NR 302 Final Exam Study Guide / NR302 Final Exam Study Guide (Latest-2021/2022): Health, Study notes of Nursing

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NR I 302 IFINAL IEXAM ISTUDY IGUIDE

Thorax Iand ILungs

• What Idata Ican Ibe Igathered Ion Ia Ipatient Iin Irespiratory Idistress Ifrom Igeneral Isurvey Ionly?
  • Do Ithey Iuse Iaccessory Imuscles Iwhen Ibreathing? IPosition-tripod, IBarrel Ichest, INasal Iflaring, Icolor
• Structure Iand IFunction: IThe Ithorax
• Thoracic Icage
  • Sternum, I 12 Ipairs Iof Iribs
  • 12 Ithoracic Ivertebrae
  • Muscles Iand Icartilage
• Thoracic ICavity
  • Mediastinium
  • Pleural Icavity
  • Lung I(Apex Iand Ibase)

Structure Iand IFunction: IPleural IMembranes

• Parietal Ipleura-lines Ithe Iwhole Icavity
• Visceral Ipleura-lines Ithe Iorgans
• Pleural Ispace/cavity-both Iabove Itotal

Structure Iand IFunction: IThe Irespiratory Isystem

• Trachea
• Bronchi
• Bronchioles
• Alveolar ISacs
• Alveoli

Landmarks-Visualize Iwhat Iyou Icannot Isee!

- Anterior Ichest - Suprasternal Inotch I“U Ishaped”

• Sternum
• Sternal Iangle I(Angle Iof ILouis) Icontinuous Iwith I 2 nd^ Irib
• Ribs I& Iintercostals
• Costal Iangle I(at Ixiphoid) I 90 Idegrees - Posterior Ichest
• Vertebra Iprominence IC
• Spinous Iprocesses IT1 Iis I 1 st^ Irib
• T3 Iseparates Iupper Iand Ilower Ilobes
• Inferior Iborder Iof Ithe Iscapula I 8 th^ Irib
• 12 th^ Irib

Subjective IData

• Difficulty Ibreathing, Isleeping, Ichest Ipain, Icough Iand Isputum I(Rusty-TB), Ismoking Ihistory, Ienvironmental Iexposure TO Icalculate Ismoking Ipack-years
  1. Multiple Ithe Inumber Iof Icigarettes Ismoked Iper Iday Iby Inumber Iof Iyears Ismoked
  2. Divide Iby I 20 i.e I 10 Icigarettes Ismoked Iper Iday Ix I 10 Iyears I/ I 20 I= I 5 Ipack Iyears

Objective IData

• Inspection Iof Ipatient: IResp. Irate I& Ieffort Ito Ibreathe I(Nasal Iflaring, Iaccessory Imuscles,Ipositioning) Iskin Icolor, Inails, Iconfiguration Iof Ichest I(Chest Ideformities)
• Palpation Iof Ianterior Iand Iposterior Ichest: ITenderness, Ilumps, Icrepitus I(Subcutaneous Iair-rice Ikrispis Iunder Iskin), Itactile Ifremitus I(99), Irespiratory Iexpansion
• Percussion Iof Ilung Ifields: IResonance, Ihyper-resonance, Idull, Idiaphragmatic Iexcursion
• Auscultation Iof Ichest: INormal, Iadventitious, Ivoice Isounds, Imeasurements Iof Ipulmonary Ifunction: IFor Iscreening**Begin Iat Ithe Imoment Iof Icontact

Normal Ibreath Isounds

• Bronchial I(Tracheal) I–Over Itrachea I& Ilarynx IE>
• Bronchovesicular—Over Imajor Ibronchi II=E
• Vesicular—over Iperipheral Ilung Ifields II>E

Normal IAssessment IFindings

• Inspection: IRR I 14 Ireg,even I& Iunlabored I(eupnea), Iskin I& Inails Ipink, Ino Icyanosis Inoted, Irelaxed Iposture, Ishape Isymmetric IAP: ITransverse I1:2, Icostal Iangle I<90 Idegrees
• Palpation: IChest Iexpansion Isymmetric, Itactile Ifremitus Isymmetric, Ino Itenderness, Ino Icrepitus, Ino Ilumps Ior Imasses
• Percussion: IResonance Ithroughout, Idiaphragmatic Iexcursion Iequal Ibilaterally
• Auscultation: INormal Ibreath Isounds

Adventitious IBreath Isounds

• Crackles/rales
• Pleural Ifriction Irub
• wheeze
• Rhonchi

Voice ISounds

• Bronchophony I“99”
• Egophony I“EEEEEE”
• Whispered IPectoriloquy I“one-two-three”

Abnormal Ibreathing Ipatterns

• Tachypnea
• Bradypnea
• Hyperventilation
• Hypoventilation

• Cheyne-strokes—fast Ibreathing Iwith Iapnea I(People Iwho Iare Idying)

Time Ito ITHINK Ias Ia INURSE…

• Discuss Idyspnea Iand Iorthopnea
• What Icauses Ipleuritic Ipain I(pleurisy)
• Differentiate ICrepitus Ivs IFremitus
• Is Iabnormal Iposture Ior Ichest Ishape Ia Iconcern? IWhy? IYes
• Connect Inasal Iflaring I& Iaccessory Imuscle Iuse
• Atelectasis-collapsed Ilung
• Differentiate Ivarious Icolors Iof Isputum
• What Iwould Icause Idense Iof Iconsolidated Ilung Itissue?—Fluid, Itumor, Imucous, Ifood Case IStudy Mr. IJS Iis Ia I 70 Iyear- Iold Imale Iwith Iprogressive ICOPD. IReason Ifor Iseeking Icare, I“I Iam InotIgetting Iair.” He Ireports Ismoking I1.5 Ipacks Iof Icigarettes Iper Iday Isince Iage I 16 I. He Ipresents Ito Ithe Iemergency Idepartment Iwith Icomplaints Iof Iworsening Idyspnea, Iproductive Icough, Ichest Itightness, Ichills I& Ifatigue Vital ISigns: Itemp. I101.2 Ioral, Iapical Iheart Irate I108, IRR I 24 Ilabored, IB/P I124/78, Ipulse Iox I88% Ion Iroom Iair I(RA)
• Subjective
  • Chest Itightness
  • Dyspnea
  • chills
  • fatigue
• Objective
  • Vitals
  • Labored
  • productive Icough
  • Accessary Imuscles
  • Tripod
  • Purse Ilipped Ibreathing
  • Pants Iunbuttoned
  • malnourished
  • Barrel Ichest
  • Clubbing/stained Inails
  • Anxious

Assessment IReveals

Inspection:

• Pt. Iis Ileaning Iforward Iin ITRIPOD Iposition
• RR I 24 Ilabored Iand Ishallow, Ilips Iappear Icyanotic
• Using Iaccessory Imuscles Iof Ithe Ineck I& Ishoulders I(hypertrophied)
• “Barrel-shaped” Ichest Iwith Icostal Iangle I> I 90 Idegrees
• Clubbing Iof Ithe Inails Iwith Iyellow Istaining Ifrom Inicotine

• Productive Icough: Ithick Iyellow I– Igreen Isputum Palpation:
• Decreased Ichest Iexpansion Ion Iright Iside
• Decreased Ifremitus Ithroughout Iwith IIncreased Itactile Ifremitus Iover Iright Ilower Ilobe I(RLL) Percussion:
• Hyper Iresonance Iover Ilung Ifields
• Dull Iover IRLL Auscultation:
• Decreased Ibreath Isounds Ithroughout
• Crackles Iover IRLL
• Bronchophony, Iegophony-bleeding Igoat, Iwhispered Ipectoriloquy-loud IRLL ICALCULATE I THIS IPATIENT’S IPACK IYEAR IHISTORY 81 Iyears!!!!!

Nursing IDiagnoses

• Self-care Ideficit: IBathing Iand Ihygiene
• Impaired Igas Iexchange
• Ineffective Itissue Iperfusion
• Activity Iintolerance
• Ineffective Ihealth Imaintenance
• Anxiety
• Nutrition: Iless Ithan Ibody Irequirements Test Iyour Iknowledge The Inurse Iis Iperforming Ithe Irespiratory Iassessment Ion Ia Ipt. Iwith Ipneumonia. IThe Ipt. Iis Iasked Ito Isay I“ninety-nine” I& Ithrough Ithe Istethoscope Ithe Inurse Ihears Ithe Iwords Iclearly Iover Ithe ILLL. IHow Iwill Ithe Inurse Idocument Ithe Ifindings? 1. Bronchophony 2. Tactile Ifremitus 3. Crepitus 4. Egophony A Ipt. Ihas Ideveloped Ia Ideep Ivein Ithrombosis I(DVT) Iand Ithe Inurse Iis Ialert Ifor Ithe Ipotential Idevelopment Iof Ia Ipulmonary Iembolism I(PE). IWhich Ifindings Iwould Isuggest Is/s Iof IPE?
  1. Non-productive Icough I& Iabdominal Ipain
  2. HTN I& Iafebrile
  3. Bradypnea I& Ibradycardia 4. Chest Ipain I& Idyspnea Which Iof Ithe Ifollowing Ipatient’s Iis Iat Igreatest Irisk Ito Idevelop Iatelectasis Iand Ipneumonia?
  4. Pt. Iw/ Ia Ihx Iof Ismoking I 2 IPPD I that Iquit I 2 Iyrs. Iago
  5. Pt. Iwho Iis Iambulatory Iq I 4 Ihrs. 3. Pt. Iwho Iis Ipost- Ioperative Irequiring I“splinting(hold Itogether)-hug Ipilow” Isecondary Ito Ipain

4. Pt. Itaking ITylenol Ifor Ipain

Chapter I 19 IHeart Iand INeck IVessels

Landmarks

- Precordium: - Clavicle Ito Ixiphoid, Ioverlying Iheart Iand Igreat Ivessels

• Base Iof Ithe IHeart:
  • Second Iintercostal Ispace
• Apex Iof Ithe Iheart:
  • Fifth Iintercostal Ispace

Structure Iand IFunction

• The Iright Iand Ileft Iatrium Iare Ithe Ireceiving Ichambers.
• The Iright Iand Ileft Iventricles Ipump Iblood Iout Iof Ithe Iheart.
• The Iright Iside Iof Ithe Iheart Itransports Iunoxygenated Iblood Ito Ithe Ilungs
• The Ileft Iside Iof Ithe Iheart Itransports Ioxygenated Iblood Ito Ithe Isystemic Icirculation

Heart IValves IStructure Iand IFunction

• Four Iheart Ivalves Ifacilitate Iunidirectional Imovement Iof Iblood Ithrough Ithe Iheart Ito Iprevent Ibackflow Atrio-ventricular I(AV) ▪ Tricuspid ▪ Mitral I(Bicuspid) ISemilunar I(SL) ▪ Pulmonic ▪ Aortic

Neck IVessels IStructure Iand IFunction

Carotid Iarteries

• Supply Ioxygenated Iblood Ito Ithe Ihead Iand Ineck
• Located Ibetween Ithe Itrachea I& ISCM
• bruire—bell Iof Istethoscope Jugular Iveins
• Return Iun-oxygenated Iblood Ito Iheart
• Jugular Ivein Idistention I(JVD) I provides Iinformation Iabout Ithe Iright Iside Iof Ithe Iheart

Subjective IData

Nonspecific IS&S

• Fatigue
• SOB I(DOE)
• Orthopnea/difficulty Isleeping
• Dizziness/syncope ILifestyle IAssessment
• Diet I& Iexercise

• Smoking/stress ISpecific IS&S
• Chest Ipain
• palpations
• edema
• cyanosis
• orthopnea/difficulty
• dizziness/syncope

Objective IData

- Inspection Iof Ipt.: - General Iappearance, Ijugular Iveins, Icarotid Iarteries, Ihands I& Ifingers, Ichest - Palpation Iof Iprecordium: - Pulsation Ior Iheave, Icarotid Ipulses, Iapical Iimpulse - Percussion : - Cardiac Iborder I(*SEE IP. I480) - Auscultation : - Carotid Iarteries, IHeart Isounds I& IApical Iheart Irate, Ipulse Ideficit

Auscultation: IFive Ilistening Ipoints Iof Ithe Iheart

Aortic: I 2 ICS/RSB I Pulmonic: I 2 ICS/LSBI Erb’s: I 3ICS/LSB Tricuspid: I 4ICS/LSB Mitral: I 5ICS/LMCL

Normal IHeart ISounds

- S1:

• Closure Iof IAV Ivalves I– “LUB” I heard Iloudest Iat Iapex I- Ilisten Iat Itricuspid I& Imitral Ipoints S2:
• Closure Iof Isemilunar Ivalves I- I “DUB” Iheard Iloudest Iat Ibase I- Ilisten Iat IPulmonic Iand IAortic Ipoints.

Time Ito Ithink Ias Ia Inurse

What Iis Itissue Iperfusion?

• enough IO2 Iin Isystem-can Isend Io2 Ito Iall Ibody Itissues. IAbility Iof Iheart Ito Ipump Io
• List Imodifiable I& Inon-modifiable Irisk Ifactors
• Differentiate Ibetween Iapical Ipulse I& Iapical Iimpulse I(impulse Iwhat II Ifeel)
• What Iis Ithe Irelationship Ibetween Icarotid Iartery Ibruit Iand Idizziness?
• Obstruction Nursing IDiagnoses
• Acute IPain—evidence Iis Ipatient Ihas Ipain I10/
• Ineffective ITissue IPerfusion
• Activity IIntolerance
• Fatigue

• Anxiety
• Decreased ICardiac IOutput
• Fear Test Iyour Iknowledge… The Inurse Iis Iperforming ICPR Ion Ian Iadult Ipt. I What Iis Ithe Icorrect Ihand Iposition Ion Ithe Ipts. Ichest?
  1. Upper Ihalf Iof Ithe Isternum
  2. Two Ifinger Iwidths Ibelow Ithe Isternal Inotch 3. Two Ifinger Iwidths Iabove Ithe Ixiphoid Iprocess
  3. Over Ithe Ixiphoid

Chapter I 20 IPeripheral IVascular ISystem Iand ILymphatic ISystem

Function Iof IPeripheral IVascular ISystem Arteries

• Transport IO2 Iand Iblood Ivia Ithe Iheart Ito Ithe Iorgans Iand Itissue Icapillaries I( perfusion )
• Have Ia Ismooth Imuscle Ilayer Ithat Icontracts Iand Irelaxes Iin Iresponse Ito Ichanges Iin Iblood Ivolume
• Arterial Ipulse Ireflects Ithe Ipumping Iof Ithe Iheart Iduring Isystole Veins
• Transport Ideoxygenated Iblood Ifrom Icapillaries Ito Ithe Iright Iside Iof Ithe Iheart
• Thinner Iwalls Imakes Iveins Imore Idistensible; Ican Iaccumulate Ilarge Iamounts Iof Ifluid
• Have Ione Iway Ivalves Ithat Iallow Iblood Ito Iflow Iagainst Igravity Iand Ireturn Ito Ithe Iheart

Function Iof ILymph ISystem

• Retrieve Iexcess Ifluid Ifrom Itissue Ispaces Iand Ireturns Ito Ithe Ibloodstream. IDamage Ito Ithis Isystem Ior Iremoval Iof Inodes Iresults Iin I lymphedema
• Lymph Inodes Ifilter Iout Imicro-organisms I(such Ias Ibacteria) Iand Iforeign Isubstances Isuch Ias Itoxins.
• Superficial Ilymph Inodes Iare Iprimarily Ilocated: - Head I& Ineck - Axillary - Epitrochlear - Inguinal

Subjective IData-Venous

• Pain Iin Ilegs? IDoes Iwalking Iincrease Ipain? ILaying Idown Iincrease Ipain?
• Numbness Iand Itingling?
• Varicose IVeins?
• Edema

Objective IData IArterial IInsufficiency

Inspection

• Skin Iis Ipale I& Ishiny
• Hair Iloss Idistribution
• Distal, Idry Iulcer

Palpation

• Absent Ior Iweak Ipulse
• Cool Itemperature I-No Iedema

Objective IData IVenous IInsufficiency

Inspection

• Swollen Ileg
• Darkened Ihyperpigmentation Iat Iankle
• Ulcers Ion Ileg Iand Iankle Palpation
• Moderate Ito Isevere Ipitting Iedema
• Palpable Ipulse I(depending Ion Iedema)
• Hard Iskin, Inormal Itemperature

Objective IData ICollection

- CMS Ichecks : IArterial ICheck I C irculation, I M otion, Iand I S ensationI Together Iwith Ithe: - 5 IP’s: I 1. IPain 2. Pulse 3. Pallor 4. Parasthesia 5. Paralysis - Remember Ithe Iedema Iscale I(0-4) Iand Ipulse Iscale(0-3)? - Perform Ithe IAllen ITest I(assess Ihand Iperfusion) The IHoman’s ISign I(not Iused Iduring Iassessment Ianymore!) Arterial Iulcer - IRound, Iapproximated, Ipink/pale Ibase, Iopen Iup Iartery Ibreak Idown Icause Ino Io I Venous IUlcer - Generally Ion Iankles, Imedial Ior Ilateral, Iskin Iopens, Iand Idrains Idark Ibreak Idown Ibecause Iold Iblood Istagnate - Elevate Ileg

Time Ito ITHINK Ias Ia INURSE…

Cluster Iand Iconnect Ithe Icues:

• Immobility
• Peripheral Iarterial Idisease I(PAD)
• Skin Iintegrity

Test IyourIknowledge

You Iare Ithe Inurse Iassessing Ia Ipt. Is/p Ifemoral-popliteal Ibypass Igraft. IWhich Iof Ithe Iassessment Ifindings Iindicate Ia Icomplication?

1. BP I110/80, IHR I86, IRR I 20 Iunlabored
2. Small Iamt. Iof Idk. Ired Iblood Ion Idressing 3. Decrease Iin Ipulse Iquality Iof Ithe Ioperative Ileg
3. Small Iamt. Iof Iswelling Iof Ithe Ioperative Ileg

Raynaud IPhenomenon-fingers, Itoes Iturn Iblue-keep Iextremities Iwarm ILymphedema-Breast Icancer Ipatients Iwith Ilymph’s Iremoved Arterial IUlcer- IVenous IUlcer-

Communicating Iin IClinical Iwith Ithe Iolder Iadult

Why Iis Icommunication Iimportant?

• BUILD IRELATIONSHIPS
• COLLECTIASSESSMENT IDATA
• PROVIDE IEDUCATION
• INTERACT IDURING IINTERVENTIONS

Communicating Iin Iclinical

• PATIENT ICENTERED ICARE-perceptions, Ifeedback Iloops
• PATIENT IAND IFAMILY ICENTERED ICARE-respectful Ifamily Iprofessional Ipartnership, Istrength Iof Iculture, Itraditions, Iprovides Itrust

The Iclinical Isetting

• Acute Icare Ior Ilong-term Icare Ifacility
• Caring Ifor Ithe Iolder Iadult Ipatient
• Develop Icommunication-facilities-pt Iexpresses Ifeelings, Iconcerns
• Develop Icritical Ithinking Iskills-promote Imore Ieffective Icommunication Ithan Ipt Iassessment

Focus Ion Iolder Iadults I–affecting Icommunication

• Patients Iwho Iare Ivisually Iimpaired
• Patients Iwho Iare Ihearing Iimpaired
• Patients Iwho Iare Icognitively Iimpaired
• Patients Iwho Icannot Ispeak Iclearly

Older Iadults Iwho Iare Ivisually Iimpaired-cataracts, Iglaucoma, Iperipheral Ivision

• Provide Ilight
• Avoid Istanding Itoo Iclose
• Stand Iin Ifront
• Use Iyellow Iand Ired Ifor Isigns
• Make Isure Itheir Iglasses Iare Iclean Iand ION
• Large Iprint
• In Ithis Iscenario, Iour I 84 - year-old Ipatient IMrs. ISmith Iis Ivisually Iimpaired. IShe Ijust Ireceived Iher Ilunch Itray. IWe Iare Igoing Ito Iset Iher Iup Ifor Iher Imeal. - Clock Iterms - Path Iwas Iclear, Iglasses Ion, Ilight Ion

Older Iadults Iwho Iare Ihearing Iimpaired

• Earwax Ibuild Iup

• Hearing Iaides Iin-battery
• Stand Iin Ifront-to Iread Ilips
• Try Ito Ilower Itone
• Noise
• Privacy
• Scenario IMr. IJohnson Iis Ian I 86 - year-old Iwho Ipresents Iwith Ihearing Iloss. IWe Iare Igoing Ito Iset Ihim Iup Iat Ithe Isink Ito Iwash Ihis Iface Iand Ibrush Ihis Iteeth.

Older Iadults Iwho Iare Icognitively Iimpaired I–Dementia—Alzheimer’s

• Simple Isentences-avoid Ilong Iexplanations
• One Iquestion
• Allow Itime-don’t Irush Ithem
• Attentive
• Include Ifamily
• Use Ipictures
• Use Igestures
• Scenario IMrs. IScott Iis I 78 Iyears Iold. IShe Ihas Icognitive Iimpairments. IShe Idoes Inot Ilike Ipeople Itouching Iher. IWe Iare Igoing Ito Itake IMrs. IScotts Iblood Ipressure Iand Ilisten Ito Iher Iheart Iand Ilungs.

Older Iadults Iwho Icannot Ispeak IClearly-Aphasia, Idysarthria, Imuteness)

• Listen Iattentively
• Be Ipatient
• Ask Iyes/ Ino Iquestions
• Allow Itime
• Communication Iaids
• Scenario IMrs. IApplehoff Iis Ia I 68 - year-old Iwho Ipresents Iwith Ia Ileft ICVA Iand Iright Isided Iweakness. IShe Iis Itrying Ito Itell Ithe Inurse Ishe Ineeds Isomething.