HA Final exam review Pathophysiology NR283, Exams of Nursing

Download HA Final exam review Pathophysiology NR283 and more Exams Nursing in PDF only on Docsity! 4 /4 /2024 12:42 م HA Final exam review - xxx about:blank 1/3 Final Exam Review New Stuff:  Understand the order and direction of proper blood flow in the heart  When listening to heart sounds- understand the meaning of listening to landmarks (example: aortic and pulmonic are valve closures)  SA node = pacemaker of the heart  Major risk factors of heart disease  “Z” pattern is used for auscultating hear sounds (understand proper areas of cardiac landmarks / ex: aortic, the 2 intercoastal space right sternal border)nd  The order of listening to heart sounds (think lab )�  Right sided heart failure VS Left sided heart failure o Understand the clinical manifestations for each and how they differ and how they are similar  Understand what the difference in auscultating, inspecting, palpating (we ASCULTATE PALPATE heart sounds, we the radial pulse)  Normal vs abnormal heart rate (athletes commonly have bradycardia although this is EXPECTED, it would still be considered abnormal)  When would the RN find it appropriate to take an apical pulse vs radial pulse  Normal vs abnormal heart sounds (Normal= S1 & S2 are present / Abnormal =turbulence)  Proper structure of the heart- understand where the apex is, where the chambers are located  Normal= auscultate/ palpate for 30 seconds and multiple by 2  Abnormal= auscultate / palpate for 1 full minute (60 seconds)  Definition of S1 & S2  Orthostatic hypotension (sitting, laying & standing- will see a change of 20 more intervals in blood pressure)  How to properly take a blood pressure (when would an abnormal blood pressure occur?) Feet should be flat on the ground, sitting position, rest time, proper cuff size for patient Old Stuff  ADPIE o Vital signs: T 98.6° F, P 79, RR 16, BP 120/83, O2 sat 99% on room air. o Pain: Pain level 5/10. Client states that his pain is located in the right upper quadrant of his abdomen. Describes the pain as a “stabbing” sensation that is worse after eating meals. o Goals: Client will have a pain level of 2 or less on a 0 to 10 scale by 1900 this evening. 4 /4 /2024 12:42 م HA Final exam review - xxx about:blank 2/3 o Orders: Implement nonpharmacologic therapies for pain management (music therapy). PRN (as needed) hydrocodone (oral) every 4 hours as needed for pain. Assessment: Vital signs, Pain (subjective or objective data) Diagnosis (nursing): acute pain (remember this is what the nurse is treating NOT a medical diagnosis Planning: goals (we want the pain to be at 2 or less by 1900 this evening) Implementation: non-pharmacological or pharmacological (Remember this what the nurse does (give pain medication, have the patient change positions, make them ice packs or heating pads ect) Evaluate: Did the implementations work- did the patient have a pain score below 2 after I gave them pain medications and an ice-pack? If it worked our plan was successful, if not we need to change our plan leading to changed in implementation.  Snellen chart= visual acuity= patient positioned 20 feet away  Clinical manifestations of Bacterial/Viral Pneumonia, Asthma (clear secretions for a cold, greenish/yellow for Pneumonia, wheezing on auscultation for asthma patients, ect)  Priorities of nursing: o ABC (airways, breathing & circulation)  Example: capillary refill: normal= >3 seconds abnormal <3 seconds (this assessment is checking circulation- be able to understand how assessment abnormalities can effect the nurses priorities)  Epitaxies- continuous can effect circulation  Appropriate use of the pain scale (example 1-10 pain scale for adults, FACES for children)  Tinnitus vs vertigo (definitions and clinical manifestations)  PERRLA (with pupils should constrict consensually or being brough tolight object patient pupil should constrict =NORMAL finding)  Communication and culture considerations: remember all translation should go through hospital translator  Signs/symptoms of metabolic syndrome  Pain can cause distress in vital signs (tachycardia is an abnormal sign the RN may see)  Signs/symptoms of dehydration  Definition of communication  Definition of assessment (example: assessing ears, subjective and focused objective information should focus on the EARS)  Employee considerations for skin care/nose (working outside in the sun for skin, painter for nose)  Understand how a patient would present if drowsy vs lethargic