FOUNDATION OF NURSING FINAL

Lordosis

Inward curvature of the spine (pregnant women)

Peripheral Pulse Points

Brachial, Radial, Ulnar, Temporal, Ulnar, Temporal, Carotid, Apical

Pulse Grading Scale

3+ increased, full, bounding
2+ normal
1+ weak
0 absent

Peripheral Arterial Disease (PAD)

Reduced blood flow caused by ischemia

Ischemia

deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel

Risk Factors for Heart Disease

Heredity, Obesity, Hish Cholesterol, Smoking, Diet, Stress

What is the leading cause of death for men and women worldwide?

Heart Disease

Ways to prevent or treat Heart Disease

Aspirin Therapy, BP Control, Cholesterol Control, Smoking Cessation, Lifestyle Changes

Mental health Assessment

Check of emotional and cognitive functioning, ABCT

ABCT

appearance, behavior, cognition, thought process

Appearance

Body posture, body movement, dress, grooming, hygiene, pupils

Behavior

A+O, Facial Expression, Consciousness, Speech, Mood and affect

Cognition

Orientation, Attention span, recent and remote memory
4 unrelated words test

Thought Processes

Should be logical, goal-directed, coherent, and relevant
Complete Thoughts

Abnormal Bruising

TEN4
(Torso, Ears, Neck on a child under 4, abnormal, abuse?)

Subjective Data of the Neurological System

Headache, Head injury, Dizziness/vertigo, syncope, seizures, tremors, incoordination, numbness or tingling, dysphagia, difficulty speaking, weakness

Seizures

Abnormal surge of electricity in the brain
effects speech and arm movement
caused by epilepsy, tumors, or infections

what kinds of questions should be asked after a seizure

Any Aura? When did it start? How long did it last? Color Change?

Ischemic stroke

Sudden interruption of blood flow, Thrombic, Embolic

Hemorrhagic stroke

Acute rupture or bleeding
caused by tumor, cocaine, disturbed coagulation cascade, congenital malformations

FAST Assessment

Facial Drooping
Arm Weakness
Speech Difficulty
Time to call 911

Nursing Process

Assessment
Diagnosis
Planning
Implementation
Evaluation

Pruritis

Itching

Pediculus

Head Lice

Stress incontinence

inability to control urine under physical stress

Urge Incontinence

Involuntary leakage of urine

Overflow Incontinence

Small amounts leak from a full bladder

Abdominal Assessment

inspection, auscultation, percussion, palpation

Acute

A condition with rapid onset and/or a short course

Chronic

A condition that is persistent or long-lasting

Prognosis

The likely course/expected outcome of a disease or ailment

Diagnosis

Identification of a disease or condition

Etiology

The study of the cause of disease

Benign

Non-cancerous

Malignant

Cancerous and potentially life-threatening

Idiopathic

Of unknown cause

brady-

Slow

Tachy-

fast

a- or an-

Without, not

dys-

bad, difficult, painful

eu-

good, normal

cyano-

Blue

erythro-

red

leuko-

white

melano-

black

angio-

vessel

arthro

joint

Abdominal Subjective Data

Appetite, dysphagia, food intolerance, abdominal Pain, Nausea and vomiting, bowel sounds, history, medications, nutrition, PICA

SMART goal

Specific, Measurable, Attainable, Realistic, Timed

Anorexia

loss of appetite

Dysphagia

difficulty swallowing

pyrosis

heart burn

OLDCARTS

Onset
Location
Duration
Characteristics
Aggravating and Alleviating Factors
Related Symptoms
Treatment
Severity

Hematemesis

blood in vomit

Do stool color and vomit color matter?

YES, especially in PEDS

Abdominal Quadrants

RLQ- appendix
RUQ- Gallbladder
LUQ- stomach
LLQ-Sigmoid Colon

Bowel Sounds

Movement of air through small intestine, high pitched, 5-30 per minute

Borborygmas

hyperistalsis (stomach growling)

GU subjunctive Data for females

Menstrual History, ob history, menopause, pt-centered care, acute pelvic pain, urinary symptoms, vaginal discharge, past history, sexual activity, contraceptive use, STI contact

GU subjunctive data for males

Frequency, Urgency, nocturia, dysuria, hesitancy or straining, urine color, past GU history, penis-pain, scrotum - self care, behaviors, lumps, sexual activity, contraceptive use, STI contact

cardiovascular subjective data

Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis, edema, nocturia, past cardiac history/family history, pt centered care

Questions to ask with Chest Pain

w/ breathing? location? severity? Reproductive? Worse w/ breathing?

Dyspnea

feeling of difficulty breathing

Orthopnea

Feeling of difficulty breathing lying down

Cyanosis

Blue colored skin

Nocturia

Going potty at night

Ankylosis

stiff joints due to bone fusion

Quantitive

Measurable, signs -> BP, Temp, RR

Qualitative

symptoms, subjective, how someone

Scoliosis

Lateral sideways curvature of the spine

vertigo

dizziness, feeling that the room is spinning

Abdominal Contours

Flat, scaphoid, rounded, protuberant

Venous stasis

temporary cessation or slowing of the venous blood flow

Pain Assessment

OLDCARTS

Blood Pressure Factors

age, gender, race, diurnal rhythm, weight, exercise, emotions, stress

Headaches

Tension, migraine, or cluster
Can be benign but also indicative or migraines or a more serious condition

What questions should I ask about Headaches?

How long?
When did it start?
Intensity?
Are there any other symptoms?

Inspection of the skin

color: no abnomal pigmentation, general pigmentation, moles, birthmarks
Temperature: warm, equal temp bilaterally
Moisture
Texture: smooth and firm
Thickness- observe for thickened areas
Edema- fluid acumulation
mobility and turgor- skin elasticity
Vascularity and bruising

cyanosis

blue

Pallor

White/pale

Erythmea

Red

Jaundice

Yellow

Venostasis

Blood pooling in the leg
causes brown or rust colored skin

Skin Assessment

Inspection, palpation, note lesions, teach self exam

Hypothermia

<96

Hyperthermia

>100.4

Diaphoresis

excessive sweating

dehydration

dryness resulting from the removal of water

Abnormal Heart Rate

<50 or >100

Abnormal BP

>160 or <90

Abnormal Temp

<96 or >100.4

Abnormal Respirations

<12 or >25

Abnormal O2

<92

Abnormal Urine Output

<30 hourly

Findings Requiring Immediate Assistance

Abnormal Vital Signs
Urine Output
Dark amber or bloody urine
post-op nausea or vomiting
pain not controlled by meds/unusual chest pain
bleeding
weak pulses
altered level of consciousness, confusion or difficulty arousing
sudden restlessness/anxiety

Normal HR

60-100

Normal BP

120/80

Normal Resp

10-20

normal O2

95-100%

Normal Temp

97-100.4