244 exam 3

what're the levels of health promotion

primary--> secondary--> Tertiary

how do you determine if its a primary health promotion

primary: education on prevention of disease (example: education on how to prevent high BP or getting vaccinated)

how do you determine is its a secondary health promotion

secondary: get screenings done or early treatment (example: BP screenings or colorectal screenings)

how do you determine if its a tertiary health promotion

tertiary: teaching people how to manage disease and make symptoms decrease (example: teach how to use insulin or getting rehab)

when does general inspection start

as soon as you lay eyes on the patient

what is the criteria for general inspection

physical appearance hygiene body structure body movement emotional status disposition behavior

what're the common findings with vital signs

- BP = 120/80 - pulse = 60-100 - 02 sats = 95-100% - respirations = 12-20 - temperature = 98.6 degree F

why do you need to know VS early on in the assessment

establishes a baseline about how the patient is doing physiologically

whats the concept related to hair, skin, and nails

integumentary

what is involved with the skin hair and nail assessment

- observe general appearance go the color and tone - inspect skin of head/scalp, neck, and upper chest for color, lesions, deformities, and symmetry - inspect skin of extremities for color, lesions, deformities, and symmetry - inspect fingernails for color and condition - inspect hair on head, face, body for distribution, fullness, color, and hygiene - palpate skin to assess moisture, temperature, mobility and turgor - palpate hair on head for texture - inspect, measure, and palpate lesion

what're expected findings you'd document for the skin hair and nails

skin: acne, wrinkles, scars, smooth/intact hair: color is normal throughout, coarse hair on scalp, facial hair fingernails: smooth, pink, intact, and angle if 160 degrees

how do you assess skin on both light and dark skinned patients

Cyanosis: - light: gray/blue tone in the nails, lips, mucous membranes - dark: ashen gray color seen in conjunctiva of the eye, oral mucosa, and nail beds juandice: - light: yellow color of skin, eyes, fingers, palms of hands, and oral mucosa - dark: yellow/green color most often seen in sclera erythema: - light: reddish tone with evidence of increased skin temp. - dark: deeper brown or purple tone with evidence of increased skin temp. pallor - light: paler white than normal - LIGHT skinned ppl: yellowing brown skin - DARK skinned ppl: ashen skin

what mnemonic device is used for suspicious nevi

ABCDE(F) a: Asymmetry b: border c: color d: diameter: e: evolving f:

who's at risk for pressure ulcers and why

anyone in the hospital and over people because they are stationary in a bed which puts them at risk due to the bony prominences

what measurement tool is used for pressure ulcers and how do you use it

Braden scale: assess the wound and score it 1-4 or unstageable (the lower the number the worse it is)

what the accurate description for a stage 1 pressure ulcer

intact skin with NON-blanchable redness if localized area

what the accurate description for a stage 2 pressure ulcer

partial thickness loss of DERMIS presenting as a shallow open ulcer with a red/pink wound bed

what an accurate description of a stage 3 pressure ulcer

full-thickness tissue loss, subcutaneous fat may be visible but BONE, TENDON, and MUSCLE are not exposed

whats an accurate description of a stage 4 pressure ulcer

full-thickness tissue loss with EXPOSED bone, tendons, and muscle

whats an accurate description of an unstageable pressure ulcer

full-thickness tissue loss and the base of the ulcer is covered by slough (yellow/tan/grey) and eschar (tan/brown/black) and the true depth of the wound can't be determined until the slough and eschar is removed to expose the base of the wound

what extra information do you document with a pressure ulcer

wounds length, width and depth plus any drainage

what're the 3 layers of the heart

- outermost: pericardium (little sac that keeps the heart where its supposed to be and where the pericardial fluid lubricates the heart to prevent friction) - middle later: myocardium (muscle layer) - innermost: endocardium (where the heart valves are)

what is APETM

aortic, pulmonic, erbs point, tricuspid, and mitral valve

what do you listen for during APETM

"lubb dubb" sound which is S1 and S2 - IF YOU HEAR EXTRA IT IS A MURMU AND NOT NORMAL

what is each valve in APETM function

- aortic: helps blood flow in correct direction through heart - pulmonic: divides right ventricular outflow into the pulmonary tract - erbs point: auscultation area for heart tones or murmurs - tricuspid: allows the blood returning to the heart from the body to go into the right ventricle where its then pumped into the lungs - mitral: keeps blood flowing in right direction

list whats going on in SYSTOLE, which 2 valves close, and if this contract or relaxes

Systole (S1 or Lubb) - ventricles CONTRACT - AV valves shut (tricuspid and mitral)

list whats going on in DIASTOLE, which 2 valves close, and if this contract or relaxes

Diastole (S2 or Dubb) - ventricles RELAX AND FILL - semilunar valves shut (aortic and pulmonic)

what're the 3 things that need to be documented about the heart

- heart tones - pulses - capillary refill

how do you describe edema

it is swelling due to excessive accumulation of watery fluid in the cells, tissues, serous cavities, or interstitial space - SIGN FOR HEART FAILURE (bilateral)

what is a DVT and who's at risk for them

deep vein thrombosis (clot) - anyone who is active and becomes inactive can get the, (post party, older adults, hospitalized people, someone on a long car ride, plane rides, students, etc.

why are DVT's dangerous/ where does it go if it were to become embolus

they can form in the lower extremities then break off where they travel to the heart where its circulated to the lungs and cause a pulmonary emboli which could then break off into the brain and cause a stroke

how do you prevent DVT's

move the patient by taking a walk/switching from bed to chair or roll them to prevent immobility

peripheral vascular disease (PVD): what is it and what would be assessment findings

it is: a slow progressive circulation disorder which narrows or blocks the perfusion to lower extremities assessment: edema that gets worse by the end of the day (need to wear compression socks), cap refill is greater than 3

how do you assess for respiratory distress

check respiratory rate, the pattern, and chest expansion (inspect, auscultate, palpate) - expected: chest should rise and expand SYMMETRICALLY, men and infants abdominal breath, women: thoracic breathe - unexpected: chest RETRACTION (intercostal muscles drawn in-between ribs, airway obstruction (in pneumonia or asthma attacks), frequent yawning (anxious or fatigued)

identify and describe what crackle lung sounds are

- fine, high pitched crackle or popping noise - NOT cleared by cough - heard in INSPIRATION - found in pneumonia, heart failure, and restrictive pulmonary diseases

identify and describe what wheezing lung sounds are

- high pitched MUSICAL sounds similar to squeaking - commonly heart on EXPIRATION - heard in airway diseases where the thickness of the airway INCREASES (asthma)

identify and describe what rhonchi lung sounds are

- low-pitch, coarse, loud, SNORING, or moving tone - hear primarily during EXPIRATION - COUGH CAN CLEAR

identify and describe what pleural friction rub lung sounds are

- superficial, low pitched, coarse rubbing or grating sounds - two layers are rubbing together - heard on both INSPIRATION and EXPIRATION - NOT CLEARED WITH COUGH - heard in: pleurisy, or pericarditis

when assessing a patient with a chronic reparatory disease like COPD what're the expected clinical findings

COPD: - breathing is difficult - cough with mucous production - frequent respiratory infections - swelling in ankles feet or legs - COARSE CRACKLES

when assessing a patient with a chronic reparatory disease like emphysema what're the expected clinical findings

emphysema: - underweight individuals with barrel chest who become SOB with MINIMAL expiration - pursed lip breathing - tripod position - DIMINISHED BREATH SOUNDS - POSSIBLE WHEEZING AND CRACKLES

when assessing a patient with a chronic reparatory disease like asthma what're the expected clinical findings

asthma: - chronic respiratory disorder which is when the airway is obstructed and theres inflammation - there are triggers such as: environment, viral illness, allergens, and genetic predisposition - persistent cough thats worse at night - increase respirations - audible wheezing - SOB and tachycardia - use of accessory muscles

when assessing a patient with an acute respiratory illness or dysfunction like a pneumothorax how will they appear and what does is sound like

pneumo: - signs vary depending on amount of lung collapsing - MINOR: slight SOB, anxiety, reports of chest pain - LARGE: severe respiratory distress (tension pneumonia) - BREATH SOUNDS ABSENT

when assessing a patient with an acute respiratory illness or dysfunction like pneumonia how will they appear and what does is sound like

pneumonia: - viral vs bacterial: productive (colored sputum) vs non-productive cough (nothing comes out) - aspirations, fever, malaise, pleuritic chest pain, pulmonary consolidation - INSPIRATORY CRACKLES, WHEEZES, OR DIMINISHED BREATH SOUNDS

RUQ pain/underlying cause (including organs found here)

- CHOLECYSTITIS OR CHOLELITHIASIS organs: - liver + gallbladder (pain) - pylorus - duodenum - head of pancreas - RIGHT adrenal gland - portion of RIGHT kidney - portions of ascending and transverse colon (pain)

LUQ pain/underlying cause (including organs found here)

- PANCREATITIS organs: - LEFT lobe of liver - spleen (pain) - stomach - body pf pancreas (pain) - LEFT adrenal gland - portion of LEFT kidney - portions of transverse and descending colon (pain)

RLQ pain/underlying cause (including organs found here)

- APPENDICITIS organs: - lower pole of RIGHT kidney - cecum and appendix (pain) - portion of ascending colon (pain) - bladder (if DISTENDED) - RIGHT ureter - RIGHT over and salpinx - uterus (if ENLARGED) - RIGHT spermatic cord

LLQ pain/underlying cause (including organs found here)

- DIVERTICULITIS organs: - lower pole of LEFT kidney - sigmoid colon (pain) - portion of descending colon (pain) - bladder (if DISTENDED) - LEFT ureter - LEFT ovary and salpinx - uterus (is ENLARGED) - LEFT spermatic cord

GERD risk factors, dysfunction, and clinical representation

- risks: eating fatty foods, smoking, coffee, eating a lot of foods - dysfunction: when stomach acid secretions flow into the lower esophagus (GERD is the CHRONIC version) - clinical presentation: heartburn more than twice a week, regurgitation, dysphagia, squeezing chest pain that radiates to back/neck/jaw/or arms - RELIEVED WITH ANTI-ACIDS, SITTING UP, OR FOODS - WORSENED BY LAYING DOWN

hiatal hernia risk factors, dysfunction, and clinical representation

- dysfunction: protrusion if the stomach through the esophageal hiatus I the diaphragm - clinical representation: heart burn, regurgitation, dysphagia

peptic ulcer risk factors, dysfunction, and clinical representation

- dysfunction: break in the duodenal mucosa lining that heals and scars (like canker sores for the stomach) - clinical finds: epigastric pain to palpation and burning pain 1-2 hours after eating

Crohn's disease risk factors, dysfunction, and clinical representation

- dysfunction: chronic inflammatory bowel disease (regional enteritis ileitis), inflammation goes from mouth to anus, affected mucosa is unulcerated, abscess are common - clinical finds: there are remission and relapse periods, can't be cured but is treated, severe abdominal pain, cramping is persistent, diarrhea, bloody poop, fever

ulcerative colitis risk factors, dysfunction, and clinical representation

- dysfunction: starts in rectum and progresses through large intestine - clinical finds: LLQ or rectal pain, can have ostomy, remission and relapse periods that can lead to colon cancer

diverticulitis risk factors, dysfunction, and clinical representation

- dysfunction: inflammation of diverticula, herniations through the muscular wall in the colon, caused by fecal mater or certain seeds/hulls from food that get trapped in the herniations

what is the order for the abdominal assessment

- observe skin color of stomach - observe for symmetry and deformity - observe for scars, lesions, stria, vascular networks - observe contour (flat or distended) - observe for motion (peristalsis or pulsation) - listen to 4 quadrants - palpate 4 quadrants lightly - deeply palpate for liver border and tenderness

risks for colon cancer

- IBD - genetic factors - lack of regular physical activity - diet low in fruits and veggies - overweight and obesity - alcohol consumption

what would make a patient NPO

- sharp or acute pain - distention - anytime before a procedure - nausea

what factors affect mobility

quality of movement activity level gender and age baseline tests

what is the musculoskeletal assessment

- observe the gait - observe posture and extremities for alignment/symmetry - observe musculature for symmetry - observe ROM (cervical neck, shoulders, elbows, forearms, wrists, fingers and thumbs, lumber spine, hips, knees, ankles, toes - test biceps/triceps, quadriceps, tibialis anterior/dorsiflex/and plantar flex strength - basic arm symmetry strength - palpate specific joint for tenderness and temperature

how do you document grade 0 strength

no evidence of contractibility

how do you document grade 1 strength

evidence of SLIGHT contractibility

how do you document grade 2 strength

complete ROM with gravity eliminated

how do you document grade 3 strength

complete ROM with gravity

how do you document grade 4 strength

complete ROM against gravity with SOME resistance

how do you document grade 5 strength

complete ROM against gravity with FULL resistance

who's at risk for osteoporosis

- age > 50 years old - women - Caucasian or Asian - small boned, thin women - long term steroid use

who's at risk for osteoARTHRITIS

- increased risk with increased age - women > 50 years old - obesity - joint injury in their history - genetics

what is a closed/simple fracture

when the overlying skin is intact but the bone is fractured

what his an open/compound fracture

when the skin of the body part is breached which can lead to infection/contamination

what is a displaced fracture

when the bone breaks and becomes unaligned where its supposed to be

what is a non displaced fracture

when bone breaks and separates but does not go out of line

what is a pathologic fracture

when the patient sustains a fracture from insufficient integrity of the bone due to cancers, chronic illnesses, or osteoporosis

what is the clinical presentation for rheumatoid arthritis

- pain, stiffness, BILATERAL EDEMA, fatigue - morning Ian and stiffness > 30 minutes (this is an AUTOIMUNE DISEASE AND NEEDS JOINT REPLACEMENT DUE TO SYNOVIAL JOINT EROSION)

what is the clinical presentation for GOUT

- sudden progressive severe onset of pain and edema - onset is at night, trauma, surgery, ETOH, and or infection (FOUND IN BIG TOE)

what is the clinical presentation for osteoarthritis

- UNILATERAL pain with movement - morning pain and stiffness is < 30 minutes (REPETITIVE OR OVERUSE INJURY)

what the best way to conduct a mental health exam

- collect subjective data (symptoms) - past, present (status), family history - specific questions about mental health (stressors, anger, alcohol and or drug use, self-concept, interpersonal relationships, domestic violence)

how's depression diagnosed

- sadness, hopelessness, worthless, helpless, despair as result of tragedy - illness interfere with ability of one to work, sleep, communicate, eat, enjoy any activity

how's PTSD diagnosed

- follows acute stress disorder - it is something one cannot get over in a certain time frame and aren't able to cope or function in life (flashbacks, anxiety, diaphoretic, high BP)

what tool is used to measure for withdrawal of drugs of alcohol

alcohol use disorders ID test

what the major concern of the nurse if a patient regularly uses drugs or alcohol

need to be aware of withdrawal and then take correct action

is depression normal aging sign

no

what the general inspection and when does it begin

first inspection nurse does on the patient as soon as they see them

what the concept for thermoregulation

actions take to keep the internal temperature at a regular level

what infection control and how does it affect patient care

its practicing to prevent the spread infection which protects patient as well

what does ADPIE stand for

A: assess D: diagnose P: plan I: intervention E: evaluation

what is AIDET

A: acknowledge I: Introduce D: duration E: explanation T: thank you

how does AIDET affect the approach to the patient and their response

allows you to give full explanation and then they feel more comfortable with what is going to happen and or ask questions

what're the WNL of an infant

- BP: 60-80/20-40 - resp.: 30-60 - HR: 120-160

what're the WNL of a 1-4 year old

- BP: 90-99/60-65 - resp.: 20-40 - HR: 80-140

what're the WNL of a 5-12 year old

- BP: 100-110/56-60 - resp.: 15-25 - HR: 70-115

what're the WNL of an adult

- BP: <120/80 - resp.: 15-20 - HR: 60-100

how do we count pulses for an ADULT

count dial for 30 secs then times by 2

how do we count pulses for an infant

count pulse on inner arm for 15 secs and times by 4

what're the relationships between vital signs

- low BP = high HR (tachy) - high temperature = high respirations

what type of data is objective

information thats seen, heard, felt, or smelled but he observer

what type of data is subjective

things person tells you that you can't observe through the senses

what're signs

objective data

what're symptoms

subjective data

how does culture impact patients

we need to make accommodations for all patients cultures because they will have different ones than ourselves most of the time

what does the nurse do I theres a language barrier

get a translator (DONT RELY ON OTHER FAM MEMBERS OR FRIENDS)

do all patients share our religion, beliefs, lab ague, family dynamic, and sexual orientation

nope wtf