Fundamentals of Nursing, 10 Ed., Potter, Perry, Stockert & Hall, 2020 | Registered Nurse (RN) School Study Aid
Child and Elder Physical Abuse Assessment
- Inconsistent Injuries
- Delay in Treatment
- Various Stages of Healing
- Symmetrical Burns
- Sexually Transmitted Infection
- Bloody/Torn Undergarments
- Shaken Baby Syndrome
- Poor Hygiene
- Overmedication
Patient Position Overview
- Trochanter Roll
- Trapeze Bar
- Ankle-Foot Orthotic (AFO) Devices
- Fowlers Position
- Supine Position
- Trendelenburg
- Side-Lying Position
- Prone Position
- Sims' Position
- Reposition q2 Hours/Prevent Skin Breakdown
- Confirm Body Alignment
Skin Anatomy
- Epidermis
- Keratinocytes
- Melanocytes
- Dendritic Cells
- Merkel Cells
- Dermis
- Sweat Glands
- Hair Follicles
- Sebaceous Glands
- Hypodermis
Interventions for Impaired Skin Integrity
- Signs of Skin Breakdown
- Pain
- Redness
- Decreased Skin Turgor
- Bleeding
- Bony Prominences
- Reposition Q2H
- Pressure Relief
- Maintain Clean and Dry Skin
- Adequate Nutrition and Hydration
Pressure Ulcers
- Prolonged Immobilization
- Neurologic Disease
- Decreased Level of Consciousness
- Stage 1: Intact Skin with Non-blanchable Erythema
- Stage 2: Partial Thickness Skin Loss
- Stage 3: Full-thickness Skin Loss without Fascial Involvement
- Stage 4: Full-thickness Skin Loss with Fascial Involvement
- Wound Care
- Surgery
- Septicemia
- Osteomyelitis
- Prevention
Eye
- Sclera
- Cornea
- Iris
- Lens
- Ciliary Muscles
- Optic Nerve
- Rods
- Cones
- Retina
Cataract
- Age-related
- No Pain
- Cloudy Opaque Lens
- Decreased Visual Acuity
- Occurs Gradually
- Surgery
Detached Retina
- Flashes of Light
- Floaters
- Curtain Like Shadow
- Eye Patch
- Bed Rest
- Surgical Emergency
- No Vigorous Activity
Age-Related Macular Degeneration (AMD)
- Dry (nonexudative)
- Wet (exudative)
- Scotomas
- Blurred, Darkened Vision
- Loss of Central Vision
- Distortion of Vision
- Drug Therapy
- Surgery
- Low-vision Assistive Devices
Primary Open-Angle Glaucoma (POAG - Chronic)
- Flow of Aqueous Humor Slowed
- Slow Onset
- No Pain
- Tunnel Vision
- IOP 22-32mm Hg
- Drug Therapy
Primary Angle-Closure Glaucoma (PACG - Acute)
- Rapid Increase in IOP
- Rapid Onset
- Pain
- Blurred Vision
- Halos Around Lights
- Nausea and Vomiting
- IOP over 30 mm Hg
- Drug Therapy
- Surgery
Otitis Media Assessment
- Red or Bulging Tympanic Membrane
- Ear Pain
- Pulling at Ear
- Fever
- Upper Respiratory Infection
- More Common in Young Children
- Eustachian Tube Narrower
- Conductive Hearing Loss
- Smoking Increases Risk
Otitis Media Interventions
- Antipyretics
- Analgesics
- Antibiotics
- Irrigation
- Position on Affected Side
- Myringotomy
- Tympanostomy Tube
Care for the Hard of Hearing
- Normal: 0-15 dB
- Rinne's Test
- Weber's Test
- Tinnitus
- Difficulty Following Conversations
- Face Patient/Speak Clearly
- Rephrase Misunderstood Statements
- Repeat Statements Back
- Hearing Aids
- Sign Language
Oral Cavity
- Mouth
- Mechanical Digestion
- Salivary Amylase Begins Carbohydrate Breakdown
- Lingual Lipase Begins Lipid Breakdown
- Esophagus
- Bolus
- Peristalsis
Neck and Shoulder Muscles
- Splenius Capitis
- Trapezius
- Rhomboid Minor
- Rhomboid Major
- Deltoid
- Latissimus Dorsi
- Levator Scapulae
- Supraspinatus
- Infraspinatus
- Teres Minor
- Teres Major
Thyroid Gland
- TSH Stimulates T3 and T4 Release
- Metabolism Regulation
- Blood Calcium Sensor
- Calcitonin Release
- Blood Calcium Decreases
- Bone Building
Respiratory Anatomy
- Nasal Cavity
- Hair Filters
- Mucus Filters and Moistens
- Capillaries Warm
- Pharynx (Throat)
- Larynx (Voice Box)
- Cilia Expel Mucus and Dust
- Trachea
- Bronchi
- Alveoli
Lung Sounds - Rhonchi
- Trachea and Bronchi
- Low Pitched Rumbling
- Gurgling
- Narrowed Airway
- Secretions or Bronchospasm
Lung Sounds - Wheezes
- Throughout Lung
- High Pitched
- Musical
- Air Moving through Narrowed Airways
Lung Sounds - Crackles
- Lower Lobes
- Fine/Coarse
- Fine: Twisting Hair through Fingers
- Coarse: Velcro
- Collapsed Small Airways and Alveoli "Popping Open"
Lung Sounds - Pleural Friction Rub
- Anterior Lateral Lung
- Dry, Rubbing, or Squeaking
- Rubbing a Balloon with Finger
- Inflamed Pleura
Left Heart Failure Assessment
- Pulmonary Congestion
- Pink Frothy Sputum
- Wheezing or Crackles
- Dyspnea with Exertion
- Cough
- Fatigue
- Tachycardia
- Weak Peripheral Pulse
- S3, S4 Heart Sounds
Right Heart Failure Assessment
- Jugular Venous Distention (JVD)
- Peripheral Edema
- Hepatosplenomegaly
- Nocturia
- Weight Gain
- Ascites
- Fatigue
ECG: Atrial Fibrillation
- Variable Rate
- Irregular Rhythm
- No P Wave
- No PR Interval
- QRS < 0.12 Seconds
ECG: Atrial Flutter
- Variable
- Regular or Irregular
- Saw Tooth, Multiple Before Every QRS
- Non-measurable
- < 0.12 seconds
Aortic Stenosis
- Age-related Calcifications
- Bicuspid Aortic Valve
- Crescendo-decrescendo Murmur
- Systolic Murmur
- Ejection Murmur
- Ejection Click
- Radiates to Carotids and Apex
- Pulsus Parvus et Tardus
- Syncope
- Helmet Cells
Aortic Regurgitation
- Diastolic Murmur
- Immediate High-pitched
- Blowing Murmur
- Wide Pulse Pressure
- Water Hammer Pulse
- Head Bobbing
- Pulsating Nail Bed
- Can Cause Austin Flint Murmur
Tricuspid Regurgitation
- Holosystolic
- Blowing Murmur
- Radiates to Right Sternal Border
- Enhanced by Inspiration
Mitral Regurgitation
- Holosystolic
- Blowing Murmur
- Loudest at Apex
- Radiates toward Axilla
- Louder by Squatting
- Hand Grip
- Expiration
Mitral Stenosis
- Murmur Follows Opening Snap
- Late Diastolic Murmur
- Enhanced by Expiration
- Low-Pitched Rumbling
- Dilation of Left Atrium (LA)
- Recurrent Attacks of Rheumatic Fever
Coronary Arteries
- Aortic Root
- Right Coronary Artery (RCA)
- Right (Acute) Marginal Artery
- Posterior Descending Artery (PDA)
- Left Coronary Artery (LCA)
- Left Anterior Descending (LAD) Artery
- Circumflex Artery
- Left Marginal Artery
Leg Arteries
- Descending Aorta
- Iliac (Ilium)
- Common Femoral
- Deep Femoral
- Superficial Femoral
- Popliteal
- Anterior Tibial
- Posterior Tibial
- Peroneal
- Dorsalis Pedis
Breast Cancer Diagnosis
- Mammography
- Ultrasound
- MRI for High Risk Patients
- Confirmed with Biopsy
- Lymph Node Involvement
- Receptor Positivity
- Estrogen and Progesterone Receptors
- HER-2
Breast Cancer Interventions
- Radiation or Chemotherapy
- Hormonal Therapy
- Tamoxifen
- Lumpectomy
- Mastectomy
- Avoid BP and Injections Affected Arm
- Hand Exercises
- Grief Related to Body Image
- Prosthetics
- Reconstruction
- Lymphedema
Types of Hernias
- Hiatal
- Gastroesophageal Reflux Disease (GERD)
- Inguinal
- Men
- Femoral
- Women
- Incisional
- Umbilical
- Strangulation
Intestinal Obstruction
- Severe Abdominal Pain
- Vomiting
- High Pitched Bowel Sounds
- Abdominal Distention
- Increased Peristalsis
- Absent Bowel Sounds
- Paralytic Ileus
Chronic Kidney Disease Early Symptoms Assessment
- GFR < 60mL/min
- Accumulation of Waste Products
- General Malaise
- Hypertension
- Proteinuria
- Hyperkalemia
- Mineral and Bone Disorders
- Neuropathy
Chronic Kidney Disease Late Symptoms Assessment
- Metabolic Acidosis
- Severe Uremia
- Arrhythmias
- Edema
- CNS Depression
- Anemia
- Oliguria
- Pruritus
- End Stage Renal Disease (ESRD)
- GFR < 15mL/min
Chronic Kidney Disease Interventions
- Daily Weights
- Strict I/O
- Renal Diet
- Strict Medication Regimen
- Erythropoietin
- Manage Hyperkalemia
- Manage CKD-MBD
- Dialysis
- Kidney Transplant
Ejaculation Pathway
- SEVEn UP
- Seminiferous Tubules
- Epididymis
- Vas Deferens
- Ejaculatory Ducts
- Urethra
- Penis
Hydrocele
- Impaired Lymphatic Drainage
- Large Scrotum
- Painless
- Needle Aspiration or Surgery
- Scrotal Support
- Monitor for Bleeding and Infection
Testicular Carcinoma Assessment
- Seminoma Germ Cells
- Non-Seminoma Germ Cells
- Painless Scrotal Mass
- Testicular Swelling
- Acute Pain Rare
- Elevated Serum Tumor Markers
- Males Between 15-35 Years Old
- Cryptorchidism
- Testicular Self Exam
Osteoporosis Assessment
- Postmenopausal Women
- Long Term Corticosteroids
- Kyphosis
- Dowager's Hump
- Loss of Height
- Back Pain
- Pathologic Fractures
- Spinal Compression Fracture
Scoliosis
- S Shaped Lateral Spinal Rotation
- Unequal Shoulder and Scapula Height
- Uneven Gait
- Impaired Oxygenation
- Hump when Bending Forward
- Body Braces
- Worn 23 Hours/Day
- Surgery
- Adolescent Screening
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
- Conscious
- Confused
- Delirious
- Somnolent
- Obtunded
- Stuporous
- Comatose
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
Cranial Nerve Function
- CN I
- CN II
- CN VIII
- CN III
- CN IV
- CN VI
- CN XI
- CN XII
- CN V
- CN VII
- CN IX
- CN X
CN I
- Olfactory Nerve
- Sensory
- Smell
CN III
- Oculomotor Nerve
- Motor
- Eye Movement
- Accommodation
- Eyelid Opening
- Pupillary Constriction
CN IV
- Trochlear Nerve
- Motor
- Abducts, Depresses, Internally Rotates
CN V
- Trigeminal Nerve
- Sensory
- Facial Sensation
- Motor Function (Via Mandibular Nerve)
- Mastication Muscles
CN VI
- Abducens Nerve
- Motor
- Abducts Eye
CN VII
- Facial Nerve
- Lacrimation
- Salivation
- Sensory
- Taste from Anterior 2/3 of Tongue
- Motor
- Facial Movement
- Stapedius Muscle
- Eyelid Closing
CN IX
- Glossopharyngeal Nerve
- Sensory
- Taste from Posterior 1/3 of Tongue
- Monitoring Carotid Body and Sinus
- Motor
- Stylopharyngeus
- Swallowing
- Salivation
CN X
- Vagus Nerve
- Sensory
- Aortic Arch Chemoreceptors and Baroreceptors
- Taste from Epiglottic Region
- Motor
- Swallowing
- Palate Elevation
- Talking
- Coughing
- Midline Uvula
CN XI
- Accessory Nerve
- Motor
- Head Turning
- Shoulder Shrugging
CN XII
- Hypoglossal Nerve
- Motor
- Tongue Movement