Unit III Exam Study Guide
Children in Surgery (p. 543, 545): Abstract reasoning is necessary for children to understand
that painful medical treatments given now will make them feel better later. Dramatic play may
help the preschool child, who is not old enough to have developed abstract reasoning, to
understand the uncomfortable experiences of the hospital stay.
What to say to them? (p 545): Explain the procedure in a language the child can
understand and be honest about how much pain a procedure will cause. Allowing the
child to practice procedures on a doll and encouraging them to express his/her feelings
openly are also beneficial.
Regression (p 523, 539): Demonstrating behavior that is more characteristics of younger
age. This can occur at any time in a response to a stressful situation/circumstances.
Examples are excessive clinging to caregivers, loss of control over elimination, and the
use of more infantile speech patterns. Reassure parent that toilet regression during
illness/hospitalization is to be expected and short-lived.
Nutritional Needs in Pregnancy (p 527): Adequate maternal nutrition is essential for normal
growth and development of embryo and fetus. A fetus not receiving adequate nutrition may be
small for gestational age, fail to have normal brain development, have learning disabilities as a
child, and be at increased risk for chronic illnesses as an adult. Vitamin and mineral deficiencies
can result in fetal megaloblastic anemia and neural tube defects (folic acid deficiency (cereal
grains contain folic acid)), inadequate bone calcification (vitamin D and calcium deficit, can
cause neural tube defect), and hypothyroidism (iodine deficiency).
Neonate Adjustment Outside the Womb (p 529): At birth, the neonate must adapt through
several significant physiological adjustments. The most important occur in the respiratory and
circulatory systems as the neonate begins breathing and becomes independent of the umbilical
cord. The neonate is immediately assessed by the Apgar scale (1 and 5 minutes after birth).
Each category is rated as 0, 1, or 2. The rating for each category is then totaled to a max score
of 10. Normal neonates are between 7-10. Neonates that score between 4 and 6 require special
assistance. Those below a 4 need immediate life-saving support.
Safety (p 533, 537, 539, 541, 544, 549): Aspiration/Safety/Choking: choking hazards include
small batteries, food, nuts, and popcorn. If an infant’s airway is obstructed and there is no
forceful coughing or no strong cry, give 5 quick back blows between infant’s shoulder while
holding infant prone over 1 arm. If this does not help, place infant in supine position over thighs
– infant’s head supported – perform 5 downward chest thrusts to lower 3rd of the sternum
(given quickly). Perform CPR if infant is unresponsive.
Pg 534 – SIDS recommendations
Accidents are a major cause of injury.
MVA, poisoning, burns, drowning, choking, aspiration, and falls are major causes of death in
toddlers.
Toddlers/Preschool
Stove = HOT (teach danger in simple terms)
Stranger danger, swimming
Stop, drop & roll, guns locked, sports injury, pedestrian/traffic safety.
Older Population
Fall Risk (p 582): Falls are the most common cause of injury and hospital admission in
older adults. Older adults are at an increased risk for accidental injury because of
impaired vision/hearing, loss of mass and strength, slower reflex/reaction, and
decreased sensory ability. 1 out of 5 falls cause serious injury.
Moles (p 573): Skin pigmentation and moles are common. The older population often
has pale skin due to loss of melanocytes.
Melanoma (p 706): also known as skin cancer (cells are known as melanocytes).
ABCDEs (p 706):
Asymmetry: line drawn through mole; 2 halves will not match
Border: uneven, scalloped, notched
Color: variety of colors (different shades of brown, tan, black (RWB))
Diameter: larger than pencil eraser (1/4 inch, 16 mm) smaller at first
Evolving: change (size, shape, color, elevation), bleeding, itching, crusting
Polypharmacy (p 575, 580): This is the use of many medications at the same time. This
should be carefully monitored to minimize the risk for adverse effects, toxicities, drugdrug interaction. Polypharmacy can cause negative outcomes. An alteration in cognition
or mental status that is new should be considered acute – considered in relation to
infections, polypharmacy, or other factors.
Suicide Risk (p 554): In 2016, suicide surpassed homicide and became the second-leading cause
of death among teenagers (15-19) in the U.S. A history of previous suicide attempts and
depression are possible risk factors. Substance abuse by adolescence and young adults is
associated with increased incidence of teen pregnancy, violence, accidents, and suicide. Suicide
risk is higher in rural areas.
How to Handle (p 554): Verbal or non-verbal indicators of suicide should not be
ignored; rather, an immediate referral should be made to a professional trained
in suicide intervention.
Respiratory: involves ventilation, diffusion, and perfusion.
Types of Respiratory Patterns (p 658):
Normal: 12-20 breaths per minute
Tachypnea: > 24 breaths per minute (shallow)
Bradypnea: < 10 breaths per minute (regular)
Hyperventilation: increased rate and depth
Hypoventilation: decreased rate and depth
Cheyne-Stokes Respirations: alternating periods of deep, rapid breathing
followed by periods of apnea; regular
Biot’s respirations: varying depth and rate of breathing followed by periods of
apnea; irregular
Adventitious Breath Sounds (p 718):
Wheeze (sibilant): musical or squeaking; high-pitched, continuous sound;
auscultated during inspiration/expiration; air passing through narrow airways
Ronchi (sonorous wheeze): sonorous/coarse, snoring quality; low pitch,
continuous sound; auscultated during inspiration/expiration; coughing may
somewhat clear sound; air passing through/around secretions
Crackles: bubbling, crackling, popping; low to high pitch, discontinuous sound;
auscultated during inspiration/expiration
Stridor: harsh, loud, high-pitch; auscultated on inspiration; narrow or upper
airway (larynx or trachea); presence of foreign body in airway
Friction Rub: rubbing or grating; loudest over lower lateral/anterior surface;
auscultated during inspiration/expiration; inflamed pleura rubbing against chest
wall
Under What Circumstances Would a Patient Have Certain Patterns? (p 658):
Normal: normal
Tachypnea: fever, anxiety, exercise, respiratory disorders
Bradypnea: depression of respiratory center by medications or brain damage
Hyperventilation: extreme exercise, fear, diabetic ketoacidosis (Kussmaul’s
respirations)
Cheyne-Stokes: drug overdose, heart failure, increased intracranial pressure,
renal failure
Biot’s: meningitis, severe brain damage
Orthopnea (p 658): Breathing easily in upright position
Assessment Techniques (p 703): Physical assessment is usually conducted in a head to toe
sequence or a system sequence, but can be adapted to meet patient needs
1. Inspection: begins with initial patient contact and continues through entire
assessment; it is deliberate and purposeful; observations are in a systemic manner;
closely observe visually; use hearing and smell; need good lighting; size, color, shape
2. Palpation: touch; hands/fingers (temp, turgor, texture, moisture, vibration (heart),
shape/structure (bones));
a. Dorsum (back of hand): temp
b. Palmar (palm): firm, contour, shape, tender, consistency
c. Ulnar (forearn): vibration (best measured this way)
3. Percussion: act of striking one object against another to produce sound; used to
assess location, shape, size, density of tissues; fingertips used to tap the body over
body tissues to produce vibrations/soundwaves; abnormal sound = alteration of
tissue/mass
4. Auscultation: listening with stethoscope to sounds produced within the body;
expose only the part you are listening to
Equipment Required (p 700): Your equipment should be readily accessible, clean and
working!
1. Thermometer/Sphygmometer: temperature and blood pressure
2. Scale: weight
3. Flashlight/Pen: inside mouth, nose, eyes
4. Stethoscope: blood pressure, heart, lungs, abdomen, cardiovascular sounds
5. Metric Tape/Ruler: measure wounds, incisions, etc.
6. Eye Chart: vision
Abdominal Assessment (p 724): This includes stomach, small intestine, large intestine,
liver, gallbladder, pancreas, spleen, kidneys, urinary bladder, and female reproductive
organs.
 Abdominal pain, nausea, elimination patterns, fluid and nutritional intake,
lifestyle.
 Presence of bowel sounds
 Ask patient to empty bladder.
 Supine
 Head slightly elevated
 Hands/arms at patient’s side
 Small pillows under head and knees
 Patient should be warm and comfortable to prevent constriction of abdominal
muscles (makes palpations difficult)
 Divide into 4 quadrants (RU, RL, LU, LL)
 Percussion and palpation AFTER auscultation (stimulate bowel sounds)
 Ask patient to breathe slowly and deeply
 Ask patient to identify painful areas
Documentation (p 735):
 After completing health history and physical assessment, organize all health
assessment date to identify actual and potential health problems.
 Identify nursing diagnosis, care plan, and evaluate patient response to
interventions
Symmetry (p 737):
 Facial feature symmetric
 External eye structure symmetric
 Thorax symmetric with equal expansion
Grade (p 654): Grading the amplitude of arterial pulses
0: absent
+1: diminished, weaker than expected
+2: brisk, expected (normal)
+3: bounding
Amplitude (p 654): quality of pulse in terms of its fullness and reflects the strength of
left ventricular contraction. It is assessed by the feel of blood flow through the vessel. It
is normally strong at all areas where an artery can be palpated.
Neuro:
Glasgow Coma Scale (GCS) (p 733): A tool used to assess the depth and duration of
impaired consciousness and coma.
Component
Eye Opening
Motor Response
Verbal Response
Score/Response
4 – spontaneous eye opening
3 – eyes open to speech
2 – eyes open to pain
1 – no eye opening
6 – obeys commands fully
5 – localizes to noxious stimuli
4 – withdraws from noxious stimuli
3 – abnormal flexion
2 – abnormal extensor
1 – no motor response
5 – alert and oriented
4 – confused yet coherent speech
3 – inappropriate words/phrases (jumbled)
2 – incomprehensible sounds
1 – no verbal response
**The maximum score is 15 indicating a fully awake, alert and oriented patient – the lowest
score is 3 indicating deep coma.**
Cranial Nerves (p 735):
On (olfactory)
Old (optic)
Olympus (oculomotor)
Towering (trochlear)
Top (trigeminal)
A (abducens)
Finn (facial)
And
A (acoustic)
German: glossopharyngeal
Viewed (vagus)
A (accessory)
Hop (hypoglossal)
Babinski: typically elicited in children 24 months or younger
Neurovascular Checks:
Why? (p 721): It is important because it leads to early identification of neurovascular
impairment and timely intervention. (circulation, motor function, sensation)
The Ps (p 724):
 Pain
 Pallor
 Peripheral pulses
 Paresthesia (sensation)
 Paralysis (movement)
 Pressure