Question

STUDY GUIDE FOR FINAL NUR 235

75 questions

Normal VS values, What would change the VS? Reasons for hypertension vs hypotension. Know orthostatic hypotension.

Transfers and positions. Ex: moving patients up in bed.

Pain scales, why used, how to use them.

Health history, What and how to ask questions? Review of systems

Rapid assessment vs routine assessment.

Levels of prevention; primary, secondary and tertiary.

Terms: urticaria, pruritis, inflammation, edema, tachycardia, bradycardia, tachypnea, bradypnea, hyperventilation, hypoventilation, nocturia, hematuria, dysuria, anuria

Assessment techniques: Inspection, palpation, percussion and auscultation

Tools: Braden scale, Glascow, mini-mental, ABCDE tool

One math conversion question regarding weight.

Skin Assessment: Edema, scale for pitting edema, what to assess on skin.

EENT assessment, hearing, eyes, ears nose and mouth, terms of abnormalities with hearing, vision

Head Neck and Face, lymph node assessment

Respiratory assessment-abnormal/adventitious lung sounds, pulse oximetry

Cardiac assessment: landmarks, know basic EKG and basic abnormal rhythms from class

Abdominal assessment, contour/shapes of abdomens, how to assess

Musculoskeletal—ROM of all joints including neck and spine, normal ranges of all joints

Neurological—Reflexes, brain function, LOC, orientation, mini-mental, cranial nerves

Answer 1

Normal vascular system value :

Vascular system include measuring blood pressure and assessing the integrity of peripheral vascular system

Blood pressure - 120/80 mmhg

Pulse rate - 60 to 100 beats per minute

Strength of pulse is measurement of force at which blood is ejected against arterial wall. Strength of pulse is measured by rating scale from 0 to 4+

0 - absent not palpable

1+ - pulse diminished, barely palpable

2+ - expected/ normal

3+ - full pulse, increased

4+ - bounding pulse.

Reason for hypertension :

Hypertension occur due to thickening and loss of elasticity in the arterial wall. Peripheral vascular resistance increases within thick and inelastic vessels. The heart continuously pumps against greater resistance. As a result blood flow to heart, brain, kidney get decreases.

Hypotension occur due to dilation of arteries and it leads to decrease in blood volume and the heart muscle fail to pump blood adequately.

Orthostatic hypotension is also called postural hypotension. Orthostatic hypotension occur when person rise from lying to upright position due to gravity the blood gets pool in the leg and circulatory blood get decreases.

Transfer and position :

Nurse often provide care for immobilized patients whose position must be transferred from bed to chair or from bed to stretcher.

- transferring patient from bed to chair : before moving person move obstacles out of the way to prepare the environment and ensure that enough help is available.

- Explain procedure to patient before transfer.

- place chair next to the bed.

- Assess if patient can beat weight. If can bear weight fully, stand near him or her during transfer as needed for safety reasons. If he or she partially bear weight and cooperative, transfer require one caregiver.

- the nurse either stand and pivot the patient into the chair using a gait or transfer belt or uses a powered standing - assist lift.

- two caregiver and full body sling are needed to transfer uncooperative patient who can bear partial weight and for patient who cannot bear weight and either uncooperative or do not have upper body strength.

- a seated transfer aid with or without gait belt for patient who cannot bear weight but who are cooperative and have sufficient upper body strength to complete the transfer.

- if a seated transfer aid is used, the chair needs to have arm that are able to be removed or moved out the way.

- transfer patient who have partial weight bearing towards their stronger side.

Transferring patient from bed to stretcher :

- explain procedure to patient before transfer.

- patient who receive opioid pain medication often need additional assistance during transfer because they may be unable to assist or may have difficulty understanding the caregiver direction.

- allow patient who can complete the transfer independently to move to stretcher on their own and stand by to ensure a safe transfer.

- determine the patient weight if he or she can assist partially or cannot assist at all.

- use friction reducing device for patient who weight less than 200 pounds.

- if patient weighs 200 pound or more, use friction reducing device and three caregiver.

- before moving the patient, place the stretcher and bed side by side to allow him or her to transfer quickly and easily using friction reducing device.

- use caution if patient has spinal cord trauma.

- if you have to move the patient, place a transfer board under him or her to maintain spinal alignment before transferring to stretcher.

- prepare patient for transfer and ask for help when possible.

- make sure that environment is free from obstacles and remove unnecessary equipment from bed.

Positions :

Supported Fowler position - the head of bed elevated 45 to 60 degree and patient knee are slightly elevated without pressure to restrict circulation in lower leg.

Supine position - patient with supine position rest on their back. Use pillow, trochanter roll, hand roll, arm splint to increase comfort and reduce injury to skin.

Prone position - patient in prone position lies face or chest down. Head turn to side. Pillow under head to prevent cervical flexion or extension and maintain alignment of lumbar spine. Place pillow on lower leg permit dorsiflexion of ankle and knee flexion.

Side lying position - patient rest on side with major portion of body weight on dependent hip and shoulder. 30 degree lateral position given for ptient at risk for pressure ulcer. Patient maintain curve of spine, the head need to be supported in line with midline of trunk and rotation of spine needs to be avoided.

Sims position - differ from side lying position. In Sims position patient place the weight in anterior ileu , humerus and clavicle.

Pain scale :

One is the most subjective and most useful characteristics of reporting pain is it's severity of intensity. Nurse use variety of pain scale to help patient communicate their pain intensity.

Pain intensity scale include, verbal descriptor scale, the numerical rating scale, visual analogue scale.

Numerical rating scale :

Numerical rating scale has number from 0 to 10 were

0 to 3 indicate mild pain

4 to 6 moderate pain

7 to 10 severe pain, severe pain is considered as emergency.

This scale work best when assessing pain intensity before and after therapeutic intervention. We're the patient is ask to rate their average pain and worst pain they have had over past 24 hours.

Verbal descriptor scale :

This scale has no pain, mild pain, moderate pain, severe pain, unbearable pain. Here the patient ask to describe the pain whether mild, moderate,severe or unbearable.

In Children oucher scale is used to assess pain level. The scale contain photograph of face of child. The child point to face on the tool, thus simplifying the task of describing the pain.