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Nur 355 Exam 1
| Question | Answer |
|---|---|
| competencies of medical-surgical nursing | o Sciences: anatomy, physiology, chemistry, pathophysiology, pharmacology |
| roles of medical-surgical nursing | Helping role, teaching-coaching, diagnostic and patient monitoring, effective management of rapidly changing situations, administering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of healthcare practices |
| Evidence based practices | o Develop the question o Search and collate the evidence o Integrate evidence into practice o Evaluate outcomes of practice change o Disseminate the evidence |
| HCAHPS | o Hospital Consumer Assessment of Healthcare Providers and Systems o Provide standardized approach for patient care/ survey patient care |
| Quality and Safety Education for Nurses (QSEN) | • Patient-Centered Care • Teamwork and Collaboration • Evidence-Based Practice • Quality Improvement • Safety • Informatics |
| Interprofessional collaboration and your role in the team | o Team members are confident in their knowledge of each other’s roles and how they contribute to patient’s care, can activate the team when needed, and hold each other accountable to meet goals o Don’t make decisions: ma, home health, uap, family, lpn |
| Social determinants of health | Economic stability, Education, Social and Community Context, Health and Healthcare, Neighborhood and built environment |
| Ethical dilemmas in adult health | DNR Withdrawal of fluids Experimental Procedures/ Stem cell Genetic testing Blood transfusions |
| Autonomy | individual’s personal right to make decisions |
| Beneficence | people acting positively on behalf of the perceived well-being of others |
| Fidelity | nurse is accountable for commitments made to others, self, and to the profession, based on the virtue of caring |
| Non-Maleficence | Do no harm |
| Paternalism | inappropriate deciding for the patient |
| Social Justice | fair and equal treatment for everyone regardless of race, religion, or gender. |
| Veracity | To tell the truth |
| Primary prevention | risk factor modification, immunization, chemoprevention |
| Secondary prevention | cancer screening for early detection |
| Tertiary prevention | reducing morbidity and mortality once the disease has been diagnosed (OT, PT) |
| benign | non-cancerous, localized |
| malignant | cancerous, it can spread |
| Tumor staging | 1. Tumor size 2. Number of lymph nodes involved 3. Presence of metastasis |
| BMI-how to calculate | Weight (kilograms)/Height (meters)2 convert height to inches and divide by 39.37 |
| Clinical manifestations of obesity | Increased waist circumference Increased weight |
| Complications of obesity | Increases mortality and morbidity (DM, heart disease), increase hospital stay length and healthcare costs |
| Obesity: Education and health promotion | Fever, Tachycardia, fever, hypotension, and abdominal pain should be reported immediately because they may be signs of anastomosis leak, a life-threatening complication associated with infection and sepsis |
| Obesity: Prioritizing and planning care | Lab and diagnostic testing Weight loss therapy Diet therapy Physical activity Behavioral therapy Medications |
| Physical dependence | tolerance, withdrawal, and cravings o Dependence occurs because the body naturally adapts to regular exposure to a substance. Can be addicted without the maladaptive tendencies of SUD |
| substance use disorders (sud) | must be associated with clinically significant manifestations pattern must be problematic |
| Risk Factors for Substance Use Disorder | o Biology/genetics o • Ethnicity/gender/age o • Presence of other mental health disorders o • Early drug use o • Peer group pressure o • Childhood adverse advents/history of sexual abuse |
| most common headache | Tension headache |
| Cranial Nerves for the eyes | II, III, IV, VI 2, 3, 4, 6 |
| Bacterial conjunctivitis clinical manifestations | o Pink eye, discharge, red, itchy, swollen, tearing o Swab to confirm bacterial |
| Cataracts | Cloudy vision Opaque lens |
| Cataracts Post op interventions and education | o Elevate hob o Use drops o No vigorous activity o Stool softeners (no straining) o Eye patch for a day or two |
| Macular Degeneration | Central vision loss Wavy vision on Amsler Grid Test |
| Risk factors for Macular Degeneration | HTN, Obesity, Age, Women, Race Complications TX: injections, phototherapy |
| Glaucoma | Loss of vision, increased pressure on optic nerve |
| Prostaglandin-type medications | Latanoprost (Xalatan), bimatoprost (Lumigan) |
| Beta-blocker medications | Timolol (Betimol, Timoptic), betaxolol (Betoptic), and metipranolol (OptiPranolol) |
| Post Op restrictions | restrictions on strenuous activities, bending at the waist, and lifting of heavy objects (greater than 25 lb) and avoiding constipation for at least the first 2 weeks postoperatively this can increase IOP and cause damage to the newly repaired eye. |
| Macular degeneration | age related and is a disease that gradually destroys sharp, central vision |
| Dry MD | drusen bodies, which are yellow deposits that are located under the retina |
| Wet MD | occurs when abnormal blood vessels located behind the retina start to grow under the macula |
| EYE TRAUMA | Significant causes of visual loss are related to blunt and penetrating trauma |
| Blunt trauma | occurs when the eye is struck with a finger, fist, racket, tennis ball, or other solid object |
| Penetrating trauma | injuries in which the eye is pierced by a sharp object such as a knife or a high-velocity missile such as a piece of metal or a BB pellet. |
| Vision Charts | Snellen, Ishihara, Rosenbaum |
| Snellen Chart | Visual Acuity test |
| Ishihara Chart | Color Blind test |
| Rosenbaum chart | Reading vision test |
| Cranial nerves for hearing | VIII (8) |
| External otitis | commonly referred to as “swimmer’s ear” because it is most often related to infectious organisms that are contracted through swimming. |
| Otitis media | common disease process that causes an inflammation of the middle ear canal, most commonly by a bacterial source. (Middle ear) |
| clinical manifestations of external otitis | Swelling visualized in and around the external ear External ear that is tender to touch Pain on movement or pressure to the outer auricle of the ear Visualized erythema and/or edema in the ear canal Scant clear drainage from the ear canal |
| Causes of hearing loss | Excess cerumen, chronic infections, trauma, medications (furosemide, acetylsalicylic acid, quinine) |
| Conductive hearing loss | Obstruction (foreign body, cerumen, external otitis) Otitis media Ear trauma Tumors |
| Sensory Hearing loss | Genetic disorders Noise exposure Presbycusis |
| Presbycusis | Progressive hearing loss bilaterally in the presence of a normal neurological examination |
| Labyrinthitis | inflammatory disorder of the inner ear labyrinth that occurs as a complication of otitis media, which results in a disturbance in balance and hearing |
| Tinnitus | commonly described as a noise or ringing in the ears and is a relatively common affliction that is often a manifestation of an underlying disorder |
| Otosclerosis | stiffening/ hardening of ossicles/ middle ear bones |
| Tinnitus treatment meds | Alprazolam (Niravam, Xanax) Anticonvulsant medications (phenytoin, carbamazepine) Antihistamines (diphenhydramine) Acamprosate (Campral) Niacin (vitamin B complex) Gabapentin (Neurontin) Tricyclic antidepressants |
| Teaching on tinnitus | Keep a diary of occurrences Antihistamines can help Educate on any well-known medications that can aggravate tinnitus |
| Vertigo | clinical manifestation that evokes a feeling of illusory movement and like tinnitus, is not a specific disorder (dizziness) fluid in semicircular canal |
| Teaching on vertigo | Change positions slowly Safety (potential falls) Medication/dietary (Decrease sodium intake/Motion sickness meds) |
| Ménière’s disease | disorder of the inner ear that affects the patient’s balance and hearing unilateral sensorineural hearing loss, tinnitus, and vertigo |
| How to speak to a patient with hearing loss | Face the patient directly when speaking to him or her Speak slowly and be attentive to enunciation Lower the pitch of voice Take care not to shout |
| Signs of Hearing Loss | • Frequently asking for instructions to be repeated • Turning the head or leaning forward to gain clarity on the question being asked • Loud conversation initiated by the patient • Failing to respond when spoken to |
| Weber test | distinguish between conductive (bone conduction) and sensorineural (air conductive) hearing loss vibrating tuning fork in the midline of the patient’s skull and ask whether the tone sounds the same in both ears or better in one. |
| Rinne test | compares air conduction and bone conduction patient should still be able to hear the vibrating sound if hearing is normal. |
| Hearing Loss prevention | yearly hearing evaluation ; use of earplugs, earmuffs, or other protective equipment in the presence of loud noise to protect; limiting use of earbuds for listening to music at levels beyond recommended levels, cotton swabs should not be used |
| Basal Cell | Non-cancerous (pearly, flesh colored, raised) |
| Squamous cancerous | Crusted papules and plaques that can become indurated and ulcerated. Larger lesions can become painful and bleed. NOT raised |
| ABCDE | A: Asymmetric appearance • B: Irregular borders • C: Variation of color (brown, black, tan, blue, red, white, or any combination) • D: Diameter greater than 6 mm • E: Elevation or an evolving, enlarging, and changing existing lesion |
| Patient Education for Skin Cancer Prevention | Limit time spent in the sun Wear clothing to protect as much of the skin as possible Use sunscreen with an SPF of at least 30, applied thickly Reapply often for best protection Wear sunglasses Avoid tanning beds Examine your body monthly |
| Treatment of burns | Stop the burning process Remove clothing or jewelry Apply cool water soaks Infection prevention Nutritional support Restoration of mobility |
| Education for burns | o Infection control precautions o Can experience many feelings o Peer or support groups o Anticipate changes in appearance o Wear compression dressings o Massage scar with moisturizer daily |
| Assessment | Health history, Risk factors, Culture, Social determinants of health, Physical Assessment |
| Analysis/Diagnostics | Assessment Data, Tools, Lab and diagnostic test Planning: Problem identification, Goal Setting |
| Intervention | Independent Nursing actions, Interdisciplinary collaboration, Patient, and family education |
| Evaluation | Goals met or Not met |
| Granulation | red/pink granular tissue composed of new blood vessels; healthy, healing tissue |
| Hypergranulation | hyperplasia of granulation tissue recognized by its friable red appearance usually in response to a prolonged inflammatory phase |
| Necrotictissue | dead or avascular or devitalized tissue |
| Eschar | Thick, leathery, devitalized tissue; black or brown; hard, soft, or boggy; loose or firmly attached to wound bed |
| Slough | Soft, moist devitalized tissue that may be white, yellow, tan, green |
| Bias influencing nursing care and judgment | this can alter judgement, influence behavior, and create isolation and dissociation between nurses and patients and/or family members. |
| Cultural awareness | the realization and recognition that personal beliefs and values impact cultural health benefits and potentially the view of those who are different |
| Cultural sensitivity | an understanding, thoughtfulness, and kindness that leads to inclusiveness and equity |
| Ethical nursing practices are guided by | ANA |
| Skin changes in older adult | Slow wound healing Decreased collagen Decreased inflammatory responsiveness Decrease T cell function Dry rough skin Loss of dermal thickness |
| Age-related physiologic chan ges in the older adult | sclerosis, stenosis, calcification, atrophy, gait slows, height diminishes, ROM decreases |
| Prioritizing care of the older adult | Physical safety (home environment, fall risk, driving) Medication safety (polymedication,) Potential for abuse Psychosocial transition |
| Risk factor modification for cancer | Avoid known carcinogens, wear sunscreen everyday, prevent and treat infections related to cancer, maintain healthy weight, plant based diet |
| Complications of bariatric surgery | impaired breathing Increased risk of a pressure ulcer increased risk of skin infection immobility urinary and fecal incontinence |
| Nursing interventions after bariatric surgery | Vitals, O2 sat, electrolytes, daily weights, skin folds, elevate HOB |
| Prioritization and planning care SUD | SBIRT, pharmacotherapy, detox, maintenance and relapse prevention, behavioral therapy, motivational interviewing, individualized interviewing |
| Clinical manifestations of alcohol | anxiety, bleeding disorders, cardiomyopathy, certain cancers, cirrhosis, delirium, depression, insomnie, hypertension |
| Migraine headache | Pulsating. throbbing |
| Cluster headache | Most severe, cause unclear, sudden extreme pain |
| Meds that cause hearing loss | vancomycin aminoglycosides acetylsalicylic |
| Risk factors of hearing loss | Age heredity occupational noises recreational noises |
| Epidermis | outer layer of skin keratin |
| Dermis | 2-4 mm thick encases blood vessels, nerves, immune system, starts where blood vessels are |
| Subcutaneous | between both layers adipose tissue connective tissue |
| Merkel cells | sensory perception "don't touch that" |
| melanocytes | pigment of skin color |
| langerhan | migrate from bone marrow outermost layer of the immune system |
| Bacterial skin infections | MRSA: swab it |
| Signs of infection | purulent drainage fever edema |
| purulent drainage | staphylococcus, pseudomonas, proteus |
| staphylococcus | creamy-yellow pus |
| pseudomonas | greenish-blue with a fruity odor |
| proteus | beige pus with fishy odor |
| serosanguinous | Blood tinged, serum, red blood cells, amber colored, normal during first 48 hours after sx |
| Cellulitis nursing interventions | Elevate the feet systemic infection obtain vitals keep comfortable |
| Tinea Capitis | (CAP) scalp or head |
| Tinea Corporis | (corpse) Body |
| Tinea Cruris | (crotch) groin jock itch |
| Tinea faciei | Face |
| Tinea pedis | Feet |
| Tinea versicolor | upper chest, back, upper arms |
| onychomycosis | nails |
| oral thrush | mouth |
| vulvovaginal candidiasis | vagina, vulva |
| Intertrigo | skin folds |
| Herpes Simplex | 1 oral 2 genital fever, malaise, myalgia, anorexia |
| Psoriasis | Plaque: most common |
| Psoriatic arthristis | common manifestation of psoriasis |
| Psoriasis meds | topicals phototherapy biologics systemic medications |
| skin trauma | break in skin laceration abrasion skin tears blisters excoriation |
| Diagnosis of skin trauma (nursing) | Impaired skin integrity Acute pain risk for infection |
| Minor burns | Treated at the scene provide analgesic cleanse with mild soap and tepid water use antimicrobial ointment apply a dressing educate family to avoid greasy lotions observe for evidence of infection |
| Deep tissue injury | intact or non intact skin localized area of deep red, maroon, purple discoloration |
| Nursing interventions for pressure injury | skin and risk assessments at regular intervals dry skin |
| Safety for pressure injury | maintain regular turning schedules proper positioning use of lift sheets |
| Braden Scale | Mild risk: 15-18 Moderate: 13-14 High risk: 10-12 Very high risk 9 or below |
| Macerated tissue | softened tissue prolonged exposure to moisture |
Created by:
Emileestephens
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