Summary NUR 111 - Exam 2 study guide.

NUR 111 Exam 2 Study Guide What is the importance of assessing a pt's pain status? It is critical to understand the patient's clinical status and progress. Which cultures care for ill members by protecting them from bad news about their health? collectivistic -Hispanic -African -Asian Why do we analyze vital signs? To interpret their significance and make decisions about appropriate interventions. Which approach ensures accuracy when taking vitals? organized & systematic What 3 actions should be taken when a significant change in vitals is observed? 1. verify changes 2. communicate changes 3. document changes When a pt's condition suddenly worsens, which site should be used to find a pulse quickly? carotid What is the most reliable & noninvasive way to assess cardiac function? apical pulse The exchange of oxygen & carbon dioxide between cells of the body & the atmosphere is ___________________ & the mechanical movement of gases into & out of the lungs is ___________________. respiration, ventilation ABG values measure... -arterial blood pH -partial pressure of 02 & C02 -arterial oxygen saturation CBC values measure... -red blood cell count -volume of red blood cells -concentration of hemoglobin Clinical judgment regarding vitals includes... -which vitals to measure -when to obtain the measurements -frequency of assessment Why would a critically ill child have cool skin & a high core body temperature? poor perfusion to the skin Why are older adults at high risk for hypothermia? -diminished sensation of cold -abnormal vasoconstrictor responses -impaired shivering What is indicated by the peripheral pulse? status of blood perfusion to that particular area When does hypotension occur? When the systolic BP falls below 90mmHg. What is indicated by orthostatic changes in vital signs? blood volume depletion List several factors that contribute to false elevations in BP. -talking during BP assessment -crossing of legs during assessment -smoking -caffeine intake -exercise What is the sequence of techniques used during a general physical assessment? 1. inspection 2. palpation 3. percussion 4. auscultation Palpable, circumscribed, solid elevation in the skin is a _______________, and a solid mass that may extend deep through subcutaneous tissue is a _________________. papule, tumor Circumscribed elevation of skin filled with serous fluid is a _________________, and a deep loss of skin surface that may extend to the dermis is an ______________. vesicle, ulcer Flat, non-palpable change in skin color. macule Assessment of the skin reveals changes in what? oxygenation, circulation, nutrition, local tissue damage & hydration Inspecting the skin includes inspecting for... color, moisture, temperature, texture, turgor, vascular changes, edema & lesions The condition of a patient's nails reflects... general health, state of nutrition, occupation & level of self-care The three types of hearing loss are... conduction, sensorineural & mixed The four types of adventitious sounds are... crackles, rhonchi, wheezes & pleural friction rub Adventitious/abnormal lung sounds result from... the air passing through moisture, mucous, or narrowed airways Key symptoms of heart disease include... chest pain/discomfort, palpitations, excess fatigue, cough, dyspnea, edema of the feet, cyanosis, fainting & orthopnea. The 5 P's of arterial occlusion are... pain, pallor, pulselessness, paresthesias & paralysis The most common symptoms of testicular cancer are... painless enlargement of one testis & a small, hard, pea-sized lump on the front or side of the testicle What is included in a complete health assessment? PT's subjective health history & head to toe physical and behavioral exams What are the main goals of the physical exam? -to collect baseline PT data -to supplement/confirm/refute data from the health history -to identify & confirm nursing diagnoses -to make clinical judgments about the patient's changing health status -to evaluate the outcomes of care The 5 essential skills of physical assessment are... inspection, palpation, percussion, auscultation & olfaction The bell of the stethoscope is best used for___________________ , & the diaphragm is best used for ____________________________. low-pitched sounds (vascular & heart), high-pitched sounds (bowel & lung) The integument includes... skin, hair, scalp & nails Assess for cyanosis by inspecting the _______________________, & assess for jaundice by inspecting the __________________________. nail beds, lips, base of tongue & skin; sclera, mucous membranes & skin Assess for pallor by inspecting the______________________________, & assess for erythema by inspecting the ________________________________. face, conjunctivae, nail beds & palms of hands; face, area of trauma, sacrum, shoulders/bony prominences The temperature of the skin depends on... the amount of blood circulating through the dermis The two main causes of edema are... direct trauma & impaired venous return Lesions must be inspected for_________________ & the scalp should be assessed for__________________________. color, location, texture, size, shape, type, grouping & distribution; thickness, texture, hair distribution & lubrication To inspect the ear of an adult or older child, pull the pinna_____________________, but for a child under 3, pull __________________. up & back, down & back Older adults are at greater risk of hearing loss due to... ototoxicity Nasal mucosa that is pale with clear discharge indicates __________________, and nasal discharge that is yellowish or greenish indicates ______________ ________________. allergy, sinus infection Things to note about the pt even before you begin taking the history... gender, race, age, body type, gait, posture, hygiene, dress, body odor, speech, mood, signs of distress Localized skin changes like pallor & erythema often indicate... circulatory changes You can identify a stage 1 pressure ulcer early by noting... warmth & erythema Examination of the eye includes... assessment of visual acuity, visual fields, and internal & external eye structures The 6 keys to a successful exam... provide privacy, have good lighting, keep pt comfortable, have all necessary equipment, communicate with the pt, be respectful During the HEENT assessment, each area should be examined for... symmetry, size, shape & color Rapid ventricular filling may create a 3rd heart sound, usually heard in... children & young adults The anatomical sites for assessment of cardiac function are... aortic, pulmonic, second pulmonic area, tricuspid, mitral & epigastric Pulse ranges for age groups are... Infant (6 months) 120-160 toddler (2 yr.) 90-140 preschooler 80-110 school age 75-100 Adolescents 60-100 adult 60-100 Respiration ranges for age groups are... Newborns 35-40 Infant (6 mo) 30-50 toddler (2 yr) 25-32 Children 20-30 adolescent 16-20 Adults 12-20 BP ranges for age groups are... newborn 40 (mean) infant (1 mo) 85/54 Infant (1 yr) 95/65 child (6 yr) 105/65 10-13 yr 110/65 14-17 yr 120/75 18 yr 120/80 The PMI is best heard at... 5th intercostal space The difference between pulses assessed from two different sites is the... pulse deficit The difference between the systolic pressure and the diastolic pressure is the... pulse pressure The components of a nursing history are... -demographics -chief complaint (CC) -history of present illness (HPI) -past medical history (PMH) -family medical history (FH) -social history (SH) -review of symptoms (ROS) -physical exam (PE) -psychosocial-mental/emotional stressors OLD CART stands for... Onset Location Duration Character (severity) Associated symptoms Radiation Therapeutic measures What kinds of sympathetic stimulation will elevate BP? pain, anxiety, fear & a full bladder The depth of respirations is measured by... observing the degree of movement in the chest wall Clubbing of the nails generally indicates... chronic lack of oxygen; heart or pulmonary disease Diminished or unequal carotid pulsations indicate... atherosclerosis List some interview techniques that will enhance communication. active listening, eye contact, empathy, paraphrasing, summarizing, open-ended questions, back-channeling What is the series of techniques used during an abdominal assessment? 1. inspection 2. auscultation 3. percussion 4. palpation While communicating as nurses, we must be aware of... pacing of words, intonation, clarity & brevity, timing & relevance These valves close during systole, S1... mitral & tricuspid Signs & symptoms of peripheral vascular disease are... -pale, cool extremities -thickened nails -thin & shiny skin with decreased hair growth Signs & symptoms of altered cardiac function are... -dyspnea -fatigue -chest pain -orthopnea -syncope -palpations -edema of dependent body parts -cyanosis or pallor Risk factors for alterations in pulse are... -history of heart disease -cardiac dysrhythmia -sudden chest pain -acute pain -hemorrhage -an infusion of a large volume of IV -invasive cardiac tests Classification of BP for adults 18+ CATEGORY SYSTOLIC DIASTOLIC normal 120 & 80 prehypertension 120-139 or 80-89 stage 1 140-159 or 90-99 stage 2 or =160 or =100 Physical signs of hypertension are... -occipital headache -flushing of the face -nose bleed -fatigue in older adults Physical signs of hypotension are... -dizziness -mental confusion -restlessness -cool mottled skin over membranes -pale/dusky/cyanotic skin & membranes Which locations are used to assess pulse? temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial & dorsalis pedis Blood pressure is dependent on what 5 elements? -cardiac output -peripheral vascular resistance -blood volume -blood viscosity -artery elasticity The three elements of respiration are -ventilation -diffusion -perfusion During pt assessment, it is important to... cluster cues, make inferences, and identify emerging patterns & potential problems Before making an inference, you must always have... supporting cues To complete your pt assessment database, you must... review nursing, medical, and pharmacological literature that is pertinent to the illness The phases of the PT interview are... preparation, orientation, working, termination During which phase do you establish trust & confidence with a pt? orientation List 2 important goals of the initial PT interview. -to begin a relationship that allows the pt to become an active partner in decisions about care -to lay the groundwork for understanding the patient's needs A comparison of the assessment data with another source is as follows: validation The last step of a complete assessment is... communication of the assessment findings, either verbally or through written documentation Which cultures feel respected by firm eye contact when speaking? Spanish & French Which cultures find firm eye contact to be rude? Asian & Middle Eastern A change in vitals signs indicates... a change in physiological functioning or a change in comfort When vitals appear abnormal, the nurse should... have another nurse repeat the assessment An acceptable temperature range for adults depends on... age, gender, range of physical activity & state of health Which mechanism regulates body temperature? hypothalamus The transfer of heat between two objects without physical contact is ___________________, & heat transfer with direct contact is _________________, while heat transfer away from the body by air movement is _________________. radiation, conduction, convection Visually evident perspiration is known as... diaphoresis Fever fights viral infections by stimulating... interferon Why do children's temperatures rise so rapidly? they have immature temperature control mechanisms The objectives of fever therapy are... to increase heat loss, reduce heat production & prevent complications The 4 patterns of febrile activity are... sustained, intermittent, remittent & relapsing The most important sign of heat stroke is... hot, dry skin Rectal temperatures are generally... 0.9 F higher than oral temperatures Tympanic & axillary temperatures are generally... 0.9 F lower than oral temperatures The priority treatment for hypothermia is... prevention of further decrease in body temperature The most common sites used for pulse rate assessment are... radial & apical The most common alteration in blood pressure is... hypertension The best position for the pt while assessing BP is... sitting Heart sounds are sometimes difficult to hear in older adults because of... an increase in air space in the lungs A healthy eardrum appears... translucent, shiny & pearly gray This is common after trauma to a vessel wall, infection, immobilization or prolonged insertion of IV catheters.... phlebitis The best pt position for abdominal assessment is __________________ _________________, & the position that aids in the detection of murmurs is _________________ _________________. dorsal recumbent, lateral recumbent The most relaxed pt position used for assessment of head & neck, anterior thorax & lungs, breasts, axillae, heart, extremities & pulses is... supine The best lighting to use during a physical examination is... natural or halogen The ABCDs of assessment for cancerous skin lesions are... Asymmetry Border irregularity Color Diameter Lateral displacement of the trachea is caused by... -masses in the neck -masses in the mediastinum -pulmonary abnormalities As blood passes through a narrowed vessel, a blowing sound can be heard, called a ... bruit Common postural abnormalities include... -kyphosis (hunchback) -lordosis (swayback) -scoliosis (lateral curvature of the spine) As a patient's consciousness lowers, use this for an objective measurement of consciousness... Glasgow Coma Scale Injury to the cerebral cortex results in _____________, & its two types are ______________ & ________________. aphasia, sensory (receptive), motor (expressive) These valves close during S2... aortic & pulmonic Adventitious lung sounds that are high-pitched, musical & squeaky are________________, and those that are low-pitched & rumbling are ___________________. wheezes, rhonchi Adventitious lung sounds with a dry, grating quality are... pleural friction rub PT teaching should be done... throughout the examination To convert Celsius to Fahrenheit... x 1.8 + 32 To convert Fahrenheit to celsius... -32 & divide by 1.8 1 cm is equal to... 10 mm 1 inch is equal to... 2.5 cm % solution is equal to... # of g per 100 mL The hypothalamus tries to regulate a comfortable body temperature called the... set point Dehydration & febrile seizures occur in children between... 6 months and 3 years. When taking the temperature of a pt on protective isolation, use a .... chemical dot thermometer An increase in cardiac output will also increase... blood pressure How much can blood pressure drop during nighttime sleep? 10-20%