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NR 302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. / NR302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,$19.99
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NR 302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. / NR302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,
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NR 302 (NR302)
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CHAMBERLAIN COLLEGE OF NURSING
NR 302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. / NR302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,NR 302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. / NR302 FINAL EXAM STUDY GUIDE HEALTH ASSESSMENT I. : 100% CORRECT,CHAMBERLAIN COLLEGE OF NURSING,N...
NR 302 FINAL EXAM STUDY GUIDE: HEALTH ASSESSMENT I
Drug hx – interactions
o It’s important to ask about drug history, so that we can ensure that we are not going to give patients
medication that will have adverse reactions to either: other medications they are taking, or to ones
that they may be allergic to.
Geriatrics – assess pulse
o Using the pads of your first three fingers, palpate the radial pulse at the flexor aspect of the wrist
laterally along the radius bone (Fig. 9-4). If the rhythm is regular, count the number of beats in 30
seconds and multiply by 2. Although the 15-second interval is frequently practiced, any one-beat
error in counting results in a recorded error of 4 beats/min.
o The 30-second interval is most accurate and efficient when heart rates are normal or rapid and when
rhythms are regular. However, if the rhythm is irregular, count for a full minute.
o As you begin the counting interval, start your count with “zero” for the first pulse felt. The second
pulse felt is “one,” and so on.
o Assess the pulse, including (1) rate, (2) rhythm, and (3) force.
Rate
In the adult at physical and mental rest, recent clinical evidence shows the normal resting
heart range of 95% of healthy persons at 50 to 95 beats/min. Traditional resting heart rate
limits established in the 1950s are 60 to100 beats/min. This range is still used; however, no
research evidence supports it.
The rate normally varies with age, being more rapid in infancy and childhood and more
moderate during adult and older years. The rate also varies with gender; after puberty females
have a slightly faster rate than males.
o In the adult a resting heart rate less than 50 beats/min is bradycardia. Heart rates in the
50s/min occur normally in the well-trained athlete whose heart muscle develops along
with the skeletal muscles. The stronger, more efficient heart muscle pushes out a larger
stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable
cardiac output. Many medications also affect heart rate, with nearly all heart disease
patients taking at least one medication that slows the heart rate.
o A more rapid heart rate, variably defined as over 95 beats/min or over 100 beats/min,
is tachycardia. Rapid rates occur normally with anxiety or with increased exercise to
match the body's demand for increased metabolism. Tachycardia occurs with fever and
also with sepsis, pneumonia, myocardial infarction, and pancreatitis. This evidence
predicts complications and worse survival rates in the latter conditions
Rhythm
The pulse normally has a regular, even tempo. One irregularity that is commonly found in
children and young adults is sinus arrhythmia. In sinus arrhythmia the heart rate varies with
the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with
expiration. Inspiration momentarily causes a decreased stroke volume from the left side of the
heart; to compensate the heart rate increases. If any other irregularities are felt, auscultate
heart sounds for a more complete assessment.
Force
The force of the pulse shows the strength of the heart's stroke volume.
A “full, bounding” pulse denotes an increased stroke volume (e.g., as with anxiety, exercise,
and some abnormal conditions).
A “weak, thready” pulse reflects a decreased stroke volume.
, o The pulse force is recorded using a three-point scale:
3+—Full, bounding
2+—Normal
1+—Weak, thready
0—Absent
Nursing process – crusted lips assessment
o Chelitis – chapped lips; usually due to dryness/dehydration
o Angular chelitis – Erythema, scaling, and shallow and painful fissures at the corners of the mouth
occur with excess salivation and Candida infection. It is often seen in edentulous persons and those
with poorly fitting dentures, causing folding in of corners of mouth, which creates a warm, moist
environment favoring growth of yeast.
Nursing process – eyes – ophthalmoscope (p. 298)
o The ophthalmoscope is used to inspect the ocular fundus. It enlarges your view of the eye so that you
can inspect the media (anterior chamber, lens, and vitreous) and the ocular fundus ( the internal
surface of the retina). It does this by directing light through the pupil to illuminate the inner
structures. Thus using the ophthalmoscope is like peering through a keyhole (the pupil) into an
interesting room. The ophthalmoscope should function as an appendage of your own eye (this takes
practice).
o The ophthalmoscope is held right up to the eye braced firmly against the cheek and brow; use the lens
selector dial to refocus as needed during the procedure w/o taking the device away from your face to
look. Be sure to move your head and the instrument together as one unit. And be sure to keep both
eyes open when using it.
Recall the set of lenses that control the focus: the unit of strength of each lens is the diopter.
Black numbers indicate a positive diopter ( they focus on objects nearer in space to the
ophthalmoscope)
Red numbers indicate a negative diopter ( they focus on objects farther away in space to
the ophthalmoscope)
o To examine a person:
Darken the room ( dilating eye drops are not needed during screening exam; they are only
used when glaucoma can be ruled out completely b/c dilating the pupils in the presence of
glaucoma can precipitate an acute episode)
Remove your glasses and those of the patient; contact lenses can be left in as they do not
interfere with instrument use, so long as they are clean ( glasses obstruct close movement, and
you can compensate your vision loss by using the diopter settings for correction)
Be sure that the light has maximum brightness
Select the large round aperture w/ white light. If pupils are small use a smaller light. ( the
instrument does have other colors/shapes for the apertures, but they are rarely used in screening
exams)
Match sides with the patient; in other words hold the ophthalmoscope in your right hand up to
your right eye, in order to view the patient’s right eye. ( You do this to avoid bumping noses);
additionally you can use your other hand/arm to rest on their shoulder or forehead to maintain
spatial orientation as your view is narrowed through the ophthalmoscope, you can also gently
anchor your thumb on the patient’s upper lid to help prevent blinking.
Observe from about 25 cm away at an angle of 15o lateral to the person’s line of vision. Note
the red glow filling the person’s pupil. This is the red reflex, caused by the reflection of your
ophthalmoscope light off the inner retina. Keep sight of the red reflex and steadily move closer to
the eye. If you lose the red reflex, this means that the light has wandered off the pupil and onto
the iris or sclera.
, As you advance, adjust the lens to +6 and note any opacities in the media. ( these appear as
dark shadows or black dots that interrupt the red reflex; normally none are present) [Cataracts
appear as opaque black areas against the red reflex]
Then adjust the diopter setting to bring the ocular fundus into sharp focus; if you and the patient
have normal vision the setting will be at 0 (zero).
Moving the diopters compensates for nearsightedness or farsightedness
o Red lenses for nearsightedness
o Black lenses for farsightedness
Nursing process – stethoscope (p.116)
o The stethoscope does not magnify sounds but it blocks out extraneous sounds.
o The fit and quality of the stethoscope are important, you cannot assess or hear through a poor
instrument.
The slope of the earpiece should point forward toward your nose. ( This matches the natural
slope of your ear canal and efficiently blocks out sound)
Chose a stethoscope with two end-pieces
The diaphragm is used most often b/c its flat edge is best for high-pitched sounds (i.e.
breath, bowel, and normal heart sounds)
o Hold the diaphragm firmly against the person’s skin, firm enough to leave a slight ring
afterward.
The bell has a deep, hollow, cuplike shape that is best for soft, low-pitched sounds (i.e. extra
heart sounds, or murmurs)
o Holed the bell lightly against person’s skin, just enough for it to form a perfect seal. (
holding it too firmly will cause it to act as a diaphragm, obliterating the low-pitched
sounds)
o Before you can evaluate body sounds, you need to eliminate any confusing factors:
Any extra room noise can produce a “roaring” in your stethoscope
Keep exam room warm ( patient shivering can drown out other sounds)
Clean stethoscope with an alcohol wipe, then warm it in your palms ( this helps avoid the
“chandelier sign” elicited when placing a cold end-piece on a warm chest.)
Wet chest hair before listening ( dry chest hair can mimic crackles)
Never listen through a gown ( this creates artificial sounds that muffle any diagnostically
valuable sound from the heart or lungs)
Nursing process – dehydration, S&S GERI
o Dehydration – severe fluid deficit in the body
Signs & symptoms – dry mucous membranes, decreased skin turgor (“skin tenting”), dry mouth,
tongue fissures, parched/cracked lips, depressed fontanels.
Nursing process – chest diameter
o Chest diameters:
AP < transverse diameter (normal chest)
AP = transverse diameter (barrel chest)
An infant will have an AP = transverse diameter but this is normal
Barrel chest is a common thing seen in elderly adults ( due to a regular increased AP
diameter or due to decreased lung elasticity, causing the entrapment of air; and/or b/c of
respiratory disease such as COPD, emphysema, etc.)
o A markedly sunken sternum and adjacent cartilage is called Pectus Excavatum (aka: funnel chest)
o A forward protrusion of the sternum, with ribs sloping back at either side and vertical depressions
along costochondral junctions is called Pectus Carinatum
Nursing process – strep pharyngitis
o Group A streptococcal pharyngitis (aka: GAS pharyngitis)
, Signs & symptoms: fever over 100.4oF, absence of cough, tonsillar exudates, and cervical
adenopathy
Confirmed with a strep culture or a rapid antigen test
Untreated GAS pharyngitis can cause peritonsillar abscess, lymphadenitis, or acute rheumatic
fever
Geriatrics – skin – assessment – GERI (p.199)
o Get a history of skin changes or disease from the patient, if they state that they have any. ( eczema,
psoriasis, hives, pigment change, mole change, excessive dryness/moisture, excessive bruising, or any
rashes/lesions)
o The aging process slowly atrophies the skin.
Loses elasticity causing it to fold and sag
By age 70, skin looks parchment thin, lax, dry, and wrinkled
Epidermis flattens ( allows for chemicals to be absorbed more readily)
Dermis thins ( this is what causes wrinkles)
Loss of collagen ( increases risk for shearing/tearing injuries)
Sweat/sebaceous glands decrease in number ( causing dry skin)
Vascularity diminishes and vascular fragility increases (minor trauma will cause dark red
discolored areas called senile purpura)
o Sun exposure and cigarette smoking further accentuate aging changes in the skin.
Coarse wrinkling, decreased elasticity, atrophy, speckled and uneven coloring, more pigment
changes, and a yellowed, leathery texture occur.
o Aging adults are at risk for skin disease and breakdown due to:
Decreased vascularity with increased vascular fragility
Skin thinning
Nutrient decrease/fluid decrease
Loss of subcutaneous layer ( “protective layer”)
Lifetime of environmental trauma
Increased sedentary lifestyle/chance of immobility
When skin breakdown does occur, cell replacement is slower ( so wound healing is delayed)
o Aging in the skin can have a profound psychological impact; sagging and wrinkling skin can prompt
a loss of self-esteem for many adults.
o Asks/Rationale
Ask about any past skin disease, family history of skin disease, or an allergies/allergic skin
problems.
Ask about birthmarks, piercings, and tattoos.
Has there been a change in color/pigmentation?
Any changes in a mole?
Excessive dryness or moisture?
Seborrhea (oily)
Xerosis (dry)
Pruritus?
Where is it and when did it start?
Excessive bruising? Any rash or lesions?
Which medications are you taking?
Prescribed? OTC?
Any environmental or occupational hazards for your skin?
Questions specific for aging adults include:
Which changes have you noticed in your skin in the past few years? ( assess impact aging
is having on self-esteem)
Any delayed wound healing?
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