NURM-102 Final Review

Phrenic nerve

Neck nerve (about C3-5) which innervates diaphragm

Diffusion

O2 and CO2 exchange between blood and alveoli

Cheyne-Stokes

Patterns of tachypnea followed by apnea

Breath quality

Effort and sound of breathing

Why is past pneumonia important?

It tends to come back

Wheeze

Musical squeaking, air passing through narrow airway

Crackles

Fine courses bubbling sound

• Air passing through fluids → Won’t clear with coughing

Rhonchi

Sonorous, snoring, air passing through or around secretions 

• May be cleared by coughing

Pleural friction rub

Dry, grating or rubbing sound

Stridor

High pitched inspiratory crowing sound or cat screaming

When do you NOT ask for a CT scan?

Pt has an iodine allergy

Aging adult lung considerations

• Decreased Gas exchange → Not as deep breaths

• Weakened cough reflex and decreased ciliary action

  • Ciliary = Little fingerlike projections that push gunk out of lungs 

• Decreased lung expansion

• Higher risk for respiratory infections

• Reduced response to hypoxia and hypercapnia

  • Hypercapnia = High CO2

Dyspnea

Shortness of breath

Orthopnea

Cannot breathe unless upright

• Get pillows

• May indicate CHF

How to inspect for JVD?

Pt at 30-45 degree angle, normal healthy adult → it should not be visible

Exercise Stress Test

How do they handle going up and downhill? Usually treadmill

Cardiac biomarkers

If it doesn’t elevate they get sent home

• Troponin 

• CK-MB

S1

Lub - AV valve closure (mitral and tricuspid)

• Heard at Apex - PMI

S2

Dub - Closure of semilunar valves (aortic and pulmonic)

• Heard at base - 2nd ICS L and R sternal border

Systole

Contraction → Blood ejected from heart

Diastole

Relaxation → Chambers fill with blood

Peripheral pulses

• Carotid

• Brachial

• Radial

• Femoral

• Popliteal

• Posterior tibial

• Dorsalis pedal

Pulse Strength Grading

• 0 = Absent

• 1+ = Thready

• 2+ = Weak

• 3+ = Normal

• 4+ = Bounding

Heart Auscultation Landmarks

• Aortic (2nd ICS on R)

• Pulmonic (2nd ICS on L)

• Erbs Point (3rd ICS MCL on L)

• Tricuspid (4th ICS on L)

• Mitral (PMI, 5th ICS on L)

Normal Age-Related Heart Changes

• Heart

  • Decreased cardiac output 

  • Increased heart size

  • Stiffer valves

  • Reduces HR and Rhythm changes 

• Blood vessels

  • Arteriosclerosis (Stiffer arteries)

  • Atherosclerosis (Plaque in arteries)

• Blood

  • Decreased BV

  • Increased clotting

    • DVT, pulmonary embolism

  • Anemia (reduced production)

Peripheral Arterial Disorder

• Atherosclerosis

• Reduced blood flow primarily to lower extremities

  • Check pedal pulse to see if anything is going down there 

• Intermittent claudication - Pain with activity

  • Relieved by rest

• Rest pain (Severe even at rest)

• Diminished/absent pulses

  • Use doppler if you can’t find it yourself 

  • Mark with an X once you find it

Peripheral Venous Disorder

• CVI (Chronic Venous Insufficiency)

  • Failure of venous valves

  • Skin changes

  • Edema 

• Clinical Manifestation

  • Aching heavy legs 

  • Skins discoloration

  • Ulcers

Deep Vein Thrombosis

Blood clot in deep vein, usually in the calves

• Pain

• Edema

• Warmth

• Redness

• Can also be asymptomatic

Arterial Ulcer

• Location - Tip of toes, web spaces, heel/pressure points if immobile

• Pain - Very painful

• Depth - Deep, usually involving joint space

• Shape - Circular

• Base - Pale to black and wet to dry gangrene

• Leg edema - Minimal unless extremity is in dependent position constantly

Venous Ulcer

• Location - Medial malleolus, lateral malleolus, anterior tibial

• Pain - Minimal to very

• Depth - Superficial

• Shape - Irregular border

• Base - Granulation tissue

• Leg edema - Moderate to severe

Intermittent Claudication

Pain brought by activity, relieved at rest

Chronic ARTERIAL problems

• Pale

• Cool

• Decreased capillary refill

• Intermittent claudication, pain when active

• Decreased hair distribution

• Arterial insufficiency

• Deep muscle pain

• Chronic pain, onset gradual after exertion

• Rest for relief

Acute ARTERIAL problems

• Pallor

• Coldness

• No pulse

• Throbbing - Beating, pulsing sensation

• Location varies but distal to occlusion

• Sudden onset

Chronic VENOUS problems

• Edema, varicosities, weeping ulcers

• In calf/lower leg

• Aching, tired, feeling full

• Chronic pain increasing at end of day

• Aggravated by prolonged standing and sitting

• Chronic venous insufficiency

Acute VENOUS problems

• Red, warm, swollen legs

• In calves

• Intense, sharp, deep muscle that is tender to touch

• Sudden onset

• Pain increases with sudden dorsiflexion

Bronchial sounds

Heard on expiration longer

• Blowing, loud, hollow sound heard over trachea and larynx

Bronchovesicular sounds

Heard equally on inspiration and expiration

• Medium pitch blowing sound heard at 1st and 2nd ICS anterior and scapula posterior

Vesicular sounds

Longer on inspiration

• Soft, low-pitched whispering heard over most of lung fields

• May be louder/intense in upper airway

Cerebellum

Regulates balance

RLQ organ(s)

Appendix

RUQ organ(s)

Liver

LUQ organ(s)

Spleen and stomach

LLQ

Intestines (also present in other quadrants)

Aging Adult Abdominal Considerations

• Fat accumulates in stomach —> Colder extremities

• Decreased salivation —> Aspiration risk and less appetite

• Esophageal emptying delayed

• Gastric acid decreased —> Food sitting in stomach longer, less hungry

Scaphoid contour

 Lack of adipose, stomach almost caves in, malnourished

• Ribcage can be seen

• Normal for children and elderly though

• You can feel the abdominal aortic pulsation

Protuberant contour

Distended belly that can’t be pressed down

HYPERactive bowel sounds

Peristalsis too fast, not absorbing enough

HYPOactive bowel sounds

Peristalsis too slow, absorbing too much

Ileus bowel sounds

Absence of sounds, listen for full 2 minutes, indicates obstruction and perforation

• Normal after anesthesia, but it has to return after waking

Aging adult musculoskeletal considerations

• Loss of bone density

  • Osteoporosis → Risk for fractures

• Kyphosis

• Muscle atrophy

  • Shrink up when we age

• Loss of muscle mass

• Loss of neurons —> Slow reaction time

• Deterioration of joint cartilage

  • Osteoarthritis and rheumatoid arthritis

• Decreased cerebral bloodflow

  • Carotid arteries can be blocked/narrowed over time

Osteoarthritis

Resulting from overuse

Rheumatoid arthritis

Autoimmune disease

Tone

Degree of tension; how does it feel when not engaged in activity

Contractures

Muscle shrinkage and dysfunction of the joint due to immobility

Ambulation muscles

Quads, glutes and hamstrings

Fine motor movement UPPER

Needed for ADLs

• Rapid alternating movement

• Finger to finger/nose

• Opposition

Fine motor movement LOWER

Tap toes against the floor to see if they will stumble

Gross motor movement lower

Heel to shin test; abnormal indicates scissor gait

Wrists and ankles

Condyloid joint

• Extension, flexion, hyperextension

• Inversion

• Eversion

Shoulders and hips

Ball and socket joint

• Extension = at rest

• Flexion forward; hyperextension backwards

• Circumduction

• Abduction and adduction

• Internal rotation and external rotation

  • Turning in and out

Crepitus

Continual joint grinding indicating dysfunction

Isometric

Helps muscle groups; just contracting and relaxing them

Isotonic

Helps muscles AND joints; Active ROM exercises are isotonic because you’re moving the joints on their own

Isokinetic

Helps muscles, joints and bones

• Resistive exercises because immobility causes bone demineralization → Bones become brittle → Risk for fracture 

  • Also important for post-menopausal women because they suffer bone demineralization too

Ambulation Requirements

• Sitting balance

  • Sit them up

• Quad strength

  • 4-5 to ambulate at all

• Dorsiflexion

  • Needed or else you stumble

• Standing balance

• Hip flexion

  • Move from the hip

Dehiscence

Separating apart

If a wound dehisces…

Cover with sterile towels moistened in sterile NS + call provider

Eschar

Leathery, dark, dead tissue

Fistula

Tunnel from one organ/cavity to another

Hematoma

Collection of blood pocketing under the skin

• As it collects, there’s less blood in the rest of the body —> Lightheadedness, hypotension, pallor and increased HR

What illnesses affect skin?

• Malnutrition

• Dehydration (Turgor)

• Diaphoresis

• Jaundice (itchy and yellow)

• Skin diseases

• Reduced sensation/paralysis

How can therapeutic measures affect skin integrity?

Some measures (like bedrest and casts) have to be prioritized over skin integrity

Contusion

Bruising, skin is intact

Abrasion

Friction/rubbing/scraping

• Top epidermal layer abraded

Avulsion

Tearing a structure from normal anatomical position

• Can indicate vascular, nervous or other damage

Chronic wounds

Takes months to heal

How often should patients be repositioned?

At least q2h

How to avoid maceration?

Only moisten the exposed mucous membranes of wounds, NOT intact skin surrounding

Edema

Impedes blood flow by pressing on blood circulation

Circulation and oxygenation

Needed for proper wound healing

Pressure ulcer

Soft tissue surfaces compressed between bony prominence for prolonged period

Pressure Ulcer Factors

• External pressure against blood vessels

• Friction/shearing damaging superficial vessels under skin

• Inactivity/Immobility

• Malnutrition

• Diaphoresis

• Incontinence

• Vascular disease

• Localized edema

• Dehydration

• Steroids

Braden Scale

6 different scales adding up to a total score for risk level and treatment protocol

• Higher score is better

Pre-Ulcer

Area of reactive hyperemia that is blanchable, should fade within 60-90 minutes if repositioned

Suspected Deep Tissue Injury

Localized purple/maroon discolored area with intact skin

• Painful, firm, mushy, boggy, different temperature

• Allegedly like mashed potatoes

Stage 1 Pressure Ulcer

Non-blanchable erythema

Stage 2 Pressure Ulcer

Partial thickness skin loss of epidermis or dermis

• Superficial and pink or clear fluid-filled blister

• NO slough

Stage 3 Pressure Ulcer

Full thickness skin loss involving damage/necrosis of subcut

• Potential slough or tunneling

Stage 4 Pressure Ulcer

• Full thickness skin loss, exposed muscle/tendons/bone

• Eschar/slough likely present, undermining/tunneling common

Unstageable pressure ulcer

Full thickness ulcer obscured by slough and/or eschar in wound bed

SKIN-E Pressure Ulcer Prevention

• Surface

• Keep Moving

• Incontinence

• Nutrition

• Education

Surface SKINE

Redistribute pressure with devices

• PAD BONEY PROMINENCES

• Ambulate prn

PRIMARY intention

Clean wound edges with minimal tissue loss

SECONDARY intention

Unapproximated wound edges, deeper wound with more tissue loss

• Heals by contraction

TERTIARY intention

Wound opened for surgery and closed

When is wound care performed?

• Doctor’s orders

• Performing drainage

• Post-surgery - SURGEON DOES INITIAL POST OP DRESSING

• Packing the wound

• Debridement

Packing a wound

Not with too much pressure to allow granulation tissue formation

Why are doctor’s orders needed for wound care?

To charge supplies used to patient

Gauze

Dry dressings

Non-adherent dressings

Doesn’t tear skin off when removed

• Adaptic, xeroform