NUR 3306
CBE notes
(charting by exception): outside normal limits, assessment data require additional documentation
Tuning Fork
-Conductive versus sensorineural hearing loss -Neuromuscular vibration sense
Very top of the lung field
Apex
What are three signs of a DVT?
Pain Edema Erythema
Latex allergy
Prevention: avoid contact when possible
Hypertension
diabetes, and hyperlipidemia are cardiovascular risk factors with strong genetic components.
Dyspena
difficulty breathing
Pallor
paleness
Essential
prompt reporting, recording of patient assessment data
Tachypena
rapid breathing
Acute pain
signals tissue damage
Jaundice
yellowing of the skin
List the scale for edema and how you would classify edema in each.
+1: Slight pitting, 2-mm depression +2: Increased pitting, 4-mm depression +3: Deeper pitting, 6-mm depression; obvious edema of extremity +4: Severe pitting, 8-mm depression; extremity appears very edematous
Active Listening
-Ability to focus on patients and their perspectives -Talking about difficult feelings helps patients to heal -Redirect interview if a patient's anger cannot be diffused
Working phase
-Closed-ended or direct questions: specific information -Open-ended questions: broad answers in patient's own words; avoid "why" questions
outter most layer of skin
epidermis
A well-defined, usually single, nontender, firm or rubbery, round or lobular mass that is freelymovable is called a
fibroadenoma
If untreated _____ may progress and result in irreversible tissue enlargement.
fibrosis
Where would you locate the point of maximal impulse
found at the intersection of the 5 ICS mitral area andthe left MCL in the mitral area.
The depth of a burn can be superficial, superficial-dermal, dermal, or ______ thickness
full
when one or both male breasts temporarily enlarge as a result of changinghormone levels
gynecomastia
Which formula will the nurse use to calculate cardiac output?
heart rate x stroke volume
A client comes to the clinic reporting pain in her legs while walking. the client states the pain is goes away when resting. The nurse suspects the client is experiencing what?
intermittent claudication
Beginning phase
introduction; state purpose for interview
Cardiac arrhythmia
is one cause of reducedcardiac output. It is a medical diagnosis that reducescontractility, causing preload to increase.
Confidentiality
keeping patient's health information private
PIE notes
problem, intervention, evaluation
A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
Inspect the area
Effective interviewing skills
Learned via practice, repetition
A temperature above 38.5°C in adults requires immediate assessment and rapid cooling measures.
-False -Rationale: Fever above 39.5°C (103°F) in adults requires immediate assessment and rapid cooling measures. Monitor rectal temperature constantly during cooling measures to prevent a hypothermic response.
Nontherapeutic Responses
-False reassurance -Sympathy -Unwanted advice -Biased questions -Changes of subject -Distractions -Technical or overwhelming language -Interrupting
Speech patterns
-Moderate pace and volume; clear articulation -Modify for those with hearing problems
Reflex hammer
-Neurological responses of deep tendons
Central nervous system entrance
-Opening or closing the "gate": impulses, substances -Lateral spinothalamic tracts à limbic system
Standard precautions
-Purpose: prevent disease transmission during contact with nonintact skin, mucous membranes, body substances, and bloodborne contacts -Respiratory hygiene/cough etiquette strategies
Four steps in nociception
-Transduction -Transmission -Perception -Modulation
Peripheral nervous system
-Two main types of nerve fibers A-delta; C fibers
Closing phase
-summarizing, stating most important two to three problems or patterns -Report any information that is required by law
Pulse Scale
0 absent +1 weak +2 normal +3 increased, full +4 Bounding
What is the normal ankle-brachial index (ABI) range?
1-1.40
What seven signs/symptoms require further investigation to rule out cancer?
1. new lump 2. skin irritation/dimpling 3. swelling on all of the breast or a part of it 4. breast or nipple pain 5. nipple retraction 6. nipple discharge 7. redness, scaliness, thickening of the breast skin or nipple
What are the 6 categories of the Braden Scale?
1. sensory perception 2. moisture 3. activity 4. mobility 5. nutrition 6. friction/shear
he nurse should have the patient sit/stand in five different positions when inspecting breasts. Whatare these five positions?
1. sitting with arms by breast 2. sitting with arms over the head 3. arms are pressed firmly on the hips 4. leaning forward over waist 5. lying in the supine position
is the AP to transverse ratio in patients with a barrel chest
1.1
is normalAP to transverse ratio.
1.2
While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6-mm depression. How would the nurse document this?
3+ pitting edema
The point of maximum impulse is most often found where?
5th intercostal space (ICS), left midclavicular line (MCL)
What are the ABCDEs for assessing of Melanoma?
A - asymmetry B - border C - color D - diameter E - evolution
What is the A in ISBARR?
Assessment Assessment (of the situation and background) • I think the problem/reason for the patient's condition is related to (respiration, circulation, neurology). • I don't know what the problem is but the patient's condition has deteriorated. • The patient is unstable, we need to do something. • I am concerned.
Stridor
A high-pitched crowing sound from theupper airway; results from tracheal orlaryngeal spasm or constriction. Can indicatean emergency
A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern?
A recently retracted nipple that was previously everted
Murmur
Abnormal heart sound that mayresult from intrinsiccardiovascular disease orcirculatory disturbance. Usuallyindicates disease of the heartvalves, either from stenosis orregurgitation.
re abnormal breath sounds, such as crackles, wheezes, or rhonchi
Adventitious
Cardiac Output
Amount of blood ejected fromthe left ventricle each minute
Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known at what?
Angina
re abnormal heart rhythms withearly (premature), delayed, or irregular beats.
Arrhythmia
Palpation is the assessment of the patient through touch. What is light palpation appropriate for?
Assessment of inflamed areas of skin
What is the B in ISBARR?
Background If it's urgent and/or you are concerned - speak up. Brief and relevant case history • Admission diagnosis and date • Previous illnesses of significance • Relevant problems and treatment/interventions to date • Allergies
refers to the very bottom of the lung fields;
Base
Popliteal
Best palpated with your fingers braced on the knee, curling your hands around the back of the knee and pressing against the lower edge of the femur. Might be felt immediately lateral to the medial tendon. Often difficult to locate.
A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?
Braden scale
Heart Rate X Stroke Volume=
Cardiac output
Therapeutic communication
Caring and empathy
Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?
Chronic obstructive pulmonary disease
What techniques can be performed when palpating the breasts? Select all that apply.
Circular pattern Wedge pattern Vertical pattern
Gallop
Common name for the extraheart sounds S3 and S4
Communication Process
Complex, ongoing, interactive
Rhonchi
Continuous, low-pitched, snoring soundsresulting from secretions moving around inairways. May clear with coughing. Associatedwith pneumonia
Systole
Contraction of the Ventricles
Hemoptysis
Coughing up frank blood
The serum ______ is assessed in the patient with a possible DVT.
D-Dimer
A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what?
Deep vein thrombosis (DVT)
Flushing, erythema
Dependent redness
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis
Chronic venous insufficiency, deep vein thrombosis, and lymphedema result in
Edema
Verbal Communication Skills
Effective interviewing skills Learned via practice, repetition
Otoscope
Enables visualization of ear canal, tympanic membrane
One extremity cooler than the other indicates venous insufficiency.
False
The Health Insurance Portability and Accountability Act mandates accuracy and completeness of medical records.
False
The only trigger for breathing is increased carbon dioxide in theblood
False
The therapeutic communication strategy of reflection is when the nurse restates content of the communication to the patient. Its purpose is to encourage the patient to elaborate.
False
__ Skin changes related to aging include melasma, lineanigra, increased sebaceous and cutaneous gland function, and hair loss.
False
e right lung has two lobes, whereas the left lung has three.
False
Brachial
Found approximately at the inner third of the antecubital fossa when the palm is held upward.
Dorsalis Pedis
Found approximately halfway up the foot immediately lateral to the extensor tendon of the great toe.
Femoral
Found halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament.
Posterior Tibial
Found in the groove between the medial malleolus and achilles tendon.
Radial
Found on the thumb side of the forearm at the wrist.
Cyanosis (Lung)
Gray or blue skin color due to lack of oxygen
Fine crackles
High-pitched, soft, brief sounds that can besimulated by rolling a strand of hair near theear. Associated with heart failure, asthma, orCOPD.
Stroke Volume
How much blood is ejected witheach beat or stroke
What is the I of ISBARR
Identify -Who are you? • Where are you? • Patient's name, age, gender and department
What is intermittent claudication?
Leg pain that is brought on by exercise and relieved by rest. It is characteristic of peripheral artery occlusion/ arterial insufficiency. It is dull or cramp like and consistently occurs in the same area of the leg and with same amount of distance.
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
Listen to the lungs starting in the apices.
Coarse Crackles
Low-pitched, moist, longer sounds similarto Velcro slowly being separated. Associatedwith respiratory edema, COPD, and respiratoryfibrosis
The heart and great vessels are located in the _______ between the lungs and above the diaphragm from the center to the left of the thorax
Mediastinum
A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?
Melanoma
s the beginning of menstruation and occurs during late puberty or Tannerstage 3 or 4
Menarche
Skin Reactions
Minimize hand eczema via alcohol-based hand rubs
Speech patterns
Moderate pace and volume; clear articulation Modify for those with hearing problems
False
Monthly assessment of the feet is essential for patients with PAD.
Pain
Most common reason people seek professional help Can occur at any time to anyone Pain profoundly affects -Quality of life -Family/friend interactions -Sense of well-being, self-esteem -Financial resources
Chronic pain
No known cause or treatment Approximately 40% of the U.S. adults experience daily
-What is the prevalence of obesity among men in the United States?
No significant variation by race/ethnicity.
bronchovesicular breath sounds
Normal breath sound, heard at larynx andtrachea, inspiration less than expiration
Vesicular
Normal breath sound, heard over most ofthe lung fields, Inspiration greater thanexpiration.
OPQRST
O: Onset P: Provocative or palliative Q: Quality R: Region, radiation S: Severity T: Timing
The nurse is caring for a client with a sudden onset of chest pain. Which assessment is highest priority?
Obtain pulse and blood pressure
OLDCARTS
Onset Location Duration Characteristics Aggravating and Alleviating Factors Related Symptoms Treatment Severity
peripheral artery disease (PAD)
Pain is relieved when extremity is in the dependent position Claudication is often seen Extremity normal in size or with apparent atrophy Ulcer borders are irregular
The nurse manager on a cardia unit should immediately intervene when observing which staff's nurse technique?
Palpating carotid pulses simultaneously.
What pulse is located in the groove between the medial malleolus and the Achilles tendon?
Posterior tibial
___ S1, or "lub," the beginning of systole, resultsfrom closure of the aortic and pulmonic valves, and S2, or"dub," the end of systole and beginning of diastole, resultsfrom closure of the mitral and tricuspid valves.
True
idclavicular line runs vertically down the center of the sternum
True
The parts of the heart that pump blood to the lungs and out tothe body are called
Pulmonary artery
A blood clot that travels from the legs to the lungs is called a
Pulmonary embolism
What is the most important lifestyle changes a client can make to improve cardiovascular health?
Quit smoking
Last R in ISBARR
READ BACK
What is the R in ISBARR?
Recommendation Request specific advice and interventions, and clarify expectations • I suggest.../What interventions do you recommend? o Immediate intervention o Investigation/treatment • How often should I. • When should I next make contact? When will you be here? • Confirm messages and interventions with a closed loop
The older adult has _____ skin texture and prolonged time for ______ healing, and thermoregulation changes increase the risk forhypothermia and hyperthermia
Rougher, wound
what is the S in ISBARR?
Situation What is the problem/reason for contact? • I'm calling because... (describe) • I have observed major changes... (ABCDE) • I have measured the following values.. (RR*, SpO24, pulse/heart rhythm, BP^, capillary refill time, tp.#) • | have received test results...
A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump?
Size
is considered the leading cause of preventable death.
Smoking
When learning about peripheral vascular disease, the nursing student would learn that signs and symptoms of a DVT require immediate
Start of anticoagulants
Complex regional pain syndrome (CRPS)
Surgery, crush-type injury
A nurse notes a bruit when auscultating over the right carotid artery. The nurse determines the abnormal sound is a bruit because a _________ sound is heard.
Swishing
Bruits
Swishing auscultatory sound thatindicates turbulent blood flow ornarrowing from constriction ordilation of a tortuous vessel
An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment?
Tenting indicates dehydration
The sternal angle at the right 2nd rib space is also known as what?
The aortic area
False
The more distal a vein is, the lower the number of valves, because the pull of gravity is stronger.
n an emergency respiratory situation, it is important to stay with and calmthe patient to reduce anxiety.
True
ngs should be auscultated from the base to the apex.
True
The nurse is preparing a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lung?
The right lobe has three and the left has two
What is the term used to describe the area where the apicalpulsation can be seen or palpated?
The term is referred to as the point of maximal impulse.
The nurse assessing a clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer?
The ulcer is necrotic
The _______ contains the heart, lungs, thymus, distal part of the trachea, and most ofthe esophagus.
Thoracic Cavity
A client in the ED tells a nurse that she feels short of breath. The nurse would document this finding as dyspnea.
True
A wound is assessed for location, size, color, texture,drainage, wound margins, surrounding skin, and healing status.
True
Arterioles have more smooth muscle, and it is here that blood pressure is controlled
True
Arteriosclerosis is seen more in older adult
True
Assessment of a client's bowel sounds is best obtained by performing auscultation?
True
Beasts often feel full, sore, or heavy just prior to menstruation and are smallest and leasttender in the days following menstruation
True
Breast cancer is the leading cause of cancer in females
True
Maintaining fluid balance is one function of the lymphatic system.
True
Nurses assess ability to perform self-care activities, also called activities of daily living.
True
S1 results from closure of the mitral and tricuspid valves
True
The coronary veins may developatherosclerotic plaques that narrow them, leading to amyocardial infarction (heart attack) or angina.
True
The most common breast concerns that cause women to seek medical evaluation are anewly discovered lump, pain, and nipple discharge
True
The most common clinical interpretation of pain transmission is nociception.
True
The nurse should recognize that the presence of a wheeze can result from air passing through constricted passageways.
True
The pulmonary artery carries deoxygenatedblood to the lungs, whereas the pulmonary vein deliversoxygenated blood to the left atrium.
True
Venous insufficiency may result in dilated and tortuous veins.
True
The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate?
Use the flat pads of three fingers.
Aortic Valve
Valve that lies between the leftventricle and aorta.
Pulmonic Valve
Valve that lies between the rightventricle and pulmonary artery
mitral valve
Valve that separates the leftatrium and left ventricle
Tricuspid Valve
Valve that separates the rightatrium and right ventricle
During the assessment, the nurse identifies warm thick skin that is swollen and reddish-blue. The nurse also notes an ulcer at the ankle that The client describes pain at the ulcer site as achy. The nurse suspects the client may have what?
Venous insufficiency
Diastole
Ventricular relaxation
Ophthalmoscope
Visualizes interior eye structures
Preload
Volume in the right atrium at theend of diastole
Continuous, high-pitched, musical soundscaused by air squeezing through narrowedairways. Associated with Emphysema, asthma,and bronchitis
Wheeze
-In what phase of the interview are open-ended questions used?
Working
Neuropathic pain
a more constant stimulus
Visceral pain
abdominal organs; "crampy, gnawing"
Atelectasis
airway collapse
The cells in the SA node are unique because they possess
automaticity
Cyanosis
bluish discoloration of the skin
Neuronal windup
can cause hypersensitivity in areas not usually identified as painful
Palpation
clinical touching of specific body areas to assess characteristics
An angle of 180 degrees or more is called ____ of the finger which indicates chronic hypoxia
clubbing
When assessing the lower extremities, it is critical that the examiner
compares side to side
Preinteraction phase
compiling existing data; preparing for patient interview from existing medical records
What characteristic nail color should the nurse recognize as an indication of hypoxia?
cyanotic
Brawny
dark leathery appearance
DAR notes
data, action, response
second layer of skin
dermis
If a patient is experiencing chest pain, dyspnea, cyanosis,diaphoresis, or dizziness, focus assessment on data to _______ he discomfort whilesimultaneously providing treatments.
effectiveness of interventions
A 62 year old client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible
myocardial infaction
Neuronal plasticity
nervous system modification in pain transmission. may cause increased pain servity
Inspection:
observing patient visually for general appearance or specific details
The six Ps of arterial occlusion include
paralysis Pallor poikilothermia Pulselessness Pain Paresthesia
Central sensitization
persisting pain "remembered" by spinal nerves after peripheral stimulation ceases
Rubor
reddish-blue discoloration of the extremities; indicative of severe peripheral arterial damage in vessels that remain dilated and unable to constrict
Biot's
respiration pattern is a regular irregular rhythm that cycles from deep and fast to shallow and slow with some periods of apnea
Cheyene-Strokes
respiration pattern is usually seen in patients at end of life.
Peripheral sensitization
result of inflammatory process -non painful touch/pressure becomes painful
Skin_____-examination assists patients to identify problematic lesions.
self
Orthopena
shortness of breath while lying flat; classic sign of heart failure
Cutaneous pain
skin layers; "burning," "sharp"
Referred pain
specific site, felt at different location Cardiac pain; phantom pain
Innermost layer of skin
subcutaneous
What are soap notes?
subjective, objective, assessment, plan
Percussion
tapping technique with hands to determine condition of solid or air-filled body areas
manual compression test
testing for valves that are incompetent, have the patient stand still place one hand on the lower part of the varicose vein and another hand and 20 cm higher..if you feel a wave that means there are incompetent valves
Hand hygiene
the most important technique used in preventing and controlling transmission of infection
Somatic pain
tissue, bones/joints; "sharp"
Auscultation
using a stethoscope to assessment movement of air or fluid within specific body systems
