med surg

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nursing92
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223679
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med surg
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2013-06-13 04:48:47
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med surg
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Med surg
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  1. what are the 5 dimensions of Pain?
    • 1. affective
    • 2. sensory
    • 3. behavioural
    • 4.physilogic
    • 5.cognitive
  2. What will help assist tissue formation?
    Vit c and d
  3. what are the 3 principles or chronic pain management?
    • 1. Give patient as much control as possible
    • 2. use preventative approach
    • 3. titrate to effect
  4. How do you care for a client with enteral tubes?
    • Oral care
    • Securing NGT, GT or PEG
    • Monitor bowel sounds
    • Fluid balance chart
    • skin integrity
    • education and reassurance
  5. What are some complications of IV/
    • Heamatoma - blood under skin
    • cellulits - inflammation of cells
    • Extravasation - Around surrounding tissue
    • Infiltration - fluid gone into surrounding area
    • phlebitis - inflammation of vein
  6. what are the 5 steps of diagnosing and treating a patient?
    • Assessment
    • nursing diagnosis
    • planning
    • implementation
    • Evaluation
  7. what is safety?
    freedom from psychological and physical injury
  8. what is environment?
    All the many physical and psychological factors that influence or effect the life and survival of the patient
  9. What is environmental safety?
    • Basic needs - oxygen nutrition
    • Physical hazards - lighting, obstacles
    • pathogen - bacteria, fungi
    • pollution - air, water, noise
  10. What are the 4 risk factors in a health care agency?
    • Falls
    • Patient inherit accidents
    • equipment inherit accidents
    • procedure related accidents
  11. What are some specific hazards?
    • scalds/burns
    • fire/electrical
    • excessive noise
    • poisons
    • radiation
  12. what are 4 types of restraints?
    • Physical- jackets, protective mittens, cast
    • environmental - bed rails, locked door
    • Chemical - medications
    • Emotional - verbal/non verbal intimidation
  13. What are some general factors affecting wound healing?
    • age
    • underlying disease
    • nutritional status
    • obesity
    • drugs
    • disorders of sensation
  14. what are some local factors effecting wound healing?
    • Hydration of wound
    • wound management practices
    • wound temp (37)
    • pressure/friction
    • foreign bodies
    • wound infection
  15. What does vitamin c assist with?
    collagen synthesis
  16. What does vitamin E do?
    enhances epithelisation, collagen synthesis
  17. what helps mitosis and cell proliferation?
    Zinc
  18. What role does fluid play in would healing?
    Essential for all cell function
  19. What are 4 status of skin integrity?
    • open-break
    • closed-nobreak, e.g haemorrhage
    • Acute - trauma
    • chronic - ulcer
  20. What are the 4 pressure ulcer stages?
    • 1 - intact skin, non blanching erythema (redness) of localised skin
    • 2- Partial thickness loss of dermis without slough
    • 3- full thickness tissue loss - sub fat may be visible slough maybe present
    • 4 - Full thickness tissue loss with exposed bone, tendon or muscle. slough and eschar may be present
  21. What does the Braden scale rate?
    • Sensory
    • Moisture
    • activity
    • mobility
    • nutrition
    • friction
  22. what is a good wound healing environment?
    • Warm, moist, non toxic
    • oxygen and perfusion
    • body temp - 37
    • free from excess exudate and dead tissue
    • adequate nutrition
  23. What are 6 wound complications?
    • haemorrhage
    • infection
    • dehiscence
    • evisceration - protrusion of visceral organs
    • fistula
  24. What can alter bowel function?
    • Paralytic ileus
    • bowel obstruction
    • bowel diversion - stoma
  25. What would you assess when assessing bowel function?
    mouth, abdomen, rectum
  26. what faecal characteristic do you look for?
    • colour
    • odour
    • constituents
    • frequency
    • amount
    • shape
    • consistency
  27. State and describe the 5 types of urinary incontinence?
    • Functional - change in environment/some sort of deficit
    • overflow - loss of small amount
    • reflex - involuntary loss (spinal cord dysfunction)
    • Stress - leakage of small amount, caused by sudden increase in intra-abdominal pressure, weak pelvic muscles
    • Urge - involuntary passage of urine after a sense of urgency
  28. What are 5 exercise activity types?
    • Isotonic (Dynamic)
    • isometric (Static)
    • Active
    • passive
  29. What are 4 factors affecting mobility?
    • Prescribed limitation - RIB, cast
    • medication - narcotics
    • Nutrition - under/over
    • health/history
  30. List some effects of immobility
    • Musculoskeletal
    • cardiovascular (thrombus, increase work load)
    • metabolic - decreased metabolic rate
    • Urinary (urinary stasis)
    • GIT (Constipation/impaction)
    • integumentary (reduced skin turgor)
    • Psychosocial (personal values)
  31. what should the nurse do post operatively?
    • explore patient feelings and alley fears
    • Be aware that no surgery is minor to the patient
    • be empathetic and listen to patient
    • education should encompass, physical and psychological care
    • Provide TED stockings
  32. what do ted stockings do?
    Maintain pressure one lower extremities, promote venous return
  33. What is hypoxia and some causes
    Insufficient O2 anywhere in the body from inspired gas to tissue.

    • Causes
    • decrease haemoglobin (Anaemia)
    • decrease diffusion into alveolar
    • impaired ventilation
  34. what are some signs and symptoms of hypoxia?
    • tachycardia, tachypnoea, shallow reps, dyspnoea
    • Light headedness
    • behavioural changes
    • cyanosis in late stages
  35. What do neurovascular obs check?
    • Colour
    • temp
    • movement
    • sensation
    • pain
    • pulses
    • comparison
    • remarks
  36. What is compartment syndrome?
    Occurs after an injury, when there is not sufficient amount of blood supply to nerves and muscles with oxegen and nutrients because of raised pressure in the compartment. The fascia layer that defines the compartment does not stretch so a small amount of bleeding into the compartment, or swelling of the muscles within the compartment can cause the pressure to rise greatly.
  37. What are the symptoms of compartment syndrome? (5 ps)
    • pain
    • Pallor
    • paraesthesia
    • paralysis
    • and pulses (absence of)
  38. what is DVT?
    Occlusion of the deep veins
  39. what are the risk factors for DVT ad S and S
    • RF
    • obesity
    • sedentary life style
    • post op
    • can dislodge = stroke

    • S and S
    • Often none
    • swelling
    • pain
    • warm and or discoloured skin
    • visible surface veins
    • leg fatigue
  40. What are the 6 levels of consciousness and describe a bit about each
    • alertness - awake, attentive, appropriate responses to stimuli, orientated
    • Confusion - attention drifts, easily distracted, disorientated
    • Lethargy - drowsy, falls asleep, but easily arouses at sound of voice
    • Delirium - severely confused, disorientated perception, react inappropriately to stimuli.
    • Stupor - Awake intermittently, aroused for only short periods requires loud noise or painful stimuli's for arousal. responds only with movement and moaning
    • Coma - not able to be aroused, moves only involuntary
  41. What does a neurological assessment look like?
    • Level of consciousness
    • pupillary check
    • vital signs
    • movement and strength of extremities
  42. What does the Glasgow coma scale assess?
    • eyes opening - spontaneous, to speech, pain or no response.
    • Assess patient orientation - name, month, season year
    • Assess motor response - single response command (touch toes)
  43. What is self concept and the 4 components?
    is an integrated set of conscious and unconscious feelings, attitudes and perceptions about self

    • identity
    • body image
    • role performance
    • self esteem
  44. what are 4 psychological challenges?
    • self concept
    • sexuality
    • spirituality
    • loss grief and death; fear unkown
  45. what are the 4 types of loss?
    • Actual
    • perceived
    • maturation/development
    • situational
  46. What are 5 manifestations of grief?
    • Physical
    • behavioural
    • cognitive
    • emotional
    • spiritual
  47. What are the 4 natures of death?
    • Sudden
    • anticipated
    • suicide
    • homicide
  48. What are the 4 process of death?
    • Social death - withdraw
    • Psychological death - personality changes
    • Biological death - no longer exits as human entity
    • Physical death - complete cessation of vital organs
  49. List the 4 sources of loss?
    • Loss of external objects
    • Loss of known environment
    • loss of significant other
    • Loss of aspect of self
    • loss of life

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