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137 Cards in this Set

  • Front
  • Back
Problems that are urgent or life threatening.
first priority
Problems that require your prompt intervention to forestall further deterioration.
second level priority
What is the mnuemonic for first level priority problems and their meanings?
A airway
B breathing
C circulation
S vital Signs
What is the mnuemonic for second level priorities and their meanings?
M mental status change
A acute pain
A acute urinary elim probs
U untreated med problems immed attention
A abnormal lab values
R risk of infection, safety, security
What is the nursing process?
ADOPIE assessment diagnosis outcome identification planning implementation evaluation
What is a clinical judgement about a person's response to an actual or potential health state?
nursing diagnosis
existing problem that is amenable to independent nursing interventions
actual diagnosis
potential problems that an indiviual is vulnerable to developing
risk diagnosis
focuses on strengths and reflects an individual's transition to higher level of wellness
wellness diagnosis
used to evaluate etiology of a disease
medical diagnosis
database that makes sure complications are not developing with chronic illness
follow up database
what are you allergic to and get to work database
emergency database
What are the leading causes of death among birth to 10 years?
1. conditions originating in perinatal period
2. congenital anomalies
3. sids
4. unintentional injury
5. motor vehicle injury
What are the leading causes of death in ages 11-24 years?
1. motor vehicle or unintentional injuries
2. homicide
3. suicide
4. malignant neoplasms
5. heart disease
What are the leading causes of death in ages 25-64 years?
1. malignant neoplasm
2. heart disease
3. motor vehicle unintent accidents
4. hiv
5. suicide and homicide
Leading causes of death 65 and older?
1. heart disease
2. malignant neoplasm (lung colorectal and breast)
3. cerebrovasc disease
4. copd
5. pnuemonia and the flu
Percent of population considered minorities.
50%
Percent of blacks in us
13.2
Percent of hispanics
24.3
percent of asian
8.9
percent of native americans
.8
How does the biomedical model of Western tradition view health?
abscense of disease
What does a complete or total health data base consist of?
complete health history and full physical exam
What does a episodic or problem centered database consist of?
one problem short time period
What are some abnormal findings for age?
looks older that states age maybe from alcholism or illness
What are the four general areas to consider in a general survey?
1. physical appearance
2. body structure
3. mobility
4. behavior
How should a patient be measured?
erect, no shoes, looking straight forward
What is obesity considered?
greater than 120% ideal body weight
Where is temp regulated in the brain?
hypothalamus
What is the range of normal oral temp?
96.4-99.1
Leading causes of death 65 and older?
1. heart disease
2. malignant neoplasm (lung colorectal and breast)
3. cerebrovasc disease
4. copd
5. pnuemonia and the flu
Percent of population considered minorities.
50%
Percent of blacks in us
13.2
Percent of hispanics
24.3
percent of asian
8.9
percent of native americans
.8
How does the biomedical model of Western tradition view health?
abscense of disease
What does a complete or total health data base consist of?
complete health history and full physical exam
What does a episodic or problem centered database consist of?
one problem short time period
What are some abnormal findings for age?
looks older that states age maybe from alcholism or illness
What are the four general areas to consider in a general survey?
1. physical appearance
2. body structure
3. mobility
4. behavior
How should a patient be measured?
erect, no shoes, looking straight forward
What is obesity considered?
greater than 120% ideal body weight
Where is temp regulated in the brain?
hypothalamus
What is the range of normal oral temp?
96.4-99.1
How does the rectal thermometer differ from oral?
.7 to 1 degree higher
What are the four factors that influence temperature?
1. exercise
2. diurnal cycle
3. age
4. menstruation
How long should one wait to take a mercury temp if smoke or eat/drink?
smoke-2 min
eatdrink- 15
How far should a rectal thermo be inserted?
1 inch. on adult
1 cm on infant
Another word for fever
hypertherima
Another word too long exposure to cold
hypothermia
What should you shake a mercury thermo down to and how long should you place it for?
3-4 mins at 35.5
What is the conversion formula for determining celsius?
c= 5/9(f-32)
What is the conversion formula for determining fahrenheit?
f=(9/5X C) +32
How much stroke volume in adult?
about 70 ml
What is amount of blood pumped into aorta?
stoke vol
WHat should you do if you have an irregular pulse?
count for full minute
What is the normal rate of bpm in adults?
60-100
How are pulse rates different in infants, women, and adult yrars?
adult- moderate
infant-high
women-high
WHat is the force flare of the arterial walls that is ejected from the contraction of the heart?"
pulse
What is a heart rate less than 60 bpm in an adult but is considered normal in a well trained athlete?
bradycardia
WHat is the bpm of over 100?
tachycardia
What is sinus arrhytmia and who is it found in?
athletes and children...speed up and slow down pulse
What indicates the strength of the heart's stroke volume?
pulse-force
What is the scale for pulse force?
0-3 2 is normal
How many respirations are normal?
10-20
What is the max pressure on the artery during left ventricular contraction?
systolic pressure
What is the pressure on the vessel walls during rest?
diastolic pressure
What is pulse pressure?
the difference between the systolic and diastolic pressures
What does pulse pressure reflect?
stroke volumes
What is the pressure forcing blood into tissues averaged over the cardiac cycle?
mean arterial pressure
What are the 8 factors that influence bp?
1. age
2. gender
3. race
4. diurnal rhythm
5. weight
6. exercise
7. emotions
8. stress
How is female bp different than male bp?
lower after puberty and higher after menopause
What are the five factors that affect the level of blood pressure?
1. cardiac output
2. peripheral vascular resistance
3. volume of circulation blood
4. viscosity
5. elasticity of blood vessels
What could be occuring if a bp is taken of both arms and their is a 10-15 mm hg difference?
arterial obstruction on side of lower reading
What is a period when kortokoff's sounces disappear during ausculation?
ausculatory gap
Tapping...
phase 1
SWOOSHING
PHASE 2
KNOCKING
3
ABRUPT MUFFLING
4
SILENCE
5
WHAT SHOULD YOU DO IF A VARIANCE GREATER THAN 10-12 MM HG BETWEEN PHASE 4 AND 5?
RECORD BOTH
WHAT IS A DROP IN SYS PRESSURE OF MORE THAN 20 MM HG THAT OCCURS WITH STANDING OR PULSE INCREASE 20 BPM?10-
ORTHOSTATIC HYPOTENSION
WHAT OCCURS IN A CUFF IS TOO NARROW OR TOO LARGE?
LARGE-LOW READING
SMALL- HIGH READING
WHEN ARE ORTHOSTATIC VS TAKEN?
VOL DEPLETION, KNOWN HTN ON MEDS TO TREAT, DIZZINESS OR SYNCOPAL EPISODE
WHAT SHOULD RAISE CONCERNS WHEN DETERMINING ORTHOSTATIC VS?
A DECREASE OF GREATER THAN 10 MM HG IN BP AND PULSE INCREASE OF GREATER THAN 20 BPM
WHAT IS ORTHOSTATIC HYPOTENSION DUE TO AND WHERE IS IT COMMONLY FOUND?
DUE TO ABRUPT PERIPHERAL VASODILATION WITHOUT COMPENSATORY INCREASE IN CARDIA OUTPUT...PROLONGED CBR, ELDERLY, HYPOVOLEMIA, AND SOME DRUGS1
HOW MUCH HIGHER IS THIGH BP THAN ARM?
10-40
WHAT SHOULD YOU WEIGH AN INFANT TO THE NEAREST UNIT?
10 G OR 1/2 OZ
WHAT AGE SHOULD YOU BEGIN USING UPRIGHT SCALE ON KIDS?
2-3
WHAT AGE SHOULD YOU USE THE HORIZONTAL MEASURING METHOD?
AGE 2
SHOULD YOU USE A TAPE MEASURE TO MEASURE A CHILD?
NO, INNACURATE
HOW LONG SHOULD YOU MEASURE HEAD CIRCUMFERENCE AND HOW LONG AFTER THAT?
EVERY WELL VISIT UNTIL 2 YEARS..THEN YEARLY UNTIL 6
WHAT IS THE NUMBER OF WEEKS FROM THE FIRST DAY OF THE MOTHER'S LAST MENSTRUAL PERIOD TO THE NEWBORN'S DATE OF BIRTH
GA
WHAT IS NORMAL GA?
38-42 WEEKS
HOW CAN YOU ASSESS GA?
NEW BALLARD SCORE- 6 NEUROMUSCULAR AND 6 PHYSICAL SIGNS
WHAT IS THE ORDER OF VS IN INFANTS?
RESP, PULSE, TEMP
WHAT KIND OF PULSE SHOULD BE PULPATED WITH INFANTS AND TODDLERS?
APICAL
HOW MANY RESP RATES ARE IN NEONATES?
30-40
WHEN SHOULD BP BE STARTED AND HOW OFTEN?
AGE 3..ANNUALLY
WHAT ARE THE BP CUFF REQUIREMENTS FOR PEDS?
CUFF MUST COVER 2/3 OF UPPER ARM AND MUST COMPETELY ENCIRCLE
WHAT ARE THE NUMBERS FOR PRE-HYPERTENSION?
120-139 S AND 80-89 D
WHAT ARE THE NUMBERS FOR STAGE 1 HYPERTENSION?
140-159 S AND 90-99 D
WHAT ARE THE NUMBERS FOR STAGE 2 HYPERTENSION?
GREATER THAN OR EQUAL TO 160 S OR GREATER THAN EQUAL TO 100
What are the four characteristics of culture?
1. learned from birth through the processes of language and social
2. shared by member
3. adapted to spec conditions related to enviro and tech factors to the avail of resources 4. dynamic
refers to desirable or undesirable state of affairs
value
what is a basic value orientation that is shared by the majority if its members as a result of early common experiences
dominant value orientation
existance in which emphasis is on the spontaneous expression of impulses and desires because they viewed as integral part of personality
being
inner control, meditation, and detachment are emphasized as ways to achieve self realization
being in becoming
active striving and accomplishment are paramount as the individual competes against externally applied standards of achievement
doing
relationship exist by virtue of heredity and kinship ties
linear
group goals and family orientation is all important
collateral
husband wife and children from previous relationships
blended family
unmarried men or women sharing house with children
cohabitation
group of men women and children
communal
cause of illness that is based on the assumption that all events in life have a cause and efffect that the human body funvtions like a car........
biomedical
human life is only one aspect of nature and a part of the genreal order of the cosmos
naturalistic
health believed to exist when all aspects of the person are in perfect balance
ying yang theory
represents female and negative forces
ying
postive warm male
yang
treatment consists of adding or subtracting cold heat and dryness or wetness to restore the balance of the humors
hot cold theory
illnesses such as earache, chest cramp, prarlysis, gi discomfort, rheumatism, tb
cold illness
illness abcessed teeth, sore throat, rash, kidney disorder
hot illness
sabedor, yerbo, espritualista, curandero
hispanic folk healer
hougan
voo doo priest
interview contract includes what 8 things?
1. time and place
2. intro of urself
3. purpse
4. how long
5. expectations
6. prescence
7. confidentiality
8. costs
four verbal responses that express your own thoughts and feelings
confrontation, summary, interpretation, explanation
what is related to avulsion
laceration
what is related to purpura
petechia
what is a collection of blood that is often but not always caused by blunt force traumaq
hemotoma
common medications that increase the risk of bruising or bleeding complications include..
aspirin, ibuprofen, anti-inflammatory antisteroidal drugs, vitamins, herbs
wound caused by rubbing the skin or mucous membrane
abrasion
the tearing away of a structure or part
avulsion
hemohaggic spot or blotch in the skin or mucuous membrane forming a rounded or regular blue purplish patch....
ecchymosis
a localized collection of extravasated blood clotted in organ space or tissue
hemorrhage
minute pinpoint nonraised perfectly round purplish red spots caused by intradermal or submuccous hemorhagge...
petechiae
loss of hair due to pulling or yanking
traumatic alopecia