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Exam 3 Notes NSG 121

Exam 3 notes based off of study guide

Course

Health Assessment (NSG 121)

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Herzing University

Academic year: 2021/2022

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Health Assessment HEALTH ASSESSMENT

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LOOK AT LAB CHECK OFFS ! !!

The heart and great vessels are located in the

mediastinum between the lungs and above the diaphragm - Summation gallop= Presence of both 53 and 54 - What must a nurse assess

frequently after a

cardiac Cath? - Bleeding at the puncture site , Hematoma at the puncture sight , increased BP , because it can cause excess bleeding or hematoma

Most important lifestyle changes to improve cardiac health are :
- stop smoking

####### Reducinghigh BP

Reducing high cholesterol
A pericardial friction rub is the most important physical sign of acute pericarditis

can be heard if the client is

####### holdingtheir breath

Outcomes related to cardiac problems include : *normal BP * adequate urinary output *Negative JVD * No S3 or S4 *No arrhythmias

adequate circulation status with strong peripheral pulses

When assessing a client with mitral stenosis the technique used to listen to this condition is , place the bell of the stethoscope over the apex with client on the left side
Jugular vein distention , weight gain , dyspnea , orthopnea , PND , S3 or 54 and edema indicate excess Fluid volume , associated with HF
Blood pressure is most important to monitor when a patient is experiencing decreased cardiac output
Treatments for MI: *Nitroglycerin * bedrest to decrease oxygen consumption *angioplasty

thrombolytics

Aortic stenosis is best heard over the 2nd or 3rd right intercostal space
The thoracic ducts return the lymph fluid to circulation

• Previous

surgeries increase the risk for adhesions, infections,

obstructions , and malabsorption

• A barium enema is contraindicated for

any acute

inflammatory condition

IX. Diverticulitis, Ulcerative colitis

RUQ =Dullness LUQ = Hollow tympanic notes

• 33 Vertebrae make

up the spinal column

- 7

cervical - 5 lumbar -31-04 coccygeal

- 12 thoracic -5 Sacral

• Lordosis = increased lumbar curvature

. Compensates for

enlarging uterus

' Restraints are not

appropriate For most situations . LAST

RESORT

• Abduction =

Away From midline

Adduction= Towards midline

• To test for Allis'

sign place the infant in supine

position with flexed hips , knees and both feet

flat on the table

*Positive

sign

= One knee lower than the

other

Barlowe maneuver = IF

clicking sound

is

audible this is a positive indication of hip

dislocation

• Assessment of the musculoskeletal

system is

done From General → specific Head → Toe

- Phalen s Test = Evaluates for

carpal tunnel

*Patient flexes wrist 90° For 60 seconds

Normal = NO discomfort

• Tiriel 's = Test for irritated nerves

• Ballotferment = Assess for increased fluid in the knee

Joint

McMurray

= Tests For tears in the Meniscus of the knee

• stiffness and

pain related to rheumatoid arthritis is

worse in the morning and after activities and usually

occurs in the upper extremities.

Risk Factors For osteoporosis are high salt intake, smoking, and alcohol consumption - Women are more at risk

Kyphosis

= An exaggerated thoracic curve and is common in

####### aging

Crepitus and decreased ROM are associated with arthritis

straight leg flexion that produces back and leg pain

radiating down the leg mayindicate a herniated disc.

The corpora cavernOsa is the part of the penis that fills with blood when the penis becomes erect
Infants

commonly produce stool after every feeding

due to Gastrocolic reflex

Newborns

with dark tarry stools and vomiting blood

may

have a Vit 1h deficiency

Risk For infection is related to

####### inadequate

knowledge , urinary reflux, recent trauma, and urinary Catherization

Paraphimosis = When the retracted prepuce cannot be placed back over the glans
Semen is ejaculated From the prostate , seminal vesicles , Vas deferens, epididymides -

Signs of partial prostate obstruction :

dribbling, recurrent acute UTI s , straining, hesitancy ,

sensation of residual urine

Testicular torsion usually occurs on the left side

presents with nausea vomiting and requires emergency surgery acute Pain
A

####### patient suffering from urinary retention may be instructed

to try double voiding '

signs of BPH .

Dribbling after

urination , weak

urinary

stream , nocturne, inability to empty

bladder

The vagina is a tube of muscular tissue that extends From the vaginal introitus to the uterus
Tobacco is contraindicated for any patient over 40 Using hormonal contraceptives

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