NUR 230 Exam #3 Ch. 11, 19, 21, 23, 24,
25 OBJECTIVES
- ANS -Excessive purine intake can lead to hyperuricemia, a condition caused when there's too
much uric acid in the bloodstream. Researchers have found that high uric acid levels in the body
are correlated with an increased risk of diabetes.
\1.Describe the local anatomical landmarks for recording data about the abdomen. - ANS -
\1.Describe the structure and function of the musculoskeletal system. - ANS -Bones;
provide structure, protection, store calcium, produce blood cells, compact & spongy bone,
various shapes (short/long)
> Compact bone; hard outer layers
> Spongy bone; inside/end of bone w spaces
Skeletal Muscles;
assist with posture, allow movement, produce body heat
> 3 types; skeletal, smooth, cardiac
• 650 muscles
• attach to bones by tendons
Joints;
where 2 bones meet, provide ROM
> Fibrous; immobile like sutures on the skull
> Cartilaginous; like between vertebrae
> Synovial; shoulders, wrists, ankles, etc.
\1.Describe the structure and function of the neurologic system. - ANS -Function; coordinates
and regulates body functions. Receives, interprets, and reacts to stimuli. Made up of the CNS
and PNS.
• CNS; brain and spinal cord, primitive brain function
• PNS; carries info to/from CNS, consists of 12 pairs of cranial nerves and 31 pairs of spinal
nerves
> Autonomic; subconscious, Thymus, lungs, digestion
> Somatic; voluntary muscle movement
º Autonomic NS;
- Sympathetic; "fight or flight", activated during
times of stress, increases BP, decreases
digestion.
- Parasympathetic; arise from craniosacral
regions "rest and digest"
\1.Locate surface landmarks and reference lines of the anterior and posterior thorax. - ANS -
,\1.Review A & P - ANS -
\1) Describe culture and its basic characteristics. - ANS -Culture is the "totality of socially
transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of
human work and thought characteristics of a population or people that guide their worldview and
decision making."
- Culture is a shared system of values, beliefs, and learned patterns of behavior
- Characteristics of Culture;
• learned from birth
• shared by others
• associated with adaptation to the environment
• universal
\10)Differentiate between skills needed for a general routine cultural screening versus skills
needed for a focused cultural assessment. - ANS -In a cultural assessment, take into
consideration; pts faiths, beliefs, view of life, extent of community involvement, religious
practices, view on purpose of life, self perception, spiritual expectations, and self care
treatments
\11)Analyze the data from the interview and assessment of a client's culture and formulate valid
nursing diagnoses, collaborative problems, and/or referrals. - ANS -
\12)Communicate interview and assessment cultural findings through clear concise
documentation and verbal reports - ANS -
\2.Describe the process of a cardiac physical assessment. - ANS -Inspect and Palpate Neck
vessels
Expected; visible jugular pulsations, but vein not visible itself, not distended, no edema, no
tenderness, no bulging
Palpated Carotid artery; (auscultate first) then palpate
unilaterally, gently
- Expected; no blowing or swishing heard, 2+ reg
Auscultate heart sounds & count apical pulse for 60 seconds
\2.Describe the process of a thorax and lung assessment.
AUSCULTATION - ANS -- patient should sit comfortable, breath through mouth, listen to a full
inspiration and expiration at each site, only use diaphragm on bare skin, complete auscultation
in an organized fashion, all anterior then all posterior.
Expected findings;
breath sounds equal, clear, without adventitious sounds bilaterally, vesicular breath sounds over
peripheral lung fields, muffled voice.
\2.Describe the process of a thorax and lung assessment.
, INSPECTION - ANS -Left lung; narrower, 2 lobes, upper lower
Right lung; shorter, 3 lobes, upper middle lower
Inspection; overall demeanor relaxed and calm
• LOC - AOx3
• Skin and nail color (no cyanosis)
• Temperature (should be warm to the touch)
• Moisture (no diaphoresis)
Inspection; Thorax
• spinous processes in straight line, position of sternum, sternal retraction?, thorax symmetric,
elliptical shape, downward sloping ribs
• AP; Transverse Diameter should be 1:2
• Barrel Chest;
- AP to transverse diameter 1:1
- Ribs horizontal (not downward sloping)
- chest appears expanded
- caused by chronic COPD or chronic emphysema
Quality of Respirations;
• smooth, effortless
• rate appropriate for age
• chest rise symmetrical, no nasal flaring, no tracheal deviation, no pursed lips, no retraction or
use of accessory muscles
\2.Describe the process of a thorax and lung assessment.
PERCUSSION - ANS -Resonance; predominant in healthy lung tissue, low pitch, clear, hollow
sound
Hyper-resonance; lower-pitched caused by too much air present
• Ex; emphysema, pneumothorax
Dull; soft, muffled thud, caused by abnormal increase density in lungs
• Ex; pneumonia, pleural effusion, atelectasis, tumor
\2.Discuss contents of the abdomen and accessibility to examination. - ANS -RUQ; liver, gall
bladder
LUQ; spleen
LLQ; descending colon, sigmoid colon
RLQ; appendix, ascending colon
25 OBJECTIVES
- ANS -Excessive purine intake can lead to hyperuricemia, a condition caused when there's too
much uric acid in the bloodstream. Researchers have found that high uric acid levels in the body
are correlated with an increased risk of diabetes.
\1.Describe the local anatomical landmarks for recording data about the abdomen. - ANS -
\1.Describe the structure and function of the musculoskeletal system. - ANS -Bones;
provide structure, protection, store calcium, produce blood cells, compact & spongy bone,
various shapes (short/long)
> Compact bone; hard outer layers
> Spongy bone; inside/end of bone w spaces
Skeletal Muscles;
assist with posture, allow movement, produce body heat
> 3 types; skeletal, smooth, cardiac
• 650 muscles
• attach to bones by tendons
Joints;
where 2 bones meet, provide ROM
> Fibrous; immobile like sutures on the skull
> Cartilaginous; like between vertebrae
> Synovial; shoulders, wrists, ankles, etc.
\1.Describe the structure and function of the neurologic system. - ANS -Function; coordinates
and regulates body functions. Receives, interprets, and reacts to stimuli. Made up of the CNS
and PNS.
• CNS; brain and spinal cord, primitive brain function
• PNS; carries info to/from CNS, consists of 12 pairs of cranial nerves and 31 pairs of spinal
nerves
> Autonomic; subconscious, Thymus, lungs, digestion
> Somatic; voluntary muscle movement
º Autonomic NS;
- Sympathetic; "fight or flight", activated during
times of stress, increases BP, decreases
digestion.
- Parasympathetic; arise from craniosacral
regions "rest and digest"
\1.Locate surface landmarks and reference lines of the anterior and posterior thorax. - ANS -
,\1.Review A & P - ANS -
\1) Describe culture and its basic characteristics. - ANS -Culture is the "totality of socially
transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of
human work and thought characteristics of a population or people that guide their worldview and
decision making."
- Culture is a shared system of values, beliefs, and learned patterns of behavior
- Characteristics of Culture;
• learned from birth
• shared by others
• associated with adaptation to the environment
• universal
\10)Differentiate between skills needed for a general routine cultural screening versus skills
needed for a focused cultural assessment. - ANS -In a cultural assessment, take into
consideration; pts faiths, beliefs, view of life, extent of community involvement, religious
practices, view on purpose of life, self perception, spiritual expectations, and self care
treatments
\11)Analyze the data from the interview and assessment of a client's culture and formulate valid
nursing diagnoses, collaborative problems, and/or referrals. - ANS -
\12)Communicate interview and assessment cultural findings through clear concise
documentation and verbal reports - ANS -
\2.Describe the process of a cardiac physical assessment. - ANS -Inspect and Palpate Neck
vessels
Expected; visible jugular pulsations, but vein not visible itself, not distended, no edema, no
tenderness, no bulging
Palpated Carotid artery; (auscultate first) then palpate
unilaterally, gently
- Expected; no blowing or swishing heard, 2+ reg
Auscultate heart sounds & count apical pulse for 60 seconds
\2.Describe the process of a thorax and lung assessment.
AUSCULTATION - ANS -- patient should sit comfortable, breath through mouth, listen to a full
inspiration and expiration at each site, only use diaphragm on bare skin, complete auscultation
in an organized fashion, all anterior then all posterior.
Expected findings;
breath sounds equal, clear, without adventitious sounds bilaterally, vesicular breath sounds over
peripheral lung fields, muffled voice.
\2.Describe the process of a thorax and lung assessment.
, INSPECTION - ANS -Left lung; narrower, 2 lobes, upper lower
Right lung; shorter, 3 lobes, upper middle lower
Inspection; overall demeanor relaxed and calm
• LOC - AOx3
• Skin and nail color (no cyanosis)
• Temperature (should be warm to the touch)
• Moisture (no diaphoresis)
Inspection; Thorax
• spinous processes in straight line, position of sternum, sternal retraction?, thorax symmetric,
elliptical shape, downward sloping ribs
• AP; Transverse Diameter should be 1:2
• Barrel Chest;
- AP to transverse diameter 1:1
- Ribs horizontal (not downward sloping)
- chest appears expanded
- caused by chronic COPD or chronic emphysema
Quality of Respirations;
• smooth, effortless
• rate appropriate for age
• chest rise symmetrical, no nasal flaring, no tracheal deviation, no pursed lips, no retraction or
use of accessory muscles
\2.Describe the process of a thorax and lung assessment.
PERCUSSION - ANS -Resonance; predominant in healthy lung tissue, low pitch, clear, hollow
sound
Hyper-resonance; lower-pitched caused by too much air present
• Ex; emphysema, pneumothorax
Dull; soft, muffled thud, caused by abnormal increase density in lungs
• Ex; pneumonia, pleural effusion, atelectasis, tumor
\2.Discuss contents of the abdomen and accessibility to examination. - ANS -RUQ; liver, gall
bladder
LUQ; spleen
LLQ; descending colon, sigmoid colon
RLQ; appendix, ascending colon
