NURSING Lecture Notes - Stethoscope, Mae, Microorganism

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OC4412951

4 Aug 2022

School

University of Negros Occidental - Recoletos

Department

Nursing

Course

NURSING

Professor

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Document Summary

Bs nursing 1st year n01: apical pulse. Assess for any risk factors for apical pulse alteration: heart disease, cardiac dysrhythmia, onset of sudden chest pain or acute pain from any site, surgery, administration of medications that alter heart function. Move aside bed linen and gown to expose sternum and left side of chest. Locate anatomical landmarks to identify the points of maximal impulse (pmi), also called the apical impulse. Heart is located behind and to left of sternum with base at top and apex at bottom. Find angle of louis just below suprasternal notch between sternal body and manubrium; can be felt as a bony prominence. Slip fingers down each side of angle to find second intercostal space. (ics). Carefully move fingers down left side to the left midclavicular line (mcl). A light tap felt within an area 1 to 2 cm (2 to 1 inch) of the pmi is reflected from the apex of the heart.

Related Questions

1. The nurse working in a long-term care facility incorporates a focused assessment of
the immune system for all newly admitted patients over the age of 65. Older adults

are more likely to develop problems related to immune function than are middle-
aged people. The focused immune assessment includes a systemic approach based

on age-related changes in immunologic function. (Learning Objective 4)
a. What changes in the immune system in the older adult increase the incidence of
infection and cancer in this population?
b. Explain why older adults may have decreased inflammatory responses.
c. Why are older adults at increased risk of gastroenteritis and diarrhea secondary
to proliferation of intestinal organisms?

2. The nurse educator for an oncology unit is preparing an in-service presentation for
new nurses about the care of patients with immunodeficiencies. Patients with cancer
who are receiving chemotherapy, as well as those with bone marrow transplants, are
immunocompromised and require special attention to assess for signs of infection.
The nurse educator focuses on special care needs of this patient population.
a. What is the rationale for assessing the pulse and respiratory rates for 1 full
minute in a patient with immunodeficiency?
b. What special precautions about dietary restrictions and food preparation should
be included in the teaching for a patient with immunodeficiency?
c. What nursing actions should be implemented to decrease the risk of infection in
the patient with immunodeficiency?
3. Molly Baker, a 22-year-old patient, presents to the clinic with the diagnosis of
allergic rhinitis. She states that she develops paroxysmal sneezing, clear nasal
drainage and congestion, watery, red eyes, and nasal itching from the late spring
until the first frost in the fall. She states that she has a dry cough and voice
hoarseness. She complains of feeling extremely tired, unable to sleep at night, and
having difficulty concentrating on her collegiate course work.
a. What further assessment should the nurse provide?

Ellie Long, a 55-year-old patient, presents to the pain clinic with the diagnosis of
fibromyalgia syndrome. The nurse at the clinic obtains a history and physical
assessment of the patient. (Learning Objective 2)
a. On what areas should the nurse concentrate when interviewing the patient
during the history process?
b. On what areas should the nurse concentrate when assessing the patient?
c. What diagnostic tests are used with fibromyalgia syndrome?

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NURSING Lecture Notes - Stethoscope, Mae, Microorganism

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