Week 2 Flashcards
Range core body temperature
36.0-37.0
97-99.5
What regulates body temperature
Homeostasis+ set point
Heat production
Heat loss
3 factors that affect body temp
Age babies+ old people < temp
Gender: women have high temp variations
Circadian rhythm- highest 4-7 pm
Temperature extremes affect body temp
Environmental temp
> metabolic rate in body > temp
So exercise, stress + illness
Febrile
Afebrile
Temp above normal
Afebrile= normal temp
Hypothermia
<97.0c
Fever
101> is natural disease fighting, not too harmful
Above 104 is very harmful
In older adults fever
Is a sign you’re in the later stage of a Disease
Older adults and infants
Small change is important. Takes a lot on their metabolize to > temp
Core body temps
Rectal or tympanic
Interventions for fevers
Monitor VS FLUID SEIZURES (in extreme cases) Administer antipyretic meds Administer IV fluids Apply ice (extreme)
Don’t use rectal
Diarrhea, bowel surgery, diseases of the rectum, nutripenic (immunocomprimised), quadriplegics, no CV surgeries
Stimulate vagus nerve= fainting
> age pulse
<
Women have slightly higher pulse
Infancy pulse range
100-160
Adult 60-100
The vagus nerve
> temp pulse?
Tachycardia
Ventricle strokes a lot, so less blood is getting out so higher pulse. Stroke volume is less
< BP
> temp
Bradycardia
<60 bpm
Men have lower HR so elderly + adults
Hypothermia < pulse rate
Vagostimulaiton/ bradycardia < Pulse
SEVERE CHRONIC PAIN < pulse
Dysrhythmias
Regular irregular (same irregular pattern)
Irregular irregular (no predictability)
Ventral ejection is the same as
Pulse= pulse generation= pulse wave= ventricular opening
Characteristics of pulse
Rate, quality, Rhythm
Indicate effectiveness of system & quality of blood flow
Quality of pulse rate determined by the force of the blood flow
Quality of pulse
0=absent 1= threats 2=weak 3= normal 4= bounding
Cardiac output is calculated as
Heart rate* stroke volume
Temporal artery
Front of upper part of ear
Carotid artery
Under the chin towards the neck
Best representative of the quality of the pulse rate directly front he heart or aorta
Brachial artery
Radical artery
Need to accurate put the BP cuff on it
Bend arm, pulse is at the antecubitol space locate medically
Anywhere within a 2in range above where the arm flexes
Radial you know this
Femoral artery
Have person bend their thigh up
Located in the medial aspect of thigh, halfway btn the anterior superior iliac spine & the synthesis pubis
Popliteal
Patient flexes their knee, reach behind and palpate the lateral aspect of the fossa
Dorsalis pedis
Top of foot
Wiggle their great toe. Tenden goes towards ankle, palpate the lateral side of that
Posterior tibial
Behind medial malleolus in each side
Always palpate both sides of parallel pulse except temporal and carotid
If the stroke volume is decreased
The pulse amplitude decreases
Doppler monitors
Feel for skin temp and capillary refill. They’re getting good pulses but you can use the Doppler to hear that artery
Knee surgery on L side. Lower leg really swelled. You wanna assess those pedal pulses on that Left leg for circulation . Or edema
Difficult pulses
Doppler monitor
Check both sides
Pulse documentation
Rate
Rhythm
Quality
68 regular, even
72 regularly irregular, and bounding
52 right dorsalis pedis via Doppler
NANDA Diagnosis regarding tissue perfusion
Decreased cardiac output
Ineffective tissue perfusion- peripheral
Deficient fluid volume
Acute pain
Factors that affect respirations
Age lungs get bigger resp. < Gender females breathe more Stress, anxiety Exercise balance breathe faster Acid-base inbalance will change respirations
Factors that affect respirations
Meds.
Altitude
Pain
Anemia < in O2 so increase is respirations
Fever
Respiratory diseases
-body position will affect ability of your lungs to expand. Tripod position is common with COPD
Eupnea
Normal rate (12-20)
Tachypnea and Bradypnea
You know
Apnea
Period of no breathing
Note quality of respirations
Unlabored, quiet, effortless
Labored, shallow, deep, gasping, painful
Note Rhythym
NANDA NURSING DIAGNOSES
Ineffective breathing patterns
Impaired gas exchange
Risk for activity intolerance
AnEroid
Digital
BP cuff
Aneroid- sphyg
Factors affecting BP
Age, older adults higher BP. Have a < in vascular existence (> plasticity of blood vessels) esp. systolic
Circadian Rhythm lowest in morning highest in later afternoon
Gender. Women are lower than men until menopause
Food intake
Exercise
Other factors that affect BP
Overweight people Emotional state activate autonomic system > stress, > BP Body position Race: HTN prevalent in AA Medication
BP cuff sizes
Cuff to big, low reading
Cuff to narrow, false high
Bladder width should be 40 of curcumference
Preparation for patient’s
Rested for 5 minutes Has not consumed coffee Has not smoked for 30 min. Sitting in a straight back chair Feet resting on ground Arm at heart level Patient is quiet
BP measurement
5 separate phases
Phase 1 systolic
Phase 5: diastolic
3 numbers in pediatric
1st, 4th, & 5th
Also in exculpatory gap
To put a Bp cuff
Medial aspect of antecubital foss
1-2 inchesfossa, same
Deflate cuff at
2-3 mm per second
Can you use a pipliteal artery for BP?
The systolic number is 10-40 mmHg higher. Diastolic the same
Use thigh cuff or large regular cuff.
Auscultatory Gap
See them in patients with HTN
Important bc common in people with atherosclerosis (plaque)& > arterial stiffness
Identify these gaps. Too high to have gone away and then it picks up again.
Top #, second number # whenyou reheard the best, 3# last beat
Causes of false readings
Mono meter not calibrated to “0” Viewing the needle below eye level Releasing the valve too slowly Reinflating the bladder during auscultation missing an ausculatory gap
Causes of false low readings
Viewing the needle above eye level Releasing valve too rapidly Not placing the stethoscope over the artery Not pumping 30mmHg above the Sbp Missing an auscukatory gap
What BO reading will you get with a Doppler monoter
The systolic reading
Moderate HTN
SEVERE
CRISIS
160-178. /100-109
180-209. / 110-119
>
- / 120
What organs are at risk for damage in BP
Brain
Heart
Kidney
Pulse pressure
A mathematical equation
Systolic-diastolic
Larger someone’s PP means their arteries are not compliant
Complaint arteries have elasticity
Non complaint/ resistance are tight
PP determined by how compliant ur arteries are & ur stroke volume
For a given stroke volume
Increased complaint= smaller pulse pressure
Decreased compliance= higher pulse pressure
A larger stroke volume fives a large pulse pressure at any compliance
Why do non compliant arteries take more time and pressure
Dump a lotta blood into artery at one time, that opens a bit, as blood flows through it’ll close again, how wide it gets vs how small it gets (systolic versus diastolic) is bigger than normal then it’ll flex smaller than normal
Boncomplaint aretiers do not open very wide and cause more pressure and it’ll take more time for the blood to pass
Pulse pressure is going to be higher
With higher volume
It’ll be much higher for someone who has arteries that are not complitany
Artery that is stiff will take longer to pass blood through
Arterial resistance increases with age
Orthostatic hypotension
AKA Postural hypotension
When you stand up and your Bp drops Lying to sitting Vasodilated arteries then quickly have to vasocstrict to stand up < O2 to the brain People at risk Older adults Prolonged bed rest like 3 days Dehydrated people Significant blood loss Analgesic and diuretic meds
Orthostatic hypotension interventions
Slow risk for lying position. Then dangle feet off side of bed
Get body moving again
What happens when you make a change in position
you have a < in your glomerular filtration rate. A < in the blood going into your kidneys which causes an increase in sodium which causes the distal tubules to absorb water to > circulating blood flow. Also have < in the pressure sensors in your carotid arteries that tell you that the circulating blood flow isn’t as high as it needs to be which stimulates the sympathetic NS which causes vasoconstriction, > cardiac output, BP >, pulse>, feel better and your symptoms go away so you can stand
How do you take measurements for someone with orthostatic hypotension.
Lay flat for 4-5 min
Sit 1
Stand up for a minute take their Bp
If there’s an increase of 40 bpm or 30 mmHg the in systolic BP
Pulse oximetry
Determines % of hemoglobin combined with O2 in the blood
96> normal
93< need for oxygen
At least =93
Where do pulse ox sensors go?
Finger, toe, ear, nose
Very small changes in oxygen levels are significant
SA o2 of 90means your actual ox in your blood is like 20 points lower than that
Patient has anemia at sa02 of 98
What does this mean?
It’s a false high bc it’s indicating that 98% of the hemoglobin in this patient’s blood is supposedly bound to an O2 molecule
This patient doesn’t have enough oxyhemoglobin receptors bc they have anemia
Does it look like they’re having difficult with profusion?
NANDA NURSING DIAGNOSES FOR BP
Decreased cardiac output
Ineffective health maintenance
Effective therapeutic regimen management
Risk for falls
Height and weight
You need both Ratio is a good indicator of Nutrition Hydration status General health
Provide sensitive care
Measuring weight
Calibrate scale to 0
Remove shoes and heavy clothing
If patient is barefoot-place paper towel on plate form
Balance scale and read the weight to the neardt 1/4 pound
Monitor daily of weekly weights
Same time each day
Similar clothing
Same scale
Stadiometer
How to measure height
Go to nearest half inch
Sternum
Sternal botch
Manubrihn
Angle of Louis:
Xiphoid process
Ribs-intercostal spaces
Landmarks
Costal margins
Sternal borders
Midclavicular arch
Know heart anatomy
D
Diastolic
Diastoli period inthe heart where he ventricular are possibly filling
A heart beat is lub-dub, s1-s2
The period of time between the last s2 and the next s1 is diastli
Systoli
Ventricles contracting, left and right atrium are passively filling with blood
So two things happen systoli happens btn s1 and s2
S1 systole s2. Diastoli s1. Systole s2
What opens and closes during systole and diastole
Contraction of ventricles (s1-s2)
Valves closing in s1 (bicuspid and mitral)
After s2 is pulmonic and semilunar (aorta)
Systole ventricles contracting
QRS= systoli
Cardiovascular assessment
Important for prevention
General state of health: fatigue, signs of distress (does the patient appear to be SOB? Palapatations?) , chest pain (angina)
Family history: HTN, DB, CVD, Hyperlipidemia
Most patients with diabetes die of CVD
Med history: prescription, OTC
Activity level: need 30 min. A day
Weight + dietary habits:Na+ fat, Cholesterol
Personality, stress, and work
Smoking alcohol, habits
Cardiovascular assessment
Survey the patient for general signs of CVD Restlessness? Anxiety?? Might be SOB
Cyanosis
Not enough o2 in blood
Can be bluish hue to them
Want to know if it’s central cyanosis, true hypoxia?
Central cyanosis
True hypoxia
Circumoral palor. Area around lips very pale.
Open their mouth and mucus membranes are pale, or Greyish look to them. Conguntival sacs in eye
Fingers might not be a sign of central cyanosis. Could be peripheral vascular disease
What to else to asses in CV assessment
Tripod position help? Flaring nose?
Breathing pattern
Breathing pattern in CVD
Are they using accessory muscles
Purse lip breathsing. In through their nose, lips pursed out
-when they do that, they don’t let enough air escape
Rate, rhythym, depth, and effort of breathing
Late sign of CVD
Long-standing hypoxia. Will have clubbed fingers
Schamroth test. Fingers aren’t touching parallel
Soft and spungy feeling
If angle is 160, 180 and up your patient has clubbed fingers
Accessory muscles for breathing
Sternocleidomastoid muscle
Connects to sternum and clavical. Pulls up on those to help people with CVD breathe. The sternocleidomastoid bulges out
Trapezious pulls up on clavical to help breathing shoulder pushed up a little
Use intercostal muscles retractions
Apical pulse
Look at slide she explains how to count ribs
What’s is the apical pulse also called
Point of maximal impulse
Left ventricular recoiling the most
Mitral valve the loudest
We want the peripheral pulse to be the same as the heartbeat. If there’s a difference there’s a pulse deficit
What would alert you to check for a pulse deficet?
The pulse rate is irregular. Are all the beats making it there?
Sinus bradycardia
Results when the SA nods generates slower than normal impulse rate.
Active during sleep, in hypothermia, beta blockers, Vagal stimulation, severe pain, > intracranial pressure, and MI
report difficulty breathing, changes in level of consciousness, < BP, ECG changes, & angina
When to use the bell of the stethoscope
When listening to low frequency sounds like those in the heart.
It screens out high frequency sounds
Respiratory rate
< with age Changes in acid base Brain lesions > altitude Respiratory diseases: difficulty breathing, using accessory muscles to breathe Anemia >?O2 Anxiety Medications Acute pain: > respiratory rate, < respiratory depth
Cheyenne-stokes
Respiration pattern that’s tachypnea then apnea
Biot’s respirations
Completely irregular respirations
meningitis, severe brain damage
How does the cardiovascular center transmits parasympathetic and sympathetic impulses
Transmits sympathetic impulses via three spinal cord and peripheral sympathetic nerves
Parasympathetic via the vagus nerve
Epinephrine is released from the adrenal cortex to increase heart rate
Activates the renin-Angiotensin- aldosterone system through angiotensin 2
Causes vasoconstriction of the arteriole
Increased peripheral resistance, and > sodium AND water retention to increase circulatory fluid volume
> total volume of water+ Na+
Vasopressin
Antidiuretic hormone
Released form the posterior pituitary when stimulated to act by < blood volume and < BP or
> osmolality of fluid
It causes vasoconstriction of blood vessels, increasing peripheral resistance
IT REUPTAKES WATER DIRECTLY FROM COLLECTING DUCTS ONLY WATER
What is a significant increase in Bp?
20-30mmHg
5-10mmHg can be attributed to metabolism > by late afternoon
High blood pressure
Starts at 140/90
BP cuff should have bladder
That is 40% of the width and 80% of the length
What is the most primary sign of a Musculoskeletal issue?
The diminished use or loss of use to move as they did before.
wheenever we proform a skeletal muscle assessment, we’re always
thinking about the potential for there to be a neurological source of the problem. Always consider the impact of a neurological assessment
pain inthe elbow due to?
True musculoskeletal issue? Like with the ligament or muscles r does it hae to do with the pain receptors in the elbow?
What two basic thins will you do in a musculoskeletal assessment
We do inspection and palpation. We don’t do percussion or ascultation in an MS situation
What do you want to inspect for in an MS assessment
1) the alignment of the body &always compare the contralateral side
2) level of the iliac crest scapula
4)look at the head and the spine. Is the head directly over the head? Is it in a straight line?
5) symmetry of the arms as they hand from the body. One arm hanging further away from the body than the other?
6) Any discoloration in their joints or swelling
&) are they hypertrophied or atrophied, spasticity or rigidity
8)Fasciculations- very small spasms of muscles
Fasciculations
spasms of muscles, very small, usually on the face
How do you palpate during an MS Assessment
- Is it tender? Hot? Swelling?
- Crepitus (crunchiness- indicates air buildup)
- Range of Motion-compare with contralateral side.
- Test strength of the muscle group as a whole
Active Range of Motion Assessment
Have patient exihbit their best ROM on limb
Note any limitations, weakness, pain, tremors
Note an > or < ROM or instability
Compare with contralateral side
Muscle Strength test
0/5 No muscle contraction
1/5 Can palpate muscle & notice trace contraction
2/5 Patient can move muscle with help
3/5 Muscle motile BUT NOT AGAINST RESISTANCE
4/5 Muscle motile against weak resistance
5/5 Muscle motile even against muscle resistance Normal muscle movement
In older patients, is 4/5 muscle strength normal?
Yes, they’re old people
Cervical Spine
Note alignment and symmetry. Palpate posterior neck, cervical spine, & area muscles ROM: flexion/extension; lateral bending; right/left rotation
Abduction
away from the body.
Adduction is back towards it
can test bot legs at the same time.
Thoracic & Lumbar Spine assessment
stand behind them
• Symmetry of scapulae, iliac crests, 7 paravertebral muscles
• Palpate for spinal tenderness
• Note spine curvature (scoliosis, lordosis, kyphosis, gibbus)
• ROM: flexion, extension; lateral bending, right/left rotation
What range of miton will you do for assessment of thi=oracic & lumbar spine?
Flexion
Hyperextension
Lateral bending (both sides)
Rotation to Left and Right
Kyphosis
Hunching of the back
Gibbus is an extreme kyphosis
Scoliosis
Sideways curvature of the spine “S” shaped
Lordosis
exaggerated lumbar curvature
Poor abdominal muscles
during pregnancy, & Obesity
Scoliosis
ages 10-15
Use scoliometer & look for reading. Symmetrical on each side=0
6-7 degrees greater then surgery
Look for uneven shoulder blades and scapula, one arm further away from body
MS assessment of the hips
- Inspect while patient stands: symmetry of iliac crests, greater trochanter of femur level of gluteal fold
- Palpate for instability, tenderness, crepitus
- ROM: flexion/hyperextension (knees extended); flexion (knee flexed); abduction/adduction; internal/external rotation
- Test strength: flexion (knee extended & flexed); adduction/abduction
MS assessment of the hips
- Inspect while patient stands: symmetry of iliac crests, greater trochanter of femur level of gluteal fold
- Palpate for instability, tenderness, crepitus
- ROM: flexion/hyperextension (knees extended); flexion (knee flexed); abduction/adduction; internal/external rotation
- Test strength: flexion (knee extended & flexed); adduction/abduction
wheenever we proform a skletal uscle assessment, we’re always
thinking about the potential for there to be a neurological source of the problem. Always consider the impact of a neurological assessment
pain inthe elbow due to?
True musculoskeletal issue? Like with the ligament or muscles r does it hae to do with the pain receptors in the elbow?
What two basic thins will you do in a musculoskeletal assessment
We do inspection and palpation. We don’t do percussion or ascultation in an MS situation
What do you want to inspect for in an MS assessment
1) the alignment of the body &always compare the contralateral side
2) level of the iliac crest scapula
4)look at the head and the spine. Is the head directly over the head? Is it in a straight line?
5) symmetry of the arms as they hand from the body. One arm hanging further away from the body than the other?
6) Any discoloration in their joints or swelling
&) are they hypertrophied or atrophied, spasticity or rigidity
8)Fasciculations- very small spasms of muscles
Fasciculations
spasms of muscles, very small, usually on the face
Ankles MS assessment
ROM: plantar flexion (down), dorsiflexion, inversion (arch inward), eversion (arch outward), rotation
Test strength: dorsiflexion/plantar flexion
Active Range of Motion Assessment
Have patient exihbit their best ROM on limb
Note any limitations, weakness, pain, tremors
Note an > or < ROM or instability
Compare with contralateral side
Muscle Strength test
0/5 No muscle contraction
1/5 Can palpate muscle & notice trace contraction
2/5 Patient can move muscle with help
3/5 Muscle motile BUT NOT AGAINST RESISTANCE
4/5 Muscle motile against weak resistance
5/5 Muscle motile even against muscle resistance Normal muscle movement
In older patients, is 4/5 muscle strength normal?
Yes, they’re old people
Elbow Assessment
- Inspect contours
- Note subcutaneous nodules along pressure points (sign of arthritis)
- Palpate olecranon process & adjacent grooves; medial & lateral epicondyles
- ROM: flexion/extension, supination/pronation
- Test strength: flexion & extension
Abduction
away from the body.
Adduction is back towards it
can test bot legs at the same time.
Thoracic & Lumbar Spine assessment
stand behind them
• Symmetry of scapulae, iliac crests, 7 paravertebral muscles
• Palpate for spinal tenderness
• Note spine curvature (scoliosis, lordosis, kyphosis, gibbus)
• ROM: flexion, extension; lateral bending, right/left rotation
What range of miton will you do for assessment of thi=oracic & lumbar spine?
Flexion
Hyperextension
Lateral bending (both sides)
Rotation to Left and Right
Kyphosis
Hunching of the back
Gibbus is an extreme kyphosis
Test strength or wrist
wrist flexion, hyperextension, finger grips, extension, abduction (turkey hand), adduction (fist)
Radial and ulnar deviation
Lordosis
exaggerated lumbar curvature
Poor abdominal muscles
during pregnancy, & Obesity
Scoliosis
ages 10-15
Use scoliometer & look for reading. Symmetrical on each side=0
6-7 degrees greater then surgery
Look for uneven shoulder blades and scapula, one arm further away from body
MS assessment of the hips
- Inspect while patient stands: symmetry of iliac crests, greater trochanter of femur level of gluteal fold
- Palpate for instability, tenderness, crepitus
- ROM: flexion/hyperextension (knees extended); flexion (knee flexed); abduction/adduction; internal/external rotation
- Test strength: flexion (knee extended & flexed); adduction/abduction
How to test hip strength
flexion (knee extended & flexed); adduction/abduction
ROM of the hip
Extended flexion, knee extended flexion with the knee flexed Abduction, adduction Internal rotation (knee flexed), & extenal
MS Assessment of the knee
• Inspect patella & alignment
o Genu valgum (knock knees)
o Genu varum (bowlegs)
• Palpate the popliteal space
• ROM: flexion, extension, hyperextension
• Test strength: flexion/extension. Support the joint, ask them to push up or down on your hand to assess
Should people be able to hyperextend their knee?
No, it means that they have weak ligaments & they’re at risk for knee injury, particularly happens in younger children. Need knee strengthening exercises
When do you inspect a person’s ankles
- Want to look at them while they’re weight bearing. Inspect medial and lateral malleolus; Achilles tendon, contour of feet
- Palpate Achilles tendon & metatarsophalangeal and interphalangeal joints
- Heel pronation, indication of weak muscles
- Palpate for swelling or tenderness of crepitus
Ankles MS assessment
ROM: plantar flexion (down), dorsiflexion, inversion, eversion, rotation
Test strength: dorsiflexion/plantar flexion
Assessing gait
Balance, ease of movement, width of steps, should have even steps,
Tandem gait- heel to toe in straight line (drinking & driving), sensitive indicator of balance
Walk on toe in straight line (plantar flexion weakness)
Heels in straight line (dorsiflexion weakness)
sit down and standup from a sitting position. If you can do that w/o your hands you have balance and strength
MS assessment of Shoulders
• Clavicle and scapulae are symmetrical?
• Palpate sternoclavicular & acromioclavicular joints
o Greater tubercle of the humorous as well
• ROM: shrug shoulders (CN XI), forward flexion & hyperextension; internal/external rotation; abduction/adduction
• Test strength: shrug shoulders. Forward flexion, abduction
Normal shoulder flexibility
shoulder shrug
forward flexion, and hyperextension
internal & external rotation
abduction and adduction
Elbow assessment pitchers elbow vs tennis elbow
If medial epicondyle is inflamed its pitchers elbow
lateral epicondyle= tennis elbow
ROM of the elbow
Should test flexion & extension
Supination & pronation
MS Assessment on hands and wrists
- Inspect dorsal & palmar aspects of hands, Note palmar and phalangeal creases; thenar & hypothenar eminences
- Palpate metacarpophalangeal & Interphalangeal joints, wrist & radiocarpal groove
- ROM: Wrist Flexion/hyperextension; radial/ulnar deviation, metacarpophalangeal flexion/hyperextension; abduction/adduction, thumb opposition
thenar & hypothenar eminences
Muscles on your hands
Thenar- group of muscles at the base of the thumb
Hypothenar- opposite thenar, meaty muscles below pinky
Test strength or wrist
wrist flexion, hyperextension, finger grips, extension, abduciton (turkey hand), adduction (fist)
Radial and ulnar deviation
Pulmonary arteries contain
Deoxygenated blood
If you have an irregular apical pulse
You should check for a pulse deficit
Glasgow coma scale
Eyes-open to pain
Verbal- moan to pain
Motor-withdraw to pain?
