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Nursing > Basic Nursing Fundamental Skills > Flashcards

Basic Nursing Fundamental Skills Flashcards

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0
Q

Apnea

A

Absence of breathing

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1
Q

Afebrile

A

Without fever

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2
Q

Arrhythmia

A

A pulse with irregular rhythm

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3
Q

Blood pressure

A

The force that circulating blood exerts against the arterial walls as the heart contracts and relaxes; the unit of measure is millimeters of mercury (mmHg). It is recorded as 2 separate pressures (e.g., systolic and diastolic) in fraction form

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4
Q

Bounding Pulse

A

An unusually strong pulse

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5
Q

Bradycardia

A

An abnormally slow heartbeat; below 60bpm in adults

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6
Q

Core Temperature

A

A measure of the amount of heat in the deep tissues

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7
Q

Diastolic Pressure

A

The pressure exerted on the arterial walls during ventricular relaxation at which point, the left ventricle is filled with blood. This is the last blood pressure sound you will heart and is the bottom number on a blood pressure reading

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8
Q

Dyspnea

A

Labored or difficult breathing

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9
Q

Expiration

A

The act of expelling air out of the lungs

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10
Q

Febrile

A

With fever

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11
Q

Hypertension

A

Typically asymptomatic abnormally high blood pressure; may cause rupture of the arteries and destruction of organs; sustolic blood pressure reading greater than 140mmHg and diastolic blood pressure reading greater than 90mmHg

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12
Q

Hyperthermia

A

Elevated body temperature related to the body’s inability to promote heat loos or reduce heat production

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13
Q

Hypotension

A

Hypotension Abnormally low blood pressure; may cause insufficient perfusion of internal organs; systolic vlood pressure reading of 90mmHg or lower

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14
Q

Hypothermia

A

Decreased body temperature related to heat loss during prolonged exposure to cold, overwhelming the body’s ability to produce heat

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15
Q

Inspiration

A

The act of taking air into the lungs

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16
Q

Korotkoff

A

Sound Sounds heard, via stethoscope, over an artery distal to the blood pressure cuff

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17
Q

Perfusion

A

The flow of blood through tissues, providing them with oxygen and nutrients, and removing waste products

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18
Q

Pulse

A

Regular, recurrent expansion and contraction of an artery produced by waves of pressure caused when the heart beats. The sensation can be felt when the fingertips lightly compress an artery against an underlying bone

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19
Q

Pyrexia

A

(Fever) Elevated body temperature

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20
Q

Orthostatic Hypotension (Postual Hypotension)

A

Occurs when a person rising upright from a lying or sitting position causes fainting, weakness, or lightheadedness and a significant drop in blood pressure

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21
Q

Respiration

A

The exchange of gases between the atmosphere, blood, and body cells

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22
Q

Respiration Rate

A

A measurement that consists of one inspiration and one expiration

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23
Q

Sphygmomanometer

A

A compression cuff with a pressure bulb containing a release valce that is used to obtain blood pressure. Comes in aneroid and mercury forms

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24
Q

Systolic Pressure

A

The peak pressure exerted on the arterial walls during ventricular contraction at which point, the left is emptied. This is the first blood pressure sound you will hear and is the top number on a blood pressure reading

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25
Q

Tachycardia

A

An abnormally elevated heartbeat; above 100 bpm in adults

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26
Q

Tachypnea

A

Excessively rapid breathing

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27
Q

Temperature

A

A measure of the amount of heat below the skin and the subcutaneous tissues

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28
Q

Thready Pulse

A

A weak and rapid pulse

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29
Q

Vital Signs

A

Health status measurements of life that are used to evaluate a patient’s condition (e.g., temperature, respiratory rate, pulse, blood pressure). Pain, a subjective symptom, is also a vital sign because of the effect it has on other vital signs

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30
Q

B/P

A

Blood pressure

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31
Q

BPM

A

BPM Beats per minute

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32
Q

C

A

Centigrade

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33
Q

DBP

A

Diastolic blood pressure

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34
Q

F

A

Fahrenheit

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35
Q

mmHg

A

millimeters of mercury

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36
Q

P

A

Pulse

37
Q

R

A

Respirations

38
Q

RR

A

Respiratory rate

39
Q

SBP

A

systolic blood pressure

40
Q

T

A

temperature

41
Q

VS

A

vital signs

42
Q

Factors that increase vital signs: - exercise

A
  • eating
  • anger
  • hormone levels
  • stress
  • stimulant drugs
  • pain
  • age (increase blood pressure)
43
Q

Factors that decrease vital signs

A
  • rest
  • depression
  • depressant drugs
  • age (decrease P and RR)
44
Q

Normal temperature for the average adult:

A

Oral: 98.6 F
Rectal: 99.6 F
Axillary: 97.6 F
Tympanic: 98.6

45
Q

Normal pulses: Adults

Children , infants

A

Adults is 60-100 bpm
Children is 100-120 bpm
Infants is 120-160 bpm

46
Q

Normal respiration rates: Adult children infants

A

Adults: 12-20 bpm
Children: 20-30 bpm
Infants: 30-50 bpm

47
Q

Normal systolic pressure in adults:

A

90-140mmHg

48
Q

Stage 1 hypertension (systolic)

A

140-159 mmHg

49
Q

Stage 2 hypertension (systolic)

A

160 mmHg and above

50
Q

Normal diastolic pressure

A

60-90 mmHg

51
Q

Stage 1 hypertension (diastolic)

A

90-99 mmHg

52
Q

Stage 2 hypertension (diastolic)

A

100 mmHg and above

53
Q

True or False: Although most vital sign values will fall within these norms and ranges, the patients overall condition must be considered so, not all values outside these ranges must be reported.

A

False: ALL values outside these ranges must be reported

54
Q

How many different types of thermometers are there?

A

5

55
Q

What are the different types of thermometers?

A
  1. Glass thermometers
  2. Electronic thermometers
  3. Tympanic thermometers
  4. Temporal thermometer
  5. Heat sensitive patch, chemical dot thermometers or tape changes color at different ranges
56
Q

Characteristics of glass thermometers:

A

Made of a hollow glass stem and bulb filled with mercury. Must shake down thermometer to lower mercury level prior to use. Marked in 0.2 degree increments. Blue probe-Oral. Red probe-Rectal. Time delay for temperature readings:
Oral-3min
Rectal-3min
Axillary-10min
Health care agencies no longer use glass thermometers

57
Q

Characteristics of electronic thermometers:

A

Read out unit that produces an audible beep when the measurement is complete and displays the reading on the screen. The probe requires a disposable plastic cover to prevent the spread of pathogens. Permanent battery models require recharging and disposable battery models require return to the base unit periodically.

58
Q

Characteristics of tympanic thermometers:

A

An infrared sensor measures the temperature fo the tympanic membrane. The tympanic thermometer is frequently used for critically ill patients, infants, and children because it can be used without rousing the patient.

59
Q

Characterisitics of temporal thermometer:

A

An infrared sensor measures the temperature of the superficial temporal artery. Used by sweeping the sensor across the forehead and just behind the ear

60
Q

Characteristics of heat sensitive patch:

A

Chemical dot thermometers or tape changes color at different ranges. Most are for single use only. Least accurate method for taking temperature. Use in accordance with local policy.

61
Q

List the BP equipment

A
  1. Stethoscope

2. Sphygmomanometer (cuff): 2 types, manual and electronic

62
Q

Steps to assess vital signs:

A
  1. Medical aspepsis
  2. Properly identify the patient
  3. Assess for patient safety, privacy, allergies, comfort and education
  4. Ensure the patient has had nothing hot or cold to eat or drink for 15min
  5. Ensure the patient has not smoked for at least 15min
  6. Ensure the patient has not been physically active for at least 15min
63
Q

How many patient identifiers does the Joint Commission require?

A

2

64
Q

True or False: Oral temperature route is contraindicated in children less than 6 years of age, patients who are mouth breathers, who have had oral or nasal surgery, a histroy of epilepsy, or who are unconscious, confused or uncooperative.

A

True

65
Q

What is a down side to taking an oral temperature?

A

Measurements can be delayed if patient recently ingested foods or fluids, smoked or is receiving oxygen by mask/cannula

66
Q

Which probe do you use when taking an oral temperature?

A

the blue probe

67
Q

Which probe do you use when taking an axillary temperature?

A

the blue probe

68
Q

When do you NOT use the blue probe?

A

Taking a rectal temperature

69
Q

When taking an axillary temperature, should you also inspect for skin lesions?

A

Yes

70
Q

Which route for taking temperature is safer and less disturbing to infants and children?

A

Axillary

71
Q

How does the tympanic thermometer provide an accurate reading?

A

It provides an accurate core temperature reading because eardrum is close to the hypothalamus

72
Q

What are the advantages of taking a tympanic temperature?

A

Very rapid measurement, 2-5 sec, unaffected by smoking or oral intake of foods or fluids.

73
Q

What are the disadvantages of taking a tympanic temperature?

A

Cerumen impaction will distort readings and it is contraindicated in patients who have had surgery of the ear or tympanic membrane

74
Q

What is the difference in procedures for taking a tympanic temperature for adults compared to children?

A

For adults, pull ear pinna backward, up and out. For children 3 years and younger, pull the pinna down and back. For children 3 years and odler, pull pinna up and back.

75
Q

For what patients are rectal thermometers contraindicated?

A

In patients with diarrhea, have had perineal/rectal surgery, with bleeding tendencies or cardiac patients

76
Q

What position should the patient be in when taking a rectal temperature

A

Sim’s position with upper leg flexed

77
Q

How much of the probe should be lubricated?

A

1-1.5 inches for adults and 1 inch for an infant

78
Q

How far do you insert the rectal thermometer?

A

1-1.5 inches for adults or 3/4-1 inch for an infant. DO NOT force thermometer

79
Q

Pulse characteristics:

A
  • Rate
  • Rhythm
  • Strength
  • Equality
80
Q

If the patient is supine, how should you position their arm?

A

Place the patient’s forearm straight alongside the body or across lower chest or upper abdomen

81
Q

If the patient is sitting, how should you position their arm?

A

Bend the patient’s elbow 90 degrees, and support lower arm on chair or on the nurse’s arm

82
Q

If the pusle is irregular, how long do you count the rate?

A

A full 60 sec

83
Q

Characteristics of Respiration

A
  • Rate
  • Rhythm
  • Depth
  • Sound by auscultation
84
Q

True or False: Do not let the patient know that you are assessing respirations;

A

a patient can alter the rate and depth of breathing True

85
Q

Where can the blood pressure be taken by auscultation?

A

Blood pressure can be taken above the antecubital space on the arm or over the mid-thigh on the leg.

86
Q

Is it normal for children’s diastolic blood pressure to continue to zero

A

Yes

87
Q

If the patient is engaging you in an interesting conversation about birds while you are trying to take their blood pressure, what should you do

A

Respectfully ask them to shut up

88
Q

When might taking a blood pressure by palpation be necessary?

A

When a working stethoscope is unavailable or the background noise is too loud to hear the pulse

89
Q

How do you record taking a blood pressure by palpation?

A

This blood pressure reading will only have 1 number, the systolic pressure, over the letter “P” for palpation

90
Q

What is the downside to taking a blood pressure electronically?

A

They are more sensitive to outside interference and are susceptible to error

Nursing (1 decks)

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