NR 304 FINAL EXAM REVIEW
- Hypovolemic Shock
• Volume depletion; plasma of the blood is too
... [Show More] 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
h. Resonant lung sounds
i. Normal vesicular sounds
j. Prolonged expiration
k. Crackles over deflated areas
l. May wheeze
- Lung Sounds
• Normal lung sounds-
a. Bronchial- high pitch, loud amplitude, I < E, harsh/hollow; TRACHEA AND LARYNX
b. Bronchovesicular- moderate pitch, moderate amplitude, I = E, mixed quality; SCAPULA AND STERNUM
c. Vesicular- low pitch, soft amplitude, I > E, rustling quality; LOBES OF LUNGS
• Abnormal lung sounds-
a. Fine Crackles- high pitched; during inspiration; not cleared by coughing;
inhaled air collides w/ previously closed airways; HEART FAILURE,
b. Coarse Crackles- loud, low pitched bubbling/gurgling sounds; start in early inspiration and can go into expiration; secretions in trachea; PULMONARY EDEMA, PNEUMONIA
c. Pleural Friction Rub- coarse and low pitched, pleurae lose lubricating fluid; PLEURITIS
d. High Pitched Wheeze- predominate in expiration; air compressed through narrow passageways; ACUTE ASTHMA OR CHRONIC EMPHYSEMA
e. Low Pitched Wheeze- predominant in expiration, can be in all phases; may clear by coughing; airflow obstruction; BRONCHITIS
f. Stridor- high pitched, inspiratory, crowing sound, louder in neck; upper airway obstruction from swollen tissues; ACUTE EPIGLOTITIS
- Human Papilloma Virus
• Genital warts
• Most common STI
• Risk factors- early age at menarche, multiple sex partners
• S/s-
a. Painless warty growths
b. Soft, pointed papules
c. Single or multiple in a cauliflower patch
d. Occur around vulva, introitus, anus, vagina, cervix
• Vaccine to prevent cervical cancer
• Boys and girls ages 9-26 y/o before sexually active
• Although pap tests save lives, cervical cancer is rare in young women
• In 2012 new recommendations are: (1) no pap tests for women under age 21 years, regardless of sexual activity.
- Anus Assessment
• Males- left lateral or standing position w/ toes pointed together
• Females- lithotomy position
• Inspection-
a. Moist and hairless
b. Coarse, folded skin that is more pigmented
c. Anal opening tightly closed
d. No lesions present
e. Sacrococcygeal area smooth and even
f. Valsalva maneuver no break in skin integrity or protrusion through anal opening
- Inguinal Hernia
• Assessment-
a. Inspect inguinal region for bulge
b. Palpate inguinal canal
c. Ask male to shift weight to opposite side (unexamined leg)
d. Place index finger low on scrotal half and palpate up spermatic cord
e. Insert finger into external inguinal ring and ask man to bear down
• Position- standing
- Cranial Nerves
• CN 1 Olfactory (sensory)- smell test
• CN 2 Optic (sensory)- confrontation test, read card
• CN 3 Oculomotor (motor)- PERRLA, cardinal fields
• CN 4 Trochlear (motor)- PERRLA, cardinal fields
• CN 5 Trigeminal (both)- clench teeth, touch face w/ q tip
• CN 6 Abducens (motor)- PERRLA, cardinal fields
• CN 7 Facial (both)- smile, frown, puff cheeks
• CN 8 Vestibulocochlear (sensory)- hearing test
• CN 9 Glossopharyngeal (both)- move tongue side to side, say ahh, light, tight, dynamite
• CN 10 Vagus (both)- move tongue side to side, say ahh, light, tight, dynamite
• CN 11 Accessory (motor)- shrug shoulders, push face
• CN 12 Hypoglossal (motor)- move tongue side to side, say ahh, light, tight, dynamite
- Self-Breast Exam
• Best time to do it after menstrual period
- Jugular Venous Pressure
• Normal jugular venous pulsation is 2cm or less above sternal angle
• Elevated pressure = 3 cm or more above sternal angle while @ 45 degrees
a. Occurs w/ heart failure, cardiac tamponade, constrictive pericarditis
- Hypertension
• Normal = <120 and <80
• Prehypertension = 120-139 or 80-89
• Stage 1 hypertension = 140-159 or 90-99
• Stage 2 hypertension = > 160 or > 100
• Risk factors-
a. Modifiable- obesity, smoking
b. Nonmodifable- race
- Wernicke’s Area
• Found in temporal lobe
• Associated with language comprehension
• When damaged, receptive aphasia results; person can hear sound but it has no meaning
- Rheumatoid Arthritis
• Chronic autoimmune disease w/ inflammation of synovial tissues and hyperplasia or swelling
• Leads to fibrosis, cartilage and bone destruction that limits motion and appears as a deformity
• Joint involvement is symmetrical and bilateral w/ heat, redness, swelling, painful
motion.
• RA carries increased cardiovascular risk of heart attack and stroke.
• Acute RA- painful swelling and stiffness of joints; fusiform and spindle shaped swelling of soft tissue of proximal interphalangeal joints; fusiform swelling is symmetric, hands are warm, veins are engorged; limited ROM
• Ankylosing spondylitis
• S/s-
a. Fatigue
b. Weakness
c. Anorexia
d. Weight loss
e. Low grade fever
f. Lymphadenopathy
- Prostatic Hypertrophy ***SATA***
• Inflammation of the prostate gland; caused by hormonal imbalance
• S/s-
a. Urinary frequency
b. Urgency
c. Hesitancy
d. Straining to urinate
e. Weak stream
f. Intermittent stream
g. Sensation of incomplete emptying
h. Nocturia
• Objective-
a. Symmetric nontender enlargement
b. Commonly in middle aged men
c. Prostate surface feels smooth, rubbery or firm
d. Median sulcus obliterated
- Subjective Data
• What the patient says about themselves and what they feel
- Objective Data
• What the nurse observes about the patient upon inspection and assessment
- Closed Ended Questions
• Questions that ask for specific information
• They elicit a short or two word answer (yes or no) or a forced choice
• Useful to fill in details that are left out and specific facts
• Only ask one direct question at a time
• Choose language the person understands
- Open Ended Questions
• Questions that ask for narrative information
• States the topic to be discussed in general terms
• Used to begin the interview, introduce new questions or when person introduces a new topic.
• Unbiased.
• Person is free to answer in any way
• Lets person express themselves freely
• Make eye contact and listen
- Nonverbal Communication
• Signs of pain
• Etc
- Kernig’s Sign
• Meningitis
• Person lays flat and extends knee; normally causes no pain
- Romberg’s Test
• Testing for balance and bodys sense of positioning
• Person stands w/ hands @ sides and eyes closed for 20 seconds
• Part of brain cerebellum
- Cerebella Ataxia
• Staggering, wide-based gait
• Difficulty with turns
• Uncoordinated movement
• Positive Romberg test
• Causes- alcohol/barbiturate effect on cerebellum, cerebellar tumor, multiple sclerosis
- Atelectasis
• Collapsed alveoli as a result of airway obstruction, compression on the lungs, lack of surfactant
• S/s-
a. Cough
b. Lag on expansion on affected side
c. Increase RR and pulse
d. Possible cyanosis
e. Chest expansion decreased on affected side
f. Tactile fremitus decreased on affected side
g. Tracheal shift toward affected side
h. Dull percussion over affected area
i. Decreased breath sounds over affected area
j. Fine crackles
- ECG Strip
• P wave- depolarization of atria
• QRS complex- depolarization of ventricles
• T wave- repolarization of ventricles
- Herpes Zoster (Shingles)
• Small grouped vesicles emerge along route of cutaneous nerve, the pustules and crusts; reactivation of chickenpox
• Unilateral; does not cross midline
• Pain is severe and long lasting in aging adults “postherpetic neuralgia”
- Atrial Fibrillation
• Cardiac arrhythmia
• Rapid, irregular beating of the atria that causes poor blood flow
• May experience-
a. Chest pain
b. Dizziness
c. Fatigue
d. Palpitation
e. Shortness of breath
f. Weakness
g. Inability to exercise
- Pelvic Inflammatory Disease
• Infection of fallopian tubes
• Caused by STI bacteria (gonorrhea and chlamydia)
• S/s-
a. Sudden fever > 100.4
b. Suprapubic pain and tenderness
c. Acute- rigid, boardlike lower abdominal musculature; purulent discharge; intense pain; bilateral adnexal masses
d. Chronic- bilateral, tender, fixed adnexal masses
• Complications- ecoptic pregnancy, infertility, reinfection
- Therapeutic Communication
• Avoid false reassurance
• Unwanted advice
• Using authority
• Using avoidance language
• Engaging distancing
• Using professional jargon
• Talking too much
• Interrupting
• Why questions
• No judging
• Instead of giving them answers give options instead [Show Less]