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semester 2 nursing > NUR 122 > Flashcards

NUR 122 Flashcards

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1
Q

when is critical thinking used

A
  • Prioritising care
  • Being adaptable
  • Choosing methods of communication
  • Collecting information
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2
Q

nursing process steps

A 
Assessing
Diagnoisis
Planning
Implementation
Evaluation
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3
Q

what is the assessment process of the nursing process

A

Assessing – making reliable observations, using relevant data, using important data, validating data, organising data, categorising data according to a frame work, Recognising assumption, identifying gaps in the data.

Clinical reasoning cycle can be helpful

Eg. Consider patients situation, collect cues and information, process information, identifying problems/ issues, establishing goals, taking action, evaluating outcomes, reflecting on process and new learning

  • Many different types of assessment ( depend on where you work)
  • Common positions during assessment … dorsal recumbent, supine, sitting
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4
Q

equipment that may be useful in the assessment phase of the nursing process

A
  • Flashlight/ penlight
  • Nasal speculum
  • Othalmoscope
  • Otoscope
  • Vaginal speculum
  • Cotton applicators
  • Gloves
  • Lubricant
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5
Q

before onjective assessment what should be done

A

if possible by objective assessment complete subjective assessment
Always approach a patient with kindness, compassion, empathy, sympathy, consideration, respect, smile…

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6
Q

4 primary techniques used in physical examination

A

conducted in this order:

Inspect, Palpate, Percuss, Auscultate

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7
Q

inspection?

A

visual assessment, eye/ otoscope/ pen torch, olfactory and auditory senses, continue with other techniques

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8
Q

palpation?

A

using touch, skin temperature/ vibration/ organ placement and size/ distension and pulsation, light palpation first with single hand, deeper palpation initially with 2 hands, Looking at mass (location, size, shape, consistency, surface, mobility, pulsatility- present/ absent/ tenderness, tenderness)

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9
Q

percussion?

A

elicits different sounds, direct (sinuses), indirect (thorax/ abdomen) , different sounds and tones depending on location

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10
Q

auscultation?

A

using sound, direct- with ear, indirect- with stethoscope/ pinnards, cardiac sounds- valves, measures in pitch/ intensity/ duration/ quality

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11
Q

what are vital signs

A

 Also called “observations” or “obs”
 Are T(emperature) P(ulse) R(espirations)
 B(lood) P(ressure) SpO2 (Saturation % of oxygen)
 Vital signs are a measure of bodily (systemic) function
 Provide objective evidence of the body’s response to a change in physiological function

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12
Q

when could you assess vital signs

A

Eg. Admission, change in health status, before-during- after surgery, before and or after administration of medication, before and after nursing interventions, following an incident- accident or injury in healthcare setting, timeliness of vital sign documentation is important

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13
Q

vital signs are not considered alone but with…

A

◦ Patient’s other signs & symptoms (not in isolation, need to cluster relevant information & past history)
◦ Their ‘normal’ results

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14
Q

what to do if alterations in vital signs occur

A

◦ Key responsibility is reporting of potential abnormalities

◦ May provide “early warning” of serious issues

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15
Q

what is respiration

A

Is breathing - The mechanism the body uses to exchange gases

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16
Q

3 processes of respiration

A
  • Gas movement in and out of lungs ( ventilation)
  • O2 and co2 between lungs and blood (diffusion)
  • Distribution of red blood cells too and from lungs (Perfusion)
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17
Q

factors affecting respiration

A
  • Emotions
  • Exercise
  • Smoking
  • Medical conditions
  • Medications (narcotics)
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18
Q

when taking respiration’s what are you assessing

A
  • Bpm

- Rate, rhythm(pattern), depth, quality, effectiveness

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19
Q

newborn normal pulse and respiration

A

pulse: 80-180
respiration: 80

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20
Q

1 year old normal pulse and resp rate

A

pulse- 80-140

resp- 20-40

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21
Q

5-8 year old normal pulse and resps

A

pulse 75-120

resps 15-25

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22
Q

10 years normal pulse and resps

A

pulse 50-90

resps- 15-25

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23
Q

Teen normal pulse and resps

A

pulse 50-90

resps 15-20

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24
Q

Adult normal pulse and resps

A

pulse 60-100

resps 12-20

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25
Q

Older adult normal pulse and resps

A

pulse 60-100

resps 15-20

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26
Q

different breathing rates (terminology)

A
  • Trachypnoea
  • Bradypnoea
  • Apnoea
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27
Q

different terminology for breathing volumes

A
  • Hyperventilation- over expansion of lungs, rapid deep breaths
  • Hypoventilation
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28
Q

what is cheyne strokes breathing

A

rhythm.

- Cheyne- strokes breathing- waxing and waning of resps- deep to very shallow breathing and temporary apnoea

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29
Q

different terminology for breathing ease/ effort

A
  • Dyspnoea- difficult laboured breathing during which individual has persistent, unsatisfied need for ai and feels distressed
  • Orthopnoea- ability to breath only upright or standing
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30
Q

different terminology for breathing sounds

A
  • Stridor- shrill, harsh sound durinh inspiration with laryngeal obstruction
  • Strenor- snoring/ snorous respiration usually due to partial obstruction of the airway
  • Wheeze- continuous, high pitched musical ssqueak or whistling sound occurring in expiration and sometimes on inspiration when air mives through a narrowed or partially obstructed airway
  • Bubbling- gurgling sounds heard as air passes through moist secretions in the respiratory tract
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31
Q

test movements for breathing

A

intercostal retraction -in drawing between the ribs

substernal retraction -in drawing beneath the breastbone

suprasternal retraction -in drawing above the clavicles

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32
Q

secretions and types of coughs during breathing

A

Secretions and coughing
Haemoptysis-the presidents of blood in the sputum

productive cough -cough accompanied by expectorated secretions

non productive cough -a dry , hash cough without secretions

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33
Q

why measure spo2

A

 To assess effective respiration measurement of the % of saturation of oxygen into the arterial blood is needed
 SaO2 defined as the % of haemoglobin (Hb) carrying oxygen within the arteries – most accurately measured using an arterial blood sample

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34
Q

how is sao2 measured

A

with a sats probe

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35
Q

sao2 affected by?

A

Every process within respiration really..
(Note the oxygen-haemoglobin dissociation curve)
This is an important (and complex) consideration

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36
Q

normal oxygen saturation level

A

 “Normal” reading accepted as ~ 94 – 100%

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37
Q

venous blood is lower

Why?-

A

 The O2 saturation of because venous blood is travelling towards the lungs to be oxygenated

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38
Q

spo2 accuracy affected by what factors

A

Interference with light transmission

Bright outside light

Carbon monoxide poisoning (artificially elevates)

Finger movement (shivering/twitching)
Jaundice (affects light reflection)

Intra-vascular dyes (artificially decreases)

Artificial nails and some nail polishes

Interference with arterial pulsations

Peripheral vascular diseases (reduces pulse volume)

Hypothermia (decreases peripheral blood flow)

Some drugs decrease peripheral blood flow

Low cardiac output (decreases peripheral blood flow)

Hypotension (decreases peripheral blood flow)

Peripheral oedema (can obscure pulse)

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39
Q

oxygen sensor probe should be considered with..

A
  • patients condition
     If you receive an abnormal reading – think critically
    …check patient condition/probe connections/other vital signs
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40
Q

what is blood pressure

A

 Defined as the lateral pressure that the pulsing blood exerts on the artery walls
 Measures the pulsing ‘waves‘ of blood flow

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41
Q

what does systolic reading represent and diastolic reading represent in BP

A

 Systolic reading = contraction of heart
(= systole)
 Diastolic reading = relaxation of heart
(= diastole)

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42
Q

what is pulse pressue

A

difference between systolic and diastolic reading

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43
Q

t or f bp trends are more useful than iusolated reading

A

true

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44
Q

t or f

bp= s/d

A

true

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45
Q

what is hypertension

A

high blood pressure

- When measured twice at different times
- Above 139 systolic and/or 89 diastolic
- Maybe undiagnosed - Cardiac/vascular/renal problems
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46
Q

what is hypotension

A

low blood pressure
When measured twice at different times
Below 110 systolic
But only when this is not their ‘normal’ BP
Orthostatic BP (Drop in BP when standing )
Can be dangerous because this may result in dizziness and falls

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47
Q

sources of error in blood pressure assessment

A

bladder cuff too narrow/ wide, arm unsupported, insufficient rest before the assessment, repeating the assessment too quickly, cuff wrapped too loosly or unevenly

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48
Q

what is a pulse

A

 Electrical impulses travel through heart to stimulate cardiac contraction
 As the blood is pumped by the heart it sends a “fluid wave” or “pulsing sensation” through the body - this is the pulse
 Mechanical, neural and chemical factors regulate heart function and blood output.
 Measured in beats per minute (bpm)

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49
Q

sites to measure pulse

A

temporal

carotid

apical

brachial

radial

femoral

popliteal

posterior tibial

dorsalis pedis

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50
Q

t or f

some conditions can prevent blood from reaching arm

A

t

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51
Q

different pulse rates (terminology)

A

Fast (tachycardia) or slow (bradycardia)

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52
Q

different pulse rhythms (terminology)

A

Normally regular

Early/late/missed beats – dysrhythmic (arrhythmic)

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53
Q

different pulse volumes (terminology)

A

Reflects the volume of blood ejected by the heart

Absent (0)/weak or thready (1)/normal or strong (2)/bounding (3)

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54
Q

what is pulse equality

A

Both sides of the body are the same

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55
Q

3 different types of body temperatures

A

 Body T° = Heat produced – heat lost
 Core T° - within the deep tissues ~ constant
 Surface T° – fluctuates according to environment and blood flow to the skin

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56
Q

 Acceptable “normal” oral T° range

A

36.0°C – 37.5°C (up to 38°C according to K & E)
Note that above 37.5°C is considered pyrexia/febrile – in practice
Though can vary according to activity and environment
And text …

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57
Q

where to place thermometer during oral temp

A

place bulb on either side of renulum

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58
Q

where to place thermometer during axillary temp

A

pat dry then put center of axilla

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59
Q

where to place thermometer during tympanic temp

A

pull pinna up and back, point probe slightly anteriorly towards eardrum, insert using circular motion till sng

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60
Q

where to place thermometer during rectal temp

A

apply gloves
instruct to take deep breath during insertion
dont force if resistence
insert 3.5 cm in adults

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61
Q

3 phases of fever

A

chill, cold phase (onset of fever)

plateau phase (course of fever)

Defervescence (or flush) phase (fever abatement)

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62
Q

Clinical manifestations of fever during Chill (or cold) phase (onset of fever)

A 
Increased heart rate (tachycardia)
■ Increased respiratory rate (tachypnoea) and depth
■ Shivering
■ Pale, cold skin
■ Complaints of feeling cold
■ Cyanotic nail beds
■ ’Goosebumps’ on the skin
■ Cessation of sweating.
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63
Q

Clinical manifestations of fever during Plateau phase (course of fever)

A

■ Absence of chills
■ Skin that feels warm
■ Photosensitivity
■ Glassy-eyed appearance
■ Tachycardia and tachypnoea
■ Increased thirst (polydipsia)
■ Mild to severe dehydration
■ Drowsiness, restlessness, delirium or convulsions
■ Herpetic lesions of the mouth (i.e. an ulceration of the skin)
■ Anorexia (persistent loss of appetite) if the fever is prolonged
■ Malaise, lethargy, weakness and aching muscles.

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64
Q

Clinical manifestations of fever during Defervescence (or flush) phase (fever abatement)

A

■ Skin that appears flushed and feels warm
■ Sweating (diaphoresis)
■ Decreased shivering
■ Possible dehydration.

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65
Q

after taking vitals what should be done

A

 Reporting abnormal results is a key nursing responsibility
Know your normal values!!!
Report anything outside those values BUT consider results in light of all information (what is “normal” for this patient/previous results/trends/history)
 Accurate documenting of results is essential

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66
Q

objective ingumentary assessment involves

A
  • Observe, measure and test skin, hair, nails
    w/ integumentary assessment use:
  • Inspection and palpation
  • Torch and gloves
  • Pt may be sitting, standing, supine and prone
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67
Q

what do you inspect during intergumentary assessmeht

A

colour

Ecchymosis/ petechiae

odema

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68
Q

coulours you may observe during intergumentary assessment

A

Pallor (inadequate circulating bl;ood/ low Hb)

Cyanosis (inadequate circulating oxygen)- blue coloured

Jaundice (usually from liver dysfunction) – yellow thinge to skin and eyes

Erythema (increase in blood supply)-…..Ecchymosis/ petechiae

Pigmentation changes

Moisture related issues

rashes and lesions

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69
Q

describing lesions by type and structure

A

. Primary (appear in response to change in environment), and secondary (result from modification such as trauma or infection)

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70
Q

describing lesions by Location and symmetry in comparable areas of body

A
  • configuration

eg. Arrangement of lesions in relation to each other

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71
Q

describing lesions by size, shape and texture

A

Irregular, round, flat, rough, thickened

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72
Q

describing lesions by colour

A

distribution, symety and asymetry

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73
Q

what is odema

A

(excess interstitial fluid)
An important assessment tool in many clinical situations (cardiac/renal/peripheral circulation)
Commonly ankle/feet/sacrum/peribulbar
Swollen, taut, shiny (blanched or erythematous

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74
Q

palpating odema

A
  • Different types/ degrees of pitting by mm
  • Pitting (stays up) non pitting (rises back up)

2mm- slightly pitting, no obvious distortion

4mm- deeper pt, no obvious distortion

6mm- pit is obvious; extremities are swollen

8mm- pit remains with obvious distortion

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75
Q

what do you palpate for during intergumentary assessment

A 
Oedema (? Pitting) 
	Lesions/cysts
	Skin temperature
	Skin turgor- fluid content in skin
Then validate this info by seeing what their fluid intake is. Getting a urine sample (specific gravity)
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76
Q

infant considerations during intergumentary assessment

A
  • monitor immunisation history
    Jaundice not uncommon soon after birth. Related to immature liver. Physiological (not pathological) treated with ‘lights’.
    Commonly ‘whiteheads’, nodules, vernix (‘over-cooked’)
    Premature – lanugo
    Nappy rash
    Allergic rashes
    Assess skin turgor to assess hydration status
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77
Q

children considerations during intergumentary assessment

A

Children:- monitor immunisation history
Commonly skin lesions (high activity levels)
Puberty induced acne (over-active oil glands)
Older adults:- white skin demonstrates age related changes earlier than dark skin
Age related changes – elasticity/thin/dry and flaky/macules and lesions/’tags’

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78
Q

older adults considerations during intergumentary assessment

A

Children:- monitor immunisation history
Commonly skin lesions (high activity levels)
Puberty induced acne (over-active oil glands)
Older adults:- white skin demonstrates age related changes earlier than dark skin
Age related changes – elasticity/thin/dry and flaky/macules and lesions/’tags’

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79
Q

what is the norton scale used for during intergumentary assessment

A

predict if a patient is at risk for development of a pressure ulcer

5 catergories- physical, mental, activity, mobility, incontinence

16 and below- at risk and preventative measures should be put in place

Different to braden which tells you what intervention

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80
Q

when conducting intergumentary assessment what might you observe about hair

A 
	Age related changes
	Genetic and ethnic related differences
	Lesions/rashes
	Infestations – lice/nits/ring worm 
	Alopecia 
	Thin and brittle hair (hypothyroidism)
	Hirsutism (hormonal)
	Absent or sparse leg hair – arterial circulation issues
	? related to shampoo or soap allergy 
	Damage from hair dryers or straighteners
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81
Q

when conducting intergumentary assessment what might you observe about nails

A

 Inspect for shape and angle between nail and nail bed
 Texture
 Colour
 General condition
Infections/inflammations/surrounding tissues/ingrown
 Blanch test

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82
Q

what is blanch test

A

similar to capillary refill

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83
Q

different nail angles can indicate conditions

t or f

A

true

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84
Q

Integumentary system Diagnostic Tests

A

Wound swab
Tissue biopsy/needle aspiration
Patch tests/scratch tests (allergy testing)
Hair/nail specimens

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85
Q

steps in the chain of infection

A
  1. etiological agent/ microorganism
  2. reservoir/ source
  3. portal of exit
  4. method of transmission
  5. portal of entry to susceptible host
  6. susceptible host
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86
Q

what are some thingsyou might observe in a wound

A

 Wound exudate (ooze)
Serous
Purulent (infected)
Sanguineous

Complications of healing
Haemorrhage
Infection
Dehiscence ( opening of a surgical wound- usually stitches etc.)

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87
Q

pressure wound classification stages

A

stage 1: non blanchable erythema

stage 2: partial thickness skin loss
- no slough, blister, shiny

stage 3: full thickness skin loss
- seb fat may be visible, slough maybe, no bone

stage 4: full thickness tissue loss
- exposed bone, tendon, muscle, slough

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88
Q

pressure injury prevention strategies

A 
skincare
microclimate control
prophylsctic dressings
fabrics and textiles
electrical stimulation
nutrition
repositioning and early mobilisation
support surfaces
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89
Q

skin tear classification

A

1a- edges aligned to normal. not pale, dusky darkened

1b- edges aligned skin pale, dusky, darkened

2a- edges not realigned, not pale, dusky or darkened

2b- edges cant be aligned, pale dusky and darkened

3- skin flap completely absent

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90
Q

what is the time framework used for

A

 This framework is mainly applied to chronic wounds though it is useful in assessing and planning the care of all types of wounds

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91
Q

what does time framework letters stand for

A

 T-tissue - non-viable or viable
 I-inflammation and/or infection
 M-moisture balance maintenance
 E-edges of wounds/epithelial

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92
Q

time framework T

A 
	Tissue assessment and management
	Viable or non viable tissue
	Must assess arterial supply first
	Must remove non-viable tissue
	Use debridement 
	Lots of different methods
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93
Q

time framework I

A

 Inflammation and infection control
Inflammation is a normal part of healing
Biofilms are a recent discovery and are considered essential to remove to ensure healing
 Infection
Affects healing, and can increase exudate
Alter colour of granulating tissue (rubra/grey)
 To treat - Anti microbial dressings (and/or systemic antibiotics)
Silver/iodine based/honey/hypertonic saline

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94
Q

time framework M

A

 Moisture balance maintenance
 Excess moisture (wet wounds) lead to slower healing and wound maceration
 Dry wounds slows healing as well
 Moisture balance is the aim
Appropriate dressing to absorb excess moisture
Appropriate dressing to provide moisture

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95
Q

time framework E

A

 Epithelial advancement of wound edges
Healthy epithelium has an edge that is silvery-white or light pink edge
Expect gradual epithelial cells of the wound margins to grow inwards to heal over the wound
Slowed by infection/drying out/excess moisture/
build up of debris/over granulation

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96
Q

wound care options for dry wound

A

hydrogels
hydrocolloids
interactive wet dressings

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97
Q

wound care options for low excudate wound

A

semi permeable film
hydrocolloids
calcium alginates

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98
Q

wound care options for moderate excudate wound

A

calcium alginate
hydrofibre
foams

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99
Q

wound care options for heavy exudate wound

A 
hydrofibre dressing
foam sheet/ cavity
super absorbent dry dressings
wound/ ostomy bag
tropical negative pressure therapy systems
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100
Q

head assessment involves..

A

the skull/face/eyes/ears/nose/sinuses/mouth/pharynx

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101
Q

what might you observe in the skull/ facial appearance during head assessment

A

Normocephalic (normal head shape)

Head shape can vary in newborns: Depending on mode of delivery

Sleeping on one side

Fontanels

Older adults Face shape changes with loss of muscle tone and fat/teeth/gum changes

Many health disorders involving the thyroid/adrenals/pituitary/ kidneys and cardiovascular systems can change facial appearances
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102
Q

during mouth and oropharynx assessment what to check for

A 
offensive breath
	Contains a number of soft and hard tissue structures as well as teeth
	Lips
	Dental and gum problems (false teeth?)
	Tongue
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103
Q

infants considerations during mouth oropharynx assessment

A

cleft lip
oral thrush
wide nodules on gumsfirst teeth at 6-7 months
fluoride

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104
Q

children considerations during mouth oropharynx assessment

A

annual dental checks
dental developments per milestones
oral fixation common

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105
Q

older adults considerations during mouth oropharynx assessment

A

decreased salviation with age

receeding gums

taste diminishes

tongue/ oropharyngeal disorders

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106
Q

what might you observe during neck assessment

A 
Contains many muscles/lymph nodes/blood vessels/numerous other structures
	Lymph nodes
	Thyroid gland (? goiter)
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107
Q

what might you observe during thorax and lungs assessment

A

Critical to assessing oxygenation status

Post-op pneumonia

Chronic obstructive pulmonary disease (COPD)

Breath sounds Adventitious = abnormal From constricted, inflamed or liquid filled airways

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108
Q

what are some chest deformaties

A

pigeon- breastbone to push outward instead of being flush against the chest

funnel- producing a concave, or caved-in, appearance in the anterior chest wall.

barrel chest-

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109
Q

what is the normal chest shape

A

thorax is oval. Its anteroposterior diameter is half

its transverse diameter

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110
Q

infant considerations during thorax and lung assessment

A

Infants:-
Thorax different shape
Diaphragmatic breathers (watch the stomach)
Right bronchi shorter and straighter than left bronchi

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111
Q

children considerations during thorax and lung assessment

A

About 6 yrs the shape of the thorax is similar to adults
About 6 yrs breathing becomes more thoracic, similar to adults
Parents should watch for scoliosis

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112
Q

older adult considerations during thorax and lung assessment

A

Physiological changes with ageing (kyphosis/osteoporosis)
Loss of muscle strength (increasing respiratory effort)
Greater risk of infections as less cilia

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113
Q

looking anterior chest what are some chest wall landmarks

A

right anterior axillary line

right midclaviclular line

midsternal line

left midclavicular line

left anterior axillary line

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114
Q

looking laterally to the chest what are some chest wall landmarks

A

anterior axillary line

mid axillary line

posterior axillary line

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115
Q

looking posterior to the chest what are some chest wall landmarks

A

left and right posterior axillary lines

left and righ scapular lines

verteral lines (c7-t12)

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116
Q

2nd rib starts..

A

mandibriosternal junction (angle of louis)

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117
Q

t or f

Each intercostal muscle is numbered by rib above 2

A

true

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118
Q

how do you palpate for chest expansion

A

w shape on back and front

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119
Q

how to palpate for tactile fremitus

A

moving right to left

  • tactile fremitus- interpretation as feeling vibrations
  • 99, blue balloon, blue moon
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120
Q

what is sequence for lung percussion

A

down shoulders

then move to center of back going left to right

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121
Q

percussing over bone what sound would you hear

A

flat

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122
Q

percussing lungs would hear what sound

A

resonance

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123
Q

percussing over liver and organs what sound would you get

A

dullness, visceral dullness

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124
Q

sequence for lung auscultation

A

right to left going down

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125
Q

percussing over stomatch what sound

A

tympany

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126
Q

ways to describe percussion sounds

A 
sound eg dull/ flat
intesity eg medium/ soft
pitch eg high/ medium
duration eg short/ long
quality eg extremely dull
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127
Q

what are some normal breathing sounds

A

vesicular- soft, heard over all lung but major bronchi

bronchovescicular- medium pitch and intesity, heard anterior over primary bronchus

bronchial- loud high pitch, gap between inspiration and expiration, heard over mandibrium

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128
Q

what are some adventitious breath sounds

A

Crackles (rales)- Fine, short, interrupted crackling sounds

gurgles- Continuous, low-pitched, coarse,
gurgling, harsh, louder sounds with a
moaning or snoring quality.

friction rub- Superficial grating or creaking sounds
heard during inspiration and expiration.

wheeze- Continuous, high-pitched, squeaky
musical sounds.
Best heard on expiration.

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129
Q

cardiac circuit cycle

A 
left atrium
left ventricle
aorta and branches
body
vena cana
right atrium
right ventricle
pulmonary arteries
lungs
pulmonary veins
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130
Q

Cardiac output

A

amount of blood ejected from the heart each minute CO+ SV x HR

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131
Q

Stroke volume-

A

amount of blood ejected from the heart with each beat

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132
Q

Contractility-

A

inotropic state of the myocardium, strength of contraction

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133
Q

Afterload-

A

resistance against which the heart must pump to eject blood into the circulation.

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134
Q

Heart rate-

A

number of beats each minute

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135
Q

Preload-

A

left ventricular end diastole volume, stretch of the myocardium

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136
Q

is heart fully left

A

no

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137
Q

cardivascular assessment includes what greater vessels

A 
Vena cavas and aorta
	Pulmonary arteries
	Carotid artery
	Jugular veins 
•	Assessed using
	Inspection, palpation, auscultation
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138
Q

what valve between the the left atrium and ventricle

A

bicuspid/ mitral

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139
Q

what valve between the the right atrium and ventricle

A

tricuspid

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140
Q

where is the aortic valve

A

left ventricle and aorta

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141
Q

where is the pulmonary valve

A

right ventricle and pulmonary artery

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142
Q

t or f

base of heart ( broadest part) is actually at the top

A

t

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143
Q

where is apex in heart

A

apex is lowest narrowest portion above the left mid clavicular line
-apex is narrowest portion above left midclavicular line

144
Q

where is point of maxiumum impact in heart

A

point of maximum impulse (pms) is apex, point where pulse can be best observed and palpated/ where stephoscope goes

145
Q

t or f

dramatic lifts near sternum mean left ventricle is enlarged or the heart is pumping greater than normal amounts of blood

A

t
Looking for dramatic lifts near sternum if left ventricle is enlarged or if the heart is pumping greater than normal amounts of blood
-dramatic lifts near midclavicular line indicates equivalent in right ventricle

146
Q

4 sites of heart auscultation

A

4 valves
- Aortic (upper left ventricle)
Patients circulation
- Pulmonic (upper right ventricle)
Pulmonary circulation
- Tricuspid valve ( right atrium-> right ventricle)
- Apical/ bicuspid (left atrium-> left ventricle)

147
Q

what valves close in s1

A

mitral, tricuspid

148
Q

what valves close in s 2

A

aortic, pulmonic

149
Q

systole and diastole in relation to valves

A

Systole- opening and closing of left ventricle pumping the blood out into the circulation at its highest most powerful pressure
Diastole- rest, valves are closed, chambers sre filling up again

150
Q

heart stages

A

ventricular filling

  1. passive filling
  2. atrial contraction

ventricular systole
3. av valves close
4. semi lunar valves open and ventricles eject blood
early diastole

  1. isovolumetric relaxation
151
Q

what happens in s1, s2, s3, s4

A

S1- beginning of systole, ventricles contract and pump blood around with power

S2- start of diastole filling up again and ventricles relax

s3- mitral valves open, passive filling of left ventricle

s4- just before S1 when the atria contract to force blood into the LV (not normally heard)

152
Q

what vessels are in the neck wich are important when assessing jugular pressure

A

internal jugular vein
external jugular vein

internal and external carotid artery (y shape)

carotid siunus (meeting of y shape)

common carotid artery (breaks into y shape at sinus)

aortic notch- leads to carotid artery

superior vena cava- leads to jugular veins

153
Q

how to assess highest point of jugular distension

A

30 degree angle
look at highest point of distension from sternal angle

Jugular vein distension can indicate systemic venous congestion

154
Q

obstruction of carotid arteries could..

A

Obstruction could lead to stroke, lack of o2 in brain

155
Q

Carotid artery

A
  • main supply of oxygenated blood to the brain
156
Q

what to do when assessing carotid arteries des

A

dont do both at same time

When comparing 2 carotid arteries sides noises could indicate occlusion stenosis on one side or not

Brewes- sype of murmur which could be an indicator of occlusion

157
Q

infant considerations during cardiovascular assessment

A

The heart sounds may be different in the infant. This can indicate abnormalities (though not always)
It is not unusual for an infant to have cardiac arrhythmias, especially with expiration

158
Q

children considerations during cardiovascular assessment

A

The apical impulse is located slightly higher and more medial up until about 8 yrs of age

159
Q

older adults considerations during cardiovascular assessment

A

Many changes even if no disease
Cardiac contraction weaker, cardiac output decreases (lower activity tolerance)
Pacemaker cells decrease in number affected impulse firing
S4 heart sound is detected (normally) in most older adults
Changes in cardiac electrics fires off more systoles
Emotional and physical stresses may cause cardiac arrhythmias
Many older adults experience cardiovascular abnormalities due to lifestyle choices, or genetic influences

160
Q

cardidiovascular assessment you are assessing

A

Looking and feeling for pulsations
Auscultating for heart sounds
Carotids and jugulars

161
Q

peripheral vascular cycle

A 
arteries
arterioles
capillaries
venules
veins
arteries
162
Q

difference between arteries and veins

A

Arteries- thicker and more elastic therefore pressure wave of blood to be pushed through (pulse)
Veins- thinner walls and wider lumen so can carry a greater volume of blood at a slower pace. Have valves / no pressure wave strength and without that push blood wouldn’t flow against gravity, valves and skeletal muscles help with this
…therefore bedridden patients can have clots forming

163
Q

function of peripheral vascular system

A

To meet the circulatory needs of the tissues
Constantly changing according to metabolic requirements
When supply doesn’t meet demand = ischaemia

164
Q

how does blood meet body demands

A 
Blood flow (from high pressure to low pressure)
(from arterial [~100mmHg]            venous [~4mmHg])

Flow rate = ΔP/R (pressure difference ÷ resistance)

Capillary Fluid exchange
- Hydrostatic (blood pressure)/osmotic pressures (proteins)

Any extra between arterial supply & venous reabsorption

lymph Imbalance = oedema

165
Q

3 main factors of peripheral vascular resistence

A

Blood viscosity (thickness). The thicker the greater resistance to flow. Contraceptive pill, smoking, various meds can increase viscosity

Length of the vessel. Longer vessel = Increased resistence

Diameter of the vessel. Smaller = greater resistance eg. Capillaries vs arteries

166
Q

Organs of the

lymphatic system:

A 
•	 Lymph nodes
•	 Spleen
•	 Thymus
•	 Tonsils
- Peyer’s patches.
167
Q

what are you assessing in peripheral vascular assessment

A

Quality is what we are assessing

Blood supply, swelling and numbness in limbs

168
Q

where can you do bilateral pulse comparisons

A
  • Brachial/radial
  • Femoral/popliteal/PT and DP
  • Dopplers

not carotid

169
Q

what to assess in arteriole and venous circulation

A
  • Inspecting all limbs for distension when at rest and when raised, and muscle wasting/hairlessness/skin changes/pallor/cyanosis/wouns
  • Thrombosed veins may be gently palpated
  • Erythema/swelling/warmth/pain especially lower leg
  • Palpation of lower leg for firmness/swelling/warmth
  • Homan’s test
  • Capillary return (refill test)
  • Raynards disease- blood supply issue, peripheries cold and capillary refill problem
170
Q

what is the homans sign test

A

An old fashioned but useful assessment for the presence of a DVT
Dorsiflex foot upwards. Positive if patient feels pain in popliteal or calf region

171
Q

Peripheral arterial disorders clinical manifestations

A

 Intermittent claudication (major symptom- mid exercise increases demand for o2 but lack of supply= cramping pain BUT after rest no pain)
 Pulses diminished or absent
 Oedema – None/minimal
 Skin changes: Trophic – cold/dry/shiny/hairless/thick opaque toe nails
 Pallor when elevated
 Red when dangling (dependent rubor)
 Ulcers – tips of extremities/ painful/deep/circular/pale to black base or dry gangrene

172
Q

Peripheral venous disorders clinical manifestations

A

 Pain: aching to cramp like, relieved by activity/elevation
 Pulses usually present
 Oedema – present/increases at the end of day
 Skin changes: warm/thick/ tough/darkened/? dermatitis
 Ulcers – medial malleolus/ pain variable/ superficial/irregular border/granulation base

173
Q

causes of odema

A

 Congestive heart failure/kidney disease/liver disease

 Blood Clots and Tumors

174
Q

how to assess odema in peripheral vasc assessmet

A

 Gentle palpitation throughout the limbs especially the lower leg
 Grading (2,4,6,8 mm)

175
Q

types of odema

A

 Dependent (gravity influenced, ambulant or sitting = legs , resting= sacrum)

 Pitting (ability to leave a dip)

176
Q

effects of odema

A 
	Poor blood circulation
	Increased local pressure
	Loss of vessel elasticity
	Painful swelling
	Problems with constricting clothes/shoes
	Difficulty in walking
177
Q

diagnostic stests that may be used in peripheral vascular assessment

A

 Blood test (D-Dimer)
 Dopplers
Venogram/phlebogram/ultrasonography
 Ankle brachial index

178
Q

infant considerations in peripheral vascular assessment

A

Changes in peripheral vascularity (bruises/petechiae/oedema) may indicate serious systemic disease (leukemia/meningococcal disease/lymphoma)

179
Q

children considerations in periheral vascular assessment

A

Changes in peripheral vascularity (bruises/petechiae/oedema) may indicate serious systemic disease (leukemia/meningococcal disease/lymphoma)

180
Q

older adults considerations in peripheral vascular assessment

A

Many changes even if no disease:-
Arterial and venous supply deterioration
Changes in symmetry of assessment results could be significant
Varicose veins common

181
Q

before breast assessment what should you ask in the Health assessment interview

A

Assess past or present occurrence of related symptoms
Breast surgery, augmentation, disorders
Pain, lump, discharge, rash, trauma
Explanation/consent/privacy/developmental and cultural considerations/family history/medications/ self-examination history/time of cycle

182
Q

what area do you inspect and palpate during breast assessment

A

The glandular tissue
(throughout breast in female/around nipple in male)

Particularly upper outer quadrant and tail of Spence Which extends into the axillae
183
Q

what should you inspect for during breast assessment

A

◦ Dimpling/retraction/colour changes/swelling
◦ Breast tissue/areola/nipple
◦ Comparing breasts (remember no 2 breasts are identical)

184
Q

3 methods of emphasizing retracted breast tissue to assess further

A

raising arms above head

  1. Pushing the hands together above head or in front of you
  2. Pressing the hands into the hips
185
Q

how to palpate during breast examination

A

middle three fingers palmar surface in rotary motion

186
Q

what are you palpating for during breast examination

A

◦ Lymph nodes
◦ Four quadrants of the breast
- masses/tenderness/discharge

187
Q

how often should you breast examine yourself

A

at least once a month

188
Q

3 ways you can breast examine

A
  1. in shower- left hand behind head, move breast in circular motion
  2. mirror- visual inspect with arms at side,
  3. lying down- pillow under shoulde, arm behind head
189
Q

breast examination infant lifespan considerations

A

Newborns often have breast engorgement and nipple discharge

Superfluous nipples maybe associated with renal conditions

190
Q

breast examination children lifespan considerations

A

Female breast development ~ 9 – 13 years

Male minor gynocaemastia during adolescence

191
Q

breast examination pregnant women lifespan considerations

A

Breast, nipple and areola enlargement occurs
Formation of Montgomery’s glands may occur on areola
Colostrum maybe expressed from first trimester on

192
Q

breast examination older adults lifespan considerations

A

Older adults:- Many changes even if no disease
Post-menopausal changes
Breasts loose firmness and shape
Lump and lesion detection easier

193
Q

how many quadrants and regions during abdominal assessment

A

Anatomical subdivision:-
Quadrants (4)
Or
Regions (9)

194
Q

what are the 4 quadrants of the abdomen

A

right upper
right lower
left upper
left lower

195
Q

organs of RUQ

A 
liver
gallbladder
duodenum
head of pancreas
right adrenal g;and
upper lobe of right kidney
196
Q

ORGANS OF RLQ

A 
lower lobe of right kidney
caecum
appendix
section of ascending colon
right ovary
right fallopian tube
197
Q

organs of LUQ

A 
left lobe of liver
stomatch
spleen
upper lobe of left kidney
pancreas
left adrenal gland
198
Q

organs of LLQ

A 
lower lobe of left kidney
sigmoid colon
section of decending colon
left ovary
left fallopian tube
left ureter
199
Q

WHAT are the 9 regions of the abdomen

A

The nine abdominal regions: epigastric; left and
right hypochondriac; umbilical; left and right lumbar; suprapubic
or hypogastric; left and right inguinal or iliac.

200
Q

organs of the right hypochondriac region of abdomen

A 
Right lobe of liver
Gall bladder
Part of duodenum
Hepatic flexure of colon
Upper half of right kidney
Suprarenal gland
201
Q

organs of the right lumbar region of abdomen

A

Ascending colon
Lower half of right kidney
Part of duodenum and
jejunum

202
Q

organs of the right inguinal region of abdomen

A 
Caecum
Appendix
Lower end of ileum
Right ureter
Right spermatic cord
Right ovary
203
Q

organs of the epigastric region of abdomen

A 
Aorta
Pyloric end of stomach
Part of duodenum
Pancreas
Part of liver
204
Q

organs of the umbilical region of abdomen

A

Omentum
Mesentery
Lower part of duodenum
Part of jejunum and ileum

205
Q

organs of the hypogastric region of abdomen

A

Ileum
Bladder
Uterus

206
Q

organs of the left hypochondriac region of abdomen

A 
Stomach
Spleen
Tail of pancreas
Splenic flexure of colon
Upper half of left kidney
Suprarenal gland
207
Q

organs of the left lumbar region of abdomen

A

Descending colon
Lower half of left kidney
Part of jejunum and ileum

208
Q

organs of the left inguinal region of abdomen

A

Sigmoid colon
Left ureter
Left spermatic cord
Left ovary

209
Q

what are some landmarks commonly used to identiy abdominal areas

A

xiphoid process

costal margins

anterior superior illiac spines

umbilicus

inguinal ligaments

superior margin of pubic bone

210
Q

what order do you assess the abdomen (using the 4 techniques)

A

Inspection, auscultation, (percussion) and palpation (last)

Different order to normal as palpation and percussion stir up the bowl sound = non accurate results

211
Q

what do you inspect during abdomenal assessment

A

Integrity, colour, contour and symmetry

Aortic pulsations

212
Q

what do you auscultate during abdominal assessment

A

Bowel sounds (hypoactive, hyperactive or normal. Often depend on what last meal was. 4 quadrants) , vascular sounds (main arteries), friction rubs (peritonitis/ inflammation of peritonium)

213
Q

what do you percuss during abdominal assessment

A

Size and shape of organs
Abdominal aorta!! Not percussing or palpating
Bladder (urine retention) empty by assessment
Kidney ‘punch’- for assessing kidney stones, inflammation etc

214
Q

how to palpate during abdominal assessment

A

Light then deeper (if no pain, guarding- pt tensing up if organs in pain)
All four quadrants
Abdominal aorta! avoid!
Re-bound tenderness- push in, take hand of quickly
Medical staff usually do this

215
Q

what is a hernia

A

“protrusion of intestine through the inguinal wall or (up the inguinal) canal” (Slater, 2015, p. 709)

Bit narrow a definition – protrusion of an organ through an abnormal opening in a muscular surrounding wall

inguinal, epigastric, hiatal, femoral, umbilical (newborns and obese people), incisional + surgical (following abdominal surgery with scar)

Intestines/ hernia can become strangled and cause sepsis

216
Q

what can cause hernias

A 
Very common
	Caused by a muscle weakness - tear
	Congenital defect 
	Lifting heavy objects
	Excessive coughing
	Injury or surgery
	Chronic constipation
217
Q

symptoms of hernias

A

Bulge/pain/’heaviness’ (not hiatal)

Larger when coughing/standing/straining

Reducible or non-reducible        

         strangulated
218
Q

hernia treatment

A

Inguinal/femoral/umbilical/incisional
Hiatal

Open or laparoscopic

Medications and surgery

Complex with high death rate

219
Q

what is an anyurysm

A

Swelling in/of the wall of an artery

220
Q

location of anyurysm

A

anywhere (commonly abdominal)

221
Q

causes of anyurysm

A

ongenital/injury/hypertension/smoking/idiopathic

222
Q

clinical manifestations of anyursm

A

Back pain/pressure in bowel/bruit (can indicate partial occlusion)/palpable
In 80% of cases, other 20% can be symptomless

223
Q

diagnostic tests that may be done in abdominal assessment

A
  • Oesophageal acidity, oesophageal manometry, acid perfusion
  • Barium swallow or upper GI series
  • Barium enema
  • Colonoscopy
  • Upper GI endoscopy
  • Magnetic resonance imaging (MRI)
  • Gastric analysis
  • Gastric emptying studies
  • Abdominal ultrasound, various USs
  • Cholecystography/cholangiography
  • MRCP/ERCP/CT
  • Serum lipase/serum amylase
  • Liver biopsy
224
Q

what to take note of in faecal assessment

A
  • Inspect the person’s faeces
  • Test the faeces for occult blood
  • Note the odour of the faeces
225
Q

abdominal assessment infant considerations

A 
Abdominal organs (liver) proportionally larger (protrudent)
Umbilical hernia
226
Q

abdominal assessment children considerations

A

‘Pot belly’ until about four yrs
Develop flatter abdomen about school age
Watch facial expression when palpating to detect pain
Use distraction ‘therapy’ when examining

227
Q

abdominal assessment pregnant women considerations

A

‘morning sickness’
Increased GORD (acid reflux)
Increased constipation
Organs displaced as uterus enlarges

228
Q

abdominal assessment older adults considerations

A

Many changes even if no disease
Loss of muscle tone and development of more adipose tissue – obesity
Palpation more accurate due to thinner abdominal wall
Increase in pain thresholds
Differentiating GI tract pain from cardiac pain

229
Q

considerations before genitalia assessment

A

General external assessment or specialised assessment

Chaperone/privacy/cultural awareness

230
Q

what are you looking for in female genetalia assessment

A

Inspection of external genitalia including pubic hair
Inflammation, discharge, discolouration, lesions
Palpation of inguinal lymph nodes
Any hard lumps, especially if unilateral

231
Q

what are you looking for in male genetalia assessment

A

Inspection of external genitalia including pubic hair
Testicles!
Inflammation, discharge, discolouration, lesions
Palpation of inguinal lymph nodes
Any hard lumps, especially if unilateral
Examination of the prostate (with anal, rectal examination)

232
Q

infant lifespan consideration genetalia assessment

A

Female – newborns evidence of hormonal influences from the mother

Male – foreskin not retractable until 2 – 3 yrs of age
Male – midwife/medical officer usually palpates for descension of testes
Male – can be born with inguinal hernia

233
Q

children lifespan consideration genetalia assessment

A

Female and male - Privacy awareness!
Female - Pap smears/breast self-examination /safe sex
Female circumcision (illegal in Australia)
Female and male - pubertal/hormonal development

Male – testes retraction (Cremasteric reflex)

234
Q

older adults lifespan consideration genetalia assessment

A

Many changes even if no disease

Female - atrophies with age/hormonal changes/vaginal flora and lubrication changes
Female – vaginal bleeding abnormal (unless on HRT)/uterine prolapses/urinary incont

Male – penis and testes shrinks with age,
Male – difficulty achieving erection and less amount of ejaculate
Male – urinary frequency, dribbling, nocturia maybe prostate related

235
Q

how to percuss and palpate bladder

A

Skill supplanted by bladder scanner(?)
Moderately distended bladder
Between symphysis pubis and umbilicus
Light to moderately palpable as a firm round mass
Percussed as dull sound
Should be empty (tympanic)
Consider results with all other information

236
Q

3 types of muscle

A

Skeletal muscle, smooth muscle and cardiac muscle

237
Q

functional properties of skeletal muscle

A

Contractibility
Extensibility
Elasticity.

238
Q

what are joints

A

Joints are formed where two or more bones meet.

Joints hold the skeleton together while allowing movement. There are three types of joints:
Fibrous joints
Cartilaginous joints
Synovial joints
Ball and socket, hinge…
239
Q

what are tendons

A

Tendons are fibrous connective tissue bands that connect muscles to the bones

240
Q

what are ligaments

A

Ligaments are fibrous connective
tissue bands that connect bone
to bone

241
Q

muscoskeletal assessment includes

A

Assessment of dependence/independence

The Barthel Index

Assessment of mobility
Physical mobility scale

Assessment of falls risk (K & E pp. 648-649)
Various tools, as per NUR112

242
Q

does muscoskeletal assessment commence on entry

A 
yes
Commences on ‘welcome’
Ambulating into room
Getting seated
Posture
Lying on couch

Remember the purpose of a full assessment is usually to evaluate capability to conduct own ADLs/care for self

243
Q

what techniques used in muscoskeletal assessment

A

Inspect, palpate, direct auscultation

244
Q

what to inspect during muscoskeletal assessment

A

muscles- bilateral symmetry, contractures, tremors

bones- symmetry, deformities

joints- swellimh, tenderness, creitation,

245
Q

what to palpate during muscoskeletal assessment

A

muscles- muscle tonicity, flaccidity and spasticity, muscle strength (grade 0-5)

bones- tenderness, odema

joints- Swelling, tenderness, crepitation

246
Q

what different movements can be assessed during muscoskeletal assessment

A

flexion/ extension

abduction/ adduction

pronation/ supination

circumduction

rotation

eversion/ inversion

protraction/ retraction

elevation/ depression

247
Q

when assessing range of movement during muscoskeletal assessment what can you note

A

Limited by contractures?
Full (variable according to genetics)
Restricted (injury or disease), pain

248
Q

Problem focused ankle and foot assessment example

A

Inspect while person sitting, standing and walking
Compare both feet
note contour of joints
foot should align with long axis of lower leg
Weight-bearing should fall on middle of foot
most feet have longitudinal arch (? “flat feet” to high instep)
Toes point straight forward and lie flat
note locations of calluses or bursal reactions (areas of abnormal friction)
Examine well-worn shoes to assess areas of wear and accommodation

Problem focused ankle and foot assessment (cont.)
Support ankle by grasping heel with your fingers while palpating joint spaces with your thumbs
should feel smooth, with no swelling or tenderness
Assess ROM
Assess muscle strength by asking person to maintain dorsiflexion and plantar flexion against resistance

249
Q

lifespan considerations for infants during muscoskeletal assessment

A

birth assessment of clavicle

return to flexed fetal position (assessing tonicity)

standing test of muscle strength

hip dysplasia

meeting milestones

250
Q

lifespan considerations for children during muscoskeletal assessment

A

different mobilisation variations normal for this group

observe playing children motor function, coordination, balance

spine development scoliosis

growth and development and nuutritional intake

251
Q

lifespan considerations for older adults during muscoskeletal assessment

A

loss of muscle mass with aging, maintaining exersise is important
decrease in strength, reaction time, coordination
development of osteoporosis and arthritis
joint replacements, related surgeries

252
Q

Diagnostic Tests For The Musculoskeletal System

A 
Blood chemistry
X-ray
Computerised Axial Tomography (CT) or (Cat) scan
Magnetic resonance imaging (MRI)
Bone scan
Bone density
Arthroscopy and arthrocentesis
Electromyogram and somatosensory evoked potential (SSEP).
253
Q

what is the barthel index in muscoskeletal assessment

A

he Barthel Scale/Index (BI) is an ordinal scale used to measure performance in activities of daily living (ADL

254
Q

what are you assessing for in neurovascular assessment

A

Neurological function (motor and sensory function)

Peripheral circulation (colour, temperature, cap. refill, pulses)

255
Q

what sorts of people would you be monitoring neurovascular assessments on

A 
Fractures, crushing or other musculoskeletal injuries
Orthopaedic or vascular surgery
Application of casts/POPs
Circumferential dressings
Tourniquets(?)
Thromboembolic disorders and infections
Poisonings (snakebite)
Excessive activity
256
Q

what is compartment syndrome

A

Mainly in limbs
Excess bleeding/fluid collection (oedema) within a compartment
Excess bleeding/fluid collection (oedema) restricted by external compression
Leading to increased pressure in compartment
Restricting blood flow
Leading to muscle and nerve ischaemia (death)

257
Q

what are the 5 p’s in neurovascular assessment

A

Pain (early sign and out of proportion with injury/? masked by analgesia)
Pallor
Pulselessness (late and very serious)
Paraesthesia (numbness, tingling, ‘pins and needles’)
Paralysis (late and very serious)

Or is it 7 P’s
Poikilothermia (taking on Tº of surroundings, cold)
Pressure (rigid, tense, shiny)

258
Q

should you just check one limb in neurovascular assessment

A

no
All assessments must involve the comparison of the affected limb with the affected limb (if possible)
Casts can impair assessment

Always compare to the baseline 
However baseline (post injury) may not be ‘good’
259
Q

how often are neurovascular assessments done

A

Depends on situation
Usually hourly for first 24 hrs post injury/application of cast
4 hrly for next 48 hrs
Maybe more frequent

260
Q

treatment of compartment syndrome

A

Fasciotomy

261
Q

sensoryt process involves 2 processes

A

reception and perception

262
Q

what is reception vs perception

A

• External (visual/ auditor/ olfactory/ gustatory/ tactile)
• Internal (gustatory/ kinesthetic ‘awareness of precision and movement of body and parts’/ visceral ‘organs of the body’)
PERCEPTION IS THE PROCESSING OF THIS SENSORY DATA

263
Q

4 components of sensory processing

A
  • Stimulus
  • Receptor
  • Impulse conduction
  • Perception

‘’the conscious organization and translation of this data, or the stimulus (from sensory organ)

264
Q

what can affect the eyes

A

alot
eg
• Diabetes, hypotension, sun exposure can affect vision

265
Q

eye assessment involves

A 
…inspection of external structures
…visual acuity (detail eye can see)
…visual fields (field of view)
…light perception 
…assessing pupil reaction (using pen light)
266
Q

some different eye conditions

A
  • Myopia (near sighted)
  • Hyperopia (far sighted)
  • Presbyopia (loss of ability to see close objects)
  • Conjunctivitis (inflammation often due to infection)
  • Cataracts (caused by opacity of lens or its capsule, requires surgery)
  • Glaucoma (increase in intraocular pressure- caused by blockage of outflow of fluid in eye)
267
Q

the eye lifespan considerations - infants

A

Gaze and follow objects at 4 weeks of age
Focus with both eyes at 6 months
Cannot form tears till 3 months of age

268
Q

the eye lifespan considerations - children

A

Visual acuity should be 20/20 by 6 years of age
Colour vision tests not compulsory but are indicated if quieried by parents/ teachers
Trachoma common in low socioeconomic areas (common bacterial eye disease)

269
Q

the eye lifespan considerations - older adults

A

Acuity and field of vision decreases with age
Loss of orbital fat and muscular structure changes
Exophthalmos
Development of cataracts

270
Q

parts of ear

A
  • Outer (catches directs sound), inner and middle ear (smallest bones in body, transmits sound vibration into inner ear, connected with nasopharynx)
271
Q

2 pathways of hearing

A
  • Air conduction- normally hear this way
  • Bone conduction
  • Can have conductive hearing loss caused by mechanical dysfunction of outer and middle ear, can be blocked with ear wax etc. but if sound is loud enough can still get through to inner ear possibly aided by bone conduction
  • Sensory neural hearing loss signifies pathology of inner ear or the branches of the auditory
272
Q

what part of ear provides equilibrium balance

A

inner ear

273
Q

ear and hearing assessment involves

A

…inspection and palpitation of external structures

  • Otoscope (visualize through to tempanic membrane)
  • Audiometry
274
Q

causes of hearing loss

A

…air conduction (blockage, interruption to sound waves)
…sensorineural (auditory nerve/ auditory centre in brain)
…age related

275
Q
  • Noise induced or arthritic changes to middle ear can be related to…
A
  • Noise induced or arthritic changes to middle ear can be related to ototoxic drugs
  • Ototoxic drugs- medications that damage hearing eg. Iv antibiotic
276
Q

colour of tympanic membrane

A

pearly white

277
Q

lifespan considerations ear- infants

A

should be formally assessed before leaving hospital
gross assessment by ringing a bell/ parent calling name- infant quietens and may open eyes wider
milestone assessment is by 3-4 months child turns head towards the sound

278
Q

lifespan considerations ear- children

A

hearing loss in this age group increasing

279
Q

lifespan considerations ear- older adults

A

hearing changes with age (often requires hearing aids)

physiological changes occur (skin/ hair/ cartilage/ membranous)

280
Q

what should you assess when assessing nose

A

External nose

  • Inspection
  • Palpation
  • Injuries/ fracture

Determine patency
- Deviated septum/ fracture/ congestion

Inspect nasal passages

  • Pen torch or speculum and otoscope with attachment
  • Frequent epistaxis/ septal defects

Olfactory assessment
Sinus assessment
- Palpation and direct percussion in adults

281
Q

outer nasal structures

A

columella, septum, nares, ala, bridge, tip

282
Q

t or f

there are chronic nasal and sinus disorders

A

true

283
Q

nose lifespan considerations - infants

A

Nasal cavity usually visualized using a pen torch

The sinuses are formed at birth

284
Q

nose lifespan considerations - children

A

Sinuses develop at different rates until about 12 years of age
Sinus infections and pain uncommon before this age, more common in adolescents
The nasal cavity usually visualized using a pen torch

285
Q

nose lifespan considerations - older adults

A

sense of smell diminishes with older age
discrimination of odours reduces with older age
otoscope may be required for a more complete visualization of the nasal cavity

286
Q

t or false the eyes help our head stay on our head

A

false

size of sinus hollows allows head to stay on our shoulders

287
Q

what does the tongue do

A
  • An important part of swallowing, loss of coordination can cause dysphagia
  • Detects taste- 4 original tastes bitter, sour, salty, sweet, umami, olinguitos
  • An indicator of hydration
288
Q

what does tongue colour indicate

A
  • white/ trush, strawberry tongue/ scarlet fever, odour (halitosis
289
Q

different levels of sensory perception

A

overload and deprivation

290
Q

Sensory function Essential for:

A

…connection with the environment

…function within the environment

291
Q

Sensory dysfunction Can occur in any of what 4 compnents:

A

…stimulus
…receptor
… impulse conduction
… perception

292
Q

different states of awareness

A

Full Conscious- alert, orientated to time, place, person
Disorientated- not orientated o time, place, persom
Confused- reduced awareness, easily bewildered; poor memory, misinterprets stimuli
Somnolent- extreme drowsiness but will still respond to stimuli
Semi comatose- can be aroused by extreme or repeatrd stimuli
Coma- state of deep unarousable unconscious

293
Q

Factors affecting sensory perception

A
  • Developmental stage
  • Culture
  • Stress
  • Illness
  • Medications
  • Lifestyle
    Adjust care accordingly providing patient centred care
294
Q

at risk of sensory deprivation if

A
  • Are confined in a non stimulating or monotonous environment in the home or healthcare facility
  • Have impaired vision or hearing
  • Have mobility restrictions such as quadriplegia or paraplegia, are confined to bedrest, and have splinting or traction restrictions
  • Are unable to process stimuli eg brain damage
  • Have emotional disorders eg. Depression
  • Have limited social contact
295
Q

prevent sensory deprivation by..

A

Encourage person to use glasses or hearing aids
Address person by name or use of touch while speaking if not culturally offensive
Communicate frequently with person and maintain meaningful interactions
Provide phone, radio and or TV, clock, calander

296
Q

at risk of sensory overload if

A
  • Have pain or discomfort
  • Are acutely ill an d have been admitted to hospital
  • Are being closely monitored in ICU and have invasive tubes
  • Have decreaded cognitive ability eg. Head injury
297
Q

prevent sensory overload by

A
  • Minimise unecessay light, noise, distraction
  • Control pain indicated at level desired by the person on a scale of 0-10
  • Introduce sef by name and address peron by name
  • Provide orientating cues such as clocks, calanders, equipment and furniture in room
  • Provide private room
  • Limit visitors
  • Plan care to allow for uninterrupted periods for rest or sleep
298
Q

what is a primary survey

A
  • A systematic assessment tool that is predominantly used in Emergency Departments (ED)
  • Used to identify and manage life-threatening illnesses/conditions/injuries
  • Useful as most patients in ED are undiagnosed
299
Q

different survey types

A
  • Primary survey secondary survey focused assessment
  • Subjective history
300
Q

steps of primary survey

A

danger

response

send for help

A – Airway . snoring, gurgling, stridor sign of obstruction

B – Breathing. Look listen feel

C – Circulationrate, strength, rhrth. If none cpr

D – Disability (eg neurological assessment)-glasgow oma ang bgl

E – Exposure- section by section, front and back

301
Q

is primary survey a dynamic process yes

A

• It is a dynamic process, you are constantly checking and re-checking
but
• Each component
must be fixed before moving onto the next

302
Q

basic life support steps

A 
danger
response
send for help
open airway
normal breathing
start cpr
attatch defrib
303
Q

primary survey examp,e of what might do at wach stage

A

A – Airway

B – Breathing Respirations, Oxygen Saturations

C – Circulation
Pulse, Blood pressure, Skin Colour, ? Temperature, signs of hemorrage

D – Disability GCS, ? Temperature, BGL, palpating for injuries

E – Exposure Head to Toe, ? Temperature

304
Q

what to do if abnormal vital signs

A
  • Is your recording accurate?
  • Is your technique precise?
  • Consider the individual patient (what is normal for them)?
  • Consider outside factors
  • Can you validate the result?

Reporting abnormal results is a key nursing responsibility

Know your normal values!!!

Report anything outside those values BUT consider results in light of all information (what is “normal” for this patient/previous results/trends/history)
“Inform Shift Coordinator/Medical Officer of any deviation in patient parameters or changes in vital sign trends or acute changes in behaviour further escalation” (RPH, 2016, p. 05)

305
Q

information about the adult observation and response chart

A
  • Legal form
  • Obs and response chart designed to ensure appropriate recognition and response to change in condition
  • Frequency changes
  • Graphical record of pts vital signs’
  • Trends in obs
  • Forces you to escalate all chages out of normal values
  • Is the abnormal normal for the patient? Have a ‘modification’ completed
306
Q

why is being aware of trends when taking vital signs important

A

Alert you early to deterioration so interventions can be introduced before situation becomes critical
Worth reporting to nurse coordinator

307
Q

what are the stages of the clinical reasoning cycle

A
  1. consider patients situation
  2. collect cues/ info
  3. process information
  4. identify problems/ issues
  5. establish goals
  6. take action
  7. evaluate outcomes
  8. reflect on process and new learning
308
Q

what is grief

A

• Grief is the reaction (in thoughts, feelings and behaviours) to the experience of loss- perceived or actual:

309
Q

loss may involve..

A
  • Loss may involve physical death ( our focus) or loss of body parts, relationships, role change, valued objects, security, football grand finals…
  • Can be ‘perceived’ loss or áctual’loss
310
Q

t or f

individual response to grief is predictable

A

false

it is inevitable but response is unpredictable

311
Q

does greif always involve mourning

A

no

312
Q

examples of different responses to within grieving process

A

Reaching out, internalising, find distractions

313
Q

• Kubler-Ross’ Five Stages of Grieving

A

Denial

Anger 

Bargaining may involve person becoming spiritual,

Depression – therapeutic touch accompanied by silence may or may not help

Acceptance- supporting and encouraging involvement in decision making process

No natural flow in the order
314
Q

femal response to grief vs male

A

Women
• more likely to express their feelings earlier
• have and reach out for social support
• are seen to publicly express more sorrow, depression, and guilt
• more willing to talk about the loss of a child

Men
• more likely to try to manage the situation
• intellectualise their emotions, rather than express them
• though when they do they may indicate feelings of anger, fear, insecurity and a lack of control
• reside in first stage ‘denial’ more
• more likely to grieve in private

315
Q

responses to death by age 2-4

A 
Ages 2-4
•	Concept of Death
	Seen as reversible or temporary
	Does not understand reality of               
•	Grief Response
	Intensive response but brief
	Very present oriented
	Notices changes in patterns of care
	Frequent and repeated questions
316
Q

responses to death by age 4-7

A

Ages 4-7
• Concept of Death
May still see as reversible or temporary
Or more mature may understand finality
Can feel responsible for the death (wishes and thoughts)
• Grief Response
More verbalisation
Wants to know the ‘ins and outs’ (How? Why?)
May also act as though nothing has happened
Or general distress and confusion
(at this age, possibly even with similar development,
response can be variable)

317
Q

responses to death by age 7-13

A

• Concept of Death
Beginning to see it as final (though still wants it reversible)
May see it as punishment for perceived sins
May also express interest in after-life

• Grief Response
Asks specific questions, wanting full detail
Can be difficult knowing how to respond in some situations
Starting to have ability to mourn and understand mourning

318
Q

responses to death by age teens

A

• Concept of Death
Able to abstract
May believe it can be defied/avoided
May view in religious or philosophical terms

•	Grief Response
	Extreme sadness, maybe withdrawal
	Can exhibit extended denial
	Regression in age behaviours
	More often willing to talk to people outside of family
	Peer support may be important
	May involve risk-taking behaviours
319
Q

what to do if child is greiving

A

What to do
• Find a way to symbolise the loss (a ceremony?)
• Difficult if they don’t understand ‘abstract’
• Express sorrow for the loss
• Sit next to ‘be there for’ a child that wants closeness
What not to do
• Try to shelter children from the reality of death
• Give false or confusing messages
• Tell a child to stop crying
• Try to cheer the person up
• Offer advice or quick solutions
• Pry or ask about the circumstances

320
Q

how to act when someone is grieving

A

• Supporting the Grieving Person
Understand the therapeutic relationship
Avoid judgment/respect privacy/respect wishes
Maintain open communication
Explore and respect their beliefs and values
Encourage expression of grief
Stay informed of resources (Australian Centre for Grief and Support)/various chaplains /professional
Acknowledge/presence/listening/silence(?)
Be there …

321
Q

when to initiate a conversation about dying

A

In the appropriate situation
After building rapport
• Especially in aged care facilities/home care situations
• Poor deaths often linked to a lack of planning and communication

322
Q

changes in a dying person

A
  • Pain
  • Dyspnoea
  • Nausea, anorexia and dehydration
  • Altered levels of consciousness
  • Hypotension
323
Q

examples of ways to provide comfort to a dying person

A
  • clean skin and linen
  • slide sheet to turn and keep comfortable
  • inconstinence pads or catheter if ordered
324
Q

care following death

A
  • The nurse documents the time and particulars of death, notifies the medical officer and supports the family.
  • If the person dies in hospital or aged care, it is important to acknowledge the death with others who may have seen the patient die.
  • Nurses may also experience grief when they have cared for the person.
  • “Last offices” often by the nurse/sometimes with family
  • Depending on cultural, personal, Coroner’s requirements
325
Q

somethings that take place in last officies

A

IVs/drains removed
Wounds covered with simple dressings
Bodily orifices sometimes packed with cotton wool/gauze ribbon to prevent leakage of fluids
Teeth/dentures are cleaned and replaced
Hair is groomed, fingernails are cleaned
Men are shaved
Eyes are closed
Lower jaw supported with a bandage
Limbs are positioned, tied in place
Identification tags are attached
The body placed in a shroud then a body bag and delivered to the mortuary

326
Q

why provide spiritual care?

A

• Is part of holistic nursing
• Meeting people (often) at the point of deepest need (? Dying)
not just ‘doing to’ but ‘being with’ them.
• It is about treating spiritual needs with the same level of attention as physical needs.
• We are a facilitator of patient’s spiritual needs
Not an ignorer
Not a convertor
Not a false hoper

327
Q

how to initiate conversation about spirituality

A
  • Do you have a source of support or help that you look to when life is difficult?
  • Would you like to talk to someone about this (offer choice)?
  • Would you like to talk about this with me?
  • This must be a very difficult time for you …, do you have anything in particular that supports you through this?
  • Would you like me to sit with you for a while?
328
Q

what is acute confusion

A

“an acute organic mental disorder characterised by confusion, restlessness, incoherence, inattention, anxiety or hallucinations which may be reversible with treatment”

delirium

329
Q

distinguishing feature of dementia vs delirium

A

delirium- acutr, fluctuating change in mental status

dementia- memory impairment

330
Q

onset of dementia vs delirium

A

delirium- sudden, acutr

dementia- slow, insidious

331
Q

duration dementia vs delirium

A

delirium- temporary

dementia- chronic, gradual irreverasble

332
Q

time of day dementia vs delirium

A

delirium- worse at night

dementia- no change

333
Q

sleep wake cycles dementia vs delirium

A

delirium- disturbed, cles often reversed

dementia- distirbed, fragmented, often awakens during night

334
Q

alertness dementia vs delirium

A

delirium- fluctuates. may be alert and oriented at day but disorientated at night

dementia- generally normal

335
Q

thinking in dementia vs delirium

A

delirium- Disorganised, distorted. Impaired attention.
Alterations in memory.

dementia- Judgment impaired. Difficulty with abstraction
and word finding.

336
Q

delusions/ hallucinations dementia vs delirium

A

delirium- May have visual, auditory and tactile hallucinations.
Misinterpretation of real sensory experiences.

dementia- Delusions. Usually no hallucinations

337
Q

causative and risk factors dementia vs delirium

A

delirium- Cerebral and cardiovascular disease, infections,
reduced hearing and vision, environmental change,
stress, sleep deprivation, polypharmacy, dehydration.

dementia- Alzheimer’s disease. Multiple infarct dementia.

338
Q

3 c’s (signs and symptoms of delirium)

A

Impaired concentration

Altered cognition

Fluctuating consciousness

also… Alternating agitation and calmness, hallucination’s, repetitive behaviors

339
Q

pathophysiology of delirium

A

Pathophysiology not clear.

340
Q

some possible causes of delirium

A

Dementia/other neurological impairment (stroke)

Sensory changes (visual/hearing)

Changes in environment

Some medications (sedatives/narcotics)

Illnesses (pneumonia, UTI, other infection)

Injuries (# NOF [hip])

Untreated pain

Any causes of metabolite/electrolyte imbalances/fluid imbalance (dehydration) 

Substance abuse/withdrawal 

Depression

Hypoxia/hypercapnia 

Constipation/sleep deprivation/stress …

Younger adults can compensate for these physical and chemical challenges, older adults may not be able to.
341
Q

adverse outrcomes of delirium

A 
Increased falls
	Pressure sores
	Increased length of stay in hospital (doubles?!) 
	Increase in dependence 
	In hospital and possibly at home 
	Increase in … death (25 - 35%)
342
Q

how to tell if a patient is demented or delirious

A 
Recognise high risk patients 
	Know past history 
	Be alert to subtle changes
	Recognise signs and symptoms
	Assess cognition (on admission and regularly)  
	Communicate with family (history) 
	Remember, it is reversible
	Use critical thinking …
343
Q

hhow to promote a therapeutic environment for a person with acute confusion/ delirium

A

Wear a readable ID badge.
■ Address the person by name and introduce yourself
frequently:
‘Good morning, Mr Richards. I am Sue Smith.
I will be your nurse today.’
■ Identify time and place as indicated: ‘Today is 5 December
and it is 8 o’clock in the morning.’
■ Ask the person ‘Where are you?’ and orientate them to place
(e.g. hospital ward) if indicated.
■ Place a calendar and clock in the person’s room. Mark
holidays
with ribbons, pins or other means.
■ Speak clearly and calmly, allowing time for your words to be
processed and for the person to give a response.
■ Encourage family to visit frequently, except if this activity
causes the person to become hyperactive.
■ Provide clear, concise explanations of each treatment procedure
or task.
■ Eliminate unnecessary noise.
■ Reinforce reality by interpreting unfamiliar sounds,
sights and smells; correct any misconceptions of events
or situations.
■ Schedule activities (e.g. meals, bath, activity and rest periods,
treatments) at the same time each day to provide a sense of
security. If possible, assign the same caregivers.
■ Provide adequate sleep.
■ Keep eye glasses and hearing aid within reach.
■ Ensure adequate pain management.
■ Keep familiar items in the person’s environment (e.g. photographs)
and keep the environment uncluttered. A disorganised,
cluttered environment increases confusion.
■ Keep room well lit during waking hours.

344
Q

what is chronic confusion

A

dementia. A collection of signs and symptoms that are caused by a number of disorders of the brain

A combination of cognitive, personality and physical changes associated with neuron death and miscommunication of those neurons

345
Q

conditions that can mimic dementia

A

Age-related cognitive decline

Mild cognitive impairment (is actually an intermediate stage between age related cognitive decline and actual dementia, pre dementia- problem with memory, language speech and judgement at a greater than age related changes)

Depression

Delirium
346
Q

what is alzheimers disease

A

 A form of dementia characterised by progressive, irreversible deterioration of cognitive functioning
 Life expectancy of ~ 8–10 years following diagnosis
 Gradual loss of function shifts burden onto caregiver
 Eventual death often by aspiration pneumonia
 Risk factors – age/family history/female

347
Q

warning signs of alzheimers

A
  • Memory loss that affects job skills
  • Difficulty performing familiar tasks
  • Problems with language
  • Disorientation to time and place
  • Poor/decreased judgment.
  • Problems with abstract thinking
  • Misplacing things
  • Changes in mood or behaviour
  • Changes in personality
  • Loss of initiative.
348
Q

stages of alzheimers

A
  1. short term memory loss (2-4y)
  2. impaired cognition, personality changes (2-12 y)
  3. cognitive abilities grossly decreased or absent (2-4y)
349
Q

Alzheimer’s Disease

Interprofessional Care

A

• There is no cure (but it is treatable)
• Some medications may assist in slowing disease progression
• Treat associated depression
Regularly present
• Alternative and complementary therapies (K & E)

Very limited research on herbs

Art, music, Snoezelen rooms

350
Q

alzheimer nursing care for impaired memory

A

• Complementary therapies
May help reduce stress which can affect memory
• Use of calendars/diaries/white-board for reminders
• Webster packs for medications as reminder and for safety
• Emergency contact details for safety
• Alarm (on watch) to cue reminders

351
Q

alzheimer nursing care for chronic confusion

A

• Label items (visual cues)
• Remove potential hazards (ensure safety)
• Minimise environmental stimuli
Calm and relaxed, decrease sensory overload and therefore anxiety
• Communication techniques require adaptation and flexibility

• Reality orientation (orientate to place/time/person – regularly?)
• Provide boundaries (red/yellow tape on floor)
Increases safety

352
Q

alzheimer nursing care for anxiety

A

• Assess for fatigue and agitation (causes)
Remove from situations that cause anxiety
• Consistent daily routine (decreases stress)
• Schedule rest periods/quiet activities
Fatigue increases anxiety
• Assess for physical causes of agitation
• Use therapeutic touch or gentle hand massage
Unless it increases anxiety

353
Q

alzheimer nursing care for adapting and enabling communication

A 
Remove distractions
•	Stop and listen, face to face 
	Call by their name, use yours
•	Use a calming, low voice, relaxed manner
	Closed-ended questions, one at a time
•	Simple short sentences
	Stopping talking! (Listening!!)
	Importance of body language
	Mirroring 
	Be specific
	Be adaptive to patient’s mood
	Assess response regularly
	Be aware of cues
	Wandering may mean the need to toilet
	Reminiscence 
	Validation therapy
	A collection of communication techniques
	Cultural safety
354
Q

alzheimer nursing care for hopelessnes

A 
•	Educate (as and where appropriate)
•	Assess coping
•	Avoid judgment or criticism
•	Support positive family bonds and enhance communication
	Share the ‘burden’
•	Encourage decision-making
	Self-control build self-efficacy
•	Encourage spiritual guidance (when appropriate)
355
Q

alzheimer nursing care for caregiver rolestrain

A

• Physical care, psycho-social, financial challenges
• Grief
• Teach self-care techniques
Prevent care fatigue ‘burn-out’
• Refer to support groups and additional resources
Meals-on-wheels
Counselling
Hospice
Respite care (essential)
Alzheimer’s Australia (numerous ‘help sheets’)

356
Q

WHAT IS GCS

A

Based on motor responsiveness, verbal performance, and eye opening to appropriate
stimuli, the Glascow Coma Scale was designed and should be used to assess the depth
and duration coma and impaired consciousness

semester 2 nursing (5 decks)

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