NR 304 Final Exam Review.

NR 304 FINAL EXAM REVIEW Final Exam Review - Hypovolemic Shock • 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