Milestone HESI Retake Latest 2023 Graded A

Milestone HESI Retake Latest 2023 Graded A Levels of Health Promotion primary, secondary, tertiary Application Examples of Levels of Promotion primary- weight loss, diet, smoking cessation Secondary- papsmears, mammograms, testicular exams Tertiary- medication therapy, surgical treatment, physical therapy, teaching foot care education to diabetic care Primary promotes health and preventing development of disease process or injury Secondary screening for early detection of disease Tertiary begins after illness is diagnosed and treatment. Aims to prevent long-term consequences of chronic illnesses or disabilities Nursing Assessments Comprehensive- (Head to Toe) = Can be done inpatient and through primary care (Physical assessment- annual exam) Focused- Health and physical hx of specific problem.- ex. Sick visit Emergency- crisis, life threatening. ex. airway, breathing, injury, disability, exposure, med reconciliation Phases of Interview process Pre-interaction, beginning, working (open and close ended questions), closing Data sources Primary- individual patient Secondary- chart info, family members Purposes of Documentation verbal communication, SBAR, written document Lifespan Nutritional Considerations - Nutrition: Pregnant Women need additional 300-500 cal/day (whole foods Lifespan Nutritional Considerations - Nutrition: infants/children infants/children: whole milk for ages 2-5 fat intake-brain development Lifespan Nutritional Considerations - Nutrition: Older BMR declines, Vitamin D supplements, Problems: decreased thirst, increase risk for osteoarthritis, osteoporosis, dementia, obesity, social isolation General Survey mental note of overall health (hygiene/appearance). Assessing pain: documentation, OLDCARTS/OPQRST. Aggravating and alleviating factors, pain goal and funtional goal Assessing Pain - Documentation Acute vs. Chronic-Location Priority Priority pain: stones (kidney, gallbladder, calcium and/or struvite), myocardial infarcation (HA), burns and sickle cell Heart Rate Elevated above 100 beats per minute Blood Pressure- Normal above systolic- 120-129, diastolic- less than 80, Blood Pressure- elevated Hypertension: Stage 1: 130-139 or 80-89, Stage Hypertension 2: more than 140, or greater than or equal to 90 When should BP be taken? after patient rests for 5 minutues or 30 minutes after caffeine, smoking Assessment of the Head and Neck Inspect, palpate, auscultate Infection If nodes are palpable, warm, tender = infection Assessment of the Ear - Techniques Adults: up and back Children: down and back Assessment of the Ear - Techniques Part 2 observe behavioral responses to speech, inspect ear formation (size, shape & any malformation to the auricle, condition) Perform whisper test & Rinne test. Pt plug one ear at a time Perform weber test (evaluate unilateral hearing loss Assessing the Chest inspect, palpate, percuss, auscultate Assessing Lung Sounds - Technique IPPA- inspect, palpate, percuss, auscultate Normal Lung Sounds Normal: bronchial (heard anteriorly) over larynx and trachea (INSPIRIATION slightly shorter than expiration), Bronchiovesicular (heard anteriorly and posteriorly)INSPIRATION AND EXPIRATION EQUAL , Vesicular (heard both) lower lungs, low pitch, INSPIRATION GREATER THAN EXPIRATION) Abnormal lung sounds: Rhonchi low- heard mainly in expiration when pt is breathing out (made up of one sound- whistle or whine and high pitch, musical instrument sound MULTIPLE sounds- mainly heard in expiration CONDITION: PNEUMONIA abnormal lung sounds: stridor airway obstruction, high pitch whispering or gas (CROUP, EMERGENCY, EPIGLOTTIS) Abnormal lung sounds: Crackles coarse(low pitch, wet sound) fine (high pitch, doesnt clear w/cough, crackling of fire sound) CONDITION:RESPIRATORY EDEMA/OBSTRUCTIVE DISEASE Abnormal lung sounds: Pleural Friction Rub Pleural friction rub (low pitch, harsh grating sound) Assessment of the Respiratory System tachypnea- rapid breathing bradypnea- slow breathing Normally, respirations are quiet and nonlabored, and occur at a rate of 12 to 20 times each minute in healthy adults. Note any flaring of the nostrils, muscular retractions, Heart Function System Abnormal size or location of the PMI or the presence of vibrations can indicate heart failure, myocardial infarction, disease of the heart valves, or other cardiac diseases. Abdominal Assessment Inspect, auscultate, percussion, and palpate. Nurse assess lumps, masses or tenderness Musculoskeletal System - Pronation & Supination prone- plank (face downward), supine- on the back, Disorder: osteoporosis- break down of bone (weight bearing activity is encouraged) Secondary osteoporosis- steroids' aka bones porous and bone prone to fractures Compression fracture- changing position slowly, tenderness of palpitation of spine, in pain Neuro Assessment- Cranial Nerves Olfactory (smell),Cranial Nerve 2: optic, cranial nerve 3: oculomotor, cranial nerve 4: Trochlear, cranial nerve 5: Trigeminal nerve, Cranial nerve 6: abducens cranial nerve 7: facial nerve cranial nerve 8: acoustic, cranial nerve 9: Glossopharyngeal cranial nerve 10: vagus cranial nerve 11: accessory cranial nerve 12: hypoglossal Full Description (Cranial Nerve 1: Olfactory (smell),Cranial Nerve 2: confrontational field (cover up eye in fields in all fields) and visual acuity (Snellen Chart) reading at 20 feet from the chart . Cranial Nerve III: oculomotor- nystagmus- moving penlight in 6 cardinal fields of gaze, Cranial nerve IV: Trochlear: assess pupil constriction (normal: 3-5 mm), PERRLA and Cranial nerve VI: Abducens , Cranial nerve 5: Trigeminal nerve- mastification (feel temporal and masseter muscle)open and close mouth against resistance, cranial nerve 7: facial nerve (open and close eyes, frown, smile, Cranial nerve 8: occlude ears and whisper word and pt repeat, Cranial nerve 9: Glossopharyngeal-test gag reflex, vagus nerve- pt able to speak and swallow, cranial nerve 11- accessory- shrug shoulders w/ease, Hypoglossal: pt moves tongue from side to side Confusion Causes underlying infections, dehydration, electrolyte imbalances Preventive Screening and Symptom Assessment - Tools & Uses Braden pressure ulcer scale (Sensory perception, moisture, activity, mobility, nutrition, friction and shear), fall risk assessment Heart Sounds - Technique & Representation of Sounds S1- louder than S2 S1-"lub", S2- "dub"= Systole S3- "dub", S4- "lub" = diastole Murmur Murmur- blowing or swooshing sound due to cardio or circulatory disturbance. Ex. anemia, pregnancy Adults aortic stenosis, mitral insufficiency Abdominal Assessment Inspect, auscultate, percuss, palpate. Feel for lumps, masses or tenderness Pronation plank (face downward Supination on the back Musculoskeletal System Disorder osteoporosis- break down of bone (weight bearing activity is encouraged Secondary osteoporosis steroids' aka bones porous and prone to fractures Compression fracture changing position slowly, tenderness of palpitation of spine, in pain Muscle Spasticity involuntary contraction of muscle. painful or tightening of muscle. muscle strength 5/5 with no pain, spasms or contractions