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Med-surg. ANCC certification
Mc burney's point - ✔Point in RLQ abd of appendix. Tenderness indicates appendicitis Murphy's sign - ✔Place fingers under rt coastal margin and instruct to take deep breath. Increased tenderness with sudden stop during inhalation is a positive murphy's sign Obturator muscle, psoas sign, Rovsing's sign - ✔All assessment used to r/o appendicitis Homan's sign - ✔Out dated and not recommended to use for assessment for DVT Jar sign(markle sign) - ✔Pain from a jarring movement to indicate peritonitis with appendicitis. Stand on toes and drop to heals or increaded pain with walking or running Beck's triad - ✔Acute cardiac tamponade- pericardial effusion
- Disended neck vein's
- Distant heart sounds
- Hypotention Treatment- pericardiocentesis Charcot's triad for MS - ✔1. Nystagmas- repetitive uncontrolled movements of the eyes
- Intention tremor- tremor that worsens as approaches end of intended movement
- Scanning or staccato speech- broken speech and each syllable pronounced separately Charcot's triad for ascending cholangitis - ✔Inf. of bile duct caused by bacteria ascending from junction with duodenum 1.Jaundice
- Fever, usually with rigors
- RUQ ABD pain Cushing's triad - ✔Signs of increased ICP
- HTN- widened pulse pressure
- Bradycardia
- Irregular respirations- cheyne- stokes( slow, fast, slow period of apnea then slow,fast,slow Kaussmaul breathing - ✔Deep and labored. Presents in severe metabolic acidosis- DKA and kidney failure Bergman's triad - ✔Signs of fat embolism
- Mental status changes
- Petechiae-late sign
- Dyspnea Brudzinski sign - ✔Sign of meningitis- supine flex neck will cause involuntary flexion of hips and knees Kernig's sign - ✔Sign of meningitis- lift flexed knee and slowly extend will cause back pain if positive Chvostek's sign Trousseau' sign - ✔Nerve hyperexcitability (tetany) seen with hypocalemia Abnormal reaction to stimulation of facial nerve Inflate bp cuff to greater than systolic and hand and wrist with involuntarly curl inward Levine sign - ✔is positive when a patient is holding a clenched fist over his chest to describe dull, pressing chest pain consistent with the discomfort of angina pectoris.
1,2. And 3 or 4 is positive The Confusion Assessment Method - ✔Onset: Acute changes in mental status. · Attention: Inattentive, stable, or fluctuating. · Thinking: Disorganized, rambling, switching topics, illogical. · Level of consciousness: Altered (ranging from alert to coma). · Orientation: Time, place, person. · Memory: Impaired. · Perceptual disturbances: Hallucinations, illusions. Psychomotor abnormalities: Agitations or retardation. · Sleep-wake cycle: Awake at night, sleepy in the daytime. Nursing process - ✔Assessment: Collecting data, history, and completing a physical exam. Diagnosis: Analyzing data, determining needs and problems, and applying a nursing diagnosis. Planning: Setting priorities, setting goals and expected outcomes, and planning interventions and strategies of care. Implementation: Applying interventions/treatments. Evaluation: Reassessing and auditing. Diabetes insipidus - ✔Extreme thirst and urination cause by imbalance in body fluid CAGE - ✔Alcoholism screening- C -Cutting down: Do you think about trying to cut down on drinking? A -Annoyed at criticism: Are people starting to criticize your drinking? G -Guilty feeling: Do you feel guilty or try to hide your drinking? E -Eye opener: do you increasingly need a drink earlier in the day? Braden score - ✔PU risk assessment PUSH score - ✔Pressure Ulcer Scale for Healing- measure over time to indicate healing or deterioration Five Stages of grief - ✔1. Denial
- Anger
- Bargaining
- Depression
- Acceptance Bloom's Taxonomy(6 levels of learning) - ✔Remember Understand Apply Analyze Evaluate Create Bloom's Taxonomy(3 types of learning) - ✔1. Cognitive: Learning and gaining intellectual skills and mastering categories of effective learning (knowledge, comprehension, application, analysis, synthesis, and evaluation). ·
- Affective: Recognizing categories of feelings and values from simple to complex (receiving and responding to phenomena, valuing, organizing, and internalizing values). ·
- Psychomotor: Mastering motor skills necessary for independence, following a progression from simple to complex (perception, set, guided response, mechanism, complex overt response, adaptation, and origination). Tertiary - ✔Soften impact of longterm ,complex illness/injury Secondary - ✔Early detection and Treatment to halt or slow progress Primary - ✔Prevention Orchiopexy - ✔Sx to move undescended testicle or resolve testicular torsion Orchiectomy - ✔Removal of one or both testicules Piaget's stages of
Resistance: The body mobilizes to resist a threat, focusing on those organs most involved in an adaptive response. · Exhaustion: As the body is weakened and overwhelmed, organs/systems begin to deteriorate (hypertrophy/atrophy) and can no longer cope with stress, resulting in stress-related illnesses and eventual death. Broca's aphasia - ✔Expressive aphasia- left frontal Wernicke's aphasia - ✔Receptive aphasia- damage to Lt posterior temporal Cryptorchidism - ✔Undescended testicles Osteopenia - ✔Decrease in bone density Thalassemia major - ✔Causes anemia Phenylketonuria (PKU) - ✔Rare inherited disorder that causes an amino acid called phenylalanine to build up in the body. Treated with strict diet of avoiding foods high in protein. Nursing process - ✔Assessment: Collecting data, history, and completing a physical exam. · Diagnosis: Analyzing data, determining needs and problems, and applying a nursing diagnosis. · Planning: Setting priorities, setting goals and expected outcomes, and planning interventions and strategies of care. · Implementation: Applying interventions/treatments. Evaluation: Reassessing and auditing. Phases of nurse/client relationship - ✔Preinteraction Phase Assessment: gathering information; assessing one's feelings, fears, and anxieties about working with a particular client Goal: Explore self-perceptions
Orientation (introductory) Phase nurse and client become acquainted Goal: Establish trust; Formulate contract for intervention Working Phase Goal: Promote client change Termination Phase Goal: Evaluate goal attainment; Ensure therapeutic closure H's and T's - ✔There are twelve main causes of cardiac arrest (six Hs and six Ts): hypovolemia, hypoxia, hydrogen ions (acidosis), hyper/hypokalemia, hypothermia, toxins, tamponade, tension pneumothorax, thrombosis, thromboembolism, and trauma. Maslow's hierarcy - ✔Physiological- most basic needs Safety Love/belonging Esteem Self-actualization Causes of post-operative fever 5 Ws - ✔w ind (atelectasis, aspiration, pneumonia), pod 1- w ater (urinary tract infection), pod 3- w alking (deep vein thrombus), pod 5- w ound (wound infection), pod 5- w hat the physician caused (drug fever, line infection). After the first week post op
Passivity: The patient defers to others, feeling he/she has no control. Leading health indicators include: - ✔1) immunization,
- access to health care,
- environmental quality,
- rates of injury and violence,
- mental health care,
- responsible sexual behavior,
- rates of substance abuse and tobacco use,
- rates of overweight and obesity, and
- levels of physical activity. Hyperkalemia - ✔often occurs with renal disease and is characterized by ventricular arrhythmia, weakness with ascending paralysis and hyperreflexia, diarrhea, and confusion. Hypokalemia - ✔is characterized by weakness, lethargy, nausea and vomiting, paresthesias, dysrhythmias (PVCs, flattened T waves), muscle cramps with hyporeflexia, hypotension, and tetany. Hypocalcemia - ✔is characterized by tetany, tingling, seizures, altered mental status, and ventricular tachycardia. Hypercalcemia - ✔is characterized by increasing muscle weakness with hypotonicity, constipation, anorexia, nausea and vomiting, and bradycardia. Adult learners - ✔Self-directed: Adults prefer active involvement and responsibility. · Knowledgeable: Adults can relate new material to information with which they are familiar by life experience or education. · Relevancy-oriented: Adults like to know how they will use information. · Motivated: Adults like to see evidence of their own achievement, such as gaining a certificate. Conflict Resolution steps include: - ✔Allowing both parties to present their side without bias. ·
Encouraging cooperation through negotiation and compromise. · Maintaining focus and avoiding arguments. · Evaluating the need for renegotiation, a formal resolution process, or a 3rd party mediator. · Utilizing humor and empathy to diffuse tension. Summarizing and outlining key arguments. · Avoiding forced resolution if possible. Drug users s/s - ✔Signs of inhaled cocaine use include nasal irritation and nosebleeds, and signs of smoked cocaine include lip burns and a cough. Constricted pupils, headaches, and abdominal pain are also common. Most abused drugs have similar symptoms. However, heroin users would have needle tracks and would not have nasal irritation. Marijuana users may exhibit tachycardia and cough from lung irritation (similar to tobacco smokers), but usually do not develop nasal irritation or nose bleeds. Methadone abuse can cause constricted pupils and abdominal pain, but does not cause nasal symptoms. disseminated intravascular coagulation (DIC) - ✔DIC causes both coagulation and hemorrhage through a complex series of events. It includes trauma of a nature that causes tissue factor (transmembrane glycoprotein) to enter the circulation and bind with coagulation factors, triggering the coagulation cascade. This cascade stimulates thrombin to convert fibrinogen to fibrin, causing aggregation and destruction of platelets and forming clots that can be disseminated throughout the intravascular system. naloxone (Narcan®) intravenously - ✔as it is an opiate antidote. Flumazenil - ✔an antidote for benzodiazepines. Charcoal - ✔may be used for an oral overdose of morphine if little time has passed since ingestion but will not have an effect on morphine that was administered intravenously. N-acetylcysteine - ✔is the antidote for overdose of acetaminophen Patients' Bill of Rights - ✔The right to pain control,respect for patient, informed consent, advance directives, and end of life care, privacy and confidentiality, protection from abuse and neglect, protection during research, appraisal of outcomes, appeal procedures, an organizational code of ethical behaviors, and procedures for donating and procuring organs/tissues. environmental assessment -
✔Fungal/yeast infection after an adrenalectomy what is important to monitor - ✔B/P because of the possibility of an Addisonian crisis. Empathy - ✔is the capacity to recognize and, to some extent, share similar feelings that are being experienced by another sentient or semi-sentient being. Apathy - ✔Indifference, lack of interest or concern is the state of Sympathy - ✔The affinity, association, or relationship between persons or things wherein whatever affects one similarly affects the other is Compassion - ✔The desire to alleviate suffering or the hardship of another is Aphasia - ✔is a total or partial impairment of language ability. The specific brain area usually associated with prosopagnosia is the fusiform gyrus. Prosopagnosia - ✔is a disorder of face perception where the ability to recognize faces is impaired. Apraxia - ✔is the loss of ability to execute learned purposeful movements. Pyuria - ✔Urine that contains pus pheochromocytoma - ✔Tumor in adrenal gland that causes increased secretion of Epi and norepinephrine and causes HTN even with treatment Watson - ✔The seven assumptions Caring can be effectively demonstrated and practiced only interpersonally.
Caring consists of carative factors that result in the satisfaction of certain human needs. Effective caring promotes health and individual or family growth. Caring responses accept person not only as he or she is now but as what he or she may become. A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. Caring is more " healthogenic" than is curing. A science of caring is complementary to the science of curing. The practice of caring is central to nursing. Carl Rogers's Theory of Personality - ✔He believed if an individual attained self-actualisation they would be a fully functioning person living "the good life". By this, he means that the individual would have a positive healthy psychological outlook, trust their own feelings and have congruence in their lives between self and experience
