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Study GuideMisc Use this type of question in your patient assessment? -Open-ended questioning Name three expected physiological changes of aging? -Difficulty seeing/hearing -Decreased Skin Turgor -Decreased sense of smell Space between vertebral disc is shortened (kyphosis)  Decreased elasticity: s...

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Study Guide Misc Use this type of question in your patient assessment? -Open-ended questioning Name three expected physiological changes of aging? -Difficulty seeing/hearing -Decreased Skin Turgor -Decreased sense of smell - Space between vertebral disc is shortened (kyphosis)  Decreased elasticity: skinfolds/sagging skin  Decreased sweat and sebaceous glands: Decrease in number and function, leaving skin dry  Senile purpura: Discoloration due to increasing capillary fragility  Skin breakdown due to multiple factors: Cell replacement is slower and wound healing is delayed  Hair matrix: Functioning melanocytes decrease, leading to gray fine hair  Thin parchment: tears, bruises, or breaks easily.  Decreased mobility and turgor  Decreased hair growth, nail growth, and brittle nails  Aging adult: Facial bones/orbits prominent. Lower face appears smaller if teeth are not there. Loss of subcutaneous fat.  Pupil size decreases: pupillary light reflex slowed. Lens cloudy (opaque) Presbyopia: lens lose elasticity (hard/glasslike), which decreases ability to change shape accommodate for near vision. By age 70, transparent fiber of lens begins to thicken and yellow (beginning of cataracts). Decreased visual functioning:     

Cataract formation: lens opacity, clumping of proteins in lens. Glaucoma: increased intraocular pressure; chronic open-angle glaucoma is most common type. Age-related macular degeneration (AMD): breakdown of cells in macula of retina; loss of central vision. Diabetic retinopathy: Leading cause of blindness in adults ages 25-74. Lacrimal apparatus- decrease tear production, eyes look dry and lusterless with burning sensation.

Name a barrier of therapeutic communication? -Decreased hearing -Blindness -Using closed ended questions -Verbal communication: words you speak & tone -Nonverbal communication: Body language (truer feelings)

-Physical appearance, posture, gestures, facial expressions, eye contact, voice, touch Posterior Curvature of thoracic spine that can be a result of osteoporosis -Kyphosis Correct order of Nursing Process (ADPIE) -Assessment: always first! -Diagnosis -Planning -Implementation -Evaluation Clinical manifestations of dehydration Mucous membranes are dry, and lips look parched and cracked. With extreme dryness the skin is fissured, resembling cracks in a dry lake bed. Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or “tents” and stands by itself. Decreased capillary refill. Sunken eyes. Decreased urine, thirst, dizziness, change in mental status. Cultural considerations: Muslim: No Pork. Arab Americans an adult male is never left alone with a female. Use trained interpreters, not family members. -Corneal light reflex: Assess the parallel alignment of the eye axes by shining a light toward the person's eyes. Direct the person to stare straight ahead as you hold the light about 30 cm (12 inches) away. Note the reflection of the light on the two corneas; it should be in exactly the same spot on each eye. Abnormality: Asymmetry of the light reflex indicates deviation in alignment from eye muscle weakness or paralysis. S/S hypokalemia 3.5-5mEq/L Cardiac dysrhythmias. Fatigue Muscle weakness, muscle twitch, leg cramps Anorexia/Nausea/Constipation Paresthesia “pins and needles” Shallow respiration Postural hypotension Cardiovascular: Frothy sputum characterizes what side of HF? -Left sided HF

This is how a nurse documents a carotid pulse WNL? - 2+ regular rhythm bilaterally This heart sound can be found in the 5th mid-intercostal space midclavicular line. -Mitral Difference between systolic and diastolic BP? -Pulse Pressure Best time to take a manual BP? -At rest Modifiable risk factor of heart disease? -Diet -Exercise -Smoking Heart condition that an S3 sound Signifies? -Ventricular Gallop The level at which a client’s arm should be when taking manual BP? -Heart level This heart sound can be found in the 4th intercostal space. -Tricuspid Heart sound found in 2nd intercostal space to right of sternum. -Aortic Heart sound 2nd intercostal space to left of sternum. -Pulmonic This should be done first after palpating an irregular peripheral pulse. -Check apical pulse for a full minute Respiratory Difficulty breathing lying down. -Orthopnea Abnormal breathing rate that a hypoxic patient would exhibit? -Hypoxic: Lack of oxygen so lungs will work harder to help you breathe -Answer: Tachypnea (Fast Breathing) Sign of long- term lack of oxygen. -Clubbing (Example: Found on emphysema) Name an occupation that may affect the respiratory Status? -Painter (any occupation that deals with chemicals) High pitched Adventitious breath sound typically heard on expiration in clients with asthma? -Wheezing Abnormal breathing pattern characterized by periods of apnea -Cheyne Stokes

Different types of breath sounds: Bronchial, Bronchial Vesicular, and Vesicular

Manifestations of pneumonia • • • • • • •

Sudden onset Systemic signs of high fever with chills, marked fatigue, and leukocytosis Dyspnea, tachypnea, tachycardia Pleuritic pain with splinting or restriction of respiratory expansion on the affected side Rales, heard initially over the affected lobe and then disappearing as consolidation occurs Productive cough, with the typical rust-colored sputum Confusion and disorientation if infection is severe or several lobes are involved

S/S Atelectasis Absence of breath sounds indicates nonaeration or collapse of a lung (atelectasis). Difficulty breathing Skin Skin tenting is a sign of this disorder? -Dehydration This type of diet promotes wound healing. -High protein diet Assessment of skin lesions “ABCDEF” This is the location in which one can assess for cyanosis in a darker skin client. -Conjunctiva/Sclera/Nail Beds (any location where there is not as much pigment) Heart sound in 3rd intercostal space? -ERBs point Skin lesion that is firm, edematous, and irregularly shaped - Wheal Circumscribed flat area with change in skin color that is less than ½ cm in diameter? -Macule

Neural Explain the difference between a cognitive disorder and physiological disorder? -Cognitive: Brain -Physiological: Physical Manifestation This type of pain is felt within an organ. -Visceral Pain Manifestations of pain Manifestations of pain: Guarding, grimacing Moaning, agitation, restlessness, stillness, diaphoresis, change in vital signs, bracing, rubbing, diminished activity, sighing, and change in appetite....