nursing exam 1 notes

medical history inquiries

childhood illnesses, immunizations, allergies, past medical/surgical history, health habits, OB/GYN (if they've had any children, when their period started, etc, N/A for males)

family health inquiries

* health of siblings, children, parents, and grandparents on all sides - important to find history of cancers or genetic disorders
* Inquire about : heart disease, hypertension, kidney disease, mental illness, intellectual disability, diabetes, cancer

day history

very specific, what a typical day looks like when not ill

* consider nutrition, sleep patterns, recreation, hygiene, sexual activity

health beliefs

 actions of the patient, what they do to promote or impair their health

health values

* what something is worth, what matters, standard guid to behaviors, this influences decisions and actions, influenced by culture, religion, family and peer groups

health attitude

* way of thinking or feeling about something, typically reflected in a person's behavior (usually done on 40-50 y/o who have chronic medical conditions)

when can a nurse do a physical assessment?

anytime

purpose of physical assessment

establishes a baseline and any changes in condition

organization of physical asssessment

typically in head to toe order

types of physical assessments

admission assessment, start of shift assessment, and focused assessments

inspection

* paying attention even if you don't interact, ex: to gait when a pt walks

palpation

* always palpate abdomen, pulses. Use palpation in other places based on pt complaints. Always compare side by side when possible, ex: if the left elbow is sore, compare to the right elbow. 

percussion

* not done often, usually replaced with scans/imaging

auscultation

* always listening to lung, heart, and bowel sounds - always listen directly on the skin (expose pt minimally), have pt lean forward for lung sounds and listen on the back of pt. 

olfaction

any noticeable odors

general survey

* When first walking into a room - Introduce yourself, wash hands, and identify patient 
* Always use hand sanitizer before going into rooms AND after leaving rooms
* gender/race, age, signs of distress, body type, posture, gait and body movements, hygiene, dress, odors, mood, speech, abuse, vitals, height/weight, orientation

room safety check

* Are there clear pathways, spills, side rails (should be 2), bed/chair alarms, bed position, brakes

vital signs include

pulse, respirations, bp, oxygen saturations, pain - you take these on admission, part of physical assessment, frequency is based on pt needs

* before/after certain meds/treatments/interventions or after a change in condition/status

temperature

heat produced - heat lost

normal range (96.8-100.4 F / 36-38 C)

hypothalamus

regulates body temp

increase in temp

*   causes sweating and vasodilation (widening of blood vessels) in order to regulate back to set point per hypothalamus

drecrease in temp

* causes shivering and vasoconstriction to regulate back to set point

heat production

caused by metabolism

higher metabolism

produces more heat

lower metabolism

produces less heat

when heat is produced

* at rest, voluntary movements, shivering, non-shivering thermogenesis (metabolic process of sympathetic nervous system, caused through metabolism of fat usually seen in infants)

radiation

transfer of heat without contact

conduction

transfer of heat with contact

convection

transfer of heat away by air movement

evaporation

transfer of heat energy when liquid changes to gas

fever (pyrexia)

* An increase of 1 degree above usual temp - not considered harmful until reaches 102 in an adult
* Alteration in hypothalamic set point
* Heat loss mechanisms unable to keep pace with excess heat production
* Important defense mechanism, serves diagnostic purpose

signs and symptoms of fever

* shivering, chills, feel cold despite rising temp, skin warm and flushed (vasodilation), diaphoresis (when the fever breaks - rapid heat loss), increase in pulse and respirations, parched lips, dry skin

nursing care of fever

* Antipyretics
* Blood Cultures as ordered - consider if antibiotics have been given, do cultures when fever spikes
* Minimize heat production/maximize loss
* O2 as ordered, replace fluids
* Promote comfort and observe trends

hyperthermia

* any increase in temp, body's inability to promote heat loss/reduce heat production - may be caused by head injury (to hypothalamus), malignant hyperthermia (result from immune system response to anesthesia), heat stroke (104.4 or greater, hot dry skin, usually not sweating, can be confused, delirious, excess thirst, muscle cramps or nausea, etc. can be fatal)

hypothermia

* body temp falls below 96.8 F - hypothalamus loses ability to regulate temp, heat loss during prolonged exposure to cold (induced or accidental, shivering, memory loss, depression, poor judgment, vasoconstriction, cardiac and respiratory collapse - this normally occurs when temp falls below 93.2F) - sometimes hypothermia is induced during open surgery or failed CPR to preserve brain function
* Interventions for hypothermia - prevent further decrease, __slow__ rewarming
* Infants, elderly, disabled patients with neurological injury are at high risk - have a hard time maintaining body temp

places to measure temps

* oral, rectail (where you get core temp, not used in newborns), axillary, tympanic (ear), skin, body cavities/organs (core temp), temporal artery (can be affected by moisture on skin)

types of thermometers

electronic, red/blue, disposable, glass, infrared

rectal, oral

red, blue

glass

oral/rectal 3-5 minutes, axillary 5-8 minutes - usually never see, old

infrared

* tympanic and temporal artery - scanner that goes across the forehead and to temporal artery behind the ear

rectal

1 degree higher than oral

axillary

1 degree lower than oral

potential nursing diagnosis for temp

* (Risk for) body temp imbalance, hyper/hypothermia, ineffective thermoregulation

pulse

the palpable bounding of blood flow in peripheral arteries

pulse rate

the number of pulsing sensations in 1 minute, normal range 60-100 bpm

pulse rhythm

the interval of time between each beat

dysrhythmia

irregular rhythm

pulse deficit

* difference between radial and apical pulse rates - to detect : have another person count peripheral/radial pulse while you auscultate , if the pulse if different than what you get apically then there is more of a pulse deficit
* insufficient contraction of heart
* frequently associated with dysrhythmia

typical places to locate pulse

* emporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis (diagram on lecture outline D2L)
* anytime someone has a cast or injury, try to check for pulse below the injury to check for blood flow - assess distal to that level of injury

assessment of pulses

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* Use 1st, 2nd, and 3rd fingers, note rate rhythm strength and equality - dont assess with thumb, press hard enough to feel the pulse
* Rate = # of bpm
* Rhythm = the time interval between each heartbeat (is the pattern regular or irregular)
* Strength (amplitude) = force of blood with each beat
* Equality = bilateral uniformity, __never__ assess carotid bilaterally, check if on both sides that the pulse is equal
* If regular count for 30 sec x2, if irregular count for 1 minutes

tachycardia

bpm greater than 100

brachycardia

bpm less than 60

auscultation

use of diaphragm of stethoscope, place over point of max impulse (PMI)

* Found at 5th intercostal space at left MCL (midclavicular line)
* The lub-dub sounds count as 1 beat
* 1st sound = lub = closure of mitral and tricuspid valves; S1- heart at work, will be loudest at apex of heart (bottom of heart)
* 2nd sound = dub = closure of aortic and pulmonic valve; S2 - heart at rest, loudest at base of heart (top of heart)

nursing diagnoses for pulse

* Activity intolerance, anxiety/fear, decreased cardiac input, decreased cardiac output, ineffective tissue perfusion

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blood pressure

* pressure exerted on the arterial walls by the pumping action of the heart
* Affected by condition of vascular bed, circulating blood volume, cardiac output
* Normal bp for average adult is less than 120/80
* Measured in mmHg

influencing factors of bp

* blood volume, cardiac output, peripheral resistance, elasticity of vessel walls, blood viscosity, age (tends to increase with age), stress, gender (males usually have higher bp than women after puberty, after menopause women usually have higher bp than men of the same age), race (african americans usually have higher bp), medications (vasoconstrictors will increase bp, cortical steroids will increase, cardiac meds usually lower bp), activity, white-coat syndrome (pts who are fine until they walk into the doctors office) , pain causes increase in bp

systolic bp

* the max pressure exerted on the arterial wall during cardiac contraction, this is the heart at work, top number on bp

diastolic bp

* minimal pressure exerted on the arterial walls between contractions, heart at rest, bottom number of bp

direct (invasive) assessment of bp

* arterial line, usually done in critical care situations, most accurate

indirectly - noninvasive assessment of bp

* includes bp cuff and stethoscope
* Aneroid - manually, occasionally needs to be calibrated
* Mercury - usually not seen
* Electronic 

bp cuffs

* Usually disposable, should cover most of the arm, if doesn't fit correctly bp will be incorrect
* Lower edge of cuff above antecubital fossa, center of cuff bladder over brachial artery

assessing a bp

* Sitting position, uncrossed legs, no talking
* Position cuff correctly, read at eye level
* Close valve on bp cuff while palpating radial artery
* Inflate cuff 30 mm Hg above the level at which radial pulse no longer felt (obliterate the pulse)
* Note level and deflate cuff
* Wait 1 minute
* Place stethoscope lightly over brachial artery, inflate cuff 30 mm Hg above palpated estimated systolic pressure
* Deflate cuff gradually (2-4 mm per sec) until 1st sound is systolic pressure
* Continue to deflate sound and not the disappearance of sound which is diastolic pressure

other sites/methods for bp assessment

* thigh, lower leg, forearm, palpate bp- record as systolic/p (only if necessary)

variations in bp

prehypertension, hypertension, hypotension, orthostatic hypotension

prehypertension

* 120-139 / 80-89, watch carefully

hypotension

* systolic less than 90 OR diastolic less than 60
* Causes - dilated arteries, decrease in PVR, decrease in circulating volume, poor cardiac output (CO), myocardial infarction (MI)
* Signs and symptoms - pale, mottling (purple/discolored limbs), clamminess, confusion, dizziness, Chest pain, increased heart rate (heart is trying to compensate for low bp), decreased urinary output (worry about kidney perfusion/injury) 

orthostatic hypotension

* Also called postural hypotension - bp drops when rising to upright position
* Causes: decreased blood volume, anemia, dehydration, some antihypertensives, prolonged bed rest - occurs within first 3 minutes of being moved to upright position
* Can see as a drop of 20 in systolic or a drop of 10 in diastolic bp
* Nursing diagnosis - decreased cardiac output, ineffective tissue perfusion, risk for fluid volume deficit (what you actually see), disturbed thought process, imbalanced nutrition, ineffective health maintenance, noncompliance

respirations

* The process of bringing CO2 to body tissues and removing carbon dioxide
* utilizes Diaphragm and intercostal muscles; other accessory muscles (abdominal, sternocleidomastoid, trapezius, scalene) - if these accessory muscles are used in respirations it should be looked into (using big upper body movements or abdominal movements to breath)

ventilation

gasses in and out

diffusion

*  taking O2 and CO2 going between alveoli of lungs and red blood cells

perfusion

* distribution of CO2 to the red blood cells to and from the pulmonary capillaries

assessing respirations

* Rate - 30 secs x 2 = bpm
* May place hand on chest, best if client is unaware of measurement, count inspiration/expiration as 1 respiration
* Normal adult 12-20 breaths per minute

bradypnea

resting rate of respirations is less than 12 per minute

tachypnea

resting rate is greater than 20 breaths per minute

apnea

lack of respiratory movement

depth

degree of movement in chest wall

pulse oximetry

can take on fingers, toes, ears, most common - come back to this section

* Indirect measurement of arterial CO2 saturation
* Recorded in %
* Probe which detects light absorbing differences between oxygenated
* Factors affecting readings: carbon monoxide, client motion, peripheral vascular disease (PVD-poor circulation to periphery), hypothermia, low cardiac output (CO), nail polish
* Rotate fingers to get better readings, sit them upwards to get better blood flow

end tidal CO2 (ETCO2)

* Measures exhaled carbon dioxide, helpful to assess ventilation and perfusion, useful in vented and non-vented patients

nursing diagnoses for pulse ox

* impaired gas exchange, activity intolerance, anxiety, ineffective breathing pattern, disturbed sleep pattern, fear

documentation of vital signs

* Graphic - usually for long term care / computer recording
* Document ASAP
* Looking at trends is important, reporting and documenting abnormals as indicated, facility policies and procedures vary

mobility

a persons ability to move around freely in their environment

factors that affect mobility

pathological: congenital defects, bone joint or muscle disordes, cns damage, musculoskeletal trauma

life influences: values, growth and development, pregnancy

barriers to moving

gravity, friction (when the bony structures move but the skin stays stationary when moving a patient, can avoid by using a transfer board, draw sheet etc.)

what to look at before moving a patient

mobility and ROM, gait, activity tolerance, activity orders, weight bearing status, is it safe in general to move that pt

ambulation

the physician may order activity, or it may be up to the nurse to determine the level of activity for the patient based on the assessment

activity orders

o   OOB with assistance

o   OOB as tolerated

o   OOB to chair (bed to chair)

important points when moving a pt

·      Dangle first before getting up

·      Assess client ability

·      Always have help the first time

·      No obstructions

·      Proper footwear

·      Use gait belt

·      Think safety!!

important points before you leave a room

·      Before you leave the room:

·      Call bell in reach

·      Bed/chair alarm activated

·      Bed in low position

·      Brakes set on bed or chair

·      Side rails up

·      Think safety!!

if ambulating client with no assistive device

·      Orthopedic patient:

o   Stand on unaffected/strong side

·      Neuro patient:

o   Stand on affected/weak side

·      All other patients:

o   Stand on affected/weak side (if they have one)

walking with a walker

Walking with a Walker

·      Move walker forward, then one leg & then the other

·      If one leg is weaker move the weaker leg first

·      Nurse on client’s weak side

walking with a cane

·      Nurse on weak side

·      Cane on strong side

·      Move the cane 6 to 10 inches

·      Move weak leg to the cane

·      Move strong leg beyond the cane

OR

·      Cane on strong/unaffected side

·      Move cane & weak/affected leg at the same time

·      Move unaffected/strong leg to the cane & once comfortable moves past cane

walking with crutches

·      Arm position & position of crutches in axilla is critical

·      Various gaits with crutches

·      Most common is Three Point:

o   Weight alternates between good leg & crutches

o   Used when client is non weight bearing (NWB)

using a wheelchair

* make sure chair is locked when client is being moved into or out of the chair
* make sure chair is locked when client is sitting in the chair

transfering pt

·      Dangling

·      Bed to chair or commode

·      Bed to stretcher

·      Use of mechanical Lift

·      Transfer/Slide board

 

·      \*\*Caution: Orthostatic Hypotension\*\*

immobility

·      State where a person is unable to independently move or change positions. 

·      Body systems are at risk for impairment because of immobility. 

helping immobility

·      Client can be placed on bedrest as part of their treatment plan:

o   Reduce oxygen needs

o   Provides for rest

o   Allow client to regain strength

o   Prevent further injury

·      Ultimate goal is to resume activity as soon as possible

range of motion ROM

·      Active:

o   Client does

·      Assist Active:

o   Minimal assistance from patient or nurse

·      Passive:

o   Nurse or therapist does

·      Isometric

·      Mechanical

positioning

done to help prevent complications associated with immobility

semi folwers

30 degrees

fowlers

45-60 degrees