MEDICAL SURGICAL FINAL EXAM 1. Know the assessment techniques A. Inspection= The visual examination -The critical observation of the client for any physical signs that indicate alteration from normal -Can be done during hygiene care -Used to assess body surface, shape, size, color, position, and sy...
1. Know the assessment techniques
A. Inspection= The visual examination
-The critical observation of the client for any physical signs that indicate alteration from normal
-Can be done during hygiene care
-Used to assess body surface, shape, size, color, position, and symmetry
B. Palpation= Using the sense of touch (DEEP PALPATION IS NOT WITHIN THE SCOPE OF LPN)
-Texture of hair
-Temperature of skin
-Vibration of joints
-Size/ Position/ shape/ Consistency/ Texture/ Mobility of masses
-Collection of fluid/ Presence of distention
-Pulses
-Tenderness and Pain
C. Percussion= The deliberate striking or tapping of a body part to elicit sounds/vibrations
-Direct percussion: striking an area directly with 1 to 3 finger pads or with the pad of the middle
finger rapidly
-Indirect percussion: striking an object against the area (another finger)
-Assesses the size and shape of internal organs (boundaries)
-Assesses if the tissue is filled with fluid/ air/ solid
D. Auscultation= Listening for sounds produced by the body
-Direct: using the unaided ear
-Indirect: using a stethoscope
-Listen for intensity (loudness of softness of the sound)
-Listen for pitch (frequency of vibrations)
-Listen for duration (length of the sound; short to long)
-Listen for quality (the subjective description of the sound; whistling, gurgling etc.)
2. Difference between normal and adventitious breath sounds
Normal Breath Sounds:
A. Vesicular= soft, breezy, sighing sound; best heard over periphery/ bases
B. Bronchovesicular= blowing sound & large amt. of air through lung tube; best heard over first
and second intercostal spaces substernal
C. Bronchial= high pitched, harsh, loud sound caused by air moving through the trachea; best
heard over anterior trachea, not normally heard over lung tissue.
Adventitious Breath Sounds:
A. Crackles (rales)= cause by air passing through fluid/ mucous in air passages
i. heard on inspiration and is most commonly heard in the bases of the lungs
ii. usually do not clear with coughing
B. Gurgles (rhonchi)= air passing through narrow air passages as a result of secretions, swelling
or tumors.
i. clear with cough
,ii. usually heard over trachea and bronchi
iii. best heard during expiration
iv. course gurgling, harsh sounds or like snoring
C. Wheezes= continuous, high-pitched, musical sound
i. caused by air passing through constricted bronchi because of secretions, swelling or tumors.
ii. best heard on expiration over all lung fields
iii. not usually cleared by coughing
D. Friction Rub= grating sound due to inflamed visceral and parietal pleurae rubbing
i. usually heard over the anterior lateral chest.
ii. can be heard on inspiration and expiration
iii. not relieved by coughing
3. Normal heart sounds
S1= Closure of the atrioventricular Valve (the “lub”)
a. mitral and tricuspid valves close when the ventricles have filled
S2= Closure of the Semilunar Valves (the “dub”)
a. higher pitched and shorter than S1
b. aortic and pulmonic valves close when the ventricles have emptied
Systole= when ventricles are contracted- begins with S1 and ends with the beginning of S2
Diastole= when ventricles relax- starts with S2 and ends with S1
4. Glasgow Coma Scale
-Originally used to predict head injury recovery- now used to assess Level of Consciousness
-Tests 3 areas:
a. Eye response
b. Motor response
c. Verbal response
(Total points= 15; less than 7= comatose)
, 5. Signs of ETOH Withdrawal
-Occurs within 4 to 12 hours after last drink and may last several days after abstinence
-Signs:
a. coarse tremor of the hands, tongue, or eyelids
b. sweating
c. N/V
d. depressed mood or irritability
e. headache
f. insomnia
g. illusions/ hallucinations in some cases
6. Care of a patient with Obsessive Compulsive Disorder
-Obsessions= recurrent and persistent thoughts, urges, or images that are intrusive and
unwanted.
-Compulsions= repetitive behaviors (hand washing, checking something, etc.) or mental acts
(praying, counting, repeating words, etc.)
-The obsessions and/or compulsions are aimed at reducing or preventing anxiety or distress or
dreaded event or situation.
-Treatment= Cognitive therapy, desensitization therapy, SSRIs
7. Care of patient with suicidal ideations
-Suicide: often due to anger toward a person or event turned inward
-Most common reason: a solution
-Stimulus: intense psychological pain, helpless, and/or hopeless
-Goal: Relief from emotional pain
Interventions:
a. Provide a safe environment
b. constant supervision- 1:1 direct; no more than arm’s length away
c. NEVER leave the patient without relief from a competent staff member- always remember to
give report
d. be alert at all times, but warm and supportive
e. search belongings/ room for items that could be used to attempt suicide- new admits
especially
f. Remove: belts, shoes laces, sheets, shaving supplies, hangers, cosmetics, mirrors
g. conduct regular body searches and check oral cavity after medication administration
h. provide a safe environment
i. non-judgmental tone/ body language
j. create a support system list- family/friends/support groups/ community organizations
8. Care or a patient with Schizophrenia Spectrum Disorder
Nursing Care:
-Avoid touching patient
-Observe for signs of hallucinations
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