Nur 155 Exam 3 with verified solutions

Atelectasis collapsed lung Fowlers position 45 degrees semi-Fowler's position 30 degrees High-Fowler's position 60-90 degreesa Stimulus Agent or act that stimulates a nerve receptor Receptor Nerve cell acts as a receptor by converting the stimulus to a nerve impulse. Most are sensitive to only one type, such as visual, Audio or touch Impulse conduction Travels along Nerve pathways to to the spinal cord or brain. Perception the process of organizing and interpreting sensory information Sensory deficit Loss or impairment of sensation Sensory Deprivation The absence of normal levels of sensory stimulation Sensory overload exposed to far more info than can be processed Kinesthetic Awareness of the position and movement of body parts Steriognosis Perceive and understand an object by size, shape and texture through touch Sensoristasis Person of optimal arousal Somnolent extreme drowsiness but does respond to stimuli Acute confusion delerium Chronic Confusion dementia Contractures permanent contraction or shortening of the muscle Atrophy to waste away from lack of use Pooling of respiratory secretions inactivity that interferes with the normal diffusion of O2 Co2 in the Alvioli Lack of exercise in the elderly muscle tone, bone density, joints lose flexibility reaction time slows, bone mass decreases Greatest risk for a Thrombus Impared Venus return, hyper coagulability, injury to a vessel wall. Stage 1 wound non blanchable Stage 2 Wound Partial Thickness, epidermis and ? dermis, blister, Erythema Stage 3 Wound Full thickness, not through the fascia Stage 4 wound Full thickness, through muscle, tendon, and fascia Unstageable Wound unknown depth thickness, covered with eschar Signs of infection Redness, warmth, swelling, pain, odor, exudate Exudate Purulent drainage Purulent Pus Dehiscence Opening of the surgical wound Evisceration internal organs exposed through body Boggy Spongy Exudate fluid that has passed out of a tissue or capillaries as a result of inflammation or injury serous fluid Clear serum (watery) (blister) Purulent exudate pus Sanguineous exudate Large amounts of red blood cells indicating capillary damage (open wounds) Serosanguineous clear and blood tinged drainage (surgical wounds) Purosanguineous Pus and blood discharge (new infected wound) 8 rights Patient, Med, Dose, Time, Route, Education, Expiration Date, Assessment, Documentation, Refusal, Evaluation Female Foley cleaning Distal, Proximal, Medial Wound Cleaning Medial, Distal, Proximal Nasal Trumpet 80-120 Oxygen face tent percent 30%-50%, Oxygen face tent Liters/hr. 4-8 l/hr. Oxygen mask simple percent 40% - 60% Oxygen mask simple Liters/hr. 5 - 8 l/hr Partial rebreather 40%-60%, 6-10 l/hr.