Exam 1 Concepts:
Integumentary System:
Know the importance of pressure injury prevention strategies i.e.. Q2 turns (pressure redistribution), moisture barrier cream (reduce moisture), pillows under bony prominences (limits friction/shearing), smooth and wrinkle-free linen (reduce bed irritation), adequate protein intake (improve wound healing)
Normal skin findings vs abnormal findings
Importance of each skin layer: epidermis (melanin, keratin), dermis (glands, vessels, nerves), hypodermis (fat, anchors skin)
How to assess for early signs of pressure injury: redness, blanching, moist vs dry
Dark skin tones: use palpation to detect tissue consistency
Early signs of pressure injury: Q2 turns/repositioning= priority, never massage area, apply heat, or use alcohol
Increase protein intake to help wound healing
Musculoskeletal System:
ROM: active vs passive. Always compare both sides of body for accurate assessment
Body mechanics when transferring a patient: bend at knees, not waist, use leg muscles, avoid twisting, stand on patient’s stronger side to optimize support
Cane=one point of contact for unilateral weakness; standard walker= four points of contact for bilateral weakness; crutches= three points of contact for non-weight bearing injury (crutches should be 6 inches from sides of feet to ensure stability and prevent tripping)
Post-op joint replacement: cold therapy reduces swelling
How to prevent contractures (splints, ROM)
Osteoarthritis and Rheumatoid arthritis: encourage ROM after pain medication given, use assistive devices as needed to protect joints, apply warm compress before activity to reduce pain/stiffness, take breaks to conserve energy, perform low impact exercises to maintain mobility and strength, quit smoking
Function of bone marrow
Neurologic System:
Correct sequence of a nerve impulse: action potential moves down axon terminal → neurotransmitter released → neurotransmitter binds to receptor → Sodium and potassium ions move to generate new action potential
Cranial nerves: CN III = oculomotor, CN VII = facial, CN IX = glossopharyngeal, CNXII = hypoglossal (know what these 4 cranial nerves control)
Cerebellum = coordination. Tested with finger-to-nose test
Aphasia = difficulty communicating (receptive or expressive). Provide calm, slow speaking/direction, allow extra time, face patient directly, do not rush, do not ask multiple questions at once, do not talk over them
Dysphagia = difficulty swallowing. High risk of aspiration. Stop oral intake and notify provider. If able, proceed with thickened liquids, sit patient up 90 degrees, observe for further signs of choking, monitor weight/hydration/nutrition
Autonomic nervous system= involuntary (automatic) functions like digestion and heart rate
Stroke prevention: adequate blood pressure control = priority
Eye/Ear:
Eye structures: cornea-bends light; lens-focuses light; retina-photoreceptors; iris-controls light entry
PERRLA = pupils equal, round, reactive to light and accommodation
Outer ear = pinna, canal; middle ear = ossicles, ET, tympanic membrane, amplifies sound, equalizes pressure, transmits sound; inner ear = cochlea, vestibular apparatus, converts sound to electrical nerve impulse
Tympanic membrane: normal = pearly gray, shiny, translucent, visible cone of light
Respiratory System:
Abnormal lung sounds: Wheezes =high-pitched, often associated with asthma. Crackles = rattling sound, fluid in alveoli/bronchioles, common in pneumonia and heart failure. Ronchi = low pitched, snoring, caused by airway obstruction, common in COPD. Stridor = high pitched sound in the larynx or trachea, medical emergency, common in foreign body obstruction or anaphylaxis
Diaphragm = breathing muscle
Alveoli = gas exchange
Pleura = serous membrane surrounding lungs and chest cavity; reduces friction, allows smooth expansion and contraction of lungs
Incentive spirometry: smoking can affect results
Chest Xray: patient should inhale fully and hold breath for best view
Pulmonary function test (PFTs): avoid caffeine before test
Bronchoscopy: post-op encourage coughing and deep breathing exercises
Laryngoscopy: NPO for 8 hours prior
ETCO2, capnography monitoring = measurement of CO2 being expired.
Gas Exchange:
Normal pH= 7.35-7.45; < 7.35 = acidosis, > 7.45 = alkalosis
Normal CO2= 35-45; <35 = alkalosis, > 45 = acidosis
Normal HCO3= 22-26; <22 = acidosis, >26= alkalosis
CO2 = respiratory
HCO3 = metabolic
Dosage Calculation/Miscellaneous:
Nursing process: always assess first before intervention
There are 5 mL in 1 teaspoon
There are 2.2 lbs per kg.
Pounds to kilograms: divide by 2.2
Kilograms to pounds: multiply by 2.2
Know how to read a 24 hour clock (military time…ex. 2000 hours is 8pm)
Fahrenheit to Celsius formula: F = (C x 9/5) + 32…….(9/5 = 1.8 in decimal form)
Example: convert 38.3 C to F
F = (38.3 x 9/5) + 32 OR (38.3 x 1.8) + 32
F = (68.94) + 32
F = 100.94 (round to nearest tenth—100
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