Quiz #3 ( CH.12, 15, & 16 ) Flashcards
lifespan considerations in older adults
- bony structures are more pronounced
➡️ D/T decreased subcuutaneous fat - skin lesions more likely
➡️ careful assessments for skin cancers, especially in commonly sun-exposed areas - hypothyroidism/hyperthyroidism is more common
➡️ hypothyroidism > hyperthyroidism - cultural considerations
urgent assessment
- acute head injuries & neurological changes
➡️ stabilization of head, neck; trauma essentials - neck pain: usually muscle tension, spasm
➡️ beware: fever & headache, possibly cardiac - lymphatics
➡️ more than 1cm, fixed, irregular, hard or rubbery
➡️ requires emergency investigation for cancer - hyperthyroidism: “ thyroid storm “, “ thyroid crisis “
➡️ hypermetabolism in all systems
common head & neck symptoms
- headache, neck pain
- limited neck movement
- vision & hearing
- facial pain
- lumps/masses
- hypo/hyperthyroidism
- sleepiness
thyroid gland
- normally smooth, rubbery, & moveable
- common to be nonpalpable
abnormal findings
- facial asymmetry
- unusual distribution of hair patterns
- nits attached to hair shaft
- thyroid asymmetry, enlargement, or masses
- degenerative joint disease ( DJD )
- temporal arteritis
- bulging or depression of scalp
- unilateral bulging may indicate thyroid goiter, cyst, or tumor
- neck masses
- tenderness
- pain or muscle spasms
- weakness or loss of sensation
- bruits
nursing diagnoses outcomes & interventions
- activity intolerance
- fatigue
- chronic pain
subjective data collection
- multiple systems may influence structure, function
- assessment of risk factors
➡️ personal history
➡️ medications
➡️ family history - risk reduction & health promotion
➡️ reducing injury risk
➡️ preventing thyroid disorder complications
➡️ early detection of masses or malignant lymph nodes
lifespan, cultural, environmental considerations on the nose, sinus, mouth & throat
in older adults:
- gustatory rhinitis: runny nose caused by smelling/tasting food
- decreased: olfactory sensory fibers; saliva production; number of taste buds
- loosening/loss of teeth
in cultural aspects:
- oral health: oral disease in children & adults is higher among poor & disadvantaged population groups
- risk factors for oral diseases: an unhealthy diet, tobacco use, harmful alcohol use, poor oral hygiene, & other social determinants
- congenital defects: cleft lip & palate
- head & neck cancers
- sleep-disordered breathing
urgent assessment
- severe nosebleeds
- ludwig angina: skin infection that is below the tongue which causes rapid edema & may cause a potential airway obstruction ( mostly in the nose, mouth, & throat )
- aspiration
- abrupt loss of smell ( possible brain tumor )
subjective data
assessment of risk factors:
- personal history/past medical history
- medications, supplements, substance use
- family history
- lifestyle & personal habits
- dental health
- environmental exposure
risk reduction & health promotion
healthy people 2030
➡️ risk factors:
- tobacco use
- sleep disorders
- cancer
- oral health
➡️ hereditary hemorrhagic telangiectasia: chronic nose bleeds
common symptoms in nose, sinus, mouth, & throat
- headache
- facial pressure, pain
- obstructive breathing: snoring, sleep apnea
- nasal congestion; epistaxis ( nose bleeds )
- dysphagia ( swallowing difficulties ); dental pain
- voice changes, oral lesions
- cough; pharyngitis ( inflammation of the pharynx )
- halitosis ( bacteria that normally lives in the throat & on the surface on the tongue ); anosmia ( loss of smell )
objective data collection
- common specialty or advanced techniques
➡️ inspection; equipment - comprehensive physical assessment
➡️ external nose: inspection; palpation
➡️ internal nose: inspection
➡️ sinuses: inspection; palpation; percussion
➡️ mouth: external, internal inspection; palpation
➡️ throat: inspection, palpation ( see tonsillar grading scale )
➡️ swallowing evaluation
abnormal findings
- asymmetry
- swelling
- bruising
- deviation of nasal septum
- redness
- mucosal inflammation
- polyps
- anosmia
- leukoplakia
- pretechiae
- tenderness
- oral candidiasis
nursing diagnoses outcomes & interventions
- impaired definition
- impaired oral mucous membrane integrity
- impaired swallowing
- ineffective breathing
upper respiratory portions
warms, moisturizes, transports air to lower
lower respiratory occurs
oxygenation, ventilation occurs
how many lobes does the left lung have?
two lobes ( due to the location of where the heart is )
how many lobes does the right lung have?
three lobes
lifespan considerations
- older adults:
➡️ respiratory strength declines
➡️ lungs lose elasticity
➡️ decreased flexibility
➡️ bone density decreases
➡️ disease prevalence - pregnancy
- newborns & infants
urgent assessment
shortness of breath & lack of adequate ventilation is EMERGENCY
- immediately assess patient & initiate interventions as needed BEFORE continuing data collection
➡️ vital signs ( respiratory rate & effort ) spO2
➡️ lung ascultation
- interventions
➡️ alert rapid response team
➡️ oxygen
➡️ elevate head of the bed
➡️ assess patient anxiety level
➡️ encourage relaxation techniques
➡️ assess for fatigue limits
risk reduction & health promotion
- smoking cessation
- prevention of occupational exposure
- prevention of asthma
- immunizations
common symptoms of the thorax & lung
- chest pain
- dyspnea ( difficulty breathing )
- orthopnea ( difficulty breathing, when standing, sitting, etc. )
- cough; sputum ( fluid in the chest )
- wheezing
- functional abilities
adventitious breath sounds
crackles, wheezes, rhonchi, pleural friction rub, stridor
