exam 3 Flashcards
What lymph nodes are assessed when conducting a breast exam?
central axillary nodes, pectoral nodes, subscapular nodes, lateral nodes
Be familiar with appropriate assessment techniques when performing a breast exam.
When performing a breast exam, appropriate assessment techniques include: visual inspection of the breasts for symmetry, skin changes, and nipple discharge, followed by palpation using the pads of the fingers with light, medium, and firm pressure to feel for lumps, thickening, or other abnormalities throughout the breast tissue, including the axillary area, while systematically covering the entire breast using a consistent pattern; always ensuring patient comfort and explaining each step of the process clearly
- circular and vertical pattern
What is Peau d’ Orange? Is this significant? Why or why not?
Peau d’orange is when the breast tissue resembles the skin of an orange. It is caused by edema, which dilates the hair follicles. This finding can be significant and is not normal as it can be associated with breast cancer.
What is an extra nipple called? Is this significant? Why or why not?
It is called a supernumerary nipple and is an expected variation. They are typically pink or brown and appear along the embryonic milk line. They are often mistaken for moles.
Can men get breast cancer? How common is it?
Yes, men can get breast cancer. Less than 1% of all breast cancer cases are in men
What is gynecomastia?
gynecomastia - an enlargement of the anatomically male breast tissue, it can be seen transiently in adolescents and with weight gain.
What is the difference in approach for teaching/interventions for adolescent male vs aging male?
with an adolescent male you need to make sure they understand it is normal, common, and temporary with puberty. With older men you need to know that it may indicate an underlying medical condition and needs further investigation
What should you consider when teaching an adolescent female about breast development?
consider the women’s BMI and know that their BMI may contribute to early or late budding.
make sure that they eventually do start self breast examinations because it is equally as important
- everyone may develop differently, around ages 8-10
Why are breast self-exams important?
Breast self-exams are important because they allow women to become familiar with the normal look and feel of their breasts, which enables them to identify any unusual changes or potential signs of breast cancer early on, by noticing new lumps, skin alterations, or nipple discharge, prompting them to consult a healthcare professional if necessary; essentially acting as a tool for early detection
What characteristics would need to be included when describing a newly found lump on a patient for documentation? (exam)
location (use clock face and distance from nipple), size in cm, shape, consistency, mobility, distinctness (solitary or multiple), nipple (displaced or retracted, or normal), how the skin looks over the lump, any tenderness, is there any lymphadenopathy
What are some risk factors for breast cancer? Which are the highest risk and which are lowest?
highest - greater than 4 (age, atypical hyperplasia, lobular carcinoma in situ, pathogenic genetic variations)
middle (2.1-4) - (ductal carcinoma in situ, high endogenous hormone levels, high-dose radiation to the chest, dense breasts, 2 or more 1st degree relatives with breast cancer)
lowest - 1.1-2 (alcohol, early menarche, excess weight, late age first pregnancy, no full-term pregnancies, tall height, recent hormonal contraceptive use, one 1st degree relative with breast cancer)
What are some common signs and symptoms of electrolyte imbalances?
muscle cramps, confusion, fatigue, nausea and vomiting, headaches, irregular heartbeat, numbness or tingling, dry mouth, dizziness, constipation, personality changes, reflex alterations
What are major risks associated with a client receiving a blood transfusion?
allergic reactions (hives, itching), febrile non-hemolytic reactions (fever), acute hemolytic reactions (destruction of red blood cells due to incompatibility), transfusion-related acute lung injury (TRALI), bacterial contamination, and transmission of bloodborne infections like HIV or Hepatitis B/C
what should a nurse monitor when it comes to transfusion reactions
a nurse should closely monitor vital signs (temperature, blood pressure, heart rate, respiratory rate), watch for signs of allergic reactions like hives or itching, and be alert for sudden changes in temperature, chills, chest pain, difficulty breathing, or dark urine, which could indicate a more serious reaction
What steps must nurses take when starting a blood transfusion?
When starting a blood transfusion, a nurse must: verify patient identity and blood product compatibility, obtain baseline vital signs, administer the transfusion slowly initially, closely monitor the patient for signs of a reaction during the first 15 minutes, and document all details
what should the nurse do if they suspect a transfusion reaction is occurring
if a reaction is suspected, the nurse must immediately stop the transfusion, maintain IV access with normal saline, monitor vital signs closely, notify the healthcare provider and blood bank, and document the incident thoroughly
Definitions of hypovolemia and hypervolemia
hypovolemia - the loss of fluids and electrolytes
hypervolemia - too much water in the body, “circulatory overload”
What might cause hypo/hyper volemia to occur
hypovolemia - blood loss, severe burns, excessive sweating
hypervolemia - commonly caused by kidney disease
manifestations of hypo/hyper volemia
hypovolemia - thirst, dryness of mucous membranes, decreased skin turgor, decreased urine output.
hypervolemia - hypertension, jugular venous distension, edema, dyspnea, adventitious breath sounds
What electrolyte imbalance is associated with osteoporosis? What client education would be appropriate?
low calcium can lead to osteoporosis
maintaining adequate sodium intake, and monitoring for potential causes of low sodium. explain the importance for sodium and the importance of proper hydration
make sure to take in small frequent amounts, less than 600
Client education for preventing and treating hypokalemia?
may order an ECG to see if it is affecting the heart. Treatment starts with identifying the underlying cause, then potassium supplements may be prescribed, eat and drink enough potassium
Why might older adults be more at risk for dehydration?
physiological changes (decreased thirst, reduced reserves, kidney changes), chronic illnesses, medications
What can occur if someone is receiving too much oxygen? What s/s might be present?
oxygen toxicity
acute - CNS manifestations (muscle twitching, decreased level of consciousness)
chronic - coughing, dyspnea, chest pains, substernal heaviness
stress, cold, and fatigue can aggravate all signs and symptoms
How do you assess for cyanosis? How do you assess for cyanosis in someone who has darker skin?
To assess for cyanosis, look for a bluish discoloration of the skin, particularly around the lips, tongue, nail beds, and earlobes; in individuals with darker skin, cyanosis may appear as a grayish hue and is best observed in the mucous membranes like the gums, inside the lips, and the conjunctiva of the eyes, along with checking the nail beds and palms of the hands
nasal cannula
nasal cannula - at low concentration 24-44% oxygen given 1-6 L/min
high flow nasal canula
high flow nasal cannula - at a higher oxygen concentration and given up to 60 L/min
simple face mask
simple face mask - someone who is a mouth breather and stating low but on a high Liter cannula would be good for this 5-10 L/min
non-rebreather
non-rebreather - typically short term, is often used to quickly stabilize someone 10-15 L/min
CPAP
CPAP - give continuous airflow into the airway. often for people with obstructive sleep apnea
BiPAP
BiPAP - delivers pressurized air to help with breathing while providing different pressures for inhalation and exhalation
Appropriate use of NRB mask (look at advantages and disadvantages table in ATI “Gas Exchange”)
advantages - Recommended for short-term use with clients having an acute illness and trauma. Deliver high percentages of oxygen (60% to 95%) at flow rates of 10 to 15 L/min for clients with hypoxia
disadvantages - Not to be used with humidification. A good seal is required around the face to ensure effectiveness of the mask and the amount of oxygen inspired. Risk of atelectasis and oxygen toxicity. During respirations, to ensure the bag is inflated, high flow rates are required. The bag of the mask must be inflated, filled with oxygen, and collapsed by one-third for setup
Know the common lung/respiratory abnormalities, their associated assessment findings, and nursing interventions for each with rationale -> COPD
is the destruction of pulmonary connective tissue; increased airway resistance, especially on expiration
barrel chest is common, signs of respiratory distress, tripod positioning, SOB on exertion, may have muffled heart sounds, wheezes heard in lungs, intercostal retractions
pursed lip breathing (breathing in through nose, out through mouth with pursed lips), incentive spirometer, breathing treatment, chest physiotherapy (percussing the chest to allows for easier breathing)
Know the common lung/respiratory abnormalities, their associated assessment findings, and nursing interventions for each with rationale -> pleural effusion
is excess fluid in the intrapleural space
will have sharp chest pains. dry cough, increased RR, cyanosis, decreased or absent tactile fremitus, dull sounds when percussed, crackles, pleural rub
monitoring, oxygen therapy, pain and fluid management, underlying issue management
Know the common lung/respiratory abnormalities, their associated assessment findings, and nursing interventions for each with rationale -> pneumonia
is when the alveoli become filled with bacteria
manifestationsL fever, cough (productive), pleuritic chest pain, SOB< fatigue, altered LOC, confusion. tachypnea, cyanosis, hypotension, decreased chest expansion and tactile fremitus, crackles, purulent yellow-green slightly bloody sputum
airway management, oxygen therapy, hydration, pain and fluid management, medication administration
What is the difference between hearing crackles and a wheeze when listening to lung sounds?
When listening to lung sounds, “crackles” are short, crackling, popping noises heard during inhalation, typically caused by fluid in the small air sacs of the lungs, while “wheezes” are continuous, high-pitched whistling sounds heard during exhalation, usually indicating narrowed airways due to conditions like asthma or COPD; essentially, crackles sound like static or bubbles popping, whereas wheezes sound like a musical whistle
What is an assessment consideration after auscultating crackles?
After auscultating crackles during a lung assessment, a key consideration is to further investigate the potential underlying cause of the crackles by considering the patient’s medical history, symptoms, and the characteristics of the crackles
- have them try to cough and see if it resolves, it is actually crackles is coughing does not resolve it
What interdisciplinary team member might the nurse expect to work with when caring for a patient with a respiratory problem? What interventions might you expect from them?
a respiratory therapist
oxygen therapy, inhaled medication administration via nebulizer or inhaler, airway suctioning, chest physiotherapy, breathing exercises (pursed lip breathing, deep breathing), patient positioning, monitoring vital signs, and performing pulmonary function tests to assess lung function and guide treatment; in severe cases, they may manage mechanical ventilation settings to support breathing
Important teaching for patients with home oxygen?
no smoking, away from heat sources, tubing no longer than 50 feet, away from flammable liquids, no (petroleum, oil, and grease), no aerosols, close to a fire extinguisher
What is purse-lipped breathing and why is it effective?
Pursed-lip breathing is a breathing technique where you inhale slowly through your nose and exhale slowly through pursed lips, creating a back pressure that helps keep airways open longer, making each breath more effective and relieving shortness of breath, particularly beneficial for people with lung conditions like COPD or asthma; it essentially slows down your breathing rate and improves gas exchange by prolonging the exhalation phase
- done for a count of 2 in and 4 out
hypoxia vs. hypoxemia
hypoxia - low oxygen levels
hypoxemia - limited amount of oxygen in the blood
manifestations of metabolic acidosis and alkalosis
acidosis - nausea, vomiting, deep and rapid breathing, confusion, sleepiness, lethargy, fatigue, weakness
alkalosis - muscle cramps, twitching, irritability, anxiety, confusion, tingling and numbness, abnormal heart rhythm
causes of metabolic acidosis and alkalosis
metabolic - diuretic overuse, alcohol abuse, excess vomiting, significant and quick loss of K and Na
acidosis - excessive diarrhea, alcohol abuse
alkalosis - vomiting, diuretics
best food to eat for calcium
baked potato
Difference in what causes metabolic alkalosis vs metabolic acidosis?
metabolic - diuretic overuse, alcohol abuse, excess vomiting, significant and quick loss of K and Na
acidosis - excessive diarrhea, kidney disease, diabetic ketoacidosis
alkalosis - vomiting, diuretics overuse, alcohol abuse
Interventions for someone experiencing respiratory alkalosis and rationale?
encouraging slow, deep breathing techniques, breathing into a paper bag to re-breathe exhaled carbon dioxide, and managing anxiety with medication if necessary
breathing into a paper bag allows the respiratory rate to slow and their CO2 to increase
