HM BMTC Unit 4 Basic Nursing

An age related decreased ability to focus on near objects
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Terms in this set (246)
Being perplexed or disconcertedConfusionAn acute mental disturbance characterized by confused thinking and disrupted attention usually accompanied by disordered speech and hallucinationsDeliriumUsually a progressive condition marked by deteriorated cognitve functioning often accompanied by emotional apathyDementiaPsychoneurotic or psychotic disorder characterized by sadness, inactivity, difficulty in thinking and concentration, a significant increase or decrease in appetite and time spend sleeping, feelings of dejection and hopelessness, and sometimes suicidal tendenciesDepressionA state of mind in which the person copes with and adjusts to the stresses of everyday living by behaving in ways acceptable to societyMental HealthUnconscious reactions that block unpleasant or threatening feelingsDefense MechanismsA disturbance in the ability to cope or adjust to stress; behavior and function are impairedMental IllnessA vague, uneasy feeling in response to stressAnxietyA response or change in the body caused by an emotional, physical, social, or economic factorStressChanges in vision can range from...partial to complete blindnessAn age related decreased ability to focus on near objectsPresbyopiaClouding of the lensCataractsAccumulation of fluid inside the eye exerts pressure on the optic nerve, eventually causing blindnessGlaucomaA gradual loss of acute, central, and color vision in the elderlyMascular DegenerationRinging in the earsTinnitusInfection of the middle earOtitis MediaCan damage the tympanic membrane or the ossicles; permanent hearing loss can occurChronic Ottitis MediaFluid builds up in the ear; pain and hearing loss can occurAcute Ottitis MediaA chronic disease of the inner ear characterized by an increase of fluid causing pressure in the middle ear. Tinnitus, hearing loss, and vertigo can occurMeniere's DiseaseDifficulty hearing normal conversations that ranges from mild to severe; deafness is the most severeHearing LossInability to hear high frequency sounds caused by genetic factors, prenatal abnormalities, trauma, and diseasesPresbycusis1.) Check the batteries 2.) Check to ensure it is "on" 3.) Check if the earpiece needs cleaningNursing interventions for patients experiencing problems:Paralysis characterized by motor or sensory loss in the lower limbs and trunkParaplegiaParalysis of the arms, legs, and trunk of the body below the level of an associated injury to the spinal cordQuadriplegiaParalysis of one side of the bodyHemiplegiaTrauma, spinal cord lesions, multiple, sclerosis, infections and abscesses of the spinal cord, and congenital defectsCauses of paralysisdecubitus ulcers, urinary tract infections, urinary calculi, and stiffening of the jointsLong term complications of paralysisWhy can't pillows, quilts, or soft toys be placed in a baby's crib?they can cause suffocationHow should a baby lay when they are sleeping?on their backsWhen can an infant lie on their sides and stomach?when they are awakeAn infant shouls always be restrained in acar seatSigns and symptoms of illness in infants include1.) Jaundice - yellowish color to the skin and eyes 2.) Redness or draining around the cord stump or circumcision 3.) High temperature 4.) Limp body, slow to respond 5.) Eating poorly 6.) Hard or watery stoolsHow many calories do young children need per day?1400 to 1800Immunization boosters are recommended between these ages...4 and 6 years; 11 adn 12 years oldBeing perplexed or disconcertedConfusionAn acute mental disturbance that is characterized by confused thinking and disrupted attention usually accompanied by disordered speech and hallucinationsDeliriumUsually a progressive condition marked by deteriorated cognitive functioning that is often accompanied by emotional apathyDementiaPsychoneurotic or psychotic disorder characterized by sadness, inactivity, difficulty in thinking and concentration, a significant increase or decrease in appetite and time spent sleeping, feelings of dejection and hopelessness, and sometimes suicidal tendenciesDepressionThe primary goal is to produce a feeling of well being in the confused and disoriented elderly patientPsychosocial measuresWhat are some examples of Psychosocial measures?1.) Reality Orientation 2.) Validation Therapy 3.) Reminiscence 4.) Remotivation Therapy 5.) ResocializationBehavorial management for the elderly includes...1.) Psychosocial measures 2.) Pharmacotherapy 3.) Family SupportA total or partial removal of an extremity, which is considered a surgical reconstructive procedureAmputationThe replacement of a missing body part by an artificial substituteProsthesisWhat are some conditions warranting an amputation1.) inadequate tissure perfusion 2.) severe trauma 3.) malignant tumors 4.) congenital deformitiesWhat are some causes of mental health disorders?1.) Inability to cope or adjust to stress 2.) Chemical imbalances 3.) Genetics 4.) Drug or substances abuse 5.) Social and cultural factorsWhat are two types of behavior?Adaptive and maladaptiveThe ability to cope with problems in ways considered appropriate by societyAdaptive behaviorThe behavior used to cope with a feelings and situations that are considered inappropriate to societyMaladaptive behaviorThis behavior type includes abuse and self abuse which are a negative action carried out on one's self or others.Maladaptive behaviorThis behavior includes being a good listener and letting the patient express their feelings, regardless of whether the patient is the one who was abused or the abuserNursing interventionsGiving insufficient attention, respect and care to someone who has a claim to that attentionNeglectWhat are the signs and symptoms of being neglected?1.) Lack of adult supervision 2.) Malnourishment 3.) Unsafte living environment 4.) Untreated chronic illnessThe intentional physical or emotional mistreatment or harm of another personAbuseA disturbance of the metabolism of carbohydrates and the use of glucose by the bodyDiabetesLow sugar in the bloodHypoglycemiaHigh sugar in the bloodHyperglycemiaThis type of diabetes is commonly seen in children and young adultsType 1This type of diabetes is characterized by a sudden onset and the inability of the pancreas to produce insulinType 1This type of diabetes requires daily insulin injectionsType 1This type of diabetes develops after the age of 40Type 2This type of diabetes is hereditary but can be treated with diet and exerciseType 2This type of diabetes develops during pregnancy and can lead to Type 2 diabetes later in lifeGastational diabetesUncontrolled diabetes can cause many problems such as1.) Retinal change leading to blindness 2.) Kidney disease 3.) Nerve damage 4.) Circulatory disordersA new growth of abnormal cellsTumorType of tumor that does not cause deathBenignType of tumor that is cancerous and death can occur if not treated or controlledMalignantMalignant tumors are divided into these two main groupsCarcinomas and SarcomasA malignant tumor that arise from epithelial tissue and can occur in the coverings of body partsCarcinomasA malignant tumor that arise in connective tissue and can occur in bone, muscle, cartilage, and other types of connective tissueSarcomasThe type of malignant tumor tends to affect primarily young people and metastasize rapidlySarcomasProcess used to describe the extent of diseaseStaging of tumorsStaging of tumors factors include1.) Size of the tumor 2.) Presence or absence of a capsule 3.) Evidence of metastasisThey list tobacco, exposure to radiation, alcohol, diet, chemicals and other substances as risk factors for tumorsNational Cancer InstituteThis is done to cure or control cancerSurgeryThis is used to destroy or retard cancer cell growth.RadiationGoals are to destroy the cancer cells without destroying too many normal cells and to cure the cancer or control the rate of cancer cell growthChemotherapyA condition in which there is a despression of cerebral function ranging from stupor to comaUnconsciousnessWhen a person can be aroused only briefly and only by vigorous external stimulationStuporWhen the eyes do not open upon stimulation, absence of comprehensible speech, and failure to obey commandsComaWhat are some causes of unconsciousness1.) Head injury 2.) Drug overdose 3.) Coma related to a disease process (liver disease, diabetes, etc.)What are some complications to unconsciousness1.) Infectious complications; pulmonary, urinary tract, and central nervous system 2.) Pressure ulcers 3.) Gastrointestinal bleedingSigns necessary to life are used to evaluate a patient's condition.Vital SignsA measure of the amount of heat below the skin and the subcutaneous tissuesTemperatureElevated body temperatureFeverWith feverFebrileWithout feverAfebrileBody temperature below the normal rangeHypothermiaBody temperature above the normal rangeHyperthermiaRegular, recurrent expansion and contraction of an artery produced by waves or pressure caused when the heart beats. The sensation can be felt when the fingertips lightly compress an artery against an underlying bonePulseAn abnormally rapid heartbeat; above 100 bpm in adultsTachycardiaAn abnormally slow heartbeat; below 60 bpm in adultsBradycardiaA weak and rapid pulseThready pulseAn unusually strong pulseBounding pulseA pulse with irregular rhythmArrhythmiaThe exchange of gasses between the atmosphere, blood, and body cellsRespirationThe act of taking air into the lungsInhalationThe act of expelling air out of the lungsExhalationLabored or difficult breathingDyspneaAbsence of breathingApneaExcessively rapid breathingTachypneaA measurement that consists of one inhalation and one exhalationRespirationThe force that circulating blood exerts against the arterial walls as the heart contracts and relaxesBlood pressureThe unit of measure for blood pressureMillimeters of mercury (mm Hg)Blood pressure is recorded in these two separate pressures in fraction formSystolic and DiastolicThe peak pressure exerted on the arterial walls during ventricular contraction at which point, the left is emptied.Systolic pressureThe pressure exerted on the arterial walls during ventricular relaxation at which point, the left ventricle is filled with blood.Diastolic pressureThe flow blood through tissues, providing them with oxygen and nutrients, and removing waste productsPerfusionAbnormally low blood pressure; may cause insufficient perfusion of internal organsHypotensionAbnormally high blood pressure; may cause rupture of the arteries and destruction of organsHypertensionWhat are some factors that increase vital signs1.) Exercise 2.) Eating 3.) Anger 4.) Stimulant DrugsWhat are some factors that decrease vital signs1.) Rest 2.) Depression 3.) Depressant Drugs 4.) AgeNormal oral temperature for the average adult98.6 Degress FNormal rectal temperature for the average adult99.6 degrees FNormal axillary temperature for the average adult97.6 degrees FNormal tympanic temperature for the average adult98.6 degress FNormal pulse for the average adult60 to 100 beats/minNormal pulse for the average child100 to 120 bpmNormal pulse for the average infant120 to 160 bpmNormal respiration rate for adults12 to 20 breaths per minuteNormal respiration rate for children20 to 40 breaths per minuteNormal respiration rate for infants25 to 40 breaths per minuteWhy do infants take in more breath per minutesmaller lung capacity and they are not fully developedMade of hollow glass stem and bulb filled with mercury or alcoholglass thermometerLong, slender bulb that is color-coded on the end opposite the bulb in the color blueOralA short, stubby bulb that is color-coded on the end opposite the bulb in the color redRectalRead out unit that produces an audible beep when the measurement is complete and displays the reading on the screenElectronic thermometerHeat sensitive patch or tape changes color at different rangesTemporal thermometerTransmits sound from patient's body to the examiner's earsStethoscopeEquipment used to take a patient's blood pressureSphygmomanometerOccurs when the blood pressure decreases rapidly in realtion to position changes from lying to sitting or standingOrthostatic hypotensionOrthostatic hypotension is commonly seen in patients with1.) Circulatory problems 2.) Dehydration 3.) Side effects to medicationWhat color ink is used for all entriesblackHow are temperatures greater than 100 degrees markedCircled and in redPulses are assumed to be _______ unless otherwise indicatedRadialA method of transferring a patient from a bed to a stretcher by grasping and pulling the loosened bottom sheet of the bedDraw-sheet methodA position in which the patient is sittingFowler's PositionA position in which the patient is lying on the sideRecovery PositionA position in which the patient's feet and legs are highter than the headTrendelenburg PositionExcercises performed by the patient with some assistanceActive-Assistant ExercisesExercises performed by the patientActive ExerciseExercises that are performed by motorized exercise machinery that keeps a joint in constant slow motionContinuous Passive Motion (CPM)A permanently flexed joint that occurs with shortened muscle tissueContractureThe circular movement of a limbCircumductionA position where that patient is lying supine with the knees flexedDorsal RecumbentA board placed at the foot of the bed that supports the feet at right angles to the bodyFootboardA position that results from raising the head of the bed to a 90 degree angleHigh FowlersA position where the patient is lying supine with the knees and hips flexedLithotomyA position that results from raising the head of the bed to a 30 degree angleLow FowlersExercises that are performed by the Corpseman/Technician when the patient is unable to move a body part independentlyPassive ExercisesThe degree to which a joint is moved by flexion and extension; defined by the degrees of a circleRange of Motion (ROM)A position that results from raising the head of the bed to a 45 degree angleSemi FowlersA side-lying position that has the patient on either side with the top leg flexed up toward the abdomenSimsThe patient is lying supine with the foot of the bed raised at a 45 degree angleTrendelenburg (shock position)Gives shape to a substance by pouring in liquid or plastic form into a mold and letting harden without pressure; a stiff dressing made of bandages soaked with plasterCastRealigning a broken bone by manual manipulation without incisionsClosed ReductionComposite structural material of plastic and fiberglass that is used in casting for children and elderly for light weight propertiesFiberglassRealigning a broken bone through surgery with incisionsOpen ReductionThe branch of medicine that is concerned with the correction or prevention of skeletal deformitiesOrthopedicsA pasty composition that hardens on drying, which is used in strips for castingPlasterAreas on the skin where the cast has been indented or pused in that may cause sores and skin breakdownPressure pointsA sore caused by pressure or rubbing against something for a period of timePressure UlcerA procedure used to reposition the ends of a broken boneReductionA soft, elastic, usually cotton fabric used especially for bandages and infants' wearStockinetinflammation of the veinPhlebitisblood clot moving in the bloodstreamEmbolusstationary blood clotThrombusinflammation of a vein associated with a thrombusThrombophlebitisThey require two patient identifier checksThe Joint Commission________ is contraindicated in children under 6 years of age, patients who are mouth breathers, individuals who have had oral or nasal surgury, or a patient who is unconscious or irrationalOral route_________ is contraindicated in patients with diarrhea or perineal/rectal surgery.Rectal routeInsert the sensing probe approximately ______ inches into the rectum of an adult.1 1/2Never use the _______ for taking a pulsethumbPulse located on the thumb side of the wristRadialPulse located medially to the antecubital space; this is the common site used for infants and toddlersBrachialPulse located in front of the earTemporalPulse located on the side of the neckCarotidPulse located on the left of the sternum and under the nippleApicalPulse that is auscultation onlyApicalPulse found in the groinFemoralPulse found in the posterior aspect of kneePoplitealPulse found on top of the footDorsalis pedisPusle found on the posterior to the medial malleolus (ankle bone)Posterior tibialisNumber of respirations per minuteRateRegular or irregularRhythmShallow or deepDepthBy auscultationSoundThe rating scale is from zero to ten with zero being no pain and ten eing the worse pain imaginableNumerical Rating Scale (NRS)Position the patient sitting on the side of bed with the legs an feet over the side.DanglingWhat is the purpose _________ is to gradually accustome the body to position changesDanglingThese are often used to transport an ambulatory patient to different areasWheelchairUsed by individuals with mobility disabilitiesGeriatric chairsWater temperature must be no greater than ____105 degrees FBedside _________ is used if a patient is able to get out of bed but too weak to walk to the bathroom.CommodeFour-point walking aids used by patients requiring added stability during ambulationWalkersProvide balance and support, and they are used when there is weakness on one side of the bodyCane_____ are used to prevent or limit weight bearing on a leg while healing takes placeCrutchesThe act of listening for sounds within the bodyAuscultationLying on the back, in the supine position, with the knees flexed; used for assessing the head and neck, anterior thorax and lungs, breast, axillae, heart, abdomen and extremitiesDorsal RecumbentA technique used in physical examination to carefully and critically examine the body using the sense of sightInspectionLying supine with the hips and knees flexed and the thighs abducted and rotated externally; used to assess the female genitalia and genital tractLithotomy PositionA technique used to assess texture, size, consistency, and location of certain parts of the body with the handsPalpationA technique in physical examination of tapping the body with the fingertips to evaluate the size, borders, and consistency of some internal organs, and to discover the presence of and evaluate the amount of fluid in a cavity of the bodyPercussionUsing the sense of smell during a physical examinationOlfactionA position in which a patient is in a side-lying position on either side, with the top leg flexed up toward the abdomen; used to assess the rectum and vaginaSim's PositionAn instrument used to examine the external ear, the eardrum, and the ossicles of the middle ear. It may be portable or wall mountedOtoscopeAn instrument used to check pupillary reaction to light and to inspect the inner eye. It may be portable or wall mountedOphthalmoscopeAn instrument used for listening to sounds produced within the body; can be used to auscultate the heart, lungs, abdomen, bowels, and blood pressureStethoscopeAn instrument used to assess the pupil's response to lightPenlight / FlashligtA rubber hammer used to assess reflexes, which is a gross assessment of the brain, spinal cord, or peripheral nerve impairmentPercussion / Reflex hammerA measuring device used to measure the circumference of an infant's head, obtain body length, obtain circumference of extremities or abdominal girth, and to collect specified body measurements for the calculation of body fate percentageTape MeasureA device used to obtain a patient's body weightScaleA bi-valved instrument, with two opening blades used for the inspection of the vaginal cavity. Basic medical corpsemen/technicians are not authorized to use the speculumVaginal SpeculumA water soluble agent capable of diminishing friction and making a surface slippery; used to lubricate the examiner's gloved hand when performing rectal or vaginal assessmentsWater Soluble Lubricant (KY Jelly)Gloves used during the examination of the buccal (oral) cavity, genitals, and perineal regionExam GlovesAn instrument used to measure a patient's blood pressureSphygmomanometerAn electronic instrument used to obtain a patient's body temperatureElectronic ThermometerA watch or a clock with a second hand is used to time the pulse and respirationsWatch or ClockA fine, very thin fabric, such as gauze, that is used during a physical exam to wipe off instruments; may also be used by patients to remove excess lubrican from membranes after the examinationTissuesA device that is used for recording the electric activity of the heartElectrocardiograph (EKG)One of several charts used in testing visual acuity; letters, numbers, or symbols are arranged on the chart in decreasing size from top to bottomSnellen ChartA small round mirror with a detachable handle that is used to view the oral cavity, reflect light, and retract the tongue and tissue, which protects the oral mucosa from injuryMouth MirrorAn instrument, with a sharp pointed end, used for exploring the mouth, which helps the examiner detect breaks in enamel (decay), check the severity of decay, and locate popcorn husks and toothpick fragmentsExplorerAn instrument with a long blunt working end calibrated with one to ten millimeter markings that is used to measure periodontal pockets in the gumsPeridiontal ProbeA tweezer-like instrument used to transport small items to and from the mouthCotton ForcepsA thin blade for pressing down the tongue during a medical examination of the mouth and throat.Tongue DepressorThis is performed for routine screening, to promote wellness behaviors, for preventive health care measures, to determine eligibility for military service, and to determine the need for admission to a hospital or long-term care facilityComplete Physical ExaminationThe examiner uses the assessments for the following1.) Gather baseline date regarding the patient's health 2.) Supplement, confirm, or refute previously gathered data 3.) Confirm and identify diagnosis 4.) Make clinical judgemnts about a patient's changing health status 5.) Evaluate the physiological outcomes of careWhat are the four basic skills involved in a physical examinationInspection, palpation, percussion, and auscultationThis skill should be used continually during the examination in order to observe for normal and abnormal findingsInspectionThis skill is often used in conjuction with or directly after inspection by using the sense of touch to make delicate and sensitive measurements of specific signs, including: resistance, resilience, roughness, texture and mobilityPalpationThis skill involves striking one object against another and interpreting the sound that is madePercussionThis skill should be used last, except when assessing the abdomen, after the other techniques have provided information that will assist in interpreting what is heardAuscultationAn awareness and observation of the nature and source of body odors can assist in detecting abnormalities that may not be detected using the other skills or testsOlfactionBreath with a sweet, fruity odor may indicate...diabetic acidosisVomit with a feces odor may indicate...bowel obstructionCast with a musty odor may indicate...infection