NR 302 Health Assessment 1 Exam 2 Study Guide, Study Guides, Projects, Research of Nursing

Download NR 302 Health Assessment 1 Exam 2 Study Guide and more Study Guides, Projects, Research Nursing in PDF only on Docsity! NR 302 Health Assessment 1 Exam 2 Study Guide Chapter 12: Skin, Hair, and Nails 1. Structure of Skin a. Know levels where burns & pressure ulcers take place 2. Structure of Nails a. Focus on color of nail bed to determine if good circulation i. Warm? Pink? Cyanotic? Pale? ii. Capillary refill is brisk; less than 2 seconds 3. Developmental Competence a. Newborns i. Lanugo = fine downy hair (replaced with fine vellus hair a few months after birth) ii. Vernix = thick, cheesy substance (made up of sebum & shed epithelial cells) iii. Sebum = water in skin producing milia (a common variation; white papules on the cheeks & forehead & across the nose & chin; caused by sebum that occludes the opening of the follicles); holds water in the skin; present first few weeks of life; produces cradle cap in some babies b. Pregnant Women i. Linea nigra = increased pigmentation midline of abdomen ii. Chloasma = discoloration in the face; “mask of pregnancy”; a blotchy, hyperpigmented area over cheeks & forehead that fades after delivery iii. Striae gravidarum = stretch marks (abdomen, breast & thighs) c. Aging Adult i. Loss of skin elasticity ii. Decrease in sweat & sebaceous glands leaving skin dry iii. Wound healing is delayed iv. Melanocytes decrease (gray fine hair) v. Bruise easier 4. Inspection & Palpation of Skin, Hair & Nails a. Color = pink, pale, cyanotic (blue), jaundice (yellow) i. Color change best seen in palms, nail beds, around mouth & in the mouth b. Turgor = c. Lesions = ALWAYS WEAR GLOVES i. Note color, elevation, pattern, size, location, exudate ii. Classified by shape & formation = Annular/Circular, Confluent, Discrete, Gyrate, Grouped, Linear, Target, Zosteriform & Polycyclic iii. Primary Skin Lesions = Macules, Papules, Patches, Plaques, Nodules, Wheals, Tumors, Urticaria (hives), Vesicles, Cysts, Bullas & Pustules iv. Secondary Skin Lesions *PAY ATTENTION TO DIFFERENCES* 1. Debris on skin = Crust & Scale 2. Break in Continuity of skin surface = Fissure, Erosion, Ulcer, Exocoriations, Scars, Atrophic Scars, Lichenifications & Keloids (excessive scar tissue; common in African Americans, Hispanics & Asians) 3. Vascular Lesions = Heamangiomas, Telangiectases, Purpuric Lesions & Lesions caused by trauma or abuse v. Common Skin Lesions in Children = Diaper dermatitis, Intertrigo (candidiasis), Impetigo, Atopic dermatitis (eczema), measles (rubeola), German measles (rubella) & chickenpox (varicella) vi. Vascular Lesions 1. Petechiae = tiny punctate hemorrhages, 1-3 mm, round & discrete; dark red, purple, or brown; caused by bleeding in superficial capillaries; will not blanch 2. Ecchymosis = a purplish patch resulting from extravasation of blood into the skin, >3 mm in diameter 3. Purpura = confluent & extensive patch of petechiae & ecchymoses; >3 mm, flat, red to purple, macular hemorrhage d. Hair = note color, texture, distribution & lesions e. Nails = note shape & contour, consistency, color & capillary refill f. ABCDE Skin Assessment i. Asymmetry ii. Border iii. Color iv. Diameter v. Elevation & Enlargement Chapter 13: Head, Face, and Neck, including Regional Lymphatics 1. Thyroid gland = an important endocrine gland that synthesizes & secretes thyroxine (T4) & triiodothyronine (T3); supports the immune system 2. Lymphatic system = an extensive vessel system, is a major part of the immune system, which detects & eliminates foreign substances from the body; nodes are small, oval clusters of lymphatic tissue that filter lymph & engulf pathogens, preventing potential harmful substances from entering the circulation a. Lymphadenopathy = enlargement >1 cm from infection, allergy, or neoplasm i. Lymph Nodes = 3. Graves Disease (Hyperthyroidism) = increased production of thyroid hormones causes an increased metabolic rate a. Symptoms = nervousness, fatigue, weight loss, muscle cramps, & heat intolerance b. Signs = forceful tachycardia, shortness of breath, excessive sweating, fine muscle tremor, thin silky hair, warm moist skin, infrequent blinking, & a staring appearance 4. Facial Asymmetry = a. Bells Palsy = a lower motor neuron lesion (peripheral), producing rapid onset of cranial nerve 7. Developmental Competence a. Children = eustachian tube is more horizontal so they are more prone to ear infections; Otitis Media (OM) = obstruction of the eustachian tube or passage of nasopharyngeal secretions into the middle ear; it is important to catch any hearing problems early because it is needed for developing speech & communication b. Adults = Otosclerosis (bone hardening); common cause of conductive hearing loss; gradual hardening that causes foot plate of stapes to become fixed in oval window, impeding transmission of sound & causing progressive deafness c. Aging Adults = i. Cilia lining the ear canal become coarse & stiff; can cause cerumen to accumulate & oxidize ii. Presbycusis = type of hearing loss that occurs with aging, even in people living in a quiet environment 8. Inspect with Otoscope a. Children = pull pinna down & back b. Adults = pull pinna up & back 9. Tympanic Membrane = normal is shiny & translucent with a pearl-gray color; cone-shaped light reflex prominent in anteroinferior quadrant, a reflection of the otoscope light; sections of the malleus are visible through the translucent drum (umbo, manubrium, & short process); at periphery annulus looks whiter & dense 10. Hearing Tests a. Whispered voice test = test one ear at a time while masking hearing in the other ear b. Romberg test = assesses ability of vestibular apparatus in inner ear to help maintain standing balance; also assesses intactness of cerebellum & proprioception as it is part of the neurologic system 11. Abnormalities Chapter 16: Nose, Mouth, and Throat 1. Nose functions = warms, moistens, & filters air; olfactory nerve = smell; cilia filter out dust & bacteria; divide in 2 by septum (shouldn’t see a deviation) 2. Developmental Competence a. Pregnant Women = nasal stuffiness & epistaxis may occur as a result of increased vascularity in the upper respiratory tract; gums may be hyperemic & softened & may bleed with normal toothbrushing b. Aging Adult = gradual loss of subcutaneous fat (may make the nose appear more prominent in some people); atrophic issues ulcerate easily, increasing risk for infections; natural tooth loss exacerbated by inadequate oral hygiene; diminished sense of taste & smell decreases interest in food & may contribute to malnutrition 3. Culture & Genetics a. Bifid uvula = a condition in which the uvulas split either completely or partially; occurs in 10% of American Indian Groups b. Cleft lip & palate = most common in Asians, intermediate in whites & least common in African Americans c. Torus palatinus = a bony ridge running in the middle of the hard palate d. African Americans have dark line along gingival margin e. Leukoedema = a benign lesion occurring on the buccal mucosa; more common in African Americans 4. Abnormalities Chapter 18: Thorax and Lungs 1. Dyspnea = a subjective feeling of discomfort that occurs when a person feels unable to inhale enough air 2. Cyanosis = the bluish coloring of the skin and mucus membranes that results from large amounts of unoxygenated hemoglobin in the blood 3. Gas exchange a. Oxygen diffuses into the blood through the alveoli b. Flow of gases between the alveolar air & blood c. Depends on the3 relative concentrations (partial pressures) of the gases (PO2 & PCO2) d. Dalton’s law = each gas moves along its partial pressure gradient, independent of other gases 4. Arterial blood gas levels a. Know the values: i. Oxygen = ii. Carbone dioxide = normal is 35-45 iii. Bicarbonate = normal is 24 iv. Serum pH = acidosis is less than 7.35, normal is 7.36-7.44, & alkalosis is greater than 7.45 b. Hypoxemia = inadequate oxygen in blood; decrease from ~105 to 60 mm Hg; chemoreceptors respond c. Hypoxia = inadequate supply of oxygen to the cells; cyanosis d. Hypercapnia = increased carbon dioxide in the blood; CO2 easily diffuses into Cerebrospinal fluid (CSF); causes respiratory acidosis e. Hypocapnia = low carbon dioxide concentration (low partial pressure of CO2) in blood; may be caused by hyperventilation; causes respiratory alkalosis 5. Anterior Lobes = tops go a little above clavicle; left is narrower because of the heart; right is shorter because of the liver; right has 3 lobes and left has 2 lobes 6. Posterior Lobes = only 2 lobes visible on both sides; deep inspiration expands lungs & their lower border drops to T12 7. Reference Lines a. Anterior i. Midsternal line = ii. Midclavicular line = bisects center of each clavicle at a point halfway between palpated sternoclavicular and acromioclavicular joints iii. Anterior axillary line = extends down from anterior axillary fold where pectoralis major muscle inserts b. Side i. Anterior axillary line = extends down from anterior axillary fold where pectoralis major muscle inserts ii. Posterior Axillary line = continues down from posterior axillary fold where latissimus dorsi muscle inserts iii. Midaxillary line = c. Posterior i. Scapular line = extends through inferior angle of scapula when arms are at sides of body ii. Vertebral line = mid-spinal line 8. Pneumothorax = air in lungs a. Patients with cancer (branchiogenic carcinoma) b. Happens because of tumor, blood in lungs, pleural effusion i. Eats through lungs = air can get through ii. Will not hear air entry c. Hemothorax = blood in thoracic space 9. Pleural Effusion = the presence of excessive fluid in the pleural cavity a. Dull sound because of liquid; diminished 10. Developmental Competence a. Pregnant Women = enlarging uterus elevates diaphragm 4 cm during pregnancy = decreases vertical diameter of thoracic cage; growing fetus increases oxygen demand on mother’s body 19. Auscultation a. Side-to-side comparison b. Use diaphragm of stethoscope c. Locations i. Bronchial ii. Bronchovesicular iii. Vesicular d. Decreased or Absent Breath Sounds i. Bronchial obstruction = secretions, mucous, foreign body ii. Decreased elasticity = hyperinflation, emphysema iii. Air or fluid in the pleural space iv. Silent chest = no air movement, ominous e. Adventitious sounds i. Discontinuous 1. Crackles = popping sounds with inspiration (rice crispies); fine & coarse 2. Atelectatic crackles 3. Pleural friction rub ii. Continuous 1. Wheezes = musical heard mostly during expiration (narrowing); sibilant & sonorous rhonchi 2. Stridor f. Voice Sounds i. Bronchophony = ask patient to say “99”; should be muffled & non-distinct ii. Egophony = “eeee” should sound normal; if a lot of mucous (consolidation) it will sound like “aaaaa” iii. Whispered pectoriloquy = whisper “123”; normal = faint & muffled g. Respiratory rate < 24 h. Bradypnea < 10 i. Abnormal Findings: Configurations of the Thorax i. Barrel Chest = AP-to-T ratio is 1:1; COPD ii. Pectus Excavatum = caved in iii. Pectus Carinatum = protruding out iv. Scoliosis = spine is not straight; S-curved v. Kyphosis = hunched back; older adults 20. Atelectasis = the non-aeration or collapse of a lung or part of a lung leading to a decreased gas exchange & hypoxia a. A collapsed lung; marked by airway obstruction (also may be a cause) b. Sound of lung is decreased on that side & the chest doesn’t rise on that side c. S&S = small areas are asymptomatic; large areas cause dyspnea, increased heart & respiratory rates, & chest pain d. Treatment = treat the cause & re-expand the collapsed lung; deep breathing exercises, changing body positions, forced coughing; removal of fluid, tissue or tumor; chest clapping or percussion, postural drainage, & medications to open airways & loosen mucus