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263 FINAL

Question	Answer
assesment	subjective and objective data
diagnosis	analyzing subjective and objective data to make a professional judgment
planning	determining outcome criteria and developing a plan
implementation	carrying out the plan
evaluation	assessing whether outcome criteria have been met and revising the plan
initial comprehensive	collection of subjective data about the client's perception of their health, health history, family history and lifestyle as well as objective data
ongoing or partial assessment	data collection after comprehensive database is established
focused or problem oriented assessment	specific health concern, specific body systems
emergency assessment	life threatening, immediate
documentation of data	provides database for nursing process, promoted effective communication
what needs to be validated	gaps between subjective and objective data, differences in what the patient says, highly abnormal findings
ways to validate	recheck own data, clarify with questions, verify with another nurse, compare subjective and objective
identify abnormal data and strengths	used to formulate diagnoses to minimize potential weakness
cluster data	consider if additional data is needed, look for related cues from identified strengths
draw inferences	infer, determine if collaborative problem or need a referral
collaborative problem	certain complications that nurse monitor to detect changes in status
propose possible nursing diagnoses	hypothesize and generate
data analysis	diagnostic phase because the end result or purpose is to identify a nursing diagnosis
wellness diagnosis	client has motivation and well being to follow care
risk diagnosis	client is vulnerable to developing complication
actual diagnosis	client is experiencing problem
syndrome	group of signs and symptoms
check defining characteristics	most accurate, delete invalid
confirm, rule out diagnosis	verify diagnoses with client
pitfalls	too much or little data, unreliable, invalid, insufficient cues to support diagnosis, cues clustered are unrelated, quick diagnosis, incorrect wording
alert	eyes are open, able to answer questions and maintains eye contact
lethargic	opens eyes, answers questions falls back asleep quickly
obtunded	opens eyes to loud voices, responds slowly
stupor	awakens to painful stimuli, returns to sleep
coma	unresponsive to painful, noxious stimuli
glasgow coma scale	records conscious state of a person, 3 is coma, 15 is fully awake
alzheimer's	poor judgment and decision making, inability to manage budget, losing track of date, misplacing items
AUDIT	alcohol use disorders identification test
SAD persons	suicide risk assessment, sex, age, depression, previous attempt, ethanol abuse, rational thinking, lack social support, organized plan
CAM	confusion assessment method
SLUMS	mental status exam (dementia or alzheimer), orientation, memory, speech, cognitive
PHQ9	depression scale
older adult BP	arteries more rigid, increased systolic BP
acute pain	recent injury
visceral pain	abdominal, thorax, cranium
somatic pain	ligaments, tendons, bones and nerves
phantom pain	nerves, missing limb
FLACC	face, legs, activity, cry, consolability
walker's cycle of violence	tension building, acute battering stage, honeymoon
domestic violence	a pattern of abusive behavior where one partner gains or maintains control
violence interview	confidentiality, develop trust, simple, direct questions, listen, discuss legal, mandatory report
violence observe	appearance and body build, children may look underdeveloped, older client thin, frail, malnourished
violence observed hygeine	neglect poor hygiene, soiled clothing, long sleeve and pants in warm weather
assess violence mental status	anxious, depressed, suicidal, withdrawn, difficult concentration, poor eye contact, soft speech, unable to recall past events
violence vital signs	prolonged stress leads to hypertension, elevated heart rate and respiratory rate
cultural awareness	knowledgable about thoughts, feelings, sensations and how it affects interactions with others
purpose of cultural assessment	learn beliefs and behaviors, compare to Western health care, compare to those of similar background, assess prevalent diseases
culture bound latin	mal de ojo
culture bound african	high blood
culture bound native american	ghost sickness
ideal body weight female	100 pound for 5ft plus 5lb for every inch over 5 ft
ideal body weight male	106 pound for 5ft plus 6lb for every inch over 5ft
normal BMI	18.5 to 24.9
obese BMI	30 - 39
IDDSI framework	how thick food is getting, drinks 0 foods until 7
hemoglobin	13 - 16/18
hematocrit	40 - 52
serum albumin	3.5 - 5
prealbumin	17 - 40
BUN	5 -25
vitamin A deficiency	dry, rough, scaly skin, night blindness
vitamin B deficiency	flaky skin, beefy red tongue, paresthesia, decreased mental status
vitamin C deficiency	spongy, bleeding gums, petechiae, sores
vitamin K deficiency	petechiae, ecchymoses
riboflavin deficiency	red conjunctiva, mouth cracks, magenta tongue
protein deficiency	thin hair, ascites, edema, poor wound healing
iodine deficiency	swollen neck, goiter
iron deficiency	brittle nails
zinc deficiency	unhealing sores
thiamin deficiency	altered mental status
dehydration	orthostatic hypotension
overhydration	crackles in lungs, pale yellow urine
diabetes	excessive weight loss despite adequate intake
older adult skin	decreased perspiration, decreased flexibility and motility lead to improper hygiene, paleness, dryness, skin lesions
older adult nails	thick, yellow, brittle
freckles	flat, small macules of pigment following sun exposure
mole	nevus, flat or raised tan marking
stage 1 pressure ulcer	intact skin, nonblanchable redness over a bony prominence, painful, firm, soft, warm or cool
stage 2 pressure ulcer	partial thickness loss of dermis, shallow open ulcer with a red pink wound bed, without slow, shiny or dry ulcer, skin tears
stage 3 pressure ulcer	full thickness tissue loss, subcutaneous fat loss with visible bone, tendon or muscle not exposed, may undermine or tunnel, visible adipose tissue
stage 4 pressure ulcer	full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar
braden scale	risk for skin breakdown, sensory perception, moisture, activity, mobility, nutrition, friction
macule and patch	flat, small, non palpable skin color change (macule - circumscribed), patch is a freckle
papule and plaque	elevated, palpable, solid mass (papule circumscribed)
plaque	psoriasis
nodule and tumor	elevated, solid, palpable extends into dermis
vesicle and bullae	circumscribed elevated
wheal	elevated mass with transient borders
pustule	pus filled vesicle or bullae, acne or impetigo
cyst	encapsulated fluid filled or semisolid mass in subcutaneous or dermis
erosion	loss of superficial epidermis
scar	cicatrix, skin mark left after healing, connective tissue
ulcer	skin loss past epidermis, necrotic tissue loss
fissure	linear crack
petechiae	pinpoint red dots, red or purple maculae
ecchymosis	round, irregular macular lesions, color varies yellow and green hues, bruising
hematoma	collection of blood under the skin
angioma	bright red spot on skin
clubbing nails	distorted, raised nail bed, due to hypoxia or long term oxygenation issues
psoriasis	yellow, nail pitting
yeast infection nails	white color, separation of nail and bed
bacterial infection nails	green, black or brown
fungal infection nails	yellow, thick, crumbling
concave or spoon nails	iron deficiency
thickened nails	decreased circulation
skin cancer	Asymmetry, border, color variation, diameter, evolving
phases of wound healing	hemostasis, inflammatory, proliferation, remodeling
hemostasis	blood vessels constrict, blood clot
inflammatory phase	WBC locate to wound, temperature increases as growth factor builds blood vessels
proliferation	regeneration, fibroblasts fill wound
remodeling	3 weeks after injury
inspecting a wound	landmarks, size, edges, drainage
serous drainage	clear, no infection
sanguineous drainage	bloody
serosanguineous drainage	light pink
purulent drainage	pus, thick and odor
debridement	removal of devitalized tissue and foreign material, promoted healing, decreases infection
3 main dressings	add, absorb, maintain moisture
autolytic debridement	own enzymes
enzymatic debridement	applies enzymatic to speed autolytic process
mechanical debridement	external force to dislodge and remove debris and necrotic tisse
eschar	dead tissue, black and leathery
shearing forces	pulled rather than lifted
dehiscence	partial or total separation of wound layers
sterile technique	surgical wounds
clean technique	pressure ulcers and chronic wounds
wound culture	taken after wound is cleaned to identify organism
irrigation of a wound	1 inch above a wound
cranium	8 bones, ethmoidal and sphenoidal not accessible
face	14 bones, mandible is only movable (jaw)
sternomastoid muscle	rotates and flexes head
trapezius	extends head, moves shoulders
cranial nerve XI	shrug shoulders, turn against resistance
use of trapezius and sternomastoid	accessory muscle use, acute airway obstruction
sinus headache	constant throbbing, pressure like pain with a cold, eye brow or cheek
cluster headache	stabbing, sudden onset, alcohol induced, eye orbit, facial and temporal
tension headache	dull, tight, diffuse, with stress and anxiety, frontal, temporal, occipital, lasts days months, years and mostly women
migraine headache	nausea, vomiting, photophobia, phono phobia, may be one sided, eyes, temples, cheeks, forehead
hypothyroidism	sleepiness, cold intolerant, weight gain, muscle aches, dry skin, brittle nails, bradycardia, constipation
hyperthyroidism	nervousness, fatigue, weakness, palpitations, heat intolerance, dyspnea, diarrhea, weight loss, tachycardia, insomnia, brain fog
scleroderma	tightened hard face, thin skin
parkinson's	expressionless face, tremors, rigidity, akinesia, postural, instability
bell's palsy	one sided facial paralysis, sudden onset peak by 48 hours, affect cranial nerve VII
stroke cerebrovascular accident	neurologic damage, decrease vision, balance, numbness
impending stroke	visual disturbances, loss of balance, trouble walking, sudden weakness
diabetic ketoacidosis	fruity or acetone breath
small bowel obstruction	fecal odor breath
end stage liver	sulfur odor breath
older adult thyroid	fibrotic changes, weak temporal artery pulse
sclera	dense protective covering
retina rods	regulate black and white
retina cones	sensitive to bright color
visual fields	what a person sees with one eye
visual perception	nerve impulses conducted to brain
visual pathways	information from right is conveyed to left
anisocoria	pupils of different size
miosis	constricted pupils, pinpoint
mydriasis	dilated pupils, fixed
ectropion	outward lid
entropion	inward lid
ptosis	drooping eyelid
hordeolum	stye
strabismus	eyes inward or outward, tropia
papilledema	swelling of optic disk, lack physiologic cup, blurred margins
glaucoma	high pressure damaging optic nerve, painful, age over 40, high BP
open angle glaucoma	tunnel vision
acute angle glaucoma	halos, eye pain, headache
diplopia	double vision, intracranial pressure
presbyopia	impaired near vision, decreased accomodation
myopia	impaired far vision
visual fields peripheral vision	confrontation test, see finger at same time
near visual acuity	jagger card, snellen card
cover test	deviation, alignment or strength, uncovered eye remains fixed ahead
corneal light reflex	test for strabismus
pupillary light reflex	pupils constrict when exposed to bright light
consensual reflex	exposure in one eye leads to reaction of other eye
middle ear	transmits vibrations through ossicles
inner ear	labyrinth
presbycusis	gradual sensorineural hearing loss, whispered sounds
newborn auditory canal	curves upward, short and straight
conductive hearing	external and middle ear
conductive hearing loss due to	earwax, otitis media, perforated eardrum
sensorineural hearing	inner ear
sensorineural hearing loss due to	dysfunction of inner ear, cranial nerve VIII, gradual nerve degeneration
weber test	distinguished conductive and sensorineural hearing loss, tuning fork in middle forehead
rinne test	compares air and bone conduction, tuning fork on mastoid process
acute otitis media	red bulging membrane
otitis externa	swimmer's ear, pain in pinna and tragus, otorrhea (drainage), itching
tinnitus	ringing
oral cancer	under tongue
tongue cancer	side of tongue
sinuses	air filled, lined with ciliated mucous membranes, easily blocked
acute tonsilitis	enlarged, erythema and large gray white patches
1 tonsils	visible
2 tonsils	midway between tonsillar pillar and uvula
3 tonsils	touch uvula
4 tonsils	touch each other
childbearing women sinuses	epistaxis, bleeding gums, nasal congestion
right lung	3 lobes
xiphoid process	above costal angle, 90 degrees, increases during hyperventilation and emphysema
landmark for lung and thorax assessment	costal angle, for people who retain oxygen, COPD angle changes
suprasternal notch	U shaped
resonance	percussed over normal lung tissue
hyper resonance	COPD, more air, pneumothorax
crepitus	crackling when air passes through subcutaneous tissue
increased fremitus	pneumonia
decreased fremitus	pneumothorax, pleural effusion
bronchial breath sound	high pitch, trachea area, short inspiration, long exhalation
broncho vesicular breath sound	bronchi, scapulae, sternum
vesicular breath sound	peripheral lung field
crackles sound	bronchitis, asthma, emphysema
coarse crackles	low pitch bubbling, pneumonia, pulmonary edema, velcro rales
pleural friction rub	grating sound, pleuritis, severe dehydration
stridor	harsh, honking wheeze, medical emergency, airway blockage
wheeze	airway obstruct
sibilant wheeze	asthma and emphysema
sonorous wheeze	bronchitis, sleep apnea
pectus excavaum	funnel chest
pectus carinatum	pigeon chest
carbon dioxide	strongest thing to regulate breathing pattern
hypercapnia	strongest stimulus to breath
tachypnea	more than 24 breaths per minute, not able to perfuse, trying to compensate
bradypnea	less than 10 breaths per minute, can be medication induced
hypoventilation	decreased rate, irregular pattern, drug overdose
dyspnea	difficulty breathing
kussamul	rapid, deep, labored, diabetic ketoacidosis
cheyne stokes	increased intracranial pressure, congestive heart failure, deep rapid breathing followed by period of apnea
chronic bronchitis	labored and noisy, occasional coughing
rust colored sputum	tuberculosis
breast function	produce and store milk, aid in sexual stimulation
glandular tissue	milk production
fibrous tissue	supports glandular tissue
fatty tissue	size and shape
lymph nodes	filter debris and return water and protein
anterior lymph node	chest wall and breasts
posterior lymph node	chest wall, part of arm
central lymph node	receive drainage, most palpated (high in axillae at top of ribs)
lateral lymph node	drain most of arms, brachial
peau d orange	orange peal appearance, associated with cancer
suggest malignancy of breast	dimpling, restricted breast tissue, retracted nipple
paget disease	redness and flaking of nipple, eczema scaly skin around areola
mastitis	red, painful, warm
cancerous tumor	irregular, firm, hard, fixed
fibroadenomas	lobular, ovoid, round and seldom tender, between puberty and menopause
benign breast disease	round, elastic, defined, tender and mobile cysts
asymmetrical breasts	benign
fibrocystic breast disease	premenstrual breast lumpiness and soreness subside after end of menstrual cycle
child breast	occurs in 5 stages, starts at puberty
breast cancer	lump, thickening of breast, discharge, bleeding, size change, BRCA1 or 2
increases risk for breast cancer	high fat diet
SNS stimulation	increased cardiac output, increased blood pressure, increased heart rate
AV valves	tricuspid and bicuspid , first heart sound s1 at closure
SV valves	pulmonic, aortic
electrical conduction	SA node, AV node, bundle of His, bundle branches, purkinje fibers
SA node	60 - 100, pacemaker of the heart
AV node	intrinsic rate of 40 - 60
preload	amount of blood in ventricles at end of diastole, stretch
systole	blood in ventricles, pressure causes AV valves to close, SV open and blood is ejected
diastole	AV valves open, ventricles relax, takes two thirds of cardiac cycle
afterload	pressure against blood ejection during contraction
murmurs	increased blood viscosity, valve disorder, malfunction, abnormal chamber opening
thrills	vibration turbulence
stenosis	narrowing
sinus arrythmia	rate speeds with inspiration, slows with exhalation
dizziness	fall risk
smoking cessation	ask, advise, assess, assist, arrange
carotid	auscultate then palpate, use bell of stethoscope, client hold breath
apical pulse	best heard at apex if not left lateral
pulsus alternans	changes in strength and amplitude
paradoxical pulse	decreased amplitude, pericardial tamponade, obstructive lung disease
orthostatic hypotension	assess lying, sitting, standing, blood pressure decrease when standing
veins	carry deoxygenated blood back to heart
deep veins	femoral and popliteal
right side of the heart	pumps blood to lungs for gas exchange
left side of the heart	receives oxygenated rich blood and pumps systemically
allen test	patency of radial and ulnar arteries
arterial insufficiency	pain, pulselessness, paralyze, paresthesia, pallor, poikilothermy, cool to cold, dry and shiny
arterial insufficiency ulcers	tips of toes, heels, very painful, circular deep black and gangrene
venous insufficiency	aching, cramping, present pulse, edema, thick and tough skin reddish to blue
venous insufficiency ulcers	medial malleolus, anterior tibial, irregular border superficial, beefy red to yellow fibrinous
peripheral artery disease	atherosclerosis
atherosclerosis	narrowing arteries due to plaque buildup, reduces blood flow
lymphadema	damaged or blocked lymphatic circulation, buildup of lymph fluid
edema	increased capillary blood pressure, venous insufficiency, decreased plasma proteins, decreased colloid osmotic pressure
raynaud	vascular disorder, constriction or spasms
thrombophlebitis	infection, inflamed, warm
RUQ	liver, dullness percussed
RLQ	colon, large intestine, appendix
LUQ	spleen
LLQ	sigmoid colon, left kidney
suprapubic region	hypogastric, bladder pain
visceral pain	hollow abdominal organs become distended or contract forcefully
parietal pain	appendicitis, peritonitis; sharp and severe
diarrhea	frequency of bowel movements
blood and mucus stool	inflammatory bowel disease
clay colored stool	fatty, malabsorption
hyperactive bowel sounds	rapid mobility, diarrhea, borborygmus (growling)
hypoactive	diminished bowel activity, paralytic ileus, late bowel obstruction
abdomen assesment	empty bladder, begins in RLQ, inspect, auscultate, percuss, palpate
kidney percussion	costa vertebral angle
crohn's disease	cramping, diarrhea, nausea and vomitting, weight loss
psoas sign	pain in RLQ when leg hyperextended, appendicitis
obturator sign	pain in RLQ when hip and knee flexed and leg rotated
murphy sign	pain when pressure applied at liver border, inflamed gallbladder
rovsing sign	pressure in LLQ causes pain in RLQ
blumberg sign	rebound tenderness
cullen sign	discolored umbilical, bluish purple
grey turner	blue abdominal flanks
scaphoid	sunken abdomen
cirrhosis	liver edge firmness
stomach emptying post op	24 - 48 hours
large intestine emptying	3 to 4 days
scoliosis	lateral curvature of spine, convexity increase on one side
kyphosis	rounded thoracic cavity, hunchback
decline in height	5th decade of life, thinning intervertebral discs
lordosis	J curve, pregnancy, lumbar curve
non weight bearing	no weight on affected limb
toe touch bearing	limb affected can be used for balance
partial weight bearing	small % of weight on affected limb
tolerated weight	client level of comfort
full weight bearing	no restriction
cerebellar ataxia	wide base, staggering, unsteady
spastic hemiparesis	flexed arm held close while toe drags
stereognosis	identify objects placed in hand
graphesthesia	correctly identify number traced on skin
cranial nerve 5	sensory and motor, clenching jaw
swallowing cranial nerves	IX and X
brudinski sign	flex neck and knees flex
kernig sign	flex hip and knee then straighten
penis inspection	skin, shaft, foreskin, scrotum, lift scrotal area and assess skin
hypospadias	urethral meatus underneath glans
epispadias	urethral meatus on top of glans (dorsal)
hyrdocele	collection of serous fluid in scrotum, transillumination
testicular tumor	small, firm, non tender nodule, heavy feeling
scrotal hernia	loop of bowel protrudes into scrotum
epididymitis	infection, scrotum enlarged, red and tender
vaicocele	dilation of veins on the spermatic cord, discomfort, bag of worms
spermatocele	sperm filled cysts, mass on epididymis, movable above testes
hemorrhoid	painless papules caused by varicose veins, bleed with bowel movement
perianal abcess	cavity of pus, infected skin around anal opening, throbbing pain and red
anal fissure	splits in tissue, pain, itching, bleeding
rectal prolapse	rectum protrudes out anal opening, doughnut like
rectal polyps	pedunculate on stalk, sessile on mucosa
prostate cancer	2nd most common, hard and fixed, median sulcus not palpable
colorectal cancer	3rd most common, colonoscopy at age 45, african american high risk
colorectal cancer signs	abdominal pain, blood in stool, bowel habit change, weight loss, fatigue
vagina	acidic environment prevents infection
bartholian's glands	lubricate
cervix	seperates vagina and uterus, firm and soft, pink
red cervix	inflammation
blue cervix	pregnant (chadwick's)
pale cervix	anemia, post menopause
uterus	round, firm, smooth
corpus	bosy, muscular
hemorrhoid education	high fiber diet, hydration
trichomonas vaginalis	frothy yellow, green discharge
bacterial vaginosis	thin, white, fishy odor
candidal vaginitis	white cottage cheese discharge, yeast infection
mucopurulent cervicitis	yellow discoloration
uterine prolapse	uterus and cervix come out together descending into vaginal cavity
cystocele	bladder prolapses through vagina
rectocele	rectum into vagin
cervical polyps	polyps of endometrial cells arising from either uterus or cervix
retroversion	posteriorly turned
anteflexion	turned anterior
retroflexion	fundus bends posteriorly
cervical cancer diagnosis	PAP smear, treatable
cervical cancer risk factors	HPV, smoking, pregnancy, younger than 17, family, multiple partners
cervical cancer signs	pelvic pain, vaginal bleeding, discharge, cauliflower lesions
general survey information	appearance, vital signs, body measurements
mental status exam	LOC, orientation, cognitive
IV assesment	needed, working, pain, dressed, infected
complications of IV	phlebitis, infiltration, extravasation, dislodgment
room air	21%
nasal cannula	low flow, low concentration
non rebreather	low flow, minimum rate of 10 L/min, one way valve
non rebreather disadvantage	malfunction cause suffocation because of increased CO2 level
venturi	high flow, specific amount of oxygen without drying mucus membranes
hypoxia	inadequate amount of oxygen available to perfuse cells
coughing	removes mucus and secretions
deep breathing	inflates alveoli, improves lung expansion, oxygenation of tissues
incentive spirometry	increases lung volume and inflation of alveoli
humidification	distilled water
breast self exam	monthly, right after menstrual cycle
amennorhea	absence of menses
menopause	48 - 52
upper outer quadrant	most common area of breast tumors

Created by: ahommel

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