NUR 230 Week 5 Notes
NUR 230 Week 5 Notes NUR 230
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This 17 page Class Notes was uploaded by Issy Notetaker on Saturday September 26, 2015. The Class Notes belongs to NUR 230 at Ball State University taught by Marjorie Pyron in Fall 2015. Since its upload, it has received 54 views. For similar materials see Health Appraisal Across the Lifespan in Nursing and Health Sciences at Ball State University.
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Date Created: 09/26/15
Week 5 Jarvis Notes Objectives Clinical Lecture Chapter 18 0 Respiratory system works in conjunction with the heart 0 Breath in 1 pint of air 17 times a minute 78 million gallons in a lifefills Hindenburg 15 times 0 Surface Landmarks o Thoracic Cage Need to know the structure in order to know what to listen for De ned by sternum 12 pairs of ribs Costochondral Junction Where ribs and cartilage meet 0 First 7 pairs are attached to sternum 810 connect to costal cartilage connected to sternum 11 and 12 are oating 0 Can palpate tips 12 Thoracic vertebrae Diaphragm Shaped like a cone w narrow top 0 Anterior Thoracic Landmarks Suprasternal Notch U shape depression above sternum Sternum or Breastbone Manubrium Body Xiphoid process Sternal Angle Manubrium and body articulation second rib Site of tracheal bifurcation into R and L main bronchi Upper border of atria Lies above 4th Thoracic vertebrae Costal Angle R and L costal margins meet xiphoid process 0 90 degrees 0 Posterior Thoracic Landmarks Vertebra Prominens C7 and T1 Spinous Processes Align w rib to T4 lnferior border of Scapula Lower tip is at 7 or 8th rib Twelfth Rib Midway bw spine and side 0 Reference Lines Anterior Midsternal Line where sternum is Midclavicular Cuts clavicle in half Posterior Midspinal Middle of back on vertebrae line Scapular Line through inferior angle Side Anterior Axillary Anterior fold MidAxillary Posterior Axillary Posterior Fold mad Thoracic Cavity o Mediastinum Middle section of thoracic cavity Esophagus trachea heart great vessels R and L pleural cavities on both sides 0 Contain lungs 0 Lung Borders Apex Highest point Anterior 34 cm above inner 13 of clavicle Laterally apex of axilla Posterior C7 Anterior about 6th rib in midclavicular line Laterally 78th rib Posteriorly T 10 0 Deep breath goes to T 12 0 Lung Lobes R is shorter 3 lobes Upper ends at 4th on sternum and 5th on midaxillary Middle lines are 5th midaxillary and diagonal to 6th midclavicular L is narrower 2 lobes Lobes create ssures bw them Anterior Oblique ssure 56th ribs 0 R lung has horizontal 3rCI to 5th rib Posterior Almost all lower lobe T3 T 10 or t 12 0 Division is at medial border of scapula Lateral Apex of axilla to T 7 or T8 0 Pleurae Serous membrane enveloping lungs and chest wall and diaphragm Envelope is formed bw lungs and chest wall Visceral is on lungs Parietal is on chest wall Space bw linings is negative pressure Costodiaphragmatic Space Pleura space that extends 34 cm below lungs o Trachea and Bronchial Tree Trachea is anterior to esophagus Begin at cricoid cartilage and splits just below sternal angle into R and L main bronchi T4 or T5 Transport gases Considered Dead space 150 mL in adult Bronchi are lined w goblet cells and cilia On level 1113 0 Protect alveoli Acinus is functional unit where gas exchange occurs Bronchial tree divide 23 times before alveoli Gas exchange on 17th level Alveoli on 23rd 300 million 0 Type I Structure and communication 0 Type II Surfactant producers Mechanics of Respiration 0 Four major functions Supply 02 to the body Removing C02 Maintaining homeostasis Maintaining heat exchange 0 Hypoventilation causes increase in C02 0 Hyperventilation causes decrease in C02 0 Control Changes wout our awareness Normal stimulus to breath is increase in C02 in the blood hypercapnia Decrease in 02 in the blood Hypoxemia also stimulates breathing 0 Changing Chest size lncreaseinspiration Lengthen vertical and elevate ribs 0 Active 0 Active process 0 Increase thoracic Cavitynegative pressure in lungs causing air to rush in 0 Compliance DecreaseExpiration Shorten Vertical and Depress Ribs Passive Diaphragm relaxes and the chest recoils Pressure is increased in the lungs causing air to move outward Elastance Dimensions 0 Vertical diameter lengthens or shortens o Diaphragm movement Anteroposterior AP diameter increases or decreases o ElevationDepression of ribs 0 Development 0 Infants and Children Lungs appear at 5 weeks 16 weeks the same number of airways are present 32 weeks surfactant is developed Birth 70 million alveoli start Respiratory system does not function until birth 300 million alveoli by adolescence Pre and Postnatal exposure to nicotine or second hand smoke increases risk of SIDS and ADHD and Depression Chest circumference is 2 cm smaller than head 3036 cm Breasts in babies may look large bc others hormone but will shrink Breathe through noses until 3 month 0 N0 N6 tube bc it can cut off breathing 11 Ratio of chest Ribs and xiphoid are visible BV sounds in peripheral until age 56 Louder and harsher sounds May hear bowel sounds when auscultating 0 Pregnant Women Thoracic cavity will appear wider Deeper breaths are made Uterus elevates and enlarges Decreases Vertical action of thoracic cavity 0 Less lung space Increase in estrogen Loosens ligaments allowing for increased circumference of chest cavity Tidal Volume is increased Physiologic Dyspnea is associated w 75 of women 0 Aging Adult Costal Cartilage becomes calci ed Decreases lung movements MM strength declines Lose elasticity Reduction is collapse and recoil Decreased vital capacity Loss of alveoli and less gas exchange occurs 0 Less 02 saturation but no change in C02 Barrel Chest develops Kyphosis is more common in women than men 0 Culture and Genetics 0 TB has declined in US Those from other countries have a higher rate Immigrants barriers to early diagnosis prevention and treatment are the cause 0 Asthma is increasing each year More prevalent in lower income families Most common childhood chronic disease Subjective Data 0 Cough Acute 23 weeks Chronic 2 months Time of day Duration OLDCARTS SOB Shortness of Breath Is it occurring now OLDCARTS Orthopnea Dif cult breathing that occurs when person is lying down Paroxysmal Nocturnal Dyspnea Waking up fro SOB Chest Pain w breathing Exact location History of Respiratory infections Past history of troubles or lung diseases Allergies TB Asthma Smoking history Packs Per Day Attempts to quit Five As 0 Ask about use status Advise suggestions about quitting Assess Readiness to quit Assist W speci c cessation plan 0 Arrange Followup visits Environmental Exposure Occupation PPE Triggers Traf c related Selfcare PtCentered Care Last tests and exams or vaccinations Additional Infants and Children Frequent or severe colds History of allergy Cough Congestion Childproof measures Smokers in home Aging Adult SOB or fatigue in normal activities Amount of Physical Activity History of COPD TB or Lung cancer Chest pain w breathing Smoking history Lung function questionnaire Objective Data 0 Prep Sit upright Warm room warm diaphragm endpiece privacy Inspect Posterior Chest Overall Demeanor Thoracic Cage Note shape and con guration 0 Symmetric ribs and downward sloping shoulder blades and straight spinous process 0 Check ratio Should be 12 lf barrel chested 11 Position breath is taken in o Relaxed support of weight placement of arms Skin color and condition 0 Consistent and match ethnicityrace o Lesions 0 Change in nevus o Cyanosis Temperature Moisture Clubbing o Palpate Posterior Chest Symmetric Expansion Place hands sideways on posterolateral chest w thumbs at T9 Slide hand together to pinch up some skin Ask to inhale and thumbs should move apart symmetrically Tactile Fremitus Palpable vibration Use quotballquot of hand while person repeats to words 99 or blue moon Symmetry is important 0 Vibrations should feel the same on each side Fremitus changes based on placement weight and voice pitch Gently palpate the entire chest wall 0 Percuss Posterior Lung Fields Determine predominant note Start at apices and percuss across top of shoulders Percuss intercostal spaces at 5 cm intervals Resonance is lowpitch hollow clear sound in healthy Ussue Hyper resonance Lowpitched too much air is present 0 Emphysema Pneumothorax Dull soft muf ed increased density in lungs 0 Tumor Diaphragmatic Excursion Percuss map of lower lung border w inspiration and expiration 0 Mark the change in sound 0 35 cm in adults more in healthy individuals o Auscultate Posterior Breath Sounds Breath through mouth more deeply and lean forward a bit 0 Hold rmly against chest wall listen for 1 full respiration and compare bilaterally Patterns 0 Tachypnea increased rate gt24 Fever fear exercise shallow o Bradypnea decreased lt10 Shallow depression diabetic coma o Hyperventilation Increased Rate and depth Exertion fear anxiety 0 Hypoventilation Irregular shallow OD of narcotics o Cheyne Stokes Increased rate and depth Apneic periods severe heart failure renal failure 0 Three types of normal breath sounds o Bronchial High Pitch Trachea and Larynx Inspiration is less then Expiration o Bronchovesicular Moderate Pitch Midline Inspiration and Expiration times are equal 0 Vesicular Low Pitch Lateral to BV Inspiration is longer than expiration Most of lung eld Adventitious Sounds 0 Added sounds that are not normally heard 0 Caused by moving air colliding w secretions or popping of de ated airways Crackles Rales Air passing over secretions in airways Wheezing Musical sound caused by narrowing of passages o Commonly caused by Asthma in high pitched o Commonly caused by COPD is lowpitched Rhonchi coarse rales Wheezing caused by secretions Crackles Not pathologic 0 Fine Short popping crackles Only in periphery Common cause in pneumonia 0 Course Bubbling or gurgling w clear cough Common Cause Pulmonary Edema and Heart Failure 0 Atelectasis Fine that don39t last Common in those who are bedridden Stridor o Croup High pitched inspiratory crowing Common cause Obstructed airway Life threatening Mostly in children Voice Sounds Sot Muf ed and Indistinct 0 Inspect Anterior Shape and con guration symmetrically Note facial expression Nasal aring tracheal deviation pursed lips Level of consciousness Skin color and condition 0 Inspect nails for clubbing Quality of respirations Smooth Effortless Easy 0 Deep Shallow Gasping Retraction or bulging Use of accessory mm Respiratory Rate 0 Papate Anterior Symmetric expansion 0 Place hands like on anterior but w thumbs at xiphoid process Tactile Fremitus Compare sides like on back Papate to note tenderness lumps or masses motility turgor temperature moisture o Percuss Anterior Begin at supracavicuar End just below T5 0 Auscultate Anterior Breath Sounds 0 From apices to T6 side to side movement for 1 full respiration Displace female breast Measurement of Pulmonary Function Status Forced Expiratory Time Number of seconds from complete expiration Spirometer Pulse Oximeter 6minute Walk test 0 Development Infants and Children 0 Let parent hold baby against chest o If sleeping auscultate rst 0 Use games for cooperation Inspection 0 Infant has rounded thorax o By 6 the 12 ratio of AP to vertical 0 First respiratory assessment is part of Apgar Sco ng o Nose breather until 3 months Palpation o Symmetric expansion Auscultation o BV breath sounds until 56 0 Small crackles are commonly heard Pregnant Thoracic cage I wider Respirations are deeper increased tidal Volume Aging 0 Increased AP diameter barrel chested Acute Illness Roll on side if no one is available to help person upright Abnormal o Emphysema or Pneumothorax Bronchial obstruction Secretions Mucus Plug Foreign Body Loss of elasticity in lungs Decreased force Lungs hyperin ation Silent Chest is the indicator 0 Asthma Allergic hypersensitivity Bronchospasm In ammation Edema Secretion of mucus into airways Increased RR SOB cyanosis Apprehension o Bronchitis Proliferation of mucus and excessive mucus excretion In amed Bronchi Hacking rasping dyspnea fatigue cyanosis Crackles or wheeze 0 Heart Failure Pump failure Increased RR SOB Ankle Edema Pallor Moist and clammy skin 0 Lung Cancer Uncontrolled growth of cells Caused by tobacco smoke asbestos radiation Persistent cough weight loss congestion wheezing hemoptysis dyspnea 0 Sleep Apnea Chapter 19 One or more breathing pauses More than 30 pauses in an hour Interrupts sleep Obstructed is the most common Airway collapses Blockage due to tonsils nasal blockage or being overweight Treatments 0 Avoid alcohol weight loss stop smoking medications CPAP Position and Surface Landmarks O O O 0000 0 CV system Heart and blood vessels Precordium Anterior area on chest where heart and great vessels lies Heart and great vessels are mediastinum 2 395th intercostal space right border of sternum to L midclavicular line Rotated R side is more anterior and L side is more posterior RV is behind sternum LV is right behind Apex points down and left Blood vessels are two continuous loops Pulmonary and Systemic circulations Great Vessels Superior and lnferior Vena Cava unoxygenated blood back to heart Pulmonary Artery Blood to Lungs Pulmonary Vein Blood to Heart from Lungs Aorta Blood to body Located mediastinum Heart Wall Chambers and Valves 0 O 0 Heart Wall Pericardium Sac double walled surrounding heart Pericardial uid for smooth movements Myocardium MM wall Endocardium Endothelial tissue covering inner surface Chambers Atrium holds blood and Ventricles Pumps blood RA RV LA LV Valves Prevent back ow Unidirectional Passive movements based on pressure gradient changes Open during Diastole and close during Systole AV Atrioventricular Valve separating Atrium from Ventricle R AV Tricuspid L AV Tricuspid Open when heart is lling Diastole SL Semilunar Valve Bw Ventricles and Arteries Pulmonic Aortic Opening during pumping Systole Abnormal high pressure in L side of heart 0 Pulmonary congestion systems Abnormal high pressure in R side Ascites and uid in legs Direction of Blood Flow 0 Liverlj Inferior Vena Cave RA 0 Head and Upper extremities Superior Vena CavaDRA o RA Tricuspid Valve RVPulmonic Valve Pulmonary Artery Lungs Pulmonary VeinD LA Mitral Valve LV Aortic Valve Aorta Cardiac Cycle 0 Diastole Ventricles relax and re ll 23 of cycle AV are open Pressure in atria is higher than in ventricles Passive lling o Systole Ventricles contract Ventricular pressure is higher than atria closing AV valves 51 All four valves are closed Isometric contraction occurs in ventricles ejecting blood into Great vessel Aortic valve opens Aortic valve closes 52 signaling end of systole o Diastole again All four valves are closed Isometric relaxation Atria have been lling and pressure is higher causing AV valves to open 0 Events in R and L side Same events at same time Pressure on R is much lower bc less energy needed HeartSounds 0 Normal 51 Closing of AV valves Loudest at apex Beginning of systole M1 precedes T1 52 Closure of SL valves Loudest at base 0 A2 precedes P2 S3 Ventricular lling AV opens Vibrations S4 Atria Push blood into ventricle Vibrations and end of diastole Effect on Respiration o More the Right Less to the Left 0 Inspiration more blood in R o Murmurs Velocity of blood increases Flow Murmur Viscosity of Blood decreases Anemia Stenotic or Regurgitation 0 Characteristics of Sound Frequency Intensity Duration Timing ConducUon 0 SA node initiates response Pacemaker o PQRST wave P Depolarization of atria QRS Depolarization of ventricles T Repolarization of Ventricles Pumping Ability o 46 L of blood minutes 0 COSV X R Stroke V times Rate equals Cardiac Output Preload and after load affect ability to increase CO 0 Neck Vessels o Carotid Artery Pulse Smooth rapid upstroke o Jugular Venous Pulse and Pressure Internal 0 Larger deeper medial to sternomastoid Usually not visible External Super cial Lateral Above clavicle Results from backwash Pulse has 5 components 0 ltltgtltOJgt Development 0 Pregnant Women Blood Volume increases 3040 Increase pulse by 1015 beatsminute BP lowers 0 Infants and Children Fetal heart beats at 3 weeks Heart sits higher in child 4th intercostal space Fetal lungs are uid lled and only a little blood is pumped from the heart into them Most blood is diverted by foramen ovale and this close after birth 0 Aging Adult Lifestyle factor greatly affect Smoking Alcohol Exercise Stress Hemodynamic Change 0 Increase is systolic BP 0 LV wall increases in thickness Diastolic BP Stays the same Dysrhythmias increases w age Electrocardiograph Prolonged PR interval and QT interval Incidence of CVD and heart failure increases age Stage I Hypertension and heart failure increase with age Arteriosclerosis and Atherosclerosis Cardiac output decreases Culture and Genetics on factor affecting CVD 0 High BP More men than women until age 45 Above age 64 women are higher African Americans have highest prevalence Develop earlier in life Smoking Decreasing rates Leading cause of preventable disease disability and death Serum Cholesterol High levels of LDL Obesity 68 of Americans are overweight or obese Type 2 Diabetes Increasing prevalence Obesity is 1 predictor Sex Differences CVD is leading cause of death in Women Variations in symptoms of a heart attack bw men and women Subjective Data 0 0000000 Chest Pain Pain or tightness OLDCARTS Dyspnea SOB activities causing OLDCARTS Wake you up at night Interfere w activities Does it occur on exertion Orthopnea How many pillows are used when laying down Cough OLDCARTS Fatigue OLDCARTS Cyanosis or Pallor Occur w MI or when low cardiac output is occurring Edema OLDCARTS Nocturia Past Cardiac History Hypertension Elevated cholesterol Murmur Congenital Heart Disease 0 Family Cardiac History Hypertension Obesity CAD Diabetes Sudden death at a young age 0 Pt Centered Care Nutrition Smoking Alcohol Exercise Drugs 0 Additional Infants 0 Mother Health during Pregnancy Cyanosiswhile nursing Growth 0 Activity Children 0 Growth 0 Activity ChestPain Respiratory infections 0 Family History Pregnancy 0 High BP during pregnancy Fainting or Dizziness Aging Adult 0 Known heart or lung disease Medications Environment Stairs ADLs Objective 0 General Appearance skin color breathing effort BP edema Turgor Temperature of skin nails 0 Prep Sitting Up Carotid Supine 3045 degrees Jugular and Precordium Stand on R side Warm room Order 0 Pulse and BP Extremities Neck Vessels Precordium 0 Neck Vessels Papate Carotid Only one at a time 0 Don39t press too hard Auscutate Carotid Note presence of bruit Blowing swishing o Precordium 0 Not normal Apply Bell at three levels InspectJugular Venous Pulse Central Venous Pressure CVP Person Supine and stand on R side Remove pillow Turn Head slightly away Look for Pulse Estimate JuguIar Venous Pressure Measure w ruler Inspect Anterior Chest Pusations O 0 May or may not see apical impulse In 4th and 5th intercostal space Papate Apical Impulse Use one nger pad Roll person on side L Location 4th or 5th intercostal space Size 1x2 cm Short gentle tap Duration is short Papate Across Precordium Apex L Sternal Border Base Papate for pulsations AuscuItation Four traditional quotvalvequot areas Second R Interspace Aortic VaIve Second L Interspace PuImonic VaIve Lower Sternal Border Tricuspid 5th Interspace at L michavicuIar area MitraI Rate and Rhythm 5095 beats per minute Check for pulse de cit if there is a irregularity Identify Sl and SZ 51 is start of systole 51 is louder than 52 at the apex Opposite at the base Assess 51 and 52 separately Spilt SZ occur on the end of an inspiration Extra heart sounds Switch to bell Midsystolic click is common Listen for murmurs Blowing or swooshing 0 Development Infants Timing Early mid late Systole or diastole Loudness Grade on scale of 6 Pitch High Medium or Low Pattern Growing Tapering Increasing then Decreasing Quality Musical Blowing Harsh Rumbling Location Area of maximum intensity Radiation Transmitted elsewhere Posture Some disappear w change in position Innocent No valvular or pathologic cause 0 Functional Caused by increased blood ow in heart Change Position Roll on L side and listen for sounds Lean forward and have exhale Assess CV system win 24 hours of birth and 23 days later 0 Note extra sounds Shunts close in rst 1015 hours sometimes it takes 48 hours Apical impulse at 4th intercostal space Auscultate apical for pulse rate 0 100180 right after birth 0 120140 0 Variations occur Murmurs are common in rst 23 days Children 0 Note clubbing poor weight gain developmental delay tachycardia tachypnea DOE Cyanosis Palpate apical pulse 0 4th space until age 7 Venous Hum is common Carotid Bruit Murmurs are common Pregnant 0 Increase in resting pulse drop in BP Apical Pulse is higher bc displaced uterus Increase blood V and heart workload Mammary Souf e is common Aging Adult 0 Rise in systolic BP and decrease in Diastolic BP Abnormal Atherosclerosis Buildup of cholesterol and fat Buildup becomes plaque Blocks vessel 0 MI CVA or PE Arteriosclerosis Hardening of vessel Ca2 deposits BP increases Afterload increase MI CVA PE Hypertension S gt140 D gt90 CVD MI CVA PE Aneurysm rupture African American is the highest risk population High Cholesterol gt240 LDL and VLDL are very bad HDL is good Triglycerides are fat oating in the blood Heart Attack MI Blood flow to heart I stopped causing damage to the heart mm Tight band around chest indigestion heavy pressure CHEST PAIN ECG is testing Treatment 02 nitroglycerin Aspirin Cardia Monitoring Heart Failure Insuf ciency Heart doesn39t pump effectively Kidneys increase water absorption to increase blood volume Causes MI Increased BP Alcohol valve problems Pale skin Dyspnea Cough crackles Decreased BP Anxiety N and V Fatigue Cool moist skin
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