305 Final EXAM Study Guide PDF

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Nursing 305-Final ReviewModule 1: QSEN Component, Evidence-Based Practice, IOM Reports, and Healthy People 2021Understand role of evidence based practice and its impact on what we do every dayEBP [Evidence Based Practice] Integration of research evidence, clinical expertise, clinical knowledge, and ...

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Nursing 305-Final Review

Module 1: QSEN Component, Evidence-Based Practice, IOM Reports, and Healthy People 2021 Understand role of evidence based practice and its impact on what we do every day

EBP [Evidence Based Practice] -

Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences Clinical decision making: best evidence from literature review + patient’s own preference + clinician’s experience/expertise + physical exam Evidence-based practice or EBP is the objective, balanced and responsible use of present research and the best available data to guide policy and practice decisions, such that outcomes for consumers are improved. Used originally in the health care and social science fields, evidence-based practice concentrates on approaches displayed to be effective through empirical research rather than through anecdote or professional experience alone.

5 step to evidence base: 1. 2. 3. 4. 5.

Ask the clinical question Acquire sources of evidence Appraise and synthesize evidence Apply relevant evidence in practice Access the outcomes.

Identify Immediate Priorities: ● First level priority problem: airway, breathing, and circulation. ● Second level priority problem: mental status change, acute pain, infection risk, abnormal values, and climate. ● Third level priority: lack of knowledge, mobility problems, and family coping. Module 2: Standard Precautions, Handwashing, Prioritization, and Documentation Steps of the nursing process: what does it include Assessment: Review of clinical record - Interview

- Health history - Physical examination - Functional assessment - Cultural and spiritual assessment - Consultation - Review of the literature

Diagnosis: symptom management and care planning from a holistic standpoint; not a medical diagnosis - Interpret data - Identify clusters of cues - Make inferences - Validate inferences - Compare clusters of cues with definitions and defining characteristics - Identifying related factors - Document the diagnosis

Planning: Establish priorities - Develop outcomes - Set time frames for outcomes Identify interventions - Document plan of care - Establish priorities - Develop outcomes -Set time frames for outcomes - Identify interventions - Document plan of care

Implementation: Determine patient readiness - Review planned interventions

- Collab with other team members - Supervise by delegating appropriate responsibilities - Counsel person and significant others - Involve the person in health care

Evaluation: Refer to established outcomes - Evaluate individual’s condition and compare actual outcomes with expected outcomes - Summarize results of the evaluation - Identify reasons for failure to achieve expected outcomes - Take corrective action to modify the plan of care - Document evaluation and plan of care

Standard precautions Hand hygiene, gloves, gown, mask, eye protection, face shield Isolation precautions Airborne: Gown, gloves, N95, face shield or google Droplet: Gown, gloves, N95, face shield or google contact: Gown, gloves, mask

Documentation normal vs. abnormal.

Module 3: General Survey and Measurement, Vital Signs, and Pain Management Pain assessment Pain management Pain is subjective Pain can be measured and quantified by pain scales àit becomes objective with a pain scale -How to assess pain

-Initial pain assessment: pt answers PQRST -Numeric Rating scales: 0-10 -Verbal descriptor scales: describes pts feelings and meaning of the pain for the person -Visual analog scales: marks along a 10 cm line from no pain to the worst pain -Descriptor scale: lists words -Ex: acute pain what is an appropriate goal? The patient reports pain acuity after giving medication

Pain treatments -pharm vs. nonpharm -

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medication - opioids - NSAIDS nonpharm - distractions: TV, music - STIM - stretching - home remedies

Module 4: Assessment of Eyes and Ears Visual assessment -Examination, visual fields/confrontation test, corneal light test

Different methods for eye assessments ]For visual acuity: 1) Snellen Eye chart: most commonly used and accurate measure of visual acuity a. Position from 20 ft away at eye level and use opaque shield to cover one eye and leave on glasses/contacts (remove reading glasses) b. Normal acuity is 20/20... If 20/30, then “You can read at 20 ft what the normal eye can see from 30 feet away.” 2) Near Vision (At bedside or for people older than 40) A. Test near vision with handheld visual screener (with glasses) B. Hold the card in good light about 14 inches from eye C. A normal result is “14/14” in each eye, read without hesitancy and without moving the card closer or farther away. When no vision screening card is available, ask the person to read from a magazine or newspaper.

For visual fields: 1) Confrontation Test: Tests for loss of peripheral vision. Compares person’s peripheral vision with your own (assuming yours is normal) A. Place yourself 2 feet away from the person. Looking straight at you, the person covers one eye (right) with an opaque card and you cover the opposite eye (left). Hold a wiggling finger as a target midline between you and the person and slowly advance it in from the periphery in several directions. (Sensitivity of test is increased by combining wiggling finger with B. Say “now” as the target is first seen; this should be just as you also see the object. For the temporal direction, start your finger somewhat behind the person. Estimate the angle between the anteroposterior axis of the eye and the peripheral axis where the object is first seen. (Normal results are about 50 degrees upward, 90 degrees temporally, 70 degrees inferiorly, and 60 degrees nasally.)

For inspecting extraocular muscle function: 1) Corneal Light Reflex Test (Hirschberg Test): Tests for symmetry and alignment of the eye axes by shining light towards a person's eyes. A. Direct person to stare straight ahead while you shine a light about 12 inches away. B. Note the reflection of light on the person’s corneas (should be exactly in the same spot) 2) Diagnostics Position Test (Six Cardinal Positions of Gaze): tests for muscle weakness, nystagmus, and lid lag A. “Keep your head steady and follow the movement of my finger with your eyes.” B. From 12 inches away and in a clockwise motion, move finger in 6 positions

Technique for use of ophthalmoscope and otoscope Otoscope - instrument for inspecting the eardrum and the passage of the outer ear, typically having a light and a set of lenses. Ophthalmoscope - instrument for inspecting the retina and other parts of the eye.

Module 5: Assessment of Head, Neck, Nose, Mouth, and Throat Assessment of skin: observation techniques, palpation techniques. Normal vs abnormal Oral assessment: Normal:

Mouth: ● Adults have 32 permanent teeth, 16 top, and 16 bottom ● The gums should be pale pink color, and stippled surface Throat: ● As the oropharynx is separated from the mouth by a fold of tissue covered on each side, the anterior tonsillar pillar. ● Behind folds: tonsils, it should be the same color as the lymphoid tissue, the tonsils tissues enlarged during childhood until puberty and then involutes. ● Inspecting tonsils: ● 1+ (visible) ● 2+ (halfway between tonsillar pillars + uvula) ● 3+ (touching the uvula ● 4+ (touch one another ● 2,3,4 means its enlarged ● How? Bc of viral pharyngitis, streptococcal ( signs: asbences cough, swollen tender, anterior cervical nodules = fever) ● Torticollis: a hematoma in one sternomastoid muscle, HOW? Bc is injured by intrauterine malposition. (Head tilt to one side + limited range of motion ● Simple diffuse goiter: chronic enlargement of the thyroid gland bc of low iodine. Abnormal: ● Sore throats are viral and resolve in 3-5 days w/ antibiotics. (Streptococcal pharyngitis bacteria = fever of 100.4) confirm with culture test ● Dysphagia: occurs with pharyngitis, gastroesophageal reflux disease,stroke, and esophageal cancer ● Leukoplakia: chalky white, thick, raised patch, well defined borders ( caused by chronic irritation of smoking + alcohol use) ● Gingivitis = Bleeding gums, red, swollen and bleed easily. Inflammation caused by poor dental hygiene and vitamin C deficiency. ● Rhinorrhea (nose congestion) = occurs with colds, allergies, sinus infection ● Rhinitis - nasal mucosa is swollen and bring red with URL (discharge can be thick, purulent, and green-yellow ● Epistaxis (nosebleeds): occurs with trauma, vigorous nose blowing, foregin body. ● Cheilitis: cracking at the corners (herpes simplex ans other lesions) Lymph nodes:

● When palpating, use gentle pressure and use both hands, comparing the two side for symmetrically ● When palpating the submandibular only use one hand to palpate, use your other hand to hold your head. ● Lymphadenopathy: enlargement of nodes from infection, allergy, or neoplasm. ● Cancerous nodes are hard like a rock ● HIV nodes are enlarged, firm non tender, and mobile (occipital node enlargement) ● Thyroid: ● To palpate move behind the person, use the fingers of your left hand to push the trachea slightly to the right ● Enlarged nodes are easily palpated before swallowing or are tender to palpation. ● Bruit: occurs with accelerated or turbulent blood flow, indicating hyperplasia of the thyroid ( hyperthyroidism) Assessment of lymph nodes of head and neck what is normal and what is abnormal Head ● Concussion: results after a direct blow to the skill cause the brain to shift rapidly back and forth inside. ● Loss of consciousness: before a fall may have a cardiac cause

● Presyncope: light-headed, swimming sensation or feeling of fainting or falling caused by lack of blood flow to brain or heart irregularity caused decreased cardiac output. ● Vertigo: is true rotational spinning or dizziness. It may be related to musculoskeletal disorder or multi sensory deficits. ● Acute Neck stiffness can be caused by meningitis ● Dysphagia (trouble swallowing) caused by chewing tobacco

Module 6: Assessment of Skin, Hair, and Nails Allergic reactions, skin assessment.

● Assessment of hair and types ○ Inspect and palpate the hair: texture, distribution and scalp lesions. ○ People have two types of hair. Fine, faint vellus hair covers most of the body (except the palms and soles, the dorsa of the distal parts of the fingers, the umbilicus, the glans penis, and inside the labia). The other type is terminal hair, the darker, thicker hair that grows on the scalp and eyebrows and, after puberty, on the axillae, the pubic area, and the face and chest in the male. ○ Lanugo- Fine, downy hair of the newborn infant.

● Assessment of the skin normal and abnormal findings with relation to disease processes and different skin colors ○ Normal Findings: ■ General Pigmentation: Consistent with genetic background. It varies from pinkish tan to ruddy dark tan or from light/dark brown and may have yellow or olive undertones. Note: Darker in sun exposed areas. ■ Presence of freckles, moles and birthmarks. ○ Abnormal Findings: ■ Pallor: When the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly white. Pallor is common in acute high-stress states such as anxiety or fear because of the powerful peripheral vasoconstriction. ● Exposure to the cold and cigarette smoke makes the skin appear more pale. ● Disease Association: Anemia—Decreased hematocrit Shock— Decreased perfusion, vasoconstriction.

○ Local artery insufficiency (Localized pallor, lower extremities especially when elevated). ○ Albinism (total absence of pigment melanin). ○ Vitiligo (Patchy depigmentation from the destruction of melanocytes). ■ Brown-Tan ● Addison disease- Cortisol deficiency stimulates increased melanin production. ● Café au lait spots- Caused by increased melanin pigment in the basal cell layer. ■ Erythema: Intense redness of the skin is from excess blood (hyperemia) in the dilated superficial capillaries. This sign is expected with fever, local inflammation, or emotional reactions such as blushing in vascular flush areas (cheeks, neck, and upper chest). ● Hyperemia- Increased blood in engorges arterioles (Inflammation, fever, alcohol, intake, blushing. ● Polycythemia- Increased red blood cells, capillary stasis. ● Carbon Monoxide Poisoning ● Venous Stasis- Decreased blood flow from area, engorged venules. ○ Sunburn, friction, poorly fitting clothes, massages, too much pressure, and exercise can also cause this. ■ Cyanosis: This is a bluish mottled color from decreased perfusion; the tissues have high levels of deoxygenated blood. This is best seen in the lips, nose, cheeks, ears, and oral mucous membranes and in artificial fluorescent light. ● Disease association: Increased amount of unoxygenated hemoglobin central -- chronic heart failure and lung disease cause arterial desaturation. ● Peripheral-- exposure to cold, anxiety. ■ Jaundice: A yellowish skin color indicates rising amounts of bilirubin in the blood. ● Increased bilirubin from liver inflammation or hemolytic disease such as after severe burns, some infections. ● Carotenemia- Increased serum carotene from ingestion of large amounts of carotene-rich foods. ● Uremia- Renal failure causes retained urochrome pigments in the blood.

Module 7: Peripheral Vascular and Lymphatic System, Domestic Violence, and Substance Abuse/Cage Questionnaire Assessment findings of vascular problems such as venous and arterial insufficiencies ● ● ● ● -

Arterial disease causes symptoms of oxygen deficit Venous disease causes symptoms of metabolic waste build up. (EDEMA) Legs Ulcers: arterial, venous, or diabetic Arterial (ischemic) ulcer If you suspect an arterial deficit, raise legs about 30 cm off table and ask the person to wag feet for 30 seconds to drain off venous blood.

What are 3 trophic changes associated with arterial insufficiency in older adults? 1. 2. 3. ●

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Thin, shiny, skin Thick, ridged nails Loss of hair in lower legs Venous (stasis) Ulcer : Deep Vein Thrombosis : it is swelling in the legs, warmth and redness from inflammation, superficial venous dilation. Th Neuropathic ulcer: Diabetes PVD in legs Superficial varicose veins Deep veins thrombophlebitis Peripheral artery disease Aneurysm Occlusions

Things to note, location, character, onset, and duration, aggravating factors and relieving factors. Venous stasis ulcers-prevention Pt education/prevention: ● Focus on foot care ● Inspect for any skin breakdowns ● Maintain exercise to improve circulation and pay attention to seated positions during the day ● Wear comfortable shoes that fit well and wear shoes outside to prevent potential injury ● Lubricate the skin then hydrate it.

Understand what loss of pulses mean/intermittent claudication

Module 8: Assessment of the Thorax, Lungs, Breast, and Regional Lymphatics Respiratory assessment: normal -

rate 14-20 and frequency should be quiet 12-16 breaths per minute symmetrical with equal movement for the chect

abnormal -

rate is irregular, too fast, too slow or shallow crackling popping bubbling sounds wheezing

Lymph node assessment – normal palpation

-gentle pressure -palpate both sides at the same time Location ● ● ● ● ●

head and neck arms axilla (armpits) inguinal area (groin) back of knees

in the thorax/what does it mean

Module 9: Assessment of the Heart and Neck Vessels Cardiac cycle assessment, and what it reflects

Physical assessment of the heart: sounds associated with cardiac cycle. ● Normal heart sounds ○ S1- first heart sound: occurs with the closure of the AV valves and signals the beginning of systole (lub) ■ M1 is the mitral component of the first sound that usually precedes the tricuspid component (T1) but usually heard as one sound ■ Can be heard over all of the precordium but is usually the loudest at the apex ○ S2- second heart sound: occurs with the closure of the semilunar valves and signals the end of systole (dub) ■ Aortic component (A1) slightly precedes the pulmonic component (P2) ■ Can be heard over all the precordium but is loudest at the base ○ Effect of respiration ■ During inspiration- right side of the heart ● Intrathoracic pressure is decreased ● Pushes more blood into the vena cava increasing venous return to the right side of the heart which increases right ventricular stroke volume ● Increased volume prolongs right ventricular systole and delays pulmonic valve closure ■ During inspiration- left side of the heart ● Greater amount of blood is sequestered in the lungs during inspiration ● Momentarily decreases the amount returned to the left side of the heart ● Decreases left ventricular stroke volume ● Decreased volume shortens left ventricular systole and allows the aortic valve to close a bit earlier ● When the aortic valve closes significantly earlier than the pulmonic valve you can hear the two components separately ● This is called a split S2. ● Extra heart sounds ○ S3- third heart sound: occurs when the ventricles are resistant tot filling during the early rapid filling phase (protodiastole) ■ Occurs immediately after S2 when the AV valves open and atrial blood first pours into the ventricles ■ Normally diastole is a silent event but in some conditions ventricular filling creates vibrations that can be heard over the chest

○ S4- fourth heart sound: occurs at the end of diastole at pre systole when the ventricle is resistant to filling ■ The atria contract and push blood into a non compliant ventricle ■ This creates vibrations that are heard as S4 ■ Occurs just before S1 ● Murmurs ○ Blood circulating through normal cardiac chambers and valves usually makes no noises ○ Some conditions create turbulent blood flow and collision currents ○ This results in murmurs ○ Gentle, blowing sound that can be heard on the chest wall ○ Conditions resulting in a murmur ■ Velocity of blood increases (flow murmur ● Exercise, thyrotoxicosis ■ Viscosity of blood decreases ● Anemia ■ Structural defects in the valves ● Stenotic or narrowed valve or unusual opening in the chambers (dilated chambers, septal defect) ● Characteristics of sound ○ All heart sounds described by ■ Frequency (pitch- high or low) ■ Intensity (loudness-loud or soft) ■ Duration (very short for heart sounds) ■ Timing (systole or diastole) Common terminology used to describe symptoms

Module 10: Assessment of the Abdomen and Nutrition Abdominal quadrants and associated organs. -

4 quadrants RLQ, RUQ, LUQ, LLQ organs: liver, spleen, stomach, intestines

RUQ: Liver, Gallbladder, duodenum, pancreas, right kidney & adrenal, part of ascending & transverse colon LUQ: stomach, spleen, body of pancreas, left kidney & adrenal LLQ: Sigmoid colon, left ureter, left ovary and tube, part of descending colon RLQ: Cecum, appendix, right ovary & tube, right ureter, right spermatic cord

Abnormalities in bile/stool content-what do they mean? What is considered normal for each?

Proper assessment techniques of the abdominal assessment

-inspection -auscultation -percussion -palpation

how to keep a patient comfortable during an abdominal assessment *Keeping your patient comfortable: warm environment, emptying the bladder, conversation

How to palpate the abdomen begin with light palpation (1-2 cm) in a rotating motion -progress to deep palpation (3-4cm) to evaluate organs and find masses

how to keep a patient comfortable during an abdominal assessment -have the patient empty the bladder -warm environment -keep the conversation going

Factors that affect nutrition (financial, mobility, age)

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income - healthy food cost more - people of lower class will spend more $$ on less healthy foods to provide for family mobility - ability to get around to ...