NR 304 Final Exam Review

- Hypovolemic Shock NR 304 Final Exam Review • Volume depletion; plasma of the blood is too low • S/s- a. Dehydration b. Dizziness c. Fainting d. Fatigue e. Thirst f. Weakness g. Nausea h. Vomiting i. Tachycardia j. Insufficient urine production k. Mental confusion l. Pallor m. Sleepiness - Deep Vein Thrombosis • Deep vein occluded by a thrombus • Inflammation, blocked venous return, cyanosis, edema • Virchow triad- stasis, hypercoagulability, endothelial dysfxn • Causes- prolonged rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, estrogen hormone use, smoking • S/s- intense, sharp, deep calf pain; warmth, swelling, redness, dependent cyanosis, tender to palpation • Wells criteria - Vitals on Infants and Toddlers • Respirations  pulse  temperature • Rectal temperature w/ infants • Tympanic or temporal w/ toddlers • Pulse- palpate or auscultate an apical rate • Respirations- watch infants abdomen for diaphragmatic respirations; sleeping rate most accurate a. Neonate = 30-40 bpm b. 1 y/o = 20-40 bpm c. 2 y/o = 25-32 bpm • Blood Pressure- annual BP 3 y/o and up; most common error is wrong size cuff; crying stopped for 5-10 mins before measuring - Peripheral Artery Disease • Affects noncoronary arteries supplying the limbs; usually caused by atherosclerosis • More men have PAD than women • S/s- coolness in skin, weak thready pulse • Ankle-Brachial Index of 0.9 or lower = PAD • Beginning vs end stage? - COPD • Obstruction of air flow • S/s- barrel chest, wheezing, decreased breath sounds, accessory muscle use, clubbing, paradoxical pulse • A-P diameter = transverse - Contact Dermatitis • Local inflammatory reaction to an irritant in the environment or an allergy • S/s- erythema, swelling, wheals (urticaria), maculopapular vesicles, scales, intense pruritus • Can be caused by poison ivy • Vaginal- a. Red, swollen vesicles b. Weeping of lesions c. Crusts d. Scales e. Thickening of skin f. Excoriations from scratching g. Pruritus • Diaper Dermatitis- a. Red, moist, maculopapular patch with poorly defined borders in the diaper area, b. Extending along inguinal and gluteal folds c. History of infrequent diaper changes or occlusive coverings d. Inflammatory disease caused by skin irritation from ammonia, heat, moisture, occlusive diapers. • Atopic Dermatitis (Eczema)- a. Erythematous papules and vesicles, with weeping, oozing, and crust b. Lesions usually on scalp, forehead, cheeks, forearms, and wrist, elbows, back of knees c. Paroxysmal and severe pruritis d. Family history of allergies - Pursed Lip Breathing • Inhaling through the nose and exhaling through pursed lips • Lips are puckered when exhaling • Helps the airways stay open during exhalation - Emphysema • Caused by destruction of pulmonary connective tissue; permanent enlargement of the air sacs distal to terminal bronchioles and rupture of interalveolar walls; increased airways resistance; hyperinflated lung and increased lung volume • S/s- a. Increased AP diameter (barrel chest) b. Accessory muscle use c. Tripod position d. SOB e. Respiratory distress f. Tachypnea g. Decreased tactile fremitus h. Decreased chest expansion i. Hyper-resonant breath sounds j. Decreased breath sounds k. Prolonged expiration l. Muffled heart sounds m. Occasional wheezing - Chronic Bronchitis • Proliferation of mucus glands in the passageways resulting in excessive mucus secretion; inflammation of bronchi w/ partial obstruction of bronchi; sections of lung distal to obstruction may be deflated; chronic caused by smoking • S/s- a. Hacking b. Rasping cough  productive (thick mucoid sputum) c. Dyspnea d. Fatigue e. Cyanosis f. Clubbing g. Tactile fremitus normal h. Resonant lung sounds i. Normal vesicular sounds j. Prolonged expiration k. Crackles over deflated areas l. May wheeze - Lung Sounds • Normal lung sounds- a. Bronchial- high pitch, loud amplitude, I < E, harsh/hollow; TRACHEA AND LARYNX b. Bronchovesicular- moderate pitch, moderate amplitude, I = E, mixed quality; SCAPULA AND STERNUM c. Vesicular- low pitch, soft amplitude, I > E, rustling quality; LOBES OF LUNGS • Abnormal lung sounds- a. Fine Crackles- high pitched; during inspiration; not cleared by coughing; inhaled air collides w/ previously closed airways; HEART FAILURE, COPD, CHRONIC BRONCHITIS b. Coarse Crackles- loud, low pitched bubbling/gurgling sounds; start in early inspiration and can go into expiration; secretions in trachea; PULMONARY EDEMA, PNEUMONIA c. Pleural Friction Rub- coarse and low pitched, pleurae lose lubricating fluid; PLEURITIS d. High Pitched Wheeze- predominate in expiration; air compressed through narrow passageways; ACUTE ASTHMA OR CHRONIC EMPHYSEMA e. Low Pitched Wheeze- predominant in expiration, can be in all phases; may clear by coughing; airflow obstruction; BRONCHITIS f. Stridor- high pitched, inspiratory, crowing sound, louder in neck; upper airway obstruction from swollen tissues; ACUTE EPIGLOTITIS - Human Papilloma Virus • Genital warts • Most common STI • Risk factors- early age at menarche, multiple sex partners • S/s- a. Painless warty growths b. Soft, pointed papules c. Single or multiple in a cauliflower patch d. Occur around vulva, introitus, anus, vagina, cervix • Vaccine to prevent cervical cancer • Boys and girls ages 9-26 y/o before sexually active • Although pap tests save lives, cervical cancer is rare in young women • In 2012 new recommendations are: (1) no pap tests for women under age 21 years, regardless of sexual activity. - Anus Assessment • Males- left lateral or standing position w/ toes pointed together • Females- lithotomy position • Inspection- a. Moist and hairless b. Coarse, folded skin that is more pigmented c. Anal opening tightly closed d. No lesions present e. Sacrococcygeal area  smooth and even f. Valsalva maneuver  no break in skin integrity or protrusion through anal opening - Inguinal Hernia • Assessment- a. Inspect inguinal region for bulge b. Palpate inguinal canal c. Ask male to shift weight to opposite side (unexamined leg) d. Place index finger low on scrotal half and palpate up spermatic cord e. Insert finger into external inguinal ring and ask man to bear down • Position- standing - Cranial Nerves • CN 1 Olfactory (sensory)- smell test • CN 2 Optic (sensory)- confrontation test, read card • CN 3 Oculomotor (motor)- PERRLA, cardinal fields • CN 4 Trochlear (motor)- PERRLA, cardinal fields • CN 5 Trigeminal (both)- clench teeth, touch face w/ q tip • CN 6 Abducens (motor)- PERRLA, cardinal fields • CN 7 Facial (both)- smile, frown, puff cheeks • CN 8 Vestibulocochlear (sensory)- hearing test • CN 9 Glossopharyngeal (both)- move tongue side to side, say ahh, light, tight, dynamite • CN 10 Vagus (both)- move tongue side to side, say ahh, light, tight, dynamite • CN 11 Accessory (motor)- shrug shoulders, push face • CN 12 Hypoglossal (motor)- move tongue side to side, say ahh, light, tight, dynamite - Self-Breast Exam • Best time to do it  after menstrual period - Jugular Venous Pressure • Normal jugular venous pulsation is 2cm or less above sternal angle • Elevated pressure = 3 cm or more above sternal angle while @ 45 degrees a. Occurs w/ heart failure, cardiac tamponade, constrictive pericarditis - Hypertension • Normal = <120 and <80 • Prehypertension = 120-139 or 80-89 • Stage 1 hypertension = 140-159 or 90-99 • Stage 2 hypertension = > 160 or > 100 • Risk factors- a. Modifiable- obesity, smoking b. Nonmodifable- race - Wernicke’s Area • Found in temporal lobe • Associated with language comprehension • When damaged, receptive aphasia results; person can hear sound but it has no meaning - Rheumatoid Arthritis • Chronic autoimmune disease w/ inflammation of synovial tissues and hyperplasia or swelling • Leads to fibrosis, cartilage and bone destruction that limits motion and appears as a deformity • Joint involvement is symmetrical and bilateral w/ heat, redness, swelling, painful motion • RA carries increased cardiovascular risk of heart attack and stroke • Acute RA- painful swelling and stiffness of joints; fusiform and spindle shaped swelling of soft tissue of proximal interphalangeal joints; fusiform swelling is symmetric, hands are warm, veins are engorged; limited ROM • Ankylosing spondylitis • S/s- a. Fatigue b. Weakness c. Anorexia d. Weight loss e. Low grade fever f. Lymphadenopathy - Prostatic Hypertrophy ***SATA*** • Inflammation of the prostate gland; caused by hormonal imbalance • S/s- a. Urinary frequency b. Urgency c. Hesitancy d. Straining to urinate e. Weak stream f. Intermittent stream g. Sensation of incomplete emptying h. Nocturia • Objective- a. Symmetric nontender enlargement b. Commonly in middle aged men c. Prostate surface feels smooth, rubbery or firm d. Median sulcus obliterated - Subjective Data • What the patient says about themselves and what they feel - Objective Data • What the nurse observes about the patient upon inspection and assessment - Closed Ended Questions • Questions that ask for specific information • They elicit a short or two word answer (yes or no) or a forced choice • Useful to fill in details that are left out and specific facts • Only ask one direct question at a time • Choose language the person understands - Open Ended Questions • Questions that ask for narrative information • States the topic to be discussed in general terms • Used to begin the interview, introduce new questions or when person introduces a new topic • Unbiased • Person is free to answer in any way • Lets person express themselves freely • Make eye contact and listen - Nonverbal Communication • Signs of pain • Etc - Kernig’s Sign • Meningitis • Person lays flat and extends knee; normally causes no pain - Romberg’s Test • Testing for balance and bodys sense of positioning • Person stands w/ hands @ sides and eyes closed for 20 seconds • Part of brain  cerebellum - Cerebella Ataxia • Staggering, wide-based gait • Difficulty with turns • Uncoordinated movement • Positive Romberg test • Causes- alcohol/barbiturate effect on cerebellum, cerebellar tumor, multiple sclerosis - Atelectasis • Collapsed alveoli as a result of airway obstruction, compression on the lungs, lack of surfactant • S/s- a. Cough b. Lag on expansion on affected side c. Increase RR and pulse d. Possible cyanosis e. Chest expansion decreased on affected side f. Tactile fremitus decreased on affected side g. Tracheal shift toward affected side h. Dull percussion over affected area i. Decreased breath sounds over affected area j. Fine crackles - ECG Strip • P wave- depolarization of atria • QRS complex- depolarization of ventricles • T wave- repolarization of ventricles - Herpes Zoster (Shingles) • Small grouped vesicles emerge along route of cutaneous nerve, the pustules and crusts; reactivation of chickenpox • Unilateral; does not cross midline • Pain is severe and long lasting in aging adults  “postherpetic neuralgia” - Atrial Fibrillation • Cardiac arrhythmia • Rapid, irregular beating of the atria that causes poor blood flow • May experience- a. Chest pain b. Dizziness c. Fatigue d. Palpitation e. Shortness of breath f. Weakness g. Inability to exercise - Pelvic Inflammatory Disease • Infection of fallopian tubes • Caused by STI bacteria (gonorrhea and chlamydia) • S/s- a. Sudden fever > 100.4 b. Suprapubic pain and tenderness c. Acute- rigid, boardlike lower abdominal musculature; purulent discharge; intense pain; bilateral adnexal masses d. Chronic- bilateral, tender, fixed adnexal masses • Complications- ecoptic pregnancy, infertility, reinfection - Therapeutic Communication • Avoid false reassurance • Unwanted advice • Using authority • Using avoidance language • Engaging distancing • Using professional jargon • Talking too much • Interrupting • Why questions • No judging • Instead of giving them answers give options instead - Pregnant Woman • Kyphosis • Lordosis • Anterior curvature of the neck • Slumped shoulders - Carpal Tunnel Syndrome • Increased uses of the wrists wears out the tendons in the wrists • Tinels sign- percussion at median nerve • Phalen test- hold hands back to back 90 degrees for 60 seconds • S/s- a. Pain b. Burning c. Numbness d. Positive Phalen test e. Positive Tinel sign f. Atrophy of thenar muscles - Lasegue’s Test • Straight leg raising • Checks for sciatic pain - Lymphedema • High protein swelling of the limb • Commonly caused by breast cancer treatment • Impeded drainage of lymph • S/s- a. Tired, thick, heavy arm b. Jewelry too tight c. Swelling d. Tingling e. Unilateral swelling f. Nonpitting brawny edema - Testicular Torsion • Sudden twisting of spermatic cord; late childhood and early adolescence; rare after 20 y/o; usually on left side; rotates medially; blood supply cut off • ***EMERGENCY*** • S/s- a. Sudden unilateral pain b. Lower abdominal pain c. Nausea d. Vomiting e. Red swollen scrotum f. One testis higher g. Thick, swollen, tender cord h. Cremasteric reflex absent on side of torsion - Hypospadias • Urethral meatus opens on ventral side of glans or shaft or at penosacral junction • Groove extends from the meatus to normal location @ tip • Congenital defect • Newborn should not be circumcised - Dehydration • S/s- a. Tenting b. Decreased BP c. Increased pulse - Prioritization • First level- a. Emergent, life threatening, immediate b. ABC’s and Vitals • Second level- a. Require prompt intervention to forestall further deterioration b. Mental status change c. Acute pain d. Acute urinary elimination problems e. Untreated medical problems f. Abnormal labs g. Risk of infection h. Risk to safety • Third level- a. Important to health but can be addressed after urgent problems b. Lack of knowledge, activity, rest, family coping - Osteoporosis • Not part of normal aging • Occurs primarily in postmenopausal white women • Decrease in skeletal bone mass and low BMD • Bone degenerates faster than new bone is created • Bones become spongy and weak • More easily broken • Risk factors- a. Sedentary lifestyle b. Smoking c. Diet d. Alcohol use e. Young age at menopause f. Lack of estrogen g. Small height and weight - Osteoarthritis • Degenerative joint disease • Noninflammatory, localized, progressive disorder involving deterioration of articular cartilages • Early stage- pain is worse with activity • Late stage- pain with rest and activity • Risk factors- a. Age b. Obesity (knee) • S/s- a. Hard, nontender, noninflammatory nodules b. Bony overgrowths  Heberden (fingertips, distal), Bouchard (knuckles, proximal) - Admin Pain Medication • 1st assessment? RESPIRATORY - Heart Sounds • Aortic Point  right 2nd intercostal space; S2 > S1 • Pulmonic Point  left 2nd intercostal space; S2 > S1 • Erbs Point  left 3rd intercostal space; S1 = S2 • Tricuspid Point  left 4th intercostal space, sternal border; S1 > S2 • Mitral Point  left 5th intercostal space, medial to midclavicular line; S1 > S2 - Infection • Lab value looking for in the assessment? ELEVATED WHITE BLOOD CELL COUNT - Toddler w/ Heart Failure? • S/s? a. Swelling of legs, ankles, eyelids, face, abdomen b. Fast breathing c. Shortness of breath d. Fatigue e. Nausea f. Falling asleep and sweating when feeding g. Lack of appetite h. Weight gain over a short period of time i. Cough and congestion in lungs j. Loss of muscle mass k. Failure to gain weight l. Change in skin temperature and color - Skeletal Traction • Placing a pin, wire, or screw in fractured bone and placing weights to pull the bone into the correct position • Infection- a. Redness b. Tenderness c. Pus - Diabetes Insipidus • Primary things to look for on this patient  frequent urination and extreme thirst leads to ***DEHYDRATION*** • Disorder of salt and water metabolism - HIPAA • Protection of patient health information - If you suspect abuse, do a complete assessment before assuming abuse only - Pregnant Woman’s Skin Appearance • Linea nigra- dark vertical line on middle of abdomen • Chloasma- increased pigment in the face • Striae gravidarum- stretch marks - Diabetes Mellitus • What to do if gave insulin @ wrong time? Incident report, call provider, monitor closely - Patient That Harms Themselves • Priority? Suicide precaution, assess cuts to determine need for medical attention • Assess mental status - HSV1 • Cold sores • Skin tingling and sensitivity  lesion erupts w/ vesicles then pustules • Lips or genital warts - Asthma • Breath sounds  wheezing - Capillary Refill • Greater than 3 seconds indicates what? ARTERIAL INSUFFICIENCY - Diarrhea, vomiting, what would you expect to see after 3 days? ***SATA*** • Skin appearance- tenting • Urine appearance- concentrated and dark • Circulatory- clubbing - What would you see with fluid volume excess? ***SATA*** • Edema • Increased BP • Shortness of breath • Bradycardia - Acute pain 10/10 • Tachycardia • Tachypnea • Increased blood pressure • Goes away after problem is resolved - Pulmonary Tuberculosis ***SATA*** • Inhalation of tubercle bacilli into alveolar wall • S/s- a. Initially nonproductive cough, later productive w/ purulent, yellow-green sputum; may be blood tinged b. Dyspnea c. Orthopnea d. Fatigue e. Weakness f. Moist skin @ night from night sweats g. Resonant sounds, dull over effusion h. Normal or decreased vesicular sounds i. Crackles over upper lobes following full expiration and cough - Anemia • S/s- a. Fatigue b. Pallor c. Tachycardia d. Shortness of breath - Procedure for Digital Rectal Exam • Checking for colorectal cancer • Insert gloved finger into rectum; patient take a deep breath; feel for abnormailities - Screening Age for Colorectal Cancer • At risk- 20-25 y/o • Not at risk- 50 y/o - Sexual Development • Males a. Puberty earlier in boys  avg age of 9 for African americans; 10 for whites and Hispanics b. 1st sign  enlargement of testes c. 2nd  pubic hair d. 3rd  penis size increases e. Sexual Maturity Rating 1. No pubic hair, fine body hair on abdomen; scrotum and penis same size as childhood 2. Few straight dark hairs at base of penis; testes and scrotum begin to enlarge 3. Sparse dark growth over entire pubis; penis begins to enlarge (length), scrotum further enlarged 4. Thick curly growth over pubic area; penis length and diameter increase (dev of glans), testes almost fully grown and darker 5. Adult size and shape of penis and scrotum • Females a. Estrogen hormones stimulate breast changes b. Breasts enlarge  fat deposition c. Duct system grows and branches d. At age 8-9 years  breast development for African American girls e. At age 10 years  breast development for white girls f. Early breast development linked to greater body mass g. Tenderness common h. Tanner staging: 1. Preadolescent- small elevated nipple 2. Breast bud stage- small mound of breast and nipple develops; areola widens 3. Breast and areola enlarge; nipple is flush with breast surface 4. Areola and nipple form a secondary mound over the breast 5. Mature breast- only nipple protrudes; areola is flush w/ breast contour i. Breast development precedes menarche (menstruation) by 2 years j. Menarche occurs in stage 3-4 of breast development (age 12) k. Sexual Maturity Rating 1. Stage 1- no pubic hair; mons and labia have fine vellus hair 2. Stage 2- sparse growth on labia; slightly curly 3. Stage 3- sparse over mons pubis; dark, coarse, curly 4. Stage 4- adult hair in smaller area 5. Stage 5- adult in type and patter (inverted triangle); also on medial thigh - Pain and Vital Signs • Pulse- increased • Blood pressure- increased • Respirations- increased - Venous Insufficiency • Brown discoloration occurs with chronic venous stasis caused by hemosiderin deposits from red blood cells degradation • Venous ulcers occurs usually at the medial malleolus because of bacterial invasion of poorly drained tissues - 45 y/o female in hospital and nonverbal cues is unhappy what are some reasons why? • Age differences • Culture • Male/female physician - Best person to get information from about a patient? • Directly from patient - Female patient normal finding • Supernumerary nipple  can get removed - How to Identify an Infection • Fever • Redness • Swelling • Heat - Type 1 Diabetes • Can cause neuropathic ulcers (feet) • Peripheral neuropathy • Assess glucose levels • S/s- a. Polyuria b. Polydipsia c. Frequent hunger d. Weight loss unexplained e. Ketones in urine f. Fatigue g. Blurred vision • Risk factors- a. Genetics b. Gestational diabetes c. Sedentary lifestyle d. Diet e. Race f. Obesity g. Age h. HTN - Testicular Self-Exam • Examine during shower or bath when testicles are warm • Thumb and first two fingers • Rubbery w/ smooth surface = normal • If lumps present  call doctor - Prostate Cancer • Common in older men • Curable • Men w/ first degree relative that has had prostate cancer are 2-3x more at risk • Diagnosis = PSA blood test and digital rectal exam - How to Assess Patient Before Initiating CPR • Check carotid pulse