NR 302 Final Exam Concepts

NR 302 Final Exam Concepts Chapter 1: Evidence-Based Assessment  Define and recognize examples of Subjective and Objective data: - Subjective Data:  Information that the pt. provides to you.  Ex: I have a headach ...

NR 302 Final Exam Concepts Chapter 1: Evidence-Based Assessment  Define and recognize examples of Subjective and Objective data: - Subjective Data:  Information that the pt. provides to you.  Ex: I have a headache; I have a tummy ache.  Symptoms are subjective data - Objective Data:  what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination). Together with the patient's record and laboratory studies, these elements form the database.  Ex: fever.  Inspection, Palpate, Percussion, Auscultation.  Identify order and tasks of each step of the Nursing Process: -Assessment: information collection/ gather data -Diagnosis: Information interpretation, stating problems and strengths -Outcome Identification/Planning: setting nursing goals, desired outcomes, and planning interventions: -Implementation: performing -Evaluation: patient’s status and effectiveness of nursing interventions.  Recognize the difference between different levels of Nursing Experience: -Novice:  has no experience with a specified patient population and uses rules to guide performance. -Competent:  2-3 years in the same clinical setting and has the ability to take action by combining knowledge, skills, values, beliefs, and experience acquired as a nurse” -Proficient:  3-5 years in the same clinical setting, understands a patient situation rather than as a list of tasks. At this level you can see long-term goals for the patient. You understand how today's interventions will help the patient in the future. -Expert:  Attained mastery of an area of learning, has an intuitive grasp of a clinical situation and zeroes in on the accurate solution. Chapter 2: Cultural Assessment  Identify beliefs about causes of illness  Identify and understand cultural competency  Understand how to complete a cultural assessment: Heritage: the country of ancestry, years in the United State.  Health practices: the use of traditional healer, alternative & complementary therapies, preventive medicine,  Communication: primary language, preferred name, and method of communication, use of touch as a communication strategy.  Family roles and social orientation: who makes healthcare decisions in the family, relationship status, family priorities.  Nutrition: any forbidden foods, fasting rituals, foods avoided during illness.  Pregnancy, birth, and childbearing: number of children, beliefs surrounding pregnancy & childbirth, child rearing.  Spirituality or religion: religious affiliation, religious beliefs, spirituality assessment.  Death: rituals in preparation for death, meaning of death  Health providers: role of nurse or doctor, preference for same sex provider or any healers. Chapter 3:  Identify techniques of communication:  Introducing the interview:  this simply means introducing yourself and keeping it short and formal. It is best to address the patient with their last name, shake hands if appropriate. You can use first names for children and teens. If unsure how to pronounce the patient’s name, ask them in order to avoid bias and it shows sign of respect.  Working phase:  this is the phase of gathering data and the use of verbal skills is best for this. The nurse should ask appropriate questions related to the patient’s need and concerns. The use of Open-ended or Closed (Direct) questions are often used here.  Open-ended questions:  The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. Use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. Ex: “Tell me how I can help you”. “What brings you to the hospital?”  Closed (direct): Closed or Direct Questions:  Closed or direct questions ask for specific information. They elicit a one- or two-word answer, a “yes” or “no,” or a forced choice. Whereas the openended question allows the client to have free rein, the direct question limits his or her answer.Ex: Did you take your medicine today?  SBAR (Situation, Background, Assessment, Recommendation): Is a method of giving or handling reports with healthcare professionals. It is also a tool used by healthcare providers to communicate critical information about a patient.  Understand how to communicate with other professionals: Chapter 4: The Complete Health History  Identify guidelines for recommending immunizations:  A strong recommendation for Immunization increases compliance on the patient. Nurses should use the current Centers for Disease Control and Prevention (CDC) for adults but also be aware of primary contraindications and precautions as well as the person’s lifestyle, occupation, and travel. Recommendation for adults include the following.  Influenza (annually)  Tdap once every 10 years & to each pregnancy during 27 to 36 weeks’ gestation.  Varicella  Human papillomavirus (HPV)  Zoster (after 60 years)  Measles-mumps-rubella (MMR) if not immunized as a child.  Pneumococcal (after 65 years).  Gay & Bisexual men to receive HPV, hepatitis A & B vaccine  Identify examples of what should be documented in the medication reconciliation: - List of current and previous list of medications with a previous list, which is done at every hospitalization and every clinic visit. -The purpose is to reduce errors and promote patient safety. -For all currently prescribed medications:  Note the name (generic or trade), dose, and schedule.  Ask “how often do you take it each day, What is it for? How long have you been taking it? Do you have side effects?”  Ask, if not taking it, “ What is the reason you stopped taking it?”  This is an important opportunity for health teaching.  Take a moment to teach the patient about medications as applicable. -Medications -include information about prescribed, OTC (over the counter) drugs such as aspirin, and/ or herbal therapy -Obtain information about r/t vitamin supplements. -Ask about dosage, schedule, and clinical indications  Identify and understand each component of mnemonic PQRSTU and its place within the health history: - P: Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse?- Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it? - R: Region or Radiation. Where is it? Does it spread anywhere? - S: Severity Scale. How bad is it (on a scale of 0 to 10)? Is it getting better, worse, staying the same? - T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur? - U: Understand Patient's Perception of the Problem. What do you think it means?  Identify how a review of systems should be recorded:  Evaluate past and present state of each body system. (2) double check in case any significant data were omitted in the present illness section. (3) Evaluate health promotion practices.  It consists of medical terms which do not need to be used on the patient, rather break it down for them.  Symptoms and health promotion activities are merely listed here.  It uses a Cephalocaudal approach (Organized manner proceeding in a logical sequence).  Use language to facilitate communication. Translate medical terms. Avoid writing negative for body systems as you want to record either presence of absence of symptoms.  Do not include objective data. Limit to patient statements or subjective data.  Include all relevant body systems. Include pertinent document relevant to the individual patient. Focus on health promotion for each identified area.  The nurse needs to ask for the Absence or Presence of disease. Chapter 5: Mental Status Assessment  Define orientation: -The awareness of the objective world in relation to the self, including person, place, and time.  Define Alert, Lethargy, Coma, and Delirium: -Alert: Awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions. -Lethargy: Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased. -Coma: Completely unconscious; no response to pain or any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away); light coma has some reflex activity but no purposeful movement; deep coma has no motor response.-Delirium: Clouding of consciousness (dulled cognition, impaired alertness); inattentive; incoherent conversation; impaired recent memory and confabulatory for recent events; often agitated and having visual hallucinations; disoriented, with confusion worse at night when environmental stimuli are decreased.  Define ABCT and differentiate the components involved within each level: (Appearance, Behavior, Cognitive, and Thought Processes) Chapter 10: Vital Signs  Identify how to assess a Pulse and normal findings for the Rate, Rhythm, and Force:  Identify how cardiac output affects blood pressure: - Cardiac output. If the heart pumps more blood into the container (i.e., the blood vessels), the pressure on the container walls increases.  Identify vital sign changes in the Aging Adult: -Temperature:  Changes in the body's temperature regulatory mechanism leave the older adult less likely to have fever but at a greater risk for hypothermia. Thus, the temperature is a less reliable index of the older person's true health state. Sweat gland activity is also diminished. -Pulse:  The normal range of heart rate is 50 to 95 beats/min, but the rhythm may be slightly irregular. The radial artery may feel stiff, rigid, and tortuous in an older person, although this condition does not necessarily imply vascular disease in the heart or brain. The increasingly rigid arterial wall needs a faster upstroke of blood, so the pulse is actually easier to palpate. -Respirations:  Aging causes a decrease in vital capacity (the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath) and a decreased inspiratory reserve volume. You may note a shallower inspiratory phase and an increased respiratory rate. -Blood pressure:  Blood Pressure. The aorta and major arteries tend to harden with age. As the heart pumps against a stiffer aorta, the systolic pressure increases, leading to a widened pulse pressure. With many older people, both the systolic and diastolic pressures increase, making it difficult to distinguish expected aging values.  Identify Major Risk Factors for Patients with Hypertension: Smoking Dyslipidemia: (a high level of lipids). Diabetes mellitus: disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high.Urination and thirst are increased, and people may lose weight even if they are not trying to. Age >60 yr. Gender (men and postmenopausal women) Family history of cardiovascular disease: women <65 yr. or men <55 yr. Chapter 11: Pain Assessment  Determine the most reliable indicator of pain  Identify Physiological Responses to Poorly Controlled Chronic Pain:  Identify Pulmonary Physiological Responses to acute pain:  Hypoventilation  Hypoxia  Decreased cough  Atelectasis  Pain in the Aging Adult: What does pain signify? -Pain indicates pathology or injury -It should never be considered something to tolerate or accept in one’s later years.  Identify Chronic Pain Behaviors: Persistent (Chronic) pain behaviors:  Often live with experience for months and years.  Adaptation occurs over time. •Clinicians cannot look for or anticipate the same acute pain behaviors to exist in order to confirm a pain diagnosis.  Shows more variability than acute pain behaviors •Higher risk for under detection -Associated Behaviors:  Bracing  Rubbing  Diminished activity  Sighing  Change in appetite  Differentiate Acute versus Chronic Pain: -Acute Pain:  Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Examples of acute pain include surgery, trauma, and kidney stones. Acute pain has a self-protective purpose; it warns the individual of actual or threatened tissue damage. -Chronic Pain: Chronic (persistent) pain is diagnosed when the pain continues for 6 months or longer. Chronic pain can be divided into malignant (cancer-related) and nonmalignant. o Chronic pain doesn’t stop after injury. o Chronic pain originates from abnormal processing of pain fibers from peripheral or central sites. o outlasts its protective purpose, and the level of pain intensity does not correspond with the physical findings. Chapter 13: Skin, Hair, and Nails  Identify skin, hair, nail changes for the aging adult: -Skin:  Coarse wrinkling, decreased elasticity, atrophy with a leathery texture occur.  A loss of elastin, collagen, and subcutaneous fat/ reduction in muscle tone occurs.  Skin color and pigmentations, hyperpigmentation, macules (Senile lentigines)  Skin tags (acrochordons)  Dry skin (xerosis)  Thinner parts of skin: dorsa of the hands, forearms, lower legs, dorsa of feet and bony prominences.  The skin may feel thicker over the abdomen and chest. -Hair:  Hair looks gray or white, feels thin and fine.  Hair distribution changes  Hair decreases in the axillae, and pubic areas.  After menopause white women may develop bristly hairs on their chin and upper lip resulting from unstopped androgens. -Nails:  Nails grow more slowly  Their surface is lusterless and characterized by longitudinal ridges resulting from local trauma at the nail matrix.  Toenails become thickened and may grow misshaped, almost grotesque  Brittle, or peeling and sometimes yellowed.  A healthy, capillary refill time is longer in aging adults, (1.5 to 2 seconds, with 4 seconds as the upper limit).  Identify prevention strategies for skin cancer: -Seek shade esp. the sun 10 a.m. – 4 pm. - Don’t get sunburned -Avoid tanning  Never use UV tanning beds -Cover up with clothing  Broad-brimmed hat UV blocking sunglasses -Use broad spectrum (UVA/UVB) sunscreen with SPF of 15 or higher every day. For extended outdoor activity, use a water-resistant, broad spectrum (UVA/UVB) sunscreen with an SPF of 30 or higher. -Apply 1 ounce (2 tablespoons of sunscreen to your entire body 30 mins before going outside. Reapply every two hours or after swimming or excessive sweating. -Keep newborns out of the sun -Examine your skin -See a dermatologist  Identify etiologies for skin color changes: pallor -Pallor: (pale skin)  Decreased hematocrit: (the percentage by volume of red cells in your blood).  Decreased perfusion: (the local fluid flow through the capillary network and extracellular spaces of living tissue).  Vasoconstriction: (when the muscles around your blood vessels tighten to make the space inside smaller).  Identify areas to assess skin color changes for light and dark skin persons: pallor, cyanosis, jaundice, erythema: - Pallor in dark skin:  Ashen gray, gull, loss of glow, cool to palpation.  Check areas with pigmentation such as: conjunctivae, mucous membrane - Pallor in Light skin:  Generalized pallor - Cyanosis in dark skin:  Dullness  Check conjunctivae, oral cavity, and nails. - Cyanosis in light skin:  Dusky blue  Nail beds dusky, still will be generalized. - Erythema in dark skin:  Purplish tinge but difficult to see.  Palpate for increased warmth with inflammation  Taunt skin and hardening of deep tissues.- Erythema in light skin:  Redness, bright pink  Check for redness in nail beds, lips, oral mucosa - Jaundice in dark skin:  Hard and soft palate, palms  Noted in junction of hard and soft palate, also palms - Jaundice in light skin:  Yellow sclera, hard palate, skin, mucous membranes  Identify skin danger signs: ABCDEF  -A-asymmetry  -B-border irregularity  -C-color variations  -D-diameter greater than 6mm  -E-elevation or evolution  -F- funny looking “ugly duckling”- different from the other ones.  Identify Primary skin lesions: Macule, Papule, Vesicles:  -Macules: Solely a color change, flat, circumscribed, less than 1 cm  -Papules: felt and caused by superficial thickening of the epidermis  -Vesicles: Elevated cavity containing fluid up to 1 cm (blister)  Identify technique used to assess skin Texture:  Inspection and palpation.  Identify stages of Pressure Ulcers/Injuries: -Stage 1: Non-blanchable erythema  Intact skin appears red, unbroken. Skin does not blanch. -Stage 2: Partial- thickness skin loss  Erosion, loss of epidermis/ dermis  Superficial ulcer appears shallow like an abrasion (open blister with redpink wound base. -Stage 3: Full- thickness skin loss:  Pressure ulcer extending into the subcutaneous tissue a resembling a crater.  -Stage 4: Full-thickness skin/ tissue loss:  Pressure ulcer involves all skin layers/ extends. Exposes muscle, tendon, or bone (necrosis) Understand the skin findings for Abnormality: Herpes Zoster (shingles) - Small, grouped vesicles emerge along the route of cutaneous sensory nerve, then pustules, then crusts. -Acute appearance, unilateral, does not cross midline. -Commonly on truck; can be anywhere. -If ophthalmic branch of cranial nerve V, it poses risk to eye. -Most common in adults older than 50 years old. -Pain often severe and long-lasting in aging adults, (postherpetic neuralgia). -Caused by the varicella zoster virus (VZV)  Dormant virus of chicken pox  Identify what causes changes in skin turgor:  severe dehydration  extreme weight loss  Diarrhea or vomiting  Decreased fluid intake  Heat exhaustion excessive sweating without enough fluid intake. Chapter 14: Head, Face, and Neck  Identify changes that occur in head, face, and neck of the aging adult: -Head/Face:  facial bones and orbits appear more prominent, and the facial skin sags as a result of decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin. The lower face may look smaller if teeth have been lost.  Characteristics of Headaches: Tension, Cluster, Migraine: -Tension Headache:  Usually both sides of the head  Band-like tightness  Provoked by overwork, stress, bad posture  Graduate onset, lasts 30 minutes- days  Migraine Headache:  Usually one-sided but can be both.  Throbbing, pulsating  Provoked by hormone changes, foods, stress, weather changes  Rapid onset, lasts 4-72 hours or more  Cluster Headache:  Always one-sided  Burning, piercing  Provoked by alcohol, stress, daytime napping, wind, heat exposure Abrupt onset, peaks in minutes (1-2 days, for 1-2 months)  Sinus Headache:  Pain is behind browbone, or cheekbones  Identify expectations when assessing Lymph nodes in adults:  Lymph nodes are NOT PALABLE for a healthy person.  Identify clinical manifestations of Hyperthyroidism:  increased metabolic rate, just like ramping up the furnace. manifested by goiter, eyelid retraction, and exophthalmos (bulging eyeballs).  Symptoms include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance.  Signs include forceful tachycardia; shortness of breath; excessive sweating; fine muscle tremor14; thin silky hair; warm, moist skin; infrequent blinking; a staring appearance; and brisk ankle jerks.  Identify clinical manifestations of Hypothyroidism:  A deficiency of thyroid hormone means that the thyroid furnace is cold. reduces the metabolic rate and, when severe, causes a nonpitting edema or myxedema. cause is Hashimoto thyroiditis.  Symptoms include fatigue and cold intolerance.  Signs include puffy, edematous face, especially around eyes (periorbital edema); puffy hands and feet; coarse facial features; cool, dry skin; dry, coarse hair and eyebrows; slow reflexes; and sometimes thick speech.  Identify clinical manifestations of Bell’s palsy: Paralysis on one side of the face because of LMN lesion -Signs/ symptoms:  -Inability to close eyelids  -Drooping of the mouth  -Facial Nerve  -Can’t wrinkle forehead  Identify clinical manifestations of Stroke:Chapter 15: Eyes  Identify normal pupillary light reflex: -Normal Pupillary light reflex:  Constriction of the same-sided pupil (a direct light reflex)  Simultaneous constriction of the other pupil (a consensual light reflex) -Abnormal Pupillary light reflex:  Dilated pupils  Dilated/Fixed pupils  Constricted pupils  Unequal/ or no response to light  Pupil abnormalities  Identify effects of Macular Degeneration:  - unable to read books, papers, sew, do fine work.  - unable to distinguish faces.  -Effects central vision  -Causes great distress Chapter 16: Ears  Identify Ear changes associated with the Aging Adult:  -Age related hearing loss (presbycusis) gradual loss of hearing loss in both ears. (Common problem linked to age).  - one in 3 adults over age 65 has hearing loss, because of the change in hearing, some people are not aware of the change at first. Chapter 17: Nose, Mouth, and Throat  Identify changes that occur in the nose, mouth, and throat of the aging adult: -Gradual loss of subcutaneous fat  Start during later middle adult years, making the nose appear more prominent in some people. - Atrophic Tissue ulcerate easily  Increasing risk for older people for infections, such as oral moniliasis and malignant lesions - Natural tooth loss exacerbated by inadequate dental care, poor oral hygiene, tobacco use  Can lead to malocclusion leading to further tooth loss/ pain.- Diminished sense of taste and smell decreases an aging person’s interest in food and may contribute to malnutrition. - Trouble with mastication can lead to dietary pattern changes which may place the older adult at risk for nutritional deficits (protein, vitamins, and minerals). Chapter 19: Thorax and Lungs  Differentiate breath sounds (bronchial, vesicular, bronchovesicular) and their locations: (normal breath sounds) -Bronchial (Tracheal)  Pitch: High  Amplitude: Loud  Location: Tracheal/ larynx  Quality: Harsh, hallow, tubular -Bronchovesicular: Pitch: Moderate Amplitude: Moderate Quality: Mixed Location: Over major bronchi (fewer alveoli are located) Posterior b/w the scapula Esp. on the right; anterior around upper sternum in 1st and 2nd intercostal spaces. Vesicular: Pitch: Low Amplitude: SoftLocation: Peripheral lung fields where air flows through smaller bronchioles/alveoli.  Identify what can cause Hypoventilation and Tachypnea -Hypoventilation:  An irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain. -Tachypnea:  An irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain.  Identify clinical manifestations of pulmonary embolism: (blood clot in the lungs) -Hurts when breathing in deeply.  chest pain, worse on deep inspiration, dyspnea, hemoptysis, cyanosis, bloody sputum, crackles, wheezes, hypertension.  Identify clinical manifestations of pneumonia (mucus filling up alveoli sac, impairing gas exchange):  High fever with chills, fatigue, leukocytosis, Dyspnea, tachypnea, tachycardia, Pleural pain, Rales, Productive cough. Typical rusty-colored sputum.  Identify clinical manifestations of emphysema (necrosis/ destruction of alveoli/ comes from smoking): -Dyspnea (Occurs first on exertion), Hyperventilation with prolonged expiratory phase (Development of barrel chest), Anorexia, fatigue, Weight loss, Clubbed fingers  Identify ways to describe wheezing, stridor, and crackles: Chapter 20: Heart and Neck Vessels  Identify clinical manifestations of heart failure: -Dilated pupils -Orthopnea -Dyspnea -Decreased BP -Nausea and vomiting -Ascites -Anxiety -Failing 02 saturation -Confusion -Jugular vein distention -Infarct -Fatigue -S3, gallop, tachycardia-Enlarged Spleen, and liver -Decreased urine output -Weak pulse -Dependent, pitting edema REMEMBER!!!!! Signs and symptoms of heart failure come from two basic mechanisms: (1) the heart's inability to pump enough blood to meet the metabolic demands of the body; and (2) the kidney's compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output. This increases blood volume and venous return, which causes further congestion.  Identify clinical manifestations and description of acute coronary syndrome (myocardial infarction) -Description:  Heaviness; viselike, squeezing, crushing, tightness; vague, burning, constricting, or pressure; poorly localized pain lasting 20-30 minutes to hours and does not resolve with rest or nitroglycerin. - Manifestations  Indigestion-like feeling, nausea, vomiting, dizziness, flushing, perspiration, palpitations, dyspnea, fatigue.  Identify clinical manifestations and description of angina: Angina pectoris stable (no change in pain pattern within last 60 days) - Description:  Pressure like pain (e.g., tightness, squeezing, burning, heaviness that lasts 3-5 minutes precipitated by activity and often resolves with rest and/or nitroglycerin) - Manifestations:  Diaphoresis (sweating), nausea, vomiting, dyspnea, fatigue Variant Angina: - Description: