Exam 3 study guide

cigarette smoking/second-hand smoke; exposure to toxins (asbestos, radon, arsenic, diesel exhaust); air pollution; radiation exposure; history of lung cancer (personal or family); diet- smokers who take beta-carotene supps are at higher risk; (unproven- marijuana, e-cigs, exposure to talc or talcum powder)
Click the card to flip 👆
1 / 240
Terms in this set (240)
no nasal flaring; client has evenly colored skin tone, w/o unusual or prominent discoloration; pink tones should be seen in the nail beds, normally a 160-degree angle bt nail base and the skin; scapulae are symmetric/nonprotruding; shoulder and scapulae are at equal horizontal positions; ration of anteroposterior (AP) to transverse diameter is 1:2
symmetric and easily identified in upper regions of lungs; decrease in intensity is normal as examiner moves towards base of lungs. should remain symmetric for bilateral positionsnormal finding when palpating for fremituspneumoniaincreased fremitus may bedecreased or absent fremitusmay be pneumothroaxplace hands on the posterior chest wall with your thumbs at the level of T9 or T10 and pressing together a small skin fold; as the client takes a deep breath, observe the movement w your thumbshow to palpate chest expansionwhen the client takes a deep breath, the examiners thumbs shoud move 5 to 10 cm apart symmetricallywhat is a normal finding when palpating/assessing chest expasion?start at the apices of the scapula and percuss across the tops of both shoulders; percuss the intercoastal space across and down, comparing sides; percuss to the lateral aspects at the bases of the lungs, comparing sideshow to percuss for tone in the posterior thoraxthe percussion tone elicited over normal lung tissue. it elicits flat tones of the scapularesonanceelicited in cases of trapped air such as in emphysema or pneumothoraxhyperresonanceoccurs over areas of increased density; present when fluid or solid tissue replaces air in the lung or occupies the pleural space, such as in lobar pneumonia, pleural effusion, or tumoran abnormal finding when percussing for diaphragmatic excursion (aka dullness)bronchial, bronchovesicular, vesicularWhat are the three normal breath sounds?over the tracheaWhere are bronchial breath sounds heard?over major bronchiwhere are bronchovesicular breath sounds heard?over the peripheral lung fieldsWhere do you hear vesicular sounds?sounds added or superimposed over normal breath sounds heard during auscultationwhat are adventitious sounds?crackles, wheezes, rhonchi, pleural friction rubwhat are some adventitious sounds?tenderness or pain at the costochondral junction of the ribs is seen w fractures, esp in older clients w osteoporosis; older adults may experience dyspnea w certain activities related to aging changes of the lungs (loss of elasticity, fewer functional capillaries, loss of lung resiliency); chest pain related to pleuritis may be absent in older clients bc of age-related alterations in pain perception; ability ot cough effectively may be decreased in the older client bc of weaker muscles and increased rigidity of the thoracic wall; deep breathing may be difficult bc fatigue easily; kyphosis is common; bc calcification of the costal cartilages and loss of the accessory musculature, the older client's thoracic expansion may be decreased, although it should still be symmetric.; The sternum and ribs may be more prominent in the older client because of loss of subcutaneous fat.what are some consideration for older adult clients?kyphosisexcessive outward curvature of the spine, causing hunching of the back.dyspnea, elevated BP with small pulse pressure, increased resp. & pulse rates, pallor, cyanosis, anxiety, restlessness, confusion, drowsinesswhat are the most common signs of hypoxia?deep breathing, using incentive spirometry, pursed-lip beathing, diaphragmatic breathingwhat are some ways to promote proper breathing?deep breathinginstruct the pt to make each breath deep enough to move the bottom ribs; unless the pt has a nasal condition that prohibts or prevents normal breathing, have the pt start slowly taking deep ventilations nasally and then expiring slowly thru the mouthincentive spirometryProvides visual reinforcement for deep breathing by the patient. Assists the patient to breathe slowly and deeply and to sustain maximal inspiration; assist pt to an upright semi-Fowler's position, asses for pain; instruct the pt to exhale normally and then place lips securely around the mouthpiece; instruct pt not to breath thru nose; inhale as slowly/deeply as possible; the pt should hold breath & count to 3pursed lip breathingcreates a smaller opening for air movement, effectively slowing and prolonging expiration; helps pt control rate and depth of respiration, helping reduce feelings of dyspnea; pt upright and inhale thru nose while counting to three, then exhale slowly and evenly against pursed lips while tightening abdominal muscles; during exhale pt counts to 7diaphragmatic breathingreduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expirationmetered-dose inhaler (MDI)mixes a single dose of the medication with a puff of air and pushes it into the mouth via a chemical propellantshake inhaler well, remove mouth piece covers from MDI and spacer, attach to spacer by inserting it in the open end of the spacer, opposite the mouth piece; place spacer into pt mouth and have them grasp securely w the teeth and seal the lips tightly around the mouthpiece lips, have pt breath normally thru spacer; Instruct the patient to exhale completely, then depress the canister once, releasing one puff into the spacer, and inhale slowly and deeply through the mouth. Instruct patient to hold his or her breath for 5 to 10 seconds, or as long as possible, then to exhale slowly through pursed lips; wait 1-5 mins before admin. the next puffhow to use MDI with a spacerinhalepatient must activate the MDI while continuing to (inhale or exhale)reservoirthe use of a spacer for MDIs acts as a -failing to shake the canister; holding the inhaler upside down; inhaling thru nose rather than mouth; inhaling too rapidly; stopping the inhalation when the cold propellant is felt in the throat; failing to hold their breath after inhalation; inhaling two sprays w one breathwhat are some of the common mistakes patients make when using MDIs?nasal canula, nasopharyngeal catheter, transtracheal catheter, face masks (4 types), oxygen tentwhat are the different oxygen delivery systems?simple mask, partial rebreather mask, nonrebreather mask, venturi maskwhat are the 4 types of face masks?nasal cannulaWhich oxygen delivery system is most commonly used?can be dislodged easily and low-flow rates can cause dryness of the nasal mucosa; if the patient breathes thru the mouth, it is difficult to determine the amount of oxygen the pt is actually recievingwhat are some disadvantages to the nasal cannula?venturi maskwhich oxygen delivery system delivers the most precise concentration of oxygen?simple maskused when an increased delivery of oxygen is needed for short periods (less than 12 hrs); mask should fit closely to face to deliver effectivelypartial rebreather masksimilar to a face mask, but is equipped with a reservoir bag for the collection of the first part of the patient's exhaled air; air in the reservoir is mixed with 100% oxygen for the next inhalation; pt rebreathes abt 1/3 of expired air from reservoir bag; bag should deflate slightly with inspirationnonrebreather maskwhich oxygen delivery system delivers the highest concentration of oxygenation to a spontaneously breathing patient? this mask has 2 one-way valves that prevent pt from rebreathing exhaled airtrach suctioningnot routinely done; if nurse auscultates coarse crackles or rhonchi, identifies moist cough, hears or sees secretions in trach tube, pt's airway should be suctioned; sterile technique; hyperoxygenate pt before and after; apply intermittent suction and gently rotate cath while withdrawling; suction 10-15 seconds at a time; flush cath with salineP waveatrial depolarization; conduction of the impulse thruout the atriaPR intervaltime from beginning of atrial depolarization to beginning of ventricular depolarization; (beginning of P wave to beginning of QRS complex)QRS complexventricular depolarization and atrial repolarization; conduction of the impulse thru the ventricles which then triggers contraction of the ventricles; measured from the beginning of the Q wave to the end of the S waveST segementperiod bt ventricular depolarization and the beginning of ventricular repolarizationT waveventricular repolarization; the ventricles return to a resting stateQT intervaltotal time for ventricular depolarization and repolarization; varies with HRU wavemay or may not be present, follows the T wave and represents the final phase of ventricular repolarizationaortic area, pulmonic area, erb point, mitral (apical), tricuspid areawhat are the tradition areas of auscultation?aortic area2nd intercostal space, right sternal borderpulmonic area2nd or 3rd intercostal space at the L sternal borderErb's point3rd ICS left sternal borderMitral (apical) arealeft fifth intercostal space at the midclavicular linetricuspid area4th or 5th intercostal space, left lower sternal borderAn S3 or S4 heart sound or a murmur of mitral stenosis that was not detected with the client in the supine position may be revealedwhy do we assess heart sounds in different positions?S3 and S4extra heart sounds that result from ventricular vibrations secondary to rapid ventricular fillingS3ventricular gallop; heard early in diastoleS4atrial gallop; heard late in diastole; the vibration is secondary to ventricular resistance (noncomplience) during atrial contractionascultation followed by palpation; bell of stethoscope over carotid artery and ask pt to hold breath for a momenthow to assess the carotid arteriesbruitwhat is an abnormal finding when ascultating the carotid arteries?a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel, is indcative of occlusive arterial disease. however, if the artery is more than 2/3 occluded, this may not be heardWhat is a bruit?pulse amplitude scale0= absent 1+= weak 2+= normal 3+= strong 4+= boundingpulse rate deficitpalpate the radial pulse while you auscultate the apical pulse, count for a full min; difference between the apical and peripheral/radial pulses; may indicate atrial fib, atrial flutter, premature ventricular contractions, varying degrees of heart blockassesing jugular veinsWith the patient supine and the head slightly elevated on a pillow, locate the right external jugular vein. If the vein is not easily seen, apply digital pressure at the region where the vein normally enters the thorax at the clavicle. This will reveal the vein in many patients. Release the pressure.jugular venous pressureThe indirectly observed pressure over the venous system via visualization of the internal jugular veinAssessing varicose veinsask the client to stand because they may not be prominent in the supine position; if found- perform the Trendelenburg testTrendelenburg testpt lies supine, elevate the pts leg to 90 degrees for about 15 seconds or until the veins empty; with the leg elevated, apply a tourniquet to the upper thigh; assist the client to a standing position and observe for venous filling; remove the tourniquet after 30 seconds, and watch for sudden filling of the varicose veins from abovePain: intermittent claudication to sharp, unrelenting, constant; diminished/absent pulses; dependent rubor skin; elevation to pallor of foot; dry, shiny skin; cool-to-cold temp; loos of hair over toes and dorsum of foot; nails thickened/ridged; ulcers- @tips of toes, toe webs, heel or other pressure areas, very painful, deep/often involving joint space, circular, pale black to dry and gangrene; minimal leg edema, unless extremity kept in dependent pos. constantly to relieve painarterial insufficiencypain: achin, cramping; present pulses, but may be difficult to palpate thru edema; skin- pigmentation in gaiter areas (area of medial and laeral malleolus); thickened and tough; may be reddish-blue color; frequently associated w dermatitis; ulcers- medial malleolus or anterior tibial area, min pain if superficial, depth-superficial; irreg. border, granulation tissue (beefy red to yellow fibrinous in chronic long-term ulcer. moderate to severe leg edemavenous insufficiencyedemapuffy swelling of tissue from the accumulation of fluidpitting edemaassociated with systemic problems, such as heart failure or hepatic cirrhosis, and local causes such as venous stasis due to insufficiency or obstruction or prolonged standing or sittingintermittent claudicationpain in the leg muscles that occurs during exercise and is relieved by restnormally cannot be examined unless distended above the symphysis pubis; check for tenderness; percussion for dullnesshow to perform a bladder examination-relieving urinary retention; obtaining a sterile urine specimen; obtaing a urine specimen when usual methods cant be used; emptying bladder before, during, or after surgery; monitoring critically ill patients; increasing comfort for terminally ill patientswhat are some reasons for catheterization?suprapubic cathetercatheter inserted into the bladder through a small abdominal incision above the pubic areaindwelling catheterremains inside the body for a prolonged time based on need; sterile procedurecolor- fresh pale yellow, straw or amber; odor- aromatic, longer it stands= ammonia odor; clear/translucent; pH- 4.6-8.0 (6.0); specific gravity- 1.015-1.025normal finding of urine characteristicsanticoagulants, diuretics, pyridium, (antidepressant) amitriptyline (elavil) or B-complex vitamins, levodopamedications that affect the color of urineanticoagulantred urinediureticspale yellow urinepyridiumorange to orange-red urineAmitriptyline (Elavil) or B-complex vitaminsgreen or blue-green urinelevodopabrown or black urineroutine UA, clean-catch or midstream specimens, sterile specimens from indwelling caths, urine spec from a urinary diversion, 24-hour urine specimen, specimans from infants and children, point-or-care urine testingurine specimens typesRoutine Urinalysis (UA)Doesnt have to be sterile Pt just voids into containerclean catch specimena urine specimen that does not include the first and last urine that is voided; also called mid-streamclamp tubing, swab port and withdrawl urine with syringeurince specimen from indwelling catheterinitiate a collection at a specific time (which is recorded) by asking pt to empty bladder; discard this urine and then collect all urine voided for the next 24 hours; at the end of 24 hrs ask pt to void, add this urine to the previously collected urine, and then send the entire specimen to the labhow to obtain 24-hour specimentreat pt with severely decreased or total loss of kidney functionhow to care for dialysis pthemodialysismachine and vascular access AV fistulaperitoneal dialysisinvolves using blood vessels in the abdominal lining with the help of a fluid washed in and washed out of the peritoneal spacecannot be delegated to nursing assistive personnel (NAP) or unlicensed assistive personnel (UAP) • Depending on the state's nurse practice and hospital policy, may or may not be delegated to an LPN/LVN. • No BP's, venipunctures, or IV's on the shunt access arm. • Instruct patient not to sleep with the access arm under the head or body. • Instruct patient not to lift heavy objects or put pressure on that arm with the access site.how to care for hemodialysis patientWeight (lbs)/ height (in)squared x 703.What is the calculation for BMI?<18.5underweight BMI18.5-24.9normal BMI25.0-29.9overweight BMI30.0-34.9obesity class I BMI35.0-39.9obesity class II BMI40.0+extreme obesityconsistent-carb diet, fat-restricted, high-fiber, low-fiber (<10 g/day), sodium restricted, renal diet, nothing by mouth (NPO)what are the different types of theraputeic diets?consistent-carbohydrate dietfor patients with diabetes; ex- counting carbohydratesfat-restrictedfor patients with chronic cholecystitis, CV disease; ex- low fat, or nonfat dairy products: yogurt, skim milk, fish, poultry; monosaturated fats found in canola, olive and peanut oils; all fresh fruits, veg., whole grain cereals, rice and pastahigh-fibertreat constipation, IBS, diverticulosis (not diverticulitis- needs low); ex- cereals and grains such as wheat or oat bran, cooked cereals, dry cereals (cornflakes, shredded wheat) whole grain breads; fruits, raw apples, peaches or pears, oranges and berries. veg: broccoli, carrots, peas, corn, beans, celery and tomatoeslow-fiber (<10 g/day)before surgery or GI procedure (colonoscopy); ulcerative colitis; diverticulitis; Crohn's disease; ex- white breads, pasta, and rice, low-fiber cereals without whole grains, potatoes w/o skin, eggs, chicken, tofu and fishsodium restrictedhypertension, hepatitis, CHF, renal insufficiency or failure, cirrhosis of liver; ex- allow most fresh fruits and vegetables (except beets, celery, frozen or canned veges w salt)renal dietnephrotic syndrome, chronic kidney disease, diabetic kidney disease; ex- protein restriction to 0.6-1 g/kg/day; sodium restriction 1000-3000mg/day. potassium and fluid restrictionnothing by mouth (NPO)before surgery, after surgery til BS return, L&D; ex-provide oral hygeine; ice chips if allowedclear liquid, pureed, mechanically altered (soft), full liquidwhat are modified diets?clear liquid dietafter surgery, GI; ex- coffee, tea, carbonated beverages, bouillon, clear fruit juicespureedoral or facial surgery, chewing and swallowing; ex- all foods in soft, fluid is added to blend to a semisolid consistencymechanically altered (soft)chewing/swallowing difficulties or after head/neck/mouth surgery. no teeth, poor fitted dentures; ex- regular diet w modifications for texture. excludes most raw fruits and vegetables and foods with seeds, nuts, and dried fruits. foods are chopped, ground, mashed, or softfull liquidprogression from clear liquid; ex- all foods in clear liquid & custards, ice cream, sherbert, yogurt, strained cereals (cream of wheat), butter, milk and liquid egg substituesenteral nutritionalternate feeding method used when patients are unable to meet nutritional needs thru oral intake of adequate diet; a tube is passed into GI tract to administer a formula containing adequate nutrientsNG tubeWhat is a short-term form of nutritional support? (Less than 4 weeks)percutaneous endoscopic gastrostomy (PEG)what is a long-term form of nutritional support?long term nutritional supportAn enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy).the preferred route to deliver enteral nutrition in the patient who is comatosegastrostomyPlacement of a tube into the stomach can be accomplished bya surgeon or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or a surgically (open or laparoscopically) placed gastrostomy tube.medications via PEGflush with 15-30mL of warm water prior to med admin; crush each med (if able) and mix each separately w warm water; use piston syringe and administer med into the G tube; flush w 15-30 mL of warm water bt each med and once the last med has been administeredpromoting patient safety, monitoring for complications, providing comfort measuresnursing actions that should contribute to successful tube feedings focus on:parenteral nutritionadministers of nutritional support via the IV routenonfunctioning GI tracts; comatose; high caloric and nutritional needs due to illness or injury; undergoing aggressive cancer therapy; recovering from extensive burns, surgery, sepsis, or multiple fracturesParenteral nutrition is used for patients who can't meet nutritional needs by oral or enteral routes, such as-total parenteral nutrition (TPN), Peripheral Parenteral Nutrition (PPN)what are the two types of parenteral nutrition?concentration of solutionswhat is the basic difference between the two types of parenteral nutrition's?administered centrally thru central venous access device; highly concentrated, hypertonic solution; used if nutritional support is needed for greater than 7-14 dayswhat is total parenteral nutrition (TPN)?administered peripherally thru access in peripheral vein; less concentrated, isotonic solution; used if nutritional support is needed for short time (less than 2 weeks)what is peripheral parenteral nutrition?total parenteral nutrition (TPN)highly concentrated, hypertonic solution; provides calories; restores nitrogen balance; replaces essential fluids, vitamins, electrolytes, minerals, and trace elements; promotes tissue and wound healing; promotes normal metabolic functioning; provides bowel a chance to heal; reduces activity in gallbladder, pancreas, and small intestines; may improve a pts response to surgerythings to remember about TPN-adding medications to TPN is the pharmacists job!; insulin & heparin are acceptable meds; pharm will add med directly to the PN mixture if compatible; nothing is added to the TPN port/tubing!insertion problems; infection and sepsis; metabolic alterations; fluid, electrolyte, and acid-based imbalances; phlebitis; hyperlipidemia; liver and gallbladder diseasewhat are some complications of TPN?what are the signs of good nutritional status?alert, responsive; has endurance, energetic, sleeps well, vigorous; normal height/weight/body build for age; shiny, lustrous, firm, not easily plucked hair; healthy scalp; face has uniform skin color, healthy appearance, not swollen; eyes are bright, clear, moist, no sores at corners, membranes moist, healthy pink color, no prominent blood vessels; lips are good pink color, smooth, moist, not chapped or swollen; tongue is deep red, surface papillae present; teeth are straight, no crowding, no cavities, no pain, bright, no discoloration, well-shaped jaw; gums are firm, good pink color, no swelling or bleeding; no enlargement of the thyroid, face not swollen; skin is smooth, good color, sightly moist, no signs of rashes/swelling/color irregularitieswhat are some signs of poor nutritional status?listless, apathetic, cachectic appearance; easily fatigued, no energy, falls asleep easily, looks tired, apathetic, depressed mood; overweight or underweight; hair is dull/dry/brittle, loss of color, easily plucked, thin and sparce; dark skin over cheeks and under eyes, flaky skin, facial edema (moon face), pale skin color; pale eye membranes, dry eyes, Bitot's spots, increased vascularity, cornea soft, small yellowish lumps around eyes, dull or scarred cornea; lips are swollen/puffy, angular lesions at corners of mouth or fissures or scars; tongue is smooth appearance, beefy red or magenta colored, swollen, hypertrophy or atrophy; teeth have cavities, mottled appearance, malpostioned, missing teeth; gums are spongy, bleed easily, marginal redness, recessed, swollen, and inflamed; enlargement of the thyroid or parotid glands; skin is rough, dry, flaky, swollen, pale, pigmented, lack of fat under skin, fat deposits around joints, bruises, petechiaecheilosisa disorder of the lips characterized by crack-like sores at the corners of the mouthxerophthalmiacondition of dry eyekeratomalaciasoftening of the corneaXanthelasmasoft, raised yellow plaques occurring on the skin at the inner corners of the eyesstomatitisinflammation of the mouthFluorosisdiscoloration and pitting of tooth enamel caused by excess fluoride during tooth developmentgoiterenlargement of the thyroid glandXanthomasyellow deposits of cholesterol in tendons and soft tissuesinspection, auscultation, percussion, palpationwhat is the proper sequence for abdominal assessment?abdominal quadrantsRUQ, LUQ, RLQ, LLQascending and transverse colon, duodenum, gallbladder, hepatic flexure of colon, liver, pancreas (head), pylorus (the small bowel- or ileum- traverses all quadrants), right adrenal gland, right kidney (upper pole), right ureterright upper quadrant (RUQ) contains what organs?appendix, ascending colon, cecum, right kidney (lower pole), right ovary and tube, right ureter, right spermatic cordthe right lower quadrant (RLQ) contains what organs?left adrenal gland, left kidney (upper pole), left ureter, pancreas (body and tail), spleen, splenic flexure of colon, stomach, transverse desccending colonwhat organs are located in the left upper quadrant (LUQ)?left kidney (lower pole), left ovary and tube, left ureter, left spermatic cord, descending and sigmoid colonwhat organs are located in the left lower quadrant (LLQ)?bladder, uretus, prostate glandwhat organs are located at the midline?pt laying supine with hands resting at the center of the chest or with arms resting comfortably at their sideswhat is the proper position for the abdominal assessment? It promotes relaxation of the abdominal musclesGeneralized tympanywhat sound predominates over the abdomen because of air in the stomach and intestinesdullnesswhat sound is heard over the liver and spleen?accentuated tympany or hyperresonancewhat sounds are heard over a gaseous distended abdomenenlarged area of dullnesswhat sound is heard over an enlarged liver or spleen?abnormal dullnesswhat sound is heard over a distended bladder, large masses, or ascites?purple discoloration at the flanks(Grey-Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.yellow huejaundice; may be more apparent in the abdomenpale, taut skin________skin may be seen with ascites (significant abdominal swelling indicating fluid accumulation in the abdominal cavity)rednessmay indicate inflammationbruises or areas of local discolorationabnormal assessment findings in the abdomendilated veinsmay be seen with cirrhosis of the liver, obstruction of the inferior vena cava, portal hypertension, or ascitesdilated surface arterioles and capillaries with a central starmay be seen with liver disease or portal hypertensiondark blueish-pink striaeassociated with cushing's syndromestraiemay be caused by ascites, which stretches the skin. ascites usually results from liver failure or liver diseaseNonhealing wounds, redness, inflammation. Deep, irregular scars may result fromburnschanges including size, color, or border symmetry; bleeding or petechiaeabnormal mole findingsCullen's signbluish or purple discoloration around umbilicus. Indicates intra-abdominal bleedingdeeply in the epigastrium, slightly to the left of midlinewhere to palpate the aortastand at the client's right side and place your left hand under the client's back at the level of the eleventh to twelfth ribs. • Lay your right hand parallel to the right costal margin (your fingertips should point toward the client's head). • Ask the client to inhale, then compress upward and inward with your fingers. • Have the client exhale and hold your hand in place as the client inhales a second time.palpate the liverStand at the client's right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. • Pull up gently. • Place your right hand below the left costal margin with the fingers pointing toward the client's head. • Ask the client to inhale and press inward and upward as you provide support with your other handpalpate the spleensupport the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL. • To capture the kidney, ask the client to inhale. • Then compress your fingers deeply during peak inspiration. • Ask the client to exhale and hold the breath briefly. • Gradually release the pressure of your right hand. • If you have captured the kidney, you will feel it slip beneath your fingerspalpate the right kidney (reverse for L)Palpate the Urinary bladder procedurebegin at the symphysis pubis and move upward and outward to estimate bladder borderspalpating deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest (McBurney point) • Suddenly release pressure • Listen and watch for the client's expression of pain • Ask client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurredassess for rebound tendernessPalpate deeply in the LLQ and quickly release pressure Normal Findings: No rebound pain is elicited Abnormal Findings: Pain in the RLQ during pressure in the LLQ is a positive Rovsing sign; suggests acute appendicitisassessing for referred rebound tendernessAsk the client to lie on the left side. Hyperextend the client's right leg -Normal Finding: No abdominal pain is present. -Abnormal Finding: Pain in the RLQ (psoas sign) is associated with irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix).psoas signSupport the client's right knee and ankle. Flex the hip and knee, and rotate the leg internally and externally Normal Finding: No abdominal pain is present. Abnormal Finding: Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix.obturator signStroke the abdomen with a sharp object (e.g., broken cotton tipped applicator or tongue blade) or grasp a fold of skin with your thumb and index finger and quickly let go. • Do this several times along the abdominal wall. Normal Findings: The client feels no pain and no exaggerated sensation. Abnormal Findings: Pain or an exaggerated sensation felt in the RLQ is a positive skin hypersensitivity test and may indicate appendicitis.hypersensitivity testMurphy's signPain with palplation of gall bladder (seen with cholecystitis)Dry hard stool; persistently difficult passage of stool; and/or the incomplete passage of stoolwhat is constipation?decreased gastric motility slows passage of feces through large intestine, resulting in increased fluid absorption from fecal mass and causing dry, hard stool; straining often accompanies defecationpreventing and treating constipationpts on bedrest or with decreased mobility; taking contipating medications; w reduced fluids, bulk, or fiber in their diet; who ignore the urge to defecate; who are depressed; w central nervous system disease or local lesions that cause pain while defecatingpeople at high risk for constipationthe passage of more than 3 loose stools a day; acute or chronicwhat is diarrheaimportant to determine consistency of stool, as frequent bowel movements alone are not always indicative of diarrhea, but pts with diarrhea usually pass stools more frequently; often associated w intestinal cramps; Nause and vomiting may occur; blood may also be noted; can be a protective response when cause is an irritant in intestinal tract; large amounts of fluids and electrolytes may be lostpreventing and treating diarrheaviral or bacterial infection, a reaction to medication, or alterations in diet; sudden onset; rehydration is essential; oral liquids may be used if patient can tolerate them or IV fluid replacement; hand hygeine; avoid antidiarrheal agents in acute diarrhea until a bacterial causative agent has been ruled outtreating acute diarrhealasts longer than 3 to 4 weeks; thorough workup is needed in pt with this to determine underlying cause; if severe or prolonged, may require pharmacologic intervention and fluid and electrolyte replacementtreating chronic diarrheainflammatory bowel disease (Crohn's disease, ulcerative colitis), IBS, malabsorption syndromes, bowel tumor, metabolic disease (diabetes, hyperthyroidism), parasitic infection, side effects of drugs, laxative abuse, surgery, alcohol abuse, and radiation and chemotherapeutic agentswhat are possible causes of chronic diarrhea?enemas, rectal suppositories, oral intestinal lavage, digital removal of stoolwhat are some medical ways to empty the colon of feces?solution intorduced into the large intestine, usualy to remove feces; also used to administer certain meds; instilled solution distends intestine and irritates intestinal mucosa, thus increasing peristalsis; generally classified as cleansing or retentionwhat are enemas?removes feces from the colon, commonly to: relieve constipation or fecal impaction, prevent voluntary escape of fecal material during surgical procedures, promote visualization of the intestinal tract by radiographic or instrument examination, help establish regular bowel function during a bowel-training program; large volume cleansing and small volume cleansingwhat are cleansing enemas?large volume cleansing enemausing solution anywhere from 750-1,000mLsmall volume cleansing enemausing solution anywhere from 100-200mLretained in bowel for a long period for different reasons; 4 tpes- oil-retention, carminative, medicated, anthelminticretention enemaslubricate the stool and intestinal mucosa, easing defecationoil-retention enemahelp expel flatus from rectumcarminative enemaprovide meds that are absorbed thru rectal mucosamedicated enemadestroy intestinal parasiteanthelmintic enemaa conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature; various are available; can be used to stimulate bowel in a constipated patient; retention suppositories deliver drug therapy and can be used to deliver meds such as antipyretics when pt is unable to take them orallyrectal suppositoriesoral intestinal lavageOral solutions, such as GoLYTELY or Colyte, which are polyethyl glycol solutions (PEG), can be used to cleanse intestine of feces; Prescribed by health care provider and can be administered before diagnostic tests that require a clear bowel for visualization purposes or as a "bowel prep" before intestinal surgery; Evacuation of feces usually begins within 1 hour after first glass and is completed within 4 to 6 hours; Considered safe, as they are not irritating to intestine and are low risk for causing electrolyte imbalancesIf patient with fecal impaction cannot expel fecal mass voluntarily and oil and cleansing enemas fail to break up mass, the impaction may need to be removed manually; An order from the primary health care provider is required; Procedure is very uncomfortable and may cause great discomfort to patient as well as irritation of rectal mucosa and bleeding; this can stimulate vagus nerve, resulting in a slowed heart rate; If this occurs, stop procedure immediately, monitor patient's heart rate and blood pressure, and notify primary health care providerdigital removal of stoolelevate HOB, assess nares and contraindications, measure NGtube, insert NG tube, aspirate gastric contents, x-rayproper NG tube insertion orderinserted to depcompress or drain stomach fluid or unwanted stomach contents- used for patients w conditions such as a prolonged postoperative ileus or a small bowel obstruction; used to allow GI tract to rest before or after abdominal surgery to promote healing; also used when conditions are present in which peristalsis is absent; inserted to monitor gastrointestinal bleedingNG tube reasons for insertionallows liquid fecal content from ileum of small intestine to be eliminated through stomaileostomypermits formed feces in the colon to exit through the stoma (opening of the ostomy attached to the skin)colostomyostomya surgically formed opening from the inside of an organ to the outsidestomathe part of the ostomy that is attached to the skin; formed by suturing the mucosa to the skinsigmoid colostomy, descending colostomy, transverse colostomy, ascending colostomy, ileostomywhat are the different types of ostomies?keep pt as free of odors as possible; empty the appliance frequently; inspect the pts stoma regularly; measure pts fluid intake and output; explain each aspect of care to the pt and self-care role; encourage pt to care for and look at ostomycolostomy caredrainable appliances- when it's approx. 1/3 full, thereby reducing the risk of leakage and potential odor; remove and change nondrainable pouches when they are half fullemptying the colostomy bagshould be dark pink or beefy red and moist; note the size, which should stabilize win 6 to 8 weeks; keep the skin around the stoma site clean and drynormal findings when inspecting the pts stomadeep breathingnurse instructs patient to breath in thru nose, deep enough to move bottom ribs, and exhale thru mouth. This is: deep breathing, pursed-lip breathing, using incentive spirometry, diaphragmatic breathingPalpating for Fremitusnurse asks client to say "99" while palpating chest wall, assessing for symmetry and intensity of vibration. this is: palpating for fremitus, palpating for crepitus, palpating for chest expansion, palpating for tendernessactivate device while continuing to inhalethe correct use of a metered dose inhaler (MDI) includes which of the following? hold canister upside down, activate device while continuing to inhale, inhale 2 sprays w 1 breath, stop inhaling when cold propellant is felt in throatnasal cannulawhat is the most commonly used oxygen delivery device? venturi mask, nonrebreather, nasal cannula, simple maskreservoir bag is filled with oxygen that enters the mask on inspirationwhich is true about using nonrebreather mask? pt rebreathes 1/3 expired air, bag delates completely w inspiration, does not impede eating or talking, reservoir bag is filled with oxygen that enters the mask on inspirationapply intermittent suctioning when withdrawling a catheterguidlines for suctioning pt with a traheostomy: apply intermittent suctioning when withdrawling a catheter, use medical asepsis, apply intermittent suction for 20 to 30 seconds,perform routine suctioning Q 2-3 hoursvesicularwhich of the following are normal breath sounds? vesicular, crackles, wheezes, rhonchipalpateto check for crepitus, fremitus, and chest expansion, the nurse will: auscultate, percuss, palpate, inspectEmphysemanurse percusses pts chest for tone and notes hyperresonance. this is the expected finding for which of the following? pneumonia, pleural effusion, emphysema, tumorthe flow rate will be no more than 2-3 L/min or lessPt with COPD recieving oxygen thru nasal cannula- what is priority nursing intervention? oxygen must be humidified, flow rate needs to be at least 5 L/min, the flow rate will be no more than 2-3 L/min or less, check the air intake valves are not blockedbradycardiaall of the following are early indications that pt is developing hypoxia except for: confusion, bradycardia, restlessness, tachypneaaortic and pulmonicclosure of which valves generates S2 heart sound? atrioventricular valves, mitral and bicuspid, chordae tendinea, aortic and pulmonicright sided heart failurefully distended jugular veins at 45, 60, 90 degrees may indicate: pulmonary hypotension, normal finding, decreased venous pressure, right sided heart failureFifth ICS near the left MCL—the apex of the heartauscultate the mitral area of the heart: fourth or fifth ICS at the left lower sternal border, third ICS at the left sternal border, Fifth ICS near the left MCL—the apex of the heart, second ICS at the right sternal border- the base of the heartphysiologic S3- is a benign finding commonly heard at the beginning of the diastolic pause in children, adolescents, and young adults: mitral valve prolapse, physiologic S3, physiologic S4, murmurtruea physiologic S3 usually subsides upon standing or sitting up- true or falseafrican americanswhich culture has the highest rate of hypertension? eskimo, african americans, asians, caucasian americansmoderate, 6mm, prolonged skin responsethe depth of pitting reflects the degree of edema. which of the following reflects 3+ edema? severe, 8mm, prolonged skin response; moderate, 6mm, prolonged skin response; mild, 4mm, 10-15 second skin response; 2mm, rapid skin responseall of the abovea pulse rate deficit (difference bt the apical and peripheral/radial pulses) may indicate [select all that apply]: atrial fib, varying degrees of heart block, atrial flutter, premature ventricular contractions, all of the aboveTask the client to stand when assessing for varicose veins bc they may not be visible when the client is supine- T or Fa. truearterial insufficiency: dependent rubor, elevation pallor of foot, dry/shiny skin, cool-to-cold temp a. true b.falseGrey-Turner signpurple discoloration at the flanks indicates bleeding within the abdominal wall, possibly from trauma or pancreatitis cullen sign, murphy sign, grey-turner sign, rovsing signclaudicationwhat is most often a symptom of peripheral artery disease?appenicitisrovsing, blumberg, psoas, obturator signs are assesing for: acities, cholescytisis, appendicitis, splenomegalyRUQduodenum, gallbladder, hepatic flexure of colon, and liver are found in: epigastric area, RUQ, LUQ, RLQgreen or blue greenantidepressant amitriptyline (Elavil) or B-comlex vitamins can change urine color: red, orange, brown, green or blue greenfalseusing aseptic technique, pour the urine into an appropriate container, label the lid with the pts name, date and time: true or falseclean catch mid stream specimenpatient voids and discards a small amount of urine, contiues voiding in a sterile container to collect the urine: indwelling catheter specimen, routine UA, 24-hour Urine specimen, clean catch mid stream specimen