Exam 2 Flashcards
vital signs, lungs & thorax, abdomen
1
Q
Visceral pain origin
A
originates from larger interior organs
2
Q
Visceral pain presents
A
autonomic responses - vomiting, nausea, pallor, diaphoresis
3
Q
Visceral pain occurs from
A
direct injury or stretching of organ
4
Q
Deep somatic pain origin
A
blood vessels, joints, tendons, mm, bone
5
Q
Deep somatic pain presents
A
nausea, sweating, tachycardia, HTN, aching, throbbing
6
Q
Deep somatic pain is usually
A
well localized and able to be identified
7
Q
Cutaneous pain origin
A
skin surface, subcutaneous tissues
8
Q
Cutaneous pain feels
A
sharp, burning sensation
9
Q
Referred pain origin
A
visceral or somatic structures
10
Q
Referred pain localization
A
felt at particular site but originates from another - same innervation
11
Q
Acute pain
A
short term, self limiting, protective purpose
12
Q
Acute incident pain
A
occurs predictably with certain movements
13
Q
Acute pain behaviors
A
autonomic response - guarding, grimacing, vocalizations, diaphoresis, change in vital signs
14
Q
Chronic pain
A
persistent, 6+ months, those with chronic pain are often not believed
15
Q
Chronic pain behaviors
A
bracing, rubbing, diminished activity, sighing, appetite change, more variable than acute behaviors
16
Q
Pain as subjective
A
self report is gold standard of pain assessment, pain is always subjective
17
Q
Infant pain assessment
A
- preverbal and incapable of self-report
- depends on behavioral/psychological cues
- CRIES: neonatal postoperative pain measurement score
18
Q
Children pain assessment
A
- children 2+ can report pain but not intensity
- rating scales introduced at 4-5 age
- FLACC
- faces pain scale
- consult caregivers
19
Q
Temperature is influenced by
A
diurnal cycle - lower in morning
menstruation - higher when ovulating
exercise - higher
age - lower in older adults, varies in kids
20
Q
Expected oral temperature
A
98.6, range of 96.4-99.1
21
Q
Oral temperature is
A
accurate and convenient
22
Q
Expected rectal temperature
A
.7-1 F higher than oral
23
Q
Rectal temperature is
A
most accurate, closest to core temp, invasive
24
Q
Tympanic temperature is
A
noninvasive, nontraumatic, quick, efficient, may be less accurate during cardiac arrest
25
Pinna positioning for temperature
adult: up and back
child: straight down
26
Temperature tips
- red tip probe for rectal
- blue tip for oral/axillary
- wait 15 min after hot/cold liquid ingestion
27
If pulse rhythm is irregular
count pulse for full minute
28
Expected HR
50-95bpm, higher the younger you are
29
HR factors
- medications - may slow hR
- age: slows with age
- gender: slightly faster in females after puberty
- athletes: lower
- anxiety: high HR
30
Respirations should be
relaxed, regular, automatic, silent
31
Expected RR
20 breaths/min, 16-25 range
32
As you age, RR becomes
slower
33
Pulse oximeters measure
the relative amount of light absorbed by HbO2 and unoxygenated HB
34
Expected SpO2 on room air
97-99%
35
Pulse oximeter placement
- translucent skin (finger, toe, pinna)
- infants: foot, big toe, palm, thumb
- remove any polish
36
Systolic pressure is
maximum pressure felt on artery during L ventricular contraction
37
Ideal systolic
90-119mmHg
38
Diastolic pressure is
pressure that blood exerts constantly between each contraction
39
Ideal diastolic
50-80mmHg
40
Pulse pressure
difference between systolic and diastolic - reflects stroke value
41
Mean arterial pressure
pressure forcing blood into tissue
42
Factors of BP
- age: gradual rise
- sex: in females, lower after puberty and higher after menopause
- race
- social determinants: low socioeconomic status = higher risk
- diurnal rhythm
- weight: obesity increases BP
- exercise, emotions, stress
43
Level of BP is determined by 5 factors
1. CO: increase CO, increase BP
2. Peripheral vascular resistance: vasoconstriction increases BP
3. Volume of circulating blood: fluid retention increases BP
4. Viscosity: increase viscosity, increase BP
5. Elasticity of vessel: increase rigidity, increase BP
44
Measuring BP
- width of cuff should equal 40% arm circumference
- length of cuff = 80% circumference
- keep arm at heart level
- uncross legs
45
What leads to high BP readings
- narrow cuff size
- applied too loose
- reinflating during procedure
46
What leads to low BP readings
- decreased inflation
- cuff size too large
47
Orthostatic vital signs indication
- suspect volume depletion
- known hypertension
- reports fainting/syncope
48
BP from sitting to standing
slight decrease in systolic
49
Infant/children vital signs
- BP not normally checked in kids <3
- avoid rectal
50
Infant vital sign order
reverse order to respirations, pulse, temperature
51
Preschooler vital signs
consider normal fear of body mutilation may increase with any invasive procedureS
52
School age vital signs
promote cooperation by explanation and participation
53
Infants/children pulse
- palpate or ausculate an apical rate with infants + toddlers
- in children 2+, use radial site
- count pulse for full minute
- fluctuates
54
Infant/children respirations
- watch infant's abdomen for movement
- sleeping RR most accurate in infants
- count for full minute
55
Thorax anatomy
posterior chest, anteroposterior to transverse ratio of 1:2 or 5:7
56
L vs R lung
L lung is narrower, 2 lobes
R lung is shorter, 3 lobes
57
Anterior lungs
almost all upper/middle lobes
apex of lungs is 3-4 cm above inner third clavicle
58
Posterior lungs
C7-T10
almost all lower lobes
59
Reference points
midclavicular line, anterior axillary lines, midsternal line, scapular line, vertebral line
60
Pleura
thin, slippery serous membrane enveloping the lungs, filled with lubricating fluid to help lungs during breathing
61
Trachea/bronchi function
transport gasses between environment and lungs
62
Gas exchange occurs in
alveoli and alveolar duct
63
Functions of breathing
supply oxygen, remove co2, maintain homeostasis, maintain heat exchange
64
Acid-base balance of blood
maintain pH of 7.4
- lungs help maintain balance by adjusting level of CO2
- hyperventilation decreases CO2, hypoventilation increases CO2
65
Hypercapnia
increase CO2, stimulus for us to breathe
66
Hypoexemia
decrease O2, also a stimulus to breathe
67
Tachypnea
rapid shallow breathing, >24 breaths/min
68
Tachypnea causes
fever, fear, exercise
69
Bradypnea
slow breathing, decreased but regular HR
70
Bradypnea causes
drug-induced, increased intracranial pressure
71
Hyperventilation cause
extreme exertion, fear, anxiety, DKA
72
Hypoventilation causes
overdose of narcotics, anesthesia
73
Cheyne-stokes
respirations gradually wax and wane
74
Health history of lungs
cough, sputum, shortness of breath, allergies, chest pain, smoking, environmental considerations
75
Lung inspection
skin color, work to breath, accessory mm use, RR, respiratory pattern, shape/configuration of chest wall
76
Lung inspection expected findings
- straight spin, symmetric scapula and thorax, ribs slope downward at 45 degrees
- AP to transverse diameter ratio is .7-.75
77
Barrel chest
ap diameter = transverse diameter
- occurs in normal aging as lungs become more rigid
- worse with chronic emphysema and asthma
78
Infant/children lung inspection
- assess for nasal flaring, grunting, blue lips
- barrel chest normal until 6
- may note abdominal breathing or irregular breath
- infants are obligatory - nose breather until 3 months
- intercostal retractions
79
Intercostal retractions
inward movement of mm between ribs from reduced pressure in chest cavity - sign of difficulty breathing
80
Lung Palpate goal
symmetric expansion
81
Anterior lung palpation
place hands along costal margins with thumbs pointing toward xiphoid process
82
Posterior lung palpation
place hands on posterior chest sideways with thumbs together at T9-T10
83
Lung palpation method
- slide hands medially to pink small fold of skin between thumbs
- ask person to take deep breath
- as person inhales, thumbs should move apart symmetrically
- note any lag in expansion
- unequal expansion = part of lung is obstructed/collapsed
84
Lung auscultation
- have patient sitting, leaning slightly forward with hands in lap
- breath through mouth
- listen one full respiration at each location
- silent chest = no air moving in or out
85
Adventitious sounds
extra sounds not normally heard
86
Fine crackles (rales)
high-pitched, short cracking, popping sounds during inspiration that aren't cleared with coughing
87
Coarse crackles
loud, low-pitched, bubbling, gurgling
88
Atelactatic crackles
fine crackles that don't last and are not pathologic
- often older patients, bedridden, just waking up
89
Rhonchi
low-pitched, musical, snoring sound from airflow obstruction from secretions
90
Stridor
high-pitched, monophonic, inspiratory crowing sound
- louder in neck than chest wall
- caused by croup in kids or foreign airway obstruction
91
Pleural friction rub
superficial sound that's coarse, low-pitched, grating quality
- louder the harder you push your stethoscope
- inspiratory and expiratory
92
Wheezing
high-pitched, musical, squeaking lung sound, sometimes clears with coughing
93
Preparing for abdominal assessment
- adequate lighting
- maintain privacy
- empty bladder, warm stethoscope, examine painful areas last
- auscultate before percussion/palpation
94
Contour
describes nutritional status and normally ranges from flat to protuberant
95
Abdomen inspection
stand on right side and look down on abdomen, then stoop to gaze across abdomen
96
Scaphoid abdomen
caves in
97
Protuberant abdomen indicates
distention
98
Inspecting abdomen symmetry
- should be symmetric bilaterally
- note any bulging, visible mass, asymmetric shape
- step to foto of bed to recheck symmetry
- hernia
99
Hernia
protrusion of abdominal viscera through abdominal opening in mm wall
100
Abdomen inspection - umbilicus
- should be midline and inverted with no discoloration, inflammation, or hernia
101
Abdomen umbilicus can be everted with
pregnancy, ascites, or underlying masses
102
Abdomen umbilicus can be deeply sunken if
obese
103
Abdomen umbilicus may be blue if
intraperitoneal bleeding (Cullen sign)
104
Abdomen inspection - skin
should be smooth, even, appropriate for ethnicity
105
Unexpected abdomen skin findings
redness (localized infection), jaundice, skin glistening and taut (ascites)
106
Expected pulsations/movement of abdomen
may see aortic pulsations or waves of peristalsis in thin people
107
Unexpected pulsations or movement in abdomen
marked aortic pulsations could indicate hypertension, aortic insufficiency, or aneurysm
108
Distended abdomens may have
marked pulsations
109
Abdomen inspection - expected demeaner
relaxed, quietly with benign facial expression and slow, even respirations
110
Abdomen inspection - unexpected demeanor
- restlessness/turning (gastroenteritis or bowel obstruction)
- absolute stillness/resisting movement (pain of peritonitis)
- knees flexed, facial grimacing, rapid respirations (pain)
111
Auscultation should occur
before percussion and palpation
112
Auscultation uses this part of the stethoscope and method
diaphragm
- bowel sounds are high-pitched
- hold lightly against skin
- begin in RLQ at ileocecal valve area
113
Abdomen auscultation expected findings
normoactive bowel sounds, occur irregularly 5-30 times/minute
114
Unexpected abdomen auscultation findings
Hyperactive sounds, borborygmus, hypoactive sounds, absent sounds
115
Hyperactive sounds are
loud, high-pitched, rushing, tinkling
- increased motility
116
Hypoactive sounds could follow
abdominal surgery or inflammation of peritoneum
117
Absent sounds are
uncommon, listen for full 5 minutes before you determine absence
118
RLQ parts
cecum, appendix, R ovary + tube, R ureter, R spermatic cord
119
RUQ parts
liver, gallbladder, duodenum, head of pancreas, R kidney + adrenal gland, hepatic flexure of colon, part of ascending + transverse colon
120
LUQ parts
stomach, spleen, L liver lobe, body of pancreas, L kidney + adrenal gland, splenic flexure of colon, part of transverse + descending colon
121
LLQ parts
part of descending colon, sigmoid colon, L ovary + tube, L ureter, L spermatic cord
122
dyphagia
difficulty swallowing
123
pyrosis
heartburn
124
eructation
burp
125
hematemesis
vomiting blood
126
pica
eating non-food items
127
melena
black, tarry stool containing blood - internal bleeding
128
grey stools
bleeding, bile deficiency, jaundice
129
Bruits are
vascular sounds
130
Bruits method + expected findings
- listen with bell
- listen over aorta, renal, iliac, femoral arteries
- usually won't hear any sounds
131
Abnormal bruit sounds
blowing, rushing - occurs with stenosis, occlusion, or anuerysm of artery
132
Abdominal percussion goal
assess relative density of abdominal contents, locate organs, screen for fluid or masses
133
Abdominal percussion method
proceed lightly in all 4 quadrants in clockwise pattern, starting with RLQ
134
Abdominal percussion expected findings
general tympany x 4 quadrants
135
Abdominal percussion unexpected findings
Dullness or hyperresonance
- distended bladder, adipose tissue, fluid, mass
- hyperresonance = gas
136
Costovertebral angle tenderness
positive findings indicate kidney inflammation
137
Costovertebral angle tenderness process
- indirect fist percussion causes tissues to vibrate
- place 1 hand over 12th rib at CVA on back
- make fist with other hand
- thump flat hand with ulnar edge of fist
- normal person feels no pain
- kidney infection = intense pain
138
Abdominal palpation goal
judge size, location, consistency of organs and screen for abnormal masses/tenderness
139
Abdominal palpation method
- use measure to relax patient, enhance mm relaxation
- begin with light palpation and proceed to deep plapation
140
Light abdominal palpation
- 1cm
- overall impression of skin surface and superficial musculature
- entire abdomen, clockwise, zigzag pattern
- save tender areas for last
141
Deep abdominal palpation
- 5-8cm
- note tenderness, location, size, consistency, and mobility of any abnormal findings
142
Expected abdominal findings
- soft, non tender to palpation x 4 quadrants
- no masses or tenderness
- voluntary guarding
143
Unexpected abdominal findings
- distended abdomen
- tender
- involuntary guarding or rigidity
144
Voluntary guarding
cold, tense, ticklish - use relaxation techniques
145
Involuntary guarding
constant board like hardness of mm
- protective mechanism from acute inflammation of peritoneum
146
Common causes of constipation
decreased activity, inadequate water intake, low-fiber, medication side effects, hypothyroidism, inadequate toilet facilities
147
Abdomen nursing considerations
- don't palpate a patient's abdomen who has had an organ transplant
- don't feed patient until they've passed flatus
- acute abdominal pain needs immediate assessment
