Nursing Fundamentals Part 2

Question 1

51 - Data collection and physical examination: Key points when assessing older adults

Answer 1

OLDER ADULTS: DATA COLLECTION AND PHYSICAL EXAMINATION

+ Perform assessments and data collection in multiple shorter sessions (vs. one long continuous session).
+ Allow for more time for responses to questions and for position changes.
+ Make sure patient has sensory aids in place (glasses, hearing aids). Reduce environmental noise.
+ Allow patient to use the restroom (and collect specimens if needed) before the examination.

Question 2

52 - Physical assessment:   
\+ Inspection
\+ Palpation
\+ Percussion
\+ Auscultation
\+ When do you go out of order?

Answer 2

PHYSICAL ASSESSMENT

INSPECTION: Use sight to assess for size, shape, color, symmetry.

PALPATION: Use touch to assess for temperature, texture, tenderness, size. Assess most tender areas last. Dorsal surface of hand is best for assessing temperature. Palmar surface of hand is best for assessing vibration.

PERCUSSION: Tap body parts to assess for size, tenderness, and density of tissue.

AUSCULTATION: Listen for sounds; assess amplitude, intensity, frequency, quality. Examples: bowel, lung, heart sounds.

NORMAL ORDER: Inspect, palpate, percuss, auscultate.

ORDER FOR ABDOMEN: INSPECT, AUSCULTATE, PER USS, PALPATE (TO AVID ALTERING BOWEL SOUNDS).

Question 3

53 - General Survey: What is included?

Answer 3

GENERAL SURVEY

PHYSICAL APPEARANCE: age, race, gender, level of consciousness (LOC), signs of substance abuse, signs of distress.

BODY STRUCTURE: height, weight, nutritional status, posture, obvious abnormalities (amputations).

MOBILITY: gait, ROM, movement.

BEHAVIOR: mood, speech, grooming.

VITAL SIGNS: temperature, pulse, respiratory rate, blood pressure, O2 saturation

Question 4

54 - Temperature:
+ Expected ranges for: Oral, rectal, axiliary, temporal temperatures
+ Factors that impact body temperature

Answer 4

TEMPERATURE

ORAL: 36-38 degrees C. (average 37 degrees C)

RECTAL: 0.5 DEGREES HIGHER (36.5-38.5 degrees C)

AXILLARY: 0.5 degrees lower (35.5-37.5 degrees C)

TEMPORAL: 0.5 degrees hight (36.5-38.5 degrees C)

FACTORS THAT IMPACT BODY TEMPERATURE:
+ Newborns have lower temps (36.5-37.5 degrees C)
+ Older adults have lower temps (average 36 degrees C)
+ Things that increase temps: Hormonal changes (menstruation, ovulation, menopause), exercise, dehydration, illness.
+ Food, fluids, smoking can impact oral temperature.

Question 5

55 - Taking Temperatures: Rectal, Tympanic, Temporal

Answer 5

TAKING TEMPERATURES

RECTAL: Place patient in Sims position. Use lubrication. Insert 1-1.5” for adults. No rectal temp for rabies under 3 months old or for patients w/high risk of bleeding.

TYMPANIC: For adults, pull ear up and back. For children under 3 years old, pull ear down and back. Excess earwax can impact tympanic temperature

TEMPORAL: Slide probe across forehead to hairline, touch soft depression behind ear.

Question 6

56 - Nursing interventions for: Hyperthermia, Hypothermia

Answer 6

NURSING INTERVENTIONS FOR:

HYPERTHERMIA (OVER 39 DEGREES C): Obtain blood cultures (and/or other specimens). Administer antibiotics, antipyretics, fluids as ordered. Prevent shivering. Provide blankets if patient is having chills.

HYPOTHERMIA (UNDER 35 DEGREES C): Provide warm blanket, warmed IV fluids, increase room temperature, keep head covered.

Question 7

57 - Pulses: Rate, Rhythm, Equality, Strength

Answer 7

PULSES

RATE: normal range for adults is 60-100 beats/minute (120-160 for infants)

RHYTHM: regular/irregular

EQUALITY: right vs. left side pulses

STRENGTH:
\+ 0 (absent)
\+ 1 (diminished)
\+ 2 (NORMAL)
\+ 3 (strong)
\+ 4 (bounding)

Question 8

58 - Radial and apical pulse:
+ Where/how to take radial pulse?
+ Where/how to take apical pulse?
+ What is the pulse deficit?

Answer 8

RADIAL AND APICAL PULSE

RADIAL PULSE: Take on thumb side of the wrist. For regular pulse, count for 30 seconds and multiply by 2. For irregular pulse, count for full minute.

APICAL PULSE: TAKE AT 5TH INTERCOSTAL SPACE AT LEFT MID-CLAVICULAR LINE. For regular pulse, count for 30 seconds and multiply by 2. For irregular pulse (or if patient is taking cardiac medications), count for full minute.

PULSE DEFICIT: Difference between apical pulse rate and radial pulse rate.

Question 9

59 - What can cause tachycardia or bradycardia?

Answer 9

TACHYCARDIA AND BRADYCARDIA

TACHYCARDIA (HEAR RATE >100 BEATS/MIN): Fever, exercise, medications, pain, hyperthyroidism, stress, hypovolemia.

BRADYCARDIA (HART RATE <60 BEATS/MIN): medications, athletes (excellent fitness), hypothyroidism, hypothermia.

Question 10

60 - Respirations:
\+ Normal range
\+ What do you assess?
\+ Respiratory control center?
\+ How to take respiratory rate?

Answer 10

RESPIRATIONS

RESPIRATORY RATE: normal = between 12-20 breaths/minute (35-40 for infants, 20-30 for school-age children).

ASSESS: Rate, depth (deep, shallow), rhythm (regular/irregular).

When chemoreceptors in body detect rising CO2 levels in blood, respiratory control center in brain increases respiratory rate.

HOW TO TAKE: Place patient in Semi-Fowler’s position, place hand on patients abdomen. For regular rate of 12-20, count for 30 seconds and multiply by 2. For irregular rate, count for full minute.

Question 11

61 - Respirations:
+ Ventilation vs. diffusion vs. perfusion
+ What increases or decreases respiratory rate?
+ Normal SpO2 levels?

Answer 11

RESPIRATIONS

VENTILATION: Exchange of O2 and CO2 in the LUNGS

DIFFUSION: Exchange of O2 and CO2 between the alveoli and RBCs (in the BLOODSTREAM)

PERFUSION: Exchange of O2 and CO2 between the RBCs and the BODY TISSUES.

INCREASES RR: anxiety, smoking, illnesses, anemia, high altitude

DECREASES RR: opioid/sedative medications, age

SPO2: normal = 95-100% (LOW 90s EXPECTED FOR COPD PATIENTS).

Question 12

62 - Blood pressure classifications:
\+ Normal BP
\+ Prehypertension
\+ Stage I hypertension
\+ Stage 2 hypertension
\+ Hypotension
\+ How many readings to diagnose hypertension?

Answer 12

BLOOD PRESSURE CLASSIFICATIONS

NORMAL: SBP < 120 and DBP < 80

PREHYPERTENSION: SBP 120-139 or DBP 80-89

STAGE 1 HYPERTENSION: SBP 140-159 or DBP 90-99

STAGE 2 HYPERTENSION: SBP > 160 or DBP > 100

HYPOTENSION: SBP < 90

Hypertension = BP readings elevated on 3 separate visits over several weeks.

Question 13

63 - Orthostatic hypotension
+ How do you assess for orthostatic hypotension?
+ What results are positive for orthostatic hypotension?
+ Nursing care for patients with orthostatic hypotension

Answer 13

ORTHOSTATIC HYPOTENSION: Take patient’s BP in supine position. Sit patient up and wait 2-3 minutes. Take patient’s BP sitting.