NR 304 Final Exam Concepts 2

NR 304: Final Exam Concepts Chapter 1:  Identify steps of Nursing Process: Evaluation o Reassessment of patient o Have goals been met?  Identify tasks in Nursing Process: Diagnosis o Compiling data to determine NANDA diagnosis for patient o Cluster data, discard irrelevant information  Types of Databases: Problem Centered o Limited or short-term problem o Concerns one problem, complex, or body system o Used in all settings Chapter 9:  Identify Components of the General Survey o Study of the whole person o Begins upon entry to the room o Physical appearance  Age: person appears their stated age  Sex: development is appropriate for sex and age; if transgender note stage of transformation  Level of consciousness: alert and oriented to person, place, time, and situation  Skin color: color tone even, pigmentation varies, skin intact, note tattoos and piercings  Facial features: note symmetry  Overall appearance: acute distress? o Body structure  Stature: height in normal range for age/genetics?  Nutrition: weight within normal range for height/build?  Symmetry: body parts equal bilaterally?  Posture: stand erect comfortably? “plumb line” through anterior ear, shoulder, hip, patella, ankle  Exceptions are toddler lordosis and aging person with kyphosis  Position: sits comfortably with arms relaxed at sides and head towards examiner  Body build, contour:  Arm span = height  Crown to pubis ≈ pubis to sole  Obvious physical deformities? o Mobility 2  Gait: feet shoulder width apart, foot placement accurate, walk smooth and even, maintain balance without assistance, symmetric arm swing present  Range of motion: full mobility for each joint; movement is deliberate, accurate, smooth, coordinated; no involuntary movement o Behavior  Facial expression: maintains eye contact (if culturally appropriate), expressions appropriate to situation  Mood and affect: person comfortable and cooperative, interacts pleasantly  Speech: articulation clear and understandable  Speech pattern: fluent with even pace, conveys ideas clearly, word choice appropriate for culture/education, communicates easily by themselves or with interpreter  Dress: clothing appropriate to climate and culture, clean and fits body  Personal hygiene: clean and groomed appropriately for age, occupation, socioeconomic group o How does the patient interact with others? Chapter 10:  Differentiate the grading of Pulse Force o Three-point scale  3+ = full, bounding pulse  2+ = normal  1+ = weak, thready  0 = absent  Identify Hypotension Occurrences and Rationales o Acute myocardial infarction  decreased cardiac output o Shock  decreased cardiac output o Hemorrhage  decrease in total blood volume o Vasodilation  decrease in peripheral vascular resistance o Addison disease (hypofunction of adrenal glands)  decrease in circulating aldosterone  Recognize how to Count Respirations o Do not tell patient you are counting respirations o Continue for 30 seconds after assessing pulse o 30 seconds multiply by 2, or full minute if you suspect abnormality  Recognize the Effects of Smoking on Blood Pressure o Contributes to hypertension Chapter 11:  Identify Physiologic Changes: Acute Pain Responses o Guarding o Grimacing 3 o Vocalizations such as moaning o Agitation o Restlessness o Stillness o Diaphoresis o Change in vital signs Chapter 13:  Recognize the ABCDEF of Skin Lesions o Asymmetry o Border irregularity o Color variation o Diameter greater than 6mm o Elevation or evolution o Funny looking  Identify how to Assess for Clubbing and its indications o Have patient make a heart with their hands and look for gap between nails o Profile sign: view profile of index finger, nail base should be about 160 degrees  Recognize how to Detect Color Changes in Light and Dark Skin o Light skin  Pallor: generalized or localized pallor  Cyanosis: dusky blue, nail beds dusky  Erythema: red, bright pink  Jaundice: yellow in sclera, hard palate, mucous membranes o Dark skin  Pallor: yellow-brown skin yellow-brown, black skin ashen gray  Cyanosis: dark but dull, lifeless; check conjunctiva, oral mucosa, nail beds  Erythema: purplish tinge; palpate for increased warmth with inflammation  Jaundice: junction of hard and soft palate, palms  Recognize the Characteristics of Pressure Injuries: Stage I, II, III, IV o Stage I  Non-blanchable redness o Stage II  Partial-thickness skin loss  Looks like open blister with red-pink bed o Stage III  Full-thickness skin loss  Extends into subcutaneous tissue, resembles a crater  See subcutaneous fat, granulation tissue, and rolled edges o Stage IV  Full-thickness skin/tissue loss  All skin layers and supporting tissue