Module 5 - Start of Exam 2 Flashcards
What to look for when doing a lower extremity evaluation?
- Vascularity and Color (lower extremities tend to have less circulation)
2.Inspect for Open areas or Ulcers
3.Identify varicosities and assess location
4.Inspect for pitting or non-pitting edema
- presence or not of hair on lower extremities
- Check for tenderness, pain, and erythema
- CMS
- Capillary refill in toes (brisk in 3 second return)
When looking at lower extremity open areas and ulcers, what should you check for?
Location, time being there, wounds, and bad perfusion leading to not even noticing its there
TED Stockings
compression stockings that prevent blood clots and aid in cardiovascular/peripheral vascular disease and varicosities
Anti Embolic Stockings
prevent pooling in lower extremities
When is the best time to put on compression stockings?
When the feet have been up for 30 minutes / when they wake up before leaving bed
NEVER use TED Stockings on …
patients with PAD (Peripheral Arterial Disease)
Pitting Edema
pushing down on an edem and seeing how long the indentation lasts - then rated on severity
No hair on lower extremities indicates?
poor circulation, and shiny skin indicated atrophy of the skin there
Deep vein thrombosis
in lower extremity area, can be palpated for warmth and swelling, and pain/inflammation/redness
CMS
“Circulation, Movement, Sensation”
Check for capillary refill in 3 seconds, can they move their toes, can they ID what toe you touch
Cardiovascular System
the heart and peripheral extremities - pump for circulation to and from the heart throughout the body through veins and arteries
Pericardium
tough, loose fitting, fiber sac that attaches to the great vessel and surrounds the OUTERmost layer and surrounds the heart
Epicardium
thin OUTERmost layer of the heart
Myocardium
thick muscular MIDDLE layer of the heart
Endocardium
thin layer of endothelial tissue that forms the INNER most layer of the heart
How many chambers are in the heart?
4
Two upper heart chambers
- left and right atria at the base of the heart
- earlike shape
- thin walled, reservoirs for returning blood from the veins
Two lower heart chambers
- right and left ventricles, at the apex
-thick walled and pumps the blood to the lungs and throughout the body
Which chamber pumps blood into the body?
Left Ventricle
Left Heart
the left atrium and ventricle
Right Heart
right atrium and ventricle
Cardiac Septum
tight partition dividing the left and right hearts
1 Way Valves
- directs the flow of blood
- AV and Semilunar Valves
Atrioventricular Valves (AV)
- Tricuspid (right; 3 cusp) and Mitral (left; 2 cusp; bicuspid) Valves
-between atrium and ventricles
Semilunar Valves
- Pulmonic and Aortic Valves
- between ventricles and great vessel / organ system
Arteries
carries oxygenated blood from the heart to the body
carries blood AWAY from the heart
Veins
carries deoxygenated blood TOWARDS the heart
Pulmonary circulation
Right heart pumps deoxygenated blood to the lungs
Systematic Circulation
Left heart pumps oxygenated blood to rest of the body
Direction of Blood Flow
Vena Cava –> R Atrium –> Tricuspid Valve –> R Ventricle –> Pulmonic Valve –> Pulmonary Arteries –> Lungs –> Pulmonary Veins –> L Atrium –> Mitral Valve –> L Ventricle –> Aortic Valve –> Aorta –> Body Systems –> repeat
Sinoatrial Node (SA Node)
- hearts “pacemaker”
- generates electricity and travels through the cardiac circuit
-in R atrium near the superior vena cava
Atrioventricular Node
-R atrium near the AV valve
-delays passage of electrical impulses from SA node to the ventricles to make sure the atria have ejected all the blood to the ventricles before ventricles contract
Bundle of HIS
passes electrical impulses from AV node to Purkinje fibers that then move back up the heart
Flow of Heart Conduction
SA node –> AV node – > Bundle of His –> Purkinje fibers
ECG
composite recording of all actions and cells of the myocardium (waves and segments of the heart)
P Wave
SA node fires and depolarizes when atria are full. Atrial contractions start 100 msec after, represented by P-Q waves
Q Wave
depolarization occurance
R Wave
wave from ventricle contraction
S Wave
repolarization occurrence; plateau in action potential when ventricles contract
T Wave
ventricular repolarization right before this wave
Systole
- contraction / work phase
-semilunar valves open
-AV valves closed - S1 best heard at APEX “LUB”
Diastole
- relaxation phase
- when blood fills the ventricles
-AV Valves open
-Aortic valve closed
-S2 Best heart at the BASE “DUB”
Where on the heart is S1 best heard?
at the apex (5th intercostal)
Where on the heart is S2 best heard?
at the base
When taking the subjective part of the cardiovascular health history, make sure to ask the …
Chief complaint
ex:
pain - COLDSPA
dyspnea on exertion or at rest
palpitations
dizziness
medications
edema
nocturia
When looking at the health assessment of a cardiovascular health history you must gather?
Chief complaints
Personal/Lifestyle Health practices
Past (personal) medical history
Risk factors
Men have higher cardiovascular issue rates until when…
when women are post-menopause
Hypernatremia
high sodium levels
High lipid levels are linked to
increased likelihood of cardiac event
Order of Physical Exam Techniques used in Cardiovascular Assessment?
- Inspection
- Palpation
- Auscultation
Cardiovascular Inspection
- move cephalocaudally in 3 positions
-look for pallor, cyanosis, vital signs, HR, heaves, smell, cough, edema, varicosities, symmetry, deformities, pulsations
3 Positions to do Physical Cardiovascular Assessment?
- Sitting
- Supine (30-45 degree angle)
- Left Lateral Recumbent
5 Important Areas of the Heart
Aortic (ALL)
Pulmonic (PEOPLE)
Erbs Point (ENJOY)
Tricuspid (TIME)
Mitral (MAGAZINE)
PMI
point of maximal impulse/apical impulse (mitral area)
Where might you be most likely to see a visible impulse on the chest?
5th intercostal or medial space (left side) (especially in thin people)
Aortic Area location
2nd ICS, right Sternal Border
Pulmonic Area Location
2nd ICS, left sternal border
Erbs Point Location
3rd ICS, left sternal border
Tricuspid Area Location
5th ICS (4th in children), left sternal border
Mitral Area Location
Mid-clavicular, left side, 5th ICS - maximal impulse
Main points of Cardiovascular Palpation
- FOCUS on inspection areas
- FEEL pulsations, vibrations, heaves, thrills, PMI
- PALPATE the 5 areas and epigastric region
What other area do we check with palpation?
the epigastric region (and peripheral pulses)
Diaphragm hears…
high pitched noises
When auscultating cardiovascular, listen for…
S1S2 (LUBDUB)
S1
LUB
Closure of AV valves, starting ventricular systole, best heard at the APEX, mitral, and tricuspid valves
S2
DUB
closure of semilunar valves after systole is complete, start of diastole, best heard at BASE, aortic and pulmonary valves
Note what when auscultating the cardiovascular system?
Rate Rhythm Strength
How long must the apical pulse be counted for during the cardiovascular physical assessment?
60 seconds
S3/S4
(S3 not uncommon sounds like KENTUCKYKENTUCKY, and normal in children and pregnancy - but concerning if new for someone)
S4 sounds like TENNASEETENASSEE and is very concerning
What does S4 indicate
that the thick left ventricle is sticking
Aortic Stenosis
harsh or high pitched sound when auscultating the heart
Splits, rubs, Pericardial Rubs, Murmurs
sounds abnormal of the heart when the valves are not closing well and there is a swishing/turbulent sound
Hypotension
low BP may not perfuse organ systems adequately
Hypertension
BP > 140/90 3X
Murmurs
blowing sounds turbulence in blood flow
Myocardial Infarction (MI)
occlusion of arterial blood flow causing tissue damage (heart attack)
Congestive heart Failure (CHF)
congestion in pulmonary and or systemic circulation related to inadequate pumping
Thrombus
blood clot
Hypovolemia
fluid volume deficit
Hypervolemia
fluid volume excess
Cardiovascular Tests
- EKG (chest pain to check for hearts long lasting effects)
- CBC (cholesterol levels)
- Electrolyte lab values
- Troponin
- Heart Catheterization ( make sure IV is working)
- CHEM7
Examples of Cardiovascular Nursing Diagnoses
Decreased Cardiac Output
Ineffective health Maintenance
Readiness for enhanced self - health management
Risk for falls
Constipation
Deficient knowledge
Sexual dysfunction related to fear, adverse effects of antihypertensive medications
Anxiety
Risk for infection
Ineffective Coping
Hyper/Hypo Volemia
Heart Base
Top of the heart
Apex
bottom of the heart
What is pain?
-whatever the person says it is
- an unpleasant sensation caused by noxious stimulation of sensory nerve endings as a result of disease or injury
Pain is ____
Subjective (it is whatever the experiencing person says it is)
According to HP2020, Pain affects ____ and ____
quality of life and wellbeing (well being is a relative state of maximizing aspects of health)
Origins of Pain
Referred
Nociceptive (Somatic/Visceral)
Neuropathic
Psychogenic
Referred Pain
pain perceived in the area is not necessarily its point of origin
Nociceptive Pain
pain at the site of origin ( receptors transfer pain signals to the brain and spinal cord)
2 Types of Nociceptive Pain
Somatic and Visceral
Somatic pain
Nociceptive pain from the skin and deep tissues
Visceral pain
Nociceptive pain from the internal organs
Neuropathic pain
pain from injury to CNS, or a neuropathic disease
can be burning, stabbing, short, or long term
Psychogenic Pain
no physical cause for the pain can be found
Phantom Limb Pain is what type?
Neuropathic pain
Descriptors and Sources of Pain
Cutaneous - skin
Visceral - abdominal/organ
Deep Somatic - ligaments/tendons/bones
Radiating - pain moves outward
Referred
Phantom - neuropathic
Nociceptive
Inflammatory
3 responses to Pain
- Physiologic
- Behavioral
- Affective
Examples of Physiologic Responses to Pain
Anxiety
Fear
Hopelessness
Sleeplessness
Thoughts of Suicide
A focus on pain
Reports of pain
Cries and Moans
Frowns and Facial Grimaces
Decrease in cognitive function
Mental confusion
Altered Temperament
High Somatization
Dilated Pupils
Increased heart Rate
Peripheral, Systemic, coronary Vascular resistance
BP Increase
Increased resp rate and sputum retention resulting in Infection and atelectasis
Decreased urinary output
Fluid Overload
Depression of all immune systems
Decreased Gastric and Intestinal Motility
Increased ADH, EP, NEP, aldosterone, glucagon’s, insulin, testosterone
Hyperglycemia
Glucose Intolerance
Insulin Resistance
Protein Catabolism
Muscle Spasm resulting in impaired muscle function and immobility
Perspiration
7 Dimensions of Pain
Physical
Sensory
Behavioral
Sociocultural
Cognitive
Affective
Spiritual
(These 7 physiologic and psychosocial phenomena affect display and perception of pain)
Acute Pain
recent injury leading to protective disposition
Chronic Pain
associated with injury lasting more than 6 months, and pain is intractable (not responding to any interventions)
Malignant v Nonmalignant Pain
Chronic Pain
Malignant is associated with cancer
Despite increases in pain treatment and success, pain is …
still undertreated and still able to have room for improvement
The Pain Process Steps
- transduction
- transmission
- perception
- modulation
Transduction (pain)
First stage of the pain process where pain receptors are activated by painful stimuli of chemical, mechanical, or thermal origin
electrical impulses converted from the pain stimuli travel to the spinal cord at the dorsal horn
Sensory part of the spinal cord
dorsal horn
Transmission (pain)
second phase of the pain process where pain sensations are conducted along pathways to the dorsal horn (if they stay there its a reflex)
Perception (Pain)
third phase of the pain process involving the sensory process that occurs when a stimulus for pain is present
this is when the brain works and perceives pain and sets up the emotional status that effects the perception of the pain
Pain Threshold
the LOWEST intensity when one perceives a stimulus that recognizes the pain
can change based on perception/emotion
Modulation
the final phase of the pain process where neuromodulators alter and temper the perception of pain through endorphins and enkephalins
this is the phase where the body can help out in pain
Gate Control Theory of Pain
The body creating good feelings (endorphins) can control pain, so it suggests pain impulses can be blocked by a gate between impulses and the dorsal horn by flooding it with modulating (not eliminating) substances
ex: Moist heating pad on back pain as a means of modulating pain
Factors that influence the pain experience?
Culture
Ethnic Variables
Family
Gender (ex: estrogen may lower pain tolerance)
Age
Religious Beliefs
Environment and Support People
Anxiety and other Stressors
Past Pain Experiences
Joint Health Commission on Pain
Standards made to improve pain management:
policies and procedures that address pain, treatment or referral for treatment, and reassessment for patients as it designates is needed by an accredited institution
Examples of JCAHO Standards
Clinical Leadership team for pain
Actively engaging med staff in improving pain assessment and management including strategies to decrease opioid use and minimize risks associated with use
Provide at least one non-pharma pain treatment modality
Facilitate access to prescription drug monitoring programs
improve pain assessment by concentrating on how pain influences physical function
engage patients in treatment and decisions on pain management
address patient education and engagement
facilitate referral of patients addicted to opioids to treatment programs
What brought about the JCAHO standards?
the opioid addiction crisis rising
Misconceptions of joint commission pain standards?
- Pain as a vital sign - no, the healthcare institution decides that
- requires pain treatment until pain reaches zero - no, reassessment needed but not need reach 0
Role of a Nurse with Good Fundamental Beliefs on Pain
- Advocate for the patient (do not be judgmental)
Acknowledge THAT PAIN IS REAL
Establish A TRUSTING RELATIONSHIP
Demonstrate COMPETENCE IN ASSESSING
Barriers/Roadblocks to Pain Management in Geriatric Patients
-Might feel its a punishment for past actions
-Might feel is an inevitable and unavoidable part of aging
-might feel its indicative that death is near
-Elders fear the detection of a serious illness and may not want to continue tests
Important factors to keep in mind when assessing pain?
Type
Etiology
Behavioral, physiologic, Affective Response
Other factors
COLDSPA: Character, Onset, Location, Duration, Severity, Pattern, Associated Factors
GET A DETAILED PICTURE
Things to consider about the patient when doing a pain assessment?
Culture/Ethnicity
Age
Cognition / Cognitive Ability
Hierarchy of Pain Assessment Techniques
Self Report > Observe Client Behaviors > Surrogate Reporting
Examples of Pain Scales
Visual Analog Scale (VAS)
Numeric Rating Scale (NRS)
Numeric pain Intensity Scale (NPI)
Verbal Descriptor Scale
Simple Descriptive Pain Intensity Scale
Graphic Rating Scale
Verbal rating Scale
Faces Pain scale
NPASS
PQRST
FLACC
NIPS
Neonatal infant pain scale
scale giving points based on observation of infants that cannot explain pain
PAINAD
Pain Assessment in Advanced Dementia Scale
Scale for cognitive level considerations since dementia has pain but may not be able to describe the information
Use the right ___ for the right population/person when assessing pain
scale/tool
Specific populations that have unique pain scales
Elders
Pediatrics
Individuals w Developmental/Cognitive Issues
Individuals with Addictions
Geographic Differences (Culture religion, rural (may not mention pain since they need to work) v urban, availability of services)
Pharma Pain Relief Measures
NSAIDS (non opioid analgesics)
Opioid (Narcotic) Analgesics
Adjuvant Drugs (help in augmentation of pain)
examples of NSAIDS
aspirin, tylenol/acetominophen
examples of Opioid Analgesics
morphine, codeine, oxycodone, dilaudid, fentanyl, stadol, methadone
examples of Adjuvant Drugs
corticosteroids, antidepressants, anticonvulsants
Opioids should only be used in ____ cases
Severe
PCA
Patient controlled Analgesia
Patient has a bolus with a button to receive medicine, and it is secured, but only the patient may touch the bolus button
could cause respiratory depression
Epidural Analgesia
anesthesiologist inserts a catheter into the mid lumbar region into the epidural space (needs reassessment for moving sequentially afterwards)
Local Analgesia
applied topically to skin or mucus membranes, or injected into the body to provide temporary loss of sensation
also called nerve Blocks
Non-Pharma Pain Relief Measures
Distraction
Music
Relaxation Therapy / Guided Imagery
TENS Unit
Acupuncture / Acupressure
Hypnosis
Therapeutic Touch
All of these work on endorphin level to modify pain interpretation according to gate theory
What is the primary reason for ineffective pain treatment?
fear of causing addiction
Addiction
a pattern of compulsive opioid use for means other than pain control
Physical Dependence
phenomenon in which the body becomes physiologically accustomed to the opioid and suffers from withdrawal symptoms
Tolerance
occurs when the body becomes accustomed to the opioid and needs a larger dose each time for pain relief
12.7% of new illicit drug users began with…
prescription pain relievers
Things a person can be addicted to?
Prescription / Illicit Drugs
Alcohol
Tobacco
Cost of Substance Abuse?
740 billion annually in costs related to crime, lost work productivity, and health care
Why is older age a specific consideration in regard to prescription medicine addiction?
Older adults tend to have polypharmacy with multiple meds they take causing addiction and synergistic effects, which increases their substance abuse risk
What gender is more apt to use illicit drugs?
Male
What gender is more likely to abuse prescription pain meds?
Female
Women are more likely to do what in regard to analgesics that men are not as likely to do, even with equal pain levels?
take prescription opioids without a prescription in order to cope
Why are women more likely to misuse opioids?
to self treat for other problems like anxiety or tension
What gender and age group are most likely to die from prescription pain reliever overdose?
Women between 45 and 54
Information on Military members and Analgesic Addiction
14.3% report using prescriptions with opioids, and females are more likely to use sedatives/opioids/antidepressants
Historically, African Americans report what in regard to pain?
higher levels of pain but lower rates of prescription, but in 2000-2015 the prescription levels evened out to other populations (a bad thing)
