NURS final

signs and symptoms: Melanoma

-Asymmetry

-Border irregularity

-Color variation

-Diameter >6mm

-Elevation and enlargement

Measuring wounds

Involves assessing length, width, and depth and assessing for any undermining or tunneling to determine appropriate treatment.

Braden risk assessment tool criteria and pressure injury prevention interventions

1. Sensory Preception

2. Moisture

3. activity

4. mobility

5. nutrition

6. friction and shear

   -Lower scores indicate higher risk for pressure injuries (1-4 for each)

Pressure injury prevention interventions:

-repositioning:every two hours

-skin care: Keeping skin clean and dry

-Nutrition

-Hydration

-Mobility

-Assessment

Developmental considerations of the integumentary system

Infants and children: Skin is thinner and more sensitive than adults. They have a higher risk of dehyrdration and more susceptible to irritants.

Adolescents: During puberty, there is more oil production and sweat gland activity

Adults: Skin gradually is losing collagen and elasticity.

Elderly: Skin is thinner, drier, and less elastic, making it more prone to injury and slower to heal.

Assessing coordination

1. Observation

2. Finger-to-nose test

3. Heel-to-shin test

4. rapid alternating movements

5. balance tests

6. gait assessment: Analyze the person’s walking pattern

Assessing level of consciousness and the Glasgow coma scale (Scoring)

Glasgow Coma Scale: most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury. Eyes, motor, and verbal. 13-15 is mild, 9-12 is moderate, and less than 8 is severe.

s/sx dehyrdation

1. Thirst

2. Dry mouth and skin

3. Dark yellow urine

4. fatigue

5. dizziness

6. rapid heartbeat

7. headache

8. confusion or irritability

Unexpected colors of and types of vomitus and stool

1. Green or yellow vomit: Can indicate bile which may occur when vomiting is severe or prolonged

2. Red or bloody: Bleeding in upper gastrointestinal tract

3. Brown or coffee ground vomit: Old blood, often from the stomach or upper intestines

4. Foul-smelling vomit: Gastrointestinal obstruction or infection

   1. Black or tarry stool: Can indicate bleeding in the upper gastrointestinal tract, associated with ulcers or more severe conditions

   2. Red Stool: Bleeding in lower gastrointestinal tract, like hemorrhoids.

   3. Pale or clay colored stool: Lack of bile from liver disease or bile duct obstruction

   4. Green stool: Result from rapid transmit through intestines or green dyes.

Abdominal emergency assessments

-Do not palpate in emergency situations

Inspection: Look for visible abnormalities.

Percussion: Tap on the abdomen to check for fluid, gas, or masses

Auscultation: Listen for bowel sounds for activity levels

Vital signs: Abnormal vital signs can indicate shock or infection

Abdominal emergency interventions

-Planned Patient goals

-Devices for collecting and measuring urine (catheters, ileal conduit, promoting normal urination, dialysis).

Physiology of the colon and how it relates to diarrhea and constipation

it absorbs water and electrolytes from indigestible food matter, forming and storing feces, and facilitating the elimination of waste.

Diarrhea: Occurs when the colon does not absorb enough water from the stool. It can be caused by infections, certain medications, or dietary factors. When the colon is inflamed, it may lead to increased watery stool. The rapid transmit time through the colon does not allow sufficient absorption, leading to diarrhea.

Constipation: Occurs when the colon absorbs too much water from the stool, making it harder and difficult to pass. Slow motility to the colon can lead to prolonged retention of the stool, which can become compacted.

Auscultation of and documentation of the abdominal assessment

Auscultation of the abdomen

-Patient laying in supine position

RLQ, RUQ, LUQ, LLQ,

-Listen to each quadrant for one minute

Normal Sounds: Described as high-pitched and gurgling, occurring every 5-15 seconds

Documentation: Presence of or absence of bowel movements in each quadrant, the frequency of the sounds (normal, hypoactive, hyperactive, absent), any additional sounds or observations.

Understand how to choose the correct interventions based on the nursing diagnosis

Difference between short-term and long-term outcomes

Short term: immediate effects of an intervention or treatment, typically assessed within a few days or weeks. Focus on the initial changes of a patient’s condition, such as symptom relief.

Long term outcomes: Effects of a treatment that are evaluated over a longer period, months to years. Consider overall success of the treatment in terms of sustained health improvements, quality of life, and prevention of complications.

Phases of the nursing process and how to apply them

1. Assessment: Nurse collects comprehensive data about the patient’s health status.

2. Diagnosis: Nurse analyzes data to identify patient problems and needs.

3. Planning: Nurse develops a care plan that outlines specific goals and interventions to address the problem.

4. Implementation: Putting care plan into action

5. Evaluation: Assesses the effectiveness of the nursing interventions and the patient’s progress toward the established goals.

Subjective and objective data

Subjective data: Information that the patient provides on their own experiences.

Objective data: Measurable and observable information collected by the nurse through a physical examination.

Priority frameworks (ABC’s, Maslow’s, acute vs. chronic)

ABC’s: Ensuring airway is clear, breathing is adequate, circulation is stable, disability, and exposure.

Maslow’’s: Hierarchy of human needs, starting with physiological needs, then safety, then love/belonging, then esteem, and then self-actualization

Acute vs. chronic: Acute conditions, which are severe and sudden in onset, typically take priority over chronic conditions which are long-developing and persistent.

apical pulse

Felt at the apex of the heart, typically located at the fifth intercostal space at the midclavicular line.

What are murmurs and extra heart sounds

Murmurs: Abnormal sounds produced by turbulent blood flow within the heart or blood vessels.

Extra heart sounds:

S3: Often referred to as a ventricular gallop, this sound occurs shortly after S2 and may indicate heart failure or volume overload.

S4: Known as an atrial gallop, occurs before S1 and may suggest decreased ventricular compliance, often seen in conditions like hypertension or left ventricular hypertrophy.

What is a bruit and how is it assessed?

A bruit is an abnormal sound when blood flows through a narrowed or partially obstructed artery. It is a whooshing sound that can indicate atherosclerosis or other vascular abnormalities. To assess for a bruit, the client can be sitting up or lying down, and the nurse will auscultate over the area of interest, such as the carotid arteries in the neck, the abdominal aorta, or the renal arteries. The nurse documents the bruit by including its location, quality, and intensity.

Hospital acquired infections

Infections that patients can get while receiving treatment for medical or surgical conditons in a healthcare setting. Common HAI’s include surgical site infections, catheter-associated urinary tract infections, and pneumonia.

Infection control, PPE, transmission-based precautions and nursing interventions

Infection Control: prevents the spread of infections in a healthcare setting.

PPE: includes items such as gloves, masks, gowns, and eye protection that healthcare workers wear to protect themselves and patients against infections.

Transmission-Based Precautions: Additional infection control measures used for patients known or suspected to be infected with highly transmissible pathogens.

Contact Precautions: Used for infections that are spread through direct contact or indirect contact. This includes wearing gowns and gloves.

Droplet: used for infections spread through respiratory droplets. Masks are required when within a certain distance of a patient.

Airborne: Used for infections that can be transmitted through the air. This requires special air filtration and the use of N95 respirators.

Nursing interventions: Educating patients and families about infection prevention, ensuring proper hand hygiene, monitoring patients for signs of infections and implementing isolation protocols when necessary, and administering vaccines and treatments when needed.

I and O addition (Calculations will be enabled)

Adding all the fluids and juices taken in and the fluids all taken out of the body to determine their overall fluid balance.

Safety and injury risks

1. Falls: For patients with limited mobility or balance issues

2. Pressure ulcers: Immobile patients are at risk due to prolonged pressure

3. Medication Errors: Confusion or lack of awareness can lead to improper medication administering

4. Aspiration: patients with swallowing difficultities are at risk

5. inadequate supervision: Patients who require assistance may be at risk.

Restraint use

Restraints are only necessary when they are needed for safety reasons, whether that is for the patient or for the people surrounding the patient. Normally they are used when other interventions have failed. It might be used to restrain the patient against aggressive behavior or to stop patients from interfering with their medical treatments.

Fall risk and the morse fall risk scale

The Morse Fall Risk Scale includes factors like a history of falling, secondary diagnosis (Having multiple medical conditions), ambulatory aid, IV therapy, gait, and mental status. Each factor is scored, and the total score helps determine the level of fall risk. This assessment helps in planning interventions, prevent falls, like using bed alarms, ensuring proper footwear, and providing assistance with mobility.

Range of motion for joints

Active ROM: Movement of joint performed by the patient themselves without assistance.

Passive range of motion: Involves the movement of a joint by an external force, such as a caregiver.

Assisted range of movement: Combination of PROM and AROM, where the patient actively moves the joint, but assistance is needed to complete the movement.

Types of pain (somatic, neurologic, cancer pain, referred pain)

Somatic Pain: Pain arises from damage to body tissues, such as skin, muscles, and bones. It is usually well-localized and can be sharp or aching.

Neurologic Pain: Results from damage or dysfunction in the nervous system. Can be described as burning, tingling, or shooting pain.

Cancer Pain: Can be caused by the tumor pressing on organs, nerves, or bones, or it may result from cancer treatments like surgery, chemotherapy, or radiation. This pain varies in intensity.

Referred Pain: Felt in a location different than the source of the injury or illness.

Characteristics of pain

1. Location

2. intensity

3. quality: Nature of the pain, sharp, dull, burning, throbbing, aching

4. duration

5. timing

6. aggravating and alleviating factors

signs and symptoms of hypoxia

1. shortness of breath

2. rapid heart rate

3. confusion or disorientation

4. cyanosis

5. fatigue

6. headache

7. nausea or dizziness

stages of hypoxia

1. Mild hypoxia: Body may experience slight symptoms

2. Moderate hypoxia: Symptoms become more pronounced

3. Severe hypoxia: Extreme difficulty of breathing, severe confusion, loss of consciousness, pronounced cyanosis

apex lung assessments

-involves evaluating the uppermost part of the lungs

1. Inspection: Observing the patient’s breathing patterns, any use of accessory muscles, and overall respiratory effort.

2. Palpation: Feeling for any abnormalities in the chest wall, such as tenderness or asymmetry, and assessing for tactile fremitus

3. Percussion: Tapping on the chest to assess the underlying lung issue. Dullness may indicate fluid or consolidation, while hyper resonance may suggest air trapping

4. Auscultation: Listening to lung sounds using a stethoscope. Normal breath sounds should be clear, while abnormal sounds can indicate various respiratory conditions.

Heart auscultation landmarks and what valve of the heart you are assessing at each

1. aortic area: 2nd intercostal space at the right sternal border

2. pulmonic area: 2nd intercostal space at the left sternal border.

3. Erbs point: Third left intercostal space

4. Tricuspid area: Fourth intercostal space at the left sternal border

5. mitral area: fifth intercostal space at the left midclavicular line

Pain scales (numeric, FACES, FLACC, non-verbal pain scale)

Numeric: 0-10 scale

Faces Pain Scale: Scale features a series of faces ranging from happy to sad or crying face. Helps children indicate level of pain

FLACC scale: Face, legs, activity, cry, and consolibility scale, used primarily for infants and non-verbal patients. It assesses pain based on observable behaviors in these 5 categories, assinging a score that reflects the level of pain.

Non-verbal pain scale: Assessing pain in individulas who can’t communicate verbally. it involves observing body language, facial expressions, and physiological reasons to guage pain levels.

Oxygen delivery devices (NC, simple mask, oxymask, non-rebreather)

Nasal cannula: (typically 1-6 liters per minute) two small prongs that fit into the nostrils and is connected to an oxygen source

Simple Mask: (6-10 liters) mask covers the nose and the mouth and delivers oxygen.

Oxymask: Newer type of mask that allows for greater flexibility of oxygen delivery and can deliver varying concentrations of oxygen based on the flow rate.

Non-rebreather mask: This mask has a reservoir bag and one way valves that prevent exhaled air from entering the bag. (10-15 liters per minute)

signs and symptoms of respiratory distress (retraction locations, nasal flaring)

Retractions: Occurs when the skin pulls in around the ribs or the neck during inhalation, indicating the patient is working hard to breathe. Locations: Supraclavicular, intercostal, subcostal (below ribcage)

Nasal flaring: widening of the nostrils during breathing, which often occurs in children and indicates increased effort to take in air.

Emergency vs. stable assessments

1. Emergency assessments: These are conducted when a patient is in a critical condition or experiencing acute distress.

   -rapid evaluation of ABC’s

   -immediate identification of any signs of shock, severe pain, or altered mental status.

   -prioritizing interventions based on the severity of the patient’s condition

2. Stable assessments: Performed on patients who are stable and do not exhibit acute distress. The focus is on monitoring and evaluating ongoing health status.

   -comprehensive history-taking and physical examination.

   -regular monitoring of vital signs and any chronic conditions

   -planning ongoing care and management based on the patient’s stable condition

Healing by primary, secondary, and tertiary intentions

1. Primary intention: Occurs when the edges of a wound are brought together and held in place, usually through sutures, staples, or adhesive. Healing is typically quick, minimal scarring, as the tissue regenerates directly across the wound.

2. secondary intention: Wound edges cannot be easily approximated. The wound heals from the bottom up and the sides in, leading to a larger scar. This process takes longer and may involve the formation of granulation tissue and more significant tissue remodeling.

3. Tertiary intention: Also known as delayed primary closure, this occurs when a wound is left open for a period to allow for drainage or infection control before being closed surgically.

Preventative measures for pressure injuries

Regular repositioning (every two hours)

use of support surfaces

Skin care

nutrition and hydration

patient education

limit friction and shear

interventions to maintain airway and prevent atelectasis

1. Deep breathing exercises

2. incentive spirometry

3. Positioning

4. mobilization

5. chest physiotherapy: Implement techniques like percussion and postural drainage to help clear secretions from the airways

6. Suctioning: Clears any obstructions in the airway

7. Hydration

signs and symptoms inadequate oxygenation

1. shortness of breath

2. increased respiratory rate

3. cyanosis

4. confusion or altered mental status

5. restlessness

6. use of accessory muscles

7. fatigue

Symptoms associated with skin (ie, burning, itching)

1. Burning

2. Rashes

3. Dryness or scaling

4. color changes

5. lesions or scars

6. itching

7. hair loss

Wound staging

Stage 1: Skin is intact but there’s redness that doesn’t go away when you press on it. It might feel warmer or cooler than the surrounding skin.

Stage 2: Part;-thickness loss of skin. It looks like a blister, abrasion, or shallow crater.

Stage 3: Full-thickness skin loss. The wound goes through the dermis and into the subcutaneous tissue, but doesn’t go down to the muscle, bone, or tendons.

Stage 4: Full-thickness skin and tissue loss with exposed bone, muscle, or tendon. Might be slough or eschar present.

Unstageable: The wound is covered with the slough or eschar, so you cannot see how deep it is

Deep tissue injury: Skin might be intact or not, but there is a deep purple or maroon discoloration, indicating damage to underlying tissue.

Wound irrigation purpose and how to perform

Purpose is to clean out any debris or bacteria trapped in wound.

1. Gather supplies: Sterile saline solution, a syringe, a basin, gloves, and gauze

2. Prepare the Area: Wash your hands and put on gloves. Make sure patient is comfortable and wound is accessible.

3. Irrigate the wound: Fill the syringe with saline solution. Hold the syringe about an inch away from the wound and gently squirt the saline over the wound. Make sure the flow is steady and not too forceful to avoid damaging the tissue.

4. Catch the fluid: Use the basin to catch the fluid if it runs off the wound. You can also use guaze to gently blot the area dry.

5. Repeat if necessary: Might need to repeat the irrigation a few times

6. Dress the wound: Once the wound is clean, apply a new, sterile dressing.

signs and symptoms of skin infections

Redness, swelling, pain, warmth, pus or discharge, fever, blisters or sores

Skin lesions to know: Macule, Papule, pustule, patch, plaque, vesicle, bulla

macule: Flat, discolored area on the skin that is usually smaller than 1 cm, like freckles.

papule: Small, raised bump on the skin, typically less than 1 cm, such as a pimple.

Pustule: A small, raised lesion filled with pus, often associated with acne or infections

Patch: Flat area of discoloration larger than 1cm, like a large birthmark

Plaque: Raised, flat topped lesion larger than 1cm, commonly seen in conditions like psoriasis.

Vesicle: Small, fluid-filled blister less than 1cm in size, chickenpox

Bulla: larger, fluid-filled blister greater than 1 cm, often seen in burns or severe skin reactions.

Skin patterns to know: Clustered, discrete, linear, dermatome, diffuse, confluent

Clustered: Lesions appear in geoups, often close together.

Discrete: Separate and distinct from one another, small moles or warts.

Linear: Form a line or streak.

Dermatome: Follow a specific nerve root distribution on the skin, often seen in conditions like shingles

Diffuse: Lesions that are spread out over a large area without a refined border

Confluence: Lesions that merge together to form larger areas of involvement, which can happen in psoriasis.

Testing muscle strength

1. Manual muscle testing: A clinician applies resistance to a muscle while the patient attempts to move it. Strength graded on scale from 0-5

2. Dynametry: Using a handheld device to measure the force exerted by a muscle group.

3. functional tests: Activities like standing up from a seated position, climbing stairs, or walking.

4. Isokinetic testing: Specialized equipment to measure muscle strength at a constant speed

5. Grip strength test: Using hand dynamometer, grip strength is measured, which can indicate overall muscle strength and function.

STI prevention

1. Abstinence

2. Condom use

3. Regular testing

4. Vaccination

5. Mutual monogamy

6. education

Safety associated with inserting a nasogastric tube

1. proper indication: ensure that the NG tube is necessary for the condition

2. patient positioning: Position the patient in an upright or semi-upright to reduce risk of aspiration

3. correct sizing

4. aseptic technique: pre infections during the insertion process

5. verification of placement: After insertion, confirm the correct placement of the tube by checking pH of gastric contents or using other methods like ausculation or imaging.

6. Monitoring

7. Documentation

Purpose of different types of nasogastric tubes

1. Feeding tubes: Deliver nutrition to patients who cannot eat by mouth. They allow for entertal feeding directly into the stomach.

2. Decompression tubes: These tubes help relieve pressure in the stomach or intestines by removing excess gas or fluid. This is often used in cases of bowel obstruction

3. Medication administering tubes: Designed for administering medications directly into the stomach, especially for patients who cannot swallow pills.

4. Suction tubes: Suction out stomach contents, which can be helpful in cases of g. i. bleeding or to clear the stomach before surgery

5. Diagnostic tubes: These are used to collect gastric contents for analysis, which can help diagnose conditions related to the digestive system

Know what intermittent claudication is and what to teach patients about it

Intermittent claudication is a condition when you experience pain or cramping in your legs during exercise due to poor blood flow usually caused by PAD. it is important to let patient’s know to manage risk factors, stay active, and follow a healthy diet (and take meds if they are prescribed.) They should report any worsening symptoms to their healthcare provider.

Proper documentation and avoidance of documentation errors

1. Be clear and concise

2. Timelieness

3. accuracy

4. legibility

5. avoid abbreviations

6. correections

7. confidentiality

Assessing acute musculoskeletal injury

1. History taking: gather information about the injury that occurred, including the mechanism of injury, the onset of pain, and any previous injuries

2. Observation: looj for visibile signs such as swelling, brusing, or deformities.

3. Palpation: Gently feel the area around the injury to identify tender spots, swelling, or crepitus

4. range of motion: Evaluate both active and passive ROM

5. Strength testing: Assess the strength of the affected area compared to the uninjured side, while being careful not to cause further injury.

6. Neurovascular assessment: Check for circulation and nerve function by assessing g pulse, capillary refill, and sensation in the area

7. Imaging: If necessary, refer for imaging studies like X-rays or MRI to evaluate the extent of an injury

Assessing patient with possible traumatic brain injury

1. initial assessment: Start with using the glasgow coma scale. This scale assess eye, verbal, and motor responses to determine the severity of the injury.

2. History taking: Gather information about the mechanism of injury, including the time of the incident, symptoms experienced immediatley after the injury, and the loss of consciousness.

3. neurological examination: Conduct a thorough neurlogical exam to check for any focal deficits, such as weakness, numbness, or changes in speech. Assess pupillary response and reflexes.

4. Vital signs monitoring

5. symptom assessment: Look for signs and symptoms of TBI, which may include headache, dizziness, confusion, nausea, vomiting, or seizures.

6. imaging studies: If indicated, arrange for imaging studies like a CT scan or MRI to assess for any structural changes.

7. Reassessment: Continuously monitor the patient for changes in condition.

Lifespan considerations of elderly in all systems

Musculoskeletal systems: Decrease in bone density and muscle mass, leading to increased risk of fractures and falls. Joint stiffness and athritis may also be more common

Cardiovascular system: Stiffening of heart and blood vessels.

respiratory system: Lung capacity and elasticity decrease with age, making it harder to breathe deeply. Also may have a reduced cough reflex.

Nervous system: cognitive function may decline, with some elderly individuals experiecning memory loss or confusion.

Endocrine: hormonal changes can affect metabolism, leading to weight gain or loss.

GI system: Decrease in digestive enzyme production, leading to issue like constipation

Integumentary system: skin becomes thinner and less elastic., leading to increased risk of injuries and skin conditions.

Immune system: Weakens with age, making the elderly more suspectible to infections and illnesses.

How immobility affects all body systems

1. Musculoskeletal: leads to muscle atrophy, decreased strength, and joint stiffness.

2. CVS: immobility can cause decreased venous return, leading to orthostatic hypotension and increased risk of DVT. The heart may also become weaker due to lack of physical activity

3. Respiratory system: Immobility can impair lung function, leading to decreased lung volumes and increased risk of atelectasis and pneumonia due to shallow breathing and reduced clearance of secretions.

4. Nervous system: Prolonged immobility may lead to decreased neurological function, including impaired coordination and balance.

5. Endocrine system: immobility can disrupt hormonal balance, affecting metabolism and increasing risk of insulin resistance, which can lead to weight gain and diabetes.

6. GI system: Often results in slowed Gi motility, leading to constipation and decreased appetite, which can impact overall nutrition

7. Immune system: Lack of movement can weaken the immune response making indivduals more suspectible to infections.

8. integumentary system: Prolonged pressure on the skin from the immobility can lead to pressure injuries

Assessing for deep vein thrombus

1. history taking

2. physical examination

   -swelling

   -pain

   -skin changes

   -homan’s sign

   3. diagnostic tests

      -ultrasound

      -D-dimer test

   4. monitoring

Peripheral arterial disease versus peripheral artery disease assessment findings

1. history of symptoms, such as intermittent claudication, numbness, weakness, heaviness in legs

2. Physical changes

   -skin change

   -pulse assessment

   -color changes

3. wound healing

4. capillary refill time

5. ankle-brachial index

Expected values of vital signs for elderly, adult, and pediatric (general) populations

Elderly

HR: 60-100

BP: Systolic; 90-150, diastolic; 60-90

RR: 12-20

TEMP: 97.0-98.6

Adult

HR: 60-100

BP: 90/60 to 120/80

RR: 12-20

TEMP: 97.8-99.1

Pediatrics:

HR: 70-120

BP: 90-110 mmHg systolic and diastolic 50-80

RR: 20-30

TEMP: 97.9-100.4

How to obtain a sputum culture and wound culture

1. Preparation

   -Ensure the area around the wound is clean. Wash your hands and clean your gloves

2. Collection

   -use a sterile swab to gently clean the wound edges with saline or antiseptic if necessary

   -insert the swab into the wound, rotating it to collect exudate or tissue. Avoid touching surrounding skin to prevent contamination.

   -if there is a deep wound, you may need to use a deeper swab or a sterile needle to collect the sample

3. Labeling: label the swab or container with the patient’s information, date, and time of collection

4. Transport: Place the swab in a sterile culture transport medium and send it to the laboratory promptly.