume?
- -reducing afterload
- -arterial vasodilators
- -angiotensin converting enzyme
- -reducing preload
- -restrict sodium & fluids
- -diuretics & vasodilators
- -improving contractility
What does right sided heart failure consist of?
What does left sided heart failure consist of?
-decreased cardiac output
-blood coming from the lungs to the heart collects in the left atrium
What is the common cause of heart failure?
What is cardiomyopathy?
-subacute or chronic
-enlargement of the cardiac muscle
- -most common
- -ETOH, chemotherapy
- -left ventricle
- -sudden death
- -least common
- -caused by endo/myocardial disease
What is endocarditis?
inflammation of the inner lining of the heart (chambers & valves)
What is cardiac tamponade?
- compression of the heart due to fluid accumulation within the pericardium
-problem with conduction
What is pericarditis?
-inflammation of the sac that surround the heart
-signs of right sided heart failure
What needs to be consumed to help heal pressure ulcers?
zince, protien, fluids
What does OLD CARTS stand for?
What becomes slower in the elderly?
-less subcu tissue
-less sebum production
-less sweat & glandular secretion
What are the different stages in Maslow?
1. survival needs: O2, food, fluid, elimination, warmth, physical comfort
2. saftey/security: risk of injury or feeling safe
3. love & belonging: family
4. self esteem: privacy, respect, positive self image
5. self actualization: grow as a person
What is the third level dysfunctional pattern priority?
- all the rest
-health problems not listed above
-higher level maslow
What is the second level dysfunctional pattern priority?
-sudden change in mental status
-medical condition requiring immediate attention (diabetic, insulin, food, bleeding, vomiting)
-abnormal lab values
-risk of infection, safety, security
What is the first level dysfunctional pattern priority?
What is supervision?
the provision of guidance or direction, evaluation and follow up by the licensed assistive personal
What is delegation?
transferring to a competent individual the authority to perform a selected nursing task in a selected situation
**RN retains accountability for the outcome
What is standard VIII?
the nurse considers factors R/T the following in planning and delievering care
**saftey, effectiveness, cost
What is a pulmonary function test (PFT)?
determines lung volume capacity, flow rates, gas exchange, airway resistance
What are restrictive disorders?
any situation that prevents expansion, recoil of lungs and/or gas exchange
What are obstructive disorders?
any situation that obstructs movement of air in and out of bronchus
What is obstructive asthma?
airflow obstruction caused by broncho-constriction from allergic or hypersensitivity reaction
What is obstructuve chronic bronchitis?
inflammation of the bronchioles that impairs airflow, can be acute or chronic
What is obstructive emphysema?
airflow obstruction from changes in lung tissue (lung hyperinflation) characterized by acute exacerbation and remissions
What is obstructive pneumonia?
-infection from bacteria, virus, fungus that causes inflammation of the alveolar spaces
-microorganisms enter alveolar spaces which results in inflammation and increase in alveolar fluid
-ventilation decreases as secretions thicken
What must orders include?
- -frequency of treatment
- -location of treatment
- -reason for PRN medications or test
What are the types of documentation formats?
1. narrative: information in statements describes surrounding client care
- 2. problem focused:
- -APIE:assessment, plan, intervention, evaluation
- -SOAP: subjective, objective, assessment, plan
- -DAR/DAE: data, action, evaluation or response
3. charting by exception: charting only significant or abnormal data
What is the time frequency to document and evaluate restraints?
Assessment of mental status?
- -cognitive functioning
- -intellectual functioning
What is wilson edema and what are the signs to indicate?
- -localized: causes dependent/inflammatopm infection DVT
- -generalized: CHF
- -1+/2mm: barely pits
- -2 +/4mm: deeper pit rebounds in 10-20 seconds
- -3+/6mm: deep pt rebounds in 10-20 seconds
- -4+/8mm: deeper pt takes over 30 seconds to rebound
What are the patterns of lesion characteristics?
- -linear" poision ivy
- -zosterform: follow in nerve (herpez zoster)
generalized: scattered all over body
What does a blue color on an occult test indicate?
positive for blood
How do you get a speciman for pinworms?
put a piece of tape over retum at night to catch pin worms, usually come out at night, mostly found in children
What is gastrocolic reflex?
after you eat you have to fo to the bathroom
What is the sequence of a GI assessment?
- -percussion (tape with fingers)
What are the organs in the RUQ?
- -rt kidney & adrenal gland
- -hepatic flexure of colon
- -head of pancreas
What are the organs in LUQ?
- -lt kidney & adrenal gland
- -splenic flexure of colon
- -body of pancreas
What are the organs in the RLQ?
- -rt ovary & fallopian tube
- -rt ureter & lower kidney pole
- -rt sermatic cord
What are the organs in the RLQ?
- -sigmoid colon
- -lt ovary & fallopian tube
- -lt ureter & lower kidney pole
- -lt spermatic cord
What is used to help indicate gallbladder disease?
What is used to help indicate for appendicitis?
What is a paralytic ileus?
decreased or absence of bowel peristalsis, can be life threating
What needs to be done to administer medications through a G-tube?
- -check placement
- -aspirate fluid & check pH (litmans paper)
- -insert air and listen for air in epigastric area
- -xray for position (done upon inital placment)
- -check gastric residual (>100 tube feeds held)
What will help with constipation?
What slows down the GI tract?
What factors affect bowel elimination?
What are the 4 different categories of laxatives?
- -bulk forming
- -saline osmotic
What is a bulk forming laxative?
-increase the fluid, gaseous, or solid bulk in the intestines & absorbs water into the intestine
-follow with additonal water to assist in clearing esphagu & avoid GI obstruction
-acts within 12-24hrs
What is a lubricant laxative?
coats the outside of the fecal mass, making it slippery and inhibiting fluid absorption
What is a stimulant laxative?
-contains poorly absorbed salts and sugar, which through osmotic activity, draws water into the intestines to increase bulk lubricates in the feces
-usually acts with in 1-3 hrs
What is a hypertonic enema?
-distends colon & irritates mucosa
-high concentration of ions in enema
ex: fleet enema
What is hypotonic enema?
-distends colon, stimulates peristalsis and soften feces
-high concentration of ions in enema
ex: tap water
What is isotonic enema?
-distends colon, stimulates peristalsis and softens feces
-concentration is equal
ex: normal saline
What is a soap suds enema?
irritates & distends colon, stimulates peristalsis
ex: castel soap & water
What is an oil enema?
lubricates the feces and colonic mucosa
ex: mineral oil
What is a carmentive enema?
helps to expel flatus from the rectum and provide relief from gaseous distention
ex: milk & molasses equal parts
What is a medicated enema?
used to administer medications that are absorbed through the rectal mucosa
What is a nutritive enema?
used to administer nutrition
What information is charted for enemas?
- -Type of enema
- -Amount of fluid
- -Return (COCA)
- -Client response
What plan of care is used for a paralytic ileus?
- -meds to jumpstart peristalsis
- -d/s or hold pain meds
- -NG tube placed to relieve pressure
- off of GI tract
What is a ascariasis?
giant roundworm resides in the small intestines
tx: pyrantel, mebendazol, albendazole
What is a enterobiasis?
pinworm that resides in the large intestine
tx: pyrantel, mebendazol, albendazole
What are the different locations of bowel diversion ostomies?
- transverse colostomy
- ascending colostomy
- descending colostomy
What are the different things that ostomy care involves?
- change bag
- skin care
- inspect the stoma for color & moisture
- inspect the stoma for excoriation, dryness and bleeding
90% of UTI are caused from what?
e. coli, staphylococcus, candid alblicans
What is the treatment for a UTI?
- increase vitamin C
- drink cranberry juice
- increase water to 3000cc/day
- regular voiding
- decrease caffeine
What antibotics are used for treatment of an UTI?
sulfa & cipro
What is BPH?
- -benign prostate hypertrophy
- -enlargment of prostate
tx: hytrine prostate
What is TURP?
- transurethral urinary resection
- cutting away excess prostate
What is anuria?
no urine output
What is dysuria?
painful of difficulty voiding
What is enuresis?
involuntary urination in children beyond the age when expected
What is hematuria?
blood in urine
What is nocturia?
voiding 2 or more times at night
What is oliguria?
voiding less thatn 30 cc/hr less than 500 cc/24hr
What is polyuria?
abnormally large amount of urine
What is pyuria?
puss in urine
What is a single lumen cath?
straight cath, used to cath someone
What is an indewwlling cath?
foley cath with 2 lumens, 1 port for urine to flow out and other port is to blow up balloon so cath can stay in
What is a triple lumen cath?
3 openings, 1 port to blow up balloon, 1 port is for urine to flow out, 1 port for irrigation
Dark urine indicates?
dehydration & liver damage
What is the normal amount of urine output per hour?
When is the doctor called for decrease urine output?
< 30 cc/hr
How is the amount of urine for children per hour calculated?
What is the normal level of pH for urine?
What is the normal level for specific gravity for urine?
What does specific gravity measure?
- measure the # of particles related to concentration
- < 1.010 diluted urine, excess fluid
- > 1.025 excess particles, concentrated urine (dehydration or kidney disease)
What is the normal levels of glucose in urine?
- no glucose should be present
- if >180 mg may indicate diabetes mellitus (not enough insuling to take sugar out of blood stream)
What is the normal level of ketones in urine?
- acetone is not present
- if present may indicate diabetes mellitus, starvation, prolonged vomiting
What is the normal level of blood in the urine?
- normally not present
- occult blood indicates hidden bleeding or kidney disease
- bright red indicates post prostate surgery or hemorrhage
What is the normal level of protien in urine?
not normally present
What does nitrates indicate in urine?
What do WBC's indicate in urine?
What are the developmental factors that affect urination?
What are the medications that cause urinary retention?
- anti depressants
- anti parkinsons
- anti histamines
- beta blockers
- anti hypertensives
- anti psychotic
- anti metics
What is the procedure for cathing for urinary retention?
- have pt. empty bladder
- cath with straight cath
- measure amount of urine drained, if greater than 100cc then urinary retention is present***call dr.
Bladder training prevents?
- over retnetion of the bladder
- sesitizes the bladder
What are some indicators showing that catherization needs to be performed?
- relieve urinary retention
- spinal cord injuries
- obtain a sterile speciman
- after TURP
- measure residual urine
- sever burns
- obtain specimen if pt. incontinent
- severe pressure ulcers
- high does chemo
- continuous bladder irrigation
What is the common cause of nosocomial infections?
What is aldosterone?
- secreted by the hypothalamus
- holds onto sald when body senses to low of NA
- increase NA in blood, increase water=increase edema, increase b/p
- to high salt no aldosterone is secreted and NA urinated out with water causing dehydration
What relationship does sodium/potassium have?
What is the normal creatine level in urine?
- 0.5-1.2 mg/dL
- increased creatine is a sign for kidney disease
How is % of kidney function calculated?
- creatine indicates this
- ex: cr=5=1/5=.2x100%=20%
What are 6 functions of the kidney?
- fluid balance (most important)
- electrolyte balance (most important)
- waste removal
- b/p regualtion
- erthropoietin secretion to stimulate RBC production
- acid base balance
What is BUN?
- blood, urea, nitrogen
- indicator for muscle breakdown
What do electrolyte imbalance cause?
- weak muscles
What are some causes of acute kidney failure?
- imparied circulation R/T decrease b/p, hemorrhage
- kidney stones
When are pt.s eligable for dialysis?
What are some causes of chronic kidney disease?
What are some treatments of chronic failure?
- monitor creatine
- control b/p low protein diet
- low K diet
- low sodium
- calcium supplements
What do steriods cause?
- increase NA retntion so get a moon face and edema and hypertension
- increase blood glucose
- increase total body fat
- buffalo hump
- decrease inflamation so immunosuppression
- affects emotions
What is removed during a radical masectomy?
lymph nodes (and swelling takes place)
Whare are the 2 methods of systematic breast palpation?
- 1. palpation in wedge sections from breast periphery to center
- 2. palpation along concentric circles from periphery to center
What is documented upon a breast exam?
- location of lesion
- size of lesion
- discreteness of borders
- dimpling over mass
- depth of mass
What is done for a self breast exam?
- examine between the 4th-14th day of cycle
- visual inspection and palpation
- visual inspection
- *arms at rest
- *hands on hips and pressed into hips
- with chest muscles contracted
- *hands over head
- *arms forward with torso leaning
- include nipples
What are 3 types of relationships?
Therapeutic communication focus' on?
pt.'s ideas, experiences and feelings
What are the phases of therapeutic relationships?
- orientation: establish trust
- working: time actually working with pt.
- termination: end of relationship, when work is coming to a close
Whare are barriers to communication?
- hearing impairment (stand in front of pt.)
- non english speaking
- unpleasent or uncomfortable environment
- lack of privacy
- illiteracy (can't read/write provide pictures)
- intubated pt
- aniexty (one of the biggest)
- distance and space
What is active listening?
hearing the word and interpreting the word
What are close ended questions?
- used sparingly
- determine specific info
- helpful with pts experiencing anxiety
- during an emergency
What are open ended questions?
purpose to get pt to talk
What are examples of non verbal communication?
- eye contact
- facial expressions
- general physical apperance
What is effective verbal communication?
- appropriate tone of voice
- be knowledgable
- think before you speak
- be clear, concise, simple, and to the point
- be flexiable
What is broad opening communication?
not specific allows people to tell their stories, for the client who is hesitant about talking
What is restatment communication?
repeating or paraphrasing the main idea expressed, lets the client know that he or she communicated the idea effectively
What is reflection communication?
having them examing their feelings, encourages the client to recognize and accept his/her own feelings
What is offering self communication?
make oneself available, make sure pt knows you are listening
What is accepting communication?
non commitale, doesnt have to agree or disagree
What is seeking information communication?
What is consensual validation communication?
searching for mutual understanding for accord in the meaning of the words
What is exploring communication?
wanting to know more
What is providing silence communication?
causes for reflection
What is a sterotypical comment?
offering meaningless cliches or trite comments
What does introducing an unrelated topic provide?
changing the subject due to being uncomfortable or not knowing what to say
What is disagreeing communication?
opposing the clients ideas
What is challenging communication?
demanding proof from the clients, causes client to defend the delusion of misperceptions more strongly than before
What does requesting an explaination do to the client?
intimidates and pt can become defensive
What is false reassurance?
indicating there is no reason for anxiety for other feelings or discomfort
What is belittling expressed feelings?
misjudging the degree of the clients discomfort, hearing problems of others is not helpful to pt
Medications that decrease libido?
- ace inhibitors
- tricylclic antidepressants
- beta blockers
- thiazide diuretics
Sex after MI?
- pt is able to climb 2 flights of stairs or walk a block with out being SOB
- pt has to be comfortable
2 reasons immune systems are automatically activated?
- eliminate the foreign material
- prepare the ijnured area for healing
What are the phases for wound healing?
- inflammatory stage
- proliferation stage
- maturation phase
break in skin or mucous membrane
tissues are traumatized with out break in the skin, can't tell from outstide
occurs during surgery, involves aspectic technique
accidental or traumatic, usually in unsterile conditions
involves epidermal layer
goes beyond epidermis, high risk of infection
penetrating wound in which foreign object enters and exits an internal organ
uninfected surgical wound that does not enter the GI tract
clean contaminated wound?
surgical wound in diffrent tracts within body, made under aspectic conditions, involved with entrance into a body cavity where microbes exist
open, fresh, accidental wounds involving a major break in sterile technique, shows evidence of inflammation
dirty or infected?
old accidental wounds containing dead tissue and wounds with evidence of infection
incised skin to approximate edges, use sutures to close
- open wounds
- heals from inside out, can not be closed with sutures
delayed primary closure?
- wound left open to monitor for infection and then surgically closed
- combo of primary and secondary closure
what is looked at when assessing wounds?
- drains or tubes
factors which delay healing?
- nutritional deficiencies
- mechanical friction
- advanced age
- corticosteroid drugs
effects of steriods in wound healing?
- suppressed inflammatory response
- phagocyte cells fail to enter wound
- decreased fibroblast proliferation
- contration and epithelialization delayed
common causes of chronic wounds?
- shearing force
- chemicals & moisture
- venous hypertension
factors that affect wound healing?
- compromised host
- wound stress
what are obese patients at risk for?
higher risk for dehiscence with possiable evisceration because of poor wound healing with adipose tissue (poor vascular supply)
dehiscence occurs when?
after a sudden strain such as coughing, vomiting, sitting up in bed
what is the 1st sign of dehiscence?
increased amount of serosangunous drainage
treatment for dehiscence/evisaration?
- cover area with sterile towels soaked in sterile saline to maintain tissue moistness of visceral organs
- notify surgeon immediately
- prepare patient for surgery
- remain with patient supporting abdominal area with sterile gloved hands to prevent further injury
complications of wound healing?
- anti-coags will interfer with healing
different types of bandages?
- dry dressing
- pressure bandage
- wet to dry
- transparent dressing
- hydrocolloid dressing
- hydro gel dressing
- elastic bandage
- abdominal, "T", breast binder
how do you wrap an extremity to promote circulation?
distal to proximal
different types of gauze dressings?
- dry to dry
- wet to dry
- wet to wet
- synthetic dressing
what is sensation?
ability to recieve input
what is perception?
ability to mentally recognize, register, interpret
what is response?
ability to take appropriate action
- testing for equal hearing with air conduction
- tuning fork to forehead
- testing for bone conduction rather than air conduction
- tuning fork at mastoid bone
- work on loop of henle to inhibit reabsorption (cause excretion) of K, Na & water
- may be given IV over 1-2 min, fast admin is associated with hearing loss & ringing in ears
- decreases edema and decreases B/P
side effects-lower b/p, dehydration, electrolyte imbalance, decrease K or hypokalemia (<3.5)
implications-assess edema, I&O, b/p, Na, K, dehydration, weight, heart, teach K supplements
- inhibits reabsorption (cause excretion) of K, Na & water
- decreases edema and decreases b/p
side effects-hypotension, dehydration, electrolyte imbalance, increased glucose & increased uric acid
implications-weight, I&O, b/p, Na, K, dehydration edema