Term
| assessment of circulatory status |
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Definition
| changes with aging are very important if the elderly client becomes challenged by stressors such as stress, fever, surgery, and even exercise |
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Term
| risk factors to circulatory system |
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Definition
- non-modifiable
- hereditary
- age
- gender
- race
- modifiable
- cigarette smoking
- physical activity
- serum lipid levels
- obesity
- hypertension
- diabetes
- stress
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Term
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Definition
- nicotine increases
- peripheral vascular resistance (by constricting arterioles)
- increases heart's workload
- heart rate
- blood pressure
- limites the bloods oxygen carrying capacity (displaces oxygen with carbon monoxide)
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Term
| physical activity vs. sedentary lifestyle |
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Definition
- exercise increases heart rate and increases oxygen supply to tissues
- heart muscle becomes stronger and more efficient with exercise
- exercise slows the atherosclerotic process
- sedentary people are at greater risk for cardiovascular disease
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Term
| elevated serum lipid levels |
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Definition
- link between increased serum lipid levels and coronary heart disease
- AHA recommends less than 30% of total calories come from fats
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Term
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Definition
- places increased workload on the heart and increases oxygen deman
- often accompanies by increasing lipid levels
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Term
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Definition
- increases workload of heart
- this increases oxygen demand and blood flow
- also causes damage to blood vessels and increases development of atherosclerosis
- diet can play a role in treatment of hypertension
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Term
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Definition
- high blood sugars are linked with increased development of atherosclerosis, increased lipids and triglycerides
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Term
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Definition
- elevates serum lipids
- increases blood coagulation
- increased blood pressure
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Term
| Nursing assessment: interview (subjective date) |
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Definition
- current and past cardiovascular problems
- family history
- history of diabetes or other medical conditions
- history of cigarette smoking
- diet
- exercise
- medications
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Term
| nursing assessment: symptom analysis |
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Definition
- any weakness or fatiguew
- difficulty breathing
- leg pain (claudication)
- edema
- shoes or rings too tight
- recent weight gain
- any chest pain
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Term
| Evaluating chest pain: onset of pain |
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Definition
- when did pain start
- what precipitated the pain (such as exercise, lifting, etc.)
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Term
| Evaluating chest pain: location of pain |
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Definition
| have client describe or point to location |
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Term
| Evaluating chest pain: duration of pain |
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Definition
| how long has it been since the pain started? |
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Term
| Evaluating chest pain: characteristics of pain |
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Definition
- have client describe the pain (terms such as sharp, dull, ache, pressing, etc.)
- constant or intermittent
- is it accompanied by nausea, vomiting, dyspnea
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Term
| Evaluating chest pain: aggravating factors |
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Definition
- what makes the pain worse (such as deep breaths or exertions)
- what makes the pain better
- does the pain go away when the client is at rest
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Term
| Evaluating chest pain: radiation |
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Definition
- does the pain radiate to the arms, neck, or jaw?
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Term
| Evaluating chest pain: treatments |
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Definition
- have treatments been tried
- did they make the client feel better
- has there been any improvement in the pain with treatments
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Term
| physical assessment: general behavior and appearance |
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Definition
- gives information about tissue perfusion and cardiac output
- cognition and perceptual function may be affected by decreased cerebral perfusion from decreased cardiac output
- assess cognition and LOC
- slowness or difficulty speaking
- inappropriate responses
- confusion/orientation
- restlessness
- anxiety
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Term
| physical assessment: skin color |
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Definition
- indicates level of blood oxygen and adequacy of blood flow
- may be pale, cyanotic, or dusky red due to venous or arterial insufficiency
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Term
| physical assessment: skin temperature |
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Definition
- cool if arterial blood supply to extremity is impaired
- a reflection of tissue perfusion
- compare extremities
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Term
| physical assessment: skin integrity |
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Definition
- any impairment (ulcers)
- reddened areas
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Term
| physical assessment: hair and nail growth |
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Definition
- hair loss on extremities
- thick, ridged toenails
- caused by chronic insufficient blood supply to areas
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Term
| physical assessment: capillary filling |
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Definition
- assesses local circulation
- apply pressure to edge of nail bed
- color should return in less than 3 seconds
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Term
| physical assessment: varicose veins |
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Definition
- dilated veins when standing can indicate inadequate venous function
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Term
| physical assessment: peripheral pulses |
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Definition
- temporal
- carotid
- radial
- brachial
- femoral
- popliteal
- dorsalis pedis
- posterior tibial
- pulse consistency (strength & equality)
- 0 = absent
- 1+ = weak, thready
- 2+ = normal
- 3+ = full, bounding
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Term
| physical assessment: edema |
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Definition
- collection of fluid in the interstitial compartment
- be sure to note amount, extent, and type
- edema can be generalized or confined to a body part
- always compare extremities
- pitting edema: feels soft and leaves an imprint when finger pressed against skin
- brawny: feels hard or gelatinous; skin looks shiny, moist, no pitting
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Term
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Definition
- gently press edematous area with fingers:
- 1+ pitting edema
- 2+ pitting edema
- deeper pit after pressing (4mm)
- pitting lasts longer than 1+
- 3+ pitting edema
- deeper pit (6mm)
- remains pitted several seconds after pressing
- 4+ pitting edema
- deeper pit (8mm)
- remains for prolonged time after pressing
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Term
| assessment of the neck: trachea |
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Definition
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Term
| assessment of the neck: thyroid |
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Definition
- normally not visible
- palpate by placing fingers on the left, push the trachea to the right and ask the pt. to swallow as you palpate the gland
- do the opposite to palpate the left side of the gland
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Term
| assessment of the neck: carotic pulse |
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Definition
- closest pulse to the heart
- palpate one side at a time
- determine rate, rythm, and quality
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Term
| assessment of the neck: jugular vein distention |
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Definition
- place patient supine with HOB at 30-45 degrees
- turn head away from you
- apply lighting to highlight pulsations and shadows
- distinguish jugular veins from carotid
- normally distended when supine and collapsed when client raised to a 30-45 degree angle
- distention beyond this point indicates increased venous pressure
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Term
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Definition
- the area of the chest that overlies the heart
- auscultated with stethoscope for heart sounds
- you will be listening for the apical pulse this semester
- located at the apex of the heart
- other heart sounds will be covered in your assessment course
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Term
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Definition
- PMI (point of maximal impulse)
- 5th intercostal space at the midclavicular line
- heart sounds
- S1 - created by the closure of the mitral and tricuspid valves
- S2 - closure of the aortic and pulmonic valves
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Term
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Definition
- increase activity by
- frequent change of position
- ambulate
- exercises
- position legs to promote venous return (decreases blood clots)
- avoid crossing legs
- avoid constrictive clothing
- antiembolism stockings (promotes venous return and prevents pooling of blood)
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Term
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Definition
- checked to monitor the body's functions
- should be looked at in total
- can reflect changes that might otherwise not be detected
- compared to the client's usual vital signs
- RN is responsible for the interpretation of the vital signs even if measurement is delegated to another
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Term
| times to assess vital signs |
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Definition
- admission for baseline
- change in health status
- before & after procedures or surgery
- before & after meds that could affect circularoty and respiratory systems
- before & after any nursing procedure that could affect vital signs (i.e. ambulation)
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Term
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Definition
- age - as age increases, pulse rate generally decreases
- gender - adult male's pulse slighly lower than females
- exercise - increases with activity
- fever - increases
- medications - can increase or decrease
- hypovolemia - loss of blood increases pulse
- stress - increases
- position changes
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Term
| Pulse: most commonly assessed sites |
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Definition
- most commonly assessed sites: (peripheral vs central)
- radial (thumb side of wrist)
- apical
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Term
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Definition
- rate - normal is 60-100 beats/minute
- tachycardia - above 100 bpm
- bradycardia - below 60 bpm
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Term
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Definition
- rhythm - regular or irregular
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Term
| Pulse: Strength & Equality |
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Definition
- normal - felt with moderate pressure and can be obliterated with greater pressure
- bounding - can only be obliterated with difficulty
- weak, feeble, thready - readily obliterated
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Term
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Definition
- healthy, normal artery feels straight, smooth, soft, and pliable
- abnormal feels tortuous (twisted), hard, and irregular
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Term
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Definition
- take both apical and radial rates (usually at the same time by 2 nurses)
- any discrepancy between the two should be reported
- radial pulse is never greater than apical
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Term
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Definition
- measured in mm Hg
- two basic components
- systole - peak force
- diastole - minimum force
- record as systole/diastole i.e. 120/80
- pulse pressure - difference between systolic and diastolic measurememnts.
- normal difference is about 40mm Hg
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Term
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Definition
- blood pressure consistently below 100/60mm Hg
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Term
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Definition
- blood pressure is chronically elevated (above 140/90mm Hg)
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Term
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Definition
- readings between 120/80 and 139/89mm Hg
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Term
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Definition
- BP falls when client stands or sits (inadequate reflex comensation)
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Term
| factors affecting blood pressure |
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Definition
- age - pressure rises with age
- gender - female lower than males as adults before menopause (after the reverse)
- sympathetic nerve stimulation (stress) - increases blood pressure
- medications - may increase or decrease
- exercise - increases
- obesity - increases
- diurnal variation - lowest in the early morning & greater in the late afternoon
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Term
| Possible falsely low BP readings |
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Definition
- environmental noise
- hearing deficit
- poor fit of ear pieces
- tubing of stethoscope too long (no longer than 12-15 inches recommended)
- failing to pump cuff up high enough
- cuff too large
- arm above heart level
- releasing valve too quickly
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Term
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Definition
- the process of gas exchange between an individual and the environment
- 2 phases: inspiration and expiration
- inspiration - air flows into the lungs
- expiration - gases flow out of the lungs
- the 2 phases make up a single breath
- adult - normally occurs 12-20 times/minute
- inspiration lasts for about 1-1.5 seconds
- expiration lasts for about 2-3 seconds
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Term
| factors affecting respiratory function |
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Definition
- age
- environment
- altitude (increases RR because of lower PO2)
- air pollution, pollens, and allergens
- exercise
- disease of the respiratory system
- medications (may depress CNS, decreases respirations)
- stres
- smoking
- obesity
- restricts chest movement
- extra work to carry extra weight
- increases oxygen demand
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Term
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Definition
- medical history of self and family
- smoking history
- medication us r/t respiratory system
- allergies (esp. noting respiratory symptoms)
- work and location of residence (for exposure to environmental contaminants)
- diet (esp. allergies to certain foods & response)
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Term
| assessment: current health problems |
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Definition
- cough
- productive or nonproductive
- sputum production
- material coughed up from the lungs
- hemoptysis
- color, consistency, odor, amount
- chest pain
- dyspnea
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Term
| physical assessment: inspection |
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Definition
- vital signs - respiration assessment (usually smooth and regular)
- rate - normal range is 12-20 respirations per minute
- depth - i.e. shallow, deep
- rhythm - regular, irregular
- respiration are normally silent
- skin color
- chest wall movements
- posture when breathing
- palpation
- feel for tenderness
- feel for abnormal masses or lumps
- feel for even chest expansion bilaterally
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Term
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Definition
- assess throacic expansion by placing thumbs on the spine at the level of the 9th ribs
- extend fingers laterally around the rib cage
- have client inhale - both sides of chest should move upward and outward together
- decreased movement on one side may indicate pain, trauma, or pneumothorax (air in the pleural cavity)
- a lag or slowed movement may indicate a mass, pneumonia, abscess, fibrosis, or atelectasis
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Term
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Definition
- involves listening with a stethoscope over the anterior and posterior chest wall for variations in breath sounds
- breath sounds are created by the movement of air in and out of the airways during each respiratory cycle
- important to determine if air is moving through all areas of the lungs
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Term
| normal breath sounds: bronchial |
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Definition
- loud and high pitched
- hollow quality
- often compated to the sound of air blowing through a pipe
- normal when heard over the trachea, but should not be heard elsewhere
- may be associated with pneumonia, pleural effusion, tumor, or atelectasis
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Term
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Definition
- intermediate in character between bronchial and vesicular sounds
- described as breezy, but softer and lower pitched than bronchial sounds
- inspiratory and expiratory times are equal
- normally heard in 2 areas only: arteriorly over the bifurcation of the main bronchi (first and second intercostal spaces at sternal border) and posteriorly between the scapulae
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Term
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Definition
- normally heard over all areas of the lung (except over or near major airways)
- described as soft and brezzy
- inspiration longer than expiration
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Term
| abnormal breath sounds: adventitious sounds |
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Definition
- abnormal sounds that occur from air passing through narrow airways or fluid or from an inflammation of lung pleura
- often superimposed over normal breath sounds and takes much practice to discern
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Term
| abnormal breath sounds: fine crackles (also called rales) |
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Definition
- high-pitched, short, popping sounds
- heard during inspiration
- not cleared with coughing
- sounds like rolling a strand of hair between your fingers near your ear
- may be heard in pneumonia, chronic bronchitis, asthma
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Term
| abnormal breath sounds: course crackles |
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Definition
- low pitched, bubbling, moist sounds
- may persist from early inspiration to early expiration
- heard in many of the same conditions listed for fine crackles, but may be indicative that condition is worse
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Term
| abnormal breath sounds: rhonchi |
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Definition
- low pitched snoring or moaning sounds
- heard primarily during expiration, but may be heard throughout the respiratory cycle
- may clear with coughing
- heard in conditions that obstruct the trachea or bronchus (such as bronchitis)
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Term
| abnormal breath sounds: wheeze |
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Definition
- high-pitched, musical sounds
- heard primarily during expiration
- may be heard upon inspiration as well
- heard in narrowed airway diseases such as asthma
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Term
| promoting health breathing |
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Definition
- sit straight or stand erect to permit full lung expansion
- regular exercise
- don't smoke and avoid second hand smoke
- positioning and changing positions freqhuently
- deep breathing and coughing
- adequate hydration
- prevent respiratory tract infections
- reduce allergans
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Term
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Definition
- oxygen is prescribed when the oxygen needs of the body cannot be met by atmospheric air alone
- goal of oxygen therapy
- use the lowest amount of inspired oxygen to obtain the most acceptable oxygenation without causing harmful side effects
- the average clients uses an O2 flow of 2-4 L/min via NC or up to 40% via venturi mask
- arterial blood gas (ABG) and pulse oximetry are measures used to determine need for and evaluating effects of O2 (PaO2 % SaO2 levels
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Term
| hazards and complications |
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Definition
- oxygen does not burn, but it enhances combustion - a fire burns more readily in the presence of O2
- prohibit smoking
- all electrical equipment must be grounded
- repair frayed cords that can spark and ignite a flame
- prohibit any blammalbe soultion containing alcohol or oil
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Term
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Definition
- damage to lungs can occur
- initial symptoms include: nonproductive cough, substernal chest pain, GI upset, and dyspnea
- with continued exposure to high concentrations of O2, symptoms become more severe
- structual damage to lungs can occur
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Term
| drying of mucous membranes |
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Definition
- when O2 flow rate is higher than 4 L/min, humidification is usually added to the delivery system
- monitor water level and change humidifier as needed
- the humidification system may be a source of bacteria as well as the delivery equipment
- change equipment per agency policy
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Term
| nursing care: oxygenation |
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Definition
- check the skin around the ears, back of neck, and face for pressure points and signs of irritation
- provide mouth care PRN
- assess nasal and oral mucous membranes for signs of dyrness.
- pad tubing in areas that pup pressure on the skin
- cleanse the cannula or mask by rinsing with clear, warm water every 4-8 hours as needed
- lubricate nostrils, face, and lips to relieve drying effects of oxygen - do not use petroleum jelly - it is combustible
- position tubing so it does not pull on face or nose
- ensure that there is no smoking in the area
- assess the document response to therapy
- make sure equipment is operating properly
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Term
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Definition
- another measurement usually taken at the same time as the traditional vital signs
- noninvasise
- measure arterial blood oxygen saturation
- can detect hypoxemia before signs & symptoms appear
- sensor placed on finger (most common), toe, nose, earlobe
- photo detector measures amount of red and infrared light absorbed by oxygenated and de-oxygenated hemoglobin in the blood
- normal is 95%-100%
- below 70% is life threatening
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Term
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Definition
- excessive secretions in the upper airway will decrease oxygenation
- suctioning is necessary when patient cannot expectorate mucus effectively
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Term
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Definition
- a temperature higher than normal (for the particular client) under resting conditions
- range 97-99 degrees for adults (older adults over age 70 would be 95-99)
- factors affecting body temperature
- age, physical activity, hormones, diurnal variations, stress, environment
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Term
| phases of a fever: onset (cold or chill phase) |
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Definition
- patient feels cold
- skin is cool & pale
- shivering with chill
- increased heart rate
- increased respiratory rate
- cyanotic nail beds
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Term
| phases of a fever: course or plateau phase |
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Definition
- absence of chills
- skin feels wam
- increased respiration & pulse rates
- increased thirst
- drowsy & restless
- loss of appetite
- photosensitive
- malaise, weakness, aching muscles
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Term
| phases of a fever: afebrile, flush phase |
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Definition
- skin warm and flushed
- diaphoretic
- client more alert with more energy
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Term
| nursing measure for fever |
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Definition
- provide fluids (3 liters per day)
- bathe with tepid water
- good oral hygiene
- keep linen dry
- well balanced meals to meet increased metabolic needs
- assess skin color and temperature
- decreased activities to decrease oxygen needs
- monitor vital signs
- decrease covering to promote heat loss (increase covering if chilling)
- administer antipyretic drugs as ordered
- measure intake & output
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Term
| temperature measurement: assessment sites |
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Definition
- mouth (PO) 3-8 minutes
- rectal 2-4 minutes
- axillary (Ax) 10 minutes
- tympanic (seconds)
- forehead - temporal artery (seconds)
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