Beginning the PE, General Survey, VS, Pain; Nutrition; Communication Flashcards
Systolic
max pressure on artery during L ventricular contraction (SQUEEZE)
Diastolic
resting pressure that blood exerts constantly between each contraction (RELAX)
False high bp (6 things)
● Cuff too small (narrow)
● Cuff too loose or uneven - not the same as too large
● Arm below heart level
● Inflating or deflating too slow= high diastolic
● Deflating cuff too quickly= low systolic, high diastolic
● crossed legs
False low bp (4 things)
● Cuff too large (wide)
● Repeating BP too quickly - give 1-2 min
● Inaccurate level of inflation (radial pulse - put enough air)
● Pressing stethoscope too tightly
What is normal difference of mmhg in orthostatic hypotension?
What is ABnormal?
normal is 10 mmHg drop in systolic value or pulse
abnormal is 20 mmHg or >20bmp → not circulating to brain properly
Method for measure postural hypotension?
■ lying - rest for 2-3 min and take bp
■ Sitting - take bp & hr
■ Standing - take bp & hr
Things that affect pulse rate
drugs, disease, exercise, age, gender, temp, BP, electrolytes, edema…etc
Things that affect RR
exercise, age, physical shape, sex, smoking
Normal Temp
Things that affect temp
37 C
■ DIURNAL CYCLE (patterns of activity/behavior that follow day/night cycles)
■ menstrual cycle (elevate)
■ exercise (elevate)
■ age (elderly have lower core body temp)
■ location of temperature taken - rectal is higher than oral, axillary is lower than oral
■ medicines: recent ingestion of aspirin, acetaminophen, corticosteroids,= and NSAIDs may mask fever and affect the temperature recorded at the time of the physical examination
Types of pain, not including parietal
○ nocioceptive: r/t tissue damage
- visceral: kidney pain, stomach pain
- deep somatic: broken bones
- cutaneous: paper cut, sunburn
○ neuropathic: r/t NS damage → burning, shock-like - shingles, diabetic neuropathy, paresthesias, carpel tunnel, MS
○ psychogenic: r/t depression, anxiety
○ idiopathic
Tolerance
adaptation, diminished drug fx
Physical Dependence
withdrawal
Addiction
characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving
LOC levels in order
Alert Lethargic Obtunded Stupor Coma
What is the difference between:
Fatigue
Lethargy
Weakness
Fatigue (r/t not enough sleep - loss of energy, normal response to hard work)
Lethargy: too tired to do even basic functions in life
Weakness: demonstrable loss of msk power, possible neuropathy or myopathy
Clutching chest, pallor, diaphoresis, labored breathing, shortness of breath, tripod position are all symptoms of?
Cardiac or respiratory distress
What do both hypothyroidism & edema cause?
weight gain
Ptn reports lactose intolerance. What is the nurse’s initial dietary concern?
inadequate intake of Calc and vitamin D → potential rickets
Rapid changes in weight over a few days suggests…
increase/decrease in body fluid, not tissue weight gain/loss
Weight gain or swelling in lower legs
water retention due to peripheral vascular disease, NOT nutrition issue
Questions regarding nutrition:
What does weakness/fatigue indicate?
anemia, electrolyte imbalance
Questions regarding nutrition:
What does weight loss indicate?
decreased calorie intake, increased calorie use, inadequate nutrient intake / absorption
Questions regarding nutrition:
What does pale skin or pale MMs indicate?
dehydration, possible anemia
Questions regarding nutrition:
What does spoon-shaped, brittle, or ridged nails indicate?
protein / iron deficiency
