Module 1 and 2 patient centered care.
Atrophy
(n.) the wasting away of a body organ or tissue; any progressive decline or failure; (v.) to waste away
Hypertension symptoms
-Typically asymptomatic -Headache- uncommon but occurs in the back of the head and person wakes up with it. -Other symptoms relate to target organ damage: -Brain- CVA -Kidneys- loss of ability to concentrate urine -Heart- Heart failure, CAD, sudden death -Circulatory- peripheral vascular disease
Pain
-algia, -dynia
What is patch testing?
-allergy testing -small amount of substance placed on skin in shallow cups ("Finn chambers")--> papular vesicular reaction within 48-72 hours
High blood pressure Stage 1 hypertension
140/80-89
Stage 2 hypertension
140/90 or higher
Hypertensive crisis measurements
180/120 or higher
Why might a 2 year old develop lead poisoning?
2 years explore by putting things in their mouth which could contain lead dust particles.
How high should a mechanical lift be raised during transfer?
3-4 inches to clear the mattress.
Serum albumin
3.5-5.5 g/dL. It's a protein made by the liver.
What muscle strength would the nurse record for a patient with full ROM with resistance?
4 is with slight resistance. 5 is full strength. 0 no contraction 1 visible contraction but no movement. 2 limb movement but not against gravity. 3 movement against gravity not resistance.
Friction
A force that opposes motion between two surfaces that are in contact
Third degree burn
A full-thickness burns that involve the epidermis, dermis, and varying levels of the subcutaneous and underlying structures. Fatty white or brown color, dry leathery texture. Little to no pain.
Second degree burn
A partial-thickness burn involving the epidermis and the dermis. Red, moist with blisters.
What kind of wound involves the epidermis and dermis but not the subcutaneous layer?
A partial-thickness wound.
Hypertensive crisis
A severe elevation in blood pressure (greater than 180/120 mm Hg) that can cause damage to organs such as the kidneys or heart.
What is a chronic wound?
A wound that fails to progress to healing in a timely manner, often remaining open for an extended period of time
What is a closed wound? Open wound?
A wound that has no breaks in the skin surface, while an open wound would.
What is an acute wound
A wound that progresses through the phases of wound healing in a rapid, uncomplicated manner
What is the pneumonic for early malginant melanoma screening.
ABCDE Or Assymetry Border that is irregular. Color that is uneven Diameter that is usually as large as a pea Evolving or changing over time.
What is a partially movable joint called?
Amphiarthrosis joint
Suspected deep tissue pressure injury
An area of intact skin that is purple or maroon or a blood-filled blister
What effect can low potassium have on the heart?
Cardiac dysrhythmia
Wound cultures
Cultures identify the organisms causing infection. Because some bacteria are present on healthy skin, normal skin flora may be identified in wound cultures along with any pathogenic bacteria.
orthostatic hypotension
Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions
DASH diet acronym
Dietary Approaches to Stop Hypertension.
Lipids
Energy-rich organic compounds, such as fats, oils, and waxes that can be measured in the blood.
Whats the term for a total seperation of tissue layers allowing visceral organs to protrude through the incision.
Evisceration
Friction vs shear
Friction: when one object moves against another Shear: when one object moves but a part of them doesn't
stage 4 pressure ulcer
Full-thickness tissue loss with exposed bone, muscle, or tendon
FIM scale
Functional independent measurement scale. For example 1 is total dependence. 2 is Max 25% 3. Is mod 50% 4. Min /CHA 75% 5. Sup/SBA No contact. 6. Mod independent. 7. Independent
African Americans are at higher risk for what?
Increased risk of strokes, heart disease and kidney disease.
What is the initial phase of healing in which bleeding is reduced as the blood vessels constrict in the area?
Inflammatory stage.
The nurse recognizes that which advisory bodies aim to improve the quality, safety, efficiency, and effectiveness of health care? Select all that apply. One, some, or all responses may be correct.
Institute of medicine. National quality forumn. National center for nursing quality. Association for healthcare research/quality. Organizations that do not are the joint comission and centers for medicare.
Ischemia
Lack of blood supply
Adjuvant medications
Medications that are not primarily indicated for treatment of pain, but are used to augment pain relief medications
primary osteoarthritis
Most common form of arthritis, aging phenomenon, oligoarticular, 80-95% of people over 65 years -> more often in females, obesity, hereditary, secondary (trauma, neuromuscular dysfunction, metabolic disorders) -> hips in men, knees in women -> knees, hips, first metatarsal of foot and hands, lumbar and cervical vertebrae -> DIPs (Heberden's) and PIPs (Bouchard's) -> when it happens in fingers most often in women it is genetic
What change in an older patient would warrant teaching isometric exercises?
Muscular atrophy.
What is an approximated wound?
One that is closed with the wounds edges touching each other.
OLD CARTS
Onset Location Duration Characteristics Aggravating and Alleviating Factors Related Symptoms Treatment Severity
Breakthrough pain
Pain that occurs between doses of pain medication
Somatic pain
Pain that originates from skeletal muscles, ligaments, or joints.
Malignant hypertension treatment
Place patient in fowler position. Administer O2. Administer IV Beta blocker. Monitor BP Q15 minutes. until diastolic >90.
What is one safety measure that you might implement for a toddler?
Placing window guards on all windows. You would want to insure safety in the home environment first.
FDA pregnancy safety categories
Pregnancy Male reproductive potential Female reproductive potential Lactation.
What is granulation
Process of wound healing where new red tissue develops made up of blood vessels.
malignant hypertension
Rapidly progressive hypertension Diastolic pressure is usually >140 mm Hg Life-threatening organ damage
What is transmission?
Second phase of nociception where pain impulse moves from the spinal cord to the brain
Wound healing where edges can't be easily approximated and wound fills with granulation
Secondary intention
What are the primary labs to look for with tissue integrity?
Serum albumin, prealbumin levels.
first degree burn
Superficial burns through only the epidermis. Redness, dry mild blister.
What kind of wound involes just the epidermis?
Superficial wounds.
Opioid analgesics
Synthetic pain-relieving substances that were originally derived from the opium poppy, Naturally occurring opium derivatives are called opiates.
Systolic/diastolic bp
Systolic is the highest pressure on walls while diastolic is lowest.
What does a full thickness wound entail?
The dermis, epidermis and subcutaneous layer are all penetrated with bone and muscle possibly being involved.
Footdrop
The foot falls down at the ankle; permanent plantar flexion
What factor in neonates might contribute to drug toxicity?
The liver having not fully developed. The liver is responsible for ridding the body of toxic substances and filtering the blood.
What is the third phase of wound healing?
The maturation phase in which scar tissue forms.
What is the proliferative phase?
The phase in which the defect is repaired and new tissue begins filling in the skin begins to resurface.
Range of motion
The range through which a joint can be moved
Procedure in which a physician removes a sample of living tissue from the wound to identify infection
Tissue biopsy
Peripheral vascular disease
Vascular disease affecting blood vessels outside of the heart and especially those vessels supplying the extremities.
What interventin might a nurse use for a patient with decreased bone density
Weight bearing exercises.
Uses black light to identify presence of infectious organisms and proteins.
Wood lamps
Is it possible for laxatives to have an impact on drug therapy?
Yes it is, they can decrease the absorption of other drugs in the body.
secondary osteoarthritis
a degenerative condition superimposed on or preexisting joint problem like a congenital hip dislocations or trauma
Patient-controlled analgesia (PCA)
a drug delivery system that uses a computerized pump with a button the patient can press to deliver a dose of an analgesic through an intravenous catheter
Titration
a measured amount of a solution of unknown concentration is added to a known volume of a second solution until the reaction between them is just complete
Tunnel (sinus tract)
a narrower passageway extending outward from the edge of the wound
Physical dependence
a physiological need for a drug, marked by unpleasant withdrawal symptoms when the drug is discontinued
Visceral pain
a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera
Prealbumin
a thyroxin-binding protein measured to evaluate the nutrition status of critically ill patients who are at high risk for malnutrition. 15-36 m/gl.
What's a fistula?
abnormal connection between two organs or between an organ and the body surface.
arteriosclerosis
abnormal hardening of the walls of an artery or arteries
Isotonic exercise
activity that combines muscle contraction with repeated movement
ABC's of nursing
airway, breathing, circulation
What is a synarthrosis joint?
an immovable joint
Nonopioid analgesics
analgesics that are not classified as opioids like NSAIDS and acetaminophen.
sanguineous drainage
bloody drainage
Bruit
blowing, swooshing sound heard through a stethoscope when an artery is partially occluded
Rheumatoid arthritis (RA)
chronic joint condition with inflammation and pain; caused by an autoimmune reaction against joint tissue, particularly the synovial membrane
Serous drainage
clear, watery plasma
Atherosclerosis
condition in which fatty deposits called plaque build up on the inner walls of the arteries
Subcutaneous layer
connective and adipose tissue layer just under the dermis. Delivers blood to dermis.
What is transduction
conversion of one form of energy into another. In sensation, the transforming of stimulus energies, such as sights, sounds, and smells, into neural impulses our brain can interpret
Fourth degree burns
destroy all layers of skin and involve tendons, muscles, and sometimes bones. Dry charred, painless, brown color.
What is a freely movable joint?
diarthrosis joint.
Cellulitis
diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling
Analgesic
drug that relieves pain
Essential hypertension
elevated blood pressure of unknown cause that develops for no apparent reason; sometimes called primary hypertension
Chronic pain
episode of pain that lasts for 3 months or longer; may be intermittent or continuous
Undermining
erosion of tissue from underneath intact skin at wound edge
hyperlipdemia
excessive amounts of lipids in the blood
Isometric exercise
exercise in which muscle tension occurs without a significant change in muscle length
Contracture
fibrosis of connective tissue in the skin, fascia, muscle, or joint capsule that prevents normal mobility of the related tissue or joint
stage 3 pressure ulcer
full thickness tissue loss with visible fat
Secondary hypertension
high blood pressure caused by the effects of another disease
First aid for burns
immediate attention,cool water, clean dressing, elevate burn site above the heart to keep from swelling, treat for shock. Do not attempt to remove clothing where skin has been burned away. With third and fourth go to emergency room.
Spinal cord stimulation
implantation of a device into the epidural space to treat chronic neurologic pain by producing a tingling sensation that alters pain perception
Dash diet directives.
increase fruit, vegetables, and low fat dairy; k, mg, ca
Osteoarthritis
inflammation of the bone and joint
Pressure injuries
injuries or wounds that result from skin deterioration and shearing
Stage 1 pressure ulcer
intact skin with nonblanchable redness
Anaerobic exercise
intense short bursts of activity in which the muscles work so hard that they produce energy without using oxygen
Normal blood pressure
less than 120/80
Pain tolerance
level of pain a person is willing to accept
Disuse osteoporosis
loss of bone mass due to lack of activity
Flaccidity
loss of muscle tone, limp
Gait
manner of walking
Patient-controlled analgesia
medications administered intravenously by means of a special infusion pump controlled by the patient within order ranges written by the physician
Logrolling
method of moving a person as a unit, without disturbing the alignment of the body.
Serosanguineous drainage
mixture of serum and red blood cells
Multi-modal
more than two modes
Nocioceptive pain
normal process, sensing a noxious stimuli, perceiving as pain
Radiating pain
pain felt at the site of tissue damage and in nearby areas
Psychogenic pain
pain for which no physical cause can be identified
Neuropathic pain
pain from damage to neurons of either the peripheral or central nervous system
What is modulation
pain message is inhibited during this last phase of nociception
Phantom pain
pain or discomfort felt in an amputated limb
Nociceptors
pain receptors
Referred pain
pain that is felt in a location other than where the pain originates
Acute pain
pain that is felt suddenly from injury, disease, trauma, or surgery. Will be short term, less than 3 months.
Hemiplegia
paralysis of one side of the body
Dehiscence
partial or total separation of wound layers
stage 2 pressure ulcer
partial thickness skin loss involving epidermis, dermis, or both
Nociception
perception of pain
Albumin
protein in blood; maintains the proper amount of water in the blood
Serum Electrolytes
reported as mEq by Liter; most of the K in the body is inside the cells and its concentration is 3.5-5.0; the heart muscle is paticularly sensitive to high or low levels of potassium; abnormal levels can produce cardiac arrest; Sodium is 135-145
Maceration
softening of tissue by soaking
Placebo
something which has a positive mental effect, but no physical effect
Aerobic exercise
sustained exercise that increases heart and lung fitness; may also alleviate depression and anxiety
Elevated blood pressure
systolic: 120-129 diastolic: less than 80
Pain threshold
the point at which a person feels pain
What is perception?
the process of organizing and interpreting sensory information, enabling us to recognize meaningful objects and events
Active range of motion
the process whereby a patient puts a joint through its full extent of movement
Drug tolerance
the tendency for larger doses of a drug to be required over time to achieve the same effect
Passive range of motion
therapist putting a patient's joints through available range of motion without assistance from the patient
Necrosis
tissue death
What are the four physiologic processes?
transduction, perception, transmission, and modulation of pain.
Pott disease
tuberculosis of the spine
Transcutaneous electrical nerve stimulation (tens unit)
uses a device that delivers electrical impulses through the skin, which cause changes in muscles
Hemiparesis
weakness on one side of the body
What is tertiary intention
when a delay occurs between injury and closure
What is pertussis?
whooping cough caused by Bordetella pertussis. Contact precautions are droplet based.
WHat is primary intention
wounds that heal under conditions of minimal tissue loss