Exam 1 Study Guide

physiology of temperature

maintained by the thermoregulatory center in the hypothalamus

heat is generated by metabolic processes, transferred to the skin, dissipated into the environment

physiology of pulse

regulated by the ANS through the SA node

parasympathetic (sympathetic) decreases (increases) heart rate and force

physiology of respiration

medulla and pons stimulated by chemoreceptors in the body

chemoreceptors in the aortic arch and carotid arteries are sensitive to hypoxemia

CO2 is strongest respiratory stimulant = increase in respiratory rate and depth

physiology of blood pressure

arterioles normally partially contracted and creates peripheral resistance

arteries stretch and relax to provide compliance and always has pressure to maintain continuous flow into capillaries

neural short-term regulation: cardiovascular center sends parasympathetic (sympathetic) stimuli to the heart via vagus nerve which slows (speeds up) the heart

humoral short-term regulation: RAAS causes vasoconstriction causing vascular resistance and increasing Na and water retention —> increase circulatory fluid volume and increases BP

long-term regulation: increase in arterial pressure when there is too much ECF causes kidneys to increase excretion of Na and fluid to return BP to equilibrium (opposite occurs if BP decreases due to decreased ECF); ECF increases cardiac output = increase BP

normal range of vital signs for adults and older adults

96.7-100.5ºF

96.4-98.3ºF

factors that increase temperature

food is a source for metabolism and rate of metabolism related to amount of heat produced

exercise

norepinephrine/epinephrine, thyroxine

production of hormones

ovulating women

circadian rhythm: between 3p-6p

stress: emotions increase hormones which increase heat production

illness: infective agents and inflammation

factors that decrease temperature

core temp is located deep in the tissues

radiation: transfer of heat from one object to another without contact

conduction: transfer of heat through direct contact

convection: transfer of heat by movement of warm matter

evaporation: heat used up to change liquid to vapor

age: infants cannot regulate heat, elderly lose SQ fat

smoking: vasoconstriction

circadian rhythm: around 3am

factors increase pulse

exercise

emotions

temperature

stimulating medications

hemorrhage

factors that decrease pulse and respiration

age

depressing medications

factors that increase respiration

pain

exercise

emotions

metabolic acidosis

stimulating medications

factors that increase blood pressure

age

heavier people

circadian rhythm: at 7p

food

emotions

increased blood volume

pain

stimulating medications

factors that decrease blood pressure

women

ICP

circadian rhythm: at 3a

depressing medications

decreased blood volume

OLDCART

O:nset

L:ocation

D:uration

C:haracteristics

A:ggravatin/alleviating

R:adiating to different location

T:imeframe

assessment of temperature

relies on appropriate site, correct equipment, correct procedures

common locations: rectal, tympanic, oral, axillary, and forehead

rectal temperature

98.7-100.5ºF

do not use: rectal sx, bleeding disorders, neonates, diarrhea, taking anticoagulants

most accurate and considered core temperature

must use lubricant and inserted no more than 1 in (children) or 1.5 in (adults)

Sims’ position

tympanic temperature

98.7-100.5ºF

do not use: scars, open lesions, abrasions, otic procedures, otic infections, discharge

more accurate than axillary

pull pinna up and back (down and back) for adult (children); angle probe toward the jawline

auditory canal checks for redness, swelling, discharge, foreign body before insertion of probe

oral temprature

97.7-99.5ºF

accessible and comfortable

must be able to close mouth around thermometer

do not use: patient just ate, confused, comatose, O2 mask being used, oral cavity/nose/mouth sx, history of seizures

wait 15-30 min after oral intake

axillary temperature

96.7-98.5ºF

common in neonates

used when oral and rectal are not available but not as accurate

location of apical pulse

5th intercostal space and left midclavicular line

used for infants, patients with rapid rates (>100bpm), irregular pulses, and before patients take cardiac medications

assessment of respiration

rate, depth, rhythm, oxygen saturation, quality

ask to breathe in/out through mouth

be aware: pt’s normal pattern, pt’s health status, current meds, cardiovascular system

eupnea

normal respiration, normal rate, normal depth

12-20 breaths/min

tachypnea

increase in respiratory rate

>20 breaths/min

normal pulse range

normal: 60-100 bpm

tachycardia

>100 bpm

caused by exercise, heat exposure, medications, pain, anemia, hypoxemia, stress, hypovolemia

interventions: monitor pain, vital signs, adverse effects from medications, avoid injury

bradycardia

<60 bpm

caused by long-term physical fitness, hypothermia, medications, position changes, severe pain, relaxation

interventions: monitor pain, vital signs, adverse effect of medications, avoid injury

assessment of pulse

rate, rhythm, amplitude, bilateral quality, perfusion

bradypnea

decrease in respiration rate

<12 breaths/min

hypoventilation

shallow breaths

hyperventilation

deep, rapid breaths

normal oxygen saturation

>95%

no intervention needed

oxygen saturation for COPD patients

88-92%

continue with assessment and monitor

oxygen saturation for hypoxic patients

85-94%

assess for underlying disease and initiate O2 therapy

oxygen for severely hypoxic patients

<85%

administer supplemental O2 immediately

orthopnea

difficult breathing when lying down

apnea

no breathing

dyspnea

difficulty breathing

assessment of blood pressure

measured during physical exams, initial admission, routine vitals, when health status changes

significant change if it is a rise or fall of 20-30 mm Hg

taken after patient rests at least 5 min, no smoking/caffeine at least 30 min

common: brachial artery (if unavailable: popliteal)

do not use: side with IV, shunt, fistula, breast/axillary sx

cuff too big when taking BP measurement

reading is too low because pressures is dispersed over disproportionately large surface area

cuff too small when taking BP measurement

reading is too high because pressure is not evenly transmitted to artery

orthostatic hypotension

physiologic response to positional changes

assess in supine, sitting, and standing (wait 1-2 min in-between measurements)

identify at least 20 mmHg decline in SBP and at least 10 mm Hg decline in DBP

complications: dizziness, pallor, lightheadedness, diaphoresis, syncope

interventions: increase fluid intake, check medications, provide education

hypertension

>130/80 mm Hg

complications: heart attack/failure, stroke, kidney damage, enlarged heart

risk factor for stroke

origins: overstimulation of angiotensin and aldosterone, permanent thickening of blood vessels causing increased peripheral resistance

hypotension

<90/60 mm Hg

complications: decrease in blood volume (hemorrhage), decrease in cardiac output (heart failure), decrease in peripheral vascular resistance (shock)

pain

measured objectively: ask patient to describe pain and rate level (1-10)

interventions: assessment, medications, evaluate and report pain relief and treatment effectiveness

oxygen saturation

% of hemoglobin that combines with O2

complications: decreased levels can cause cyanosis or impact consciousness

measured with pulse oximetry

decrease in levels = assess mental status, activity tolerance, remeasurement of O2 saturation

why take vital signs

gives baseline that is used to identify changes in patient status

establishes trends

shows abnormalities that could indicate underlying health conditions

when to take vital signs

admission to a facility, part of physical assessment, routine monitoring for inpatient stay, change in health status, before and after sx, before and after administering medications, before and after ambulation, ongoing care to detect improvement or not, before unit transfer or discharge

hyperthermia

elevated temperature

complications:

interventions: medications (aspirin [not for kids because of Reye’s syndrome], acetaminophen, ibuprofen), cool bath, cool blankets, cool packs, fluids

hypothermia

decreased temperature

complications:

interventions: warm IV/oral fluids, gradual warming, warm blankets

types of hypertension

elevated: 120-129/80 mm Hg

stage 1: 130-139/80-89 mm Hg

stage 2: >140/>90 mm Hg

stage 3": >180/>120 mm Hg

normal blood pressure

120/80 mm Hg

dependent on patient

general survey

observe patient’s level of consciousness, orientation, clarity of speech, facial expression, facial/body symmetry, appearance, and room

physical appearance, body structure, mobility, behavior, vital signs

preparing for physical assessment

review chart for chief complaint, medical history, sx history, vital trends, lab trends, recent procedure and its results

gather equipment, arrange for privacy, check for appropriate lighting, space for patient to stand/sit/lie down, ensure temp is okay, surfaces are clean, raise bed head to 30º

patient: provide comfort, safety, and privacy

health history components

biographical data: about the patient

reason for seeking care

present health concern: include symptoms (objective data), onset of problem, location, duration, intensity, quality, occurrences, current treatments, affects on patient

past health history: insight into causes of current symptoms and alerts to certain risk factors

family health history: insight into diseases and conditions that patient is at increased risk

functional health: effects of chief complaint on patient’s self-care abilities and quality of life

review of systems: questions about body systems that reveal concerns

inspection

use of vision and smell to assess physical characteristics of whole patient and individual body systems

palpation

use touch to assess body, skin texture, temp, moisture, turgor, tenderness

percussion

tapping patient to cause vibration to travel through skin and underlying structure

auscultation

listening to sounds made by organs with/without stethoscope

physical assessment: head, neck

inspection and palpation

questions: history of injuries to the area? disorders? using any assistive devices? any pain? any changes vision, hearing, smell, appetite?

check the head: position, motion, skull, lesions, masses, locations of ears and eyes, swelling, pallor, etc.

check the eyes: symmetry, eyelids, eyebrows, abnormalities, pupillary light reflex,

check the ear: presence of cerumen, tympanic membrane appearance, hearing, backside of the ear

check the nose: symmetry, inside nostrils, abnormalities

check the mouth: oral cavity, teeth, tongue, gums, eating, chewing, swallowing

check the neck: carotid pulse, symmetry, trachea

check skin turgor

physical assessment: thorax

inspection: entire chest, symmetry, shape, breathing patterns

palpation: chest size, shape, movement, lumps, skin temperature, tenderness, redness

auscultation: anterior and posterior lung sounds, adventitious breath sounds

auscultation: heart sounds, apical pulse, lub and dub, dysrhythmia, pulse deficit, murmurs, pulse rate

check for pressure injuries: coccyx, shoulders

questions: any difficult breathing? any chest pain? any coughing?

crackles

crackling, popping sounds when a blocked airway opens

rhonchi

low-pitch, snoring sounds that can be cleared with coughin

wheezing

high-pitch, whistling sounds

stridor

intense, high-pitch, continuous monophonic wheeze or crowing sound when airways collapse due to lower internal lumen pressure

friction rub

low-pitch, grating, creaking sound

pulse deficit

apical pulse - radial pulse

when radial pulse is slower than apical pulse

pulse grades

+4: bounding

+3: pulse with increased intensity

+2: normal

+1: faint but detectable

0: absent

physical assessment: abdomen

inspection: stomach is flat or distended? any redness or swelling? look at all four quadrants at eye level

auscultation: detect altered bowel sounds

palpation: check for pain and point to area of discomfort; palpate all four quadrants; note for spasm, rigidity, guarding, rebound, tenderness;

questions: any nausea or vomiting? last bowel movement? quality of BM? difficulty passing stool or urine?

physical assessment: extremities

inspection and palpation: redness, moisture, diaphoresis, IV site, ROM, color, muscle tone

check for strength: flexing/extending feet, pushing up or down with hands, squeezing fingers

check for pulses: radial and pedal

check capillary refill: fingernails and toenails

check for pressure injuries: heels and elbows

question: assistive devices? daily activity?

health

state of complete physical, mental, and social well-being

wellness

active state of being healthy, including living a lifestyle that promotes good physical, mental, and emotional health

disease

pathologic changes in structure of function of the body/mind

illness

response to a disease

acute illness

rapid onset

<6 months

ex: common cold, diarrhea

chronic illness

permanent changes in health

slow onset

periods of remissions and exacerbation

require long periods of care

ex: diabetes, stroke

health illness continuum

conceptualizes person’s level of health and views health as a changing state

illustrate changes to maintain a state of well-being

dimensions that influence on health and illness

physical

emotional

intellectual

sociocultural

spiritual

environmental

physical dimension

genetic inheritance, age, developmental level, race, and sex influence health status and health practices

ex: Down syndrome, color blindness, young adult males at risk for car crashes, young female with breast cancer family history likely to have annual mammograms

emotional dimension

mind affects body functions and responds to conditions

long term stress, anxiety, calm acceptance, relaxation

ex: diarrhea before exam, relaxation techniques to reduce sx pain

intellectual dimension

cognitive abilities, education background, past experience understand cause of disease and importance of healthy lifestyle

ex: diabetic person tries to follow a strict diet but continues bad eating habits

sociocultural dimension

economic level, lifestyle, family, culture affect health practices and influence patterns of living and values about health and illness

ex: low-income populations less likely to seek treatment or have fewer treatment options

spiritual dimension

beliefs and values connected to health and illness, allows people to feel thy are part of something larger and more meaningful than their individual lives

nurse role in promoting health

activities that promote health

involve patient

encourage good decision making

provide patient education

help patient who want to change lifestyle/behaviors

encourages wellness assessments and risk screenings

nurse role in preventing illness

early interventions, promote safety, reduce risk of illness

Maslow’s hierarchy of needs

framework for nursing assessment; understand needs of patients at all levels; shows interventions to meet priority needs which become a part of the care plan (aim at meeting basic human needs)

physiologic: highest priority

safety/security

love/belonging

self-esteem

self-actualization: highest need

Maslow’s: physiologic

oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest met to maintain life

ex: Nurses asses oxygen levels by looking at skin or vital signs, assess fluid intake and elimination by checking skin/mucous membranes and weight, assess food and elimination by looking at nutritional status via weight, muscle mass, strength and lab values, assess temperature by looking as vital signs, assess sexuality as part of holistic care

Maslow’s: safety/security

being protected from harm and trusting others/free of fear/anxiety/apprehension

ex: Nurses protect by using hand hygiene, using equipment properly, teaching parents about things dangerous to kids

ex: Nurses provide trust by encouraging spiritual practices to support patient, promote independence and decision making, explain procedures and treatments

Maslow’s: love/belonging

high-level need, understanding and acceptance of others in giving and receiving love, feeling of belonging to groups

ex: Nurses display love and belonging needs by developing a care plan and include interventions, include others in care of patient, establish nurse-patient relationship, provide resources to patients

Maslow’s: self-esteem

need for a person to feel good about themselves, feel pride and accomplishment, believe others respect and appreciate those accomplishments

ex: Nurses understand person’s perception of the change affects the person’s self-esteem, help patients’ self-esteem by respecting their values, beliefs, help patients create attainable goals, facilitate support from others

Maslow’s: self-actualization

reach full potential through development of their unique capabilities, acceptance of self and others as they are, focus of interest on problems outside oneself, be objective, happiness and affection for others, respect for all, discriminate between good and evil, creativity for solving problems, purse interests

ex: Nurse focus on person’s strengths and possibilities, provide nursing interventions to maximize potentials

primary preventative care

intervene before negative health effects occur

ex: vaccines, birth control, smoking cessation classes, reduce alcohol consumption and drug use, diet, exercise, effective parenting, safe sex practices

secondary preventative care

reduce impact of disease or injury

ex: HIV testing, medical/dental/vision exams, diagnostic testing, family counseling, PAP smears, cancer screenings,

tertiary preventative care

delay affects of disease or disability

ex: support group for women after mastectomy, use physical therapist to prevent contractures after a stroke, rehab, sx treatment, medication/medical therapy, occupational therapy

screenings

process to detect disorders or risk factors of which people are unaware of

ex: physical and eye exams every 3-5 years, PAP/PSA, mental health diabetes

workplace safety

consider body mechanics, fire hazards, and up to date/working equipment

community safety

consider car accidents, drug use, sports activities, weapons, and relationships

home safety

consider poly pharmacy, poison risks, and abuse

healthcare setting safety

consider restraints, safe practices, mandated reporting, and people

% of adverse events that are preventable

44%

% of hospitalizations that are due to adverse events

2.9-3.7%

adverse events

medication errors

falls

HAIs

pressure injuries

sx errors

restraint-related injuries