307 Exam 2 Study Guide PDF

307 Exam 2 Study Guide Body Systems A. Cardiovascular- 40% ➔ Anatomy and physiology of heart and circulatory system (vessels of the heart) ◆ Anatomy 4 chambers of the heart = top (atria) & bottom (ventricles) Vessels...

307 Exam 2 Study Guide Body Systems A. Cardiovascular- 40% ➔ Anatomy and physiology of heart and circulatory system (vessels of the heart) ◆ Anatomy 4 chambers of the heart = top (atria) & bottom (ventricles) Vessels ○ Vena cavas = return deoxygenated blood from body ○ Pulmonary arteries = return deoxygenated blood from ventricles -> lungs -> oxygenated blood returned to pulmonary vein ○ Aorta = pumps oxygenated blood to the body ◆ Physiology Cardiac cycle ○ Diastole Ventricles relaxed, AV valves open Blood fills ventricles ★ S2= Semilunar (aortic and pulmonary) valves close -> diastole ○ Systole Ventricular pressure rises = closes AV valves Semilunar valves open Blood pumped into pulmonary artery and aorta  ★ S1 = AV (mitral & tricuspid) valves close -> systole ➔ Assessing pulses (Rhythm, rate, strength) ◆ Strength: 0 = absent +1 = weak +2 normal brisk pulse +3 increased strong pulse +4 bounding ◆ Rhythm & rate = equal bilaterally, consistent/ regular momentum (expected findings) ➔ Recognition of normal and abnormal cardiovascular assessment findings including vital signs 1. Neck vessel Expected ○ Jugular vein = no distention ○ carotid = visible pulsations Unexpected ○ Bulging jugular -> right sided heart failure (lack of blood return to superior vena cava) ○ Absence of carotid -> blockage of blood flow ○ Bounding carotid -> fluid overload due to heart failure 2. Anterior chest Expected ○ Symmetrical chest movement with gentle pulsations Unexpected ○ Forceful thrusting to PMI area 3. Extremities Expected ○ Presence of hair evenly distributed Unexpected ○ Edema and or atrophy ○ Skin tone paleness -> decreased circulation or cv condition ○ Lack of hair & shininess = decreased circulation ○ Dilated twisted veins = weakened valves ○ Swelling of nail bases (clubbing) -> chronic low oxygen level  ○ Delayed capillary refill greater than 2 seconds -> poor perfusion ○ Elevated skin after turgor -> fluid overload 4. Vital signs HR ○ Normal: 60-100 beats per minute (bpm) ○ Abnormal: ◆ Bradycardia: 100 bpm BP ○ Normal: Around 120/80 mmHg ○ Abnormal: ◆ Hypotension: systole ◆ S2 = Dub Closing of aortic and pulmonic valves, sharp higher pitches -> diastole ◆ ABNORMALS Indicate presence of heart disease and valve malfunction (should NOT be heard) ○ S3 = Rapid ventricular filling (ventricular gallop) Normal in children and pregnant women  Pathological causes -> Left ventricular failure and mitral regurgitation ○ S4 = Strong atrial contraction (atrial gallop) ALWAYS pathological (hypertension, cardiomyopathy, ASD) ➔ Documentation of a cardiovascular assessment 1. Patient identification 2. Chief complaint 3. Vital signs 4. Physical examination findings (inspection, palpation, auscultation) 5. Peripheral vascular assessment 6. Medical history questionnaire ➔ Health Promotion ◆ Risk factors for cardiovascular disease High levels of LDL cholesterol Diabetes Secondary lifestyle Tobacco use (damages cells) ◆ Benefits of exercise Strengthen heart muscles to pump effectively & prevent plaque build up Engage in 150- 300 min moderate exercise per week ◆ Heart healthy diet Fruit, vegetables, whole grain, low fat dairy & meats ○ LIMIT Saturated & trans fats Sugar and processed carbs Sodium to 2-3 g a day Alcohol ( high consumption leads to hypertension, irregular HR, blood clots) ➔ Nursing Actions for Chest Pain ◆ Additional subjective data ◆ Assessment Vital signs Inspection ○ Determine oxygenation level by assessing skin and mucous membranes  Additional actions ○ Administer ordered supplemental oxygen (nasal cannula) ○ Ensure IV access ○ Continuous ECG monitoring ○ Notify Provider & rapid response team STOP activities -> set patient in semi flowers = decrease exertion and oxygen needs to sufficiently supply the heart B. Respiratory-20% ➔ Anatomy and physiology of lungs ◆ Lungs Right: 3 lobes Left: 2 lobes ◆ Landmarks Midsternal line -> right down middle sternum Midclavicular line -> vertical line down middle of clavicle ◆ Physiology Movement of o2 low concentration to high O2 to alveoli -> capillary exchange with co2 -> removed from pulmonary capillaries to alveoli -> trachea -> out ○ Alterations of gas exchange = pulmonary edema ( high c02 -> increase blood co2 concentration) ➔ Chest shape and configuration ANTERIOR ◆ Expected: Chest is wider than is deep, ribs are angled slightly downward & scoliosis ◆ Unexpected: Barrel chest (associated with COPD); in tripod position Funnel chest = sunken sternum and costal cartilage ( NO respiratory distress) Pigeon chest = protrusion of sternum (NO respiratory distress) ➔ POSTERIOR  ★ Assess for deformities = scoliosis & kyphosis (spine outward + rounded -> hunchback shaped -> decrease lung expansion) ◆ Expected: Comfortable breathing position (posture), symmetry (palpitations), equal chest expansion (chest shape) ◆ Unexpected: Unequal expansion -> thoracic trauma (rib fracture, pneumonia & or pneumothorax) Tripod positioning, inability to sit still (agitation) Chest retractions = respiratory distress ○ SOUNDS Pleural friction rub = inflammation of pleural space Crackles = increase fluid, inflammation, and or consolidations Wheezing = airway swelling -> asthma & bronchitis (edema in bronchioles) Rhonchi = Fluid & mucus (can clear with coughing) Stridor = Upper airway obstruction & inflammation ➔ Oxygen and carbon dioxide transportation in the body ◆ Oxygen is inhaled into the lungs -> binds to hemoglobin in red blood cells for transport to tissues -> carbon dioxide is a byproduct of metabolism -> carried back to the lungs as bicarbonate for exhalation. ◆ Breathing rate adjust co2 levels ➔ Proper use of incentive spirometer ◆ @ every hour 4-10 times STEPS 1. Seal lips around mouthpiece 2. Breathe in as slowly & deeply as possible 3. Once reached max inhalation, hold breath until for at least 3- 5 seconds 4. Take off mouthpiece and breathe out slowly until the piston reaches the bottom of the chamber ➔ Breathing patterns (bradypnea, tachypnea, hyperventilation, hypoventilation, Cheyne-Stokes, ataxic)  1. Bradypnea -> less than 12 Hypoventilation -> irregular, shallow respirations 2. Tachypnea -> more than 20 ( exercise, fever, fear) Hyperventilation -> rapid, deep breathing associated with tachypnea -> lightheadedness, dizziness (FALL RISK), numbness of extremities 3. Cheyne stroke -> Lack of o2 due disease progression Pattern: Stop breathing -> hyperventilation -> hypoventilation -> apnea 4. Ataxic breathing -> involves period of apnea due to brain injury, respiratory depression, meningitis ➔ Recognizing cues (abnormal findings in a nursing chart/ report) ◆ Abnormal breath sounds ◆ Respiratory rate ◆ Oxygen saturation levels ◆ Work of breathing (accessory muscles, nasal flaring, retractions) ◆ Cough ( w sputum & or blood, dry cough) ◆ Abnormal chest expansion ◆ Patient symptoms -> shortness or breath, chest pain, cyanosis ◆ Clinical findings -> fever, abnormal lung function test results ◆ History of smoking & environmental exposures ➔ COPD ◆ Assessment findings of a client with COPD Equal anterior and posterior diameters = barrel chest Reduced breath sounds & wheezing Use of accessory muscles & intercostals drawing in during inspiration Central cyanosis with prolonged expiration ➔ Nursing actions for unexpected findings ◆ Shortness of breath (dyspnea) & congested cough Hypoxia/low oxygen saturation ○ Measure by assessing nail beds & mucous membranes, o2 saturation and RR rate Positioning clients in respiratory distress ○ Upright ○ Tripod -> expands rips to improve oxygenation Cough & deep breathing  ○ Maintain clear airways and decrease atelectasis (complete alveoli deflation) -> expands intrathoracic pressure C. Abdomen (Gastrointestinal)- 20% ➔ Anatomy and physiology of the GI tract ◆ REGIONS & ORGANS ◆ Accessory GI organs role Liver: Stores minerals, vitamins, stores and releases glucogen of carbs, clotting factors (bile), protection against harmful bacteria Gallbladder: Stores bile to release into duodenum Pancreas: Exocrine (enzymes for digestion) & endocrine glands (insulin and glucagon -> regulate blood sugar) Spleen: filters RBC and produces WBC (lymphocytes) ➔ Subjective versus objective findings in an abdominal/GI assessment ◆ Subjective 1. Medical history 2. Current medication & OTC products 3. Intake/ appetite 4. Ability to swallow 5. Bowel and & urination habits and changes 6. Issues with digestion ◆ Objective 1. Abdominal symmetry -> contour, scars, umbilicus 2. Auscultations -> abdominal sounds of RLQ, RUQ, LUQ, LLQ 3. Percussion -> dull and solid structures ➔ Order of assessment and rationale (inspect, auscultate, palpate)  ★ Minimize overstimulating abdomen ➔ Expected versus unexpected findings and meaning ◆ Inspection Skin Tone: Unexpected ○ Yellow hue -> liver dysfunction & jaundice ○ Taunt skin -> buildup of fluid ○ Purplish pink striate -> recent stretching of skin due to weight gain and or abdominal distention ○ Dilated veins & spider angiomas -> liver disease Symmetry: Unexpected ○ Aortic pulsations -> abdominal aortic aneurysm (AAA) Shape: Unexpected ○ Distention -> gas, tumors, fluid, constipation ○ Scaphoid Umbilicus: Unexpected ○ Redness, discoloration, swelling (hernias), lesions ◆ Auscultate Expected: Borborygmus = high pitched gurgling, hyperactive bowel sounds caused by peristalsis Unexpected findings ○ Hyperactive bowel -> increased mobility & peristalsis = potential diarrhea ○ Hypoactive bowel -> impaired mobility related to medication, anesthesia, constipation, bowel obstruction ○ Vascular swishing -> blood vessel & or liver disorders ◆ Palpate Expected: Voluntary guarding -> difficulty relaxing Unexpected: Involuntary guarding -> indicate inflammation of abdominal cavity ➔ Health Promotion ◆ Testing Stool in occult/ hidden blood Flexible sigmoidoscopy = examines rectum & descending colon Double contrast enema = xray and dye administered by enema to examine large intestine ★ Colorectal cancer screening @ 45 y/o : ◆ high risk patients @ 20’s ◆ Fiber- good sources of fiber -> Maintain peristalsis and remove fats and waste products  Beans - Kidney beans Fruit- Blackberries Whole grains/ bread- Oatmeal & granola ◆ Exercise (moderate 30 minutes a day) -> increase peristalsis, prevents constipation, decrease stress ◆ Probiotics -> promote growth of healthy bacteria D. Genitourinary- 20% ➔ Anatomy and physiology of reproductive organs and urinary system organs (male and female) ◆ Urinary System ★ FUNCTION: Eliminate excess fluid and waste Kidneys ○ R & L posterior region ○ Regulate fluid and electrolyte balance, acid base balance within blood stream ○ Secrete erythropoietin -> promotes RBC in bone marrow & BP control Ureters ○ Muscular tubes w mucous membranes to prevent reflux of urine back into urethra Bladder ○ Holds -300mL Urethr ○ Membrane tube through urinary meatus Male long urethra Women SHORT urethra -> higher risk for urinary infections ◆ Anus Internal and external sphincter muscles (involuntary & voluntary) ➔ Normal urinary output ◆ Normal: 1- 2.5 L/ day ○ Abnormalities 1. Oliguria 2.5L/ day ○ Increased water intake ○ Diabetes mellitus and insipidus ➔ Assessment techniques for reproductive organs (inspection and palpation) ◆ Anal and Perianal Area 1. Anus a. Inspection ○ Unexpected findings: Inflammation, lesions, rectal prolapse ★ External Hemorrhoids: Exposed dilated veins, can lead to -> thrombosed hemorrhoid-> due to lack of blood flow (clotting)-> causes localized pain, bluish discoloration 2. Bladder Distention a. Inspection ○ Caused by urinary retention (inability to empty bladder) -> obstruction, weak bladder muscles, neuro condition b. Palpation ○ Distention = smooth rounded mass (*Note tenderness & pain) ◆ Female Inspection ○ Mons Pubis- unexpected findings: Swelling & redness, patchy hair/ loss, lice, ulcerations ○ Labia, etc- unexpected findings: Inflammation, edema, discolored discharge, pain/ bruising, white patches (leukoplakia), lesions and nodules, Bartholin gland abscess (NOTIFY provider) ★ Menopause can cause = mons pubis atrophy, spare hair, and dry vaginal membranes due to the lack of estrogen ◆ Male Inspection  ★ Older Adults: Spare hair, difference in testicle length, pendulous scrotum sac ○ Penis- unexpected findings: Inflammation and edema, lesions, nodules, lice ○ Urethral Meatus- unexpected findings: Meatus on ventral side (hypospadias), and meatus on dorsal side of penis shaft (epispadias) ○ Scrotum and testes- unexpected findings: Edema, tenderness, nodules, absent testes (cryptorchidism) ○ Inguinal/ Femoral area - unexpected findings: Bulges, swelling of tissue from abdominal wall, hernia ★ LESIONS: Herpes (fluid filled blisters; HPV), warts (painless growths), syphilitic chancre (single raised patch with yellow serous discharge), chlamydia, and gonorrhea (yellow discharge from meatus) ➔ Health Promotion ◆ Cervical cancer screening and prevention ○ 21-29: every 3 years with cytology ○ 30-65: ever 3 years with cytology or every 5 with cytology & HPV testing ◆ Human papillomavirus (HPV) vaccine -> cancer ○ Begins at 9 y/o - 26 y/o & 27- 45 y/o if not yet administered ○ Administer before sexual activity for highest level of benefits ◆ Testicular self-examination ○ Annually with physical exam ◆ Prostate cancer screening (PSA and DRE) - blood test that detects protein of prostate gland  ○ Average risk: Screen @ 50-70 y/o ○ High Risk: Screen @ 40-45 y/o ◆ Colonoscopy ○ Start @ 50 y/o: Every 10 years ATI eBook Chapters 1. Fundamentals for Nursing Education a. Chapter 16 Health Promotion and Disease Prevention Risk assessment -> genetics, sex, physiologic factors (BMI, pregnancy), environmental, lifestyle risk behaviors, age ○ Screening test Routine physical exam Dental assessment yearly TB screening for high risk patients (Health care workers) Rectal exam Colorectal screening @ 45-75 Cancer screening exams Prevention = primary (prevent), secondary (screen), tertiary (treat) b. Chapter 29 Thorax, Heart, and Abdomen 1. Thorax 2. Heart 3. Abdomen Obtain health history: ROS Assessment ○ Assess skin, shape and contour, movements (peristalsis & pulsations) ○ Auscultate for bowel sounds (expected and unexpected- borborygmi= loud growling sounds) ○ Percuss -> Expect dullness over liver, tympany over abdomen & assess kidney tenderness over costovertebral angles ○ Palpitations -> light taps with finger pads ; expect softness, no guarding, no nodules ★ Urinate before examining c. Chapter 34 Self-Concept and Sexuality Self concept = inner beliefs regarding self identity, self esteem, body image ○ Stressors = unrealistic expectations, surgery, chronic illness  ○ Impacts of well being = positive and negative perceptions of oneself Body Image ○ Influenced by developmental factors, societal attitudes, loss of bodily function/ parts, unrealistic ideals Sexuality and sexual health ○ Influenced by cultural and societal views ★ NURSE CONSIDERATIONS: Self assess first, provided sexual health education with therapeutic communication, promote healthy lifestyle and coping skills, acknowledge emotional responses to body changes with body image topics, create a safe space for discussion ★ ASSESSMENT a. Observation factors: posture, demeanor b. Sexual History: collect information regarding sexual health concerns and sexual dysfunction (ex: some medications affect proper function, diuretics and anti depressants) c. PLISSIT: Framework to discuss sexuality -> permission, limited information, specific suggestions, intensive therapy (referral if needed) d. Chapter 43 Bowel Elimination Daily fiber intake = 25 - 38 g/day Fluid intake = 2.7 L/day - 3.7 L/ day Patient centered care ○ Monitor fluid and elimination pattern ○ Record food intake and output ○ Promote regular bowel elimination ( proper fiber, physical activity - 15/ 20 min daily, fluid intake) Constipation -> Increase fiber and water, enemas as last resort ★ COMPLICATION: Fecal impaction, hemorrhoids, bradycardia and hypotension Diarrhea -> Administer medication to decrease peristalsis, promote yogurt consumption, encourage fluids and avoidance of bowel irritants (caffeine and alcohol)  ★ COMPLICATIONS: Dehydration, skin breakdown, fluid and electrolyte disturbances ( metabolic acidosis) 2. Adult Medical Surgical Nursing a. Chapter 32 Angina and Myocardial Infarction (focus on health promotion, assessment, risk factors, expected findings Health promotion ○ Maintain physical activity ○ Have cholesterol and BP checked regularly ○ Consume low saturated fat and sodium diet ○ Promote smoking cessation Assessment ○ Risk factors ○ Expected findings -> chest pain, indigestion, dizziness, pain between shoulders, ache of jain (seen in females) ○ Physical findings -> tachypnea and tachycardia, vomiting, decreases level of consciousness, pallor & cool skin Differences between S.A & M.I ★ S.A: occurs by exertion or stress, relieved by rest & nitroglycerin, last min 15 minutes ★ M.I: occurs without cause, relieved ONLY by opioids, last more than 30 minutes, associated with nausea, GI distress, dyspnea, anxiety b. Chapter 23 Chronic Obstructive Pulmonary Disease Health promotion ○ Promote smoking cessation ○ Avoid secondhand smoke exposure ○ Influenza and pneumonia immunizations Assessment ○ Risk factors Old age, cigarette smoking, Alpha 1 antitrypsin deficiency (enzyme by liver to regulate other enzymes from attacking lung tissue), environmental factors ○ Expected findings -> chronic dyspnea, RR of 40- 50/ min, productive cough, crackles and wheezing, shallow respirations, barrel chest, irregular breathing pattern, pallor and cyanosis nail beds, clubbing of fingers (late stage of COPD) ○ Patient centered care  High fowler's position Encourage incentive spirometer Administer supplemental oxygen Monitor for skin breakdown from o2 devices Promote adequate nutrition Administer prescribed medications (provide patient education) c. Chapter 47 Gastrointestinal Diagnostic Procedures (focus on assessment of stool) 1. Patient history ○ Bowel habits (frequency, consistency, color) ○ Dietary intake (fiber, hydration, dietary changes) ○ Medication (laxatives, antidiarrheals, etc) 2. Observation ○ Color (blood, melena, pale -> bile obstruction, green) ○ Consistency (hard, liquid, mucus or undigested food) d. Chapter 64 Diagnostic and Therapeutic Procedures Breast exams: ○ Not for average or high risk patients (family history of BC, BRCA gene, or those who have received chest radiation) -> little to no support in detecting EARLY stage breast cancer Pelvic exam and bimanual exam ○ Types Pap smear HPV test Cervical cultures for STIs ○ Patient education Schedule 6-10 after last menstrual cycle Void before exam Relax muscle and take deep breaths ○ Testicular exams: Palpate for swelling, tenderness, and lumps -> occurs on yearly check ups ○ Digital rectal exam: Exam prostate, rectum, pelvis, and lower abdomen for unexpected masses or lesions @40 y/o for great risk patients (family history of prostate c) @45 y/o for high risk (relative diagnosis of p.c at early age of 65 y/o) @50 y/o for average risk individuals ○ Mammography -> radiologic pictures of breast tissue Start @ 40-44 y/o 3. Nutrition a. Chapter 13 Cardiovascular and Hematologic Disorders Heart failure ○ Increase protein intake ○ Reduce sodium ○ Monitor fluids Myocardial infarction ○ Liquid diet for first 24 hrs ○ Caffeine avoidance ○ Heart healthy diet education Anemia ○ Increase iron intake (red meat, fish, tofo, whole grain, dried peas and beans) ○ Vitamin c (facilitate absorption) ○ Increase b12 (fish, meat, eggs, milk) ○ Increase folic acid (green leafy veggies, seeds, orange juice) b. Chapter 14 Gastrointestinal Disorders Monitor Gastrointestinal Parameters ○ Weight and Weight Changes ○ Laboratory Values ○ Elimination Patterns ○ Intake & Output (I&O) Dietary Considerations ○ Low-Fiber Diet: Avoid high-residue foods (e.g., whole grains, raw fruits/vegetables). Reduces frequency/volume of fecal output. Used short-term for diarrhea or malabsorption. ○ High-Fiber Diet: Includes foods with >5 g of fiber per serving. Increases stool bulk. Stimulates peristalsis. Prevents constipation. Protects against colon cancer.