Quiz 3 Study Guide - PA.docx - 1 2 2 1 1...

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1 Breast self examination for child bearing age vs. postmenopausal women a Self examine is best 4-7 days after menstrual, in the shower with soapy hands.  b once you turn 20, you should have your first breast exam & every year after that (or  every other) 2 Pt. has a mastectomy - pt. education regarding complications that could develop removal of breasts  women who have had a mastectomy require same breast assessments many experience anxiety or fear as they worry about recurrence of cancer or  metastasis  some women have personal issues regarding body image and may feel self- conscious about exposing their chest nurse should be sensitive and reassure client it is necessary to have a  comprehensive exam 2 Sy/Sx pneumothorax Air moves into pleural space & causes partial or complete collapse of the lung Spontaneous, traumatic, or tension Subjective: Shortness of breath Sharp chest pain with inspiration Anxiety  Objective: Tracheal deviation to unaffected side Diminished or absent breath sounds over affected area Hyperresonnace to percussion over affected area   1 Pt. coughing during assessment, how do you assess their breathing, cough and breathing  sounds   3 deep breaths - Hold in breath and cough - make sure pt has pain meds, MAY HURT - pt can put pillow on incision to ease pain   1 Normal percussion sounds on the anterior and posterior thorax  Observation/Inspection of anterior & posterior thorax Color: varies, pink undertones (normal oxygenation), consistent with rest  of body Structures: clavicles same height, sternum midline, costal angle < 90  degrees; height of scapulae even, vertebrae midline Symmetry: structures of chest and movement Configuration: adult transverse diameter is approx. twice that of  anteroposterior diameter (AP:T=1:2) Respiratory rate: count number of respiratory cycles per minute – normal  adult (12 to 20) o Observe chest movement & accessory muscles including  intercostal muscles & sternocleidomastoid
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Abnormal Findings Include  Circumoral cyanosis often early warning sign for respiratory distress or  hypoxia  o immediately evaluated & treated Intercostal muscle retraction, prominent sternocleidomastoids may be seen in respiratory distress Pallor, cyanosis, rubor, erythema, grayness o Requires further evaluation
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  • Fall '15
  • Rowan
  • Respiratory distress, Objective pronoun, Breast self examination, Sharp chest pain, Observe chest movement

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