NUR 216 Exam 2 Review PDF

lOMoARcPSD|33372414 NUR 216 Exam 2 Review - completed Health Assessment (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Ryanna Mae Claveria ([email protected]) ...

lOMoARcPSD|33372414 NUR 216 Exam 2 Review - completed Health Assessment (Arizona College of Nursing) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 NUR 216 Exam 2 Review When performing a tympanic temp/otoscopic exam - How do you pull the pinna? Up and back adult, down and back for child - What supplies are needed? otoscope - Expected vs unexpected findings of the tympanic membrane Expected: pearly gray translucent Unexpected: Redness inflammation, drainage, perforations - Conductive hearing loss with excessive ear wax (cerumen) Clubbing of the fingernails - What does it look like? enlarged curved downward - What does it indicate? Cystic fibrosis, heart failure, pulmonary disease, copd indication of chronic hypoxia - Expected nail findings (i.e., what degree of curvature – 180 degrees, convex, rounded pinkish - Normal angle of nails 160 degrees, characterized as convex Melanoma - ABCDE Asymmetry, Border irregular, Color(variations/changing), Diameter less than 6mm, Evolving (in color and size) / should see a dermatologist if they have any of these things - Prevention measures annual checkups, clothing, sunscreen, exposure time in sun / heightened case of sunburns higher risk for developing skin cancer - Risk factors Caucasian, family hx, UV exposure, occupation / cloudy days still need sunscreen uv exposure is higher Wounds- ask in review - Indications of infection inflammation, redness, elevated white blood cells, purulent drainage, pain, fever / low BP less than 90systolic/60diastolic - Signs of wound healing scabbing, signs of adhesion, dryness, itching / no erythema, no edema, WBC trending down, patient reports less pain Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 The older adult and the integumentary/HEENT system - i.e., loss of SubQ fat, moisture, elasticity decreases, facial bones are more prominent& difficulty hearing high frequency sounds - expected vs unexpected findings (i.e., liver spots, etc.) expected, vascularity is decreased, loss of sweat glands, thinning hair/hairloss, decrease sense of taste, decreased vision, cenial lentignes unexpected – redness of lower extremities bruises, edema, lesions, hematoma, scales, pressure ulcers HEENT: Lymph node examination - Palpation, how is it performed? Pads of index and middle fingers, feel in circular motion using gentle pressure - Expected/unexpected findings? Ex: non-palpable, non-tender Un Ex: if they are palpable, they should be movable - Thyroid: Feel swallowing up/down, non-tender, should be smooth Hearing loss- - Assessment questions do you wear hearing aids, can you hear me, recent change in hearing, hx of ear infections - What could cause conductive hearing loss? Excessive cerumen build up / occupational, use of headphones, trauma, hx of middle ear infection , q tip usage, sinus infections Cranial Nerves: I, III, IV, VI, XI, VIII 1. Olfactory (smell) / test by closing eye tell what they smell 2. Optic (visual equity) 3. (III) Oculomotor (eye movement, raise eyelid) / 8 or H test 4. (IV) Trochlear (downward/inner eye movement) / 8 or H test 5. Trigeminal (facial sensation/biting chewing) tests for tongue movement 6. (VI) Abducens (lateral eye movement) /8 or H test 7. Facial (facial expressions/taste) 8. (VIII) Vestibulocochlear (balance and hearing) / whisper test 9. Glossopharyngeal (gag reflex, swallowing/taste) 10. Vagus (gag reflex/sensation of pharynx and larynx) Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 11. (XI)Accessory (shoulder neck movement) shrug shoulder and turn their head 12. Hypoglossal (tongue movement/speech) Weber test - tuning fork on top of head or base, tests for bilateral hearing for conductive hearing loss expected finding is hearing on both side - unexpected findings hearing on one side or not at all Integumentary signs of dehydration Tinting, mucous membranes, skin turgor pale/white, lips dry and chapped, back of hand and clavicle Lack of fluids, exercise, vomiting/diarrhea causes for dehydration, certain medications (diuretics) Bony prominences - What/where are they? Ankles, knees, shoulders, back of head, elbows - Pressure ulcer preventative measures? Moving every 2 hours, reduce moisture by changing linens/barrier creams, assisted devices to reduce pressure, elevate heels put pillows underneath - Who is at risk? Elderly, unconscious, chronic health issues/infection Braden Scale- at risk for skin break down basic nursing 32 page 1329 - What categories does it include? Sensory mental, moisture, activity, mobility, nutrition, friction/shear - 80/discharge less risk… younger/bed ridden higher risk Liver failure - What would we expect to see? Jaundice, yellowing eyes, and skin and mucous membranes, palate PERRLA – pupils, equal (same size), Round , Reactive to, Light and Accommodation - What does it assess? Pupils are both reactive and equal, looks at brain damage - Consensual constriction Both pupils constrict at the same time when light is shown into 1 eye - Accommodation light and dark, near and far- pupils constrict when focusing on near objects Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Signs of possible abuse when assessing the skin bruises, upper arms and upper thighs (hidden), bite marks, deformity that doesn’t match up to injury, belt marks,burns Snellen chart- eye chart Determines if client has myopia (impaired far vision). Tests for visual acuity 20/20 is an expected finding 20/40-client needs to be 20ft away from letter that a person with normal visual acuity can read at 40ft away First number is how far patient is away from chart/ bottom distance that the normal eye can see the light Remove reading glasses. Test with and without corrective lens. Rosenbaum eye chart-hold 14in away from client. Determines if a client has presbyopia (impaired near vision). Ishihara-test for color vision - What is it used for? To see how near and far you can read/ looks for 20/20 vision and what you can be corrected. Foot care - Diabetic patient Water based lotions(not between toes), no flip flops, file nails straight, daily checks, no soaking feet, make sure toes are dry in between, closed toed shoes Herpes zoster - Priority nursing diagnosis – shingles - Type of rash expected –nerve tracks ( vesicular lesions contagious when open or blistered) Function of the skin- Skin is waterproof, protective, and adaptive Protection from environment -1st line of defense Prevents penetration Perception Temperature regulation Identification Communication Wound repair Absorption and excretion Converts vitamin A to vitamin D (vitamin D synthesis) Necessary for the intestines to absorb calcium Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Staging of pressure ulcers- slide 33 – skin slides Stage 1- non blanchable erythema, intact skin , darker skin tones may be blue or purple hue Stage 2 – partial thickness, skin break down of epidermis and dermis- superficial, red pink wound bed Stage 3 full thickness skin loss, damage to sub q tissue , deep without exposed muscle or bone Stage 4- full tissue lost, necrosis, slough, black scabbing, tunneling or undermining (whole) Unstageable- unknown- unsure of how deep or injury is, needs debridement to start healing process. DTI – deep tissue injury – discoloration of intact skin, damage to underlying skin Edema chapter 30 fundamentals book - Scale 1-4 - 1+ is trace 2 mm in depth w/ rapid skin response - 2+ is mild 4mm 10- 15 sec response - 3+ is moderate 6 mm prolonged skin response - 4+ severe 8mm prolonged skin response - When assessing mucous membranes on dark skinned patients where is the best place to assess? Oral mucous membranes, conjunctiva Thyroid glands slide 14 HEENT - Hyperextend their neck/ ask to swallow How to assess temperature when palpating - Use pads of fingers Drainage characteristics - Serous: clear - Sanguineous: pink tinge - Purulent: pus with odor Skin turgor - Possible sign of dehydration/ tenting - Where to assess- Clavicle older adult , young adult back of hand - Normal – goes back quickly - abnormal findings slower to go back down - Tenting indicates? Dehydration Downloaded by Ryanna Mae Claveria ([email protected])  lOMoARcPSD|33372414 Primary lesion- nodules, pustules, atrophy wheals, plaques. Patches, tumors, vesicles, bullas uticaria(hives)- slide 43 skin ppt secondary lesion- comes from the primary lesion slide 51- keloids, crust, scales, fissures, erosions, scars, atrophic scars Sinus palpation-u Use your thumbs Palpate frontal – press firmly in an UPWARD motion just under the eyebrows r thRefer to Health Assess for technique How to assess skin? Inspection- color, temp, hair, lesions, moles, inflammation and palpation- General pigmentation, freckles, moles, birthmarks Appropriate for ethnicity or widespread color change - - Can we auscultate/percuss? Color of skin - i.e., pallor pale – loss of color - erythema redish tone - Cyanosis blue - Jaundice yellow to yellow orange When palpating how do we assess for moisture? Use finger tips for moisture , dorsal side of hand for temp - Dorsal, fingertips, forearm? How to assess capillary refill slide 17 skin- press fingernail- wait for return of circulation- sluggish is slower return takes longer than 1-2 seconds Neck assessment slide 11- HEENT - Normal findings- normal movement, forward and back,side to side, trachea midline - Unexpected- shift in trachea, non movement of neck Downloaded by Ryanna Mae Claveria ([email protected])