Adult Health, Mental Health, and Nursing Practice Review

Essential Vital Signs and Normal Physiological Values

• Blood Pressure (BP): Optimal is defined as less than $120/80\,mmHg$. Normal is less than $130/90\,mmHg$. High Normal is $120-139/85-90\,mmHg$. Hypertension is diagnosed at levels greater than $140/90\,mmHg$.

• Heart Rate (HR): Normal resting range is $60-100\,bpm$.

• Oxygen Saturation ($SPO_2$): Normal range is $95-100\%$. For patients with Chronic Obstructive Pulmonary Disease (COPD), the target range is $88-92\%$.

• Body Temperature: Normal range is $36.5-37.5\,^{\circ}C$.

• Respiratory Rate (RR): Normal range is $12-20\,rpm$ (breaths per minute).

Cardiovascular Health and Regulation

Blood Pressure Regulation Mechanisms

• Components: Blood pressure is regulated by blood volume, overall compliance, cardiac output, and peripheral resistance.

• Parasympathetic Nervous System: Releases acetylcholine to slow the heart rate.

• Sympathetic Nervous System: Releases catecholamines (epinephrine/adrenaline and norepinephrine/noradrenaline) to increase heart rate.

• Renin-Angiotensin-Aldosterone System (RAAS): Activated when blood pressure drops.

  1. Blood pressure drops.

  2. Sympathetic nervous system stimulation.

  3. Kidney cells release RENIN.

  4. Renin activates angiotensinogen (produced by the liver).

  5. This creates angiotensin 1.

  6. ACE (angiotensin-converting-enzyme), found on lung and kidney surfaces, converts angiotensin 1 to angiotensin 2.

  7. Angiotensin 2 constricts vessels and increases blood volume to raise blood pressure.

Cardiac Function and Electrical Activity

• Cardiac Output (CO): The amount of blood ejected by each ventricle in 1 minute. Regulated by Heart Rate ($HR$) and Stroke Volume ($SV$). CO is calculated by the formula $CO = HR \times SV$.

• Stroke Volume Regulation: Influenced by Preload (venous return, blood volume, atrial contraction), Afterload (hypertension, vasoconstriction), and Contractility.

• Electrical Impulses (ECG/EKG):

  • P wave: Atrial depolarisation; the impulse is then delayed at the AV node.

  • QRS complex: Ventricle depolarisation.

  • T wave: Ventricle repolarisation.

Ischemic Heart Disease and Angina

• Oxygen Imbalance: Ischemia occurs when oxygen demand exceeds supply.

  • Decreased Supply Factors: Atherosclerosis, anaemia, hypotension, aortic valve incompetence.

  • Increased Demand Factors: Stress, physical exertion, tachycardia, hypertension, thyrotoxicosis.

• Angina Types:

  • Stable Angina: Pain occurs only on exertion; lasts $5-15\,minutes$; relieved by rest or Glyceryl trinitrate.

  • Unstable Angina: Occurs at any time (even rest); lasts longer than $10\,minutes$; high risk for myocardial infarction.

Congestive Heart Failure (CHF)

• Definition: Cardiac output is insufficient to maintain metabolic needs.

• Failure Types:

  • Systolic Failure: A contraction issue (cannot squeeze the blood out).

  • Diastolic Failure: A filling issue (not enough blood enters the chamber).

• Left-Sided Heart Failure (DROWNING): Fluid backs up into the lungs. Symptoms include dyspnoea, rales, orthopnoea, weakness, nocturia, nagging cough, and weight gain.

• Right-Sided Heart Failure (SWELLING): Fluid backs up into the body. Symptoms include enlarged liver, swelling in hands/legs, oedema, large neck vein (JVD), lethargy, and nocturia.

• Diagnostics: B-type Natriuretic Peptide (BNP) biomarkers, X-ray (hypertrophied ventricles), Echo, and Troponin levels.

Myocardial Infarction (MI)

• Pathophysiology: A "heart attack" where blood flow stops in coronary arteries, causing muscle damage. Often due to plaque (cholesterol) build-up.

• Diagnostic Findings:

  • ECG Changes: Hyperacute peaked T waves, then ST elevation (STEMI), followed by negative T waves and pathologic Q waves.

  • Blood Test: Troponin T is the definitive enzyme released upon heart muscle injury.

• Treatment: Aspirin (antiplatelet), Thrombolytics (clot-dissolving), Nitroglycerin (vasodilation), and surgical interventions like CABG (Coronary Artery Bypass Graft) or Angioplasty (stent placement).

Peripheral Vascular Conditions and Shock

Deep Vein Thrombosis (DVT)

• Virchow's Triad (Risk Factors):

  1. Stasis: Immobilisation, varicose veins, AFib, traveling.

  2. Hypercoagulability: Cancer, sepsis, dehydration, birth control, postpartum.

  3. Endothelial Damage: IV drug use, trauma, surgery.

• Symptoms: Redness, swelling, heat, and pain in the extremity.

• Management: Elevation, bed rest, anticoagulants (Heparin, Warfarin). Warning: Do not massage the area, as it can dislodge the clot.

Aortic Dissection

• Types: Type A (closer to the heart) and Type B (moving down the aorta).

• Pathophysiology: A tear in the aorta causes blood to build up and clot, risking DVT or stroke.

• Symptoms: Sudden severe chest/back pain ("tearing" sensation), loss of consciousness, and trouble talking.

Classification of Shock

• Obstructive: Blood flow is physically blocked (e.g., Pulmonary Embolism, cardiac tamponade, tension pneumothorax).

• Cardiogenic: The heart fails as a pump (e.g., MI, arrhythmias).

• Distributive: Loss of blood vessel tone (open/floppy vessels).

  • Anaphylactic: Allergen-induced histamine release.

  • Septic: Overwhelming infection response.

  • Neurogenic: Loss of sympathetic nervous system tone.

• Hypovolemic: Low intravascular fluid. Symptoms appear after losing >15\% of blood volume ($70/56\,mmHg$ BP, weak pulse, oliguria).

  • Absolute: Outside fluid loss (bleeding, vomiting, sweating).

  • Relative: Inside fluid shift (internal bleeding, third spacing from burns).

Respiratory Disorders

Asthma

• Three Stages: (1) Bronchoconstriction, (2) Inflammation (thickened mucosa), (3) Mucus hypersecretion.

• Management: Short-term Beta 2 agonists (Salbutamol) and Corticosteroids for inflammation.

COPD and Emphysema

• Pathophysiology: Irritants cause loss of lung elasticity and narrowed passages. Reduced oxygen extraction capacity.

• Characteristics: Barrel-shaped chest (ribcage expansion), pursed-lip breathing, and cyanosis.

• Treatment: Oxygen therapy (often $16\,hrs/day$), smoking cessation, and pulmonary rehab.

Pneumonia and Bronchitis

• Pneumonia: Infection causing alveoli to fill with fluid/pus. Symptoms: fever, chills, productive cough, pleuritic pain.

• Bronchitis: Inflammation of bronchial tubes. Acute usually follows a cold; Chronic is often due to smoking (mucus build-up).

Acute Thoracic Conditions

• Pulmonary Embolism: Thrombus in pulmonary artery. Signs: blood-tinged sputum, tachypnoea, feeling of "impending doom."

• Pneumothorax: Air in pleural space causing lung collapse. Priority: Cover chest opening with a three-sided semi-occlusive dressing.

• Flail Chest: Segment of rib cage breaks and detaches. Characterised by uneven chest rising/falling (paradoxical breathing).

Neurological and Nervous System Health

Stroke (Cerebrovascular Accident)

• Types: Ischemic (blockage/stenosis) and Haemorrhagic (rupture/aneurysm).

• TIA (Transient Ischemic Attack): A "warning stroke" where symptoms resolve quickly.

• TPA (Tissue Plasminogen Activator): Dissolves clots. Must be given within $3\,hours$ of onset and only for ischemic strokes (requires negative CT for bleed).

Cerebral Palsy (CP)

• Spastic CP: Most common; increased muscle tone and stiff movements. Subtypes include Quadriplegia (all limbs), Diplegia (lower limbs), and Hemiplegia (one side).

• Dyskinetic CP: Repetitive twisting (dystonia) or writhing (athetosis) motions.

• Ataxic CP: Poor balance and coordination.

Epilepsy and Seizures

• Generalised Seizures: Affect both sides of the brain (e.g., Absence, Tonic-Clonic/Grand Mal).

• Focal Seizures: Start in one part of the brain; may progress to bilateral.

• Seizure Care: Stay with the patient, prevent injury, do NOT restrain or put objects in the mouth. Call emergency services if the seizure lasts >5\,minutes.

Autoimmune Neuro Conditions

• Guillain-Barre Syndrome: Immune system attacks myelin sheath of peripheral nerves. Ascending paralysis (starts in lower extremities and moves up).

• Multiple Sclerosis (MS): Immune system attacks myelin in the brain and spinal cord, creating scar tissue (sclerosis). Types: Relapsing-remitting, Secondary progressive, Primary progressive.

Intracranial Pressure (ICP) and Glasgow Coma Scale (GCS)

• ICP Symptoms: Headache, blurred vision (late sign), nausea, increased BP, and coma.

• GCS Components: Eye Opening ($1-4$), Verbal Response ($1-5$), Motor Response ($1-6$). Max score is $15$, min is $3$.

Gastrointestinal and Renal Health

Stool Analysis

• Small, dry, hard: Constipation.

• Light grey/clay: Biliary obstruction.

• Mucus: Ulcerative colitis.

• Greasy/fatty: Pancreatitis.

• Black/tarry: Upper GI bleed.

• Bright red (melena): Lower GI bleed.

Common GI Conditions

• Appendicitis: Pain in right lower quadrant. If it bursts, it causes hard, tight abdomen (peritonitis).

• Paralytic Ileus: Lack of movement in intestines; often post-surgical. Symptoms: inability to pass gas, stomach swelling.

• Peptic Ulcers: Destruction of mucosa. Often caused by H. pylori bacteria or NSAIDs.

Renal Function and Failure

• Tests:

  • Serum Creatinine: Early sign of failure if >1.2\,mg/dL (women) or >1.4\,mg/dL (men).

  • GFR: Normal is >90. Under $60$ indicates impairment; under $15$ suggests failure/dialysis.

  • BUN: Normal is $7-20\,mg/dL$.

• Acute Renal Failure (ARF) Phases:

  1. Oliguric Phase: Reduced GFR, fluid retention, electrolyte imbalance.

  2. Diuretic Phase: High GFR, massive fluid loss, risk of dehydration/necrosis.

  3. Recovery Phase: Normalisation of labs; output of $1-2\,L/day$.

Metabolic and Endocrine Health

Acid-Base Balance

• Normal pH: $7.35-7.45$

• Normal $PaCO_2$: $35-45\,mmHg$

• Normal $HCO_3^-$: $22-26\,mmol/L$

• Metabolic Acidosis (pH < 7.35, $HCO_3^-$ < 22): Caused by diarrhoea or ketoacidosis.

• Respiratory Acidosis (pH < 7.35, $PaCO_2$ > 45): Caused by airway obstruction or respiratory depression.

Diabetes Mellitus

• Type 1: Autoimmune destruction of beta cells. Symptoms: Polyuria, Polydipsia, Polyphagia, and weight loss.

• Diabetic Ketoacidosis (DKA): Metabolic acidosis with ketones in urine. Fruity breath/nail polish breath.

• Type 2: Insulin resistance. Managed by diet, aerobic exercise, and Metformin.

• Insulin Table:

  • Ultra-short (Humalog): Onset $15\,min$, Peak $1\,hr$, Duration $3\,hrs$.

  • Short (Actrapid): Onset $30\,min$, Peak $2\,hrs$, Duration $8\,hrs$.

  • Intermediate (NPH): Onset $2\,hrs$, Peak $8\,hrs$, Duration $16\,hrs$.

  • Long-acting (Lantus): Onset $2\,hrs$, No Peak, Duration $24\,hrs$.

Integumentary and Wound Care

Wound Healing Phases

1. Inflammatory: Initial response to injury.

2. Proliferative: Tissue rebuilding.

3. Maturation/Remodelling: Final scar formation.

• Exudate Types: Serous (clear/watery), Serosanguinous (pink/watery), Sanguinous (bright red/blood), Purulent (thick, yellow/green, indicates infection).

Burns Management

• Superficial (1st degree): Epidermis only, red, no blisters.

• Partial Thickness (2nd degree): Blistering. Can be superficial dermal or deep dermal (loss of sensation).

• Full Thickness (3rd degree): Waxy, charred appearance; no sensation.

• Acute Treatment: Apply room-temp water for at least $20\,minutes$ within $3\,hours$ of injury. Never use ice.

Pressure Injuries

• Stage 1: Intact skin, non-blanchable redness.

• Stage 2: Partial-thickness skin loss involving dermis; may be an open ulcer or blister.

• Stage 3: Full-thickness loss; subcutaneous fat may be visible.

• Stage 4: Full-thickness loss with exposed bone, muscle, or tendon.

Maternity and Children's Health

Pregnancy and Complications

• Presumptive Signs: Absent period, fatigue, nausea.

• Probable Signs: Positive test, Chadwick's sign (bluish cervix), Goodell's sign (softening of cervix).

• Pre-eclampsia: Hypertension (>20\,weeks) plus proteinuria. Due to narrow spiral arteries in the placenta. Magnesium sulphate is given to prevent seizures ($calcium\,gluconate$ is the antidote).

Newborn Assessment

• APGAR Score: Appearance, Pulse, Grimace, Activity, Respiration. Scored at $1\,min$ and $5\,min$.

• Infant Reflexes: Moro (startle), Rooting (cheek stroke), Babinski (toes fan out - normal in infants, abnormal in adults indicating motor neuron lesion).

• Congenital Defects:

  • Coarctation of the Aorta: Narrowing of the aorta; high BP in upper body, low BP and weak/absent pulses in lower body.

  • Transposition of the Great Arteries (TGA): Pulmonary artery and aorta are switched. Results in "Blue Babies" because no oxygenated blood reaches the body.

Pediatric Illnesses

• Cystic Fibrosis: Genetic defect affecting exocrine glands (thick mucus). Managed with chest physiotherapy and pancreatic enzymes.

• Reye's Syndrome: Brain/liver damage in children after viral infection. Risk increased by taking Aspirin.

• Rheumatic Fever: Autoimmune response to Group A Strep (strep throat). Can lead to Rheumatic Heart Disease (valve scarring).

Pharmacology Essentials

Specific Medication Classes

• Beta-blockers (-lol): Decrease HR and BP. Caution: Mask hypoglycaemia symptoms and can cause bronchoconstriction (avoid in asthma).

• ACE Inhibitors (-pril): Prevent conversion of Angio 1 to 2. Common side effect: dry cough.

• Digoxin: Positive inotropic (stronger beat), negative chronotropic (slower beat). Toxicity level is >2.4\,ng/mL. Antidote is Digibind.

• Naloxone: Opioid antagonist; reverses respiratory depression. Onset $1-5\,min$, duration $30-90\,min$.

• Diuretics:

  • Loop (Frusemide): Most powerful; works on Loop of Henle.

  • Thiazide: Works on distal tubule; used for hypertension.

  • Potassium-sparing (Amiloride): Monitor for hyperkalaemia; avoid high-potassium foods like spinach and bananas.

Mental Health and Legal Frameworks

Mental Health Act 1992 (NZ)

• Section 111: Power of RN to detain a person for up to $6\,hours$ for urgent assessment.

• Section 30: Inpatient compulsory treatment order.

• Mental Disorder Definition: Abnormal state of mind shown by delusions or disorders of mood, perception, volition, or cognition, creating a serious danger to health/safety.

Psychiatric Support Models

• Recovery Model: "Achieving the life we want in the presence or absence of mental distress." Focuses on hope, self-determination, and personal meaning.

• CBT (Cognitive Behavioural Therapy): Addresses the cycle of Thoughts → Feelings → Behaviour.

• Mental Status Exam (MSE): Assesses Behaviour, Affect/Mood, Thought Form (Logical vs. Flight of Ideas), Orientation, Memory, and Insight.

Safety and Rights

• Restraints: Only used when all other interventions fail. Physical restraints checked every $15\,minutes$; environmental checked every $2\,hours$.

• Enduring Power of Attorney (EPA): Only comes into force if the person is declared mentally incapable by a health practitioner.

• Nursing Council of NZ: Regulatory body that sets competencies, codes of conduct, and protects the public.