NURSING 106

-direct response

• -consensual response
• -speed & degree of constriction
• -degree of
• constriction (before/after)
• -speed (brisk/sluggish)

-parallel gaze/corneal light reflex

-coordinated eye movement

-convergence

-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

uneven curvature of cornea, retina can't focus horizontal/vertical at same time

double vision

blind or decrease vision in half of each eye

circumference of the head is more than two standard deviations smaller than average for person's age and sex

-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

-alignment, shape, symmetry, skin color

-smoothness, free movement, no pain, or tenderness

-no redness, welling, discharge or presence of foreign body

-look at size

-position

-symmetrical

-facial movment & expressions

-temporal artery

-corotid artery & jugular vein

-trachea

-thyroid

-lymph nodes

-migraine

-cluster

-tension

• < 40 yrs old
• q 3-5 yrs

• >40 yrs old
• q 2 yrs

**more frequently done if there is a history of HTN, diabetes...

jaegar chart

head and all major organs of the head are in normal condition w/o significan abnormalities

head is abnormally large, this includes the scalp, the cranial bone and the contents of the cranium

• -position of the eyelid
• -eye drooping, swelling, redness,
• discharge, even disrtibution of eye
• lashes

-globes bilateral

-conjunctiva: clear, pink

-sclera: smooth, moist

-iris: similar in shape

-pupils: 3-5mm (PERRLA)

small firm elevated lesion, under 1cm

ex: wart, mole

-caused by strep and other bacteria

-usually after trauma to area

-begins with pain in area, red, swollen, hot becomes violet with blisters, necrosis

-high fever

-treatment: debride, penicillin, vancomycin

-benign tumor of small blood vessels

-check for neuro fibroma, motor weakness in thoraci cervical regions

-strawberry angioma

-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

-big pustule, hot, tender

-localized

-scaly white plaques

-eyebrows, ears, axillae

-virus lies dormant until stress, ultraviolet light, febrile, illness

-oral cold sore: vesicle, crust

-treament: acyclovir

-genital herpes caused by different virus, latent infection

-reddened patch and blisters

-complication: childbirth, encephalitis

-appears as a scalding red rash

-common below breast and genetalia

-shingles

-zosterform lesions

-follow nerve path

-dormant chickenpox virus in root ganglia of sensory, cranial or spinal nerves

-can only get shingles if already had chicken pox

-skin intact, red, does not blanch, warm, soggy

-dark skin: red, blue or purple hues

-skin gone, loss of epidermis and dermis

-abrasion, blister, crater

thin skin surface with loss of skin markings

es: straie (stretch marks)

wide fissue, only involves epidermis after vesicles, bullae or pustules

ex: varicella, herpes simplex

thickened areas of epidermis caused by chronic rubbing and scratching, rough thick

ex: chronic dermatitis

vesicles filled with cloudy or purulent fluid

ex: acne

dried serum or pus, may have some liquid, usually broken vesicle or pustules

large vesicles/blisters with clear fluid

ex: second degree burn

elevated, irregular, transient area on dermis

ex: insect bite, TB skin test

visible thickened stratum corneum, that is dry, whitish, looks like a "snake shedding skin"

ex: psoriasis, eczema

linear cracks in epidermis

ex: atheletes foot

encapsulated nodules filled with liquid or semisolid material that can be expressed

es: sebaceous cysts

raised and solid, extends 1-2cm into dermis, marble like, more then 1cm wide

ex: lipomas

blisters filled with clear fluid, less than 1cm

ex: chicken pox, dermatitis

-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

flat, less thatn1 cm in diameter

ex: freckle

large macules, over 1 cm in diameter, may scale or wrinkle

ex: cafe au lait spots

Ph < 7.35

PCO2 > 45

bicarb and base excess are the same

indicates COPD, enphysemia, bronchitis, severe asthma

result of hypoventilation

-round

-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

-decreased blood flow to peripheral vessels

-poor tissue perfusion

-loss of red tone

-cyanosis in african american: lips, tounge, mucous membranes are grayish

-decreased hemoglobin or blood flow

-look: conjunctiva, mucous membrane, palms, soles, lips

-conditions: anemia, shock, blood loss, emotional upest

-cause: increased serum bilirubin level or serum carotene level

-look: sclera, mucus memebrane

-condition: hemolysis, liver diseases, renal failure

-reddish blue discoloration caused by broken blood vessels

-cause: trauma, anticogulants, decreased platelets

-check for coumadin, ASA, heparin

-check PT and PTT

-deoxygenated hemoglobin

-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

-full thickness, necrosis, damage to muscle, bone, undermining

-can get osteomylitis and septic

-inflammatin of skin on lower leg, brown pigment R/T chronic edema, poor peripheral circulation

-peripheral insufficancy

-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

pustule around hair follicule

elevated more thatn 1cm in diameter

ex: psoriasis

usually from jewelry or detergents, cosmetics

-small reddish purple lesion under 0.5mm, do not fade or blanch

-cause: capillary fragility, decreased platelets, decreased clotting ability

-scattered all over body

-"birth marks"

-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

blood supply is cut off to parts of the brain causing loss of function to cells in the brain "miny strokes"

-antibotics: vancomyacin-balance, hearing

-diuretics: lasix-hearing loss

-analgesics: ASA-tinnitus, hearing loss

-chemo: hearing loss, taste

-OTC: nasal spray, cocaine

Ph > 7.45

PCO2 normal

bicarb >28

base excess >+2

indicates severe vomiting, peptic ulcer, hepatic failure, cystic fibrosis

• Ph <7.35
• PCO2 normal
• bicarb <24

base excess <-2

indicates DKA, severe diarrhea, kidney failure, acute MI

Ph >7.45

PCO2 <35

bicarb and base excess are normal

indicates anxiety, fever, hyperthyroidism, pregnancy

results of hyperventilation

vibrations are produced by rapid ventricular filling (heard early in diastole, dull, low- pitched) may be normal in chidren and young adults

resistance to ventricular filling after contraction of atria, low pitched, considered abnormal

mitral and tricuspid calces are forced closed at the beginning of systole (lub) contraction, longer and lower pitched than S2, closure of valves

aortic and pulmonic valves are forced cloesed at the beginning of diastole (dub) relaxation

-caused when there is a reflux of blood through a valve

-considered abnormal

-caused by stenosis or insfficiency of a valve

-categories: grade 1-6, grade 1 being faint and grade 6 being loudest possiable sound

more common on expiration or early inspiration, coarse, rattling sounds caused by secretions in large airways

heard at the end of inspiration, a popping sound caused by air moving into previously deflated airways, alveoli popping open

-hyperventilation

-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

-hypoventilation

-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

-rate & depth increased, a compensatory mechanism to eliminate excess CO2

-associated with diabetis (acid/base balance), sweet smell associated with DKA

-restlessness

-behavorial changes

-decreased concentration/consciousness

Ph: 7.35-7.45

PCO2: 35-45

PO2: 80-100

HCO3: 22-26

• HCT
• male: 40-54%
• female: 37-47%

• HGB
• male: 13-17
• female: 12-16

percentage of blood volume that is RBC

-neural controls the rate & depth

-automatic control is in the medulla oblongata

incomplete lung expansion

• 1. ventilation
• -getting air into lungs

• 2. diffusion
• -exchange of O2 & CO2 between
• alveolar sacs and capillaries

• 3. perfusion
• -functioning cardiovascular system

1. conduction of air

2. mucociliary clearance

3. production of surfactant

4. gas exchange in the alveoli

reduces surface tension, maintains alveolar distension & stability

• 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

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

• -reducing afterload
• -arterial vasodilators
• -angiotensin converting enzyme
• (ACE)

• -reducing preload
• -restrict sodium & fluids
• -diuretics & vasodilators

• -improving contractility
• digoxin

systemic congestion

-decreased cardiac output

-pulmonary congestion

-blood coming from the lungs to the heart collects in the left atrium

myocardial infarction

-subacute or chronic

-enlargement of the cardiac muscle

• -dialated
• -most common
• -ETOH, chemotherapy

• -hypertrophic
• -left ventricle
• -genetic
• -sudden death

• -restrictive
• -least common
• -caused by endo/myocardial disease

inflammation of the inner lining of the heart (chambers & valves)

- compression of the heart due to fluid accumulation within the pericardium

-problem with conduction

-inflammation of the sac that surround the heart

-signs of right sided heart failure

zince, protien, fluids

• Onest
• Location
• Duration

• Characteristics
• Aggrevation
• Related
• Treatment
• Severity

-cell replacement

-injury response

-sensory perception

-thermoregulation

-vascular circulation

-less elasticity

-less subcu tissue

-less sebum production

-less sweat & glandular secretion

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

- all the rest

-health problems not listed above

-potentially dysfunctional

-higher level maslow

-sudden change in mental status

-medical condition requiring immediate attention (diabetic, insulin, food, bleeding, vomiting)

-acute pain

-abnormal lab values

-risk of infection, safety, security

-airway

-breathing

-cardiac/circulation

the provision of guidance or direction, evaluation and follow up by the licensed assistive personal

transferring to a competent individual the authority to perform a selected nursing task in a selected situation

**RN retains accountability for the outcome

the nurse considers factors R/T the following in planning and delievering care

**saftey, effectiveness, cost

determines lung volume capacity, flow rates, gas exchange, airway resistance

any situation that prevents expansion, recoil of lungs and/or gas exchange

any situation that obstructs movement of air in and out of bronchus

airflow obstruction caused by broncho-constriction from allergic or hypersensitivity reaction

inflammation of the bronchioles that impairs airflow, can be acute or chronic

airflow obstruction from changes in lung tissue (lung hyperinflation) characterized by acute exacerbation and remissions

-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

• -date
• -time
• -frequency of treatment
• -location of treatment
• -reason for PRN medications or test
• -signature

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

every hour

• -appearance
• -affect
• -speech
• -orientation
• -cognitive functioning
• -intellectual functioning

• -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

• -sigular
• -linear" poision ivy
• -zosterform: follow in nerve (herpez zoster)

generalized: scattered all over body

positive for blood

put a piece of tape over retum at night to catch pin worms, usually come out at night, mostly found in children

after you eat you have to fo to the bathroom

• -inspection
• -auscultation
• -percussion (tape with fingers)
• -palate

• -pylorous
• -duodenum
• -gallbladder
• -liver
• -rt kidney & adrenal gland
• -hepatic flexure of colon
• -head of pancreas

• -stomach
• -spleen
• -lt kidney & adrenal gland
• -splenic flexure of colon
• -body of pancreas

• -cecum
• -appendix
• -rt ovary & fallopian tube
• -rt ureter & lower kidney pole
• -rt sermatic cord

• -sigmoid colon
• -lt ovary & fallopian tube
• -lt ureter & lower kidney pole
• -lt spermatic cord

murphy's sign

psoas sign

decreased or absence of bowel peristalsis, can be life threating

• -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)

• -fruit
• -fiber
• -water
• -exercise

pain meds

• -lifestyle
• -culturel
• -developmental
• -physiological
• -psychological

• -bulk forming
• -lubericant
• -stimulant
• -saline osmotic

-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

coats the outside of the fecal mass, making it slippery and inhibiting fluid absorption

-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

-distends colon & irritates mucosa

-high concentration of ions in enema

ex: fleet enema

-distends colon, stimulates peristalsis and soften feces

-high concentration of ions in enema

ex: tap water

-distends colon, stimulates peristalsis and softens feces

-concentration is equal

ex: normal saline

irritates & distends colon, stimulates peristalsis

ex: castel soap & water

lubricates the feces and colonic mucosa

ex: mineral oil

helps to expel flatus from the rectum and provide relief from gaseous distention

ex: milk & molasses equal parts

used to administer medications that are absorbed through the rectal mucosa

used to administer nutrition

• -Type of enema
• -Amount of fluid
• -Return (COCA)
• -Client response

• -assessment
• -goal
• -interventions
• -meds to jumpstart peristalsis
• -d/s or hold pain meds
• -NG tube placed to relieve pressure
• off of GI tract
• -evaluation

giant roundworm resides in the small intestines

tx: pyrantel, mebendazol, albendazole

pinworm that resides in the large intestine

tx: pyrantel, mebendazol, albendazole

• transverse colostomy
• ascending colostomy
• descending colostomy
• ileostomy
• cecostomy
• sigmoidostmy

• change bag
• irrigation
• skin care
• inspect the stoma for color & moisture
• inspect the stoma for excoriation, dryness and bleeding

e. coli, staphylococcus, candid alblicans

• increase vitamin C
• drink cranberry juice
• increase water to 3000cc/day
• regular voiding
• decrease caffeine

sulfa & cipro

• -benign prostate hypertrophy
• -enlargment of prostate

tx: hytrine prostate

• transurethral urinary resection
• cutting away excess prostate

no urine output

painful of difficulty voiding

involuntary urination in children beyond the age when expected

blood in urine

voiding 2 or more times at night

voiding less thatn 30 cc/hr less than 500 cc/24hr

abnormally large amount of urine

puss in urine

straight cath, used to cath someone

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

3 openings, 1 port to blow up balloon, 1 port is for urine to flow out, 1 port for irrigation

dehydration & liver damage

60 cc/hr

< 30 cc/hr

1ml/kg/hr

4.6-8

1.010-1.025

• measure the # of particles related to concentration
• < 1.010 diluted urine, excess fluid
• > 1.025 excess particles, concentrated urine (dehydration or kidney disease)

• no glucose should be present
• if >180 mg may indicate diabetes mellitus (not enough insuling to take sugar out of blood stream)

• acetone is not present
• if present may indicate diabetes mellitus, starvation, prolonged vomiting

• normally not present
• occult blood indicates hidden bleeding or kidney disease
• bright red indicates post prostate surgery or hemorrhage

not normally present

infection

indicates infection

• child
• aging
• control
• food/fluid
• lifestyle
• illness
• medication
• diuretics
• cystoscopy

• anti depressants
• anti parkinsons
• anti histamines
• beta blockers
• anti hypertensives
• anti psychotic
• anti metics

• have pt. empty bladder
• cath with straight cath
• measure amount of urine drained, if greater than 100cc then urinary retention is present***call dr.

• over retnetion of the bladder
• sesitizes the bladder

• surgery
• 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

catherterizations

• 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

opposite

• 0.5-1.2 mg/dL
• increased creatine is a sign for kidney disease

• creatine indicates this
• ex: cr=5=1/5=.2x100%=20%

• fluid balance (most important)
• electrolyte balance (most important)
• waste removal
• b/p regualtion
• erthropoietin secretion to stimulate RBC production
• acid base balance

• blood, urea, nitrogen
• indicator for muscle breakdown

• confusion
• dysrythmias
• weak muscles
• N/V
• fatigue

• dehydration
• imparied circulation R/T decrease b/p, hemorrhage
• medications
• kidney stones
• pyelonephritis
• infections

creatine >5

• diabetes
• hypertension

• monitor creatine
• control b/p low protein diet
• low K diet
• low sodium
• calcium supplements

• 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

lymph nodes (and swelling takes place)

• 1. palpation in wedge sections from breast periphery to center
• 2. palpation along concentric circles from periphery to center

• location of lesion
• size of lesion
• shape
• consistency
• discreteness of borders
• mobility
• tenderness
• erythema
• dimpling over mass
• depth of mass

• 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
• forward
• include nipples

• social
• intimate
• therapeutic

pt.'s ideas, experiences and feelings

• orientation: establish trust
• working: time actually working with pt.
• termination: end of relationship, when work is coming to a close

• noise
• hearing impairment (stand in front of pt.)
• non english speaking
• pain
• unpleasent or uncomfortable environment
• lack of privacy
• illiteracy (can't read/write provide pictures)
• anger
• aphasia
• intubated pt
• aniexty (one of the biggest)
• confusion
• distance and space

hearing the word and interpreting the word

• used sparingly
• determine specific info
• helpful with pts experiencing anxiety
• during an emergency

purpose to get pt to talk

• touch
• eye contact
• facial expressions
• posture
• gait
• getures
• general physical apperance
• silence
• sounds

• appropriate tone of voice
• be knowledgable
• think before you speak
• be clear, concise, simple, and to the point
• be flexiable

not specific allows people to tell their stories, for the client who is hesitant about talking

repeating or paraphrasing the main idea expressed, lets the client know that he or she communicated the idea effectively

having them examing their feelings, encourages the client to recognize and accept his/her own feelings

make oneself available, make sure pt knows you are listening

non commitale, doesnt have to agree or disagree

seek clarification

searching for mutual understanding for accord in the meaning of the words

wanting to know more

causes for reflection

offering meaningless cliches or trite comments

changing the subject due to being uncomfortable or not knowing what to say

opposing the clients ideas

demanding proof from the clients, causes client to defend the delusion of misperceptions more strongly than before

intimidates and pt can become defensive

indicating there is no reason for anxiety for other feelings or discomfort

misjudging the degree of the clients discomfort, hearing problems of others is not helpful to pt

• ace inhibitors
• nitrates
• tricylclic antidepressants
• antihistamines
• beta blockers
• thiazide diuretics
• NSIADS

• pt is able to climb 2 flights of stairs or walk a block with out being SOB
• pt has to be comfortable

• eliminate the foreign material
• prepare the ijnured area for 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

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

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

• wound left open to monitor for infection and then surgically closed
• combo of primary and secondary closure

• appearance
• drainage
• swelling
• pain
• drains or tubes

• nutritional deficiencies
• infection
• mechanical friction
• advanced age
• corticosteroid drugs

• suppressed inflammatory response
• phagocyte cells fail to enter wound
• decreased fibroblast proliferation
• contration and epithelialization delayed

• pressure
• shearing force
• friction
• chemicals & moisture
• venous hypertension
• ischemia
• neuropathy

• anemia
• age
• compromised host
• wound stress

higher risk for dehiscence with possiable evisceration because of poor wound healing with adipose tissue (poor vascular supply)

after a sudden strain such as coughing, vomiting, sitting up in bed

increased amount of serosangunous drainage

• 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

• hemorrhage
• infection
• dehiscence
• evisceration
• anti-coags will interfer with healing

• dry dressing
• pressure bandage
• wet to dry
• transparent dressing
• hydrocolloid dressing
• hydro gel dressing
• elastic bandage
• abdominal, "T", breast binder
• sling

distal to proximal

• dry to dry
• wet to dry
• wet to wet
• synthetic dressing

ability to recieve input

ability to mentally recognize, register, interpret

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