NR 304 Final Exam Concepts
Student Name
Chamberlain University
NR-304: Health Assessment II
Prof. Name
Date
Chapter 1
Identify steps of Nursing Process: Evaluation
The evaluation step in the nursing process involves reassessing the patient and determining whether the goals of care have been met. This step is crucial for adjusting interventions as needed and ensuring patient-centered outcomes.
Identify tasks in Nursing Process: Diagnosis
During the diagnosis phase, nurses compile patient data to identify a NANDA diagnosis. Data is clustered, and irrelevant information is discarded to accurately define the patient’s health problem.
Types of Databases: Problem Centered
A problem-centered database focuses on a limited or short-term problem, often involving one complex problem or a specific body system. It is used in all healthcare settings for efficient and targeted assessment.
| Type of Database | Characteristics | Setting |
|---|---|---|
| Problem-Centered | Limited scope, short-term, focuses on one problem | All settings |
Chapter 9
Identify Components of the General Survey
The general survey involves a study of the whole person and begins upon entry to the room. Key components include:
Physical Appearance:
- Age: Appears their stated age.
- Sex: Development appropriate for sex and age; for transgender patients, note stage of transformation.
- Level of Consciousness: Alert and oriented to person, place, time, and situation.
- Skin Color: Even tone, pigmentation varies; note tattoos and piercings.
- Facial Features: Symmetry of the face.
- Overall Appearance: Look for signs of acute distress.
Body Structure:
- Stature: Height appropriate for age/genetics.
- Nutrition: Weight within normal range for height/build.
- Symmetry: Body parts equal bilaterally.
- Posture: Stand erect with a “plumb line” through ear, shoulder, hip, patella, ankle. Exceptions: toddler lordosis, aging kyphosis.
- Position: Sits comfortably, arms relaxed at sides, head toward examiner.
- Body Build/Contour: Arm span ≈ height; crown to pubis ≈ pubis to sole.
- Obvious Physical Deformities: Note any visible deformities.
Mobility:
- Gait: Feet shoulder-width apart, smooth, balanced, symmetric arm swing.
- Range of Motion: Full mobility for joints; movement smooth, coordinated, no involuntary motion.
Behavior:
- Facial Expression: Maintains eye contact appropriately; expressions suit situation.
- Mood/Affect: Comfortable, cooperative, pleasant interactions.
- Speech: Clear articulation, fluent pattern, appropriate word choice.
- Dress: Appropriate to climate/culture, clean, fits body.
- Personal Hygiene: Clean, groomed according to age, occupation, socioeconomic group.
- Interaction with Others: Observe patient’s interpersonal interactions.
Chapter 10
Differentiate the grading of Pulse Force
| Grade | Description |
|---|---|
| 3+ | Full, bounding pulse |
| 2+ | Normal |
| 1+ | Weak, thready |
| 0 | Absent |
Identify Hypotension Occurrences and Rationales
- Acute myocardial infarction: Decreased cardiac output
- Shock: Decreased cardiac output
- Hemorrhage: Decrease in total blood volume
- Vasodilation: Decrease in peripheral vascular resistance
- Addison disease: Decreased circulating aldosterone
Recognize how to Count Respirations
- Do not inform patient you are counting respirations.
- Count for 30 seconds after pulse assessment, then multiply by 2, or a full minute if abnormality is suspected.
Recognize the Effects of Smoking on Blood Pressure
Smoking contributes to hypertension.
Chapter 11
Identify Physiologic Changes: Acute Pain Responses
Acute pain manifests through guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, and changes in vital signs.
Chapter 13
Recognize the ABCDEF of Skin Lesions
- A: Asymmetry
- B: Border irregularity
- C: Color variation
- D: Diameter >6 mm
- E: Elevation or evolution
- F: Funny looking
Assessing Clubbing
| Technique | Indication |
|---|---|
| Patient makes a heart with hands | Look for gap between nails |
| Profile sign | Nail base should be ~160° |
Detect Color Changes in Light and Dark Skin
| Skin Type | Pallor | Cyanosis | Erythema | Jaundice |
|---|---|---|---|---|
| Light | Generalized/localized | Dusky blue, nail beds dusky | Red, bright pink | Yellow in sclera, hard palate, mucous membranes |
| Dark | Yellow-brown, ashen gray | Dark, dull; check conjunctiva, oral mucosa, nail beds | Purplish tinge; palpate warmth | Hard/soft palate junction, palms |
Characteristics of Pressure Injuries
| Stage | Description |
|---|---|
| I | Non-blanchable redness |
| II | Partial-thickness skin loss, open blister, red-pink bed |
| III | Full-thickness skin loss, crater, subcutaneous fat visible |
| IV | Full-thickness tissue loss, exposes muscle/tendon/bone, slough/eschar |
Chapter 14
Neck Assessment Techniques: ROM
- Ask patient to touch chin to chest, turn head side to side, ear to shoulder, extend backward.
- Note limitations in movement.
Manifestations of Hypothyroidism
- Goiter, eyelid retraction, exophthalmos.
Chapter 18
Clinical Manifestations of Breast Cancer
- Discomfort, inverted nipple, lumps, nipple discharge.
Complications of Mastectomy
- Bleeding, infection, pain, arm swelling, shoulder stiffness, numbness from lymph node removal.
Chapter 19
Thorax and Lung Inspection Techniques
- Observe chest wall shape, spinous process alignment, thorax symmetry, skin color/condition, and breathing position.
Adventitious Breath Sounds
| Sound | Characteristics |
|---|---|
| Wheezes | High-pitch: musical, squeaking; Low-pitch: snoring, moaning, may clear by coughing |
| Crackles | Fine: high-pitch, discontinuous, inspiration, not cleared by cough; Coarse: low-pitch, bubbling, may decrease by coughing |
Clinical Examples
| Crackles | Condition |
|---|---|
| Fine | Pneumonia, heart failure, interstitial fibrosis, chronic bronchitis, asthma, emphysema |
| Coarse | Pulmonary edema, pneumonia, pulmonary fibrosis, terminally ill |
Tachypnea Indications
- Rate >24/min
- Fever, fear, exercise, respiratory insufficiency, pneumonia, alkalosis, pleurisy, pontine lesions
Pulmonary Embolism Manifestations
| Method | Findings |
|---|---|
| Subjective | Chest pain on inspiration, dyspnea |
| Inspection | Apprehension, restlessness, cyanosis, tachypnea, cough |
| Palpation | Diaphoresis, hypotension |
| Auscultation | Tachycardia, crackles, wheezes |
NR 304 Final Exam Concepts
Asthma Manifestations
| Method | Findings |
|---|---|
| Inspection | Increased RR, SOB with wheeze, accessory muscle use, cyanosis, barrel chest (chronic) |
| Palpation | Decreased tactile fremitus, tachycardia |
| Auscultation | Diminished air movement, prolonged expiration, bilateral wheezing |
Chapter 20
Heart Failure Manifestations
- Dilated pupils, pale/cyanotic skin, dyspnea, orthopnea, crackles/wheezes, cough, decreased BP, edema, anxiety, falling O₂ sat, jugular vein distention, fatigue, enlarged liver/spleen, weak pulse, cool/moist skin.
Health Promotion Tips
- Aspirin therapy, BP/cholesterol control, smoking cessation, lifestyle changes.
Acute Coronary Syndrome Symptoms
- Indigestion, nausea, vomiting, dizziness, flushing, perspiration, palpitations, dyspnea, fatigue.
Chapter 21
Peripheral Vascular System Assessment
| Assessment | Findings |
|---|---|
| Subjective | Leg pain/cramps, skin changes, swelling, lymph node enlargement, smoking, medications |
| Inspection/Palpation | Pulses, capillary refill, clubbing |
Nursing Diagnosis for Lymphedema
- Inadequate lymphatic drainage.
Alleviating Factors for Venous Insufficiency
- Elevation, lying, walking.
Varicose Veins Manifestations
| Type | Findings |
|---|---|
| Subjective | Aching, heaviness, fatigue, restless legs, burning, throbbing, cramping |
| Objective | Dilated, tortuous veins |
DVT Manifestations
| Type | Findings |
|---|---|
| Subjective | Sudden intense deep muscle pain |
| Objective | Warmth, swelling, redness, tenderness |
Venous Return Mechanisms
- Skeletal muscle contraction, breathing pressure gradient, intraluminal valves.
Chronic Venous Symptoms
- Edema, varicosities, weeping ankle ulcers.
Edema Grading
| Grade | Description |
|---|---|
| 1+ | Mild pitting, slight indentation, no swelling |
| 2+ | Moderate pitting, indentation subsides rapidly |
| 3+ | Deep pitting, short-lasting indentation, swollen leg |
| 4+ | Very deep pitting, prolonged indentation, grossly swollen |
Chronic Arterial Symptoms
- Low ankle-brachial index, cool/pale skin, diminished pulses, pallor on elevation.
Peripheral Vascular Changes: Aging Adult
- Arteriosclerosis, enlarged intramuscular calf veins, lymphatic tissue loss.
Chapter 22
Abdominal Distension Assessment: Obesity
| Method | Findings |
|---|---|
| Inspection | Uniformly rounded, sunken umbilicus |
| Auscultation | Normal bowel sounds |
| Palpation | Normal, may be hard through thick wall |
Hypoactive Bowel Sound Causes
- Decreased motility from peritonitis, paralytic ileus post-surgery, late bowel obstruction.
Intestinal/Bowel Obstruction Findings
| Type | Findings |
|---|---|
| Laboratory | Dehydration, electrolyte loss, possible sepsis |
| Radiology | Fluid/gas accumulation proximal to obstruction |
| Physical Exam | Restless, ill-appearing, distended abdomen, hyperactive early, hypoactive late, tenderness, hypovolemic shock |
Clinical Manifestations
- Vomiting, fever, absent stool/gas, colicky pain above obstruction.
Positive Murphy Sign Indication
- Inspiratory arrest.
Involuntary Rigidity vs Voluntary Guarding
- Involuntary: Constant boardlike hardness from peritoneal inflammation.
- Voluntary: Bilateral, relaxes on exhalation, occurs if cold, tense, ticklish.
Chapter 23
Late Rheumatoid Arthritis Manifestations
- Ulnar deviation/drift.
Osteoarthritis Spinal Deformities
- Kyphosis, limited ROM.
Osteoporosis Risks
- Postmenopausal white women, small height/weight, early menopause, lack of physical activity, estrogen deficiency.
Chapter 24
Cranial Nerve I-XII Assessment
| Nerve | Test |
|---|---|
| I | Present familiar scent, eyes closed |
| II | Visual fields by confrontation |
| III, IV, VI | Pupils, light reaction, gaze positions |
| V | Motor: palpate masseter/temporal; Sensory: cotton wisp touch |
| VII | Facial mobility: smile, frown, raise eyebrows, show teeth, puff cheeks |
| VIII | Whispered voice test |
| IX, X | Tongue depressor, say “ahhh”; uvula rises, tonsillar pillars move |
| XI | Raise shoulders, turn head against resistance |
| XII | Inspect tongue, say “light, tight, dynamite” |
Glasgow Coma Scale Score
- Normal: 15
- ≤7: Coma
FAST Plan for Stroke
- Face drooping, Arm weakness, Speech difficulty, Time to call 911
Stroke Risks and Manifestations
| Type | Findings |
|---|---|
| Risks | Hypertension, smoking, heart disorders |
| Manifestations | Weakness/numbness on one side, confusion, vision changes, dizziness, loss of balance, severe headache |
Positive Romberg Test
- Loss of balance with eyes closed, seen in cerebellar ataxia, proprioception or vestibular loss.
Chapter 25
Urinary Retention Manifestations
- Inability to pass urine, may cause UTI.
Chapter 26
BPH Manifestations
| Type | Findings |
|---|---|
| Subjective | Urinary frequency, urgency, hesitancy, weak/intermittent stream, incomplete emptying, nocturia |
| Objective | Symmetric, nontender enlargement, smooth/rubbery/firm surface, occurs midlife males |
Chapter 27
Older Adult UTI Symptoms
- Communication problems, confusion, lethargy.
References
Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.
Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care (8th ed.). Elsevier.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (9th ed.). F.A. Davis Company.
NR 304 Final Exam Concepts
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2017). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.