Week 7 FINAL ATI Worksheet NR 304 VERIFIED BY EXPERT TUTOR

Week 7 FINAL ATI Worksheet NR 304 Purpose: This activity provides each student with the opportunity to review some of the main concepts that have been covered in Health Assessment I and II. This worksheet can help students better understand the concepts, learn strategies for mastering this content from other students, and more accurately apply the concepts to future patient care situations. Due Date: Submit the completed worksheet to the Canvas Module on or before the due date for up to 50 points. Points Possible: 50 points Requirements: Please answer these questions. If working on a computer, please use a color font other than black. You may use any notes that you have taken in this class session. You may use the textbook, any other book or other resource to answer the questions. Questions: Define subjective and objective data. Give three examples of each and state if the findings are documented in the history or physical examination findings. Subjective data= things that the patient states Pain Back hurts Headache Subjective data= things that can be observed or measured. Lab results Temperature Blood pressure List five actions a nurse should take when assessing a patient with a potentially critical hemodynamic state. Put your actions in priority order of 1-5. LOC Respiratory rate Blood pressure Heart rate What does the priority setting ABC mean? How does the nurse use this mnemonic in patient assessment? If a patient has a slow or rapid respiratory rate, is airway the primary concern? ABC= Airway, Breathing, Circulation If airway is compromised, then they won’t be able to breath and circulation will then be affected. Yes, because if the airway is causing the respiration to change it needs to be addressed or they’ll eventually not be able to breath What is HIPAA? Describe one situation when the nurse must adhere to HIPAA. Health Insurance Portability and Accountability Act, which establishes policies and procedures for maintaining the privacy and the security of individually identifiable health information. A nurse will use it when she has her patient’s information and not talking about the patient outside the room or using patient’s personal information to other people. Describe the process of taking a pulse. What is a normal pulse? What are qualities of a normal pulse? What is the first action a nurse should take when the pulse is not as expected? Pulses should be palpable (2+), if not feet should still have good color and be warm. What is dehydration? List three subjective and three objective findings of dehydration. List the expected vital signs of a patient who is dehydrated. Excessive loss of water from the body tissues accompanied by a disturbance of body electrolytes Subjective findings: thirsty, headache, lethargic Objective findings: skin turgor, color of urine (more concentrated) , low blood pressure  HR Fever  blood pressure How is fluid volume deficit related to dehydration? How would concentrations of some solutes (solids) change with dehydration? Why? Body fluids have decreased volume but normal osmolality With dehydration the concentration increases, and urine becomes darker because there’s not enough water in the urine to dilute it. What is an undesirable response of the body to a fever? Sweating, chills, shivering, headache, muscle aches, loss of appetite, irritable, dehydration, general weakness Why is this undesirable? What effect does it have? can cause hypothermia flu or cold that can lead to bed rest and have all the undesirable symptoms What is the most serious skin cancer? What is one risk factor for this cancer and one teaching item to address with your patient? Describe this most serious skin cancer below. Malignant Melanoma UV exposure and reducing exposure and wearing sunscreen Potentially lethal lesions that are the malignant transformation of melanocytes. May arise from preexisting nevus or de novo. Usually brown; can be tan, black, pink-red, purple, or mixed pigmentation. Often irregular or notched borders. May have scaling, flaking, oozing texture. Common locations: trunk and back; legs in women; and palms, soles of feet, and nails in Blacks. Risk factors are UV radiation from sun exposure and indoor tanning and family history. Rates are increasing in White men over 55 years and White women of all ages. Melanoma is the most common cancer in women ages 25-29 years and 2nd most common (after breast cancer) in women ages 30-34 years. In dark skinned client, where is the best area to assess for jaundice (not skin or sclera)? Best place to assess for pallor? Best place to assess for cyanosis? Jaundice= hard palate in mouth Pallor= mucous membranes, lips, and nail beds. Cyanosis= lips, nose, cheeks, ears, and oral mucous membranes To document pitting edema, the nurse measures the following depths of pitting. What is the corresponding scale (1+, 2+, 3+, 4+ )2mm deep = _1 +, 4mm deep = 2_+, 6 mm deep = 3_+, 8 mm deep = _4 + What is a body system complication for the client who is a chronic heavy drinker? Name 3 possible associated findings associated with this complication. Argyll Roberstson pupils Peripheral neuropathy Liver cirrhosis It is important to encourage the elderly client to continue to be as active as possible. List five complications associated with the inability to move independently. Degenerative disease Neurological trauma Chronic illness Stroke Falls or injury Describe fluid volume overload. List a possible cause of FVO. List three signs/symptoms of FVO. Caused by rapid infusion or larger volume of blood products. Pitting Edema 4+ Puffy eyelids Elevated blood pressure Describe fluid volume deficit. List a possible cause of FVD. List three signs/symptoms of FVD. Fluid loss exceeds intake and electrolyte levels become unbalanced Recent rapid weightloss Change in mental status Fever Differentiate between oral candidiasis and leukoplakia. List one possible cause of each. Oral candidiasis= thrush; when yeast infection develops on the inside of the mouth and on tongue. Leukoplakia= white or gray patch that develops on the tongue, the inside of the cheek, or on the floor of the mouth. It is the mouth’s reaction to chronic irritation of the mucous membranes of the mouth. What is a common manifestation that an elderly client has an acute problem such as infection or stroke Delirium/ confusion What are crackles? How would you describe the sound crackles? Discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing. Describe two pathological conditions when the nurse would expect crackles on auscultation. Pneumonia Heart failure What are wheezes? How would you describe the sound of wheezes? Continuous, coarse, whistling sound produced in the respiratory airways during breathing. Describe two pathological conditions when the nurse would expect wheezes on auscultation. Obstruction Chronic emphysema What is the significance of a syncopal episode in the elderly client? Postural hypotension Describe the subjective and objective findings of a client with a pneumothorax. Subjective= sharp pain on inspiration Objective= unequal chest expansion Describe the subjective and objective findings of a client with a pulmonary embolus? Subjective= dyspnea & sudden chest pain Objective= cyanosis, tachycardia, drop in blood pressure Describe the subjective and objective findings of a client with pneumonia. Subjective= chest pain and dyspnea Objective= fever, chills, productive cough, purulent mucus Describe the subjective and objective findings of a client with emphysema. Subjective= shortness of breath Objective= absent breath sounds on one side, JVD Describe the subjective and objective findings of a client with a myocardial infarction. Subjective= chest pain that radiates to left side; crushing or stabbing pain Objective= lack of oxygen in the heart Describe the subjective and objective findings of a client with congestive heart failure Subjective= tightness in chest, fatigue, anxiety Objective= decreased O2, tachycardia, left sided fluid backup in lungs Describe the subjective and objective findings of a client with a suspected stroke or TIA. List at least three assessments a nurse will perform for a suspected stroke or TIA. Subjective= tingling, numbness, disphasia, headache, nausea, dizziness Objective= facial drooping, paralysis, aphasia, dysphasia, incontinence, LOC change