-movement -bones protect organs, and help maintain calcium phosphorus balance -skeletal muscles provide stability, help posture, and movement -ligaments=cartilage to bone -tendons=muscle to bone Joints: Fibrous, cartilaginous, synovial
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Functions of the nervous system
-control movement, posture, balance and gait -cerebral cortex=motor activity -cerebellum= coordination and balance
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functions of the cardiopulmonary system
circulates oxygen and nutrients throughout the body
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How to notice changes in musculoskeletal system
-Osteoporosis/bone fragility -lack of muscle tone -rheumatoid arthritis or osteoarthritis -genetic disorders
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How to notice changes in nervous system
-Ischemia-an inadequate blood supply to an organ or part of the body, especially the heart muscles. -Hemiparesis-Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles. -Plegias-a complete paralysis of skeletal muscle
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How to notice changes in cardiopulmonary system
-heart failure -peripheral vascular disease-thin blood vessels reduce blood flow to the limbs -chronic obstructive pulmonary disease-a group of lung diseases that block airflow making it hard to breathe
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What are some interventions that can be implemented for a patient experiencing alterations to their ability to move?
-Encourage the patient to do exercises -Walking outside of the room (only if this can be done safely) -Assessing for pain -Positioning or turning every 2 hours -Applying TED hose or SCDs -Assessing the environment for fall hazards If they are bed bound have the bed up 90 degrees -encourage protein fiber and fluid intake -timed toilet or timed incontinence assessment -bony prominence protection -respect patients typical sleep and wake schedule -encourage contact with patients support system
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What is the normal function of the brain?
when body is stimulated impulses move up the spinal cord and cross over to the other side the body before reaching the brain
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What body regions are involved in cognition and sensation?
How do alteration in cognition affect functioning?
delirium-reversible state of confusion depression-mood disorder dementia-decline in cognitive abilities
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How do alterations in sensation affect functioning?
-Tactie-peripheral neuropathy -smell-anosmia (loss of smell totally or partially) -taste-decreased. gustatory cells -hearing conductive hearing loss -equilibrium- motion sickness -vision- myopis, presbyopia, cataracts, glaucoma, diabetic retinotherapathy, molecular degeneration
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What should you consider when planning care?
-Always consider your patients specific circumstances when planning -Talk with patient and their support persons to determine the patients goals during hospital stay -always include patient and family in plan of care
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What interventions can be implemented for a patient experiencing alterations to cognition and sensations?
-orient (or re-orient) -environmental safety -timed toileting/ offer help with bathing/oral hygiene -turn and off to reposting patient every two hours -encourage eating (ask what they like to eat) -face patient when speaking, minimize background noise -provide social interaction -brush teeth
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Why do we take vital signs?
Quick efficient method of monitoring a patients basic physiologic status
What things should be done before taking blood pressure?
-Make sure your using the correct cuff size -Don't have a conversation -Make sure the bladder is empty first -Support back/feet -Keep legs uncrossed -Support arm at heart level -Put cuff on bare arm
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What does the pulse pressure measure?
pressure in the arteries in one cardia cycle
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How to find the pulse pressure? What is the average range?
systolic pressure - diastolic pressure
Average Range: 30-50
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What can change pulse pressure?
-stiffness of the aorta because of hypertension
*Greater the pulse pressure, the stiffer and more damaged the vessels are thought to be
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What does temperature measure?
The balance between heat produced and heat lost
Heat production-heat loss=Body Temperature
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What is happening when you have a fever?
You are producing more heat than you're losing.
You also lose more oxygen.
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What can influence temperature?
-Smoking -Circadian rhythm (cold in the morning and night) -Hormones -Age -Stress -Enviornment -Exercise -Drinking hot/cold drinks
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How can you take temperature?
-Hand held with rectal and oral/axillary probe -By ear -Under armpit -Forehead
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What does pulse measure?
heart rate -measures the palpable bounding of blood flow noted at various points on the body
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What is the normal range for pulse?
60-100 beats/minute
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What is the pulse rate?
number of heart beats per minute
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What can influence pulse?
exercise, emotions, nervousness
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What ways can you take pulse?
Radial pulse or apical pulse
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How do you assess pulse?
location (apical or radial), rate (how fast; BPM), rhythm (irregular or regular), force, and quality
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Bradycardia
slow heart rate (less than 60 bpm)
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Tachycardia
fast heart rate (more than 100 bpm)
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arrhythmia
irregular heartbeat
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peripheral vascular resistance
anything working against the blood flow through your arteries
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Blood Volume
The total amount of blood circulating within the body
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artery elasticity
allows arteries to absorb pressure waves that come with each heartbeat
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Ventilation
moving air in and out of the lungs
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Diffusion
Exchange of respiratory gases (O2 and CO2 are being swapped)
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Perfusion
Circulation of blood within an organ or tissue in adequate amounts to meet current needs of the cells.
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What can happen if something goes wrong with the 3 functions of respiration?
You can have respiratory failure
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How to access respiration? What is average range?
-rate -rhythm/pattern -depth -effort-any retractions of associated movements like tripoding (body shaped like tripod because patient is trying to catch breath or not getting enough air.
Average Range: 12-20 respiratory/minute that are regular and unlabored
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Work of Breathing (WOB)
The effort required to expand and contract the lungs
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Hypoxia/Hypoxemia
hypoxemia-low oxygen in blood hypoxia-low oxygen in cells and tissue
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hypercapnia
increases level of mucus
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Dyspnea
feel short of breath (sensation)
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What is the SaO2 range?
95-100%
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when do we use nasal cannula?
when a patient can not tolerate a nonrebreather
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pros and cons: nasal cannula
pros: simple, non-evasive, easy to use, low cost, and disposable
cons: easily dislodged, not as effective is a patient is a mouth breather or has blocked nostrils or a deviated septum or polyps.
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Nasal cannula flow rate
1-6 L/min 24-44%
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when do we use simple oxygen mask?
when patient requires high concentration of oxygen
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pros and cons of simple oxygen masks
pros: effective for mouth breathers or those with nasal obstruction, delivers more oxygen
cons: bad for patients with COPD due to the imprecise nature and CO2 retention masks
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simple oxygen mask flow rate
6-10 lpm
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when do we use nonrebreather masks?
can deliver high concentrations of oxygen in emergency situations
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Pros and cons of nonrebreather mask
pros: can deliver 60-85% O2 without CO2 retention
cons: difficult to achieve >75% due to issues with seal; not for long term use due to risk of O2 toxicity
has a high liter flow but its inaccurate
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Nonrebreather mask liter flow
10-15L/min
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When do we use Venturi masks?
the hospital setting to deliver controlled percentages of oxygen
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Pros and Cons of Venturi Masks
pros: delivers constant, precise O2 from 24-60%, useful for chronic lung patients due to exhalation ports, makes wearing O2 easier
cons: not useful if greater than 60% is needed
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What does pulse oximetry measure?
reads the level of oxygen saturation of oxygenated blood (how much O2 is in each of your blood cells)
What are some interventions for alternations in elimination?
-Educate the patient one foods and activities that promote eliminations, and hygiene considerations -assist patient with elimination using bedside commode or other tools -documenting intake and output -proper indwelling catheter care
What examinations can you do to see if patients can swallow?
barium swallow, EGD
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What to do if patient is at risk for aspiration?
patient should be made NPO nurse can perform bedside swallow study consult speech therapy consult dietician
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What are some special diets?
Clear Liquid (apple juice, broth, black coffee, jello-easily digested, with) Full liquid (milk, coffee with cream, orange juice WITH pulp, ice cream, dairy products Mechanical soft-foods that require less chewing than regular diet
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What are some dietary restrictions?
NPO-nothing by mouth regular diabetic cardiac-give less sodium so cholesterol goes down renal give less potassium, sodium, and phosphorus, and protein
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What is a nasogastric tube?
-It is a tube placed in the nose into the stomach. -Used for short term feeding and suctioning
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What is a nasoduodenal tube?
-it is a tube placed into the nose into the first part of the small intestine
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What is a nasojejunal tube?
-it is a tube placed into the nose ending in the second part of the small intestine
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What is a gastrostomy?
Insertion of a feeding tube into stomach through an opening in the abdomen.
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What is a jejunostomy?
creation of an opening between the jejunum and the surface of the abdominal wall
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