Exam 2 Flashcards
vital signs, lungs & thorax, abdomen
Visceral pain origin
originates from larger interior organs
Visceral pain presents
autonomic responses - vomiting, nausea, pallor, diaphoresis
Visceral pain occurs from
direct injury or stretching of organ
Deep somatic pain origin
blood vessels, joints, tendons, mm, bone
Deep somatic pain presents
nausea, sweating, tachycardia, HTN, aching, throbbing
Deep somatic pain is usually
well localized and able to be identified
Cutaneous pain origin
skin surface, subcutaneous tissues
Cutaneous pain feels
sharp, burning sensation
Referred pain origin
visceral or somatic structures
Referred pain localization
felt at particular site but originates from another - same innervation
Acute pain
short term, self limiting, protective purpose
Acute incident pain
occurs predictably with certain movements
Acute pain behaviors
autonomic response - guarding, grimacing, vocalizations, diaphoresis, change in vital signs
Chronic pain
persistent, 6+ months, those with chronic pain are often not believed
Chronic pain behaviors
bracing, rubbing, diminished activity, sighing, appetite change, more variable than acute behaviors
Pain as subjective
self report is gold standard of pain assessment, pain is always subjective
Infant pain assessment
- preverbal and incapable of self-report
- depends on behavioral/psychological cues
- CRIES: neonatal postoperative pain measurement score
Children pain assessment
- children 2+ can report pain but not intensity
- rating scales introduced at 4-5 age
- FLACC
- faces pain scale
- consult caregivers
Temperature is influenced by
diurnal cycle - lower in morning
menstruation - higher when ovulating
exercise - higher
age - lower in older adults, varies in kids
Expected oral temperature
98.6, range of 96.4-99.1
Oral temperature is
accurate and convenient
Expected rectal temperature
.7-1 F higher than oral
Rectal temperature is
most accurate, closest to core temp, invasive
Tympanic temperature is
noninvasive, nontraumatic, quick, efficient, may be less accurate during cardiac arrest
Pinna positioning for temperature
adult: up and back
child: straight down
Temperature tips
- red tip probe for rectal
- blue tip for oral/axillary
- wait 15 min after hot/cold liquid ingestion
If pulse rhythm is irregular
count pulse for full minute
Expected HR
50-95bpm, higher the younger you are
HR factors
- medications - may slow hR
- age: slows with age
- gender: slightly faster in females after puberty
- athletes: lower
- anxiety: high HR
Respirations should be
relaxed, regular, automatic, silent
Expected RR
20 breaths/min, 16-25 range
As you age, RR becomes
slower
Pulse oximeters measure
the relative amount of light absorbed by HbO2 and unoxygenated HB
Expected SpO2 on room air
97-99%
Pulse oximeter placement
- translucent skin (finger, toe, pinna)
- infants: foot, big toe, palm, thumb
- remove any polish
Systolic pressure is
maximum pressure felt on artery during L ventricular contraction
Ideal systolic
90-119mmHg
Diastolic pressure is
pressure that blood exerts constantly between each contraction
Ideal diastolic
50-80mmHg
Pulse pressure
difference between systolic and diastolic - reflects stroke value
Mean arterial pressure
pressure forcing blood into tissue
Factors of BP
- age: gradual rise
- sex: in females, lower after puberty and higher after menopause
- race
- social determinants: low socioeconomic status = higher risk
- diurnal rhythm
- weight: obesity increases BP
- exercise, emotions, stress
Level of BP is determined by 5 factors
- CO: increase CO, increase BP
- Peripheral vascular resistance: vasoconstriction increases BP
- Volume of circulating blood: fluid retention increases BP
- Viscosity: increase viscosity, increase BP
- Elasticity of vessel: increase rigidity, increase BP
Measuring BP
- width of cuff should equal 40% arm circumference
- length of cuff = 80% circumference
- keep arm at heart level
- uncross legs
What leads to high BP readings
- narrow cuff size
- applied too loose
- reinflating during procedure
What leads to low BP readings
- decreased inflation
- cuff size too large
Orthostatic vital signs indication
- suspect volume depletion
- known hypertension
- reports fainting/syncope
BP from sitting to standing
slight decrease in systolic
Infant/children vital signs
- BP not normally checked in kids <3
- avoid rectal
Infant vital sign order
reverse order to respirations, pulse, temperature
Preschooler vital signs
consider normal fear of body mutilation may increase with any invasive procedureS
School age vital signs
promote cooperation by explanation and participation
Infants/children pulse
- palpate or ausculate an apical rate with infants + toddlers
- in children 2+, use radial site
- count pulse for full minute
- fluctuates
Infant/children respirations
- watch infant’s abdomen for movement
- sleeping RR most accurate in infants
- count for full minute
Thorax anatomy
posterior chest, anteroposterior to transverse ratio of 1:2 or 5:7
L vs R lung
L lung is narrower, 2 lobes
R lung is shorter, 3 lobes
Anterior lungs
almost all upper/middle lobes
apex of lungs is 3-4 cm above inner third clavicle
Posterior lungs
C7-T10
almost all lower lobes
Reference points
midclavicular line, anterior axillary lines, midsternal line, scapular line, vertebral line
Pleura
thin, slippery serous membrane enveloping the lungs, filled with lubricating fluid to help lungs during breathing
Trachea/bronchi function
transport gasses between environment and lungs
Gas exchange occurs in
alveoli and alveolar duct
Functions of breathing
supply oxygen, remove co2, maintain homeostasis, maintain heat exchange
Acid-base balance of blood
maintain pH of 7.4
- lungs help maintain balance by adjusting level of CO2
- hyperventilation decreases CO2, hypoventilation increases CO2
Hypercapnia
increase CO2, stimulus for us to breathe
Hypoexemia
decrease O2, also a stimulus to breathe
Tachypnea
rapid shallow breathing, >24 breaths/min
Tachypnea causes
fever, fear, exercise
Bradypnea
slow breathing, decreased but regular HR
Bradypnea causes
drug-induced, increased intracranial pressure
Hyperventilation cause
extreme exertion, fear, anxiety, DKA
Hypoventilation causes
overdose of narcotics, anesthesia
Cheyne-stokes
respirations gradually wax and wane
Health history of lungs
cough, sputum, shortness of breath, allergies, chest pain, smoking, environmental considerations
Lung inspection
skin color, work to breath, accessory mm use, RR, respiratory pattern, shape/configuration of chest wall
Lung inspection expected findings
- straight spin, symmetric scapula and thorax, ribs slope downward at 45 degrees
- AP to transverse diameter ratio is .7-.75
Barrel chest
ap diameter = transverse diameter
- occurs in normal aging as lungs become more rigid
- worse with chronic emphysema and asthma
Infant/children lung inspection
- assess for nasal flaring, grunting, blue lips
- barrel chest normal until 6
- may note abdominal breathing or irregular breath
- infants are obligatory - nose breather until 3 months
- intercostal retractions
Intercostal retractions
inward movement of mm between ribs from reduced pressure in chest cavity - sign of difficulty breathing
Lung Palpate goal
symmetric expansion
Anterior lung palpation
place hands along costal margins with thumbs pointing toward xiphoid process
Posterior lung palpation
place hands on posterior chest sideways with thumbs together at T9-T10
Lung palpation method
- slide hands medially to pink small fold of skin between thumbs
- ask person to take deep breath
- as person inhales, thumbs should move apart symmetrically
- note any lag in expansion
- unequal expansion = part of lung is obstructed/collapsed
Lung auscultation
- have patient sitting, leaning slightly forward with hands in lap
- breath through mouth
- listen one full respiration at each location
- silent chest = no air moving in or out
Adventitious sounds
extra sounds not normally heard
Fine crackles (rales)
high-pitched, short cracking, popping sounds during inspiration that aren’t cleared with coughing
Coarse crackles
loud, low-pitched, bubbling, gurgling
Atelactatic crackles
fine crackles that don’t last and are not pathologic
- often older patients, bedridden, just waking up
Rhonchi
low-pitched, musical, snoring sound from airflow obstruction from secretions
Stridor
high-pitched, monophonic, inspiratory crowing sound
- louder in neck than chest wall
- caused by croup in kids or foreign airway obstruction
Pleural friction rub
superficial sound that’s coarse, low-pitched, grating quality
- louder the harder you push your stethoscope
- inspiratory and expiratory
Wheezing
high-pitched, musical, squeaking lung sound, sometimes clears with coughing
Preparing for abdominal assessment
- adequate lighting
- maintain privacy
- empty bladder, warm stethoscope, examine painful areas last
- auscultate before percussion/palpation
Contour
describes nutritional status and normally ranges from flat to protuberant
Abdomen inspection
stand on right side and look down on abdomen, then stoop to gaze across abdomen
Scaphoid abdomen
caves in
Protuberant abdomen indicates
distention
Inspecting abdomen symmetry
- should be symmetric bilaterally
- note any bulging, visible mass, asymmetric shape
- step to foto of bed to recheck symmetry
- hernia
Hernia
protrusion of abdominal viscera through abdominal opening in mm wall
Abdomen inspection - umbilicus
- should be midline and inverted with no discoloration, inflammation, or hernia
Abdomen umbilicus can be everted with
pregnancy, ascites, or underlying masses
Abdomen umbilicus can be deeply sunken if
obese
Abdomen umbilicus may be blue if
intraperitoneal bleeding (Cullen sign)
Abdomen inspection - skin
should be smooth, even, appropriate for ethnicity
Unexpected abdomen skin findings
redness (localized infection), jaundice, skin glistening and taut (ascites)
Expected pulsations/movement of abdomen
may see aortic pulsations or waves of peristalsis in thin people
Unexpected pulsations or movement in abdomen
marked aortic pulsations could indicate hypertension, aortic insufficiency, or aneurysm
Distended abdomens may have
marked pulsations
Abdomen inspection - expected demeaner
relaxed, quietly with benign facial expression and slow, even respirations
Abdomen inspection - unexpected demeanor
- restlessness/turning (gastroenteritis or bowel obstruction)
- absolute stillness/resisting movement (pain of peritonitis)
- knees flexed, facial grimacing, rapid respirations (pain)
Auscultation should occur
before percussion and palpation
Auscultation uses this part of the stethoscope and method
diaphragm
- bowel sounds are high-pitched
- hold lightly against skin
- begin in RLQ at ileocecal valve area
Abdomen auscultation expected findings
normoactive bowel sounds, occur irregularly 5-30 times/minute
Unexpected abdomen auscultation findings
Hyperactive sounds, borborygmus, hypoactive sounds, absent sounds
Hyperactive sounds are
loud, high-pitched, rushing, tinkling
- increased motility
Hypoactive sounds could follow
abdominal surgery or inflammation of peritoneum
Absent sounds are
uncommon, listen for full 5 minutes before you determine absence
RLQ parts
cecum, appendix, R ovary + tube, R ureter, R spermatic cord
RUQ parts
liver, gallbladder, duodenum, head of pancreas, R kidney + adrenal gland, hepatic flexure of colon, part of ascending + transverse colon
LUQ parts
stomach, spleen, L liver lobe, body of pancreas, L kidney + adrenal gland, splenic flexure of colon, part of transverse + descending colon
LLQ parts
part of descending colon, sigmoid colon, L ovary + tube, L ureter, L spermatic cord
dyphagia
difficulty swallowing
pyrosis
heartburn
eructation
burp
hematemesis
vomiting blood
pica
eating non-food items
melena
black, tarry stool containing blood - internal bleeding
grey stools
bleeding, bile deficiency, jaundice
Bruits are
vascular sounds
Bruits method + expected findings
- listen with bell
- listen over aorta, renal, iliac, femoral arteries
- usually won’t hear any sounds
Abnormal bruit sounds
blowing, rushing - occurs with stenosis, occlusion, or anuerysm of artery
Abdominal percussion goal
assess relative density of abdominal contents, locate organs, screen for fluid or masses
Abdominal percussion method
proceed lightly in all 4 quadrants in clockwise pattern, starting with RLQ
Abdominal percussion expected findings
general tympany x 4 quadrants
Abdominal percussion unexpected findings
Dullness or hyperresonance
- distended bladder, adipose tissue, fluid, mass
- hyperresonance = gas
Costovertebral angle tenderness
positive findings indicate kidney inflammation
Costovertebral angle tenderness process
- indirect fist percussion causes tissues to vibrate
- place 1 hand over 12th rib at CVA on back
- make fist with other hand
- thump flat hand with ulnar edge of fist
- normal person feels no pain
- kidney infection = intense pain
Abdominal palpation goal
judge size, location, consistency of organs and screen for abnormal masses/tenderness
Abdominal palpation method
- use measure to relax patient, enhance mm relaxation
- begin with light palpation and proceed to deep plapation
Light abdominal palpation
- 1cm
- overall impression of skin surface and superficial musculature
- entire abdomen, clockwise, zigzag pattern
- save tender areas for last
Deep abdominal palpation
- 5-8cm
- note tenderness, location, size, consistency, and mobility of any abnormal findings
Expected abdominal findings
- soft, non tender to palpation x 4 quadrants
- no masses or tenderness
- voluntary guarding
Unexpected abdominal findings
- distended abdomen
- tender
- involuntary guarding or rigidity
Voluntary guarding
cold, tense, ticklish - use relaxation techniques
Involuntary guarding
constant board like hardness of mm
- protective mechanism from acute inflammation of peritoneum
Common causes of constipation
decreased activity, inadequate water intake, low-fiber, medication side effects, hypothyroidism, inadequate toilet facilities
Abdomen nursing considerations
- don’t palpate a patient’s abdomen who has had an organ transplant
- don’t feed patient until they’ve passed flatus
- acute abdominal pain needs immediate assessment
