NUR 3306

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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


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