HESI Flashcards
Complete Assessment:
heath history, physical examination. (Purpose to form a baseline)
Subjective
Self care behaviors, history skin disease, medications, environment hazards, changes in pigmentation, mole changes, sore that doesn’t heal
Focused Assessment
focuses on limited or short term problem, such as the clients complaint
Assessment of mental status
Assessed while obtaining subjective data
• Appearance: posture, body movements, dress, hygiene, grooming
• Behavior: LOC, alertness, awareness, ability to interact or follow a command appropriately, facial expression, body language, eye contact, mood and affect, is it consistent with an appropriate situation? speech pattern, cognitive level.
• Inappropriate dress could indicate depression, manic disorder, dementia, organic brain disease,
• Someone who becomes angry or upset, validate their “suffering”!
What do I do if my client is violent, angry or rude?
Be professional, disorder, disease, life changes are stressful!
• Keep a safety margin
• Call for assistance
• Validate the client concerns and repeat back to client you sound like you are upset…..
Cognitive level
- Orientation (A &O x 3): person, place, time, (4-happening)
- Attention Span: Assess concentration
- Recent memory: Recall a current event
- Remote memory: Recall a past event
- New learning: recall words nurse stated 10 minutes ago
- Judgment: clients actions and decisions, are they realistic?
- Thought Process: way client thinks, is it logical, coherent and relevant?
The nurse is interviewing a client to determine the reason for his visit. He is unable to answer the questions appropriately. What interview question is most appropriate at this time?
B) “Do you even know why you came today?”
What is the limitation of utilizing the BMI? (Select all that apply)
A) Athletic persons can be classified as over weight
B) It doesn’t account for cultural differences of body compositions
C) Chinese have been proportionately higher body fat mass
D) There are no inconsistencies to the Body Mass Index Calculation
A) Athletic persons can be classified as over weight
B) It doesn’t account for cultural differences of body compositions
C) Chinese have been proportionately higher body fat mass
The nurse is interviewing a client who came to the ER with Chest pain. What focused questions concerning pain are most appropriate to ask this client? (Select all that apply)
A) “What does the pain feel like”
• B) “What were you doing when the pain started?
” • C) “How are you feeling today?”
• D) “How long have you had this pain?”
• E) “When did the Pain Begin?”
A) “What does the pain feel like”
• B) “What were you doing when the pain started?”
• D) “How long have you had this pain?”
• E) “When did the Pain Begin?”
You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
A. Multiple sclerosis
B. Anorexia nervosa
C. Bulimia
D. Systemic sclerosis
B. Anorexia nervosa
An Arabic speaking client arrives to the emergency room and states that he “no speak English, need interpretation”. What is the best action for this situation? And why?
A) Have the family member interpret for the client
B) Have the receptionist interpret
C) Page the interpreter for the hospital services
D) Obtain a dictionary to assist with the interview
C) Page the interpreter for the hospital services
Assessment order:
” inspection, palpation, percussion, and auscultation.”
EXCEPT abdomen: auscultate before utilizing touch: inspection, auscultation, percussion, and palpation
Percussion sounds:
Normal –over lung tissue resonance
Over-inflation – hyper resonance (emphysema pneumothorax )
Dull -solid or fluid areas
Korotkoff sounds 5 phases
1- period of initiated by the first faint clear, tapping sound
2- period during which the sounds become softer and longer
3- period sounds become crisper and louder
4- period during which sounds become muffled and have soft blowing quality
5- point at which the sound disappears
Objective:
color, temperature, dryness, moisture, turgor, texture, bruising, itching, rash, hair loss, nail abnormalities, scars, birthmarks, edema, capillary filling time. (May inspect with woods lamp/light)
Client Teaching:
Factors harmful to skin Self-inspection of skin monthly
Characteristics of Skin Color
Cyanosis: mottled bluish
Erythema: redness
Pallor: Pale, whitish
Jaundice: yellow
Capillary refill
normal is a return of blood in within 3 seconds
Turgor
poor turgor sign of dehydration, extreme weight loss, check turgor older client on chest
Dehydration in older adult problem:
don’t experience thirst appropriately, or withhold fluid so they don’t have go bathroom in night
May be sign of caregiver neglect, other signs of dehydration: skin dryness, flaking, scaling, tenting, dry mucosa
Vertical nail ridges
are fairly common in older adult.
Vertical nail ridges extend from the cuticle to the tip of the nail.
Vertical nail ridges often become more numerous or prominent with age, possibly due to variations in cell turnover within the nail.
Nail pitting
small depressions in the nails. Nail pitting is most common in people who have psoriasis — a condition characterized by scaly patches on the skin. Nail pitting can also be related to connective tissue disorders, such as Reiter’s syndrome, and alopecia areata — an autoimmune disease that causes hair loss
Nail clubbing
is sometimes the result of low oxygen in the blood and could be a sign of various types of lung disease. (chronic cardiopulmonary disease) Nail clubbing is also associated with inflammatory bowel disease, cardiovascular disease, pulmonary disease, COPD, cor-pumonale, liver disease and AIDS. (Cor pulmonale is an increase in bulk of the right ventricle of the heart, generally caused by chronic diseases or malfunction of the lungs. This condition can lead to heart failure) more info on next slide. Angel between skin and nail base is over 160 degrees
Spoon nails (koilonychias)
are soft nails that look scooped out. (Concave)The depression usually is large enough to hold a drop of liquid. Often, spoon nails are a sign of iron deficiency anemia or a liver condition
• Beau’s lines run across the nails
The indentations can appear when growth at the area under the cuticle is interrupted by injury or severe illness. Conditions associated with Beau’s line: diabetes, peripheral vascular disease, scarlet fever, measles, mumps and pneumonia. Beau’s lines can also be a sign of zinc deficiency
Petechiae
- small pinpoint red flat spots, frequently occurs with anticoagulation therapy, difficult to detect in darker skin, do not blanch, Causes: fragile capillaries, septicemias, liver disease, vitamin C and K deficiency •
Purpura
various sizes, red blue flat irregular shaped, from scurvy, capillary fragility in older adult.
The Nurse is caring for a client who states that a mole on his back has gotten bigger and is itchy. The nurse recognizes the changes in a mole are often associated with which disease? A) Impetigo • B) Tinea Corporis • C) Gyrate • D) Skin Cancer
D) skin cancer
Gyrate describes a lesion coiled and twisted
Impetigo bacterial skin infection
Tinea corporis fungal infection on the body
Skin cancer is often described as a long existing growth that suddenly changes in character
During an interview the nurse ask the client if she utilizes bleach, color, perms and chemicals to straighten her hair. The nurse recognizes that use of these products may cause which of the following symptoms?
A) Telogen effluvium
B) Peeling nails from protein deficiency
C) Oily scalp and infections behind the ears
D) Hair and scalp damage and possible hair loss
D) Hair and scalp damage and possible hair loss
Which of the following individuals is least likely to be at risk of developing psoriasis?
• a. A 32 year-old-African American
• b. A woman experiencing menopause
• c. A client with a family history of the disorder
• d. An individual who has experienced a significant amount of emotional distress
• a. A 32 year-old-African American
Psoriasis occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups. A genetic predisposition has been recognized in some cases. Emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbations
The nurse is assigned to care for a female client with herpes zoster. Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?
• a. Clustered skin vesicles
• b. A generalized body rash
• c. Small blue-white spots with a red base
• d. A fiery red, edematous rash on the cheeks
• a. Clustered skin vesicles
When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following?
• a. An irregular shaped lesion
• b. A small papule with a dry, rough scale
• c. A firm, nodular lesion topped with crust
• d. A pearly papule with a central crater and a waxy border
a. An irregular shaped lesion
Nurse Carl reviews the client’s chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment?
- a. Red shiny skin around the nail bed
- b. White taut skin in the popliteal area
- c. White silvery patches on the elbows
- d. Swelling of the skin near the parotid gland
- A Red shiny around the nail bed
* Paronychia is infection of the skin adjacent to the nail caused by bacteria or fungi • Red, swollen, painful, pus
A female client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms? • a. Purpura • b. Petechiae • c. Ecchymosis • d. Erythema
- C- Ecchymosis
- Ecchymosis is a type of purpuric lesion and also is known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.
- The nurse is caring for a dark skin client with Vitamin K and Vitamin C deficiency. During the assessment of the skin the nurse realizes that Petechiae is a common occurrence with these decencies. The nurse expects to find what characteristics of this clients skin assessment regarding petechiae?
- A) Bright red radiating blood vessels
- B) Flat reddish blue, irregularly shaped patches
- C) Petechiae is never visible in a dark skin client
- D) Possible visible petechiae in the oral mucosa
- E) Blanching Petechiae on the feet and hands
Answer is D) Possible visible petechiae in the oral mucosa
• Dark skin clients may have petechiae visible, more likely in oral mucosa or conjunctiva, but difficult to detect and do not blanch. • Petechiae are flat red or purple rounded 1-3 cm seen back, buttocks mostly
Changes in Skin Pallor: Dark and Light Skin
Light Skin • White skin: loses rosy tones • Natural yellow: appears more yellow
• Dark Skin • Black Skin: Loses red undertones and appears ash-gray • Brown Skin: Yellow tinged, dull
Changes in Skin Cyanosis Dark and Light Skin
Light skin skin lips mucous membrane look blue tinged conjunctiva and nail beds blue
• Dark Skin • Appear shade darker, difficult to see in skin. lips tongue, oral mucosa nail beds appear pale or blue tinged
The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment? • a. Lips • b. Sacrum • c. Earlobes • d. Back of the hands
lips
Pitting Edema
1+ Barely perceptible pit 2mm 2+ Deeper pit, rebounds in a few seconds 4mm 3+ Deep pit, rebounds in 10-20 seconds 6mm 4+ Deeper pit rebounds in > 30 seconds 8mm
Temporal artery
– above cheek bone between eye and top of the ear
• Periorbital swelling
– swelling around the eye
• Thyroid gland
moves up with sip of water
• Lymph nodes are enlargement
of lymph nodes (lymphadenopathy) are due to infection, allergy, or a tumor, infections that cause enlarged lymph nodes are usually tender to touch
• Auscultate the thyroid
– presence of bruit is abnormal and is an indication of increased blood flow
• Abnormalities in lymph nodes,
irregular border, non movable fibrous stringy (attached), enlarged
Hypothyroidism –
iodine deficiency gives rise to goiter, problem in areas where no iodine is in the diet • Goiter can occur in hyper, hypo thyroid
Sign and symptoms of hypothyroidism
- Rough scaly skin, pale
- Fatigue, weakness
- Weight gain
- Constipation
- Memory impairment
- Intolerance to cold
- Depression
- Horse voice
- Brittle finger nails and hair, decreased hair growth
- Heavier mensuration
Sign and symptoms of Hyperthyroidism
Smooth velvety skin • Irritability/nervousness • Muscle weakness • Amenorrhea • Sudden weight loss • Tachycardia and palpitations • Insomnia • Enlarged thyroid glad • Sweating • Heart sensitivity • Visual disturbance • Increased sensitivity to heat • Bowel changes, more frequent bowel movement
Ptosis –
eye drooping
• Exophthalmos-
eye protrusion, bulging eyes
• Sclera
white
• Iris –
flat round shape, even color
• Lacrimal
– abnormal: may have excessive tearing or redness
• Cornea
smooth clear
Eyes objective
inspect, symmetry, brow, lash, conjunctiva, sclera, lacrimal apparatus, cornea, lens, iris eyelids, pupils Objective: inspect, symmetry, brow, lash, conjunctiva, sclera, lacrimal apparatus, cornea, lens, iris eyelids, pupils
Eyes subjective
difficulty seeing, acuity, double vision, blurring, blind spots, pain, redness, swelling, watery, discharge, corrective wear, medications, history of eye problems
PERRLA
P - pupil • E - equal • R - round • RL – reactive to light • A – accommodation Lack of convergence- problem with cranial nerves III, IV and VI
Pupillary light Reflex
• Checking constriction, dilation, and consensual
Accommodation
• Client focus distant (dilation) than close object held 3 inches from nose (constriction and convergence
Which information should the nurse communicate immediately to the healthcare provider?
• A. White yellow material around cornea
• B. Sudden onset left eye pain
• C. Persistent absence of red reflex
• D. Dark pigmented spots on sclera of dark skin client
• B. Sudden onset left eye pain
Snellen Eye Chart
– 20 feet, eye level, read smallest line
• Near vision
–hand held, 12-14 inches from eye, client to read
• Confrontation
– measure peripheral vision, comparing to examiner, nurse two feet facing client
• Corneal light reflex
– parallel alignment of axes of eye. Gaze straight, holds light 1`2 inches away on bridge of nose, reflection in cornea’s
• Cover test
- checking deviated alignment, gaze straight, normal steady fixed gaze no turning in or out
• Six cardinal fields of gaze
– checking for muscle weakness, head steady, follow object, assessing for nystagmus (involuntary eye movement), oscillating movement
• Color vision
– Ishihara chart tool used to assess color vision
The nurse is caring for a client who recently had surgery and is unable to ambulate. The client also has significant Macular Degeneration. Which intervention is most appropriate for a client with Macular Degeneration?
• A. Placing the call bell directly in front of the client on the table
• B. Arrange the client’s personal items within the client’s peripheral vision
• C. Assessment of corneal light reflex on each eye
• D. Identify risk factors associated with glaucoma
B) Arrange the client’s personal items within the client’s peripheral vision
Macular degeneration – visual loss is center vision (macula- centralis fovea)
Ophthalmoscope
Optic Disc round or oval yellow orange depression with distinct margin
• Macula – darker circle (area of central vision)
• Fovea Centralis small white spot located on center of macula (sharpest vision)
• Note major vessels, color, width, and crossing
The nurse is testing the Extraocular movements in a client to assess for muscle weakness in the eyes. The nurse implements which physical assessment technique to determine eye muscle weakness? A) Corneal Reflex B) Six Cardinal Positions of Gaze C) Visual Acuity with Snellen Chart D) Corneal light reflex
B) Six Cardinal Positions of Gaze
Voice Test (Whisper)
Occlude one ear
• 1-2 feet behind client
• Whisper two syllable words after exhales fully
Tuning Fork Test
Weber – midline client scull, comparing sound in both hears equal
Rinne – Mastoid process (bone conduction) then next to external canal.
Air is heard twice as long as bone in normal adult AC > BC
Cerumen
ear wax
Tinnitus
– ringing in the ears, some medications can cause ringing in the ears (one example-aspirin)
otoscope
Pulls pinna up and back and out on adult and older child,
younger child down and back
Insert approximately half inch into ear canal, slight down and forward
• When inserting speculum check auditory canal for foreign bodies
• Instruct client not to move during exam to avoid damage to canal and tympanic membranene
The nurse is going to palpate lymph nodes of the client, which process is the most appropriate?
• a. Start palpation at the preauricular lymph node
• b. Palpate the occipital with one hand at a time
• c. Being with the Superficial Cervical chain
• d. Utilize the palm of each hand simultaneously
• d. Utilize the palm of each hand simultaneously
The nurse is assessing a child for ear pain. Utilizing the otoscope to visualize the tympanic membrane the nurse recognizes an abnormal membrane which needs more immediate attention.
• A) absent light reflex
• B) redness and swelling of the auricle
• C) dark spot of the ear drum
• D) white patches of scar tissue
C • Dark spot may indicate a perforation or injury
The nurse is performing an assessment of the internal ear on an adult client, what is the best procedure to have full visual view of the tympanic membrane and provide for client safety?
• A) Utilize the smallest speculum to prevent injury • B) pull back and down to straighten the canal • C) pull up and out on the pinna to straighten the canal • D) insert the speculum into the canal to the ear drum
- C Pull up and out on the pinna to straighten the canal.
* B for infants, shorter straighter ear canal
The nurse is interviewing a client in the clinic. The client states that he has experienced sudden hearing loss in one ear recently. The nurse knows this may be a sign of which problem. Mark all that apply • A) Complete blockage from cerumen • B) Ruptured tympanic membrane • C) Old Age • D) Infection of the external ear
- A) Complete blockage from cerumen
* B) Ruptured tympanic membrane •
The nurse receives in report that the client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which of the following?
A) A defect in the cochlea
B) A defect in the 8th cranial nerve
C) A physical obstruction to the transmission of the sound wave
D) A defect in the sensory fibers that lead to he cerebral cortex
C) A physical obstruction to the transmission of the sound wave
Results as a physical obstruction to the transmission of sound wave A Sensorineural hearing loss occurs as a result of pathological process in the inner ear
NOSE MOUTH THROAT
INSPECTION AND PALPATION
Subjective: discharge, epistaxis, facial sinus pain, history of problems, colds, altered smell, allergies, medications, history of trauma or surgery.
Objective: • Nose -midline, patent nostril, inner-inspect septum redness, swelling, discharge, bleeding, foreign body. • Lips – color, moisture, cracking, lesions • Teeth - condition, number, clean decay, alignment of upper and lower jaw • Gums – swelling, bleeding, discoloration, and retraction of gingival margins • Tongue – color, surface characteristics, moisture, white patches, nodules, ulcerations • Buccal Mucosa – color, presence of nodules, lesion
Hemoptysis
– blood in sputum many causes, foreign object younger, cardio problems, respiratory infections and other major problems
The nurse recognizes that a client who has a positive Romberg test has which of the following symptom? • A) nasal swelling • B) Hearing loss • C) Equilibrium disturbances • D) Ringing in the ears
C) equilibrium disturbances
The nursing is assessing a client. She inspects and palpates the Wharton’s and Stenson’s ducts for which abnormalities
• A) Flow of salvia
• B) Tenderness, pain, swelling or redness
• C) Retraction, bleeding, and overgrowth
• D) Decay, plaque and discoloration
no idea!!!!!
LUNGS SUBJECTVIE DATA
Cough
• Sputum
• SOB
• Smoking History
• Environmental Exposure
• Medication
• History of Disease or Infection
• Last TB Test, Flu and Pneumonia Immunization
• History of Pneumonia and Chest X-rays
• Pillows for sleep (questions about orthopnea SOB laying supine, chest pain at night)
Lungs OBJECTIVE
Inspection: anterior, posterior chest, color, rate quality pattern of respirations, lumps, lesions, shape and configuration of chest wall. UTILIZING ACCESSORY MUSLCES is the client in a tripod position? Resp distress.
Palpation: entire chest wall, temperature, moisture, tenderness, lumps lesions masses, chest excursion and tactile or vocal fremitus, crepitus (subcutaneous emphysema- popping with palpation usually chest area, leaking air into subcutaneous)
Percussion: start a apices, across top of shoulders moving to interspaces, side to side compare all way down lung area. Determine predominant note
Resonance is noted in health lung tissue
Noted in healthy lung tissue
• Hyper-Resonance –
noted over excessive air
• Dull note
indicates lung density, consolidation, fluid, pneumonia, pleural effusion,atelectasis
• Posterior Chest Expansion –
10th rib, thumbs 2 inches apart, thumb pointed spine, fingers pointed lateral (deep breath , exhale)
• Anterior Chest Expansion
– hands on anterolateral wall thumbs along costal margins, pointing toward the xiphoid process
• Normal
– symmetrical separating thumbs about 2 inches,
• Tactile or vocal fremitus
– ball or lower palm of hand, diminished over alveoli in normal lungs
VOICE SOUNDS LUNGS
Bronchophony presence of - repeat words, 99. sound is distinct
- (Normally- soft, distant, muffled, indistinct)
- Egophony presence of – repeat EE sounds like AA (Normal – hear EEE sound)
- Whispered Pectoriloquy presence of – whisper word 99. clear distinct) (Normal – faint, muffled, almost inaudible.
ABNORMAL BREATH SOUNDS
- Crackles (fine – used to be called rales)
- Crackles – medium
- Crackles – coarse
- Wheeze
- Rhonchi
- Pleural Friction Rub
Auscultation Breath Sounds
Chronic Bronchitis – Wheezes, Rhonchi
Emphysema – decreased vesicular, possible wheeze
Lobar Pneumonia – Crackles, Bronchial breath sounds
Pleural Effusion – breath sounds decreased, pleural rub
Asthma – wheezes, no breath sounds, wheeze may be audible
Atelectasis – decreased or absent breath sounds
Pneumothorax – Decreased or absent breath sounds on side
CHF – Wheezes or crackles at bases
The nurse is caring for a client with Asthma who was admitted to the hospital for respiratory distress. What type of Adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? A) Stridor B) Crackles C) Wheezes D) Diminished
Answer is C Wheezes
Asthma is characterized by dyspnea, constriction of bronchi, wheezing (high pitched musical sounds) Stridor is often associated with EMS, obstruction, Crackles – air passing over retained airway secretions or fluid, Diminished – poor oxygen exchange is occurring
(HEART) Inspection:
anterior chest for pulsation (apical impulse)
(heart) • Palpation:
apical impulse, 4-5th midclavicular, Apex
(heart)• Percussion:
outline heart border check for enlargement (denoted by resonance over lung and dull notes over the heart)
(heart) • Auscultation:
areas of heart: aortic, pulmonic, Erb’s point, Tricuspid, Mitral.
Apical impulse –
left ventricle rotates against the chest wall during systole, isn’t always visible (PMI)
Palpation
– normally none are present (thrils heaves- palpatable sensations over heart usually indicates murmurs
Auscultation: areas of heart
Aortic -2RICS • Pulmonic - LICS • Erb’s point -3LICS • Tricuspid – 4LICS • Mitral – 5LMCL
P wave
– atrial contraction (atrial depolarization) SA (pace maker ) emits an electrical charge that initially spreads through the right and left atria, as a result myocardial cells contract
• PR interval
- time needed for the electrical current to travel across both atria and arrive at the AV node
• Resting state
more positively charged on outside of cell and negatively charge on the inside of the cell
• Spread of electrical current is called depolarization
when cardiac cells inside become more positively charged and outside negative
• Depolarization
occurs when electrical current normally initiated in the SA node spreads across the atria contraction of the atria follows
• After contraction repolarization occurs
where the inside of cells return to more negative charge
• QRS
– ventricular depolarization – ventricular myocardium become positive electric charge (this change is depolarization)
• T wave
– Ventricular repolarization , once ventricles has been stimulated and contract they return to their normal electrical potential state
• QT interval
- beginning of ventricular depolarization to the moment of repolarization Thus it represents ventricular contraction (electrical events occur slightly ahead of mechanical events)
• S1
QRS
S1 - “Sound One” or first heart sound.
The LUB in lub-dub. It is created by near simultaneous closure of the mitral and tricuspid valves.
• S2 - “Sound Two” or second heart sound.
The DUB in lub-dub. It is created by near simultaneous closure of the aortic and pulmonic valves.
• S3 - Third heart sound or “ventricular gallop”.
Low in volume and in frequency (pitch). Heard in the early diastolic period and is normal in children. In adults >35 indicates CHF. It is NOT caused by valves, it is created by sudden tensing of the ventricular wall.
• S4 - Forth heart sound or “atrial gallop”.
Low in volume and in frequency. Heard in the end-diastolic period. Can indicate HTN, CAD, or a MI
Point of Maximal Impact (PMI)
location on the anterior chest wall where the apex of the heart is felt most strongly. It can be felt in 70% of individuals in the sitting/standing position or in the left lateral decubitus position
Murmur -
A sound, heard with a stethoscope, usually created by turbulent blood flow through abnormal valves. Blowing, swooshing sound
THrills
Thrills are vibratory sensations (palpation) caused by the heart and felt on the body surface. Thrills are always associated with murmurs. Palpate for thrills as follows:
• Place the patient in the supine position.
• Use the proximal part of your hand (not fingers)and press gently over the anterior chest wall over the heart.
• Note any thrills appreciated
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which of the following best describes the sound of a heart murmur? A) Scratchy leathery heart noise B) Gentle, blowing or swooshing noise C) Abrupt, high pitched snapping noise D) Musical high pitched heart sound
B) Gentle, blowing or swooshing noise
In report the nurse receives information that the client has. paresthesia. The nurse plans to assess for paresthesia by asking the client the following questions?
• A) “Do you have a history of migraines?”
• B) “Are you nails attached securely?”
• C) “Do you feel dizziness when walking?”
• D) “Do you feel tingling, numbness or prickling in legs?
D) Do you feel tingling, numbness or prickling in legs?
Parasthesia • In older individuals, paresthesia is often the result of poor circulation in the limbs (such as in peripheral vascular disease, also referred to by physicians as PVD or PAD), most often caused by atherosclerosis, the build up of plaque within artery walls, over decades, with eventual plaque ruptures, internal clots over the ruptures and subsequent clot healing but leaving behind narrowing of the artery openings or closure, both locally and in downstream smaller branches. Without a proper supply of blood and nutrients, nerve cells can no longer adequately send signals to the brain.
• Because of this, paresthesia can also be a symptom of vitamin deficiency and malnutrition, as well as metabolic disorders like diabetes, hypothyroidism, and hypo-parathyroidism
Changes as aging occurs
Cardio-pulmonary
• Less efficient utilization of O2 which reduces ability to maintain physical activity • Blood pressure changes, increases especially in systolic • Peripheral circulation decreases • Increase in anterior-posterior chest (barrel chest) • Stiffing and inelasticity of soft tissue in lungs. Passages drier, more shallow breathing, decreased gas exchange • Vaccines are suggested for older adults each year • Widening pulse pressure , stiffing aorta,
Changes as aging occurs
eyes
Diminished eye sight (near vision – presbyopia) results in loss of independence • Sluggish pupillary light reflex • Decreased upward gaze • Increased dryness in eyes • Xanthelasma-soft yellow plaques inner canthus lid, may be associated with high cholesterol • Development of cataracts, Macular degeneration
Changes as aging occurs
skin
Dry wrinkled skin from subcutaneous loss, dermis less elastic • Tenting on dorsal hand (check chest for turgor indicating dehyration) • Increase skin tags, liver spots, cherry angiomas etc • More susceptible to injury • Nail changes may thick, yellow, oddly shaped, brittle, thin, peeling
Changes as aging occurs
head & neck
Tooth loss is not normal- educate on good dental care • Decreased cervical ROM • Tympanic membrane more opaque • Presbycusis • Scalp hair fine, loss, gray • Facial hair coarse, long • Loss sub Q fat in face, • Thyroid produces less hormone • Decreased sense of taste and smell • Less appetite, poorly nutrition • Decreased salvia, gums recede • Problem ill fitting dentures because of mouth structure changes that occur
Changes as aging occurs
Psychosocial
Lack of stimulation or overload of changes can result in increased confusion • Many losses contribute to emotional and mental stress • Tend to have less sleep
