New Own Nursing Review

•Which of the following is an early manifestation of decreased cardiac output?

A •Fatigue •B. Substernal pain •C. Nail bed cyanosis •D. Shortness of breath ---A ---

You have the following information: •Oral temperature-36.8°C.Radial Pulse-112 weak, threadyApical pulse-117 regularRespirations-24 regularBlood Pressure-104/56 right arm-102/50 left arm •What is the pulse deficit?

•. 2 •B. 5 •C. 6 •D. 48 --- B ---

•What is the major health problem resulting from a pulse deficit?

•. Bradycardia •B. Activity intolerance •C. Decreased cardiac output •D. Impaired tissue perfusion --- C --

Factor for irregular pulse:

•Orthopnea - shortness of breath, occur when lying flat, causing person to sleep only propped up or sitting in a chair •Palpitations - a rapid strong irregular heartbeat •Dyspnea - difficulty breathing during non-strenuous activities or in any position. •Fatigue - Chest pain-

how does poor controlled pain affect physiological changes

Acute pain responses cardiac = tachycardia, elevated BP, increased myocardial O2 demand, increased cardiac output Pulmonary = Hypoventilation, Hypoxia, Decreased cough, atelectasis. Gastrointestinal = nausea, vomiting, Ileus. Renal = Oliguria, urinary retention, Musculoskeletal = spasms, joint stiffness Endocrine = increased adrenergic activity. Central Nervous Syt = Fear, anxiety, fatigue Immune System = impaired cellular immunity Poorly controlled paid = depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life.

Assessing apical & radial Pulse

Counting of the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical-radial pulse rate. A difference between the apical and radial pulse rates is called the pulse deficit and indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.

•To verify irregular pulses

Two provider should assess the pulses while in a sitting position * If more than 2 beats diff. btw radial and apical = cardiac deficit •Check for other signs for cardiac output : •*Edema,( swelling of body parts causing to leak fluid into tissues •swelling * syncope ( loss of consciousness related to insufficient blood flow to the brain, fainting, passing out) * dizziness * cyanosis (bluish discoloration)

What is neuropathic pain

pain due to a lesion or disease in the somatosensory nervous system. It implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat. Pain is often perceived Long after the site of injury heals, and it evolves into a chronic condition. Conditions that cause neuropathy = diabetes mellitus, Herpes Zoster ( shingles), HIV ( AIDS), sciatica, trigeminal neuralgia, phantom limp pain, and chemotherapy.

•What should the nurse do when a pulse deficit is suspected?

•Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute. •B. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds. •C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute. •D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse. -- D ---

•Which action should the nurse perform after identifying a pulse deficit?

•Reassess the apical-radial pulse in 5 minutes. •B. Assess the patient for signs of decreased cardiac output. •C. Notify the primary health care provider of the pulse deficit. •D. Initiate interventions directed toward managing the patient's symptoms. --- B ---