Exam 3 V2: NUR 210/ NUR210– Principles of Pharmacology Guide | Galen (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A

Exam 3 V2: NUR 210/ NUR210– Principles of Pharmacology Guide | Galen (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A 1. The nurse auscultates the patient's abdomen and hears in RUQ rushing, tinkling, high pitched sounds. These type of sounds indicate: a. Hyperactive bowel sounds b. Small bowel obstruction c. Normal finding d. Hypoactive bowel sounds a. Hyperactive bowel sounds 2. Which statement by the patient indicates he has a medical history of dysuria? a. "I seem to void alot at night." b. "My urine is red or rust color" c. "My urine is cloudy" d. "I have trouble starting to void d. "I have trouble starting to void 3. The patient, during a comprehensive assessment, asks why the nurse listens to the bowel sounds before palpation or percussion. Which statement by the nurse below indicate correct rationale about assess the abdomen a. "I just finished assessing your lungs and heart and proceeded to the abdomen because you were in the proper position for it." b. "There are not any set rules of assessment." c. "To avoid altering bowel sound activity" d. "To avoid you any pain or discomfort" c. "To avoid altering bowel sound activity" Where is the vertical line of the abdomen? xyphoid of sternum thorugh umbilicus What line runs through umbilicus across abdomen? lateral How many abdominal regions are there? -9 -rt. hypochondriac region -rt. lumbar region -rt. iliac (injuinal) region -epigastric region -umbilical region -hypogastric region -lt. hypochondriac region -lt. lumbar region -lt. iliac (inguinal) region Is elimination, abdominal pain, indigestion, appetite, history, lifestyle practices considered subjective or objective data? subjective Is it important to recognize elimination as sensitive & facilitate response w/ descriptive terms/ex? yes What does referred pain means in terms of abdominal pain? the pains coming from different locations Would older adults have diminished pain sensitivity? yes Dull, aching, knife like, stabbing, throbbing are all abdominal pain descriptions? yes Emesis nausea/vomiting What are the most important ?'s to ask w/ emesis? -when does it occur -what triggers it What is declined appetite in older adults caused by? -altered metabolism -decreased tastes -decreased mobility What are the 3 ?'s to ask with elimination? -# of stools/ day -consistency -any recent change? What are the 4 urine ?'s to ask? -# times void in day -# times void at night -color -odor Do older adults have a risk for complications w/ diarrhea and are more prone to UTI's? yes bc protective bacteria decreases w/ age Are voids often w/ pregnancy? yes Alcohol use, food preferences, caffenien use, exercise, stress are all lifestyle practices that effect what? -abdominal health asses. Is it important to allow the client to empty their bladder before assessment? yes Supine with arms by side, legs flexed slightly is important position for what? -abdominal asses. -raising arms above head tenses muscle -towel under knees helps relax muscles Inspection, ausculation, percussion, palpation is the sequence for what? abdominal asses. To avoid altering bowel sound activity what must be done? ausculate BEFORE percussion & palpation Is it normal for abdomen skin to be paler than general skin tone? yes A purplish color at flanks (looks like bruising & browner skin that is dried blood) is what sign & indicates what? -Grey-turner sign -indicates bleeding w/in abd Can jaundice be evident on abd? what is it usually accompanied w/? -yes -paler, taunt skin, ascites What is ascites? swelling associated w/ fluid accumulation Are scattered veins normal with abd asses.? yes Are dilated veins normal w/ abd asses.? What does it indicate? -no -cirrhosis of liver What is a common finding with older adults in terms of vascular abd asses.? dilated superficial capillaries w/out pattern are visible in light Striae is what? stretch marks Is new striae that is pink or bluish color and old striae that is silvery, white & linear normal in an abd asses.? yes Dark bluish-pink striae is normal when assessing abd TRUE OR FALSE false What S&S are associated w/ adrenal syndrome or ascites? dark bluish pink striae Presence of scars should alter you to the possibility of what in abd asses.? adhesions Scars should be pale, smooth, minimally raised (old scars) TRUE or FALSE true Healing wounds, redness, inflammation, keloid scars are what w/ abdominal asses.? abnormal Keloid scars are most common w/ -african amer. -asians None or some flat or raised brown moles are normal lesions with skin asses on abdomen? yes How do you know a mole is irregular? -size -shape -borders -symmetry -bleeding Is petechiae a normal finding in an abd. asses? no Should the umbilicus be of similar color as skin tone on abd? yes What is cullen's sign? -blue or purple around umbilicus meaning periumbilical ecchymosis -seen when inspecting abdomen Should the midline be at the lateral line when asses. umbilicus? yes A deviated umbilicus could be caused by? -pressure from mass -enlarged organs -hernia -fluid or scars Inverted, recessed or slight protusion is normal or abnormal when asses. countour of umbilicus? normal Everted due to abdominal distention & umbilical hernia are abnormal findings when asses. umbilicus contour TRUE OR FALSE true Abdominal contour should be flat, evenly rounded or scaphoid in thin adults TRUE OR FALSE true Look from what position to determine abd. contour? side while laying down from slightly higher than level of abd. A protuberant abd could indicate what? -obesity -air -fluid Distention below umbilicus could indicate what? -distended bladder -uterine enlargement -ovarian tumor or cyst Distention of upper abd could indicate what? -pancreatic masses -gastric dilation -scaphoid (sunken) w/ severe weight loss What are the 6F's/ major causes of abd. distention? -fat -feces -fetus -fibroids -flatulence -fluid What could asymmetry of the abdomen mean? -organ enlargement -masses -hernia -bowel obstruction -diastasis recti (gap between muscle) When inspecting the abdomen and the client raises head what is abnormal? -hernia bulge -diastasis recti bulge -incisional hernia -more prominent masses in abdominal wall Is it normal to see abdominal movement with respirations? yes Thoracic breathing is abnormal with clients with what? peritoneal irritation Is it normal for slight pulsation of the abdominal aorta in the epigastrium? What type of individuals is it most visible in? -yes -thinner ppl Vigorous, wide, exaggerated aortic pulsations are S&S of what? -abdominal aortic aneurysm -EMERGENCY How is an AAA screened? When is a normal screening? -ultrasound -men 65-75 old who have smoked Can peristaltic waves be seen usually? no unless very thin If peristaltic waves are increased and progress in what type of way what may be the problem? -ripple like fashion -intestinal obstruction With an intestinal obstruction, the ripple of the peristaltic waves move from what quadrant to what quadrant? LUQ to RLQ What part of the stethoscope do you use to auscultate the bowl? diaphragm What quadrant do you begin at to auscultate the bowl? why? -RLQ with light pressure -bc its the most active site What direction do you move to auscultate the bowl? clockwise What 3 things are important to note when auscultating the bowel? -intensity -pitch -frequency TRUE OR FALSE it is abnormal for bowl sounds to be intermittent, soft, clicks, and gurgles 5 10/ min False Borborygmus hyperactive bowel sounds, loud, prolonged gurgles What might be heard with hyperactive bowel sounds? -rushing -tinkling -high pitched Are hyperactive, hypoactive, and absent bowel sounds abnormal? yes Is absence of bowel sounds an emergency? yes bc absence of bowel motility How long must you listen to determine no bowel sounds present? _ 1/min per quadrant What pt of the stethoscope do you use to auscultate for vascular sounds of the abdomen? bell What are you listening for when auscultating the bowel? -bruits over abdominal aorta & renal arteries -venous hum -friction rub In the epigastric & umbilical area what are you listening for? venous hum Where do you listen for a friction rub? rt & lft lower rib cage with diaphragm Aneurysm or arterial stenosis could be noticed with what abnormal finding with vascular sounds? -bruit with both systolic & diastolic components Tympany presence of air Should dullness over liver and spleen or descending colon w/ stool & tympany be noted with percussing for tone? yes Accentuated tympany or hyperresonance over gaseous abdomen or enlarged area of dullness over liver or spleen, distended bladder, large masses, ascites are what what with percussion? abnormal Where would you do blunt percussion over kidneys? at CVA (constovertebral angels) Where is the CVA? What position is need to assess it? -over the 12th rib -requires client to sit up w/ back facing examiner Is it important to minimize voluntary guarding/ non-relaxation when palpating abdomen? yes so pillow under knees taking slow deep breaths through mouth What depth should abdominal light palpation be to? What are you feeling for? 1 cm looking for tenderness & muscle resistance What is abnormal with light palpation of abdomen? -involuntary reflex guarding -rigid abdomen -no relaxation of rectus abdominus w/ exhalation What depth should abdominal deep palpation be? What are you looking for? -5-6cm -delineate abdominal organs & detect masses Is it normal to have mild tenderness over xiphoid, aorta, cecum, sigmoid colon, & ovaries? no What is important to note with abnormal deep palpation assessment of abdomen? -location -size -consistency -demarcation -pulsatility -tenderness & mobility of any masses Where are you palpating the aorta? what are you using? What are you assessing? -slightly left of midline -use thumb & forefinger -pulsations How many cm is a normal width for the aorta? 2.5-3.0 cm Moderately strong & regular pulse & mild tenderness is possible when palpating the aorta? TRUE OR FALSE true A wide, bounding pulse with AAA (audible bruit) is what? -abnormal DO NOT PALPATE (could cause it to burst) Is rebound tenderness a test for appendicitis? How would you test it? -yes -palpate deelply LLQ, suddenly release pressure, listen & watch for expression of pain It's not important for the client to describe which hurts worse the palpation or the release? TRUE OR FALSE false What test is always performed at end of abdominal asses? -appendicitis test Should rebound tenderness be present when testing for appendicits? no Referred rebound tenderness has what S&S? Where? -sharp, stabbing pain -RLQ during pressure in LLQ Pain in RLQ during pressure in LLQ is what sign? What does it indicate? -rovsing's sign -tests for appendicitis What is rebound tenderness? What sign is it? What does it test for? -sharp, stabbing pain w/ release of pressure -Blumberg's sign -used for appendicits What is super important to not do if Rovsing's sign & Blumberg's sign are positive? dont continue palpation What is psoas sign? What does it test for? -client lays on left side w/ hyperextended rt leg -this is test for appendicits Pain in RLQ is a positive for what sign? Psoas sign & Obturatior sign When client is supine, examiner supports rt knee & ankle, flex hip & knee & rotate leg internally & externally this is what sign? What test is this for? -obturator -test for appendicitis The urethra run through what for males? What shape is the prostate gland? -urethra -walnut What develops semen? -vas deferens -seminal vesicles What is the endocrine function of the kidneys? -erythropoietin (helps generate blood cells) -vit D How does kidney regulation affect BP? since filters fluid & electrolytes affects BP SELECT ALL THAT APPLY the kidneys: -remove & filters waste -maintains vol status -regulates acid base balance -assist in reg. of BP -endocrine function all Polyuria frequent urination Hematuria blood in the urine Nocturia urination at night What are you asking about with genitourinary assessment? -dysuria -frequency -urgency -polyuria, hematuria, nocturia -urinary incontinence -penile discharge -pain in genitals -lesions Does asking about tabacco, alc, drugs, exercise, and occupation matter when assessing genitourinary? yes -ex: Tabaco causes HTN which puts pressure on kidneys & could cause problems What position to asses kidneys & bladder? Why? -supine -easiest to percuss Where would blunt percussion be important to see if kidney problem? -pain at CVA -BE ABLE TO POINT TO ON PIC FOR TEST Can you percuss to determine bladder vol? yes How long is the female urethra? 3-5 cm Could genitourinary problems affect respirations & mental status? yes Within how many hrs should newborns void? 24 hrs Hypospadias opening of urethra is on underside not tip of penis What is it called when urethra ends in opening on upper aspect of penis? epispadias What is the condition where one or both the testes fail to descend from the abd into the scrotum? cryptorchidism Pseudomenstration is what? Who is it seen in? -when there is discharge but its false bc its mucoidal from mothers estrogen -newborn females Can pregnancy cause renal structure changes? yes the hormonal changes put pressure from uterus which increases blood vol - changes S&S of UTI -dark urine -pain -excessive urine -fowl smell -high templ -hematuria Do children 2 usually get UTI's? no What could be a sign of UTI in peds? if previously toilet trained & returns to wetting Why are UTI's common with elders? -bladder muscles weaken (especially after multiple preg.) -pH changes w/ menopause -medications -sexual activity -lack of fluid intake What are other S&S of elders with UTI's? -SOB -confusion -chest pain When tissues protrudes through weak spot in abdominal muscles its what? inguinal hernia With an inguinal hernia the bulge can be painful when doing what? -coughing -bending over -sneezing or lifting heavy objects What it is when the bowel or fatty tissues protrudes into umbilicus? umbilical hernia What type of incontinence causes leaking with activities like couching, laughing, sneezing, or exercising? stress incontinence Leaking urine after strong sudden urge to urinate is what type of incontinence? urge Mixed incontinence is what? mix of stress & urge incont. Illness like UTI that causes frequent & sudden urination is what? temporary incontinence 2. The nurse writes a number five on a patient's palm and asks the patient to describe what was written. This action is indicative of which type of test? a. Point Localization Test b. Graphesthesia test c. Romberg test. d. Weber test b. Graphesthesia test 3. You notice a patient with a shuffling gait, turns stiffly, has a stooped over posture, and with knees and hips flexed. Which gait does this patient exhibit? a. Scissors b. Spactic Hemiparesis c. Cerebellar Ataxia d. Parkinsonian d. Parkinsonian 1. Which patient description below indicates a functional problem with cranial nerve 6? a. "I seem to have a hard time moving my eyes to the left and right today." b. "I seem to have a hard time moving my eyes up and down today." c. "I seem to have a hard time focusing on objects close to me." d. "I seem to have a hard time shrugging my left shoulder." a. "I seem to have a hard time moving my eyes to the left and right today." What sends sensations or messages to other pts. of the body & body sends them back to brain? spinal cord What are the 4 spinal sections? -cervical -thoracic -lumbar -sacral How many vertebrae are in the cervical section? 8 How many vertebrae are in the thoracic section? 12 How many vertebrae are in the lumbar section? 5 How many vertebrae are in the sacral section? 1 How many cranial nerves are there? 12 TURE OR FALSE the cranial nerves evolve from the brain or brain stem true If a patient cannot swallow correctly, which nerve is affected? 1.IX 2.II 3.XII 4.IX 4. IX glossopharyngeal nerve On the drawing, which number makes up each of the features? Where are each lobes of the brain? The olfactory nerve is which nerve? 1 The optic nerve is which nerve? 2 The oculomotor nerve is which nerve? 3 The trochlear nerve is which nerve? 4 The trigeminal nerve is which nerve? 5 The abducens nerve is which nerve? 6 The facial nerve is which nerve? 7 The vestibulocochlear (acoustic) nerve is which nerve? 8 The glossopharyngeal nerve is which nerve? 9 The vagus nerve is which nerve? 10 The spinal accessory nerve is which nerve? 11 The hypoglossal nerve is which nerve? 12 How many spinal nerves are there? 31 How many spinal nerves are in the cervical section? 8 How many spinal nerves are in the thoracic region? 12 How many spinal nerves are in the lumbar region? 5 How many spinal nerves are in the sacral region? 5 How many spinal nerves are in the coccygeal region? 1 Each nerve is attached to the spinal cord by how many nerve roots? 2 The sensory root of each spinal nerve innervates an area of the skin called a what? dermatome Which nervous system is responsible for fight or flight? sympathetic When is the sympathetic nervous system activated? during times of stress TRUE OR FALSE gastric secretion's decrease w/ fight or flight true TRUE OR FALSE bronchiole constrict w/ fight or flight false: dilate Does the pulse rate increase or decrease w/ fight or flight? increase TRUE OR FALSE the pupils dilate w/ fight or flight true Living in the state of fight or flight is what? chronic stress Is awareness or recruitment increased or decreased w/ fight or flight? decreased A patient recalls a time when they were running to grab the last PS5 in the store, and got it before 3 others could get it off the shelf. Which response during this phase would be a normal bodily response: 1.Heart rate of 112 BPM 2.Respirations at 12 per minute 3.Hyperactive bowel sounds 4.Slow response in dodging customers and the competition 1.Heart rate of 112 BPM A patient is discussing her neurological health history the nurse, which statement(s) below indicates a type of neuro history? (Select all that apply) 1."I have been diagnosed with gingivitis and need to brush with a soft toothbrush because my gums are so sensitive now." 2."I passed out last year because my blood pressure was very low" 3."After my car accident, my left fingers are in a constant state of numbness" 4." I have had a stroke 6 years ago." 5."I was so dizzy 2 years ago when I had a massive ear infection." 4." I have had a stroke 6 years ago." 5."I was so dizzy 2 years ago when I had a massive ear infection." What is assessed in neuro asses.? -mental status -cranial nerves -motor& cerebellar systems -sensory systems -reflexes Unusual involuntary movements correspond to what system? motor & cerebellar Slow or uncertain gaits w/ older adults may be due to what? -neuro -muscle/skeletal -aging process Which of the follow would be an indication of a positive Romberg test? 1.Patient able to touch their toes with little difficulty 2.Patient sways after standing for 20 minutes and eyes closed 3.Patient backs up after closing their eyes to catch their balance' 4.Patient complains of leg pain after closing their eyes 3.Patient backs up after closing their eyes to catch their balance' Tandem walking heel to toe What position should the client be in for the romberg test? standing erect w/ arms at side & feet together What is important to note during the romberg test? any unsteadiness or swaying How long should client close eyes while standing on 1 leg before hoping for the romberg test? 20 sec TRUE OR FALSE the romberg test is sometimes not safe for elderly? true A positive romberg test shows signs to abnormalities of what system? motor & cerebellar neuro system The finger to nose test assesses what? coordination What are the 2 tests that can be done to asses rapid alternating movements? -have client sit and touch each finger to thumb & increase speed as they process before switching sides -palms on lap switching palms up to down quickly What position should the client be in for the shin to heal test? supine What occurs during the shin to heel test? slide heel down shin then repeat with other Primitive posture is seen in what states? Why? -unconscious states due to loss of motor control What are the 2 types of primitive posture? -decorticate -decerebrate What occurs w/ decorticate posturing? -arms, wrist, fingers flexed -arms adducted -lower extremities extended, internally rotated -plantar flexion of feet What posture occurs w/ lesions of cerebral cortex? decorticate What posture occurs w/ lesions of brain stem & midbrain or upper pons? decerebrate posturing What is seen w/ decerebrate posturing? -arms extended, adducted, internally rotated -wrists pronated -fingers flexed -back hyperextended -teeth clinched -legs extended w/ planar flexion For sensory testing should eyes be open or closed? closed so cant see what object but know through feeling How do you asses light touch? use wisp of cotton ball on top of hand Using blunt & sharp ends of paper clip or safely pin on top of hand tests what? pain How do you asses temp? use cold & hot objects on top of hand A tuning fork can be used to assess vibratory sensation by placing the base where? -distal radius -forefinger tip -medial malleolus -great toe What is graphesthesia testing? write w/ blunt object on palm with eyes closed & ask for description Placing a familiar object in hand w/out looking to see if they can say what it is is assessing for what? tactile discrimination (stereognosis) What is normal with point localization testing? if the patient can tell where you lightly touched them Where can 2 pt descrimination be determined? -fingertips -forearm -dorsal hands -back -thighs What do you ask the client when doing 2 point descrimination? can you identify # of points, 1 or 2, felt when touched What do you do when the client can no longer distinguish the 2 pts. as separate with the 2 point discrimination test? measure the distance between the 2 pts What would be an abnormal finding when testing extinction? A.Patient can identify both spots touched correctly B.Cannot identify the areas simultaneously touched C.Pain at the site touched D.Increased heart rate and breathing after the test B.Cannot identify the areas simultaneously touched Simultaneously touch the client in the same area on both sides then ask them to identify the area touched is testing what? extinction Reflexs to test a.Deep Tendon Reflexes b.Biceps Reflexes c.Brachioradialis Reflex d.Triceps Reflex e.Patellar Reflex f.Achilles Reflex g.Ankle Clonus h.Superficial Reflex i.Plantar Reflex j.Abdominal Reflex k.Cremasteric Reflex (males only) Reflex scale 0-4+ Hyperactive, very brisk, rhythmic oscillations (clonos), abnormal & indicative of a disorder is what # on the reflex scale? 4+ 3+ on the reflex scale is what? brisk or active then normal, NOT indicative of disorder Normal, usual response is what grade on the reflex scale? 2+ A decreased, less active than normal reflex is what grade? 1+ No response is what grade on the reflex scale? 0 TRUE OR FALSE in older adults the reflexes may be difficult to elicit or absent true Which reflexes may be absent in older adults? -achilles reflex: flexion of toes TRUE OR FALSE a tence patient will affect testing outcomes. Who is this most common with? true: older adults may have difficulty relaxing Brudzinshkis sign is what? as flex neck, watch hips & knees in reaction to maneuver What is a normal brudzinski sign? hips & knees remain relaxed & motionless Pain & flexion of hips & knees are + of what sign? Brudzinski's What suggests meningeal inflammation? + brudzinski's sign What sign is flexing clients leg at both hip & knee then straightening knee? Kernig sign What is a normal kernig sign? no pain but discomfort behind knee during full extension NORMAL Pain & increased resistance to extending knee are what? +/ abnormal Kernig sign When kernig sign is bilateral the examiner suspects what? meningeal irritation Brief, repetitive, stereotyped, coordinated movements occurring at irregular intervals in eyes are what? eye tics Repetitive winking, grimacing, shoulder shrugging are examples of what? eye tics What are 2 causes of eye tics? -tourettes syndrome -medication induced What are brief, rapid, jerky, irregular & unpredictable movements? chorea choreiform movements TURE OR FLASE chorea choreiform movements seldom repeat & can involve the face, head, lower arms, & hands true Resting (static) tremors happen when? at rest & decrease or disappear w/ voluntary movement What type of tumor appear when the affected pt is actively maintaining a posture postural What type of tumor is absent at rest, appear w/ activity & often get worse as the target is neared intention Cerebellar ataxia is what? wide based, staggering, unsteady abnormal gait Positive Romberg test goes with what abnormal gait? cerebellar ataxia Stiff, short gait, thighs overlap each other w/ each step is what gait abnormal gait? scissors gait Flexed arm held close to body while client drags toe of leg or circles is stiffly outward & forward is why type of abnormal gait? spastic hemiparesis Footdrop is an abnormal gait w/ what s&s? -client lifts foot & knee high w/ each step, then slaps foot down hard on ground -client cannot walk on heels S&S of parkinsonian gait -shuffling gait -turns accomplished in very stiff manner -stooped over posture w/ flexed hips & knees What provides structure & protection, serves as levers, stores Ca, & produce blood cells? bones How many bones make up the axial & appendicular skeletons? 206 What are the 2 types of bones? -compact: dense & hard -spongy: numerous spaces, make up ends & centers What assists w/ posture, produce body heat, & allow body to move? muscles What are they 3 types of muscles? -skeletal -smooth -cardiac How many skeletal muscles are in the body? 650 Where _ 2 bones meet is joint Fibrous jounts -sutures between skull bones -fibrous CT -immovable Joints between vertebrae & joined by cartilage is what type of joint? cartilaginous Synovial joints are where? -shoulders, wrists, hips, knees, ankles -contain space between bones filled w/ lubricating fluid Major joints 1.Temporomandibular 2.Sternoclavicular 3.Elbow 4.Shoulder 5.Wrist, Fingers, Thumb 6.Vertebrae 7.Hip 8.Knee 9.Ankle & Foot What is moving toward midline of body? adduction What is circumduction? circular motion Inversion is what? What is eversion? moving inward Turning or facing downward is what? pronation Turning or facing upward is what? supination Protraction is what? moving forward Retraction is what? moving backward What is straightening extremity at joint & increasing angle of joint? extension Hyperextension is when bends # 180 degress Bending the extremity at joint & decreasing angle of joint is what? flexion Dorsiflexion vs plantar flexion toes draw upward to ankle vs toes pt away from ankle Turning bone on long axis is what? rotation Internal rotation vs. external rotation turning toward center of body vs away What are the 3 knee tests? -bulge -ballottement -McMurray TRUE OR FALSE ROM does not test muscle strength false TURE OR FALSE it is very important to compare bilaterally true What is the muscle strength scale? 0-5 No musclular contraction, paralysis on the muscle strength scale is what score? 0 Slight flicker of contraction, severe weakness on the muscle strength scale is what score? 1 A 2 on the muscle strength scale is what S&S? passive ROM (gravity removed & assisted by examiner), poor ROM A 3 on the muscle strength scale is what S&S? active motion against gravity, average weakness Active motion against some resistance, slight weakness on the muscle strength scale is what score? 4 Active motion against full resistance, normal on the muscle strength scale is what score? 5 TMJ inspection & palpation -sit -middle finger just anterior to external ear opening -open mouth wide -tips of fingers should drop into joint spaces as mouth opens Move the jaw from side to side & protrude & retract jaw while assessing what? TMJ How do you test jaw ROM? -open mouth against resistance -contract teeth, feel for contraction of temporal & masseter muscles to test integrity of cranial nerve V Where is the sternoclavicular joint? How do you test ROM of cervical spine? -chin to chest -look up to ceiling -lateral bending: ear to shoulder for both sides -evaluate rotation: turning head rt. to left -add resistance to them How to test ROM of lumbar spine -bend forward & touch toes -observe symmetry of shoulders, scapula, hips -bend side to side, backwards & twist shoulders Test for back & leg pain that radiates down the back with what? -cervical, thoracic, & lumbar spine The straight leg test is used to check for what? herniated nucleus pulposus (inner core of vertebral disc) How is the straight leg test preformed? -lie flat -raise each relaxed leg independently to pt. of pain then dorsiflext foot What do you note when pain occurs for straight leg test? degree of elevation, distribution & character of pain & results of dorsiflexion Notice 1 shorter then other measuring both legs could show affects of what? fractured hip: fractured side shorter than healthy Clavicle, acromioclavicular joint, subacromial area, biceps all should be palpated anteriorly or posteriorly? anteriorly Glenohumeral (shoulder) joint, coracoid area, trapezius muscle, scapular area should all be palpated anteriorly or posteriorly? posteriorly Coracoid area Brining hands together behind head w/ elbows flexed tests what? external rotation Bringing hands together behind back w/ elbows flexed tests what? internal rotation For ROM first you do the motion then you add what & do it agian? resistance How many degrees should you palpate elbows when flexed? 70 What fingers should be used to palpate olecranon process & epicondyles? thumb & middle fingers Palpating for tenderness & nodules is done w/ what test? -squeeze test -palpate anatomic snuffbox for tenderness for both wrists What occurs during the squeeze test? squeeze client's hand across knuckle joints What tests & signs indicate carpal tunnel syndrome (CTS)? -phalen test -tinel sign How is the phalen test completed? -hold both hands aginst each other -flex wrists 90 decress w/ fingers pointing downward & wrists dangling -hold 60 sec. 30% of the time false positives occur w/ what test? 50%? -phalen test -tinel sign No tingling, numbness, buring, or pain is what kind of result with the phalen test? - Using fingers to percuss lightly over median nerve (located inner aspect of wrist) is done when looking for what sign? tinel signs If patient experiences pain while flicking or shaking wrist, its a good indication for CTS & a what signal? flick signal You should palpate fingers my moving in what direction? distal end proximally crepitus a crackling or grating sound usually of bones How many degrees is abduction? 45-50 How many degrees is adduction? 20-30 40 degrees is what rotation? internal hip 45 degress is ecternal hip rotation TRUE OR FALSE true 15 degress is hip what hyperextension How many cm above the patella do you begin palpating? 10 What fingers do you use to move down toward the knee? fingers & thumb When is the budge test only done? if swelling is present Accumulation of fluid or soft tissue swelling can cause what? Is it important to determine the cause? -swelling -yes Is the patient supine for the bulge test? yes Using the ball of hand to stroke medial side of knee upward 3-4 times to displace any accumulated fluid is done w/ what test? bulge What is done after stoking on the medial side of the knee for the bulge test? press lateral side of knee & look for bulge on medial side What does the ballottement test help detect? large amounts of fluid in the knee What position is the patient in for the ballottement test? supine Firmly press non dominant thumb & index finger on each side of patella for what test? What does it do? -ballottement -displace fluid in suprapatellar bursa (between femur & patella) What is done after firmly pressing non dominant thumb & index finger on each side of the patella for the ballottement test? use dominant fingers to push patella down on femur If patient complains of knee giving in or locking what test is done? McMurray What is included in the McMurray test? -supine -flex one knee and hip -thumb and index finger of one hand on either side of the knee -hold the heel of the foot w/ other hand -Rotate the lower leg and foot laterally -Slowly extending the knee, noting pain or clicking -Repeat How do you asses foot metatarsophalangeal joints? squeeze foot from each side w/ thumb & fingers Flattening of lumbar curvature may be seen w/ what? herniated lumbar disc or ankylosing spondylitis (inflammatory arthritis affecting spine & large joints) Lumbar hyperlordosis is what? hip flexion ccontracture & hip ecxtensor weakness drive the lumbar spine in increasing lordosis to balance head over pelvis Kyphosis is what? rounded thoracic convexity Scoliosis is what? lateral curvature of spine w/ increase in convexity on side thats curved Tender, painful, swollen, stiff joints could be what? acute rheumatoid arthritis Chronic rheumatoid arthritis chronic swelling & thickening of metacarpophalangeal & proximal interphalangeal joins, limited ROM, finger deviation to ulnar side Osteoarthritis degenerative joint disease Hammer toe is an abnormal finding where hyperextension at metatarsophalangeal joint w/ flexion at proximal interphalangeal joint Where does hammer toe commonly occur? 2nd toe Intimate partner violence is what? physical, sexual or psychological harm by current or former partner or spouse Psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, reproductive coercion are all forms of what? IPV TRUE OR FALSE age, religion, economic status, race, ethnicity, sexual orientation, ed. background affect IPV false What happens if there is no intervention w/ IPV? escates w/ severity & frequency S&S of IPV -chronic pain -HA -difficulty sleeping -poor physical or mental health TRUE OR FALSE it is the nurses duty to report suspected abuse but cannot make person leave bad situation true frequency of ER visit could indicate what? IPV 1. A nurse is assessing a patient's sternoclavicular joint, which motion can the patient normally demonstrate for this assessment?A.Adduction B.Abduction C.Flexion D.No obvious movements E.Can demonstrate adduction, abduction, & flexion D.No obvious movements 2. What cranial nerves that result in the "gag reflex" and rise and fall of the uvula when a patient says "ah"? Select all that apply A.Glossopharyngeal B.Vagus C.Hypoglossal D.Trigeminal E.Spinal Accessory A.Glossopharyngeal B.Vagus 3. Murphy's sign can be best described as abdominal pain elicited by: A.Palpation in the right upper quadrant of the abdomen B.Asking the patient to stand on tiptoes and then letting body weight fall on heels C.Asking the patient to cough D.Abdominal percussion A.Palpation in the right upper quadrant of the abdomen 1. Which tests are designed to detect Carpal Tunnel Syndrome? (Select all that Apply) a. Phalen Test b. Tinel Sign c. Bulge Test a. Resistance Test b. Flick Signal a. Phalen Test b. Tinel Sign b. Flick Signal 1. When palpating the knee, the nurse should start __cm above the patella using your__ & __ to move downward to toward the knee. When palpating the knee, the nurse should start _10_cm above the patella using your_fingers_ & _thumb_ to move downward to toward the knee. 1. A patient comes to the clinic with some weakness in their left knee. How would the nurse document this finding? a. 4/5 left knee b. 4/5 bilateral knees c. 3/5 left knee d. 3/5 bilateral knee a. 4/5 left knee What is the upper respiratory system composed of? nose down to the trachea, also referred to as "dead space" What does dead space mean? no gas exchange; no oxygen or CO2 Why do we have to account for dead space as nurses? accounts for 500 ml; if we are trying to ventilate a patient because we need to make sure they are receiving adequate ventilation and getting enough air to overcome the dead space so they can have adequate gas exchange What does the lower respiratory system consist of? bronchi, bronchioles, alveoli where does gas exchange happen? the alveoli Describe how oxygen and CO2 moves through the body. oxygen from the air that we breath goes into the blood, to be pumped to the body, and then the CO2 from the blood goes to the lungs so that we can exhale it What is ventilation? includes the inflow and the outflow of air: breathing in and out chest wall movement: if the brain tells you there is too much CO2 that we need to breath your diaphragm will contract and the pressure in the thoracic cavity goes down so that the air can go into your lungs, when the air comes in the pressure equalizes and that is when we breath out work of breathing: what is respiratory rate? is the chest moving bilaterally? What is flail chest? when you have two or more breaks in the ribs; often seen in blunt thoracic or chest trauma with a fall, car crash, CPR; chest wall moves opposite of what it should known as a paradoxical movement; when they take a deep breath in the person's chest sinks and when they expire it expands What is compliance? the ability of the bronchioles or bronchiole passages to expand and contract and to let the air in; has to do with alveoli Is it more or less difficult to expand an alveoli that has collapsed versus one that stays open? more difficult What are factors that affect compliance of the airways? inflammation: throat swelling, any infection that happens in lungs can cause inflammation in lung passages; more difficult for air to go in and out infection: bronchitis, pneumonia; bronchiole passages are stiffer increased mucous production: cold all make it more difficult for air to move in and out What is surfactant? increases surface tension or elasticity of the alveoli; helps keep them open so patient doesn't have to work as hard to keep opening alveoli What is an example of a potential nursing diagnosis related to compliance respiratory issues? ineffective airway clearance; if someone has pneumonia, bronchitis, etc What is diffusion? the movement of gases from areas of higher pressure concentration to lower pressure concentration What is an example of a potential nursing diagnosis related to diffusion respiratory issues? impaired gas exchange What are some factors that affect diffusion decreased surface area: alveoli that are collapsed patient has part of lung removed infection with mucous and fluid; alveoli membrane is thick and gas can't get through; CHF, pulmonary edema, pneumonia perfusion of alveoli with blood that gas exchange goes into; caused by anemia, blood clot blocking flow, or poor pumping of the heart What is the term for collapsed alveoli? atelectasis Describe the pathway of air. air enters through mouth or nose, through throat, enters trachea, moves from trachea to the lungs, where it goes through left and right bronchus, through the bronchioles, to the alveoli, alveoli inflate/deflate with inhalation and exhalation Explain how gas exchange occurs. lungs exchange oxygen to the bloodstream while CO2 passes from the blood to the lungs; oxygen attaches to RBC and travels to the heart while the CO2 in the lungs is exhaled How is blood transported to the cells? oxygen combines with hemoglobin (oxyhemoglobin) and be carried to the tissues What are we measuring when we put a pulse ox on somebody? oxyhemoglobin What are factors that affect pulse ox readings? severe anemia: gives falsely low readings; underestimates real pulse ox What factors affect transportation? decreased cardiac output: amount of blood heart pumps with each beat; caused by lack of fluid (hypovolemia) and poorly pumping heart (CHF) decreased hemoglobin: lack of red blood cells to carry oxygen; result of some type of anemia Which part of the respiratory steps will each of these factors affect? pneumonia anesthesia fractured ribs anemia CHF asthma pneumonia: compliance, diffusion (blockage by mucous) anesthesia: ventilation (have to overcome dead space) fractured ribs: ventilation (flail chest, paradoxical chest wall movement) anemia: transportation (not enough RBC) CHF: transportation (poorly pumping heart), diffusion (fluid roadblock) asthma: compliance (inflammation and constriction) blood clot in lungs: diffusion (poor perfusion due to clot blocking flow) how do we asses the respiratory system? looking for signs of hypoxia: lack of oxygen to tissues hypoxemia: lack of oxygen in the blood what do we see with acute or emergent hypoxia? first thing you see is changes in the CNS; become confused, delirious, restless, agitated, "air hunger" increased respiratory rate, HR, and BP what is pulsus paradoxus? exaggerated drop in BP when you breath in; decrease un systolic BP of 10 mmHg in systolic during inspiration; can be seen with patients with acute asthma, COPD, attention pneumothorax, pleural fusion, or pulmonary embolism What do we see with chronic respiratory issues? lethargy and fatigue chronically having a hard time breathing; choose between eating and breathing and talking and breathing increased respiratory rate with labored breathing, increased hemoglobin (make more thinking it'll help transport oxygen, which causes clubbing in the nails, which is a sign of low oxygen in the blood) increased muscle use of accessory muscles of the neck and diaphragm change in chest wall shape if they are using these muscles all the time; barrel chest common with people who have COPD what is a normal breathing pattern? normal: relaxed, unlabored, respiratory rate of 12-20 BPM, no use of accessory muscles, even, regular, respirations What is tachypnea? greater than 20; seen with fever, pain, hypoxia, rapid rate what is bradypnea? slow rate, less than 12, somebody who has recently been giving narcotics, sedation what is hyperventilation? increased rate and depth because we are trying to get rid of CO; seen with someone with anxiety and metabolic acidosis what is hypoventilation? decreased rate and depth of respirations what is SOB? shortness of breath; subjective statement from patient what is dyspnea? objective; patient is SOB observed by nurse what is orthopnea? patient can't lie flat because they have such a hard time breathing; seen with people with CHF; important to ask when taking history because you want to know where they are sleeping and how many pillows they are using what is rales? crackling, fluid present in the lungs if a patient is lying flat where will you hear rales? posteriorly if the patient is sitting up in a chair where will you hear rales? lower lobes does coughing relieve rales? no; if it's fluid it won't go away; have to actually remove fluid what kind of patient will you see with fluid in their lungs? hypovolemic, CHF, pneumonia what is wheezing? caused by mucous in the bronchial passages, can be cleared with coughing, if you can move the mucous you can clear it seen with asthmatics, COPD, bronchitis, allergic reactions, early heart failure (poor pump, retaining fluid in the lungs, bronchioles constrict to keep fluid out) if the patient is wheezing really bad and then their chest goes silent should you be concerned? yes; concerned if they are moving any air at all; constricted so badly they stop breathing; seen in bad asthmatics what is rhonchi? can be cleared with coughing, low-pitched wheezing, snoring, crackle, continuous sound seen with pneumonia or respiratory infections with a lot of mucous build up how should we be listening to lung sounds? under clothing, stethoscope to skin, make sure we have a good stethoscope, longer sounds have to travel won't be as clear or as accurate invest in a good stethoscope what is peak expiratory flow rate (PEFR)? pulmonary function test volume of air lungs can move tidal volume: amount of air inspired and expired with each breath normally total lung capacity: how much more air you could get in if you really tried confused with peak flow meter: things we use at home, hospital, in office that is used for asthmatics, gives us a reading what does a chest x-ray tell us? if there is fluid, a mass, broken ribs what are lung scans? CT scans or VQ scans look for pulmonary embolism or problems with perfusion VQ: ventilation perfusion scan looking at airflow and blood flow in the lungs; done with nuclear medicine; done when patient can't tolerate IV dye what is endoscopy? patients have procedural sedation; scope down trachea and look around with camera; diagnostic or therapeutic diagnostic: go in and take biopsy therapeutic: pulmonary toilet; go in and try to flush out all the mucous and infection if possible endoscopy in general is a procedure that looks inside the body; many types of endoscopies what is thoracentesis? go in with a needle and aspirate fluid from the pleural space what is arterial blood gasses (ABG's)? tells us how much oxygen and CO2 are in the blood; drawn from the wrist; in the ER a nurse draws them, sometimes respiratory draws them; depends on where you work what are sputum specimens? done in the morning prior to patient eating anything; identify bacteria causing infection, difficult to obtain because you need sample from lungs not saliva; done by respiratory so they can get specimens straight from lungs; easier on ventilated patients what are true range for pulse oximetry? 95-100% is expected range 91-100% is acceptable level below 91% requires interventions: check the patient or check the sensor below 86% is an emergency below 80% is life threatening what are factors that affect pulse ox readings? make sure patient is not cold; low patient with poor perfusion; low nail polish; beam can't get through to measure lower values with patients with darker skin carbon monoxide poisoning; pulse ox may be normal because sensor can't tell difference between peroxyhemoglobin and oxyhemoglobin; some newer devices can or if you do an ABG; patients will have deep red flushed skin color if they have carbon monoxide poisoning versus blue seen with hypoxia; deep red color is associated with death of carbon monoxide patient what do we do after we make our assessment? first intervention is monitoring assessments in our patient looking at symptoms, breathing patterns, lung sounds, and diagnostic tests what nursing actions can we take? priority all the time is airway maintenance: open, patent airway; if airway isn't open patient can't breath; nasal or oral airway may have to be used; patient may need a CPAP or BIPAP positioning: ambulate, elevate HOB, make sure patient turns from side to side how do we mobilize secretions? make sure they are slippery by humidification and hydration drink fluids to mobilize secretions chest physiotherapy (percussion): physically move secretions around; done by respiratory therapy postural drainage: position patient for maximal drainage suctioning: last resort because there is risk for infection or adding more different bacteria nebulization: helps with bronchodilation may need pain meds to help with turn, cough, and deep breath; mobilize secretions by managing pain what are our nursing interventions? teaching patient about stopping smoking, breathing exercises, effective coughing, teach about medications what is pursed lip exhalation? breath in through nose and prolonged expiration out of mouth pretend you are blowing through a straw, go slowly, allows air to fully leave lungs what is an incentive spirometer? something you have to do after surgery; visual to help patients take a deep breath; when they inhale the ball/piston rises to help pop airways open so they don't develop pneumonia or atelectasis after surgery have to remind patient to use; ie do every commercial break what are the different causes of airway obstructions? bronchial smooth contraction: bronchioles constrict to asthma mucous hyper secretion: chronic bronchitis and COPD inflammation or infection: main cause of asthma is inflammation; pneumonia describe the pathophysiology of asthma. exposure to allergen which is trigger; mast cells activated releasing histamines and prostaglandins; leads to bronchospasm or inflammation causing airflow limitation What are the three categories of medications that improve respiratory function? antibiotics to treat bacterial infections bronchodilators glucocorticoid steroids What is an example of how antibiotics would be used to treat respiratory bacterial infections? used to treat pneumonia what are some examples of common antibiotics seen in practice? azithromycin: aka z pack levaquin: treat respiratory bacterial infections doxycycline what are some examples of common bronchodilators seen in practice? albuterol inhaler/nebulizer dilate bronchioles so there is easier air exchange What is an example of how bronchodilators would be used to improve respiratory function? used to treat viral bronchitis; COPD; asthmatic patients what are some examples of common glucocorticoid steroids seen in practice? prednisone if you are giving something parenterally it would be solumedrol what do glucocorticoid steroids do? decrease inflammation see these medications with patients who have asthma because main issue with asthmatic patients is inflammation What class are bronchodilators? beta-2 agonists what do bronchodilators do? help with compliance of the bronchioles what do the bronchioles do? they expand and contract and let air in What affects the bronchioles? inflammation, infection, and increase in mucous production what are the two kinds of bronchodilators? relievers and controllers describe the relievers bronchodilators. short-acting beta agonist (SABA) typical inhaler: albuterol, ventolin, pro air (all albuterol sulfate just different brand names) rescue inhaler: used for acute episodes or attacks; gives immediate relief, peaks in 30-60 minutes describe the controller bronchodilators. long-acting beta agonist (LABA) salmeterol (serevent) take these as daily routine medications; fixed schedule; take 15 minutes to work chronic conditions what are adverse drug reactions of bronchodilators? increased HR, BP, jittery, muscle tremors, anxiety think as this person as someone who drinks a ton of red bulls stimulating sympathetic nervous system what are inhaled glucocorticoids? suppress bronchiole inflammation and decrease airway mucous production can be taken via inhalation or orally what are examples of inhaled glucocorticoids? Qvar, Flovent, Puulmicort what is an example of an oral glucocorticoid? prednisone what are adverse drug affects associated with glucocorticoids? thrush: fungal yeast infections in the mouth dysphonia: voice gets really hoarse; may notice this before you even notice the thrush what do we want our patient to do if they are using an inhaler with a steroid in it? gargle after they use it each time encourage them to use a spacer so less of the medication is in the mouth and throat and more gets into the lungs describe bone loss as an ADR to glucocorticoids. seen more in oral medications such as prednisone reduce body's ability to absorb calcium; increases how fast bone is broken down make sure patient is receiving calcium supplement especially if they are at risk for osteoporosis or bone loss why are spacers beneficial? superior delivery of medication with use of a spacer without use of a spacer 81% of the medication stays in the mouth and the throat; increases risk of thrush with a spacer more medication makes it to the lungs; 21% reaching the lungs versus 9% without a spacer how do we teach a patient to use a spacer? have patient do first puff and wait one minute between doses so the patient can get more medicine into their lungs; hold their breath if the patient is prescribed a bronchodilator like albuterol and also prescribed an inhaled steroid, which one should be given first and why? bronchodilator to open up the airways so that more of the steroid can get into the lungs and work better what are the effects, both desired and undesired, of oral steroids? anti-inflammatory properties immunosuppressant actions sodium retention lose potassium ions via the urine what are other conditions that oral steroids can be used for? rheumatoid arthritis (inflammatory condition) systemic lupus erythematosus (inflammatory condition) inflammatory bowel disease (inflammatory condition) allergies prevention of allograft rejection: transplant rejection; get lifelong medication to keep immune system at bay so they do not reject their organ what is one oral steroid commonly seen in practice? cortisone what are the adverse effects of cortisone? adrenal insufficiency: adrenal gland does not think that it has to work anymore, so it stops osteoporosis infections diabetes muscle wasting Cushing's syndrome fluid retention growth retardation mood swings cataracts/glaucoma peptic ulcers hypokalemia what are common characteristics related to Cushing syndrome? "moon face" thinning of hair red cheeks buffalo hump supraclavicular fat pad acne increased body and facial hair weight gain purple striae pendulus abdomen ecchymosis resulting from easy bruising slow wound healing thin skin and subcutaneous tissue thin extremities with muscle atrophy what kind of problems arise when the body stops working and your patient needs more steroids? may need more steroids if they are acutely ill, having surgery, or because they are given a dose of steroids they are supposed to take for 7 days, but they abruptly stop the medication (cause adrenal insufficiency and Cushing's) how long does it take for the adrenal gland to start working again? a couple days; why you see issues develop what are monitoring nursing interventions related to steroid medications? monitor for hypokalemia since steroids cause potassium loss check blood sugars; since they go up with steroids; not great for someone with uncontrolled diabetes monitor for fluid retention; steroids make you retain sodium; where sodium goes so does water monitor for osteoporosis because steroids promote bone loss gastric ulcers; GI irritation; steroids increase acid secretion of stomach monitor for infections; can cause infections because they are immunosuppressive; especially for someone on long term steroids what are action nursing interventions related to steroid medications? increase potassium intake: might need oral supplements or more potassium rich foods prevent infection: make sure we are adhering to infection protection measures; increased risk for infection increase calcium intake: steroids promote bone loss; calcium supplements and also vitamin D because it helps absorb calcium better what are teaching nursing interventions related to giving steroid medications? DO NOT STOP ABRUPTLY: taper so adrenal gland can kick back in and start working inform about mood swings take with food: decrease gastric irritation that leads to gastric ulcers no NSAIDS: double risk of gastric irritation and formation of ulcers may need to increase dose during times of increased physiological stress: if they have acute illness, surgery, etc what is an Addison's crisis? lack of cortisol; low BP, low blood sugar, high potassium levels what are methylxanthines? theophylline (oral) aminophylline (IV) bronchodilators: relax smooth muscle of bronchi "cousin of caffeine" so same side effects caffeine has half life of 5 hours given orally or IV because it is not active via inhalation What drug class has a longer duration, beta-2 agonist or methylanthines? methylanthines when are methylanthines most helpful? most helpful with patients who have nocturnal symptoms why do we rarely five methylanthines? they have a narrow therapeutic indec narrow TI: plasma level 10-20 mcg/ml, as low as 5 mcg/ml does a larger therapeutic index indicate a drug is safer or more dangerous? safer what factors affect toxicity of drugs? age, liver disease, food, smoking status, differing rates of metabolism (children: half life of 4 hours, adults: half life of 8 hours, smoker: half life of 4 hours) what are mild/early signs of toxicity related to methylxanthines? nausea vomiting tachycardia muscle tremors what are late signs of toxicity related to methylxanthines? seizure and/or coma above 30 mcg what is normal body flora? bacteria that inhibits healthy humans; does not cause disease; friendly bacteria or probiotics helps keep balance in body's ecosystem where can you find normal body flora? bowel: e. coli; if friendly bacteria is disturbed we get diarrhea; commonly seen when antibiotics are given for infection, antibiotics kill good and bad bacteria causing diarrhea upper respiratory: alpha haemolytic strep; staph; diphtheroids; Candida albicans; have this bacteria to impair growth of invading organisms or pathogens trying to cause us problems skin: staph and strep; protective bactericidal action that kills other organisms landing on the skin vaginal vault: lactobacilli; yeast infections or bacterial vaginosis form with lack of lactobacilli what is the difference between pathogens and normal body flora? pathogen: microorganism that can cause disease normal flora: probiotics, good for body what are the different lines of defense against infection? individual immunity: heredity; previous immunity or exposure to the disease, hygiene (hand washing, bathing, good perineal care), immunization nutrition: proteins, carbs, fats to help us fight infection and wound healing anatomical: intact skin and mucous membranes biochemical: acidity of GI and GU tract, fatty acids on skin, indigenous microflora mechanical: coughing, sneezing, flushing from urinary tract, glandular secretions, saliva (enzymes that break down cell walls) immune system status: are we immunocompromised? are we immunosuppressed?; able to develop inflammatory response with a healthy immune system what is the role of white blood cells with infection? WBC (leukocytes): part of CBC (complete blood count) test, normal range is 6-9,000 what value is associated with leukopnea? less than 6,000 leukocytes what value is associated with leukocytosis? more than 9,000 leukocytes is it uncommon to see a value of 30,000 WBC in a person with an acute infection? no what are the two categories of WBC? granulocytes and agranulocytes what are granulocytes? a type of WBC; including neutrophils, eosinophils, and basophils contain granules of digestive enzymes that are formed in the bone marrow to give the body rapid protection against outside invaders what are neutrophils? first white blood cells that arrive increase in first 4-8 hours neutrophil increase indicates an acute infection neutrophils think "new" what are bands? immature neutrophils what does "left shift" mean? old term that older doctors use used when lab values were written on paper greater the shift means the bigger the problem look at bands and they are greater than 7700 that is considered a left shift what are eosinophils? elevate during an allergic response; antibody/antigen response; consider these to be weak phagocytes (paceman eating invaders) what are basophils? start increasing during healing phase; contain histamine and heparin; help decrease clotting during inflammatory phase what does a high number of neutrophils indicate? some sort of new infection what are the agranulocytes? lymphocytes and monocytes important defensive cells in someone who has chronic inflammation where are agranulocytes produced? the lymph tissue what are lymphocytes? seen late in the inflammatory process trying to review someone's labs and you see a bunch of lymphocytes this tells you this is something that has been around for awhile what are monocytes? seen with chronic inflammatory conditions; someone with arthritis scavengers that clean up inflammatory sites what are the two types of inflammatory responses? local reaction and systemic reaction what is a local inflammatory reaction? redness, warmth, edema, swelling, pain , drainage, fever, chills what is a systemic inflammatory reaction? leukocytosis: WBC are elevated general malaise and fatigue fever: increased HR and respiratory rate; happens because they get neutrophil in a bacterial toxin release body aches loss of appetite confusion especially in older adults enlarged lymph nodes: especially around area infection drains what are health care associated infections? previously called nosocomial or health care acquired infections what are health care associated infections caused by? invasive procedures antibiotic administration: inappropriate use; given for viral infections. (not needed), exposure to multidrug resistant organisms: MRSA, VRE failure to adhere to infection and prevention control activities: super important; healthcare workers' soiled hands; biggest means of transmitting infection to patients heredity nutritional deficiencies why are health care associated infections (HAI) harped on so much by hospitals? they are super expensive; increase cost of all of our healthcare; increases complications for all of our patients; can possibly lead to death; extend hospital stays and cause readmissions how do we prevent health care associated infections? vaccinations take catheters out as soon as possible targeting pathogens (important to do cultures); target bacteria and treat it fully, not just giving broad spectrum accessing experts in the hospital; patients who contract MRSA want to make sure infectious disease team is interacting with patient to give best care what compromises a host? age: newborns have immature immune systems and elderly have a decreased immune response heredity: people with congenital immune deficiencies nutritional deficiencies: increased metabolism with infection; so need good nutrition to begin with exposure to the health care system: HAI, invasive procedures, medications (chemo, steroids), catheters coexisting medical conditions: diabetic, burn, lupus, RA, COPD, cardiovascular disease, HIV, cancer physiological stress: increased blood cortisone levels increase serum glucose level, which is a good medium for bacterial growth, decrease resistance to infection what are our nursing interventions related to infection? monitor: look at level of alertness, check vital signs (is HR increased? respiratory rate increased?), look at lab results (C