Final Exam Concept Guide
1. Pain responses (physiological)?
- Respirations shallow, grimacing, guarding, verbalization, and holding or touching
the affected area. mild,sharp, dull, aching, constant, and intermittent = ↑ HR ↑BP
2. Pain assessment?
- Provocation/ Palliation : what causes it? What makes it better/ worse?
- Quality / Quantity: how does it feel like? Look? Sound? How much of it is there?
- Radiation / Region: where is it? Does it spread?
- Severity / Scale: interfere w activities? Rate on a scale of 0-10?
- Timing / Type of Onset: start? How often does it occur? Sudden or gradual?
3. Prevention strategies (primary, secondary, & tertiary)?
- Primary: promote health & prevent disease before begins (ex: vaccines, nutrition)
- Secondary: prevent worsening H status + early detect (ex: screening)
- Tertiary: prevent long-term consequence after disease (ex: rehab, support group)
4. Lung sounds (wheezing, crackles, rhonchi)?
- Wheezing: high-pitched whistling, musical sounds as air passes thru
narrowed/obstructed airways - louder on expiration
- Crackles / Rales: fine to coarse bubbly sounds (NOT cleared w cough) air passes
thru fluids / re-expands collapsed small airways
- Rhonchi: coarse, loud, low-pitched rumbling sounds during inspir/ expiration from
fluid / mucus - can clear w cough
5. Effects of immobility?
- ↑ serum lactic, ↑ excretion of calcium, ↑ stagnation?, DVT atrophy, wasting, stiff
joints, contractures, joint ankylosis, edema, risk thrombosis, orthostatic
hypotension, pooling in lungs, risk atelectasis + pneumonia, pressure injury,
glucose intolerance, risk fx, diminish appetite, slow digestion, muscle broken
down, supine position inhibits drainage, ↓ ADLs, ↓ cardiac reserve, ↓ ventilation, ↓
ATP, ↓ metabolic rate, ↓ muscle mass, ↓ peristalsis
6. Nursing interv immobile patient (ex: prvnt pressure inj, atelectasis, constipation, etc.)?
- Oxygen: assist orthopneic position - allow lung expansion + prvnt atelectasis &
pneumonia
- Nutrition: protein diet for muscle mass
- Skin integrity: turn q2hrs, bed clean + dry, NOT tuck in tight cuz foot drop -
restricts movement + circulation
- Cardiovasc: pt sit edge of bed prvnt orthostatic hypotension
- Musculosk- assist standing position + ambulation, use dev maintain body
alignment
7. Lab results (know the normal)?
- ESR = around 22-29 , less than 20 = inflammation
8. Non-modifiable vs Modifiable risk factors for disease processes?
- Non: nothing can change them ( age, ethnicity, genetics)
- Mod: can be ↓ / removed w lifestyle adjustments (obesity, smoke, stress)
9. Sleep disorders (narcolepsy, sleep disturbances, etc)?
- Sleep disturbances: pain, music
, - Narcolepsy: excessive daytime sleepiness (safety- DONT operate heavy
machinery)
- Insomnia: difficulty falling / staying asleep
- Sleep apnea: breathing repeatedly stop / start during sleep
10. Maslow’s hierarchy of needs?
- Physiological: air, food, temp reg, elimination, rest, sex, blood flow, activity, water
- Safety: security
- Love /Belonging: intimate r.ship, friends
- Esteem: feeling accomplishment
- Self-actualization: achieving one’s full potential
11. Hypoxia?
- Decreased tissue oxygenation
- Early S/S: restlessness, irritability, abn breathing (use accessory muscles, nasal
flaring, adventitious lung sounds), tachycardia, tachypnea, HTN, pallor
- Late S/S: ↓ LOC, cyanosis, ↑ lactic acid, dysrhythmias, bradycardia, bradypnea,
hypotension
- Encourage breathing technique (pursed-lip, cough, deep breathe, reposition)
12. Cancer prevention?
- Primary: strategies prvnt occurrence - most effective w known cancer
- Secondary: use screenings to detect early - when cure / control more likely
13. HCW safety, preventing injuries, & infection, promoting safety, preventing falls?
- Falls: ensure bed locked, lowest position, bed alarm, keep things + call light in pt
reach, pt wear non-slip well-fit footwear, round hourly on pt, reg opportun for
toileting + nutrition, move near nurse station, floor clean+dry+uncluttered,
encourage sit edge bed then dangle legs b4 stand up
- Injury: stand w feet shoulder width apart, raise bed waist lvl, avoid twist spine,
bend w knees, hold objects close, use assistive dev
- Infection: hand hyg, room cohort, sign on room door + keep PPE cart outside
room for isolation prec, disposable stethoscope + equipm @ bedside w
transmission prec, cluster care limit exposure, limit invasive procedure - remove
lines/ tubes/ drains/ ASAP, perform line/ tube/ drain care (dressing changes)
14. Hygiene: total care, self-care, partial care?
- Total: totally dependent, in bed, UNABLE care self; use commercial bag bath /
cleansing pack (↓ risk for infection for disease- producing gram - organisms) +
may be exhausting for pt
- Self: dressing, feeding, toilet-training
- Partial: bath ONLY parts that cause discomfort if not bathed (hands + face +
axillae + back + perineal) for pts who dependant & or pts who MUST remain in
bed but can’t reach all areas of body
15. Elimination: potential imbalances, incontinence?
- Incontinence: lack of control
- Fluid excess/ deficit
16. First actions: priorities!
- Airway, Breathing, Circulation, then Maslow’s hierarchy - physiological
, 17. Systemic vs Localized inflammation?
- Systemic: all over the body (fever, ↑ WBC) if no tx - Sepsis, ↓ perfusion,
hypotension, eventually organ failure
- Localized: in one area, ex: cellulitis (redness, warmth, pain, swelling) if no tx -
systemic inf
18. CAM - alternative, complementary, integrative?
- Complementary: tx used together w traditional medical care
- Alternative: used instead of traditional medical care; range of philosophies,
approaches, & therapies -not commonly used, accept, understand, study, or
avail.by conventional healthcare system - most tx holistic
- Integrative: coordinated care that has ALL txs & health practices
19. CAM - guided imagery, acupressure (acupuncture?), herbal therapies?
- G: use direct words + music, holistic techniq → harmony between mind + body
- Acupr: w/o needle to relieve pain, gentle pressure to points along 12 energy
meridians (channels) / acupoints
- Acupunc: penetration of skin w needle- select acupoints based on pulses,
appearance, tongue color, odors, + complaints - stimulation restore qi along
meridians
- Herb: promotes overall H + wellness, prvnt illness,
- Aloe = wound healing
- Chamomile = calming, anti-inflammatory
- Echinacea = immunity
- Garlic = inhibits platelet aggregation
- Ginger = antiemetics
- Ginkgo Biloba = ↑ memory
- Ginseng = ↑ physical endurance
- Kava = skeletal muscle relaxant, treated anxiety + insomnia
- Milk Thistle = antioxidant, ↓ liver edema
- St. John’s Wort = mineral + antiviral, antibacterial, antidepressant
- Valeria = ↑ sleep, ↓ anxiety
- Zinc = mineral + antiviral, mineral / stimulates immune system
20. RICE: Ice helps control Swelling
- Rest
- Ice
- Compression
- Elevate
21. Prevention of aspiration?
- High Fowler / Chair
- Hygiene after meals
22. Therapeutic communication: empathy, clarifying, non-verbal, active listening,
pause/silence, genuineness, confrontation, etc
- Empathy: desire to understand & be sensitive to feelings + beliefs + situation
- Clarifying: Ensure decode message correctly - understand sum thats unclear
