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nur101 exam2
| Question | Answer |
|---|---|
| Jaundice | yellow (sclera) r/t impaired bilirubin |
| cyanosis | blue (mouth, nailbeds)decreased oxygen |
| erythema | redness (local or widespread) |
| Edema | excess fluid in tissue |
| trace edema 1+ edema 2+ edema 3+ edema 4+ edema brawny | not measurable 2mm 4mm 6mm 8mm warm, weeping, shiny, tight |
| turgor | elasticity (dehydration) |
| brisk turgor | normal |
| sluggish turgor | tenting of skin |
| symptom analysis "Old Carts" | onset, location, duration, characteristics, aggravating/alleviating systems, related symptoms, treatment, severity |
| Symptoms analysis "coldspa" | character (feel, sounds, smell, etc), onset, location, duration, severity, pattern, associated factors |
| Importance of nutrition and metabolic health pattern | deficiencies may explain other problems, fluid intake important, problems related to underweight/obesity, skin is line of 1st defense against infection, HC treatment may interfere with cellmatabolism, |
| essential nutrients | water, electrolytes, minerals, vitamins & protein for tissue building |
| daily calorie requirement for men/women | 2800/2000 |
| carbohydrates, fats, proteins & alcohol | help provide energy and support metabolic processes |
| nutrients | supply the body with necessary elements for growth, maintenance, and repair |
| macronutrients | carbohydrates, protein, fats |
| metabolism | process of producing and using energy within body cells |
| plays major role in metabolism | thyroid hormones |
| ways energy is used in the body | breathing, circulation, nervous system function |
| Basal Metabolic Rate (BMR) | the amount of energy required for essential life processes |
| BMR is measured by | when the body is physically, metabolically and emotionally at rest |
| BMR is influenced by these factors | activity, hormonal imbalance, temperature, stress, and illness |
| Metabolic processes | Anabolism, catabolism |
| anabolism | cell building, fat(adipose tissue), |
| catabolism | breaking down of cells and tissues |
| normal body mass index (BMI) | 18.5-24.9 |
| Nutritional processes | Ingestion, digestion, absorption, transport, metabolism |
| ingestion | nutrients taken into the gastrointestinal (GI) tract |
| digestion | breakdown of ingested nutrients to be absorbed by the body. |
| digestion process | begins in mouth (chewing saliva), peristalsis to stomach, to small intestines. |
| major digestive area | stomach |
| absorption | passage of digested food from gi tract to the blood or lymph circulation |
| place where most nutrients and electrolytes are absorbed | small intestines |
| transport | movement of nutrients across the cell membrane |
| metabolism | final process of nutrition. energy is produced and used in the body cells |
| Lab assessment for metabolism positive balance | more consumed than excreted |
| lab assessment for metabolism negative balance | intake less than output |
| lab tests | 24 hour urine. bun blood test (albumin and protein) |
| 1st line of defense | skin |
| functions of skin | protects underlying tissues and organs. also plays a role in maintaining temp, fluid/electrolyte balance, absorption, excretion, immunity, vit D synthesis, id of one's appearance. |
| layers of skin | epidermis, dermis, subcutaneous |
| epidermis | outer layer of skin |
| dermis | connective tissue and blood vessels |
| subcutaneous | connective tissue infiltrated with fat, blood vessels, nerves, and glands |
| Decubitus ulcers | pressure sores |
| stage 1 pressure sore | redness, blood stasis, warm to touch |
| stage 2 pressure sore | epidermal loss, possible damage to dermis |
| stage 3 pressure sore | fullthickness skin loss, sero-sanguinous or purulent drainage common |
| stage 4 pressure sore | full thickness, deep into connective tissue, muscle, bone. may have necrosis. may need debridement. |
| factors affecting wound healing | need adequate proteins, normal albumin, hemoglobin, hematocrit and transferrin levels |
| s/s of impaired wound healing | increased redness & swelling, pus formation, dehiscence (wound edges break loose), wound color changes, decreased granulation tissue |
| Lymphatic system/lymph nodes | act as filters of lymph fluid |
| location of lymph nodes | head, neck, breast, axilla, inguinal, clavicle & popliteal areas |
| lymphadenitis | inflammation of lymph nodes (painful) |
| lymphangitis | inflammation along the course of lymphatic vessel |
| lymphedema | lymph tissue swelling |
| largest endocrine gland | thyroid gland |
| thyroid gland controls | metabolic rate hormone production and secretion |
| hormones secreted by thyroid gland | t3(thyronine), t4, calcitonin |
| T3 hormone | increases BMR, increases chemical reaction rates, increase heat production, stimulates metabolism of essential nutrients, promotes human growth, short life span |
| T4 hormone | same function as T3, can be converted to T3, secreted in greater amounts, longer life span than T3 |
| calcitonin | calcium metabolism |
| daily requirement of iodine | 100-200 mcg from bread, salt, seafood, milk, eggs |
| parathyroid glands are located | posterior surface of thyroid gland |
| parathyroid glands regulate | calcium, phosphorus metabolism |
| signs of hyperthyroidism | exopthalmus (big eyes), weakness, fatigue, diaphoresis, tachycardia, chest pains, dysrhythmias, increased blood pressure, weight loss, increased appetite, diarrhea, or constipation, restless, nervous, insomnia, irritable, hyperactivity |
| signs of hypothyroidism | myxedema, decreased cardiac output and conduction, enlarged heart, decreased blood pressure, atherosclerosis (fat in blood vessels), increased cholesterol, lethargy, fatigue, slow speech, thick tongue, deep voice, weight gain, decreased appetite, constipa |
| other skin related problems | diabetes, liver, renal, cancer, fluid imbalance, impaired O2, peripheral vascular disease, skin infections |
| oral cavity | mucus mucosa, salivary glands, tongue, gums/teeth, palate |
| mucus mucosa | keeps mouth hydrated, aids in digestion, chemical barrier to trauma and infectious organisms |
| salivary glands | secrete up to 1500 ml/day, provides moisture, initiates starch breakdown |
| tongue | taste buds, moves food with saliva, initiates swallowing |
| palate | forms the roof of the mouth (hard and soft) |
| oropharnyx | moves food into the esophagus |
| questions for interviewing | diet, weight problems, ingestion problems, food and fluid intake nausea and vomiting, preferences, activity levels, psychosocial, cultural and personal influences, nutrition knowledge, physical changes |
| Physical Assessment - assess for: | subcutaneous fat, muscle mass, height, weight, skin integrity, hair, nails, oral cavity, abdomen, thyroid gland, body temp |
| skin assessment | color, pigment, moisture, temp, texture, thickness, turgor, mobility, hygiene, lesions |
| hair assessment | color, pigment, quantity, texture,distribution, hygiene |
| nail assessment | shape,configuration, color, lesions, thickness, cap refill |
| normal shape of nail | 160 degree angle |
| abnormal findings of nails | clubbing, spooning, cyanosis |
| normal cap refill of nails | <3 seconds |
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