NUR 216 Exam 2 Study Guide PDF

NUR 216 Exam 2 Study guide [Skin/Hair/Nails] - Rash - Assessment - Ask about pain or itching when assessing chief complaint (OLDCA**R**TS) - ALWAYS wear gloves during physical assessment - Family members should also wear gloves if touching...

NUR 216 Exam 2 Study guide [Skin/Hair/Nails] - Rash - Assessment - Ask about pain or itching when assessing chief complaint (OLDCA**R**TS) - ALWAYS wear gloves during physical assessment - Family members should also wear gloves if touching the patient - Interventions - Itchy rashes: discourage scratching; cool cloth may soothe - Ice packs/cold therapy: nursing intervention- may be useful for injury/pain - Do not place directly on skin (use cloth or towel as a barrier) - Assess site q5-10minutes for color, pain, sensation, blisters, etc. - Document intervention, including duration, skin condition, & tolerance - Instruct patient to report any discomfort or new symptoms r/t site - Health promotion - Daily sunscreen use: educate on importance (even if patient "doesn't get burnt") - Abnormal moles/nevi - These are the most concerning type of lesions (use ABCDE mnemonic) - A: asymmetry - B: border irregularity - C: color variation - D: diameter \>6mm - E: evolving or changing (lesion is new, unlike patient's other nevi, or is changing/growing) - Priority nursing intervention for a suspicious mole is to report findings to provider - Debriding is a surgical procedure, which is NOT within our scope - Older adult changes - Hair thinning or loss on head, may grow hair in other places - Increased risk for onychomycosis (nail fungus) - Nail clubbing: nail bed angle \>180 degrees - Results from chronic hypoxia (chronic lung or heart disease) - Dehydration- priority nursing diagnosis (r/t circulation) - Assess for risk factors - GI losses: Emesis and diarrhea - Inadequate intake: nausea, poor PO fluid intake in general - Conditions requiring extra fluids: infection/sepsis, bleeds, fever, etc. - Assess for signs and symptoms - Skin tenting (decreased skin turgor- pinch below clavicle to assess) - Dryness of skin - Lesions - Vesicles: SMALL fluid-filled blisters; seen in Herpes Zoster & HSV - Bullae: LARGE fluid-filled blisters - Macules: small flat hypo/hyperpigmented areas (cherry angiomas, lentigines/liver spots, birthmarks, etc.) - Papules: small raised solid lesions - Pustules: pus-filled lesions, usually inflamed/erythematous/painful - Patches: large macules, usually erythematous such as in eczema - Eczema: itchy erythematous patches typically found in antecubital space - Wheals: erythematous, raised, swollen lesions (e.g., hives or TB skin test) - Pressure injuries - Assessment - Braden Scale is the best tool to assess risk factors - Score ranging from 6 (HIGHEST risk) to 23 (LOWEST risk) - Immobility - Poor nutrition (low serum albumin or protein may indicate this) - Friction/shear - Sensory impairments - Moisture - Lack of movement - Elderly patients with hip fractures are at HIGH risk due to immobility - VERY important to assess upon admission to the hospital - Especially if the patient has several risk factors - Staging - Stage 1: non-blanchable erythema (no open wound yet) - Stage 2: superficial ulcer, no involvement of deeper tissues - Stage 3: involves subcutaneous tissue, may have tunneling/undermining - Stage 4: involves muscle or bone, very deep, tunneling & undermining - Assess for signs of healing when evaluating treatment interventions - E.g., evaluating treatment of a stage 4: assess for muscle/bone involvement - Prevention and treatment interventions - Keep skin clean and dry - Frequent monitoring & management of incontinence - Avoid lotion/ointment on bony prominences - Check for incontinence every **TWO** hours - Cleanse with lukewarm water (NOT HOT WATER) - Avoid excessive bathing if not indicated (keep skin dry!) - Use gentle soap & fully dry skin as necessary - Avoid scrubbing skin & using powders on skin - Avoid briefs for prolonged periods (keeps moisture on skin) - For patients at high risk, the BEST intervention is [offloading pressure] - Turn/reposition every **TWO** hours (while in bed) - Use bed with alternating pressure, heel lift pads, and turning wedge - If patient is sitting in a chair, shift weight [every **15** minutes] - Keep HOB low to offload pressure on sacrum/coccyx - Maintain adequate hydration status - Patient may need extra protein supplements - Especially if poor PO intake or serum albumin or protein are low [HEENT] - Priority findings - Asymmetry of face or possible signs of dysphagia - Unilateral weakness or symptoms of stroke - Cranial trauma/bleed - Angioedema (swelling around lips) -- may indicate anaphylactic allergic reaction - Neck mass/goiter - Jaundiced sclera - Migraine headaches - Should **NOT** cause signs of neuro dysfunction, such as facial drooping - Expected findings with acute episode: - **SEVERE** unilateral throbbing - Sensitivity to light/sound - Nausea/vomiting - Patients often experience chronic episodes - Prevention is the goal (if episodes are frequent, may need preventive meds) - Assess for interference with daily life and functioning - Cranial Nerves - see chart below (study highlighted cranial nerves) - I: Olfactory (sense of smell) - II: Optic (vision) - III, IV, & VI: Oculomotor, Trochlear & Abducens (ocular movements) (up/down/medial/lateral AND pupil dilation/constriction) - V: trigeminal ("cotton wisp" on forehead, cheek, & chin to assess facial sensation- dysfunction associated with trigeminal neuralgia/facial nerve pain) - VII: Facial (facial expressions/movements -- dysfunction r/t Bell's Palsy) - VIII: Acoustic/Vestibulocochlear (hearing/balance) - IX: Glossopharyngeal (uvula & soft palate rising when you say 'ah') - X: Vagus (sensation in pharynx, larynx, & parasympathetic processes/digestion) - XI: Spinal Accessory (shoulder shrugging) - XII: Hypoglossal (tongue movements) - Head and face - Skull should be normocephalic, symmetrical, and nontender - Tops of ears should align with outer canthus of eyes - Central cyanosis: purple/blue discoloration on nose, lips, or mucosa - Assess for sinus tenderness - Maxillary (cheek below eyes) & frontal (forehead) sinuses - Eyes - Assess conjunctivae, sclera, iris, eyelids, eyelashes, ocular movements - For ANY eye complaint assess far vision using a Snellen eye chart - Visual impairments can be BIG safety issues at home or while driving - Snellen Eye Chart interpretation: - Numerator: distance from chart - Denominator: distance at which a normal eye can see - Normal: 20/20 - Interpreted as "the patient can read at 20 feet what an average person can read at [ ] feet" (because patient always stands 20 feet away from chart) - E.g., vision 20/40: the patient can read at 20 feet what an average person can read at 40 feet (decreased vision) - 20/200 is legal blindness - Assess & document each eye separately & then bilaterally - Other vision assessments - Ishihara chart: assesses for color blindness - Rosenbaum chart: assesses near vision - Hold 14 inches away from patient's eyes - Environmental interventions to promote safety for visual impairments: - Avoid trip hazards (small rugs, cords, & clutter on ground) - Encourage electronics that read or speak out loud - Consistent use of eyeglasses, adequate lighting, and cane - Clean eyeglasses & dry with soft cloths - Nystagmus: rapid jerky or tremor-like eye movement back and forth - Diplopia: double vision (may be a sign of serious complication r/t head injury) - Assess for **SUDDEN ONSET** - PERRLA: evidence of CNs III, IV, and VI (does NOT indicate vision/CN II) - **P**upils - **E**qual (in size) - **R**ound (and) - **R**eactive (to) - **L**ight (and) - **A**ccommodation: - Pupils constrict when looking at near object & dilate when looking at far object - Ears - Inspect and palpate external ears - Hearing loss: - Conductive hearing loss is caused by excessive cerumen buildup - Sensorineural hearing loss is dysfunction of CN VIII - May be associated with tinnitus - Nursing considerations for hearing impairments - First assess level of impairment, use of hearing aids, & patient preferences - Face the patient and speak slowly; do not shout at the patient - For acute hearing loss complaints, assess for: - Hearing aid use, exposure to loud noises, & tinnitus (ringing in the ears) - Nose - Assess for septal alignment, symmetry, color, tenderness, & swelling of turbinates - Epistaxis after head injury assess for ear bleeding - Mouth - Buccal mucosa (mucous membranes) -- best place to assess for discoloration in dark skinned patients - Neck - Assess for masses or goiter (especially if patient's having difficulty swallowing) - If goiter is noted upon inspection, auscultate for bruit (**do NOT palpate**) **Cranial Nerve** **Name** **Mnemonic** **Function** **Nerve** **Mnemonic** ------------------- ----------------------- -------------- ------------------------------- ------------- -------------- CN I **O**lfactory **O**h Smell **S**ensory **S**ome CN II **O**ptic **O**h Vision **S**ensory **S**ay CN III **O**culomotor **O**h Eye movement & pupil dilation **M**otor **M**arry CN IV **T**rochlear **T**o Vertical eye movement **M**otor **M**oney CN V **T**rigeminal **T**ouch Facial sensation & chewing **B**oth **B**ut CN VI **A**bducens **A**nd Lateral eye movement **M**otor **M**y CN VII **F**acial **F**eel Facial expressions **B**oth **B**rother CN VIII **V**estibulocochlear **V**ery Hearing **S**ensory **S**ays CN IX **G**lossopharyngeal **G**ood Swallow/gag reflex **B**oth **B**ig CN X **V**agus **V**eins Digestion & throat sensation **B**oth **B**rains CN XI **S**pinal Accessory **A**h Shoulder movements **M**otor **M**atter CN XII **H**ypoglossal **H**eaven Tongue movements **M**otor **M**ore [Respiratory] - Assessment - Ask patient to take deep breaths while auscultating breath sounds - Inspect the chest and observe for respiratory effort and symmetry of respirations - Ask patient to take deep breaths when auscultating - Symptoms & nursing considerations - Productive cough - May indicate pneumonia - Assess for sputum color, crackles, and vital signs (RR, SpO2) - Encourage coughing and deep breathing; do NOT give cough suppressant! - We want patient to cough up secretions and bacteria - Dyspnea (SUBJECTIVE) = respiratory distress - Usually, patient is also tachypneic - May see "tripod" position (leaning forward over bedside table) - If patient is having dyspnea **FIRST** ELEVATE THE HEAD OF BED! - Breathing patterns - Kussmaul respirations: constant deep, rapid breathing without pauses - Seen in DKA or metabolic acidosis to correct acidosis - Cheyne-Stokes: progressive increase in respiratory depth & rate followed by period of apnea - Breath sounds - Crackles - Caused by air passing through secretions - Often heard in pneumonia - Usually heard in bases only - **Should NOT be found in ALL lobes!** - Fine crackles: soft, high-pitched; sound like crunching - Coarse crackles: louder, low-pitched, sound like Velcro ripping open - Wheezing - High-pitched sounds caused by air passing through narrow airways - **May indicate RESPIRATORY DISTRESS** - Heard in COPD and asthma (typically during dyspnea) - Rhonchi: - Louder and deeper than crackles - Best heard in large bronchi during exhalation (not heard in lung periphery) - Bronchovesicular: heard over sternum anteriorly and between scapulae posteriorly - COPD (emphysema and/or chronic bronchitis) - Avoid over-oxygenation (many patients will need spO2 kept low) - Do NOT administer oxygen if spO2 is not low - If COPD patient is c/o "anxiety" and SOB check pulse ox! - Barrel chest appearance is a normal finding - Clubbing may be seen - Pursed lip breathing (mouth mostly closed) is encouraged - Asthma - May cause wheezing (assess for wheezing if c/o dyspnea) - Patients often c/o chest tightness - Exercise-induced bronchospasm (NOT a normal finding): - May experience wheezing, chest tightness, and dyspnea (mimics asthma sx) - Follow up with provider, may need prophylactic albuterol inhaler - We still encourage exercise along with appropriate treatment - Nursing intervention: encourage incentive spirometer to prevent atelectasis & pneumonia - Important for post-op patients, respiratory issues, & prolonged hospitalizations - Prioritizing - If priority findings present perform focused assessment (interview or full head-to-toe assessment can wait) - Priority findings: - RR \> 22 or \< 12 - Sudden or severe hypoxia, or if not immediately improving with O2 - Dyspnea (subjective) - Increased WOB (objective)- accessory muscle use or depth of respirations - HR \>110 along with any acute respiratory symptom - Signs of airway compromise (obstruction or altered mental status) - Asymmetry of chest expansion or abnormal breathing pattern - Crackles in ALL lobes - Treating low-grade fever is less of a priority than abnormal HR, RR, or pulse ox, BUT if fever \> 100.5, patient at risk for dehydration (& less able to expectorate) - RRT is used for respiratory distress/hypoxia/airway compromise, etc. (not necessary for cough, mild fever, or spO2 in high 80s if improved with O2) - First determine priority issue and then how to intervene - E.g., if SpO2 is the priority findingadminister supplemental O2 - E.g., if severe pain is impeding respiratory care or directly causing priority findings, treat the pain first (patient will not improve if pain not addressed) - Tips: - Increasing HOB is a universal priority intervention for dyspnea - Perform all immediately appropriate nursing interventions before calling doctor or RRT - BP not as much of a priority for patients with respiratory issues (ABCs) - In NCLEX world, we usually don't call the respiratory therapist (NCLEX wants you to recognize what you can do as the nurse) - Supplemental oxygen - Only administer if hypoxia present - If appropriate (low spO2, no COPD, etc.), priority intervention (perform **FIRST**) - Patients requiring O2 via nasal cannula need portable O2 tank for ambulation (do NOT discourage ambulation!) [Delegation] - CAN delegate hygiene/ADL assistance to UAP - This includes checking for incontinence ONLY (not assessing patient) - CANNOT delegate assessment to UAP (including use of Braden tool) [General tips] - Resist the urge to go back and change your answers! - Remember to use OLDCARTS when assessing any chief complaint - There is a time & place for past medical history, family history, etc. but that should wait until after chief complaint is assessed - READ THE QUESTION AND ANSWERS THOROUGHLY - E.g., If it's asking for subjective data, eliminate all answers that involve objective data & vice versa [Med Math] - LitersmL (e.g., 4.5L = [       ]mL) - Calculating mcg/dose when given an order for a medication in mL\ (e.g., order is for 20mL, but the med comes in 200mcg/5mL; you will give [     ]mcg/dose) - Calculating mL/dose when given an order for a medication in mg/mL \ (e.g., order is for 1,000mcg, but the med comes in 2mg/mL; you will give [     ]mL/dose) - Kgpounds (e.g., 140 kg =[      ] pounds) - Calculating \# tablets/dose while converting Mcgmg (e.g., order is for 100mcg, but the med comes in 0.1mg/tablet; you will give [    ]tablets)