NUR 304 Comprehensive Final Exam Study Guide

NUR 304 Comprehensive Final Exam Study Guide PowerPoint information (highlighted) Exam Rationales (highlighted) EXAM 1 Assessment phase of Nursing Process - Collection of Subjective data Collection of Objective data Validation of data Documentation of data Analysis of data (nursing diagnosis) Preparation for assessment (preintroductory phase) - Review client record Review with team members Educate about client condition and tests Introductory Phase - “Hello, my name is…” Protect HIPPA (close door, escort people out of room) “We are here for… we will discuss… I will take notes for my records.” Develop trust and rapport Subjective Data (working phase) - Biographical information History of present illness (COLDSPA) Personal health history Family history Health and lifestyle Review of systems Objective Data - Physical characteristics Body functions Appearance Behaviors Measurements (vitals, Intake and Output) o BP: 120/80 (< 130/90 = hypertensive, >100/80 hypotensive) o HR: 60-100 (> 60 = bradycardia, < 100 = tachycardia) o RR: 12-20 (> 12 = bradypnea, < 20 = tachypnea) o Temp: 97.8-100.4 (< 100.4 = febrile) o SP02: 94%-100% (> 94% = hypoxia) - Test (labs and radiology) Closing Phase - Summarize information Validate problems and goals Identify and discuss plan of care Analysis of data (nursing diagnosis) - Identify abnormalities/problems Cluster cues Draw inferences Propose and investigate possible nursing diagnosis, confirm or rule out Document conclusions Non-verbal communication - Appearance and demeanor Facial expression and attitude Silence and listening Verbal communication - Open-ended questions Closed-ended questions Laundry list Rephrasing Well-placed phrases Inferring Providing information Client Positioning - Sitting position Supine position (dorsal recumbent): lying on back Sims’ position: lies on their left side with their right hip and knee bent, and their left hip and leg straight (rectal exam) Standing position Prone position: Face down Knee–chest Lithotomy position: patient lying on their back with their legs raised and separated (vaginal exams) Palpation - Light, moderate, deep, bimanual Fingers: sensitive to fine discrimination (pulse, texture, size, shape, crepitus) Palmar (ulnar): sensitive to vibration, thrills, and fremitus - Dorsal (back): sensitive to temperature Percussion - Size, location, density, masses, pain and reflexes Direct, indirect, blunt Sounds: resonance (lung tissue), hyperresonance, tympany, dull (organs and masses), flat (scapula) Auscultation - Diaphragm: high pitch Bell: low pitch Documentation: use phrases for more concise documentation - Nonerasable ink Write legibly Facility-approved abbreviations Document client perception of their illness Dress and Appearance: determined upon first examining a client - Older generation: wear excess clothing due to cold intolerance (slowed metabolism and loss of sub-q fat Order of Assessment (NOT ABDOMINAL) - Inspection Palpation Percussion Auscultation Order of Assessment (ABDOMINAL) - Inspection - Auscultation - Percussion - Palpation Open-Ended Questions - Elicit feelings and perceptions Require more than a one-word response Beings with how or what Close-ended Questions - Obtain facts and focus on specific information 1–2-word response Begins with when or did General Assessment - Physical development, fat distribution and body build Level of consciousness Behavior, body movements, and affect - Vital signs Social support and socioeconomic status Clustering cues: Allows for relationship to be developed between the data (ex: wheezing, cough, SOB are all cues that relate to each other) Culture in healthcare: - Asians believe in the yin/yang theory (all aspects of a person are in perfect balance) Africans believe in holistic approaches Native Americans use shamans Hispanics use folk healers Hair Characteristics - Older adults: thinner hair (pubic, axillary, and body) Dull, dry hair may be seen with hypothyroidism and malnutrition Alopecia: hair falls out of places around the body (common in men) Older women can develop hair on chin due to hormonal changes Nail Characteristics - Older client: thickened, yellowed, and brittle (poor circulation) Spoon Nails: iron deficiency anemia Pitting: Psoriasis Beau lines: injury, hypocalcemia Clubbing: COPD, Crohn’s disease, CHF Leukonychia: hypoalbuminemia Pressure Ulcers - Stage 1: redness, non-blanchable Stage 2: partial-thickness skin loss Stage 3: Full thickness loss into the subcutaneous tissue Stage 4: Full thickness loss into the muscle and fascia Unstageable: unknow due to slough and eschar EXAM 2 Anatomy of Thorax and Lungs: - right main bronchus is shorter and more vertical than the left (aspirated objects more likely to enter the right lung than the left) Sternum: Manubrium, the body, xiphoid process 12 pairs of ribs Inspection of Thorax and Lungs - - AP diameter should be less than the transverse diameter (1:2 ratio) Barrel chest: costal angle of < 90 degrees (2:2 ratio) caused by emphysema due to hyperinflation Pectus excavatum: congenital malformation sunken sternum Pectus carinatum: forward protrusion of sternum Sternal retraction: severe labored breathing Kussmaul: rapid, deep, labored (DKA pts) Kyphosis: Hunched back Scoliosis: curved spine Accessory muscle usage o Neck: seen in chronic airway obstruction or atelectasis o Abdominal: seen in COPD o Tripod: seen in COPD Older clients: loss of lung elasticity, fewer functional capillaries, and a loss of lung resiliency (sternum and rib more prominent) Auscultation Thorax and Lungs - - Normal: bronchial, bronchovesicular, vesicular Adventitious Sounds o Fine crackles: high pitch popping during inspiration o Course crackles: low pitch bubbling o Wheezes: high pitch musical (foreign body obstruction) o Pleural friction: low pitch dry grating during both inspiration and exhalation (pleuritis) Bronchophony: “99” heard soft and muffled Egophony: “E” heard soft and muffled (“A” = pneumonia) Whispered pectoriloquy: “1-2-3” heard very faint and muffled Palpation Thorax and Lungs - - Aorta: use thumb and point in the epigastrium, slight left of midline (2.5-3cm wide) place the hands on the posterior chest wall with thumbs at the level of T9 or T10 and press together a small skin fold, client take a deep breath and observe the movement of the thumbs (symmetry) Fremitus: use ball of hand to feel vibrations Percussion Thorax and lungs - Start at the apices of the scapulae and percuss across the tops of both shoulders. Then percuss the intercostal spaces across and down, comparing sides. Percuss to the lateral aspects at the bases of the lungs, comparing sides. Anatomy of the Abdomen - RUQ: ascending/transverse colon, gallbladder, duodenum, liver, pancreas head, adrenal gland, kidney/ureter RLQ: appendix, cecum, ascending colon, right kidney, right ovary LUQ: adrenal gland, kidney/ureter, pancreas body and tail, spleen, stomach, transverse descending colon LLQ: kidney/ureter, ovary, spermatic cord, descending and sigmoid colon Midline: uterus, bladder, prostate gland Types of abdominal pain - Dull, aching: IBS, appendicitis, gastric ulcer Burning: PUD, GERD Pressure: BPH, prostate cancer, urinary retention Colicky: colon cancer Sharp: splenic rupture, renal tumor, vascular liver tumor Variable: stomach cancer Palpation of Abdomen - Psoas sign: pt lie on left side, hyperextend right leg (appendicitis) Rovsing sign: pain in the RLQ when deep palpating the LLQ (appendicitis) Rebound tenderness: pain immediately following palpation of the LLQ (appendicitis) Obturator sign: flex right knee medial and proximal (ruptured appendix) Cholecystitis: RUQ tenderness (murphy sign) Kidney: support flank while placing other hand in the upper quadrant, ask pt to inhale and hold breath *should feel kidney slip under fingers if done correctly* Percussion of the Abdomen - Kidney: use ball of hand, testing for tenderness (kidney infection) Tympany: over abdominal quadrants Dull: over liver and spleen Liver: 6-12cm long Inspection of the Abdomen - Ascites: pale, taunt skin, abdominal swelling Fluid wave test: place ulnar side of hand midline and tap with other hand accessing for movement EXAM 3 Neck - Structure: composed of muscles, ligaments, and the cervical vertebrae Within: hyoid bone, several major blood vessels, the larynx, trachea Thyroid gland: in the anterior triangle of the neck Heart sounds - First heart sound: closure of the atrioventricular valves. Second heart sound: closure of the semilunar valves. Ventricular contraction: all four valves are closed during systole. Diastole: AV valves are open and the ventricles are relaxed. Closure of the pulmonic valve: "dub" Pulses - 0=absent pulse 1+ =weak, diminished 2+ =normal, obliterate with moderate pressure 3+ =strong, obliterate with firm pressure 4+ =bounding, unable to obliterate Auscultation heart and neck - Aortic, pulmonic, Erb's point, tricuspid, mitral Murmur: swooshing or blowing Carotid arteries: use the bell, have client hold breath Bruit: blowing, swishing sound Inspection heart and neck - Jugular vein: have client look up and to the left/right, observe for distension or pulsation Apical: have client lie supine, look under diaphragm for pulsation Edema: collection of fluid, can be pitting or non-pitting o +1 = 2mm depression, +2 = 4mm, +3 = 6mm, +4 = 8mm Arteries - Carry oxygenated blood, nutrient rich Upper: brachial, ulnar, radial Lower: femoral, popliteal, dorsalis pedis, posterior tibial Veins - Carry deoxygenated blood Deep, superficial, perforator Femoral, popliteal, saphenous veins Lymphatic System - Capillaries and fluid exchange Connection between arterioles and venules Maintain vital equilibrium Venous insufficiency - aching and cramping pain, change in pigmentation of skin on lower extremities, thick and tough skin Pulses are present but may be difficult to palpate through edema Skin may be thickened and tough, reddish blue in color Breast - - Cancer risks: early menstruation, presence of BRAC1/BRACA2 genes, increasing age (average age 62), night shift work, secondhand smoke, large milk consumption and no prior pregnancies Invasive ductal carcinoma (IDC): 70-80% of breast cancers Woman and men can have breast cancer Palpating: use flat pad of fingers, vary levels of pressure, nipple to tail of spence Inspect breast while sitting first then supine Older clients: decrease in size and firmness, glandular tissue loss Male genitalia - External: penis, scrotum Internal: tetes, spermatic cord Inspection: have client stand Penis - Phimosis: tight foreskin than cannot be retracted Hypospadias: displacement of meatus to the ventral surface Epispadias: displacement of the meatus to the dorsal surface Yellow discharge is common in gonorrhea Clear or white discharge is common with urethritis Scrotum - Hydrocele: fluid collection in scrotal sac Hematocele: blood collection Varicocele: vein enlargement (lead to low sperm production) Cryptorchism: undescended testicle Prostate - Palpate the anterior surface of the rectum by turning the hand fully counterclockwise so that the pad of your index finger faces toward the client's umbilicus - Client will feel the urge to urinate during palpation Two lateral lobes between the sulcus, 2.5cm long and heart shaped Palpation is likely to raise the PSA level Female Genitalia - External: vulva, mons pubis, labia majora, labia minora, clitoris Internal: vagina, cervix, uterus, fallopian tubes, ovaries Lithotomy position for assessment Bimanual exam: insert two fingers inside the vaginal opening, pressure on the lower abdomen with other hand (palpating uterus and ovaries) Uterus - Anteverted: typical position, cervix pint posterior and uterus at level of bladder Anteflexed: uterine body flexed anteriorly in relation to the cervix Midposition: cervix pointed anteriorly; uterus more posterior Retroverted: body of uterus tilted backwards Bartholin Gland - Located inside the vaginal opening Palpate by placing your index finger in the vaginal opening and thump on the labia majora. Gently pinch. Swelling, pain and discharge indicate infection and abscess EXAM 4 Lymph Nodes - Filter lymph, a clear substance composed mostly of excess tissue fluid Produce lymphocytes and antibodies as a defense against invasion by foreign substances Less than 1 cm long and are buried deep in the connective tissue Clusters of 2-10 individual nodes Normally NON-palpable *know the locations under chin and in the neck* Head - Cluster headache: localized in the eye, radiate to the temporal region, common in late evening/ night, sudden onset, stabbing pain Brudzinski’s sign: flex neck forward, observe knees/hips flex involuntary (meningitis) Facial Nerves - I: smelling ability II: visual acuity with Snellen chart III: IV: V: VI: VII: ask client to smile, frown, wrinkle forehead etc. VIII: (auditory) Webber and Rinne test IX: open mouth and say “Ahh” X: open mouth and say “Ahh” XI: shrug shoulders XII: stick out tongue and move side to side Tendon reflexes - Arms: have client clench teeth Legs: have client interlock hands Tonsils - 1+: tonsils are visible 2+: tonsils are midway between tonsillar pillars and uvula 3+: tonsils touch the uvula 4+: tonsils touch each other Ears - Outer ear: pinna, external auditory canal, tympanic membrane Middle ear: malleus, incus, stapes Inner ear: cochlea, vestibules, eustachian tube, pharynx - Conductive hearing loss: block the passage of vibration to inner ear Sensorineural hearing loss: damage within the inner ear Weber test: vibration should be heard in both ears equally Rinne test: tuning for on the base of the mastoid process Romberg test: feet together arms at side and close eyes (check equilibrium) Cone of light is at 5 o’clock Eyes - Arcus senilis: appears as a white arc around the limbus (normal in older clients) Myopia: far vision impairment with floaters or spot in vision (clients over 40) Cataracts: opacity over lens, sunlight and smoking are risk factors PERRLA, size: 1-7mm Ptosis: drooping of upper lip (oculomotor damage) Exophthalmos: protruding eyeball Entropion: inward turned lower eyelid Ectropion: outward turned lower eyelid Hordeolum: stye Range of motion - Adduction: toward the midline Abduction: away from midline Flexion: Extension: Goniometer: used to measure the angle of joint Lordosis: exaggerated curve of lumbar spine (pregnancy) Hands - Phalen’s test: place back of hands against one another at 90 degrees, hold for 60 seconds (carpal tunnel) Tinel’s sign: percussing lightly over the median nerve located on the inner aspect of the wrist (carpal tunnel)