NUR 122 Flashcards
(356 cards)
1
Q
when is critical thinking used
A
- Prioritising care
- Being adaptable
- Choosing methods of communication
- Collecting information
2
Q
nursing process steps
A
Assessing Diagnoisis Planning Implementation Evaluation
3
Q
what is the assessment process of the nursing process
A
Assessing – making reliable observations, using relevant data, using important data, validating data, organising data, categorising data according to a frame work, Recognising assumption, identifying gaps in the data.
Clinical reasoning cycle can be helpful
Eg. Consider patients situation, collect cues and information, process information, identifying problems/ issues, establishing goals, taking action, evaluating outcomes, reflecting on process and new learning
- Many different types of assessment ( depend on where you work)
- Common positions during assessment … dorsal recumbent, supine, sitting
4
Q
equipment that may be useful in the assessment phase of the nursing process
A
- Flashlight/ penlight
- Nasal speculum
- Othalmoscope
- Otoscope
- Vaginal speculum
- Cotton applicators
- Gloves
- Lubricant
5
Q
before onjective assessment what should be done
A
if possible by objective assessment complete subjective assessment
Always approach a patient with kindness, compassion, empathy, sympathy, consideration, respect, smile…
6
Q
4 primary techniques used in physical examination
A
conducted in this order:
Inspect, Palpate, Percuss, Auscultate
7
Q
inspection?
A
visual assessment, eye/ otoscope/ pen torch, olfactory and auditory senses, continue with other techniques
8
Q
palpation?
A
using touch, skin temperature/ vibration/ organ placement and size/ distension and pulsation, light palpation first with single hand, deeper palpation initially with 2 hands, Looking at mass (location, size, shape, consistency, surface, mobility, pulsatility- present/ absent/ tenderness, tenderness)
9
Q
percussion?
A
elicits different sounds, direct (sinuses), indirect (thorax/ abdomen) , different sounds and tones depending on location
10
Q
auscultation?
A
using sound, direct- with ear, indirect- with stethoscope/ pinnards, cardiac sounds- valves, measures in pitch/ intensity/ duration/ quality
11
Q
what are vital signs
A
Also called “observations” or “obs”
Are T(emperature) P(ulse) R(espirations)
B(lood) P(ressure) SpO2 (Saturation % of oxygen)
Vital signs are a measure of bodily (systemic) function
Provide objective evidence of the body’s response to a change in physiological function
12
Q
when could you assess vital signs
A
Eg. Admission, change in health status, before-during- after surgery, before and or after administration of medication, before and after nursing interventions, following an incident- accident or injury in healthcare setting, timeliness of vital sign documentation is important
13
Q
vital signs are not considered alone but with…
A
◦ Patient’s other signs & symptoms (not in isolation, need to cluster relevant information & past history)
◦ Their ‘normal’ results
14
Q
what to do if alterations in vital signs occur
A
◦ Key responsibility is reporting of potential abnormalities
◦ May provide “early warning” of serious issues
15
Q
what is respiration
A
Is breathing - The mechanism the body uses to exchange gases
16
Q
3 processes of respiration
A
- Gas movement in and out of lungs ( ventilation)
- O2 and co2 between lungs and blood (diffusion)
- Distribution of red blood cells too and from lungs (Perfusion)
17
Q
factors affecting respiration
A
- Emotions
- Exercise
- Smoking
- Medical conditions
- Medications (narcotics)
18
Q
when taking respiration’s what are you assessing
A
- Bpm
- Rate, rhythm(pattern), depth, quality, effectiveness
19
Q
newborn normal pulse and respiration
A
pulse: 80-180
respiration: 80
20
Q
1 year old normal pulse and resp rate
A
pulse- 80-140
resp- 20-40
21
Q
5-8 year old normal pulse and resps
A
pulse 75-120
resps 15-25
22
Q
10 years normal pulse and resps
A
pulse 50-90
resps- 15-25
23
Q
Teen normal pulse and resps
A
pulse 50-90
resps 15-20
24
Q
Adult normal pulse and resps
A
pulse 60-100
resps 12-20
25
Older adult normal pulse and resps
pulse 60-100
| resps 15-20
26
different breathing rates (terminology)
- Trachypnoea
- Bradypnoea
- Apnoea
27
different terminology for breathing volumes
- Hyperventilation- over expansion of lungs, rapid deep breaths
- Hypoventilation
28
what is cheyne strokes breathing
rhythm.
| - Cheyne- strokes breathing- waxing and waning of resps- deep to very shallow breathing and temporary apnoea
29
different terminology for breathing ease/ effort
- Dyspnoea- difficult laboured breathing during which individual has persistent, unsatisfied need for ai and feels distressed
- Orthopnoea- ability to breath only upright or standing
30
different terminology for breathing sounds
- Stridor- shrill, harsh sound durinh inspiration with laryngeal obstruction
- Strenor- snoring/ snorous respiration usually due to partial obstruction of the airway
- Wheeze- continuous, high pitched musical ssqueak or whistling sound occurring in expiration and sometimes on inspiration when air mives through a narrowed or partially obstructed airway
- Bubbling- gurgling sounds heard as air passes through moist secretions in the respiratory tract
31
test movements for breathing
intercostal retraction -in drawing between the ribs
substernal retraction -in drawing beneath the breastbone
suprasternal retraction -in drawing above the clavicles
32
secretions and types of coughs during breathing
Secretions and coughing
Haemoptysis-the presidents of blood in the sputum
productive cough -cough accompanied by expectorated secretions
non productive cough -a dry , hash cough without secretions
33
why measure spo2
To assess effective respiration measurement of the % of saturation of oxygen into the arterial blood is needed
SaO2 defined as the % of haemoglobin (Hb) carrying oxygen within the arteries – most accurately measured using an arterial blood sample
34
how is sao2 measured
with a sats probe
35
sao2 affected by?
Every process within respiration really..
(Note the oxygen-haemoglobin dissociation curve)
This is an important (and complex) consideration
36
normal oxygen saturation level
“Normal” reading accepted as ~ 94 – 100%
37
venous blood is lower
| Why?-
The O2 saturation of because venous blood is travelling towards the lungs to be oxygenated
38
spo2 accuracy affected by what factors
Interference with light transmission
Bright outside light
Carbon monoxide poisoning (artificially elevates)
```
Finger movement (shivering/twitching)
Jaundice (affects light reflection)
```
Intra-vascular dyes (artificially decreases)
Artificial nails and some nail polishes
Interference with arterial pulsations
Peripheral vascular diseases (reduces pulse volume)
Hypothermia (decreases peripheral blood flow)
Some drugs decrease peripheral blood flow
Low cardiac output (decreases peripheral blood flow)
Hypotension (decreases peripheral blood flow)
Peripheral oedema (can obscure pulse)
39
oxygen sensor probe should be considered with..
- patients condition
If you receive an abnormal reading – think critically
...check patient condition/probe connections/other vital signs
40
what is blood pressure
Defined as the lateral pressure that the pulsing blood exerts on the artery walls
Measures the pulsing ‘waves‘ of blood flow
41
what does systolic reading represent and diastolic reading represent in BP
Systolic reading = contraction of heart
(= systole)
Diastolic reading = relaxation of heart
(= diastole)
42
what is pulse pressue
difference between systolic and diastolic reading
43
t or f bp trends are more useful than iusolated reading
true
44
t or f
bp= s/d
true
45
what is hypertension
high blood pressure
- When measured twice at different times
- Above 139 systolic and/or 89 diastolic
- Maybe undiagnosed
- Cardiac/vascular/renal problems
46
what is hypotension
low blood pressure
When measured twice at different times
Below 110 systolic
But only when this is not their ‘normal’ BP
Orthostatic BP (Drop in BP when standing )
Can be dangerous because this may result in dizziness and falls
47
sources of error in blood pressure assessment
bladder cuff too narrow/ wide, arm unsupported, insufficient rest before the assessment, repeating the assessment too quickly, cuff wrapped too loosly or unevenly
48
what is a pulse
Electrical impulses travel through heart to stimulate cardiac contraction
As the blood is pumped by the heart it sends a “fluid wave” or “pulsing sensation” through the body - this is the pulse
Mechanical, neural and chemical factors regulate heart function and blood output.
Measured in beats per minute (bpm)
49
sites to measure pulse
temporal
carotid
apical
brachial
radial
femoral
popliteal
posterior tibial
dorsalis pedis
50
t or f
| some conditions can prevent blood from reaching arm
t
51
different pulse rates (terminology)
Fast (tachycardia) or slow (bradycardia)
52
different pulse rhythms (terminology)
Normally regular
Early/late/missed beats – dysrhythmic (arrhythmic)
53
different pulse volumes (terminology)
Reflects the volume of blood ejected by the heart
Absent (0)/weak or thready (1)/normal or strong (2)/bounding (3)
54
what is pulse equality
Both sides of the body are the same
55
3 different types of body temperatures
Body T° = Heat produced – heat lost
Core T° - within the deep tissues ~ constant
Surface T° – fluctuates according to environment and blood flow to the skin
56
Acceptable “normal” oral T° range
36.0°C – 37.5°C (up to 38°C according to K & E)
Note that above 37.5°C is considered pyrexia/febrile – in practice
Though can vary according to activity and environment
And text …
57
where to place thermometer during oral temp
place bulb on either side of renulum
58
where to place thermometer during axillary temp
pat dry then put center of axilla
59
where to place thermometer during tympanic temp
pull pinna up and back, point probe slightly anteriorly towards eardrum, insert using circular motion till sng
60
where to place thermometer during rectal temp
apply gloves
instruct to take deep breath during insertion
dont force if resistence
insert 3.5 cm in adults
61
3 phases of fever
chill, cold phase (onset of fever)
plateau phase (course of fever)
Defervescence (or flush) phase (fever abatement)
62
Clinical manifestations of fever during Chill (or cold) phase (onset of fever)
```
Increased heart rate (tachycardia)
■ Increased respiratory rate (tachypnoea) and depth
■ Shivering
■ Pale, cold skin
■ Complaints of feeling cold
■ Cyanotic nail beds
■ ’Goosebumps’ on the skin
■ Cessation of sweating.
```
63
Clinical manifestations of fever during Plateau phase (course of fever)
■ Absence of chills
■ Skin that feels warm
■ Photosensitivity
■ Glassy-eyed appearance
■ Tachycardia and tachypnoea
■ Increased thirst (polydipsia)
■ Mild to severe dehydration
■ Drowsiness, restlessness, delirium or convulsions
■ Herpetic lesions of the mouth (i.e. an ulceration of the skin)
■ Anorexia (persistent loss of appetite) if the fever is prolonged
■ Malaise, lethargy, weakness and aching muscles.
64
Clinical manifestations of fever during Defervescence (or flush) phase (fever abatement)
■ Skin that appears flushed and feels warm
■ Sweating (diaphoresis)
■ Decreased shivering
■ Possible dehydration.
65
after taking vitals what should be done
Reporting abnormal results is a key nursing responsibility
Know your normal values!!!
Report anything outside those values BUT consider results in light of all information (what is “normal” for this patient/previous results/trends/history)
Accurate documenting of results is essential
66
objective ingumentary assessment involves
- Observe, measure and test skin, hair, nails
w/ integumentary assessment use:
- Inspection and palpation
- Torch and gloves
- Pt may be sitting, standing, supine and prone
67
what do you inspect during intergumentary assessmeht
colour
Ecchymosis/ petechiae
odema
68
coulours you may observe during intergumentary assessment
Pallor (inadequate circulating bl;ood/ low Hb)
Cyanosis (inadequate circulating oxygen)- blue coloured
Jaundice (usually from liver dysfunction) – yellow thinge to skin and eyes
Erythema (increase in blood supply)-…..Ecchymosis/ petechiae
Pigmentation changes
Moisture related issues
rashes and lesions
69
describing lesions by type and structure
. Primary (appear in response to change in environment), and secondary (result from modification such as trauma or infection)
70
describing lesions by Location and symmetry in comparable areas of body
- configuration
| eg. Arrangement of lesions in relation to each other
71
describing lesions by size, shape and texture
Irregular, round, flat, rough, thickened
72
describing lesions by colour
distribution, symety and asymetry
73
what is odema
(excess interstitial fluid)
An important assessment tool in many clinical situations (cardiac/renal/peripheral circulation)
Commonly ankle/feet/sacrum/peribulbar
Swollen, taut, shiny (blanched or erythematous
74
palpating odema
- Different types/ degrees of pitting by mm
- Pitting (stays up) non pitting (rises back up)
2mm- slightly pitting, no obvious distortion
4mm- deeper pt, no obvious distortion
6mm- pit is obvious; extremities are swollen
8mm- pit remains with obvious distortion
75
what do you palpate for during intergumentary assessment
```
Oedema (? Pitting)
Lesions/cysts
Skin temperature
Skin turgor- fluid content in skin
Then validate this info by seeing what their fluid intake is. Getting a urine sample (specific gravity)
```
76
infant considerations during intergumentary assessment
- monitor immunisation history
Jaundice not uncommon soon after birth. Related to immature liver. Physiological (not pathological) treated with ‘lights’.
Commonly ‘whiteheads’, nodules, vernix (‘over-cooked’)
Premature – lanugo
Nappy rash
Allergic rashes
Assess skin turgor to assess hydration status
77
children considerations during intergumentary assessment
Children:- monitor immunisation history
Commonly skin lesions (high activity levels)
Puberty induced acne (over-active oil glands)
Older adults:- white skin demonstrates age related changes earlier than dark skin
Age related changes – elasticity/thin/dry and flaky/macules and lesions/’tags’
78
older adults considerations during intergumentary assessment
Children:- monitor immunisation history
Commonly skin lesions (high activity levels)
Puberty induced acne (over-active oil glands)
Older adults:- white skin demonstrates age related changes earlier than dark skin
Age related changes – elasticity/thin/dry and flaky/macules and lesions/’tags’
79
what is the norton scale used for during intergumentary assessment
predict if a patient is at risk for development of a pressure ulcer
5 catergories- physical, mental, activity, mobility, incontinence
16 and below- at risk and preventative measures should be put in place
Different to braden which tells you what intervention
80
when conducting intergumentary assessment what might you observe about hair
```
Age related changes
Genetic and ethnic related differences
Lesions/rashes
Infestations – lice/nits/ring worm
Alopecia
Thin and brittle hair (hypothyroidism)
Hirsutism (hormonal)
Absent or sparse leg hair – arterial circulation issues
? related to shampoo or soap allergy
Damage from hair dryers or straighteners
```
81
when conducting intergumentary assessment what might you observe about nails
Inspect for shape and angle between nail and nail bed
Texture
Colour
General condition
Infections/inflammations/surrounding tissues/ingrown
Blanch test
82
what is blanch test
similar to capillary refill
83
different nail angles can indicate conditions
t or f
true
84
Integumentary system Diagnostic Tests
Wound swab
Tissue biopsy/needle aspiration
Patch tests/scratch tests (allergy testing)
Hair/nail specimens
85
steps in the chain of infection
1. etiological agent/ microorganism
2. reservoir/ source
3. portal of exit
4. method of transmission
5. portal of entry to susceptible host
6. susceptible host
86
what are some thingsyou might observe in a wound
Wound exudate (ooze)
Serous
Purulent (infected)
Sanguineous
Complications of healing
Haemorrhage
Infection
Dehiscence ( opening of a surgical wound- usually stitches etc.)
87
pressure wound classification stages
stage 1: non blanchable erythema
stage 2: partial thickness skin loss
- no slough, blister, shiny
stage 3: full thickness skin loss
- seb fat may be visible, slough maybe, no bone
stage 4: full thickness tissue loss
- exposed bone, tendon, muscle, slough
88
pressure injury prevention strategies
```
skincare
microclimate control
prophylsctic dressings
fabrics and textiles
electrical stimulation
nutrition
repositioning and early mobilisation
support surfaces
```
89
skin tear classification
1a- edges aligned to normal. not pale, dusky darkened
1b- edges aligned skin pale, dusky, darkened
2a- edges not realigned, not pale, dusky or darkened
2b- edges cant be aligned, pale dusky and darkened
3- skin flap completely absent
90
what is the time framework used for
This framework is mainly applied to chronic wounds though it is useful in assessing and planning the care of all types of wounds
91
what does time framework letters stand for
T-tissue - non-viable or viable
I-inflammation and/or infection
M-moisture balance maintenance
E-edges of wounds/epithelial
92
time framework T
```
Tissue assessment and management
Viable or non viable tissue
Must assess arterial supply first
Must remove non-viable tissue
Use debridement
Lots of different methods
```
93
time framework I
Inflammation and infection control
Inflammation is a normal part of healing
Biofilms are a recent discovery and are considered essential to remove to ensure healing
Infection
Affects healing, and can increase exudate
Alter colour of granulating tissue (rubra/grey)
To treat - Anti microbial dressings (and/or systemic antibiotics)
Silver/iodine based/honey/hypertonic saline
94
time framework M
Moisture balance maintenance
Excess moisture (wet wounds) lead to slower healing and wound maceration
Dry wounds slows healing as well
Moisture balance is the aim
Appropriate dressing to absorb excess moisture
Appropriate dressing to provide moisture
95
time framework E
Epithelial advancement of wound edges
Healthy epithelium has an edge that is silvery-white or light pink edge
Expect gradual epithelial cells of the wound margins to grow inwards to heal over the wound
Slowed by infection/drying out/excess moisture/
build up of debris/over granulation
96
wound care options for dry wound
hydrogels
hydrocolloids
interactive wet dressings
97
wound care options for low excudate wound
semi permeable film
hydrocolloids
calcium alginates
98
wound care options for moderate excudate wound
calcium alginate
hydrofibre
foams
99
wound care options for heavy exudate wound
```
hydrofibre dressing
foam sheet/ cavity
super absorbent dry dressings
wound/ ostomy bag
tropical negative pressure therapy systems
```
100
head assessment involves..
the skull/face/eyes/ears/nose/sinuses/mouth/pharynx
101
what might you observe in the skull/ facial appearance during head assessment
Normocephalic (normal head shape)
Head shape can vary in newborns: Depending on mode of delivery
Sleeping on one side
Fontanels
Older adults Face shape changes with loss of muscle tone and fat/teeth/gum changes
Many health disorders involving the thyroid/adrenals/pituitary/ kidneys and cardiovascular systems can change facial appearances
102
during mouth and oropharynx assessment what to check for
```
offensive breath
Contains a number of soft and hard tissue structures as well as teeth
Lips
Dental and gum problems (false teeth?)
Tongue
```
103
infants considerations during mouth oropharynx assessment
cleft lip
oral thrush
wide nodules on gumsfirst teeth at 6-7 months
fluoride
104
children considerations during mouth oropharynx assessment
annual dental checks
dental developments per milestones
oral fixation common
105
older adults considerations during mouth oropharynx assessment
decreased salviation with age
receeding gums
taste diminishes
tongue/ oropharyngeal disorders
106
what might you observe during neck assessment
```
Contains many muscles/lymph nodes/blood vessels/numerous other structures
Lymph nodes
Thyroid gland (? goiter)
```
107
what might you observe during thorax and lungs assessment
Critical to assessing oxygenation status
Post-op pneumonia
Chronic obstructive pulmonary disease (COPD)
Breath sounds Adventitious = abnormal From constricted, inflamed or liquid filled airways
108
what are some chest deformaties
pigeon- breastbone to push outward instead of being flush against the chest
funnel- producing a concave, or caved-in, appearance in the anterior chest wall.
barrel chest-
109
what is the normal chest shape
thorax is oval. Its anteroposterior diameter is half
| its transverse diameter
110
infant considerations during thorax and lung assessment
Infants:-
Thorax different shape
Diaphragmatic breathers (watch the stomach)
Right bronchi shorter and straighter than left bronchi
111
children considerations during thorax and lung assessment
About 6 yrs the shape of the thorax is similar to adults
About 6 yrs breathing becomes more thoracic, similar to adults
Parents should watch for scoliosis
112
older adult considerations during thorax and lung assessment
Physiological changes with ageing (kyphosis/osteoporosis)
Loss of muscle strength (increasing respiratory effort)
Greater risk of infections as less cilia
113
looking anterior chest what are some chest wall landmarks
right anterior axillary line
right midclaviclular line
midsternal line
left midclavicular line
left anterior axillary line
114
looking laterally to the chest what are some chest wall landmarks
anterior axillary line
mid axillary line
posterior axillary line
115
looking posterior to the chest what are some chest wall landmarks
left and right posterior axillary lines
left and righ scapular lines
verteral lines (c7-t12)
116
2nd rib starts..
mandibriosternal junction (angle of louis)
117
t or f
Each intercostal muscle is numbered by rib above 2
true
118
how do you palpate for chest expansion
w shape on back and front
119
how to palpate for tactile fremitus
moving right to left
- tactile fremitus- interpretation as feeling vibrations
- 99, blue balloon, blue moon
120
what is sequence for lung percussion
down shoulders
| then move to center of back going left to right
121
percussing over bone what sound would you hear
flat
122
percussing lungs would hear what sound
resonance
123
percussing over liver and organs what sound would you get
dullness, visceral dullness
124
sequence for lung auscultation
right to left going down
125
percussing over stomatch what sound
tympany
126
ways to describe percussion sounds
```
sound eg dull/ flat
intesity eg medium/ soft
pitch eg high/ medium
duration eg short/ long
quality eg extremely dull
```
127
what are some normal breathing sounds
vesicular- soft, heard over all lung but major bronchi
bronchovescicular- medium pitch and intesity, heard anterior over primary bronchus
bronchial- loud high pitch, gap between inspiration and expiration, heard over mandibrium
128
what are some adventitious breath sounds
Crackles (rales)- Fine, short, interrupted crackling sounds
gurgles- Continuous, low-pitched, coarse,
gurgling, harsh, louder sounds with a
moaning or snoring quality.
friction rub- Superficial grating or creaking sounds
heard during inspiration and expiration.
wheeze- Continuous, high-pitched, squeaky
musical sounds.
Best heard on expiration.
129
cardiac circuit cycle
```
left atrium
left ventricle
aorta and branches
body
vena cana
right atrium
right ventricle
pulmonary arteries
lungs
pulmonary veins
```
130
Cardiac output
amount of blood ejected from the heart each minute CO+ SV x HR
131
Stroke volume-
amount of blood ejected from the heart with each beat
132
Contractility-
inotropic state of the myocardium, strength of contraction
133
Afterload-
resistance against which the heart must pump to eject blood into the circulation.
134
Heart rate-
number of beats each minute
135
Preload-
left ventricular end diastole volume, stretch of the myocardium
136
is heart fully left
no
137
cardivascular assessment includes what greater vessels
```
Vena cavas and aorta
Pulmonary arteries
Carotid artery
Jugular veins
• Assessed using
Inspection, palpation, auscultation
```
138
what valve between the the left atrium and ventricle
bicuspid/ mitral
139
what valve between the the right atrium and ventricle
tricuspid
140
where is the aortic valve
left ventricle and aorta
141
where is the pulmonary valve
right ventricle and pulmonary artery
142
t or f
base of heart ( broadest part) is actually at the top
t
143
where is apex in heart
apex is lowest narrowest portion above the left mid clavicular line
-apex is narrowest portion above left midclavicular line
144
where is point of maxiumum impact in heart
point of maximum impulse (pms) is apex, point where pulse can be best observed and palpated/ where stephoscope goes
145
t or f
dramatic lifts near sternum mean left ventricle is enlarged or the heart is pumping greater than normal amounts of blood
t
Looking for dramatic lifts near sternum if left ventricle is enlarged or if the heart is pumping greater than normal amounts of blood
-dramatic lifts near midclavicular line indicates equivalent in right ventricle
146
4 sites of heart auscultation
4 valves
- Aortic (upper left ventricle)
Patients circulation
- Pulmonic (upper right ventricle)
Pulmonary circulation
- Tricuspid valve ( right atrium-> right ventricle)
- Apical/ bicuspid (left atrium-> left ventricle)
147
what valves close in s1
mitral, tricuspid
148
what valves close in s 2
aortic, pulmonic
149
systole and diastole in relation to valves
Systole- opening and closing of left ventricle pumping the blood out into the circulation at its highest most powerful pressure
Diastole- rest, valves are closed, chambers sre filling up again
150
heart stages
ventricular filling
1. passive filling
2. atrial contraction
ventricular systole
3. av valves close
4. semi lunar valves open and ventricles eject blood
early diastole
5. isovolumetric relaxation
151
what happens in s1, s2, s3, s4
S1- beginning of systole, ventricles contract and pump blood around with power
S2- start of diastole filling up again and ventricles relax
s3- mitral valves open, passive filling of left ventricle
s4- just before S1 when the atria contract to force blood into the LV (not normally heard)
152
what vessels are in the neck wich are important when assessing jugular pressure
internal jugular vein
external jugular vein
internal and external carotid artery (y shape)
carotid siunus (meeting of y shape)
common carotid artery (breaks into y shape at sinus)
aortic notch- leads to carotid artery
superior vena cava- leads to jugular veins
153
how to assess highest point of jugular distension
30 degree angle
look at highest point of distension from sternal angle
Jugular vein distension can indicate systemic venous congestion
154
obstruction of carotid arteries could..
Obstruction could lead to stroke, lack of o2 in brain
155
Carotid artery
- main supply of oxygenated blood to the brain
156
what to do when assessing carotid arteries des
dont do both at same time
When comparing 2 carotid arteries sides noises could indicate occlusion stenosis on one side or not
Brewes- sype of murmur which could be an indicator of occlusion
157
infant considerations during cardiovascular assessment
The heart sounds may be different in the infant. This can indicate abnormalities (though not always)
It is not unusual for an infant to have cardiac arrhythmias, especially with expiration
158
children considerations during cardiovascular assessment
The apical impulse is located slightly higher and more medial up until about 8 yrs of age
159
older adults considerations during cardiovascular assessment
Many changes even if no disease
Cardiac contraction weaker, cardiac output decreases (lower activity tolerance)
Pacemaker cells decrease in number affected impulse firing
S4 heart sound is detected (normally) in most older adults
Changes in cardiac electrics fires off more systoles
Emotional and physical stresses may cause cardiac arrhythmias
Many older adults experience cardiovascular abnormalities due to lifestyle choices, or genetic influences
160
cardidiovascular assessment you are assessing
Looking and feeling for pulsations
Auscultating for heart sounds
Carotids and jugulars
161
peripheral vascular cycle
```
arteries
arterioles
capillaries
venules
veins
arteries
```
162
difference between arteries and veins
Arteries- thicker and more elastic therefore pressure wave of blood to be pushed through (pulse)
Veins- thinner walls and wider lumen so can carry a greater volume of blood at a slower pace. Have valves / no pressure wave strength and without that push blood wouldn’t flow against gravity, valves and skeletal muscles help with this
…therefore bedridden patients can have clots forming
163
function of peripheral vascular system
To meet the circulatory needs of the tissues
Constantly changing according to metabolic requirements
When supply doesn’t meet demand = ischaemia
164
how does blood meet body demands
```
Blood flow (from high pressure to low pressure)
(from arterial [~100mmHg] venous [~4mmHg])
```
Flow rate = ΔP/R (pressure difference ÷ resistance)
Capillary Fluid exchange
- Hydrostatic (blood pressure)/osmotic pressures (proteins)
Any extra between arterial supply & venous reabsorption
lymph Imbalance = oedema
165
3 main factors of peripheral vascular resistence
Blood viscosity (thickness). The thicker the greater resistance to flow. Contraceptive pill, smoking, various meds can increase viscosity
Length of the vessel. Longer vessel = Increased resistence
Diameter of the vessel. Smaller = greater resistance eg. Capillaries vs arteries
166
Organs of the
| lymphatic system:
```
• Lymph nodes
• Spleen
• Thymus
• Tonsils
- Peyer’s patches.
```
167
what are you assessing in peripheral vascular assessment
Quality is what we are assessing
| Blood supply, swelling and numbness in limbs
168
where can you do bilateral pulse comparisons
* Brachial/radial
* Femoral/popliteal/PT and DP
* Dopplers
not carotid
169
what to assess in arteriole and venous circulation
* Inspecting all limbs for distension when at rest and when raised, and muscle wasting/hairlessness/skin changes/pallor/cyanosis/wouns
* Thrombosed veins may be gently palpated
* Erythema/swelling/warmth/pain especially lower leg
* Palpation of lower leg for firmness/swelling/warmth
* Homan’s test
* Capillary return (refill test)
* Raynards disease- blood supply issue, peripheries cold and capillary refill problem
170
what is the homans sign test
An old fashioned but useful assessment for the presence of a DVT
Dorsiflex foot upwards. Positive if patient feels pain in popliteal or calf region
171
Peripheral arterial disorders clinical manifestations
Intermittent claudication (major symptom- mid exercise increases demand for o2 but lack of supply= cramping pain BUT after rest no pain)
Pulses diminished or absent
Oedema – None/minimal
Skin changes: Trophic – cold/dry/shiny/hairless/thick opaque toe nails
Pallor when elevated
Red when dangling (dependent rubor)
Ulcers – tips of extremities/ painful/deep/circular/pale to black base or dry gangrene
172
Peripheral venous disorders clinical manifestations
Pain: aching to cramp like, relieved by activity/elevation
Pulses usually present
Oedema – present/increases at the end of day
Skin changes: warm/thick/ tough/darkened/? dermatitis
Ulcers – medial malleolus/ pain variable/ superficial/irregular border/granulation base
173
causes of odema
Congestive heart failure/kidney disease/liver disease
| Blood Clots and Tumors
174
how to assess odema in peripheral vasc assessmet
Gentle palpitation throughout the limbs especially the lower leg
Grading (2,4,6,8 mm)
175
types of odema
Dependent (gravity influenced, ambulant or sitting = legs , resting= sacrum)
Pitting (ability to leave a dip)
176
effects of odema
```
Poor blood circulation
Increased local pressure
Loss of vessel elasticity
Painful swelling
Problems with constricting clothes/shoes
Difficulty in walking
```
177
diagnostic stests that may be used in peripheral vascular assessment
Blood test (D-Dimer)
Dopplers
Venogram/phlebogram/ultrasonography
Ankle brachial index
178
infant considerations in peripheral vascular assessment
Changes in peripheral vascularity (bruises/petechiae/oedema) may indicate serious systemic disease (leukemia/meningococcal disease/lymphoma)
179
children considerations in periheral vascular assessment
Changes in peripheral vascularity (bruises/petechiae/oedema) may indicate serious systemic disease (leukemia/meningococcal disease/lymphoma)
180
older adults considerations in peripheral vascular assessment
Many changes even if no disease:-
Arterial and venous supply deterioration
Changes in symmetry of assessment results could be significant
Varicose veins common
181
before breast assessment what should you ask in the Health assessment interview
Assess past or present occurrence of related symptoms
Breast surgery, augmentation, disorders
Pain, lump, discharge, rash, trauma
Explanation/consent/privacy/developmental and cultural considerations/family history/medications/ self-examination history/time of cycle
182
what area do you inspect and palpate during breast assessment
The glandular tissue
(throughout breast in female/around nipple in male)
Particularly upper outer quadrant and tail of Spence Which extends into the axillae
183
what should you inspect for during breast assessment
◦ Dimpling/retraction/colour changes/swelling
◦ Breast tissue/areola/nipple
◦ Comparing breasts (remember no 2 breasts are identical)
184
3 methods of emphasizing retracted breast tissue to assess further
raising arms above head
2. Pushing the hands together above head or in front of you
3. Pressing the hands into the hips
185
how to palpate during breast examination
middle three fingers palmar surface in rotary motion
186
what are you palpating for during breast examination
◦ Lymph nodes
◦ Four quadrants of the breast
- masses/tenderness/discharge
187
how often should you breast examine yourself
at least once a month
188
3 ways you can breast examine
1. in shower- left hand behind head, move breast in circular motion
2. mirror- visual inspect with arms at side,
3. lying down- pillow under shoulde, arm behind head
189
breast examination infant lifespan considerations
Newborns often have breast engorgement and nipple discharge
| Superfluous nipples maybe associated with renal conditions
190
breast examination children lifespan considerations
Female breast development ~ 9 – 13 years
| Male minor gynocaemastia during adolescence
191
breast examination pregnant women lifespan considerations
Breast, nipple and areola enlargement occurs
Formation of Montgomery’s glands may occur on areola
Colostrum maybe expressed from first trimester on
192
breast examination older adults lifespan considerations
Older adults:- Many changes even if no disease
Post-menopausal changes
Breasts loose firmness and shape
Lump and lesion detection easier
193
how many quadrants and regions during abdominal assessment
Anatomical subdivision:-
Quadrants (4)
Or
Regions (9)
194
what are the 4 quadrants of the abdomen
right upper
right lower
left upper
left lower
195
organs of RUQ
```
liver
gallbladder
duodenum
head of pancreas
right adrenal g;and
upper lobe of right kidney
```
196
ORGANS OF RLQ
```
lower lobe of right kidney
caecum
appendix
section of ascending colon
right ovary
right fallopian tube
```
197
organs of LUQ
```
left lobe of liver
stomatch
spleen
upper lobe of left kidney
pancreas
left adrenal gland
```
198
organs of LLQ
```
lower lobe of left kidney
sigmoid colon
section of decending colon
left ovary
left fallopian tube
left ureter
```
199
WHAT are the 9 regions of the abdomen
The nine abdominal regions: epigastric; left and
right hypochondriac; umbilical; left and right lumbar; suprapubic
or hypogastric; left and right inguinal or iliac.
200
organs of the right hypochondriac region of abdomen
```
Right lobe of liver
Gall bladder
Part of duodenum
Hepatic flexure of colon
Upper half of right kidney
Suprarenal gland
```
201
organs of the right lumbar region of abdomen
Ascending colon
Lower half of right kidney
Part of duodenum and
jejunum
202
organs of the right inguinal region of abdomen
```
Caecum
Appendix
Lower end of ileum
Right ureter
Right spermatic cord
Right ovary
```
203
organs of the epigastric region of abdomen
```
Aorta
Pyloric end of stomach
Part of duodenum
Pancreas
Part of liver
```
204
organs of the umbilical region of abdomen
Omentum
Mesentery
Lower part of duodenum
Part of jejunum and ileum
205
organs of the hypogastric region of abdomen
Ileum
Bladder
Uterus
206
organs of the left hypochondriac region of abdomen
```
Stomach
Spleen
Tail of pancreas
Splenic flexure of colon
Upper half of left kidney
Suprarenal gland
```
207
organs of the left lumbar region of abdomen
Descending colon
Lower half of left kidney
Part of jejunum and ileum
208
organs of the left inguinal region of abdomen
Sigmoid colon
Left ureter
Left spermatic cord
Left ovary
209
what are some landmarks commonly used to identiy abdominal areas
xiphoid process
costal margins
anterior superior illiac spines
umbilicus
inguinal ligaments
superior margin of pubic bone
210
what order do you assess the abdomen (using the 4 techniques)
Inspection, auscultation, (percussion) and palpation (last)
| Different order to normal as palpation and percussion stir up the bowl sound = non accurate results
211
what do you inspect during abdomenal assessment
Integrity, colour, contour and symmetry
| Aortic pulsations
212
what do you auscultate during abdominal assessment
Bowel sounds (hypoactive, hyperactive or normal. Often depend on what last meal was. 4 quadrants) , vascular sounds (main arteries), friction rubs (peritonitis/ inflammation of peritonium)
213
what do you percuss during abdominal assessment
Size and shape of organs
Abdominal aorta!! Not percussing or palpating
Bladder (urine retention) empty by assessment
Kidney ‘punch’- for assessing kidney stones, inflammation etc
214
how to palpate during abdominal assessment
Light then deeper (if no pain, guarding- pt tensing up if organs in pain)
All four quadrants
Abdominal aorta! avoid!
Re-bound tenderness- push in, take hand of quickly
Medical staff usually do this
215
what is a hernia
“protrusion of intestine through the inguinal wall or (up the inguinal) canal” (Slater, 2015, p. 709)
Bit narrow a definition – protrusion of an organ through an abnormal opening in a muscular surrounding wall
inguinal, epigastric, hiatal, femoral, umbilical (newborns and obese people), incisional + surgical (following abdominal surgery with scar)
Intestines/ hernia can become strangled and cause sepsis
216
what can cause hernias
```
Very common
Caused by a muscle weakness - tear
Congenital defect
Lifting heavy objects
Excessive coughing
Injury or surgery
Chronic constipation
```
217
symptoms of hernias
Bulge/pain/’heaviness’ (not hiatal)
Larger when coughing/standing/straining
Reducible or non-reducible
strangulated
218
hernia treatment
Inguinal/femoral/umbilical/incisional
Hiatal
Open or laparoscopic
Medications and surgery
Complex with high death rate
219
what is an anyurysm
Swelling in/of the wall of an artery
220
location of anyurysm
anywhere (commonly abdominal)
221
causes of anyurysm
ongenital/injury/hypertension/smoking/idiopathic
222
clinical manifestations of anyursm
Back pain/pressure in bowel/bruit (can indicate partial occlusion)/palpable
In 80% of cases, other 20% can be symptomless
223
diagnostic tests that may be done in abdominal assessment
* Oesophageal acidity, oesophageal manometry, acid perfusion
* Barium swallow or upper GI series
* Barium enema
* Colonoscopy
* Upper GI endoscopy
* Magnetic resonance imaging (MRI)
* Gastric analysis
* Gastric emptying studies
* Abdominal ultrasound, various USs
* Cholecystography/cholangiography
* MRCP/ERCP/CT
* Serum lipase/serum amylase
* Liver biopsy
224
what to take note of in faecal assessment
* Inspect the person’s faeces
* Test the faeces for occult blood
* Note the odour of the faeces
225
abdominal assessment infant considerations
```
Abdominal organs (liver) proportionally larger (protrudent)
Umbilical hernia
```
226
abdominal assessment children considerations
‘Pot belly’ until about four yrs
Develop flatter abdomen about school age
Watch facial expression when palpating to detect pain
Use distraction ‘therapy’ when examining
227
abdominal assessment pregnant women considerations
‘morning sickness’
Increased GORD (acid reflux)
Increased constipation
Organs displaced as uterus enlarges
228
abdominal assessment older adults considerations
Many changes even if no disease
Loss of muscle tone and development of more adipose tissue – obesity
Palpation more accurate due to thinner abdominal wall
Increase in pain thresholds
Differentiating GI tract pain from cardiac pain
229
considerations before genitalia assessment
General external assessment or specialised assessment
| Chaperone/privacy/cultural awareness
230
what are you looking for in female genetalia assessment
Inspection of external genitalia including pubic hair
Inflammation, discharge, discolouration, lesions
Palpation of inguinal lymph nodes
Any hard lumps, especially if unilateral
231
what are you looking for in male genetalia assessment
Inspection of external genitalia including pubic hair
Testicles!
Inflammation, discharge, discolouration, lesions
Palpation of inguinal lymph nodes
Any hard lumps, especially if unilateral
Examination of the prostate (with anal, rectal examination)
232
infant lifespan consideration genetalia assessment
Female – newborns evidence of hormonal influences from the mother
Male – foreskin not retractable until 2 – 3 yrs of age
Male – midwife/medical officer usually palpates for descension of testes
Male – can be born with inguinal hernia
233
children lifespan consideration genetalia assessment
Female and male - Privacy awareness!
Female - Pap smears/breast self-examination /safe sex
Female circumcision (illegal in Australia)
Female and male - pubertal/hormonal development
Male – testes retraction (Cremasteric reflex)
234
older adults lifespan consideration genetalia assessment
Many changes even if no disease
Female - atrophies with age/hormonal changes/vaginal flora and lubrication changes
Female – vaginal bleeding abnormal (unless on HRT)/uterine prolapses/urinary incont
Male – penis and testes shrinks with age,
Male – difficulty achieving erection and less amount of ejaculate
Male – urinary frequency, dribbling, nocturia maybe prostate related
235
how to percuss and palpate bladder
Skill supplanted by bladder scanner(?)
Moderately distended bladder
Between symphysis pubis and umbilicus
Light to moderately palpable as a firm round mass
Percussed as dull sound
Should be empty (tympanic)
Consider results with all other information
236
3 types of muscle
Skeletal muscle, smooth muscle and cardiac muscle
237
functional properties of skeletal muscle
Contractibility
Extensibility
Elasticity.
238
what are joints
Joints are formed where two or more bones meet.
```
Joints hold the skeleton together while allowing movement. There are three types of joints:
Fibrous joints
Cartilaginous joints
Synovial joints
Ball and socket, hinge…
```
239
what are tendons
Tendons are fibrous connective tissue bands that connect muscles to the bones
240
what are ligaments
Ligaments are fibrous connective
tissue bands that connect bone
to bone
241
muscoskeletal assessment includes
Assessment of dependence/independence
The Barthel Index
Assessment of mobility
Physical mobility scale
Assessment of falls risk (K & E pp. 648-649)
Various tools, as per NUR112
242
does muscoskeletal assessment commence on entry
```
yes
Commences on ‘welcome’
Ambulating into room
Getting seated
Posture
Lying on couch
```
Remember the purpose of a full assessment is usually to evaluate capability to conduct own ADLs/care for self
243
what techniques used in muscoskeletal assessment
Inspect, palpate, direct auscultation
244
what to inspect during muscoskeletal assessment
muscles- bilateral symmetry, contractures, tremors
bones- symmetry, deformities
joints- swellimh, tenderness, creitation,
245
what to palpate during muscoskeletal assessment
muscles- muscle tonicity, flaccidity and spasticity, muscle strength (grade 0-5)
bones- tenderness, odema
joints- Swelling, tenderness, crepitation
246
what different movements can be assessed during muscoskeletal assessment
flexion/ extension
abduction/ adduction
pronation/ supination
circumduction
rotation
eversion/ inversion
protraction/ retraction
elevation/ depression
247
when assessing range of movement during muscoskeletal assessment what can you note
Limited by contractures?
Full (variable according to genetics)
Restricted (injury or disease), pain
248
Problem focused ankle and foot assessment example
Inspect while person sitting, standing and walking
Compare both feet
note contour of joints
foot should align with long axis of lower leg
Weight-bearing should fall on middle of foot
most feet have longitudinal arch (? “flat feet” to high instep)
Toes point straight forward and lie flat
note locations of calluses or bursal reactions (areas of abnormal friction)
Examine well-worn shoes to assess areas of wear and accommodation
Problem focused ankle and foot assessment (cont.)
Support ankle by grasping heel with your fingers while palpating joint spaces with your thumbs
should feel smooth, with no swelling or tenderness
Assess ROM
Assess muscle strength by asking person to maintain dorsiflexion and plantar flexion against resistance
249
lifespan considerations for infants during muscoskeletal assessment
birth assessment of clavicle
return to flexed fetal position (assessing tonicity)
standing test of muscle strength
hip dysplasia
meeting milestones
250
lifespan considerations for children during muscoskeletal assessment
different mobilisation variations normal for this group
observe playing children motor function, coordination, balance
spine development scoliosis
growth and development and nuutritional intake
251
lifespan considerations for older adults during muscoskeletal assessment
loss of muscle mass with aging, maintaining exersise is important
decrease in strength, reaction time, coordination
development of osteoporosis and arthritis
joint replacements, related surgeries
252
Diagnostic Tests For The Musculoskeletal System
```
Blood chemistry
X-ray
Computerised Axial Tomography (CT) or (Cat) scan
Magnetic resonance imaging (MRI)
Bone scan
Bone density
Arthroscopy and arthrocentesis
Electromyogram and somatosensory evoked potential (SSEP).
```
253
what is the barthel index in muscoskeletal assessment
he Barthel Scale/Index (BI) is an ordinal scale used to measure performance in activities of daily living (ADL
254
what are you assessing for in neurovascular assessment
Neurological function (motor and sensory function)
Peripheral circulation (colour, temperature, cap. refill, pulses)
255
what sorts of people would you be monitoring neurovascular assessments on
```
Fractures, crushing or other musculoskeletal injuries
Orthopaedic or vascular surgery
Application of casts/POPs
Circumferential dressings
Tourniquets(?)
Thromboembolic disorders and infections
Poisonings (snakebite)
Excessive activity
```
256
what is compartment syndrome
Mainly in limbs
Excess bleeding/fluid collection (oedema) within a compartment
Excess bleeding/fluid collection (oedema) restricted by external compression
Leading to increased pressure in compartment
Restricting blood flow
Leading to muscle and nerve ischaemia (death)
257
what are the 5 p's in neurovascular assessment
Pain (early sign and out of proportion with injury/? masked by analgesia)
Pallor
Pulselessness (late and very serious)
Paraesthesia (numbness, tingling, ‘pins and needles’)
Paralysis (late and very serious)
Or is it 7 P’s
Poikilothermia (taking on Tº of surroundings, cold)
Pressure (rigid, tense, shiny)
258
should you just check one limb in neurovascular assessment
no
All assessments must involve the comparison of the affected limb with the affected limb (if possible)
Casts can impair assessment
```
Always compare to the baseline
However baseline (post injury) may not be ‘good’
```
259
how often are neurovascular assessments done
Depends on situation
Usually hourly for first 24 hrs post injury/application of cast
4 hrly for next 48 hrs
Maybe more frequent
260
treatment of compartment syndrome
Fasciotomy
261
sensoryt process involves 2 processes
reception and perception
262
what is reception vs perception
• External (visual/ auditor/ olfactory/ gustatory/ tactile)
• Internal (gustatory/ kinesthetic ‘awareness of precision and movement of body and parts’/ visceral ‘organs of the body’)
PERCEPTION IS THE PROCESSING OF THIS SENSORY DATA
263
4 components of sensory processing
* Stimulus
* Receptor
* Impulse conduction
* Perception
‘’the conscious organization and translation of this data, or the stimulus (from sensory organ)
264
what can affect the eyes
alot
eg
• Diabetes, hypotension, sun exposure can affect vision
265
eye assessment involves
```
…inspection of external structures
…visual acuity (detail eye can see)
…visual fields (field of view)
…light perception
…assessing pupil reaction (using pen light)
```
266
some different eye conditions
- Myopia (near sighted)
- Hyperopia (far sighted)
- Presbyopia (loss of ability to see close objects)
- Conjunctivitis (inflammation often due to infection)
- Cataracts (caused by opacity of lens or its capsule, requires surgery)
- Glaucoma (increase in intraocular pressure- caused by blockage of outflow of fluid in eye)
267
the eye lifespan considerations - infants
Gaze and follow objects at 4 weeks of age
Focus with both eyes at 6 months
Cannot form tears till 3 months of age
268
the eye lifespan considerations - children
Visual acuity should be 20/20 by 6 years of age
Colour vision tests not compulsory but are indicated if quieried by parents/ teachers
Trachoma common in low socioeconomic areas (common bacterial eye disease)
269
the eye lifespan considerations - older adults
Acuity and field of vision decreases with age
Loss of orbital fat and muscular structure changes
Exophthalmos
Development of cataracts
270
parts of ear
- Outer (catches directs sound), inner and middle ear (smallest bones in body, transmits sound vibration into inner ear, connected with nasopharynx)
271
2 pathways of hearing
- Air conduction- normally hear this way
- Bone conduction
- Can have conductive hearing loss caused by mechanical dysfunction of outer and middle ear, can be blocked with ear wax etc. but if sound is loud enough can still get through to inner ear possibly aided by bone conduction
- Sensory neural hearing loss signifies pathology of inner ear or the branches of the auditory
272
what part of ear provides equilibrium balance
inner ear
273
ear and hearing assessment involves
…inspection and palpitation of external structures
- Otoscope (visualize through to tempanic membrane)
- Audiometry
274
causes of hearing loss
…air conduction (blockage, interruption to sound waves)
…sensorineural (auditory nerve/ auditory centre in brain)
…age related
275
- Noise induced or arthritic changes to middle ear can be related to...
- Noise induced or arthritic changes to middle ear can be related to ototoxic drugs
- Ototoxic drugs- medications that damage hearing eg. Iv antibiotic
276
colour of tympanic membrane
pearly white
277
lifespan considerations ear- infants
should be formally assessed before leaving hospital
gross assessment by ringing a bell/ parent calling name- infant quietens and may open eyes wider
milestone assessment is by 3-4 months child turns head towards the sound
278
lifespan considerations ear- children
hearing loss in this age group increasing
279
lifespan considerations ear- older adults
hearing changes with age (often requires hearing aids)
| physiological changes occur (skin/ hair/ cartilage/ membranous)
280
what should you assess when assessing nose
External nose
- Inspection
- Palpation
- Injuries/ fracture
Determine patency
- Deviated septum/ fracture/ congestion
Inspect nasal passages
- Pen torch or speculum and otoscope with attachment
- Frequent epistaxis/ septal defects
Olfactory assessment
Sinus assessment
- Palpation and direct percussion in adults
281
outer nasal structures
columella, septum, nares, ala, bridge, tip
282
t or f
there are chronic nasal and sinus disorders
true
283
nose lifespan considerations - infants
Nasal cavity usually visualized using a pen torch
| The sinuses are formed at birth
284
nose lifespan considerations - children
Sinuses develop at different rates until about 12 years of age
Sinus infections and pain uncommon before this age, more common in adolescents
The nasal cavity usually visualized using a pen torch
285
nose lifespan considerations - older adults
sense of smell diminishes with older age
discrimination of odours reduces with older age
otoscope may be required for a more complete visualization of the nasal cavity
286
t or false the eyes help our head stay on our head
false
| size of sinus hollows allows head to stay on our shoulders
287
what does the tongue do
- An important part of swallowing, loss of coordination can cause dysphagia
- Detects taste- 4 original tastes bitter, sour, salty, sweet, umami, olinguitos
- An indicator of hydration
288
what does tongue colour indicate
- white/ trush, strawberry tongue/ scarlet fever, odour (halitosis
289
different levels of sensory perception
overload and deprivation
290
Sensory function Essential for:
…connection with the environment
| …function within the environment
291
Sensory dysfunction Can occur in any of what 4 compnents:
…stimulus
…receptor
… impulse conduction
… perception
292
different states of awareness
Full Conscious- alert, orientated to time, place, person
Disorientated- not orientated o time, place, persom
Confused- reduced awareness, easily bewildered; poor memory, misinterprets stimuli
Somnolent- extreme drowsiness but will still respond to stimuli
Semi comatose- can be aroused by extreme or repeatrd stimuli
Coma- state of deep unarousable unconscious
293
Factors affecting sensory perception
- Developmental stage
- Culture
- Stress
- Illness
- Medications
- Lifestyle
Adjust care accordingly providing patient centred care
294
at risk of sensory deprivation if
- Are confined in a non stimulating or monotonous environment in the home or healthcare facility
- Have impaired vision or hearing
- Have mobility restrictions such as quadriplegia or paraplegia, are confined to bedrest, and have splinting or traction restrictions
- Are unable to process stimuli eg brain damage
- Have emotional disorders eg. Depression
- Have limited social contact
295
prevent sensory deprivation by..
Encourage person to use glasses or hearing aids
Address person by name or use of touch while speaking if not culturally offensive
Communicate frequently with person and maintain meaningful interactions
Provide phone, radio and or TV, clock, calander
296
at risk of sensory overload if
- Have pain or discomfort
- Are acutely ill an d have been admitted to hospital
- Are being closely monitored in ICU and have invasive tubes
- Have decreaded cognitive ability eg. Head injury
297
prevent sensory overload by
- Minimise unecessay light, noise, distraction
- Control pain indicated at level desired by the person on a scale of 0-10
- Introduce sef by name and address peron by name
- Provide orientating cues such as clocks, calanders, equipment and furniture in room
- Provide private room
- Limit visitors
- Plan care to allow for uninterrupted periods for rest or sleep
298
what is a primary survey
* A systematic assessment tool that is predominantly used in Emergency Departments (ED)
* Used to identify and manage life-threatening illnesses/conditions/injuries
* Useful as most patients in ED are undiagnosed
299
different survey types
* Primary survey secondary survey focused assessment
* Subjective history
300
steps of primary survey
danger
response
send for help
A – Airway . snoring, gurgling, stridor sign of obstruction
B – Breathing. Look listen feel
C – Circulationrate, strength, rhrth. If none cpr
D – Disability (eg neurological assessment)-glasgow oma ang bgl
E – Exposure- section by section, front and back
301
is primary survey a dynamic process yes
• It is a dynamic process, you are constantly checking and re-checking
but
• Each component
must be fixed before moving onto the next
302
basic life support steps
```
danger
response
send for help
open airway
normal breathing
start cpr
attatch defrib
```
303
primary survey examp,e of what might do at wach stage
A – Airway
B – Breathing Respirations, Oxygen Saturations
C – Circulation
Pulse, Blood pressure, Skin Colour, ? Temperature, signs of hemorrage
D – Disability GCS, ? Temperature, BGL, palpating for injuries
E – Exposure Head to Toe, ? Temperature
304
what to do if abnormal vital signs
* Is your recording accurate?
* Is your technique precise?
* Consider the individual patient (what is normal for them)?
* Consider outside factors
* Can you validate the result?
Reporting abnormal results is a key nursing responsibility
Know your normal values!!!
Report anything outside those values BUT consider results in light of all information (what is “normal” for this patient/previous results/trends/history)
“Inform Shift Coordinator/Medical Officer of any deviation in patient parameters or changes in vital sign trends or acute changes in behaviour further escalation” (RPH, 2016, p. 05)
305
information about the adult observation and response chart
- Legal form
- Obs and response chart designed to ensure appropriate recognition and response to change in condition
- Frequency changes
- Graphical record of pts vital signs’
- Trends in obs
- Forces you to escalate all chages out of normal values
- Is the abnormal normal for the patient? Have a ‘modification’ completed
306
why is being aware of trends when taking vital signs important
Alert you early to deterioration so interventions can be introduced before situation becomes critical
Worth reporting to nurse coordinator
307
what are the stages of the clinical reasoning cycle
1. consider patients situation
2. collect cues/ info
3. process information
4. identify problems/ issues
5. establish goals
6. take action
7. evaluate outcomes
8. reflect on process and new learning
308
what is grief
• Grief is the reaction (in thoughts, feelings and behaviours) to the experience of loss- perceived or actual:
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loss may involve..
* Loss may involve physical death ( our focus) or loss of body parts, relationships, role change, valued objects, security, football grand finals…
* Can be ‘perceived’ loss or áctual’loss
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t or f
individual response to grief is predictable
false
| it is inevitable but response is unpredictable
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does greif always involve mourning
no
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examples of different responses to within grieving process
Reaching out, internalising, find distractions
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• Kubler-Ross’ Five Stages of Grieving
Denial
Anger
Bargaining may involve person becoming spiritual,
Depression – therapeutic touch accompanied by silence may or may not help
Acceptance- supporting and encouraging involvement in decision making process
No natural flow in the order
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femal response to grief vs male
Women
• more likely to express their feelings earlier
• have and reach out for social support
• are seen to publicly express more sorrow, depression, and guilt
• more willing to talk about the loss of a child
Men
• more likely to try to manage the situation
• intellectualise their emotions, rather than express them
• though when they do they may indicate feelings of anger, fear, insecurity and a lack of control
• reside in first stage ‘denial’ more
• more likely to grieve in private
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responses to death by age 2-4
```
Ages 2-4
• Concept of Death
Seen as reversible or temporary
Does not understand reality of
• Grief Response
Intensive response but brief
Very present oriented
Notices changes in patterns of care
Frequent and repeated questions
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responses to death by age 4-7
Ages 4-7
• Concept of Death
May still see as reversible or temporary
Or more mature may understand finality
Can feel responsible for the death (wishes and thoughts)
• Grief Response
More verbalisation
Wants to know the ‘ins and outs’ (How? Why?)
May also act as though nothing has happened
Or general distress and confusion
(at this age, possibly even with similar development,
response can be variable)
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responses to death by age 7-13
• Concept of Death
Beginning to see it as final (though still wants it reversible)
May see it as punishment for perceived sins
May also express interest in after-life
• Grief Response
Asks specific questions, wanting full detail
Can be difficult knowing how to respond in some situations
Starting to have ability to mourn and understand mourning
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responses to death by age teens
• Concept of Death
Able to abstract
May believe it can be defied/avoided
May view in religious or philosophical terms
```
• Grief Response
Extreme sadness, maybe withdrawal
Can exhibit extended denial
Regression in age behaviours
More often willing to talk to people outside of family
Peer support may be important
May involve risk-taking behaviours
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what to do if child is greiving
What to do
• Find a way to symbolise the loss (a ceremony?)
• Difficult if they don’t understand ‘abstract’
• Express sorrow for the loss
• Sit next to ‘be there for’ a child that wants closeness
What not to do
• Try to shelter children from the reality of death
• Give false or confusing messages
• Tell a child to stop crying
• Try to cheer the person up
• Offer advice or quick solutions
• Pry or ask about the circumstances
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how to act when someone is grieving
• Supporting the Grieving Person
Understand the therapeutic relationship
Avoid judgment/respect privacy/respect wishes
Maintain open communication
Explore and respect their beliefs and values
Encourage expression of grief
Stay informed of resources (Australian Centre for Grief and Support)/various chaplains /professional
Acknowledge/presence/listening/silence(?)
Be there …
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when to initiate a conversation about dying
In the appropriate situation
After building rapport
• Especially in aged care facilities/home care situations
• Poor deaths often linked to a lack of planning and communication
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changes in a dying person
* Pain
* Dyspnoea
* Nausea, anorexia and dehydration
* Altered levels of consciousness
* Hypotension
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examples of ways to provide comfort to a dying person
- clean skin and linen
- slide sheet to turn and keep comfortable
- inconstinence pads or catheter if ordered
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care following death
* The nurse documents the time and particulars of death, notifies the medical officer and supports the family.
* If the person dies in hospital or aged care, it is important to acknowledge the death with others who may have seen the patient die.
* Nurses may also experience grief when they have cared for the person.
* “Last offices” often by the nurse/sometimes with family
* Depending on cultural, personal, Coroner’s requirements
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somethings that take place in last officies
IVs/drains removed
Wounds covered with simple dressings
Bodily orifices sometimes packed with cotton wool/gauze ribbon to prevent leakage of fluids
Teeth/dentures are cleaned and replaced
Hair is groomed, fingernails are cleaned
Men are shaved
Eyes are closed
Lower jaw supported with a bandage
Limbs are positioned, tied in place
Identification tags are attached
The body placed in a shroud then a body bag and delivered to the mortuary
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why provide spiritual care?
• Is part of holistic nursing
• Meeting people (often) at the point of deepest need (? Dying)
not just ‘doing to’ but ‘being with’ them.
• It is about treating spiritual needs with the same level of attention as physical needs.
• We are a facilitator of patient’s spiritual needs
Not an ignorer
Not a convertor
Not a false hoper
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how to initiate conversation about spirituality
* Do you have a source of support or help that you look to when life is difficult?
* Would you like to talk to someone about this (offer choice)?
* Would you like to talk about this with me?
* This must be a very difficult time for you …, do you have anything in particular that supports you through this?
* Would you like me to sit with you for a while?
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what is acute confusion
“an acute organic mental disorder characterised by confusion, restlessness, incoherence, inattention, anxiety or hallucinations which may be reversible with treatment”
delirium
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distinguishing feature of dementia vs delirium
delirium- acutr, fluctuating change in mental status
dementia- memory impairment
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onset of dementia vs delirium
delirium- sudden, acutr
dementia- slow, insidious
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duration dementia vs delirium
delirium- temporary
dementia- chronic, gradual irreverasble
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time of day dementia vs delirium
delirium- worse at night
dementia- no change
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sleep wake cycles dementia vs delirium
delirium- disturbed, cles often reversed
dementia- distirbed, fragmented, often awakens during night
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alertness dementia vs delirium
delirium- fluctuates. may be alert and oriented at day but disorientated at night
dementia- generally normal
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thinking in dementia vs delirium
delirium- Disorganised, distorted. Impaired attention.
Alterations in memory.
dementia- Judgment impaired. Difficulty with abstraction
and word finding.
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delusions/ hallucinations dementia vs delirium
delirium- May have visual, auditory and tactile hallucinations.
Misinterpretation of real sensory experiences.
dementia- Delusions. Usually no hallucinations
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causative and risk factors dementia vs delirium
delirium- Cerebral and cardiovascular disease, infections,
reduced hearing and vision, environmental change,
stress, sleep deprivation, polypharmacy, dehydration.
dementia- Alzheimer’s disease. Multiple infarct dementia.
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3 c's (signs and symptoms of delirium)
Impaired concentration
Altered cognition
Fluctuating consciousness
also... Alternating agitation and calmness, hallucination’s, repetitive behaviors
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pathophysiology of delirium
Pathophysiology not clear.
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some possible causes of delirium
Dementia/other neurological impairment (stroke)
Sensory changes (visual/hearing)
Changes in environment
Some medications (sedatives/narcotics)
Illnesses (pneumonia, UTI, other infection)
Injuries (# NOF [hip])
Untreated pain
Any causes of metabolite/electrolyte imbalances/fluid imbalance (dehydration)
Substance abuse/withdrawal
Depression
Hypoxia/hypercapnia
Constipation/sleep deprivation/stress …
Younger adults can compensate for these physical and chemical challenges, older adults may not be able to.
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adverse outrcomes of delirium
```
Increased falls
Pressure sores
Increased length of stay in hospital (doubles?!)
Increase in dependence
In hospital and possibly at home
Increase in … death (25 - 35%)
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how to tell if a patient is demented or delirious
```
Recognise high risk patients
Know past history
Be alert to subtle changes
Recognise signs and symptoms
Assess cognition (on admission and regularly)
Communicate with family (history)
Remember, it is reversible
Use critical thinking …
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hhow to promote a therapeutic environment for a person with acute confusion/ delirium
Wear a readable ID badge.
■ Address the person by name and introduce yourself
frequently:
‘Good morning, Mr Richards. I am Sue Smith.
I will be your nurse today.’
■ Identify time and place as indicated: ‘Today is 5 December
and it is 8 o’clock in the morning.’
■ Ask the person ‘Where are you?’ and orientate them to place
(e.g. hospital ward) if indicated.
■ Place a calendar and clock in the person’s room. Mark
holidays
with ribbons, pins or other means.
■ Speak clearly and calmly, allowing time for your words to be
processed and for the person to give a response.
■ Encourage family to visit frequently, except if this activity
causes the person to become hyperactive.
■ Provide clear, concise explanations of each treatment procedure
or task.
■ Eliminate unnecessary noise.
■ Reinforce reality by interpreting unfamiliar sounds,
sights and smells; correct any misconceptions of events
or situations.
■ Schedule activities (e.g. meals, bath, activity and rest periods,
treatments) at the same time each day to provide a sense of
security. If possible, assign the same caregivers.
■ Provide adequate sleep.
■ Keep eye glasses and hearing aid within reach.
■ Ensure adequate pain management.
■ Keep familiar items in the person’s environment (e.g. photographs)
and keep the environment uncluttered. A disorganised,
cluttered environment increases confusion.
■ Keep room well lit during waking hours.
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what is chronic confusion
dementia. A collection of signs and symptoms that are caused by a number of disorders of the brain
A combination of cognitive, personality and physical changes associated with neuron death and miscommunication of those neurons
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conditions that can mimic dementia
Age-related cognitive decline
Mild cognitive impairment (is actually an intermediate stage between age related cognitive decline and actual dementia, pre dementia- problem with memory, language speech and judgement at a greater than age related changes)
Depression
Delirium
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what is alzheimers disease
A form of dementia characterised by progressive, irreversible deterioration of cognitive functioning
Life expectancy of ~ 8–10 years following diagnosis
Gradual loss of function shifts burden onto caregiver
Eventual death often by aspiration pneumonia
Risk factors – age/family history/female
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warning signs of alzheimers
* Memory loss that affects job skills
* Difficulty performing familiar tasks
* Problems with language
* Disorientation to time and place
* Poor/decreased judgment.
* Problems with abstract thinking
* Misplacing things
* Changes in mood or behaviour
* Changes in personality
* Loss of initiative.
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stages of alzheimers
1. short term memory loss (2-4y)
2. impaired cognition, personality changes (2-12 y)
3. cognitive abilities grossly decreased or absent (2-4y)
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Alzheimer’s Disease
| Interprofessional Care
• There is no cure (but it is treatable)
• Some medications may assist in slowing disease progression
• Treat associated depression
Regularly present
• Alternative and complementary therapies (K & E)
Very limited research on herbs
Art, music, Snoezelen rooms
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alzheimer nursing care for impaired memory
• Complementary therapies
May help reduce stress which can affect memory
• Use of calendars/diaries/white-board for reminders
• Webster packs for medications as reminder and for safety
• Emergency contact details for safety
• Alarm (on watch) to cue reminders
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alzheimer nursing care for chronic confusion
• Label items (visual cues)
• Remove potential hazards (ensure safety)
• Minimise environmental stimuli
Calm and relaxed, decrease sensory overload and therefore anxiety
• Communication techniques require adaptation and flexibility
• Reality orientation (orientate to place/time/person – regularly?)
• Provide boundaries (red/yellow tape on floor)
Increases safety
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alzheimer nursing care for anxiety
• Assess for fatigue and agitation (causes)
Remove from situations that cause anxiety
• Consistent daily routine (decreases stress)
• Schedule rest periods/quiet activities
Fatigue increases anxiety
• Assess for physical causes of agitation
• Use therapeutic touch or gentle hand massage
Unless it increases anxiety
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alzheimer nursing care for adapting and enabling communication
```
Remove distractions
• Stop and listen, face to face
Call by their name, use yours
• Use a calming, low voice, relaxed manner
Closed-ended questions, one at a time
• Simple short sentences
Stopping talking! (Listening!!)
Importance of body language
Mirroring
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```
Be specific
Be adaptive to patient’s mood
Assess response regularly
Be aware of cues
Wandering may mean the need to toilet
Reminiscence
Validation therapy
A collection of communication techniques
Cultural safety
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alzheimer nursing care for hopelessnes
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• Educate (as and where appropriate)
• Assess coping
• Avoid judgment or criticism
• Support positive family bonds and enhance communication
Share the ‘burden’
• Encourage decision-making
Self-control build self-efficacy
• Encourage spiritual guidance (when appropriate)
```
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alzheimer nursing care for caregiver rolestrain
• Physical care, psycho-social, financial challenges
• Grief
• Teach self-care techniques
Prevent care fatigue ‘burn-out’
• Refer to support groups and additional resources
Meals-on-wheels
Counselling
Hospice
Respite care (essential)
Alzheimer’s Australia (numerous ‘help sheets’)
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WHAT IS GCS
Based on motor responsiveness, verbal performance, and eye opening to appropriate
stimuli, the Glascow Coma Scale was designed and should be used to assess the depth
and duration coma and impaired consciousness
