NURS 258 Study Guide exam 1
NURS 258 Study Guide exam 1 258
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This 21 page Study Guide was uploaded by Ally Marcello on Wednesday September 21, 2016. The Study Guide belongs to 258 at Catholic University of America taught by Jean E. Toth in Fall 2016. Since its upload, it has received 24 views. For similar materials see Health Assessment in NURSING at Catholic University of America.
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HEALTH ASSESSMENT EXAM 1 STUDY GUIDE CHAPTER 1 Evidence Based Practice Data such as noting respirations and a pulse is objective data o It is the data that you actually collect from the patient after running tests and assessments done by the professional as they inspect, percuss, palpate, and auscultate during the physical exam. Data from what the patient tells you is subjective during the history potion of the interview. o Could say they feel nauseous, anxious, and feel hot but it is subjective unless you find it yourself The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. In these settings the nurse is the first health professional to see the patient and has primary responsibility for monitoring the person's health care. o The patient’s record, laboratory studies, objective data, and subjective data combine to form the data base. When you are unsure of what you hear or palpate, always verify data you need to make sure is accurate. If you have less experience in an area, ask an expert to listen. Intuition: characterized by pattern recognition- expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. Evidence based practice- a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well a patient preferences and values, to make decisions about care and treatment. o It is important to question tradition when no compelling research evidence exists to support it. First-level priority problems are those that are emergent, life threatening, and immediate (ex: establishing an airway, supporting breathing, maintaining, circulation, and monitoring abnormal vital signs) o Remember ABCs Second-level priority problems are those that require prompt intervention to forestall further deterioration (ex: mental status change, acute pain, abnormal laboratory values, and risks to safety or security) Third-level priorities are important to a patient's health but can be addressed after more urgent health problems are addressed (i.e., patient education) Developing an appropriate nursing intervention for a patient relies on the appropriateness of the nursing diagnosis o Accurate nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. The nursing process is a method of problem solving that includes assessment (data collection through pt hx, fhx, physical examination, and the interview), diagnosis (Used to evaluate the response of the whole person to actual or potential health problems), outcome identification, planning, implementation, and evaluation (nurse should evaluate the individual's condition and compare actual outcomes with expected outcomes.). Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis o There are several barriers to incorporating evidence based practice for a nurse because they lack research skills in evaluating quality of research studies, are isolated from other colleagues who are knowledgeable in research, and lack time to go to the library to read research. Consideration of the whole person is the essence of holistic health o It views the mind, body, and spirit as interdependent. o The basis of disease originates from both the external environment and from within the person Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state. Prevention places emphasis on the link between health and personal behavior. In a focused or problem-centered data base, the nurse collects a "mini" data base, smaller in scope than the completed data base. It concerns mainly one problem, one cue complex, or one body system. A follow-up data base is used in all settings to follow up short-term or chronic health problems. The emergency data base calls for a rapid collection of the data base, often compiled concurrently with life-saving measures. The inclusion of cultural considerations in health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care. In the health promotion model, the focus of the health professional is on helping the consumer choose a healthier lifestyle. Risk diagnoses are potential problems that an individual does not currently have but is particularly vulnerable to develop. The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than a list of tasks and is able to see how today's nursing actions apply to the point the nurse wants the patient to reach at a future time. CHAPTER 3 The Interview The interview is the first point of contact with a client and the most important part of data collection Two types of data o Subjective data- which is what the client tells you about why they came in, about their history and family history, and so on o Objective data- what you actually observe through physical examination o Not the purpose of the interview because you will collect this data from observing posture, physical appearance, ability to carry a conversation, and overall demeanor Successful interviews allow you to o Gather complete and accurate data about the person’s health state o Establish trust o Teach the person about his or her own health state o Build rapport for a continuing therapeutic relationship o Discuss health promotion and disease prevention o Think of it as a contract between you and your client- what your client needs and expects from you, and vice versa with a mutual goal of optimal health for the client The process of communication o If you have not conveyed your meaning, communication has not occurred o Communication is based on behavior, conscious and unconscious, because all behavior has meaning o Sending- Included verbal (words you speak, tone) and nonverbal communication posture, eye contact) Nonverbal communication may be more reflecting of true feelings o Receiving Interpretations of what you are trying to convey are influenced by past experiences, culture, self-concept, physical and emotional states, bias The client usually has a health problem which emotionally charges the professional relationship intensifies communication because client relies on you to make them better o Internal factors Those specific to you, the examiner. Focus on 4 Liking others o Means having a generally optimistic view of people-an assumption on their strengths and a tolerance of their weaknesses o Respect for other people extends to respect for their own control over their own health- don’t make them dependent on you, but help them be more independent in their health decisions Empathy o Viewing the world from the other person’s eyes while remaining as you basically recognizing the other person’s feelings without being critical Feeling with the person not like the person The ability to listen o Listening requires complete and focused attention o Not just hearing but also checking for your understanding, interpreting, asking follow up questions when appropriate o Do not interrupt o Be aware of the way a story is told- what was the tone? What is the person leaving out? Self-awareness o Understanding your personal biases, prejudices, and stereotypes is an important part of developing your skills as an interviewer Knowing yourself helps to show how some unintentional actions can have a negative impact Also helps you put your own feelings about the situation aside to effectively support the patient’s decision If you can’t put your feelings to the side, you may need to ask a colleague to complete the interview o External factors Preparing the physical setting- could be a hospital, clinic, office, or home. Focus on 3 Ensure Privacy o You may have to ask someone to step out of the room, find a new room for you and the client, or create psychological privacy by use of a curtain. Either way check that the patient is comfortable before you being because any bit of discomfort could lead to withholding information o You may have to advocate for a teenager and ask that the parent or guardian leave the room for questioning Refuse Interruptions o Discourage other health professionals from interrupting you with their need for access to the patient o Interruptions can destroy what took you precious minutes to build up, so if you anticipate an interruption let the patient know ahead of time Physical Environment o Comfortable room temp o Sufficient lighting o Quiet o Remove distracting objects or equipment and avoid clutter o Keep 4 to 5 feet between you and the client so as to keep their personal space o Arrange equal status seating- seated at eye level and keeping chairs at 90 degrees because it allows the person to face you or look straight ahead Avoid facing a client from across a desk because it makes a barrier o Avoid standing! It communicates your haste and assumes superiority o When talking to a bedridden patient and try to get a face to face position where you are not standing over them. Also make sure they aren’t looking at the ceiling Dress o Client should remain in street clothes during the interview unless it is an emergency Note-taking o Keep it to a minimum excessive notetaking has disadvantages Breaks eye contact too often Shifts attention away from the client too often Client’s natural mode of expression is lost Impedes your observation of the patient’s nonverbal communication Threatening to the client during discussion of sensitive issues (questions about alcohol, drugs, or sex) Electronic Health Record (EHR) o Eliminates handwritten clinical data and provides access to online health education materials o Poses problems for the provider-client relationship Worst case, the client sits idly by while the provider interacts silently with the computer o Start the interview the same and explain the computerized charting, and position the monitor so the client can see it Techniques of communication o Introducing the interview Keep intro short and formal address person with their surname and shake hands if appropriate Avoid using the first name unless the client directs you otherwise Introduce yourself and state your role in the agency and reason for the interview (if collecting full hx) Ask open ended questions o The working phase Data-gathering phase Combination of open ended questioning with closed questions o Open ended questions Ask for narrative information states the topics to be discussed in general terms Use it to Begin the interview Introduce a new section of questions Whenever the person introduces a new topic Unbiased- leaves the person free to answer in any way o Closed or direct questioning Ask for specific information- short one or two-word answer Useful to fill in details that were missed or intentionally left out Try to ask only one closed question at a time to avoid bombarding the person with questions, but use it to speed up the process Avoid double barreled questions (ex: do you eat healthy and exercise?) because the person will not know which to answer Choose language the person understands- may need you use regional or colloquial expressions o Verbal responses- Assisting the Narrative Help the person amplify their story 9 types of verbal responses Facilitation, silence, reflection, empathy, and clarification involve your reactions to the facts of feelings o Patient leads Confrontation, interpretation, explanation and summary start to express your own thoughts and feelings. o You lead o 10 traps of interviewing Providing false assurance or reassurance You may have promised something that may not come true You can reassure clients that you are listening to them, that you have hope for them, that you understand them, and that you are taking good care of them Giving unwanted advice If advice is based off of a hunch or a feeling or is your personal opinion, then it is likely inappropriate wait for them to ask for your advice o Avoid starting a sentence with “if I were you...” even if they ask for advice, include them in the problem-solving process Using authority Using avoidance language Using euphemisms promotes avoidance of reality and allows people to hide their feelings use direct language Distancing The use of impersonal speech to put space between a threat and the self o Ex: “there is a lump in the left breast” not saying “your left breast” allows the woman to deny any association with her diseased breast and protect herself from it Using specific language and blunt terms indicates you are not fearful of the disease or procedure Using leading or biased questions Framing questions that make one answer seem “better” than the other or making the client’s answers seem forced Talking too much Listen more than you talk Interrupting Indicated impatience or boredom Don’t think of what you are going to say while the client s talking Using “why” questions Usually implies blames or condemnation when coming from adults and puts the client in defense mode o When speaking to a deaf patient The nurse should ask the deaf person the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him or her squarely and have good lighting on the nurse's face The nurse should not exaggerate lip movements because this distorts words. Shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and should supplement his or her voice with appropriate hand gestures or pantomime. o Nonverbal Skills More important than verbal communication in that nonverbal is unconscious and could conduct feelings contrary to what your verbal communication is saying When nonverbal and verbal messages are congruent, the verbal message is reinforced. When they are incongruent, the nonverbal message tends to be the true one because it is under less conscious control. When interviewing a patient, note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic. Eye contact is perhaps among the most culturally variable nonverbal behaviors. Asian, American Indian, Indochinese, Arabian, and Appalachian people may consider direct eye contact impolite or aggressive, and they may avert their eyes during the interview. American Indians often stare at the floor during the interview, which is a culturally appropriate behavior indicating that the listener is paying close attention to the speaker. Touching children may have associated meaning cross-culturally. Many Asians believe that one's strength resides in the head and touching the head is considered disrespectful. CHAPTER 4 Health History Purpose of a health hx is to collect subjective data When evaluating a patient’s reliability o A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The reason for seeking care is a brief spontaneous statement in the person's own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the person's exact words. The symptom of pain is difficult to quantify because of individual interpretation. With pain, avoid adjectives and ask how it affects daily activities, ask the patient to point to where it hurts. Make sure the patient describes the setting of his/her pain o The setting describes where the person was or what the person was doing when the symptom started. Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). o This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, record the duration and whether the pregnancy resulted in spontaneous (S) or induced (I) abortion. When someone tells you they are allergic to something, note the allergen and the reaction they have. o With a drug, this symptom should not be a side effect but a true allergic reaction. When taking a family history, specifically ask for any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancer, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis. The purposes of the review of the systems are to evaluate the past and current health state of each body system, to double check in case any significant data were omitted in the present illness section, and to evaluate health promotion practices. Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness measures day-to-day activities. o it also includes interpersonal relationships and home environment. Questions about coping and stress management include questions regarding the kinds of stresses in one's life, especially in the last year, any change in lifestyle or any current stress, methods tried to relieve stress, and whether these have been helpful. A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). It is important for the nurse to recognize positive health measures: what the person has been doing to help himself or herself stay well and to live to an older age. When asking an older adult about their medications, and they forget the names, have them tell a family member or a care giver to bring their medications Sign vs. symptom o A symptom is a subjective sensation that a person feels (such as chest pain) from a disorder. o A sign is an objective abnormality that the examiner could detect on physical examination or in laboratory reports The CAGE test is known as the "cut down, annoyed, guilty, and eye-opener" test. If a person answers "yes" to two or more of the four CAGE questions, the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment. Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history The mnemonic PQRSTU may help the nurse to remember to address the critical characteristics that need to be assessed: o P: Provocative (Asking what makes the pain better) or Palliative; o Q: Quality or Quantity; o R: Region ("where is the pain") or Radiation; o S: Severity Scale (Asking the patient to rate the pain on a 1 to 10 scale); o T: Timing (Asking "how often"); and o U: Understand Patient's Perception. CHAPTER 9 Vital Signs The general survey is a study of the whole person that includes observation of physical appearance, body structure, mobility, and behavior. A standardized balance scale is used to measure weight. The patient should remove his or her shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse should aim for approximately the same time of day and type of clothing worn each time. The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly in between each contraction. o The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of vessel walls. According to the JNC-VII guidelines, prehypertension blood pressure readings are systolic 120 to 139 mm Hg or diastolic 50 to 89 mm Hg. o Normal <120 systolic and <80 diastolic o Prehypertension 120-139 systolic or 80-89 diastolic o Hypertension stage I 140-159 systolic or 90-99 diastolic o Hypertension Stage II >160 systolic or >100 diastolic The incidence of hypertension is twice as high in blacks as it is in whites. After menopause, blood pressure in women is higher than in men; blood pressure measurements in obese people are usually higher than in those who are not overweight. Normally, a gradual rise occurs through childhood and into the adult years. When taking BP o Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery. o A comfortable, relaxed person yields a valid blood pressure. Many people are anxious at the beginning of an examination; the nurse should allow at least a 5-minute rest before measuring his blood pressure. How to take BP o Make sure the cuff is the appropriate size for the pt--> the width of the bladder should equal 40% of the arm circumference and the length of the bladder should equal 80% of arm circumference o Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears This will ensure you don’t miss an auscultatory gap (a period when the Korotkoff sounds disappear and then reappear during auscultation.) only happens in 5% of people, most often in people with hypertension o Deflate the cuff slowly o The first sound you hear is the systolic pressure o The last sound you hear, the onset of silence, is the diastolic pressure The DON’Ts of blood pressure- don’t let the pt support his or her own arm during the reading, don’t use a BP cuff that is too large or small, don’t let the pt sit with crossed legs If the person is known to have hypertension, is taking antihypertensive medications, or reports a history of fainting or syncope, then take the blood pressure reading in three positions: lying, sitting, and standing. Physical growth is the best index of a child's general health; recording the child's height and weight help to determine normal growth patterns. The newborn's head measures about 32 to 38 cm and is about 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are about the same, and after age 2 years, the chest circumference is greater than the head circumference. o Head > chest, 6mo-2yrs= about same, 2+= chest > head o To measure chest circumference, encircle the tape around the chest at the nipple line. Length should be measured on a horizontal measuring board. o Weight should be measured on a platform-type balance scale. o Head circumference is measured with the tape around the head, aligned at the eyebrows, at the prominent frontal and occipital bones; the widest span is correct. Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur. Although rectal temperatures are the most reliable, they should be taken when the other routes are not practical, such as for comatose or confused persons, for persons in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunctions. The tympanic thermometer (TMT) is a noninvasive, non-traumatic device that is extremely quick and efficient. There is minimal chance of cross-contamination with the tympanic thermometer because the ear canal is lined with skin, not mucous membrane. o Useful for younger children who may not cooperate for oral temperatures and fear rectal temperatures. Keep in mind that TMT use with newborn infants and young children is conflicting. o In the ear How vital signs change with aging o systolic blood pressure increases, o diastolic may increase as well o widened pulse pressure. o The pulse rate and temperature do not increase temp usually lower than most adults, with a mean temperature of 36.2C (97.2F) o Increase in respiratory rate, shallower inspiration An unexplained weight loss may be a sign of a short-term illness or a chronic illness such as endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic pulmonary disease To accurately assess a rectal temperature on an adult o Insert a lubricated rectal thermometer (with a short, blunt tip) only 2 to 3 cm (1 inch) into the adult rectum, and leave in place for 2 1/2 minutes. Taking a radial pulse: 30-second interval multiplied by two is the most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. o If rhythm is irregular, then count for one full minute. Pulse is assessed for rate, rhythm and force (stroke volume) o Sinus arrhythmia (when the heart speeds up at the peak of inspiration, and slowing with expiration) is commonly found in children and young adults o Normal range of rate for a pulse is 60-100 BPM less than 60 is bradycardia and greater than 100 is tachycardia When counting respirations, do not tell the patient that you are assessing/counting breathing because then the patient alters their normal breathing pattern try to sneak it in with pulse o Count breaths for 30 and multiply by 2 if normal, count for one minute if abnormal. Orthostatic hypotension is a drop in systolic pressure of more than 20 mm Hg, which occurs with a quick change to a standing position. Aging people have the greatest risk of this problem. Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face). CHAPTER 13 Head, Face, Neck The C7 vertebra has a long spinous process, called the vertebra prominens, that is palpable when the head is flexed. Soft spots on a baby’s head are normal and allow for growth of the brain during the first year of a baby’s life o They gradually ossify the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years. o Depressed and sunken fontanels occur with dehydration or malnutrition. Cranial nerves o I- olfactory (smell) o II- optic (sight) o III- oculomotor (eye movement, pupil constriction) o IV- trochlear (eye movement) o V- trigeminal (somatosensory information (touch, pain) from face and head; muscles for chewing o VI- abducens (eye movement) o VII- facial (taste, sensory info from ears, controls muscles used in facial expression) o VIII- vestibulocochlear (hearing, balance) o IX- glossopharyngeal (taste, sensory info from tongue, tonsil ad pharynx, controls muscles used in swallowing) o X- vagus (sensory, motor, and autonomic functions of viscera (glands, digestion, heart rate)) o XI- spinal accessory (controls muscles used in head movement in conjunction with the major next muscles: sternocleidomastoid and the trapezius muscles) o XII- hypoglossal (controls muscles of the tongue) Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. o The parotid glands are not normally palp able. Thyroxine (T4) and tri-iodothyronine (T3) = thyroid o T4 and T3 stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, a nurse might expect to find diffuse enlargement (goiter) or a nodular lump. Lymph nodes are not hard, not tender, and are mobile o However, acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer. 4 areas in the body where lymph nodes are accessible are the head and neck, arms, inguinal area, and axillae. When you see that lymph nodes are enlarged, assess the patient’s area proximal (upstream) to the enlarges lymph node for the source for the problem because that is the area in which the lymph node drains Headaches o Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last 1/2 to 2 hours each. o Tension headache o Meningeal inflammation- Acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. o Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are of a severe quality and are relieved by lying down not associated with stiff neck Migraines are associated with family history of migraines. Hydrocephalus o occurs with obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and enlargement of the head. o Symptoms and signs: The face looks small compared with the enlarged cranium, and dilated scalp veins and downcast, or "setting sun," eyes are noted. The temporomandibular joint is just below the temporal artery and anterior to the tragus. Swelling with the parotid gland occurs below the angle of the jaw and is most visible when the head is extended. Swelling occurs anterior to the lower ear lobe. Cerebrovascular accident (CA) or stroke will lead to paralysis of lower facial muscles, but the upper half of the face is not affected due to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. CHAPTER 18 Thorax and Lungs The spinous process of C7 is the vertebra prominens. It is the most prominent bony spur protruding at the base of the neck. o Used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. The right and left costal margins (the lower edge of the chest formed by the bottom edge of the rib cage) form an angle where they meet at the xiphoid process (Usually 90 degrees or less) o The angle increases when the rib cage is chronically overinflated, as in emphysema. Right lung has 3 lobes and is shorter (due to the liver underneath) the left lung has 2 lobes and is narrower due to the heart The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds. The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. o Forced inspiration involves the use of other muscles, such as the accessory neck muscles (sternocleidomastoids, scalene, trapezii). o Forced expiration involves the abdominal muscles. Paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort. Normally, fremitus (vibratory tremors that can be felt through the chest by palpation) is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. o Have the person say “99” o Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission. Resonance is the expected finding in normal lung tissue. o The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate. o Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli. Breath sounds o Decreased, or absent, breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion. o Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis. o Atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough. o Wheezing- whistling, musical sounds caused by narrowing of airways such as in asthma, COPD, a foreign body o Pleural friction rub-nonmusical, superficial, course and low-pitched (sounds like leather rubbing together) caused by inflammation of lung linings rubbing together, lung tumors o Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Breathing and aging o The costal cartilages become calcified with aging, resulting in a less mobile thorax. o Chest expansion may be somewhat decreased o chest cage commonly shows an increased anteroposterior diameter. o Lungs are less elastic and distensible, which decreases their ability to collapse and recoil. o There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. o The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload. Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness, skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. o Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or atelectasis. An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. o If the pneumothorax is large, then tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. o Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day. Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes. Hypoventilation vs bradypnea o Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. o Bradypnea is slow breathing, with a rate less than 10 respirations per minute. CHAPTER 19 Heart and Neck Vessels Superior and inferior vena cava empty deoxygenated blood into the right atrium The right atrium is superior to the right ventriclethe tricuspid (AV) valve separates the R atrium and the R ventricle Right vertical is inferior to the right atrium and pumps blood through the pulmonic valve. Its walls (myocardium) are thick because it has to pump blood to the lungs. Left atrium is superior to the left ventricle the mitral (AV) valve separates the L atrium and the L ventricle. Left ventricle is inferior to the L atrium and pumps blood through the aortic valve. Its walls are the thickest because it has to pump blood to the rest of the body The pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid. Direction of blood flow o Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta. Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the "atrial kick." The heart sounds o S1 (lubb) occurs during ejection of the blood from the heart and signals the beginning of systole. Heard loudest at the apex of the heart S1 coincides with the carotid artery pulse. S1 is louder than S2 at the apex of the heart; S2 is louder than S1 at the base. *In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1). o The second heart sound (S2) (dub) occurs with closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base of the heart. In the second heart sounds, the o S3 coincides with rapid filling of the heart when the AV valves first open ventricular filling creates vibrations that can be heard over the chest. o The S4 occurs at the end of diastole, at presystole, when the ventricle is resistant to filling. It occurs when atria contract late in diastole. It is heard immediately before S1. Vibration; very soft sound with a very low pitch needs a good bell and must listen for it. It is heard best at the apex, with the person in the left lateral position. Electrical components of the heart flow o Specialized cells in the SA node (the pacemaker of the heart) near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so that the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles. Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. o Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure-> called jugular venous distension A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle. Aging (again) o Increase in systolic blood pressure. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging. o If cardiovascular disease is suspected, auscultate each carotid artery for the presence of a bruit. avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain. The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. Mitral regurgitation subjective findings include fatigue, palpitation, and orthopnea. Objective findings are (1) a thrill in systole at apex, (2) lift at apex, (3) apical impulse displaced down and to the left, (4) S1 diminished, S2 accentuated, S3 at apex often present, and (5) murmur: pansystolic, often loud, blowing, best heard at apex, radiating well to the left axilla. Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue. The S3 is associated with heart failure and is always abnormal after age 35. The S3 may be the earliest sign of heart failure. A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur. When listening to the carotid for a bruit o lightly apply the bell of the stethoscope over the carotid artery at three levels; while listening, the nurse should have the patient take a breath, exhale, and hold it briefly. Examine only one carotid artery at a time to avoid compromising arterial blood flow to the brain. Avoid pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope. Pulse deficit: when you auscultate the heart and palpate the radial pulse at the same time and they do not bet at the same time. o Indicates a lack of peripheral perfusion CHAPTER 20 Peripheral Vascular System and the Lymphatic System The pumping heart makes the arterial system a high-pressure system. The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. o In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches. The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The posterior tibial pulse is palpated in the groove between the medial malleolus (ankle) and the Achilles tendon. The popliteal artery is palpated behind the knee. Experiencing pain in your calf when exercising which that disappears after resting for a few minutes is most consistent with ischemia caused by partial blockage of an artery supplying the left leg. o Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase. pain in the calf when climbing stairs which is relieved by sitting for about 2 minutes; then able to resume activities is called claudication o Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes leg pain that wakes patient at night, pain in legs when they are elevated that disappears when dangled. Development of a sore on the inner aspect of the right ankle are all signs of arterial insufficiency. Early clubbing- clubbing is a physical sign characterized by bulbous enlargement of the ends of one or more fingers associated with certain cardiopulmonary disorders o The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing. Mechanisms by which venous blood returns to the heart o Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart. The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return. o Can be excised without harming the circulation as long as the femoral and popliteal veins remain intact Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia. A normal pulse force is 2+ o 0+ absent o 1+ thread hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease. o 2+ normal o 3+ bounding Risk factors for venous disease o people who undergo prolonged standing, sitting, or bed rest. o Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. o Obesity and pregnancy are also risk factors, but not the early months of pregnancy. A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems. A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test. Homan’s sign- Calf pain on dorsiflexion of the foot is a positive Homans' sign, which occurs in about 35% of deep vein thromboses. o It also occurs with superficial phlebitis, Achilles tendinitis, and gastrocnemius and plantar muscle injury. Aging and peripheral blood flow o Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. o Aging produces progressive enlargement of the intramuscular calf veins. The flow of lymph is slow compared with that of the blood. o Lymph flow is not propelled by the heart, but rather by contracting skeletal muscles, pressure changes secondary to breathing, and by contraction of the vessel walls. o The vessels do have valves, so flow is one way from the tissue spaces to the bloodstream. Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy. Edema grading scale o 1+ Mild pitting, slight indentation, no perceptible swelling of the leg o 2+ Moderate pitting, indentation subsides rapidly o 3+ Deep pitting, indentation remains for a short time, leg looks swollen o 4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema). Elevating the patient’s legs 12 inches off the table and have them wag feet to drain off venous blood, then sitting up and dangling legs off the table tests venous refill. o In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Marked elevational pallor as well as delayed venous filling occurs with arterial insufficiency. Legs feel heavy in the calf, foot cramps at night, and dilated, tortuous veins in the lower leg are signs of varicose veins more common in women and pregnancy Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and it can impede drainage of lymph When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound. Raynaud’s disease (red white and blue disease- how patriotic!) o The condition with episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress is known as Raynaud's disease. Arterial ischemic ulcers o (s)- Deep muscle pain in the calf or foot, pain with walking (claudication), (pain at rest indicates worsening of condition) o (o)- coolness, pallor, elevational pallor, and dependent rubor, diminished pulses, systolic bruits, signs of malnutrition o occur at toes, metatarsal heads, heels, and lateral ankle, and they are characterized by a pale ischemic base, well-defined edges, and no bleeding. Venous stasis ulcer o (s)- aching pain in calf or lower leg, worse at the end of the day, worse with prolonged standing or sitting, itching with stasis dermatitis o (o)- Lower leg edema that does not resolve with diuretic therapy. Firm, brawny edema, coarse thickened skin, pulses normal, brown pigmentation o Ulcers occur at the medial malleolus and are characterized by bleeding and uneven edges, boarders are irregular, shallow, and may contain granulation tissue. Neuropathic ulcer (diabetics) o Ulcers are mostly on the plantar of the foot, where excessive moisture increases risk. Pain and sensation are increased and there is a callous around the ulcer. Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems. Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset, with exertion, and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems. CHAPTER 21 Abdomen RUQ LUQ Liver, gallbladder, duodenum, head of Left lobe of liver, spleen, stomach, pancreas, right adrenal gland, right jejunum and proximal ileum, body and kidney, superior part of the ascending tail of pancreas, left adrenal gland, left colon, right transverse of colon kidney, superior part of descending colon, last half of transverse colon RLQ LLQ Cecum, appendix, most of ileum, right Sigmoid colon, inferior part of the ovary and tube, ascending colon, right descending colon, left ovary, left uterine ureter tube, left ureter One should expect to hear dullness over the 7 right intercostal space at the midclavicular line because you are percussing over the liver. Dysphagia- difficulty swallowing Distended bladder- inability to urinate even when urge is felt due to an obstruction in the urethra which can be caused by things such as an enlarged prostate or kidney stones. o Assess for this condition by percussing and palpating the midline area above the suprapubic bone. An enlarged spleen should not be palpated because it can rupture easily o This is why you cannot play contact sports when you have mono Protuberant abdomen- the abdomen is bulging ad stretched in appearance Scaphoid abdomen- has a concave contour (goes in like a cave) Rounded abdomen isn’t as big as a protuberant abdomen Normal abdominal aortic pulsations are found between the xiphoid process of the sternum and the umbilicus A potential cause of hypoactive bowel sounds is peritonitis Abdominal borborygmi- hyperactive bowel sounds The umbilical region normally has a tympanic percussion note Kidney inflammation is associated with a sharp pain along the costovertebral angles Deep palpation used to feel enlarged organs When auscultating the abdomen o If you do not hear bowel sounds, wait 5 minutes before reporting the finding as “silent bowel sounds” o Large amounts of ascites (fluid) is associated with dullness across the abdomen Also tested for by looking for a fluid wave- have the patien
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