Difference between Peripheral Vasoconstriction and Peripheral Vasoconstriction 

Vascular resistance is increased when vasoconstriction takes place
Vascular resistance is decreased when vasoconstriction takes place 
 
Think of it this way if a container gets smaller the force needs to be greater to push the contents forward
Vascular resistance is an after load problem

Pulse
Count the pulse starting with Zero 
Normal adult pulse 60-100
Less than 50 bpm = bradycardia 
Over 90 bpm = tachycardia
When assessing pulse assess the following rate, rhythm, force, and elasticity
Pulse force is recorded using three-point scale 

3+ = full, bounding
1+ = weak, thready (weak, thready pulse is associated with decreased stroke volume ie. Hemorrhagic shock and hemorrhagic is shock is a preload issue)
2+= normal		
0 = absent

Some use a four point scale but the descriptions do not change except that a four is bounding and three is increased

Pain (the fifth vital sign)
Neuropathic pain
Abnormal processing of pain message and most difficult to assess and treat
Visceral pain 
Originates from the larger interior organs ie. Kidney, stomach, intestine, gallbladder, pancreas 
ex. Urethral colic, acute appendicitis, ulcer pain, and cholecystitis
This pain is transmitted by ascending nerve fibers and with the fibers of the autonomic nervous system thus presents with vomiting, nausea, pallor and diaphoresis (profound sweating)
Cutaneous Pain 
Skin surface and SQ tissue, injury is superficial w/ sharp burning sensation
Referred Pain 
Felt at certain site but originates from another location (pg. 559 table 12-2 common sites of referred abdominal pain)
Salivary glands

Purpose of nutritional assessment 
Identify those who that are malnourished or at risk, provide information to help them reduce/prevent malnourishment and establish baseline data for evaluating efficacy of nutritional care 
Developmental milestone
First year birth weight triples and 50% in length, massive brain growth, loss of certain reflexes
Erikson and Piaget’s stages

Importance of Hand washing
Makes for a safer environment
It is the single most important step in preventing the spread of microorganisms
Wash hands before and physical contact w/ every patient 
After contact with any body secretions
After removing gloves

Where valve closures can be heard best

Auscultatory areas where you listen to the heart at ( z pattern)

Second right intercostalspace- aortic valve area
Second left intercostalspace- pulmonic 
Left lower sterna border- tricuspid valve area
Fifth intercostalspace at round left midclavicular line- mitral valve area 

Heart sounds S1 & S2 
S1= systole  

S1 is caused by the closure of the AV (auscultate the AV  at the second right ineterspace)  Reference point for all other heart sounds because it is the first sound, together with S2  makes a lub-dup sound S1 is the lup and S2 is the dup sound It is loudest at the apex of the heart it coincides with the carotid artery pulse 

S2 is associated with the closing of the semilunar valves it loudest at the base of the heart

Percussion of the Posterior Chest and Anterior 

“Determine the predominant note over the lung fields”
For percussion of the posterior start w/ the tissue across the tops of the shoulders (three spots) this not done for auscultation and proceed with to percuss using the same nine spots that are used for auscultation of lung sounds (photo on p. 425) 

The percussion of anterior chest the locations are the same for as for auscultation (five spots)
Resonance- low-pitched clear, hollow sound normal in healthy lung tissue of adults
In obese adults, fat produces a scattered dullness
Hyperresonace- low-pitched booming, found when too much air is present, i.e. emphysema, or pneumothorax
Dull- soft muffle thud signals abnormal density in lungs i.e. pneumonia, pleural effusion, atelectsis, or tumor 
There will be dullness over the liver and visceral 
Flat over the bone of the scapula 

Over bone =                                                (normal)
Over organs =                                             (normal)     

Interview Techniques (not all are listed for full list pp 32-34)

Open ended – ask for more information

States the topic only in a general sense
If the person is short or pause looking for directions, try to facilitate (also called general leads) more information i.e. “tell me more about it” or “anything else?”  

Closed or Direct questions- ask for specific information, short to the point require a one or two word answer generally a yes or no

Uses:
 to fill in areas that were left out the narrative given that was obtained by using a open ended question 
speed up the interview
when specific facts are needed  i.e. system reviewing

Avoid: 
Loaded questions
Asking more question at once
Double barrel questions  

Reflection- echoes the patient’s words
Helps them to elaborate

Interpretation-  NOT based on observations like confrontation is based on inferences or conclusions  it implies causes

Clarification-  when word choice is ambiguous or confusing , can be used to explain terminology to a patient or used to understand what a patient saying by simplify and checking if you understood correctly. Clarification is NOT same as Explanation 

Explanation- inform the person by using factual, objective information
May explain the cause of something

Subjective vs. Objective

Subjective- what they tell you think subject (the person) is where the information comes from symptoms are subjective 
Objective- this is what you can see
Signs are objective

Effects of aging on the Skin 

They are a higher risk for skin break down due to thinning of the skin, decreased vascularity and nutrients, loss of protective cushioning, lifetime of environmental trauma to skin, limited mobility or sedentary lifestyle. 
Healing of skin breakdown takes longer

Characteristic: 
Loses its elasticity it folds, sags 
Tears easier
Around  70s to 80s looks parchment thin, lax(limp), dry and wrinkled 

Physiology: 
Skin tends to tear more easily on the elderly due to loss of collagen 
Atrophy of skin structure with age
Epidermis flattens allowing chem. More assess into the body
Wrinkles are due to underlying dermis flattening and thinning
Sweat glands and sebaceous decrease in number and in function resulting in dry skin
Decrease response to temp regulation puts the elderly at a greater risk for heart stroke

When to take a rectal temp.
Normal temp. 37 C 

Only take a rectal temp when other routes are not practical i.e. comatose, confused person, person in shock, or those who have tubing or anything else preventing access to the mouth 

Sides note the hypothalamus controls the body’s temp. Do NOT use if they have low WBC. Rectal temps are add a degree

Blood Pressure-Cuff Size
 Normal BP is 120/80 or less 

If the cuff is, too small it will cause the reading to be too high and if it is too larger, the reading will be too low

 How to Listen for a Bruit (normally none present)

Lightly press the bell of the stethoscope over the carotid artery at three spots (photo p.471)
1.	Angle of jaw
2.	Midcervical area 
3.	Base of neck 

A bruit indicates turbulence due to local vascular cause i.e. atherosclerotic
Heart sounds can sometimes be heard in those locations that is okay, and do Not confuse them with bruit.