Fundamentals of Nursing

Pinch Test

Cavities

Ear Wax

2nd skin layer, inner layer.

Sweaty

1st layer of skin, outer layer.

Dead/necrotic skin.

• Condition that worsens.
• EG: COPD Exacerbation

Lump

Softening, usually used to describe skin surrounding a wound.

Light headed, causes fainting.

Absence of breathing.

Abnormal heart beat.

Listening, used during exams, usually with a stethesecope.

Shallow breathing, followed by an absence of breathing.

Shrill, harsh sound on inspiration; caused by obstruction of the upper air passages, as occurs in croup or laryngitis.

To get rid of the fever.

Low O2 in the blood, causes low O2 sats.

The different sound while obtaining a BP

High/quick rate and depth, but, a long exhale.

A difference in apical and radial pulses.

The difference of systole and diastole.

Fever >100.2

Causative agents of fever.

Dry rattles during auscultation of lungs.

Circulatory failure

Snoring sound caused by blockage in bronchioles.

Amount of blood exiting the heart with each beat.

1st stage, begins when antigen first enters the body lasts until symptoms occur. Can be transmitted during this stage.

Lasts between onset of vague mild symptoms and disease specific symptoms. Highly contagious.

3rd stage, localized and systemic symptoms occur. General malaise symptoms accompanied with disease specific ones. Depending on antigen depends on severity of symptoms and contagion.

Last stage, occurs when symptoms begin to subside and persons health is restored.

135-145 mEq/L

22-26 mmol/L

80-100 mm Hg

35-45 mmHg

7.35-7.45

Endoscopic Retrograde Choliangiopancreatography

Enhances; works with

Works against

Refers to removal of tissue

Diagnostic, exploratory, curative, palliative, and cosmetic.

Drugs not classified as analgesics, but can be used for pain. IE muscle relaxants.

• Face
• Legs
• Activity
• Console
• Cry

scale used to determine pain in a non vocal patient

• Neonate
• Infant 
• Pain 
• Scale

• Premi
• Infant
• Pain
• Profile

• Continuos 
• Positive
• Airway
• Pressure

Keeps airways open during sleep.

Afferent (ascending) carries messages to the brain.

Efferent (descending) carries messages away from the brain.

Nociceptors are irritated. Stubbed toe, superficial burn etc...

Caused by a malfunction in the nervous system. Due to injury or illness. Most commonly chronic pain. spinal injuries is an example.

• PH decreases
• PaCO2 increases

• PH increases 
• PaCO2 decreases

• PH decreases
• Bicarb decreases

• PH increases 
• Bicarbonate increases

Inadequate blood volume to maintain supply of oxygen and nutrients.

When the heart fails as a pump

Physical impairment of adequate blood flow

Excess dilation of vessels. 

Anaphylactic Shock (chemicals causing vasodilation during an allergic rxn)

Septic Shock (hypotension unresponsive to fluids, metabolic acidosis, acute encephalopathy oliguria, and/or coag probs)

Neurogenic Shock (disruption in the nervous system affects the vasomotor center in the medulla, disrupting sympathetic nerve impulses. This causes vasodilation.)

Acute Respiratory Distress Syndorme

Leads to tissue hypoxia and anoxia, respiratory failure, metabolic acidosis.

Then causes cardiac issues. Disseminated intravascular coagulation, this is caused by destructed RBC's releasing clotting factors.

• Thirsty
• Irritable/Restless
• Decreased-BP & pulse pressure, urine output, and hypoactive bowel.
• Increased-pulse (unless neurogenic), resprs (rate and depth), blood glucose.  
• Cool/pale skin

• Confused/listlessness
• Tachycardiac, with weak thready pulses
• Subnormal temp (unless septic)
• Skin is cool, clammy, slow refil and, cyanotic
• Urine output decline; possible kidney failure
• Decreased BP, pulse pressure is narrow
• Peripheral edema
• Muscle weakness
• Resprs increase, deep, crackles.

• Loss of consciousness
• Systole falls, diastole can reach zero
• Pulse is irregular
• Resprs are slow shallow and irregular
• Little to no urine output
• Skin is cold, clammy and cyanotic

Brain cells begin to die at 4 minutes

Systemic Inflammatory Response Syndrome