NR302 Final Exam Study Guide: Health Assessment I: Chamberlain Thorax and Lungs -What data can be gathered on a patient in respiratory distress from general survey only? -Do they use accessory muscles when breathing? Position-tripod, Barrel chest, Nasal flaring, color -Structure and Function: The thorax -Thoracic cage -Sternum, 12 pairs of ribs -12 thoracic vertebrae -Muscles and cartilage -Thoracic Cavity -Mediastinium -Pleural cavity -Lung (Apex and base) Structure and Function: Pleural Membranes -Parietal pleura-lines the whole cavity -Visceral pleura-lines the organs -Pleural space/cavity-both above total Structure and Function: The respiratory system -Trachea -Bronchi -Bronchioles -Alveolar Sacs -Alveoli Landmarks-Visualize what you cannot see! -Anterior chest -Suprasternal notch “U shaped” -Sternum -Sternal angle (Angle of Louis) continuous with 2nd rib -Ribs & intercostals -Costal angle (at xiphoid) 90 degrees -Posterior chest -Vertebra prominence C7 -Spinous processes T1 is 1st rib -T3 separates upper and lower lobes -Inferior border of the scapula 8th rib -12th rib Subjective Data -Difficulty breathing, sleeping, chest pain, cough and sputum (Rusty-TB), smoking history, environmental exposure TO calculate smoking pack-years 1. Multiple the number of cigarettes smoked per day by number of years smoked 2. Divide by 20 i.e 10 cigarettes smoked per day x 10 years / 20 = 5 pack years Objective Data -Inspection of patient: Resp. rate & effort to breathe (Nasal flaring, accessory muscles, positioning) skin color, nails, configuration of chest (Chest deformities) -Palpation of anterior and posterior chest: Tenderness, lumps, crepitus (Subcutaneous air-rice krispis under skin), tactile fremitus (99), respiratory expansion -Percussion of lung fields: Resonance, hyper-resonance, dull, diaphragmatic excursion -Auscultation of chest: Normal, adventitious, voice sounds, measurements of pulmonary function: For screening**Begin at the moment of contact Normal breath sounds -Bronchial (Tracheal) –Over trachea & larynx E>1 -Bronchovesicular—Over major bronchi I=E -Vesicular—over peripheral lung fields I>E Normal Assessment Findings -Inspection: RR 14 reg,even & unlabored (eupnea), skin & nails pink, no cyanosis noted, relaxed posture, shape symmetric AP: Transverse 1:2, costal angle <90 degrees -Palpation: Chest expansion symmetric, tactile fremitus symmetric, no tenderness, no crepitus, no lumps or masses -Percussion: Resonance throughout, diaphragmatic excursion equal bilaterally -Auscultation: Normal breath sounds Adventitious Breath sounds -Crackles/rales -Pleural friction rub -wheeze -Rhonchi Voice Sounds -Bronchophony “99” -Egophony “EEEEEE” -Whispered Pectoriloquy “one-two-three” Abnormal breathing patterns -Tachypnea -Bradypnea -Hyperventilation -Hypoventilation -Cheyne-strokes—fast breathing with apnea (People who are dying) Time to THINK as a NURSE… -Discuss dyspnea and orthopnea -What causes pleuritic pain (pleurisy) -Differentiate Crepitus vs Fremitus -Is abnormal posture or chest shape a concern? Why? Yes -Connect nasal flaring & accessory muscle use -Atelectasis-collapsed lung -Differentiate various colors of sputum -What would cause dense of consolidated lung tissue?—Fluid, tumor, mucous, food Case Study Mr. JS is a 70 year- old male with progressive COPD. Reason for seeking care, “I am not getting air.” He reports smoking 1.5 packs of cigarettes per day since age 16 . He presents to the emergency department with complaints of worsening dyspnea, productive cough, chest tightness, chills & fatigue Vital Signs: temp. 101.2 oral, apical heart rate 108, RR 24 labored, B/P 124/78, pulse ox 88% on room air (RA) -Subjective -Chest tightness -Dyspnea -chills -fatigue -Objective -Vitals -Labored -productive cough -Accessary muscles -Tripod -Purse lipped breathing -Pants unbuttoned -malnourished -Barrel chest -Clubbing/stained nails -Anxious Assessment Reveals Inspection: -Pt. is leaning forward in TRIPOD position -RR 24 labored and shallow, lips appear cyanotic -Using accessory muscles of the neck & shoulders (hypertrophied) -“Barrel-shaped” chest with costal angle > 90 degrees -Clubbing of the nails with yellow staining from nicotine -Productive cough: thick yellow – green sputum Palpation: -Decreased chest expansion on right side -Decreased fremitus throughout with Increased tactile fremitus over right lower lobe (RLL) Percussion: -Hyper resonance over lung fields -Dull over RLL Auscultation: -Decreased breath sounds throughout -Crackles over RLL -Bronchophony, egophony-bleeding goat, whispered pectoriloquy-loud RLL CALCULATE THIS PATIENT’S PACK YEAR HISTORY 81 years!!!!! Nursing Diagnoses -Self-care deficit: Bathing and hygiene -Impaired gas exchange -Ineffective tissue perfusion -Activity intolerance -Ineffective health maintenance -Anxiety -Nutrition: less than body requirements Test your knowledge The nurse is performing the respiratory assessment on a pt. with pneumonia. The pt. is asked to say “ninety-nine” & through the stethoscope the nurse hears the words clearly over the LLL. How will the nurse document the findings? 1. Bronchophony 2. Tactile fremitus 3. Crepitus 4. Egophony A pt. has developed a deep vein thrombosis (DVT) and the nurse is alert for the potential development of a pulmonary embolism (PE). Which findings would suggest s/s of PE? 1. Non-productive cough & abdominal pain 2. HTN & afebrile 3. Bradypnea & bradycardia 4. Chest pain & dyspnea Which of the following patient’s is at greatest risk to develop atelectasis and pneumonia? 1. Pt. w/ a hx of smoking 2 PPD that quit 2 yrs. ago 2. Pt. who is ambulatory q 4 hrs. 3. Pt. who is post- operative requiring “splinting(hold together)-hug pilow” secondary to pain 4. Pt. taking Tylenol for pain Chapter 19 Heart and Neck Vessels Landmarks -Precordium: – Clavicle to xiphoid, overlying heart and great vessels -Base of the Heart: -Second intercostal space -Apex of the heart: -Fifth intercostal space Structure and Function -The right and left atrium are the receiving chambers. -The right and left ventricles pump blood out of the heart. -The right side of the heart transports unoxygenated blood to the lungs -The left side of the heart transports oxygenated blood to the systemic circulation Heart Valves Structure and Function -Four heart valves facilitate unidirectional movement of blood through the heart to prevent backflow Atrio-ventricular (AV) Tricuspid Mitral (Bicuspid) Semilunar (SL) Pulmonic Aortic Neck Vessels Structure and Function Carotid arteries -Supply oxygenated blood to the head and neck -Located between the trachea & SCM -bruire—bell of stethoscope Jugular veins -Return un-oxygenated blood to heart -Jugular vein distention (JVD) provides information about the right side of the heart Subjective Data Nonspecific S&S -Fatigue -SOB (DOE) -Orthopnea/difficulty sleeping -Dizziness/syncope Lifestyle Assessment -Diet & exercise -Smoking/stress Specific S&S -Chest pain -palpations -edema -cyanosis -orthopnea/difficulty -dizziness/syncope Objective Data -Inspection of pt.: -General appearance, jugular veins, carotid arteries, hands & fingers, chest -Palpation of precordium: -Pulsation or heave, carotid pulses, apical impulse -Percussion: -Cardiac border (*SEE P. 480) -Auscultation: -Carotid arteries, Heart sounds & Apical heart rate, pulse deficit Auscultation: Five listening points of the heart Aortic: 2ICS/RSB Pulmonic: 2ICS/LSB Erb’s: 3ICS/LSB Tricuspid: 4ICS/LSB Mitral: 5ICS/LMCL Normal Heart Sounds -S1: -Closure of AV valves – “LUB” heard loudest at apex – listen at tricuspid & mitral points S2: -Closure of semilunar valves – “DUB” heard loudest at base – listen at Pulmonic and Aortic points. Time to think as a nurse What is tissue perfusion? –enough O2 in system-can send o2 to all body tissues. Ability of heart to pump o2 -List modifiable & non-modifiable risk factors -Differentiate between apical pulse & apical impulse (impulse what I feel) -What is the relationship between carotid artery bruit and dizziness? -Obstruction Nursing Diagnoses -Acute Pain—evidence is patient has pain 10/10 -Ineffective Tissue Perfusion -Activity Intolerance -Fatigue -Anxiety -Decreased Cardiac Output -Fear Test your knowledge… The nurse is performing CPR on an adult pt. What is the correct hand position on the pts. chest? 1. Upper half of the sternum 2. Two finger widths below the sternal notch 3. Two finger widths above the xiphoid process 4. Over the xiphoid Chapter 20 Peripheral Vascular System and Lymphatic System Function of Peripheral Vascular System Arteries -Transport O2 and blood via the heart to the organs and tissue capillaries (perfusion) -Have a smooth muscle layer that contracts and relaxes in response to changes in blood volume -Arterial pulse reflects the pumping of the heart during systole Veins -Transport deoxygenated blood from capillaries to the right side of the heart -Thinner walls makes veins more distensible; can accumulate large amounts of fluid -Have one way valves that allow blood to flow against gravity and return to the heart Function of Lymph System -Retrieve excess fluid from tissue spaces and returns to the bloodstream. Damage to this system or removal of nodes results in lymphedema -Lymph nodes filter out micro-organisms (such as bacteria) and foreign substances such as toxins. -Superficial lymph nodes are primarily located: -Head & neck -Axillary -Epitrochlear -Inguinal Subjective Data-Venous -Pain in legs? Does walking increase pain? Laying down increase pain? -Numbness and tingling? -Varicose Veins? -Edema Objective Data Arterial Insufficiency Inspection -Skin is pale & shiny -Hair loss distribution -Distal, dry ulcer Palpation -Absent or weak pulse -Cool temperature -No edema Objective Data Venous Insufficiency Inspection -Swollen leg -Darkened hyperpigmentation at ankle -Ulcers on leg and ankle Palpation -Moderate to severe pitting edema -Palpable pulse (depending on edema) -Hard skin, normal temperature Objective Data Collection -CMS checks: Arterial Check Circulation, Motion, and Sensation Together with the: -5 P’s: 1. Pain 2. Pulse 3. Pallor 4. Parasthesia 5. Paralysis -Remember the edema scale (0-4) and pulse scale(0-3)? -Perform the Allen Test (assess hand perfusion) The Homan’s Sign (not used during assessment anymore!) Arterial ulcer- Round, approximated, pink/pale base, open up artery break down cause no o2 Venous Ulcer-Generally on ankles, medial or lateral, skin opens, and drains dark break down because old blood stagnate -Elevate leg Time to THINK as a NURSE… Cluster and connect the cues: -Immobility -Peripheral arterial disease (PAD) -Skin integrity Test your knowledge You are the nurse assessing a pt. s/p femoral-popliteal bypass graft. Which of the assessment findings indicate a complication? 1. BP 110/80, HR 86, RR 20 unlabored 2. Small amt. of dk. red blood on dressing 3. Decrease in pulse quality of the operative leg 4. Small amt. of swelling of the operative leg Raynaud Phenomenon-fingers, toes turn blue-keep extremities warm Lymphedema-Breast cancer patients with lymph’s removed Arterial Ulcer- Venous Ulcer- Communicating in Clinical with the older adult Why is communication important? • BUILD RELATIONSHIPS • COLLECT ASSESSMENT DATA • PROVIDE EDUCATION • INTERACT DURING INTERVENTIONS Communicating in clinical • PATIENT CENTERED CARE-perceptions, feedback loops • PATIENT AND FAMILY CENTERED CARE-respectful family professional partnership, strength of culture, traditions, provides trust The clinical setting • Acute care or long-term care facility • Caring for the older adult patient • Develop communication-facilities-pt expresses feelings, concerns • Develop critical thinking skills-promote more effective communication than pt assessment Focus on older adults –affecting communication • Patients who are visually impaired • Patients who are hearing impaired • Patients who are cognitively impaired • Patients who cannot speak clearly Older adults who are visually impaired-cataracts, glaucoma, peripheral vision • Provide light • Avoid standing too close • Stand in front • Use yellow and red for signs • Make sure their glasses are clean and ON • Large print • In this scenario, our 84-year-old patient Mrs. Smith is visually impaired. She just received her lunch tray. We are going to set her up for her meal. • Clock terms • Path was clear, glasses on, light on Older adults who are hearing impaired • Earwax build up • Hearing aides in-battery • Stand in front-to read lips • Try to lower tone • Noise • Privacy • Scenario Mr. Johnson is an 86-year-old who presents with hearing loss. We are going to set him up at the sink to wash his face and brush his teeth. Older adults who are cognitively impaired –Dementia—Alzheimer’s • Simple sentences-avoid long explanations • One question • Allow time-don’t rush them • Attentive • Include family • Use pictures • Use gestures • Scenario Mrs. Scott is 78 years old. She has cognitive impairments. She does not like people touching her. We are going to take Mrs. Scotts blood pressure and listen to her heart and lungs. Older adults who cannot speak Clearly-Aphasia, dysarthria, muteness) • Listen attentively • Be patient • Ask yes/ no questions • Allow time • Communication aids • Scenario Mrs. Applehoff is a 68-year-old who presents with a left CVA and right sided weakness. She is trying to tell the nurse she needs something.
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