Quiz #3 ( CH.12, 15, & 16 ) Flashcards
lifespan considerations in older adults
- bony structures are more pronounced
➡️ D/T decreased subcuutaneous fat - skin lesions more likely
➡️ careful assessments for skin cancers, especially in commonly sun-exposed areas - hypothyroidism/hyperthyroidism is more common
➡️ hypothyroidism > hyperthyroidism - cultural considerations
urgent assessment
- acute head injuries & neurological changes
➡️ stabilization of head, neck; trauma essentials - neck pain: usually muscle tension, spasm
➡️ beware: fever & headache, possibly cardiac - lymphatics
➡️ more than 1cm, fixed, irregular, hard or rubbery
➡️ requires emergency investigation for cancer - hyperthyroidism: “ thyroid storm “, “ thyroid crisis “
➡️ hypermetabolism in all systems
common head & neck symptoms
- headache, neck pain
- limited neck movement
- vision & hearing
- facial pain
- lumps/masses
- hypo/hyperthyroidism
- sleepiness
thyroid gland
- normally smooth, rubbery, & moveable
- common to be nonpalpable
abnormal findings
- facial asymmetry
- unusual distribution of hair patterns
- nits attached to hair shaft
- thyroid asymmetry, enlargement, or masses
- degenerative joint disease ( DJD )
- temporal arteritis
- bulging or depression of scalp
- unilateral bulging may indicate thyroid goiter, cyst, or tumor
- neck masses
- tenderness
- pain or muscle spasms
- weakness or loss of sensation
- bruits
nursing diagnoses outcomes & interventions
- activity intolerance
- fatigue
- chronic pain
subjective data collection
- multiple systems may influence structure, function
- assessment of risk factors
➡️ personal history
➡️ medications
➡️ family history - risk reduction & health promotion
➡️ reducing injury risk
➡️ preventing thyroid disorder complications
➡️ early detection of masses or malignant lymph nodes
lifespan, cultural, environmental considerations on the nose, sinus, mouth & throat
in older adults:
- gustatory rhinitis: runny nose caused by smelling/tasting food
- decreased: olfactory sensory fibers; saliva production; number of taste buds
- loosening/loss of teeth
in cultural aspects:
- oral health: oral disease in children & adults is higher among poor & disadvantaged population groups
- risk factors for oral diseases: an unhealthy diet, tobacco use, harmful alcohol use, poor oral hygiene, & other social determinants
- congenital defects: cleft lip & palate
- head & neck cancers
- sleep-disordered breathing
urgent assessment
- severe nosebleeds
- ludwig angina: skin infection that is below the tongue which causes rapid edema & may cause a potential airway obstruction ( mostly in the nose, mouth, & throat )
- aspiration
- abrupt loss of smell ( possible brain tumor )
subjective data
assessment of risk factors:
- personal history/past medical history
- medications, supplements, substance use
- family history
- lifestyle & personal habits
- dental health
- environmental exposure
risk reduction & health promotion
healthy people 2030
➡️ risk factors:
- tobacco use
- sleep disorders
- cancer
- oral health
➡️ hereditary hemorrhagic telangiectasia: chronic nose bleeds
common symptoms in nose, sinus, mouth, & throat
- headache
- facial pressure, pain
- obstructive breathing: snoring, sleep apnea
- nasal congestion; epistaxis ( nose bleeds )
- dysphagia ( swallowing difficulties ); dental pain
- voice changes, oral lesions
- cough; pharyngitis ( inflammation of the pharynx )
- halitosis ( bacteria that normally lives in the throat & on the surface on the tongue ); anosmia ( loss of smell )
objective data collection
- common specialty or advanced techniques
➡️ inspection; equipment - comprehensive physical assessment
➡️ external nose: inspection; palpation
➡️ internal nose: inspection
➡️ sinuses: inspection; palpation; percussion
➡️ mouth: external, internal inspection; palpation
➡️ throat: inspection, palpation ( see tonsillar grading scale )
➡️ swallowing evaluation
abnormal findings
- asymmetry
- swelling
- bruising
- deviation of nasal septum
- redness
- mucosal inflammation
- polyps
- anosmia
- leukoplakia
- pretechiae
- tenderness
- oral candidiasis
nursing diagnoses outcomes & interventions
- impaired definition
- impaired oral mucous membrane integrity
- impaired swallowing
- ineffective breathing
upper respiratory portions
warms, moisturizes, transports air to lower
lower respiratory occurs
oxygenation, ventilation occurs
how many lobes does the left lung have?
two lobes ( due to the location of where the heart is )
how many lobes does the right lung have?
three lobes
lifespan considerations
- older adults:
➡️ respiratory strength declines
➡️ lungs lose elasticity
➡️ decreased flexibility
➡️ bone density decreases
➡️ disease prevalence - pregnancy
- newborns & infants
urgent assessment
shortness of breath & lack of adequate ventilation is EMERGENCY
- immediately assess patient & initiate interventions as needed BEFORE continuing data collection
➡️ vital signs ( respiratory rate & effort ) spO2
➡️ lung ascultation
- interventions
➡️ alert rapid response team
➡️ oxygen
➡️ elevate head of the bed
➡️ assess patient anxiety level
➡️ encourage relaxation techniques
➡️ assess for fatigue limits
risk reduction & health promotion
- smoking cessation
- prevention of occupational exposure
- prevention of asthma
- immunizations
common symptoms of the thorax & lung
- chest pain
- dyspnea ( difficulty breathing )
- orthopnea ( difficulty breathing, when standing, sitting, etc. )
- cough; sputum ( fluid in the chest )
- wheezing
- functional abilities
adventitious breath sounds
crackles, wheezes, rhonchi, pleural friction rub, stridor
nursing diagnosis
- impaired gas exchange
- ineffective airway clearance
- ineffective breathing pattern
- activity intolerance
accessory muscles
use of neck & chest muscles to exert more oxygen
apex
the top of the lung fields
asymmertrical movements
abnormal and/or decreased ventilation in one side
atelectasis
collapse of part or whole of the lung
barrel chest
deformity in which the chest becomes expanded in size
base
the bottom of the lung fields
bradypnea
slow breathing
clubbing
abnormal nail findings
crackles
small airways snapping open on inspiration
cyanosis
bluish discoloration of the skin
dyspnea
difficulty breathing
nasal flaring
nostrils flaring wide when breathing
orthopnea
difficulty breathing in supine position
pursed lips
technique used to help people living with COPD or asthma when experiencing shortness of breath
retractions
area between ribs & the neck sinking in when attempting to inhale
rhonchi
continous, low breathing pitched sounds
stridor
noisy breathing that occurs due to obstructed airflow through a narrowed airway
tachypnea
rapid breathing
wheezes
breathing problems
dyspnea on exertion
sensation of running out of air of not being able to breath fast enough or deeply enough when doing physical activity
nocturia
peeing more often during the night
REVIEW QUESTION #1: which of the following is part of the upper GI tract?
throat
REVIEW QUESTION #2: the nurse is assessing the nares to evaluate the site of epistaxis. the most common site of bleeding is which of the following?
kiesselbach plexus
REVIEW QUESTION #3: the nurse knows that the floor of the mouth is highly vascular & therefore a good location for which of the following?
absorption of sublingual medications
REVIEW QUESTION #4: acute airway obstruction is a situation that should be?
quickly assessed & treated
REVIEW QUESTION #5: risk factors for nose, sinus, mouth, & throat problems include?
topical decongestant use, smoking, allergies
REVIEW QUESTION #6: the nurse has assessed the nose & documents expected findings as?
nose symmetrical & midline
REVIEW QUESTION #7: the nurse is assessing a patient who has been taking antibiotics for 10 days. oral assessment is important because of the increased risk for which of the following?
candida albicans
REVIEW QUESTION #8: an adolescent male presents with complaints of nosebleeds. the nurse would further assess for?
nasal trauma
REVIEW QUESTION #9: the nurse assesses the child with purulent, unilateral nasal change. the nurse knows that most likely causative factor is?
foreign body in nose
REVIEW QUESTION #10: during routine physical examination of a 20 year old female, the nurse notes a septal perforation. this finding may be significant foe which of the following causes?
illicit drug use
REVIEW QUESTION #1: when the nurse assesses a 78 year old patient with pneumonia. what is the priority assessment?
airway patency
REVIEW QUESTION #2: a 45 year old male has been admitted to the hospital with suspicion of PE. which of the following symptoms should be the nurse report to the primary health practitioner immediately?
chest pain
REVIEW QUESTION #3: a 62 year old female comes to the clinic with an exacerbation of asthma. which of the following findings indicate a diagnosis of asthma? select all that apply
increased wheezing & oxygen saturation 90%
REVIEW QUESTION #4: a 3 year old child is brought to the ED with stridor, nasal flaring, intercostal & supraclavicular retractions, & respiratory rate of 40 breaths/min. what type of situation is this?
emergency
REVIEW QUESTION #5: a 92 year old female with a history of COPD presents with increasing shortness of breath, wheezing, no sputum, & 5 lb weight gain in 1 week. what is the most likely problem?
impaired breathing
REVIEW QUESTION #6: which of the following factors is the most significant risk factor of COPD?
tobacco smoking
REVIEW QUESTION #7: when the nurse assesses a client with respiratory symptoms, which of the following complaints should be evaluated first?
dyspnea
REVIEW QUESTION #8: when assessing a patient with atelectasis, what assessment findings are expected? select all that apply
shortness of breath, decreased breath sounds, decreased oxygen saturation, increased tactile fremitus
REVIEW QUESTION #9: which assessment findings would indicate that inhaled bronchodilators have been effective?
vesicular breath sounds, O2 saturation 96%, pink
REVIEW QUESTION #10: the nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. the nurse interprets this as?
a normal finding over the bronchi
