Test 2

  1. Radiation
    transfer of heat from the surface of one object to the surface of another without contact btwn the 2 objects, mostly in the form of infrared radiation
  2. Conduction
    transfer of heat from one molecule to a molecule of lower temp with contace
  3. convection
    dispersion of heat by air currents
  4. evaporation/vaporization
    continuous vaporization of moisture from the respiratory tract and from the musosa of the mouth and from the skin
  5. intermittent fever
    body temp alternates at regular intervals btwn periods of dever and periods of normal or submoral temperatures

    ex. malaria
  6. remittent fever
    a wide range of temperature fluctuations occurs over a 24 hr period all of which are above normal (more than 3.6 deg)
  7. relapsing fever
    short febrile periods of a few days are interspered with periods of 1 or 2 days of mormal temperature.
  8. constant fever
    the body temp fluctuates minimally but always remains above normal

    ex typhoid fever
  9. Fever Onset CHILL PHASE
    • increased heart rate
    • increased resp rate and depth
    • shivering
    • pallid, cold skin
    • complaints of feeling cold
    • cyanotic nail beds
    • gooseflesh appearance of skin
    • cessation of sweating
  10. Fever Course PLATEAU PHASE
    • absence of chills
    • skin that feels wam
    • photosensitivity
    • glassy eyed appearance
    • increased pulse and resp rates
    • increased thirst
    • mild to severe dehydration
    • drowsiness, restlessness, delirium, or convulsions
    • herpetic lesions of the mouth
    • loss of appetitie (if the fever is prolonged)
    • malaise, weakness, and aching muscles
  11. Fever Defervescence ABATEMENT/FLUSH PHASE
    • skin that appears flushed and feels warm
    • sweating
    • dcreased shivering
    • possible dehydration
  12. Nursing interventions for clients with fever
    • monitor vitals signs
    • assess skin color and temp
    • monitor white blood cell count, HCT value, and other pertinent laboratory reports for indications of infection or dehydration
    • measure intake and output
    • reduce physical activity to limit heat production especially during the flush phase
    • antipyretics as ordered
    • provide oral hygiene to keep mucous membranes moist
    • tepid sponge bath to increase heat loss through conduction
    • provide dry clothing and bed linens
  13. Hypothermia
    • decreased body temp less than 95 deg
    • severe shivering at onset
    • feelings of cold and chills
    • pale, cool, waxy skin
    • frostbite (discolored, blistered nose, fingers, toes)
    • hypotension
    • decreased urinary output
    • lack of muscle coordination
    • disorientation
    • drowsiness progressing to coma
  14. Nursing interventions for clients with Hypothermia
    • provide warm environment
    • dry clothing
    • warm blankets
    • limbs close to body
    • cover scalp with cap or turban
    • warm oral or IV fluids
    • warming pads
  15. cyanosis - cardiac and respiratory disease
    conjunctiva of eyes (lining of eyelids), nail beds, lips, buccal mucosa. Palms and soles of feet in dark skinned people
  16. Jaundice - liver and gallbladder disease, anemia, hemolysis
    scelera of eye, nail beds, mucous membranes and skin, posterior hard palate
  17. Pallor - anemia, inadequate blood or hemoglobin circulation resulting in reduction in tissue oxygenation
    conjunctiva, oral mucous membranes, nail beds, palms and soles
  18. ecchymosis
    bruises; bleeding into subcutaneous tissue
  19. hematoma
    accumulation of blood in tissue or organ, note swelling
  20. petechiae
    broken blood vessel, pin point hemorhages
  21. macule
    flat, unelevated change in color; ie freckles, measles rash, port wine stain
  22. papule
    raised, solid elevation of skin; ie mole, wart, acne
  23. vesicule
    fluid filled, round, thin translucent mass filled with serous fluid or blood; ie chicken pox, burn blisters, poison ivy
  24. pustule
    vesicule filled with pus; ie acne vulgaris, impetigo
  25. hirsutism
    excessive, coarse hair on face and trunk; ovarian dysfunction
  26. lentigines
    age spots
  27. telangiectasias
    spider veins
  28. epistaxis
  29. miosis
    abnormal constriction of pupils
  30. mydriasis
    abnormal dialation of pupils
  31. anisocoria
    unequal pupils
  32. ptosis
    droopy eyelid
  33. nystagmus
    involuntary movement of eye
  34. Abdominal RUQ
    • liver
    • gallbladder
    • duodenum
    • head of pancreas
    • right adrenal gland
    • upper lobe of right kidney
    • hepatic flexure of colon
    • section of ascending colon
    • section of transverse colon
  35. Abdominal LUQ
    • left lobe of liver
    • stomach
    • spleen
    • upper lobe of left kidney
    • pancreas
    • left adrenal gland
    • splenic flesure of colon
    • section of transverse colon
    • section of descending colon
  36. Abdominal RLQ
    • lower lobe of right kidney
    • cecum
    • appendix
    • section of ascending colon
    • right ovary
    • right fallpian tube
    • right ureter
    • right spermatic cord
    • part of uterus
  37. Abdominal LLQ
    • lower lobe of left kidney
    • sigmoid colon
    • section of descending colon
    • left ovary
    • left fallopian tube
    • left ureter
    • left spermatic cord
    • part of uterus
  38. Glasgow coma scale
    Eye opening
    • spontaneous 4
    • to verbal command 3
    • to pain 2
    • no response 1
  39. Glasgow coma scale
    Motor Response
    • To verbal command 6
    • to localized pain 5
    • flexes and withdrawals 4
    • flexes abnormally 3
    • extends abnormally 2
    • no response 1
  40. Glasgow coma scale
    Verbal response
    • oriented, converses 5
    • disoriented, converses 4
    • uses approriate words 3
    • makes imcomprehensible
    • sounds 2
    • no response 1
  41. olfactory I
    sensory - ask client to close eyes and identify different mild aromas
  42. optic II
    sensory - read snellen chart, check visual fields by confrontation, and conduct opthalmoscopic exam
  43. oculomotor III
    motor - assess 6 ocular movements
  44. trochlear IV
    motor - assess 6 ocular movements
  45. Trigeminal V
    Ophthalmic branch
    • sensory - while client looks up, lightly touch lateral sclera fo the eye to elicit blink reflex.
    • To test light sensation, have client close eyes, wipe a wisp of cotton over clients forehead and paranasal sinuses.
    • To test deep sensation, use alternating blunt and sharp ends of a safety pin over same areas.
  46. Trigeminal V
    Maxillary branch
    sensory - assess skin sensation as for ophthalmic branch
  47. Trigeminal V
    Mandibular branch
    motor and sensory - ask client to clench teeth
  48. Abducens
    motor - assess directions of gaze
  49. Facial VII
    motor and sensory - ask client to smile, raise the eyebrows, frown, puff out cheeks, close eyes tightly. Ask client to id various tastes placed on tip and sides of tongue: sugar, salt, lemon juice, and quinine (bitter); id areas of taste
  50. Acoustic (auditory) VII
    Vestibular branch
    sensory - romber test
  51. Acoustic (auditory) VII
    Cochlear branch
    assess clients ability to hear spoken word and vibrations of tuning fork
  52. Glossopharyngeal IX
    motor and sensory - apply tastes on posterior tongue for id. ask client to move tongue from side to side and up and down
  53. Vagus X
    motor and sensory - assess with cranial nerve IX; assess clients speech for hoarseness
  54. Accessory XI
    motor - ask client to shrug shoulders against resistance from your hands and turn head to side against resistance from your hand (repeat on other side)
  55. Hypoglossal XII
    motor - ask client to protrude tongue at midline, then move it side to side
  56. sternocleidomastoid
    client turns the head to one side against the resistance of your hand - repeat with the other side
  57. trapezius
    client shrugs the shoulders against the resistance of your hands
  58. deltoid
    client holds arm up and resists while you try to push it down
  59. biceps
    client fully extends each arm and tries to flex it while you attempt to hold arm in extension
  60. triceps
    client flexes each arm and then tries to extend it against your attempt to keep arm in flexion
  61. wrist and finger muscles
    client spreads the fingers and resists as you attempt to push the fingers together
  62. grip strength
    client grasps your index and middle fingers while you try to pull the fingers out
  63. hip muscles
    client is supine, both legs extended; client raises one leg at a time while you attempt to hold it down
  64. hip abduction
    client is supine, both legs extended. place your hands on the lateral surface of each knee; client spreads the legs apart against your resistance
  65. hip adduction
    client is in same position as for hip abduction. place your hands btwn the knees; client brings the legs together against your resistance.
  66. hamstrings
    client is supine, both knees bent. client resists while you attempt tp straighten the legs
  67. quadriceps
    client is supine, knee partially extended; client resists while you attempt to flex the knee
  68. muscles of the ankles and feet
    client resists while you attempt to dorsiflex the foot and again resists while you attempt to flex the foot
  69. Grading Muscle Strength
    • 0:0% of normal strength; complete paralysis
    • 1:10% of normal strength; no movement, contraction of muscle is palpable or visible
    • 2:25% of normal strength; full muscle movement against gravity, with support
    • 3:50% of normal strength; normal movement against gravity
    • 4:75% of normal strength; normal full movement agaist gravity and against minimal resistance
    • 5:100% of normal strength; normal full movement against gravity and against full resistance
  70. Flexion
    • decreasing the angle of the joint (eg. bending the elbow, nodding head yes)
    • move the head from the upright midline position forward so that the chin rests on the chest
  71. Extension
    Increasing the angle of the joint (eg. straightening the arm at the elbow, nodding head yes)

    move the head from the flexed position to the upright position
  72. Adduction
    • movement of the bone toward the midline of the body
    • move each arm from a position at the sides across the front of the body as far as possible. the elbow may be straight or bent.
    • bring the fingers of hand together
    • move thumb back to the palm of hand
    • move leg back to the other leg and beyond in front of it
  73. Abduction
    • movement of the bone away from the midline of the body
    • move arm laterally from a resting position at the sides to a side position above the hear, palm of the hand either toward or away from the head
    • spread the fingers apart
    • extend thumb laterally
    • move leg out to the side
  74. Circumduction
    • movement of the distal part of the bone in a circle while the proximal end remains fixed
    • move arm forward, up, back, and down in a full circle
    • move leg backward, up, to the side, and down in a circle
  75. Supination
    moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body
  76. Pronation
    moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body
  77. Sensory, Motor, or Both
    Some Say Marry Money, But My Brother Says Big Brains Matter Most
  78. Oh, Oh, Oh, To Touch And Feel All Good Vibes Ahh Haaa
    • Olfactory
    • Optic
    • Oculomotor
    • Trochlear
    • Trigeminal
    • Abducens
    • Facial
    • Acoustic
    • Glossopharyngeal
    • Vagus
    • Accessory
    • Hypoglossal
  79. Cognitive Domain-knowing
    6 Intellectual Abilities
    • knowledge
    • comprehension
    • application
    • analysis
    • synthesis
    • evaluation
  80. Affective Domain - Feeling
    someones emotional response to a task
    attitudes, values and emotion
  81. Psychomotor Domain - Doing
    using skills involved in the learning process
Card Set
Test 2
Flash cards test 2