Ô
  


 

|
|

 Key Terms
! |  -state of being independent & self-directed
without outside control, to make one¶s own decisions
! 0
 -illness that lasts for an extended
period of time, usually greater than 6 months
! „
 -alteration in body function resulting in
reduction of capacities or shortening the normal life
span
! ? -causal relationship between a problem & it¶s
related or risk factors
! ?
 
-period during a chronic illness when
symptoms reappear after remission
! Ô
-
   
  
 

  
 
  
 
 
 
   
 
 
! Ô

 - State of health of an individual at a
given time. A report of health status may include
anxiety, depression, or acute illness & thus describe
the individual¶s problem in general.
! Ô
  - Concepts about health one believes to
be true
! Ô

 - actions people take to understand
their health state, maintain an optimal state of health.
Maintain an optimal state of health, prevent illness, &
injury, & reach their maximum physical & mental
potential
!
 -  

   
  
 

  
 

 
!
  
-course of action a person takes to
define state of his/her health & pursue a remedy
! › -period during a chronic illness when there
is a lessening of severity or cessation of symptoms
! ›
-factors that cause a client to be
vulnerable to developing a health problem
!   -subjective perception of balance,
harmony & vitality\
!   -
    


    

 
 
 
  
!  
 

 0 Ô
     
! Oraditionally
is defined in terms of the presence
or absence of disease.
! @orld Health Organization (@HO) definition of health ³a
state of complete physical, mental & social well-being, &
not merely the absence of disease or infirmity´
! ANA, Social Policy 1980 p 5 defined health as ³a
dynamic state of being in which the developmental and
behavioral potential of an individual is realized to the
fullest extent possible´. In this definition, health is more
than just absence of disease; it includes striving toward
optimal functioning and is affected by the following
personal traits: People¶s health beliefs influence their
health practices.
! Previous experience
! Expectations of self
! Age
! Socio-cultural influences
      
! @ellness is a state of well being.

! @ell-being is a subjective view of vitality & feeling well - can be

described objectively & can be plotted on a continuum

O  
     

1. " 
# Ability to carry out daily tasks, achieve fitness;
practice positive lifestyle habits
2. 
# Ability to interact w people & within environment that
each person is a part, to develop intimacy,
respect & tolerance for those with different beliefs.
3. ?
# Ability to manage stress & express emotions
appropriately, to accept limitations
4.
  
# Ability to learn & use info effectively, striving for
continued growth & learning to be able to
deal with new challenges.
5. 
# Belief in some force that serves to unite human
beings & provide meaning & purpose to life,
includes a person¶s own morals, values, & ethics.
 º Ô
   
! $º 
describes four models of health (Judith
Smith, 1981)
! 1) 0
 : Ohe narrowest interpretation of health
! Opposite of health is disease or injury
! @hen the s/s of disease are no longer present in a person the medical
practitioner considers health restored
!  › " 
 º 
! According to this model, people who can fulfill their roles are healthy
even if they appear clinically ill.
! Ohis model assumes that sickness is the inability to perform one¶s work
! Problem with this model is the assumption that a person¶s most
important role is the work role
! i.e. a man who works all day is healthy even though an x-ray film of his
lung indicates a tumor
! ´ |
 º 
! Health is a creative process; disease is a failure in adaptation, or
maladaption
! Ohe aim of treatment is to restore the ability of the person to adapt
(cope)
! Ë ?  º 
! Health is seen as a condition of actualization or realization of a person¶s
potential
! Illness is a condition that prevents self ±actualization
 V
  0
$| Ô? 
Also called the Ecologic Model predicts illness rather than in
promoting wellness, although identification of risk factors that
result form the interactions of agent, host, environment are
helpful in promoting & maintaining health. Ohis model has 3
dynamic interactive elements:
1.
 %factor or stressor that by its presence or absence
can lead to illness or disease
2. %person who may or may not be at risk of acquiring a
disease
3.  %all factors external to the host that may or
may not predispose the person to the development of disease
Since these 3 interact with each other, health is an ever-
changing state -

In balance = health

not balanced = disease

 Ô

 0 

! (grids or graduated scales) used to measure a

person¶s perceived level of wellness, from high level
of health a person¶s condition can move throughout
good health, normal, poor, extremely poor,
eventually to death
OÔ?Ô?|VOÔ
VV ?0
O


º

An individual's state of health is one of continual change. He moves back and

forth from health to illness and back to health again. His condition is rarely
constant. He may wake up feeling great, develop a headache mid-morning, and
feel fine again by noon. Ohe health-illness continuum (see figure 1-1) illustrates
this process of change, in which the individual experiences various states of
health and illness (ranging from extremely good health to death) that fluctuate
throughout his life.
 „ $ÔV    &

! a grid in which a health axis & environmental axis intersect. Ohe

health axis extends from peak wellness to death & the
environmental axis extends from very favorable to unfavorable. Ohe
intersection of the two axes forms four quadrants of health &
wellness. Dunn believes social wellness must be considered on a
worldwide basis

! High level wellness in favorable environment

! Emergent high level wellness in & unfavorable environment

! Protected poor health in favorable environment

! Poor health in an unfavorable environment

 O
$
   0 

! ranges form high-level wellness to premature death.

! Oo increase levels of health it occurs in 3 steps-
(1) awareness
(2) education
(3) growth
]

 
 Ô

    
"
 

 


 
1.  : genetic makeup, race, sex,
age & developmental level
2.  
 : mind-body interactions
& self concept
3. 0  : cognitive or intellectual
factors- lifestyle choices, spiritual & religious beliefs
?  


 
1. geography
2. environment
3. standards of living
4. Family & cultural beliefs
5. Social support & networks
 Ô
  º 

! Ô
V 0º 

used to determine whether it is likely to take action
regarding health
1) internals: people who think health is self-determined
2) externals: health controlled by outside forces

  „


!
 : highly personal state client physical, emotional,
intellectual, social developmental or spiritual function is
thought to be diminished

! 
 : alteration in body function resulting in decreased

capacities

!  %causation of disease

!
   : severe symptoms short duration

!  : >6 months;  : symptoms disappear;

 
: symptoms reappear

  


' 
 'Symptom experience 3 aspects

! physical experience of illness

! cognitive aspect

! emotional response
2) 
 Assumption of sick role
3) 
 ´Medical cure contact
 validation of real illness
 explanation of symptoms
 Reassurance
4) 
 Ëdependent client role
5) 
 (recovery or rehabilitation
 ?  

1) Impact on client: behavioral-emotional, self-concept,

body image, lifestyle change
2) Impact on family: role changes, task reassignment,
increased demands, increased stress. financial
problems, loneliness, change in social customs
 Ô
Ô

 
 
 



| 
 º 
O 
 

! |    : Chinese practice based on principle that
energy is channeled through the body along specific
pathways. Needles are inserted into specific body
points along the channels called meridians. Organs are
believed
to be attached to the skin points & meridians. Studies
have shown it is effective for pain.
0
O 
 : manipulation of the spine to decrease
back pain. Some MDs believe it is only effective with
conditions of the back, not the nervous, respiratory, or
GI systems as chiropractors believe.
 Ô 
º  : plants valued for medicinal
properties, flavor, scent, etc. Ohese herbs may label their
effectiveness but must be accompanied by an FDA disclaimer.
Ohere are no government standards for quality of herbs sold in the
U.S. Assess for herb use in clients. Some commonly used herbs
are:

Echinacea: supports the immune system

Ginseng: improves physical endurance, reduced

cholesterol

Gingko Biloba: enhances memory, acts as an antioxidant

St. John¶s @ort: reduces depression

Milk Ohistle: acts as antioxidant, revitalizes liver

!
 
 : involves herbs, nutritional
counseling, acupuncture, & homeopathy
! Ô 
 %based on theory that cure for the
disease lies in the disease itself. Sick are treated
with highly diluted amounts of substance that
produce same symptoms as the disease (i.e.
taking belladonna, which produces cold-like
symptoms for a cold or minute amount of allergen
to treat an allergy)
 ]


! 0 O  
  ± temp of deep tissues of the body,
remains relatively constant.
!  
 O  
  ± temp of skin, subQ tissue &
fat ± rises & falls in response to environment
! Ô


 ± when the amount of heat produces =
amount of heat lost.
! 

  $
 :
1) Basal metabolic Rate (BMR) ± rate of energy used by
body, required to maintain essential activities ± Ļč age.
2) Muscle activity ± increases the metabolic rate
3) Ohyroxin output - ^ thyroxin output increases rate of
cellular metabolism ± called chemical thermo-genesis
4) Epinephrine, norepinephrine & sympathetic
stimulation.
5) Fever
! Ô
  
 
! Radiation ± the transfer of heat from the surface of one
object to the surface of another without contact

! Conduction ± the transfer of heat from one molecule to

a molecule of lower temp. ± can not take place without
contact.

! Convection ± dispersion of heat by air currents

! Vaporization (Evaporation) ± continuous evaporation of

moisture from the respiratory tract ± called insensible
water loss producing insensible heat loss
O 
 ]
1) 
to a health care agency to obtain
baseline data
2) @hen a client has

 

 or
reports symptoms such as chest pain or feeling hot
or faint
3)    
 surgery or invasive    
4)   
)
 the administration a
 
that could affect the respiratory or
cardiovascular systems, for example, before giving a
digitalis preparation
5)    
 any nursing   that
could affect the vital signs (ambulating a pt who has
been on bed res
 ]


] | 

|
 
 

  
 




   
Yewborn 36.8 Axillary 130 (80-180) 35 (30-80) 73/55
1 ± 3 Years 37.7 Rectal 120 (80-140) 30 (20-40) 90/55
6 - 8 years 37 Oral 100 (70-120) 20 (15-25) 95/57
10 years 37 Oral 70 (50-90) 19 (15-25) 102/62

Teen years 37 Oral 70 (50-90) 18 (15-20) 120/80

Adult 37 Oral 80 (60-100) 16 (12-20) 120/80

Older Adult >70 years 36 Oral 80 (60-100) 16 (12-
20) Possibly > Diastolic
  O  
  
! ›  
  %system that regulates
body temp has 3 main parts: sensor in shell &
core, integrator in hypothalamus & effecter system
that adjusts the production & loss of heat
!  : most are in the skin, & there are more
receptors for cold than warmth. @hen the skin
becomes chilled 3 physiologic processes to
increase body temperature take place:
! 1) Shivering increases heat production
! 2) Sweating inhibited to decreased heat loss
! 3) Vasoconstriction decreases heat loss
Ô 

 
: controls core temp.
! @hen senses heat send out signals to decrease
heat production, increase heat loss, when cold
sensed signals to increase heat production,
decrease heat loss.
! Signals form cold-sensitive receptors of
hypothalamus initiate effectors such as
vasoconstriction.
! Shivering, release of epinephrine.
! @armth receptors effectors- sweating, peripheral
vasodilatation
 

   
1. Age: old & young are more sensitive to temp of
environment.
2. Diurnal variations: temp usually changes as much
as 1.8 F between early morning & late afternoon.
3. Exercise: hard work and strenuous exercise
increase temperature.
4. Hormones: ovulation increases body temp.
5. Stress: increases metabolic activity therefore
increased temp.
6. Environment: extremes in environmental temp can
affect temp regulatory system.
 | 
  :
! Pyrexia, hyperthermia, fever: above usual temp
range

! Hyperpyrexia: very high fever (105.8 F)

! Febrile: has fever

! Afebrile: no fever
 0    *Ë 
1)
    : body temp alternates between periods of
fever & no fever at regular intervals (seen in some very specific
illnesses like malaria).
2) ›    : wide range of temp variations (>3.6 F) over 24
hr. period, all above normal
3) › 
  : short febrile periods of a few days are
interspersed with periods of 1 ±2 days of
normal temp
4) 0
  : fluctuates minimally always above normal

! In fever the set point of hypothalamic thermostat changes form

normal to higher. Until body reaches this chills result. @hen
reached pt. Comfortable, when drops profuse diaphoresis,
flushing occurs Ohis is known as crisis, flush, or defervescent
stage

! Very high temp damages parenchyma of cells in body particularly

in brain where destruction of neuronal cells is irreversible. Can
eventually cause death
0
  

! Onset (cold or chill stage)

! Increased heart rate

! Increased respiratory rate & depth

! Shivering

! Pallid, cold skin

! Complaints of feeling cold

! Cyanotic nail beds

 0ont..

! Gooseflesh appearance of skin

! Cessation of sweating

! Absence of chills

! Skin touch feels warm

! Photosensitivity

! Glassy-eyed appearance
! Increased pulse & respiratory rates
! Increased thirst
! Mild to severe dehydration
! Drowsiness, restlessness, delirium or convulsions
! Herpetic lesions of the mouth
! Loss of appetite (if the fever is prolonged)
! Malaise, weakness, & aching muscles
! Defervescence (fever abatement)
! Skin appears flushed & feels warm
! Sweating
! Decreased shivering
! Possible dehydration
 
   
  
1) Monitor vital signs
2) Assess skin color & temp
3) Monitor white blood cell count, hematocrit value, &
other pertinent laboratory reports for indications of
infection or dehydration
4) Remove excess blankets when the client feels warm,
but provide extra warmth when the client feels chilled
5) Provide adequate nutrition & fluids (e.g. 2500-3000
mL per day) to meet the increased metabolic demands &
prevent dehydration. Clients who sweat profusely can
become dehydrated
6) Measure I & O
7) Reduce physical activity to limit heat production,
especially during the flush stage.
8) Administer antipyretics as ordered
9) Provide oral hygiene to keep the mucous
membranes moist. Ohey can become dry & cracked
as a result of excessive fluid loss
10) Provide a tepid sponge bath to increase heat
loss through conduction
11) Provide dry clothing & bed linens.
Ô  
%     

´  

1) Excessive heat loss
2) Inadequate heat production
3) Impaired hypothalamic thermoregulation
0
  

1) Decreased body temp
2) Severe shivering (initially)
3) Feelings of cold & chills
4) Pale cool waxy skin
5) Hypotension
6) Decreased urinary output
7) Lack of muscle coordination
8) Disorientation
9) Drowsiness progressing to coma
    

1) Accidental: exposure to cold environment,
immersion in cold water, lack of adequate clothing,
shelter, or heat
2) Induced hypothermia: to decrease need for
oxygen during surgery

    


1) Provide a warm environment (room temp)
2) Provide dry clothing
3) Apply warm blandest
4) Keep limbs close to body
5) Cover the client¶s scalp with a cap or turban
6) Supply warm oral or intravenous fluids
7) Apply warming pads
 |   % 
 
1. Oral: most accessible & convenient, but glass can
break if bitten contraindicated in kids under 6 or those
with convulsive disorders
2. Rectal: most reliable, but inconvenient & unpleasant,
injure rectum following rectal surgery, stool may
interfere with temp, or may cause perforation
3. Axillary: safest & most non-invasive, but thermometer
must be left there a long time to get an accurate
measure
4. Oympanic membrane: readily accessible; reflects the
core temp. Very fast, but can be uncomfortable,
may injure membrane if placed in too far, repeated
measures may vary, Right & left measures may vary.
"   @ave of blood created by contraction of
left ventricle of the heart

! Pulse wave represents stroke volume output & amount of

blood that enters the arteries with each ventricular
contraction

! Compliance of arteries is their ability to contract & expand

! At rest heart pumps ~ 5 L of blood per minute. Ohis is

Cardiac Output (CO).

! CO= Stroke volume x Heart Rate

! Peripheral pulse: located in periphery

! Apical pulse: apex of heart, central pulse



   
 
1. Age: age increases, pulse rate decreases
2. Sex: @ puberty M > F
3. Exercise: increases with activity
4. Fever: increase in response to lowered b/p &
increases metabolic rate
5. Meds: some increase, some decrease
6. Hemorrhage: increase
7. Stress: increase rate & force
8. Position change: sitting or standing decrease b/p,
increase pulse rate
 "   
1. ›

%readily accessible
2. O 
: used when radial pulse is not accessible
3. 0
: used for infants, used in cases of cardiac arrest,
used to determine circulation to the brain
4. |
: routinely used for infants & children up to 3 years of
age, used to determine discrepancies with
radial pulse, used in conjunction with some medications
5

: used to measure b/p, used during cardiac arrest
in infants
6.  
l: used in cases of cardiac arrest, used for infants &
children, used to determine circulation to a leg
7. "
%used to determine circulation to the lower leg
8. " 
: used to determine circulation to the foot
9. " 
%used to determine circulation to the foot
|    # 


 ԛ%
1. Meds that affect HR
2. Has client been active
3. Baseline data
4. @hether client should assume a particular position
    


1. Rate: tachycardia > 100 bpm, bradycardia < 60
bpm
2. Rhythm: dysrhythmia: irregular rhythm, assess
apical, get ECG
3. Pulse volume: normal, full, bounding, weak,
feeble, thready
4. Elasticity of arterial wall: expansibility or deformity
5. Check that peripherals are = bilaterally
"  
*

  
  %
 

  
! Newborns & kids up to 2 or 3 years. Use apical

! Very obese or elderly. Use Doppler or apical

! Ohose with heart disease. Use apical

! Oo specific body part (i.e. pedal after surgery to leg

|
  
  : indicated for those with

irregular peripheral, or known cardio pulmonary or renal
disease. Assess before giving heart meds. Use in
newborns ± 3 years
› 
 - act of breathing
1. External respirations: interchange of oxygen & carbon
dioxide between alveoli of lungs & pulmonary blood
2. Internal respirations: takes place throughout body; it is
interchange of O2 & CO2 between circulating blood &
cells of body tissues
3. Inhalation or inspiration: intake of air into lungs
4. Exhalation or expiration: breathing out or the
movement of gases from lungs to atmosphere
5. Ventilation: refers to movement of air in & out of lungs
6. Hyperventilation: very deep rapid breath
7. Hypoventilation: very shallow breath
8. Costal breathing: external intercostals muscles & other
accessory muscles. Chest move up & out
9. Diaphragmatic breathing: involves contraction &
relaxation of diaphragm, observed by movement of
abdomen
|  
: resting
respirations should be assessed when pt is relaxed.
Anxiety affects rate/depth. Before assessing a nurse
would be aware of:
1. Pt normal breathing pattern
2. Influence of health problem on respiration
3. Meds or therapies that might affect respiration
4. Relationship or respiration to cardio function
›
     


 
 
  
  

1. Rate: normal= eupnea, slow = bradypnea, fast =

tachypnea
2. Depth: normal, deep, shallow; normal inspiration
500 mL of air is taken in, this is tidal volume
3. Rhythm: regular or irregular: infant less regular
than adult
4. Respiratory quality or character: aspects of
breathing that are different form normal effortless
breathing (i.e. labored breathing) also sound is
important
?    

   

! Uptake of oxygen from air into blood & release of

carbon dioxide from blood

! Hemoglobin in arterial blood that is saturated with

oxygen (measure with pulse ox)
› 
 O %
0   
: rhythmic waxing & waning of respirations,
form very deep to very shallow breathing & temporary apnea; often
associated with cardiac failure, increased intracranial pressure, or brain
damage

„ 
%difficult & labored breathing


: ability to breathe only in upright sitting or standing

positions

: shrill, harsh sound heard during inspiration with laryngeal

obstruction

 r: snoring or sonorous respiration, usually due to a partial

obstruction of the upper airway

 ! %continuous, high-pitched musical squeak or whistling sound

occurring on expiration & sometimes on inspiration when air moves
through a narrowed or partially obstructed airway
!  : gurgling sounds heard as air passes through
moist secretions in the respiratory tract

!
 
l retraction: indrawing between the ribs

! 
 : the ballooning out of the chest wall through

injured rib spaces; results in paradoxical breathing, during
which the chest wall balloons on expiration but is depressed
or sucked inward on inspiration

! Ô  : the presence of blood in the sputum

! "   ; a cough accompanied by expectorated

secretions

!    : a dry harsh cough without

secretions
 "   

| 
)": measure of pressure by blood as it flows

through arteries
· Systolic: result of contraction of ventricles, pressure
@ height of blood wave
· Diastolic: pressure of ventricles @ rest
· Pulse pressure: difference between diastolic &
systolic
 „  
)"

! Pumping action of heart: CO volume of blood pumped

into arteries, by heart. @hen heart pumping is strong &
volume increases, b/p increases
! Peripheral vascular resistance: peripheral resistance
increases B/P. Some factors are
Size of arterioles & capillaries
Lumen (small) increases pressure
Arteriosclerosis
Blood volume: decreases b/p decreases,
increases b/p increases
Blood viscosity: b/p higher if blood is more
viscous
 

 )"

! Age: pressure increases with age, peak @puberty

! Exercise: increased CO, rest 20-30 minutes for normal

! Stress: stimulation of SNS results in increased CO, vasoconstriction

! Race: African American males > 35 have higher b/p

! Obesity: increases b/p

! Sex: after puberty F have lower than M

! Meds: increase or decrease

! Diurnal variations: low early morning, rises throughout day

! Disease process: increase or decrease

 Ô   

! B/P that is consistently above normal. Usually

asymptomatic; contributes to MI.

! Dx. made when the average of 2 or more diastolic

readings on two visits subsequent to initial visit is 90
mmHG or higher

! Factors include thickening of artery walls

! Lifestyle factors: smoking, obesity, heavy alcohol

consumption, lack of exercise, increased cholesterol
levels, continued exposure to stress
Ô  %B/P below normal


Ô  : B/P falls when pt sits
or stands. Results from peripheral vasodilation. Do these
things when measuring B/P of pt with OH

1. Pt supine 2-3 minutes

2. Record pulse & b/p

3. Assist pt to slowly sit or stand, support in case of

faintness

4. After 1 minute in upright position, recheck pulse & b/p

5. Record rise in pulse of 40 bpm or drop in b/p of

30mmHg indicates Orthostatic VS, report
| )"
! Equipment: b/p cuff, sphygmomanometer, & stethoscope

! Site: usually on arm using brachial artery. Leg & forearm

can be taken. B/P on thigh when B/p can¶t be measured on
either arm

! Shoulder, arm, hand diseased

! Cast or bulky bandage on any part of limb

! Pt removal of axilla or hip lymph nodes on that side

! IV in that limb

! AV fistula in that limb

 º 

! Directly: catheter into brachial, radial, or femoral

artery; highly accurate
! Indirectly: Ausculatory: cuff, sphygmomanometer,
stethoscope relatively accurate. Use Kortokoff¶s
sounds:
! Palpatory: palpates pulsations, read
sphygmomanometer when first palpation is felt
(systolic) a single whip like vibration felt at diastolic
 0 
 )"

! Bladder cuff too narrow: high

! Bladder cuff to wide: low

! Arm unsupported: high

! Insufficient rest before reading: high

! Repeating too quickly: high systolic or low diastolic

! Cuff wrapped too loosely: high

! Deflating cuff too quickly: low systolic, high diastolic

! Deflating cuff too slow: high diastolic

! Failure to use same arm: inconsistent measure

! Arm above level of the heart: low

! After a meal or while smoking or in pain: high

 Ô
 

" 
Ô
|   Ô


  
 ´  
1) Complete assessment (upon admission)
2) Assessment of body system
3) Assessment of body part
!   

 
or uncomfortable to most invasive: Head,
neck, heart, lungs, ROM, (ears, mouth,
abdomen, genitals last). Usually nurses
assess a specific body area rather than the
whole body
 Ô

   
 :
! Be aware of normal physiological changes that occur with age

! Expose only areas of the body to be examined in order to avoid chilling

! Permit ample time for the client to answer questions & assume the required positions

! Beware of cultural differences. Ohe client may wasn¶t a family member present during disrobing

! Arrange for an interpreter if the client¶s language differs from that of the nurse

! Ask clients how they wish to be addressed, such as Mrs. or Miss

! Adapt assessment techniques to any sensory impairment; for example, make sure eyeglasses
or hearing aids are nearby

! Preparing the environment: well lighted & equipment organized for use. Provide privacy & room
should be warm

! Positioning: based on what needs to be assessed, client¶s physical condition, energy level &
age

! Draping: area to be assessed exposed all other areas draped

! Instrumentation: clean, good working order, readily accessible

! Inspection: visual examination, using sight. Should be deliberate, purposeful, & systematic.
Inspect with the naked eye or lighted instrument. Also olfactory & auditory cures are noted.
Visual inspection assesses for moisture, color, texture, shape position, size, color, & symmetry.
Lighting must be sufficient. Observation can be combined with the other techniques.

! Palpation: examination using sense of touch. Use pads of fingers because nerve endings make
them highly sensitive. Used to determine

! Oexture

! Oemperature

! Vibration

! Position, size, consistency, & mobility of organ masses

! Distention

! Pulsation

! Presence of pain upon pressure

  


! V%nurse extends dominant hand¶s finger parallel to
skin surface & presses gently while moving hand in circle
! „ %bimanually, done only with caution & with a qualified
instructor because pressure can damage internal organs.
Contraindicated with abdominal pain or undiagnosed pain
! Oo test skin temp use back of hand & fingers. Oo test for
vibration use palmer surface of hand

! General guidelines for palpation

! Hands clean & warm, fingernails short

! Areas of tenderness last

! Deep palpation after superficial

"  %Striking body surface to elicit sound that can be
heard or vibrations that can be felt
O  
   
! 1) Direct: strike area to be percussed directly with pads of
2, 3, or 4 fingers, or with pad of middle finger. Strikes are
rapid. Not used on thorax. Commonly used on adult
sinuses
! 2) Indirect percussion: striking an object held against body
area to be examined. Middle finger of nondominant hand
(pleximeter) is placed on skin (only distal phalanx) use tip
of flexed middle finger of other hand (plexor). Strike
pleximeter @ interphalangeal joint. Blows must be rapid,
short, firm to hear clear sound
! 3) Indicates whether tissue is fluid or air filled, or solid.
Flatness reflects most dense tissue (least amount or air) &
tympany least dense (greatest amount of air). Percussion
sound described according to intensity, pitch, duration, &
quality.
?    
! 1. Flatness: dull sound produced by very dense
tissue (muscle or bone)
! 2. Dullness: thud like by dense tissue (liver,
spleen, heart)
! 3. Resonance: hollow sound produced by lung
filled with air
! 4. Hyperresonance: not produced in normal body;
booming heard over emphysematous lung
! 5. Oympany: musical or drum like, produced form
air filled stomach
|  
%listening to sounds in the body. Direct
uses unaided ear. Indirect uses stethoscope.
Sounds are described as:
! 1. "(frequency of vibrations) low pitched:
heart sounds, high pitched: bronchial sounds
! 2.
  (amplitude) loudness or softness
(loud: bronchial heard form trachea, soft: breath
sounds in lungs
! 3. „ 
%(how long or short)
! 4. M
 (whistling, gurgling, or snapping etc.)
  
   

1. Stress can result from both positive & negative experiences

2. Concept or stress provides a way of understanding the person
as a unified being who response in totality to a variety of changes
that take place in daily life
3. Stress: a condition in which the human responds to changes in
its normal balance
4. Stressor: any event or stimulus that causes one to experience
stress
5. Coping mechanism: response to stress

   
Internal: originate within a person (cancer, depression)
External: originate outside the person (death, moving)
„   %
! Child: resolving conflict between independence & dependence,
beginning school & establishing peer relationships & adjustments, &
coping with peer competition

! Adolescent: accepting changing physique, developing relationships

involving sexual attraction, achieving independence, & choosing a
career

! Young adult: getting married, leaving home, managing a home, getting

started in an occupation, continuing one¶s education, & rearing children

! Middle adult: accepting physical changes of aging, maintaining social

status & standard of living, helping teenage children to become
independent, & adjusting to aging parents

! Older adult: accepting decreasing physical abilities & health, accepting

changes in residence, adjusting to retirement & reduced income, &
adjusting to death of spouse & friends

! Situational: unpredictable, occur at anytime (death, marriage)

?  

! Physical: threaten physiologic homeostasis

! Emotional: produce negative or non constructive

feelings about self

! Intellectual: influence perception & problem solving

! Social: alter relationships with others

! Spiritual: challenge one¶s beliefs

º  
  
 º : stress is defined as a
stimulus that arouses physiologic and/or psychologic
reactions that may increase one¶s vulnerability to illness.
Homes & Rahe assigned numerical value to 43 life
changes or events. Ohe higher the score the higher the
stress
›  
 º : stress is considered a
response. Non-specific response is called general
adaptation syndrome (GAS). Ohe response of the body
occurs with release of certain adaptive hormones &
subsequent changes in the structure & chemical
composition of the body. Besides overall adaptation the
body could also adapt locally one organ or body part.
Ohat is called local adaptation syndrome (LAS)
&| V|
 ´
 

1. Alarm reaction (AR): alerts the body¶s defense against

the stressor. Ohis stage has 2 parts
Shock phase: autonomic nervous system reacts.
Epinephrine & cortisone are released into the body.
Short-lived response 1 minute to 24 hours
Countershock: changes produced in the shock phase
are reversed
2. Stage of Resistance (SR): when body¶s adaptation
takes place. Body attempts to cope with stressor, & limit
stressor to smallest area of body it can deal with.
3. Stage of exhaustion (SE): Ohe adaptation can¶t be
maintained if adaptation has not overcome stressor,
stress effects spread to entire body. Either body will
return to normal or death occurs.


 
! Physiologic indicators

! Pupils dilate to increase visual perception when serious threats to the body arise

! Sweat production (diaphoresis) increases to control elevated body heat due to increased
metabolism.

! Ohe heart rate increases, which leads to an increased pulse rate to transport nutrients & by
products of metabolism more efficiently

! Skin is pallid because of constriction of peripheral blood vessels, an effect of norepinephrine

! Constriction of vessels in blood reservoirs, such as the skin, kidneys, & most large interior
organs

! Increased secretion of rennin, an effect of norepinephrine

! Increased sodium & water retention due to release of mineralocorticoids, which results in
increased blood volume

! Increased cardiac output

! Ohe rate & depth of respirations increase because of dilation of the
bronchioles, promoting hyperventilation

! Urinary output decrease

! Ohe mouth may be dry

! Peristalsis of the intestines decreases, resulting in possible constipation

& flatus

! For serious threats, mental alertness improves

! Muscle tension increases to prepare for rapid monitor activity or

defense

! Blood sugar increases because of release of glucocorticoids &

gluconeogenesis

! Psychologic indicators: anxiety, fear, anger, & depression. Some help,

some hinder
|   %reaction to stress, state of mental
uneasiness, apprehension, dread, or foreboding. It is
experience at conscious, unconscious, &
subconscious levels. It differs from fear in 4 ways

1. Source of anxiety is not identifiable

2. Anxiety is r/t future, fear is r/t present

3. Anxiety is vague, fear is definite

4. Anxiety is result of psycho logic or emotional

conflict, fear is result of discrete physical or
psychologic entity
|   
 
     
1. Mild: produces slight arousal state that enhances
perception, learning, & productive abilities
2. Moderate: increases arousal state to a point
where the person expresses feelings of tension,
nervousness, or concern
3. Severe: consumes most of the person¶s energies
& requires intervention. Perception is further
decreased
4. Panic: overpowering, frightening level of anxiety,
causing the person to lose control. Less frequently
experienced

%an emotion or feelings of apprehension aroused
by impending or seeming danger, pain or other
perceived threat
| %emotional state consisting of a subjective feeling
of animosity or strong displeasure. A clearly expressed
verbal communication of anger is constructive. Ohe
angry person ³gets it off the chest: & prevents emotional
build-up.
„  %a common reaction to events that seem
overwhelming or negative
I. Emotional symptoms can include feelings of tiredness,
sadness, emptiness, or numbness
II. Behavioral signs: irritability, inability to concentrate,
difficulty making decisions, loss of sexual desire, sleep
disturbance, crying social withdrawal
III. Physical signs: loss of appetite, weight loss,
constipation, headache dizziness

      
: psychologic defensive mechanisms that develop as the personality
attempts to defend itself, establish compromises, & allay inner tensions

0 
%covering up weaknesses by emphasizing a more desirable trait or overachievement in a more

comfortable area (a high school student too small to play football becomes the star long distance runner for track)

„ 
: an attempt to screen or ignore unacceptable realities by refusing to acknowledge them (a woman, though
her father has metastic cancer, continues to plan a family reunion 18 months in advance)

„
  : the transferring or discharging of emotional reactions from one object or person to another object
or person (husband & wife have an argument; he becomes angry & hits the door instead of his wife).

 
: an attempt to manage anxiety by imitating the behavior of someone feared or respected (a
student nurse imitating the nurturing behavior she observes one of her instructors using with clients)

  
!
: a mechanism by which an emotional response that normally would accompany an

uncomfortable or painful incident is evaded by the use of rational explanations that remove form the incident any
personal significance & feelings. (Ohe pain over a parent¶s sudden death is reduced by saying; ³He wouldn¶t have
wanted to live disabled.)´

+ : a form of identification that allows for the acceptance of others¶ norms & values into oneself, even
when contrary to one¶s previous assumptions. (A 7 year old tells his little sister, ³don¶t talk to strangers.´ He has
introjected this value from the instructions of parents & teachers.
! º!
: not acknowledging the significance of one¶s behavior (a person says, µdon¶t
believer everything my wife tells you. I wasn¶t so drunk I couldn¶t drive.´)

! "+ : a process in which blame is attached to others or the environment for
unacceptable desires, thoughts, shortcomings, & mistakes (a husband forgets to pay a bill &
blames his wife for not giving it to him sooner.)

! ›

!
: justification of certain behaviors by faulty logic & ascription of motives that are
socially acceptable but did not in fact inspire the behavior. (A mother spanks her kid too hard &
says it was all right because he couldn¶t feel it through the diaper anyway.)

! ›
formation: a mechanism that causes people to act exactly opposite to the way they
feel. (An executive resents his bosses for calling in a consulting firm to make recommendations
for change in his department but verbalizes complete support of the idea & is exceedingly
polite & cooperative.)

! ›  : resorting to an earlier, more comfortable level of functioning that is

characteristically less demanding & responsible. (An adult throws a temper tantrum when he
does not et his own way)

! ›  : an unconscious mechanism by which threatening thoughts, feelings, & desires

are kept form becoming conscious; the repressed material is denied entry into conscious (a
teenager, seeing his best fiend killed in a car accident, becomes amnesiac bout the
circumstances surrounding the accident.)
!  
: displacement of energy associated with more primitive sexual or aggressive drives into socially
acceptable activities. (A person with excessive, primitive sexual drives invests s\psychic energy into a well-
defined religious value system)

!   : the replacement of a highly valued, unacceptable, or unavailable object by a less valuable
actable, or available object. (A woman wants to marry man exactly like her dead father & settles for someone
who looks a little bit like him.)

!
: an action or words designed to cancel some disapproved thoughts, impulses, or acts in which the
person relieves guilt by making reparation. (A father spanks his child & the next evening brings home a
present for him.)

! 0 
: thinking responses that include problem solving, structuring, self-control or self
discipline, suppression, & fantasy

! " : thinking through the threatening situations, using specific steps to arrive at a solution

!   : arrangement or manipulation of a situation so that the threatening events do not occur.

!  : assuming manner & facial expression that convey a sense of being in control or in charge, no
matter the situation

!   : consciously & willfully putting a thought or feeling out of mind; ³I won¶t deal this that today, I will
tomorrow´

! 

 : unfulfilled wishes & desires are imagined as fulfilled.