Nursing 110- exam 2 SG - Lecture notes Unit 2 PDF

Preview

Summary

Health assessment of the aging adult client. ...

Description

Nursing 110- Exam 2 Study Guide Physical Assessment -Purpose of Physical Assessment •Gather a health history. Primary purpose of Physical Assessment •Develop nursing diagnosis and care plan. •Manage client problems. •Evaluate nursing care. -Sitting Positions TABLE 31-2 PG 536 -Subjective Data- Symptoms/ what the patient says/ health history -Objective Data- Signs/ What you assess/ physical assessment and diagnostic test -Dont ask leading question when interviewing- use open ended questions -ask patient to clarify what you’ve heard and then summarize what they said -when investigating pain asses for- location, quality, quantity, leading factors, and have them use one finger to point to affected location. (some due to nerve endings) - assess previous level of functioning -Techniques for Physical Exam -Inspection> Palpation (TABLE 31-5/ Start with light palpation and end with deep)> Percussion> Auscultation> Olfaction TABLE 31-4 -Techniques for Physical Exam On Abdomen -Inspection (distended, concave, how it looks)> Auscultation (Diaphragm Steth. Listen to Bowel sounds, all 4 quadrants) > Palpation -Palpation- Light:½ inch- Deep: 2 in. - Percussion- tapping body parts with finger (denser the tissue quieter the sound) Resonant- low pitched, hollow, heard of normal lung tissue Flat- over bone Dull/ Thud Like- dense area (heart liver) or fluid or solid tissue replace air in lungs -Stethoscope- Bell- low pitched sounds (bruits, press lightly) Diaphragm- high pitched Sounds (heart, bowel, lung sounds, and bruits {bruits- created by turbulence in major artery due to to blockages or increased vasculature such as enlarged thyroid press firmly}) BOX 31-2 PG 541 -2 Types of Latex allergies: 1- The body develops antibodies known as immunoglobulin E which can lead to an anaphylactic response. 2- allergic contact dermatitis type 4 response, which

causes a delayed reaction that appears 12 -48 hours after exposure. Both require prior exposure to the substance. TABLE 31-1 PG 535 - Prep for Exam: Equipment> Psychological Prep for client> Assessment of age groups -Tips: Compare both sides for symmetry/ seriously ill clients assess body system most at risk first, allow rest period if client fatigues easily, document findings in approved documentation records - General Survey (1st encounter inspection)- 1) appearance: groomed? In need of basic care? 2) vital signs: baseline, last time ate, drank, smoked, exercise, medications 3) height and weight - Summary of what you can assess in general survey- • Signs of distress, body type, posture, gait, body movements, hygiene, grooming, dress, body odor, mood, affect, and speech

Skin, Head, Eyes, Ears, and Neck Skin Assessment: Inspection and Palpation Integumentary system- skin, hair, scalp, and anils TABLE 31-6 -Temperature is best assessed using the dorsal (back) of the hand. -Assessing skin note: color, moisture, temp. Texture, turgor (elasticity of skin), Vascularity (pressure areas), Edema (build up of fluid in the tissues caused by trauma or impairments of venous return) Petechiae are pinpoint size, red/ purple spots on the skin caused by small hemorrhages Table 31-8 Skin Colors Pallor (Pale/ decrease in color)- decreased blood flow from shock or anemia Cyanosis- bluish color in nails, skin, mouth/ indicated heart & lung disease, cold environment, decreased oxygen in blood Erythema- Red Discoloration caused by increased blood flow due to fever, trauma, blushing, alcohol intake, sunburn, and inflammation. -shiny scaly brown skin and red taught shiny skin indicates vascular insufficiency TABLE 31-9 PG 547 Jaundice- yellow-orange discoloration- best place to inspect is patients sclera. Caused from increased deposits of bilirubin in tissues (Liver Disease) -types of Edema: dependent, pitting (when pressure from the examiners’ fingers leaves an indentation) FIGURE 31-6 PG 548 , due to injury, obstruction

-Lesions: any unusual finding of skin. Primary Lesions: pathological process like insect bite. Secondary Lesion: from later formation of trauma like pressure ulcer BOX 31-6 PG 549 & SEE TABLE 31-7

-Basal Cell Carcinoma- most common form of skin cancer BOX 31-7 - Squamous Cell Carcinoma- caused by abnormal growth of squamous cell - measuring Skin Malignancies: ABCD- Asymmetry, Border irregularity, Color that isnt uniform, Diameter greater than 6mm [size of pencil eraser] -Circumscribed = a confining area -Ecchymosis= a bruise -Hematoma=a swelling comprising a mass of extravasated blood (usually clotted) confined to an organ, tissue or space cased by a break in a blood vessel -Vesicle is circumscribed elevation of skin filled with serous fluid, smaller than 1 cm (herpes) -Pustule is circumscribed elevation of skin filled with pus and varies in size ( acne, staph infection) Hair and Scalp Asses type of hair, color, distribution, thickness, texture -3 types of lice: Pediculus humanus corporis (body lice), Pediculus humanus capitis (head lice), and Pediculus pubis (crab lice). -TABLE 31-10 PG 550 & BOX 31-8 551 Nails BOX 31-9 PG 552- normal angle of nail bed 160 degrees A larger angle and softening of the nail bed indicate chronic oxygenation problems. TABLE 31-11 PG 551 BOX 31-9 BOX 31-10 FIGURE 30-8 AND 30-9 PG 506 -Cap Refill < 3 secs Nose Assessment -Pale mucosa with clear discharge indicates allergies -Normal: mucosa dark pink Mouth Assessment -Anemia cause pallor of lips -Cyanosis caused by respiratory or cardiovascular problems -Cherry colored lips indicate carbon monoxide poisoning FIGURE 31-22 PG 563 AND FIGURE 31-23

- Thick white patches (leukoplakia) are often a precancerous lesion seen in heavy smokers and alcoholics -A common site for oral cancer is under the tongue Ear Assessment -Outer Ear: intact, bruising, swelling, scaling -Middle Ear: Canal clear, exudate, draining, redness, swelling [use otoscope] -Inner ear: tympanic membrane Normal: pearly gray with visible light reflex -Auricles are normally smooth and without lesions -Extreme pallor indicated frostbite -Redness indicates inflammation or fever -If palpation causes pain an external ear infection is likely Ear pain but palpation does not cause additional pain then infection may be present in middle ear -cerumen- yellow waxy substance -yellow or green foul smelling discharge as well as a reddened canal indicates infection FIGURE 31-16 PG 557 FIGURE 31-17 3 types of hearing loss: Conduction (interrupts sound waves as they travel from outer to inner ear caused by swelling of auditory canal and tears in tympanic membrane), sensorineural (sound becomes interrupted at some point beyond bony ossicles), and mixed •Whisper test -Patient should hear you 1-2 ft away •Rinne test -Air conduction greater than bone conduction 2:1 •Weber test -Sound heard equally both ears Neck Assessment ROM, strength, thyroid, Lymph Node, Trachea alignment FIGURE 31-27 PG 564 Eye Assessment -Visual Acuity tests central vision: near or far sightedness. Must use Snellen Chart -Bulging eyes-( exophtalmos) usually indicated hyperthyroidism -Cross eyed- (strabismus) result from neuromuscular injury or inherited -Abnormal drooping- (Ptosis) caused by edema or impairment of 3rd cranial nerve -Nystagmus- involuntary rhythmical oscillation of eyes, result of local injury to eye READ PG 555 -Presbyopia- impaired near vision in middle age and older adults caused by lack of elasticity of lens -PERRLA: pupils equal, round, reactive to light and accommodation -Pinpoint pupils are a common sign of opioid intoxication. -Dilated pupils result from glaucoma, trauma, neurological disorders, eye medications or withdrawal from opioids.

-redness in the conjunctiva indicates allergic or infectious conjunctivitis -yellow sclera may indicate liver problems -scratchy eye may indicated corneal abrasion due to surgery -exudate and lacrimal area swelling can indicate a clogged duct -Arcus Senilis- thin white ring along the margin of the iris BOX 31-11 PG 554 Thorax and Lungs, Vascular System, Male/Female, Neurological, Musculoskeletal Physical Assesment Thorax & Lungs -Exam: Inspection> Palpation> Ausculation - angle of Louis- point at which the 2nd rib articulates with the sternum FIGURE 31-11 PG 567- Identify anatomical landmarks *Risk for lung disease are reviewed during respiratory assessment BOX 31-17 PG 567/ TABLE 31-19 PG 568 -Normal Respirations: no intercostal or accessory muscle retraction or nasal flaring during respirations/ RR: 16-20/ Trachea midline/ No cough -Abnormal: cough/ RR-12-25, Labored/ use of accessory muscles ¨**Anytime you see respiratory difficulty, immediately obtain an O2 Sat and get a complete set of VS. If not on O2, apply O2. No resolution, call rapid response Oxygenation problems- indicated from Reduced mental alertness, nasal flaring, somnolence, and cyanosis -Posterior Thorax- observe shape & symmetry of chest from back and front -Inspect for deformities, position of the spine, slope of the ribs, retraction of the intercostal spaces during inspiration, bulging of the intercostal spaces, and rate and rhythm FIGURE 31-33 PG 569 -Vocal/Tactile Fremitus- vibrations of sound transmitted through the lungs to the ches wall -To palpate us palms of fingers over symmetrical intercostal spaces beginning at the lung apex and using a firm, light touch; ask patient to say 99; palpate top to bottom Normal: Equal vibrations and stronger at the top FIGURE 31-36 PG 570 -Auscultation: abnormal sounds: Crackles- caused by random sudden reinflation of groups of alveoli OR disruptive passage of air through small airways (small medium or coarse and best heard in lung bases) HIGH PITCHED * think rice krispies* Rhonci- LOW PITCHED continuous sounds caused by muscular spasm, fluid or mucus in larger airways OR new growth or external pressure causing turbulence Wheezes- HIGH PITCHED continuous whistling sounds during inspiration and expirations. Usually louder in expirations (ASTHMA) heard in bronchial tree

Pleural friction rub- DRY GRATING QUALITY caused by inflamed pleura [parietal rubs against visceral pleura] HIGH PITCHED TABLE 31-20 PG 570 TABLE 31-21 PG 571 * use diaphragm of stethoscope A patient is admitted with pneumonia. When auscultating the patient’s chest, you hear low-pitched, continuous sounds over the bronchi. These sounds are labeled as RHONCI -Breaths sounds heard while auscultating lateral thorax are vesicular TABLE 31-20 PG 570 Best heard over periphery of lung/ breezy low pitched Bronchovesicular sounds (blowing) best heard between scapulae and anteriorly over bronchioles lateral to sternum HEART -Compare assessment of heart functions with vascular findings -PMI- point of max. Impulse (apical impulse) TABLE 31-22 PG 572 FIGURE 31-7 FIGURE 31-39 -The PMI is located at the 4th-5th ICS just left of midclavicular line -2 phases of cardiac cycle: systole and diastole S1 (closing of mitral & tricuspid valves “lub”) S2 (closing of aortic and pulmonic valves “dub”) S3 (heart attempts to fill an already distended ventricle ex: congestive heart failure) S4 (atria contract to enhance ventricular filling) FIGURE 31-38 PG 572 -thrill- continuous palpable sensation that resembles purring of cat; vibrations -estimate size of heart by noting the diameter of PMI and its position relative to the midclavicular line. FIGURE 31-39 PG 573 FIGURE 31-40 PG 574 -dysrhythmia- failure of the heart to beat at regular successive intervals. * use the bell of the stethoscope and listen for low pitched extra heart sounds such as S3 and S4 gallops, clicks and rubs -Murmurs are sustained swishing sounds heard at during systolic or diastolic (record usung grades 1-6) FIGURE 31-40 PG 574 Vascular System -Blood Pressure- tends to be higher in the right arm can vary as much as 10 mm Hg -Carotid arteries- reflect heart function better than peripheral arteries -An absent carotid pulse wave indicates arterial occlusion (blockage) or stenosis (narrowing Use Inspection Palpation Auscultation TABLE 31-23 PG 575 TABLE 31-43 PG 576 -Best to examine right internal jugular vein because it follows a more direct anatomical path to the right atrium of the heart. FIGURE 31-46 PG 577 FIGURE 31-47 PG 577 -Pulse strength- measurement of the force at which blood is ejected against the arterial wall 0: absent/ 1+: pulse diminished/ 2+: expected normal/ 3+: full pulse/ 4+: bounding pulse -The 5 P’s: pain, pallor, pulselessness, parathesia’s, and paralysis characterize and occlusion (absent blood flow) -Variscosities- superficial veins that become dilated, especially when the legs are in a dependent position

-Dependent edema around the area of the feet and ankles is a sign of venous insufficiency or right- sided heart failure -Phlebitis- inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, immobilization, and prolonged insertion of IV catheters. (Unilateral edema of the affected leg is one of the most reliable finding of phlebitis) TABLE 31-25 PG 580 Breasts BOX 31-22 PG 583 -Leading cause of death in women with cancer, behind lung cancer -best time to perform Breast Self Examination (BSE) is the 4th-7th day of the mestrual sycler or right after the menstrual cycle ends FIGURE 31-22 -”A large part o f lymph from the breasts drains into axillary lymph nodes. If

cancerous lesions metastasize (spread), the nodes commonly become involved. The axillary nodes drain lymph from the chest wall, breasts, arms, and hands. Palpate nodes while supporting the arm. Normally lymph nodes are not palpable. One or two small, soft, nontender palpable nodes are normal. An abnormal palpable node feels like a small mass that is hard, tender and immobile. Palpate abnormal masses to determine location in relation to quadrants, diameter in centimeters, shape, consistency, tenderness, mobility and boundaries. Cancerous lesions are hard, fixed, non-tender, irregular in shape and usually unilateral.” Abdomen -abdominal pain is one of the most common symptoms that patients report -Xyphoid process is the upper boundary and the symphysis pubis marks the lower boundary PG 586 TABLE 31-27 -Peristalsis- movement of contents through the intestines -Borborygmi- hyperactive sounds of abdomen Male Genitalia -Testicular cancer is a solid tumor commin in men ages 18-34 Musculoskeletal System -General Inspection: Gait, Postural abnormalities, age-related changes -Lordosis- swayback increased lumbar curvature -Kyphosis- Hunchback, exaggeration of posterior curvature of the thoracic spine -Scoliosis- lateral spinal curvature BOX 31-29

-Loss of height is frequently the first clinical sign of osteoporosis (systemic skeletal condition that is noted to have both decreased bone mass and deterioration of bone tissue making bones fragile) -Hypertonicity- increased resistance with any sudden passive movement of a joint -Hypotonicity- Feels Flabby/ Little muscle tone -Assess muscle strength and tone during ROM -Atrophy- reduce muscle size/ soft and boggy TABLE 31-32 PG597 Neurological System -LOC- Level of consciousness -Glasgow Coma Scale (GCS)- objective measurement of consciousness on a numerical scale [TABLE 31-36 PG 601] -Mini-Mental State Examination (MMSE) BOX 31-30 PG 600 -MMSE Sample Question -Orientation to time “What is todays date” -”Repeat these three words back to me” -Naming: “What is this [point to pen]?” -Reading “Please read this and do what is says” -Behavior and appearance- nonverbal and verbal -Language- Aphasia [two types sensory and motor] -Sensory/Receptive aphasia- a person can not understand written or verbal speech -Motor/ expressive aphasia- a person understands written and verbal speech but cannot write or speak appropriately TABLE 31-37 PG 602 Presents cranial nerve function and assessment TABLE 31-38 PG 603 Neurological System -¨Reflexes: 0: no response 1+: sluggish/diminished 2+: active/expected response 3+: more brisk than expected, slightly hyperactive 4+: brisk and hyperactive with intermittent or transient clonus -Muscle Spindle- controls muscle tone and detects changes in the length of muscle fibers

The Skin Risk for impaired skin integrity -Immobilization- pressure and reduced circulation -Reduced sensation- paralysis, circulatory insufficiency, diabetes •Secretions and Excretions on the Skin ØMoisture serves as a medium for bacterial growth •Vascular Insufficiency ØIschemia and skin breakdown •External Devices ØFriction, pressure •Altered Cognition ØDecreased awareness or communication deficit -Oral cavity -normal oral mucosa is light pink, soft, moist, smooth, and without lesions -Xerostomia- dry mouth -Patient Centered Care -Explore the patient’s viewpoint

Implementation -Use caring to reduce anxiety, promote comfort -Administer meds for symptoms before hygiene -Be alert for patient’s anxiety or fear -Assist and prepare patients to perform hygiene as independently as possible -discuss signs and symptoms of problems -inform patients about community resources -Bathe “clean” body parts before “dirty” body parts -Prevent Aspiration- have head of bed up at least 45 degrees during oral activities -Prevent Injury- head of bed flat to move patient -Turn immobile patients every two hours to prevent pressure sores -Provide ROM exercise to each mobile joint prevent contractures Sequential Compression Devices: SCD’S -Prevention or treatment of DVT (Blood clots)/ keeps blood moving Safety Asepsis -Do not allow dressings to get wet during bath -Do not soak feet if: patient is diabetic/ peripheral vascular disease is present/ lesions, sores, or rashes are present on feet Documentation and Informatics -Purpose of Medical Record: Communication, Legal documentation, Reimbursement, Education, Research, Auditing HITECH- established provisions to promote the meaningful use of health information technology (HIT) to improve the quality of patient care EHR (Electronic Health Record) EMR (Electronic Medical Record) -Documentation needs to conform to standards of National Committee for Quality Assurance (NCQA) and TJC to maintain institutional accreditation and minimize liability -Narrative- the traditional method -Problem- Oriented Medical Record (POMR)- database, problem list, care plan, progress notes Methods of Documentations: Progress Notes -SOAP: Subjective, objective, assessment, plan -SOAPIE- Subjective, objective, assessment, plan, intervention, evaluation -PIE- problem, intervention, evaluation -Focus Charting (DAR)- data, action, response

Methods of Reporting -Charting by exception (CBE)- Focuses on documenting deviations -Standardized care plans or clinical care guidelines (CPGs)- preprinted, established guidelines used to care for patients who have similar health problems -Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance Informatics and Information Management in Health Care -The Technology Informatics Guiding Education Reform (TIGER) is focused on better preparing the clinical workface to use technology and informatics to improve the delivery of patient care -TIGER transformed to Healthcare Information and Management Systems Society (HIMSS) -CPOE- Computerized Provider Order Entry -CDSSs- clinical decision support system -Point of Care Documentation(POC)- recommended whenever possible RULES FOR DOCUMENTING CLIENT CARE 1. Document firsthand knowledge 2. Give clear information 3. Use nonjudgmental descriptions 4. Chart facts, not interpretations 5. Use correct spelling, grammar and approved abbreviations 6. Dont write “client” or “patient” 7. Dont chart “I”- its about the patient 8. Never use the words such as “mistake, accident or forgot” 9. Dont chart before someone else 10. Dont use tentative statements such as apparently or probably 11. Be professional 12. Chart objective facts- “ate 100%” not “good appetite” 13. Do a teach back Paper Charting tips 1. Use black ink 2. Draw single line through errors 3. Draw horizontal line to fill up a partial line 4. Begin narrative entry with time and a note 5. Sign with initial, full last name, then title 6. When something is forgotten write “late entry” at end of note Document every phone call and TOs (Telephone orders) and VOs (Verbal orders) and enter in CPOE/ read back all orders to verify accuracy

Initiating consent is NOT a nursing function NURSING A...