Health Assesment Exam 2

Visceral Pain

originates from larger interior organs

deep somatic pain

from sources such as vomiting, nausea, pallor

cutaneous pain

from skin surface and subcutaneous tissues

referred pain

felt at a particular site but orginates from another location

acute pain

short term and self limiting

self protective purpose

acute pain warns individual of actual or potential tissue damage

incident pain

type of acute pain that occurs predictably with certain movements

chronic pain

episode of pain that lasts for 6 months or longer; may be intermittent or continuous

types of pain assessment tools

provocation
quality
region
severity
timing
understanding

pain assesment: children/ infant

infants do FEEL pain, children 2 yrs of age can report pain and point to its location but cannot rate pain intensity

Acute pain behaviors

- Involve autonomic responses
- Protective purpose
-Individuals experiencing moderate to intense levels of pain may exhibit the following behaviors:
-Guarding,
- grimacing
-Vocalizations such as moaning, agitation, restlessness, stillness
-Diaphoresis,
- Change in vital signs

Chronic pain

persistant (chronic) pain behaviors, live with experience for months and years, adaption occurs over time

mechanism of regulation

-Cellular metabolism requires a stable core, or "deep body," temperature of a mean of 37.2° C (99° F).
-Body maintains steady temperature through feedback mechanism regulated in hypothalamus of brain.
-Balances heat production with heat loss
-Various routes of temperature measurement reflect body's core temperature.

Dinurnal cycle

1F to 1.5 F → may be lower in early morning hours and peak in late afternoon to early evening

menstration cycle in women

-progesterone secretion
-occurs with ovulation
-midcycle
-causes a 0.5 to 1.0 *F rise in temp that continues until menses

excercise

moderate to hard excerise increases body temp

age (and body temp)

-wider normal variation occur in infant and young chidren due to less effective heat control mechanisms
-older adults--temp usually lower than in other age groups

expected temp reading

oral temp is accurate
oral sublingual site has rich blood supply from cartoid arteries that quickly responds to changes in inner core temperature
Resting person 96.4-99.1
rectal 0.7-1.0 higher

Tympanic membrane temp reading

-senses infrared emissions of tympanic membrane (eardrum)
-noninvassive, nontraumatic, quick and efficient
- may be less accurate during cardiac arrest
-probe tip has shape of otoscope

pinna positioning up and back for adults

child--straight down

temporal artery temp

-uses infrared emissions from temporal artery
-slide probe across forehead and behind ear
-takes multiple readings and produces average result in 6 sec. (not that reliable)

Pulse

-with every beat the heart pumps an amount of blood or stroke volume into the aorta
-the force creates a pressure wave, which is felt peripherically as a pulse
-provides indicator of rate and rhythm of HB

How does medication affect HR

may slow HR *beta blockers

how are athletes heart rate different than an average persons?

lower pulse rates may occur in well trained athletes whose heart muscles develops along with skeletal muscles

how does age affect HR

-more rapid in infancy and childhood
- moderate during adult and older years

how does gender affect HR

after puberty females have slightly faster rate than males

respirations

-normally a persons breathing is relaxed regular automatic and silent

oxygen saturation

-pulse oximeter: a noninvasive method to assess spO2
-sensor attached to person finger or ear lobe has diode that emits light and detector measure HB02

systolic pressure

maximum pressure felt on artery during left ventricular contraction or systole

diastolic pressure

elastic recoil, or resting, pressure that blood exerts constantly between each contraction

pulse pressure

difference between systolic and diastolic --reflects stroke volume

Mean Arterial Pressure (MAP)

pressure forcing blood into tissues, averaged over cardiac cycle

Hypertension

130/80

hypotension

90/60

peripheral vascular resistance

increased resistance (vasoconstriction) leads to increase in BP whereas decrease in resistance(vasodilation) leads to decrease in BP

what does palpating a peripheral pulse primarily assess for

rate, rhythm and force

what is an adult at rests normal HR

50-95

the blood pressure level is determined by five factors

cardiac ouput, peripheral vascular resistance, volume of circulating blood, viscosity, and vessel wall elasticity

thoracic cage

a bony structure that protects the lungs and heart, as well as the liver and spleen

what is the thorax defined by

the sternum 12 pairs of ribs and 13 thoracic vertebrae. in the spine

What is the normal/ expected chest

the thorax has an elliptical shape with an cinteroposterior to transverse ratio of 1:2 to 5:7

describe the lungs

the lungs are not exactly symmetrical
3 lobes for right 2 lobes for right

the anterior lungs

above clavicle--in the anterior chest, the apex od the lungs is 3-4 cm above the inner third of the clavicles
the base rests on the diaphragm at about the 6th rib
-where do you think our upper boundary is for stethoscope placement on the anterior chest

the posterior lungs

bottom
posteriorly the location c7 marks the apex of the lungs and the t10 usually corresponds to the base

Addition ausculation considerations

The posterior lungs are almost all lower lobes. you cannot even see the middle lobe on the posterior onset

Pleurae

serous membrane that form an envelope around the lungs
-filled with lubricating fluid to help the lungs during breathing

The trachea and Bronchi

• transport gasses between the environment and the lungs.
•The bronchi are line with goblet cells that secrete mucous that traps particles and cilia which sweep the particles upward where they can be swallowed or expelled.

Gas exchange

-occurs in the alveoli and alveolar
-The alveoli are clustered around the duct like grapes
-this increases space available for gas exchange. Bunched arrangement creates a space a space for gas exchange that is as big as a tennis court

four functions of breathing

-Supplying oxygen to the body for energy production
-Removing CO2 as a waste product of energy reactions
-Maintaining homeostasis (acid-base balance) of arterial blood
-Maintaining heat exchange

acid base balance of the blood

the blood has to be a certain PH or acid base balance to maintain life 7.35-7.45
-there are a number of compensatory mechanisms that regulate the pH but the lungs help maintain the balance by adjusting the level of Co2 through respirations

control of respirations

directed by the brain stem
-hypercapnea is an increase of Co2 in the blood
-hypoexmia is a decrease of o2 in the blood.

tachypnea

rapid, shallow breathing, >24 breaths per minute

bradypnea

slow breathing
decreased, but regular rate
drug induced, increased intracranial pressure

hyperventilation

-increase in rate and depth
-extreme exertion, fear or anxiety
-DKA (Kussmals)

Hypoventilation

-irregular shallow pattern
-overdose of narcotics
-anesthesia

Cheyne stokes

-respirations gradually wax and wane
- breathing cycle alterations breathing patterns followed by apnea

what should we inspect for with respirations?

-note shape and configuration of chest wall
-spine should be straight
-scapula symmetric

what should we insepect with infants and children with respirations?

Infants are obligatoy nose breather until 3 months
-intercostal refractions are the inward movement of muscles between the ribs as a result of reduced pressure in the chest cavity, usually a sign of difficulty breathing

What do we document with auscultation?

expected--lungs clear to auscultation in all 5 lobes anterior and posterior. No adventitious lung sounds noted

What happens to respiration during pregnancy?

the growing uterus displaces the diaphragm. The fetus increases meaternal oxygen demands which are met by an increased tidal volume.

right upper quadrant

-liver
-gallbladder
-duodenum
-part of ascending and transverse colon
-head of pancreas
-right kidney
-right kidney and adrenal gland
-hepatic flexure of colon

left upper quadrant

-stomach
spleen
-left lobe
part of transverse and descending colon
-body of pancreas
-left kidney and adrenal gland
-splenic fixture of colon

right lower quadrant

-cecum
-appendix
-right ovary and tube
right ureter
-right spermatic cord

left lower quadrant

part of descending colon
-sigmoid colon
left ovary and tube
left ureter
left spermatic cord

anorexia

a loss of appetite from GI disease as a side effect to some medications with pregnancy or with mental health disorders

dysphagia

occurs with disorders of the throat or esoohagus such as thrush, neurologic changes, or obstruction; difficulty swallowing

pyrosis

(heartburn) a burning sensation in esophagus and stomach from reflux of gastric acid

Eructation

belching

hematemesis

vomiting blood

gray stool

occurs with hepatitis

pica

an abnormal craving or appetite for nonfood substances, such as dirt, paint, or clay that lasts for at least 1 month

visceral pain

pain that originates in the internal organs such as the heart, lungs, bladder, reproductive system and digestive system

parietal pain

a localized, intense pain that arises from the parietal peritoneum, the lining of the abdominal cavity

referred pain

pain that is felt in a location other than where the pain originates

melena

Black tarry stool

contour abdomen

describes nutritional state and normally ranges from flat to rounded

scaphoid abdomen

caves in

protuberant abdomen

indicates abdominal distention

symmetry of abdomen

shine a light across abdomen. should be symmetric bilaterally
should be smooth and symmetric

umbilicus of abdomen

-should be midline and inverted with no signs of discoloration inflammation of hernia
-can be everted with pregnancy ASCITES or underlying masses
-deeply sunken+obesity

cullen sign

bruising around umbilicus (pancreatitis or ectopic pregnancy)

assesment of skin

skin should be smooth, even, appropriate for ethnicity
-unexpected findings--redness= indicated localized infection jaundice

ascites

abnormal accumulation of fluid in the abdomen- skin glistening and taut

striae

stretch marks, silvery white linear jagged marks.

pulsations or movement of abdomen

expected findings--may see aortic pulsations in thin people, may see waves of persistalsis in thin people

What could the patients demeanor tell us?

expected finding-- relaxed quietly with benign facial expressions and slow even respirations

unexpected findings-

restlessness and turning could mean gastroneritis or bowel obstruction

-absolute stillness or resisting movement could mean pain or peritonitis

Why should she ausculate before palpate on abdomen?

pressing the abdomen prior to auscultation can increase peristalsis and give a false interpretation of bowel sounds

hyperactive bowel sounds

loud, high-pitched, rushing, tinkling sounds that signal increased motility

hypoactive bowel sounds

could follow abdominal surgery or with inflammation of the peritoneum

Absent bowel sounds

uncommon must listen for a full 5 minutes, you can determine completely absent sounds

bruits

abnormal "swishing" sounds heard over organs, glands, and arteries

Light palpation of abdomen

1cm
-overall impressions of the skin surface and superficial musculature
-entire abdomen
-zig zag pattern

deep palpation of abdomen

5-8cm (2-5in)
note tenderness
note location, size, consistency, and mobility of any abnormal findings

expected findings of palpation of abdomen

-soft, non-tender to palpation x4 quadrants
-no masses, no tenderness
-voluntary guarding

unexpected findings of palpation of abdomen

-distended abdomen, tender to palpation
-involuntary guarding or rigidity

voluntary guarding

cold, tense, ticklish,

involuntary guarding

constant board like hardness of the muscles
-protective mechanism accompanying acute inflammation to the peritoneum

Common cause of constipation

-decreased physical activity
-inadequate intake of water
-low fiber diet
-side effect of meds
-hypothyroidism

What are some nursing considerations to note when assessing abdomen?

-DO. NOT. palpate a patients abdomen who has had an organ transplant
-do not feed a patient until they have passed flatus
- acute abdominal pain needs immediate assesment