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Diagnosis
judgement regarding a pts health using subjective and objective data
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nursing diagnosis
pts response to actual or potential health problems
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Nursing Process
- A-assess
- D-diagnose
- O-outcomes id
- P-plan
- I-implement
- E-evaluate
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Weight Gain causes
- Fluid volume Excess
- Hypothyroid - slows metabolism
- Meds - corticosteroids
- Diabetes
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Weight Loss causes
- Increased metabolism
- Diabetes
- Malignancy
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Normal Temps
- Oral 98.6/37
- Rectal/Tympanic +1/0.5
- Axillary -1/0.5
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Sinus Arrythmia
Pulse increases with Inspiration
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Pulse site before 2 years old
Apical
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Pulse Deficit
Difference b/w Apical and Radial
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Pulse Deficit causes
Cardiac Arrythmia; sign of Heart Disease
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Respirations Assessment
- Rate
- Rhythym
- Depth
- Character (thoracic-women, abd-men/kids)
- Abnormalities
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Pulse Pressure
Difference b/n Systolic and Diastolic
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MAP
- Mean Arterial Pressure
- DBP + 1/3 PP
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Increased Viscosity causes
- Polycythemia
- Altitude
- Chronic lung disease
- Stimulates SNS (vasocontricts)???
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Korotkoff sounds (BP)
1st and 5th
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Paradoxical Pulse
Difference in SBP during inspiration v. expiration >10mm
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Paradoxical Pulse causes
- Cardiac Tamponade
- Constrictive Pericarditis
- Emphysema
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Thigh BP
10-40mm higher than brachial
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OLD CART
- Onset
- Location
- Duration
- Character
- Associated factors
- Relieving factors
- Treatment
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PQRST
- Provokes
- Quality/Quantity
- Region/Radiation
- Severity
- Timing
-
HEEADSSS
- Home environ
- Education and employment
- Eating
- Activities
- Drugs
- Sexuality
- Suicide
- Safety
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Para
# of births - 20 weeks (twins count as 1)
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Calcium Needs
- 4-8 yo: 800mg
- 11-24: 1200-1500mg
- >24: 1000mg
- >64: 1500mg
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ABCT Mental Health Status
- Appearance
- Behavior
- Cognition
- Thought processes
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Tactile Hallucinations cause
Alcohol withdrawal
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Increassed Costal Angle cause
Hyperinflation (Emphysema)
-
Anterior Lung Borders
- 3-4cm above 1st rib
- to
- 5th ICS on R
- 6th ICS on L
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Posterior Lung Borders
C7 - T10 (12 with inspiration)
UL: T1 - T3
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Horizontal Fissure
- 4th rib sternal border
- to
- 5th rib MAL
R only
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Oblique Anterior Fissures
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Trachea
- starts at Cricoid
- bifurcates at T4 / Louis
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Right Bronchus Size
Shorter and Straighter
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Respiratory Center
Brain Stem - Pons and Medulla
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Chronic Hypoxia results in
- desensitizes CO2 receptors
- low O2 becomes stimulus to breathe
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Continuous Cough cause
Respiratory Infection
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Nightime Cough cause
- post nasal drip
- GERD
- Sinusitis
-
Morning Cough cause
- Chronic Bronchitis
- Smoker's cough
-
Hacking Cough cause
Mycoplasma Pneumonia
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Dry Non-productive Cough cause
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Barking Cough cause
Croup
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White to Grey Sputum
- Chronic Bronchitis
- Smoking
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Green to Yellow Sputum
- Bacterial Bronchitis
- Pneumonia
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Rust colored Sputum
Pneumococcal Pneumonia
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Pink Sputum
Pulmonary Edema
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SOB / Dypsnea (Orthopnea/PND) cause
HF
-
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f/c/s cause (fever/chills/sweats)
Infection
-
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Histoplasmosis / Coccidioidmycosis (valley fever) cause
Inhaled fungus
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Pnuemoconiosis cause
Coal miner's inhalation
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Older adults breathing chamge
- Decreased Vital Capacity
- Increased Residual Capacity
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Tactile Fremitus Test Results
- "99"
- Increased vibration: consolidation (Pneumonia)
- Decreased vibration: Bronchial obstruction, COPD, Pneumothorax, Pleural
- Effusion
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Crepitus
- SQ Emphysema
- Course crackiling due to escape of air into tissues
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Hyperresonant Percussion Sounds
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Dull Percussion Sounds (Lung Fields)
- Atelactasis
- Pneumonia
- Pleural Effusion
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Crackles / Rales
- Fluid in lungs
- Atelactasis
- Pneumonia
- Fibrosis
- HF
- Pulmonary Edema
-
Rhonchi
- Airflow obstructed by: secretions, spasms, or tumor (Bronchitis)
- Deeper and prolonged during Expiration
- Clears up with coughing
-
Wheeze
- Constricted airway
- Asthma
- Bronchitis
-
Stridor
- Inspiratory Wheeze
- Obstruction
-
Splinting
Shallow breaths to control Pain
-
Tension Pneumothorax
Trachea shifts away from collapsed lung
-
Hypertrophied Accessory Muscles
chronic respiratory Disease
-
Tachypnea cause
- Insufficiency
- Pneumonia
- Alkalosis
- Pleurisy
-
Hyperventilation cause
Diabetic Ketoacidosis
-
Bradypnea cause
- Meds
- Increased ICP
- Diabetic Coma
-
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Cheyne-stokes Syndrome
- Regular then apnea breathing pattern
- CHF
-
Biots (Ataxic) breathing
Precedes Cheyn-stokes
-
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Stridor
- Croup
- Foreign Body
- Growth on vocal cords
-
Atelactasis
- Collapsed Alveoli
- Predisposes to Pneumonia
-
Emphysema
- Destroyed alveoli
- Increased lung volume d/t distended alveoli
-
Bronchitis
Inflamation of Bronchi
-
-
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Hemodynamic System dependent on
Pressure gradients
-
Conduction order
SA node - AV node - Bundle of HIS - Perkinje fibers
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P Wave
- Depolarization of Atria
- if missing: SA node problem
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PR Segment
Stim of atria to Stim of ventricles
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QRS Segment
Depolarization of ventricles
-
T Wave
Repolarization of ventricles (resting stage)
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R Wave
S1, ventricular contraction
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APE To Man
- Aortic
- Pulmonic
- Erb's
- Tricuspid
- Mitral
- ICS: 2,2,3,4,5
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Murmurs, best position
Extra sounds
- Sitting, leaning forward
- Left Lateral Decubitus
-
S1
- AV valves close
- Systole
- R Wave
-
S3
- Ken-tucky
- Early Diastole
- Less compliant heart wall
- HF, Pregnancy
-
S4
- Teness-ee
- resistance during atrial kick
- Late Diastole
- HTN
-
S2 Split
- During deep Inspiration
- At 2nd ICS
-
Murmurs d/t
- Increased velocity
- Decreased viscosity
- Decreased volume
- Defective valves
- Septal defects
-
Stenosis
Narrowed valve d/t hardening
-
Regurg
Insufficiency, backflow
-
Diastolic Murmurs always indicate
Heart disease
-
ACS
Acute Coronary Syndrome
-
Cardiac chest pain d/t
- MI
- Angina
- Mitral Valve Prolapse
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Pulmonary chest pain d/t
- Pulmonary Emboli
- Pneumonia
- Pleurisy
-
GI chest pain d/t
- Ulcer
- Hiatal Hernia
- Esophagitis
- Indigestion
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Nocturia d/t
- Increased venous return while recumbent
- Increases Renal perfusion
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JVP
- Jugular Venous Pressure
- JVD + 5cm
- Should be <10cm
-
Hepatojugular Reflex
If neck veins stay distended signifies HF
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Thrills
Loud, Harsh Murmurs
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Cardic Tamponade
Fluid buildup in Pericardium
-
Cor Pulmonale
- Right side heart hypertrophy and failure
- d/t pulmonary HTN
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