NR i304 iFinal iWorksheet
Questions:
1. Define isubjective iand iobjective idata. iGive ithree iexamples iof ieach iand istate iif ithe ifindings ia... [Show More] re documentedi iin ithe ihistory ior iphysical iexamination ifindings.
• Subjective iData iwhat ithe iperson isays iabout ihimself ior iherself iduring ithe iphysical examination;i isymptom iis ia isubjective isensations ithat ithe iperson iis ifeeling; o Examples: iitching, ipain, ifeelings iof iworry, inausea, idepression, ifatigue, ianxiety, loneliness, ietc.
• Objective iData iwhat ithe iyou ias ithe ihealth iprofessional iobserve iby iinspecting, ipercussing, ipalpating, iand iauscultating iduring ithe iphysical iexamination; ia isign iis ian iobjective iabnormality ithat iyou ias ithe iexaminer icould idetect ion iphysical iexamination ior ini ilaboratory ireports; iobservable iand imeasurable; o Examples: iblood ipressure, idiscoloration iof ithe iskin, iskin imoisture, ivomiting, temperature,i iweight, ibleeding, iblood icell icount, ietc.
2. List ifive iactions ia inurse ishould itake iwhen iassessing ia ipatient iwith ia ipotentially icritical hemodynamici istate. iPut iyour iactions iin ipriority iorder iof i1-5.
• Hemodynamic iState iinstable iblood ipressure, iwhich ican ilead ito iinadequate iarterial bloodi iflow ito iorgans; iheart ifailure.
• Priority iActions: imain igoals ifor inurse iare ito ievaluate ithe icardiac iand icirculatory ifunction, as iwell ias ithe iresponse ito iany iinterventions. i.i
3. What idoes ithe ipriority isetting iABC imean? iHow idoes ithe inurse iuse ithis imnemonic iin ipatient assessment?i iIf ia ipatient ihas ia islow ior irapid irespiratory irate, iis iairway ithe iprimary iconcern?
• A: iairway.
• B: ibreathing.
• C: icirculation.
4. What iis iHIPAA? iDescribe ione isituation iwhen ithe inurse imust iadhere ito iHIPAA.
• Health iInsurance iPortability iand iAccountability iAct iof i1996 i(HIPAA) ilaws ito iimprove efficiencyi iin ihealth icare idelivery iby istandardizing ielectronic idata iinterchange iand iprotection iof iconfidentiality iand isecurity iof ihealth idata iby isetting iand ienforcing istandards; icomposed iof i4 iparts ithat ihave irules, iwhich iinclude: istandards ifor ielectronic itransactions, iunique iidentifiers istandards, ithe isecurity irule, iand ithe iprivacy irule.
o Example: iif ipatient iisn’t iable ito igive iconsent ia ispouse, irelative, ior ia iclose ifriend ican i(but, ithe inurse imust idocument iit); i2 inurses iassigned ito ithe isame ipatient ican italk iabout ithe ipatient’s imedical idiagnosis iin ithe ipatients iprivate iroom; ia inurse ican givei iinformation iabout ia ipatient iover ithe iphone iif ithe ipatient igives ipermission ito ido iso ito ithat iperson; inurses ican iperform iresearch ias ilong ias ipatient iconfidentiality isi imaintained iat iall itimes;
5. Describe ithe iprocess iof itaking ia ipulse. iWhat iis ia inormal ipulse? iWhat iare iqualities iof ia inormal pulse?i iWhat iis ithe ifirst iaction ia inurse ishould itake iwhen ithe ipulse iis inot ias iexpected?
• Normal iPulse i2+ ibilaterally iforce; i60-100 ibeats iper iminute; i50-95 ibeats iper iminute iin healthyi iindividuals.
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o Qualities iof iA iNormal iPulse irhythm ishould ibe iregular, ieven itempo; symmetricali i2+ ibilateral iforce;
• Process iof iTaking iA iPulse iusing ithe ipads iof iyour i1st i3 ifingers, ipalpate ithe iradial ipulse i@ ithe iflexor iaspect iof ithe iwrist ilaterally ialong ithe iradius ibone; iif irhythm iis iregular, icountthe i i# iof ibeats iin i30 iseconds iand imultiply iby i2; iif iit’s iirregular ithan icount ifor ia ifull iminute; • 1ST iAction iif iPulse iIs iNot iExpected
6. What iis idehydration? iList ithree isubjective iand ithree iobjective ifindings iof idehydration. iList ithe expectedi ivital isigns iof ia ipatient iwho iis idehydrated.
• Dehydration iosmolar ifluid iloss iof iwater, iwith ino iloss iof ielectrolytes.
o Subjective i Findings: i ithirst, i dizziness, i syncope, i confusion, i weakness, i fatigue,nausea, i o Objective iFindings: idry, ifurrowed itongue, ivomiting, iweight iloss, ioliguria i( ioutput iof iurine), idistended ibladder, isunken ieyes, idiminished icapillary irefill, idiaphoresis, icool iclammy iskin, iflattened ineck iveins, i iurine ispecific igravity, i osmolality, i i iblood iurea initrogen i(BUN), i ielectrolytes, i iglucose, i iserum isodium.
• Expected iVital iSigns iof iDehydrations itachycardia, iweak, ithread ipulse; ihypotension, iorthostatic i hypotension, i icentral i venous i pressure; i tachypnea i ( irespirations), i hypoxia;hyperthermia i
7. How iis ifluid ivolume ideficit irelated ito idehydration? iHow iwould iconcentrations iof isome isolutes
(i solids) ichange iwith idehydration? iWhy?
• Fluid iVolume iin idehydration, iit iis iosmolar ifluid iloss, iin iwhich ithere iis ionly ia iloss iof wateri iand ithere’s ino iloss iof ielectrolytes.
8. What iis ian iundesirable iresponse iof ithe ibody ito ia ifever?
• It ican ireset ithe ithermostat iof ithe ibrain i@ ia ihigher ilevel, iresulting iin iheat iproduction iand conservation.i
Why iis ithis iundesirable? iWhat ieffect idoes iit ihave?
• It ican iresult iin ian iincreased iinternal ithermostat, iwhich iwill imean ithat inext itime ithe tolerancei iof ia ifever iwill ibe ihigher iand iresult iin ian iincreased iheat iproduction iand iincreased iheat iconservation.
9. What iis ithe imost iserious iskin icancer? iWhat iis ione irisk ifactor ifor ithis icancer iand ione iteaching itemi ito iaddress iwith iyour ipatient? iDescribe ithis imost iserious iskin icancer ibelow.
• Most iSerious iSkin iCancer imelanoma.
o Risk iFactors: ifair iskin, ihistory iof isunburn, iexcessive iUV iexposure, iliving iclosure ito iequator ior i@ ia ihigher ielevation, ihave imany ior iunusual imoles, ifamily ihistory iof melanoma,i iweakened iimmune, ietc.
o Teaching iItems iTo iAddress: iprotect iyour iskin, ilimit iyour iexposure ito ithe isun, weari ia iheat ior iprotective igear, iwear isunscreen, icheck ian iunusual imoles iand ialways icheck ion iyour imoles ito ibe iable ito inote iany idifferences, ietc.
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10. In idark iskinned iclient, iwhere iis ithe ibest iarea ito iassess ifor ijaundice i(not iskin ior isclera)? i Best placei ito iassess ifor ipallor? iBest iplace ito iassess ifor icyanosis?
• On iDark iSkinned iPT’s iWhere iWould iYou iCheck iFor:
o Jaundice ibest inoted iin ithe ijunction iof ihard iand isoft ipalate iof ithe ihands ior ifeet, o Pallor: ioral imucous imembranes iand ithe iconjunctiva iof ithe ieye. o Cyanosis: ioral imucous imembranes iand ithe iconjunctiva iof ithe ieye.
11. To idocument ipitting iedema, ithe inurse imeasures ithe ifollowing idepths iof ipitting. iWhat iis ithe correspondingi iscale i(1+, i2+, i3+, i4+ i) ifor:
• 2mm ideep i= i 1+ • 4mm ideep i= i 2+ • 6mm ideep i= i 3+
• 8mm ideep i= i 4+
12. What iis ia ibody isystem icomplication ifor ithe iclient iwho iis ia ichronic iheavy idrinker? iName i3 possiblei iassociated ifindings iassociated iwith ithis icomplication.
• Body iSystem iComplication(s) ifor iHeavy iDrinkers iliver idisease, ialcoholic iliver idisease, fattyi iliver, ihepatitis, icirrhosis, ipancreatitis, icancer, iulcer iand igastrointestinal iproblems, iimmune isystem idysfunction, ineurological idamages, ivitamin ideficiencies, ietc.
• Possible iFindings iAssociated iWith iThis iComplication istomach iulcers, iacid ireflex, iheartburn, igastritis, iweakens iyour iimmune isystem iand icauses ia idecreased iin iWBCs, idifficulty iprocessing iinformation iBC iit iinterferes iwith ithe ibrain ireceptors iand ineurotransmitters, ias iwell ias itheir icognitive ifunction, imalnourishment, ianemia, itiredness, weakness,i imemory iloss, ietc.
13. It iis iimportant ito iencourage ithe ielderly iclient ito icontinue ito ibe ias iactive ias ipossible. iList ifive complicationsi iassociated iwith ithe iinability ito imove iindependently.
• Complications iAssociated iWith iElderly iBeing iUnable iTo iMove iIndependently:
a. Urinary iSystem iretention, istasis, irenal icalculi, iincontinence, ias iwell ias iUTI’s.
b. Gastrointestinal iSystem constipation, iimpaction, iand idifficulty ievacuating.
c. Musculoskeletal iSystem idisuse iosteoporosis, ihypercalcemia, iand ifractures; ijoints ican ibecome istiff, ipainful, ialong iw/impaired irange iof imotion iand icontractures ithat iinclude ifoot idrop, iwhich iis ia iplantar iflexion icontracture; imuscles cani ibe iweak iand iatrophy ican iresult.
d. Respiratory iSystem ithickening iof irespiratory isecretions, ithe ipooling iof irespiratory i secretions, i and i an i iinability i of i the i client i to i mobilize i and i expectoratethese i isecretions, iall iof iwhich ican ilead ito iatelectasis, ihypostatic ipneumonia, iand irespiratory itract iinfections; ican ialso ilead ito ishallow, iineffective irespirations, i imovement, iand ia i iin iterms iof ithe iclient’s ivital icapacity.
e. Circulatory iSystem ivenous istasis, ivenous idilation, i iBP, iedema, iembolus iformation, ithrombophlebitis, iand iorthostatic ihypotension, iwhich iis ia irisk ifactor alsoi ioften iassociated iw/client ifalls.
f. Metabolic i System irate i of i metabolism, i which i can i lead i to i unintended i weight igain, ia inegative icalcium ibalance isecondary ito ithe iloss iof icalcium ifrom ithe ibones duringi i immobilization, i a i negative i nitrogen i balance i secondary i to i an i iin i terms i ofcatabolic i iprotein ibreakdown, iand ianorexia.
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g. Integumentary iSystem iskin ibreakdown, ipressure iulcers, iand ipoor iskin iturgor.
h. Psychological iAlterations iapathy, iisolation, ifrustration i,a ilowered imood, ias iwell asi idepression.
14. Describe ifluid ivolume ioverload. iList ia ipossible icause iof iFVO. i List ithree isigns/symptoms iof
FVO.i
• Fluid iVolume iOverload i(FVO) ialso iknown ias ihypervolemia, iis ia imedical icondition
wherei ithere iis itoo imuch ifluid iin ithe iblood; ithe iexcess ifluid iis iprimarily isalt iand iwater, whichi ibuilds iup ithroughout ithe ibody iresulting iin iweight igain; iit’s iexpansion iof ithe iextracellular ifluid ivolume, iincluding ithe iintravascular ior iinterstitial ispace;
• Possible iCause iof iFVO imay ibe ithe iproduct iof icompromised imechanisms ifor iregulating wateri iand isodium, ias iseen iin icongestive iheart ifailure, ihepatic ifailure, iand irenal ifailure; iliver imalfunction; iinaccurate isodium iand iwater iretention iinclude ilow iprotein isources, iuse ofi icorticosteroids, iglomerulonephritis, inephritic isyndrome, inephropathy, ihyperaldosteronism, iand iliver icirrhosis; itoo imuch iintake iof isodium iand ifluids; ifluid ishift iinto ithe iintravascular ispace ithat imay ioccur iin iresponse ito ifluid iremobilization iduring iburn itherapy, ias ia iresult iof igiving ialbumin, iand ifrom imannitol ior iany ihypertonic ifluid iadministration.
o S/S: iSOB, i irespiratory irate, iboth idue ito i iin iRBC’s, i ipulses iw/ ibounding icharacter istemmed ifrom icirculatory ioverload iand iconcomitant ielevation iof icardiac icontractility, ilabored ibreathing iand idifficulty iof ibreathing icaused iby ian i
15. Describe ifluid ivolume ideficit. iList ia ipossible icause iof iFVD. iList ithree isigns/symptoms iof iFVD.
• Fluid iVolume iDeficit i(FVD) ithis irefers ito idehydration, iwater iloss ialone iWITHOUT ia changei i in i the i amount i of i sodium; i iintravascular, i interstitial, i and/or i intracellular i fluid.
• Possible iCause iof iFVD isevere idiarrhea, ivomiting, ifever, iheat iexposure, itoo imuch iexercise, i or i work-related i activity, i iurination i due i to i infection, i diseases i such i as i diabetes o S/S: inot ipeeing ior ihaving ivery idark iyellow ipee, ivery idry iskin, ifeeling idizzy, irapid heartbeat,i irapid ibreathing, isunken ieyes, isleepiness, ilack iof ienergy, iconfusion ior iirritability, ifainting, ietc.
16. Differentiate ibetween ioral icandidiasis iand ileukoplakia. iList ione ipossible icause iof ieach.
• Oral iCandidiasis ia iwhite, icheesy, icurd-like ipatch ion ithe ibuccal imucosa iand itongue; iit scrapesi ioff, ileaving ia iraw, ired isurface ithat ibleeds ieasily; itermed i‘Thrush’ iin inewborn; o Possible iCauses: iit iis ian iopportunistic iinfection ithat ioccurs iafter ithe iuse iof antibiotics iand icorticosteroids, ias iwell ias iin iimmunosuppressed ipeople.
• Leukoplakia ichalky iwhite, ithick, iraised ipatch iwith iwell-defined iborders; ithe ilesion iis firmlyi iattached ian idoes inot iscrape ioff; iit imay ioccur ion ithe ilateral iedges iof ithe itongue.
o Possible iCauses: idue ito ichronic iirritation iand ioccurs iw/heavy ismoking iand alcohol iuse; ilesions iare iprecancerous; imust irefer ito ispecialist. [Show Less]
