chap 8 Flashcards
who created AIDET?
Studor group
AIDET is a
evidence based communication tool
AIDET
- acknowledge
- introduce
- duration
- explanation
- thank you
acknowledge
- show enthusiasm
- eye contact
- smile & greet
- “10/5” rule
introduce
- complete any time change responsibilities
- job title
- certification/licensure
- experience
- number of procedures
duration
- how long you will be w/ pt
- if any delays/interruptions may occur
explanation
- what you will be doing/why
- what pt/family should expect
- what might be nxt steps
thank you
- you enjoyed working w/ them
- thank for time
- shake hand
how do you prepare for general survey?
observe
- skin color
- dress
- hygiene
- posture/gait
- physical development
- body build
- apparent age
- gender
general survey
- physical development
- gender/sexual development
- apparent age
- skin condition/color
- dress/hygiene
- posture/gait
- LOC
- behaviors, body movements, affect
- facial expressions
- speech
- vital signs
VS
- temp
- pulse
- respirations
- BP
VS provide data on
status of
- cardiovascular
- neurologic
- peripheral vascular
- respiratory
- pain
is physical examination subjective/objective?
objective
equipment for physical exam
- thermometer
- disposable covers
- BP cuff
- stethoscope
- watch w/ second hand
order of VS
- temperature
- pulse
- respirations
- BP
- pain
factors that affect temperature
- dinural cycle
- ovulation/mensuration
- strenuous exercise
- age
- stress
- exposure to cold/heat
- illness
tympanic temp range
98-100.9 F
oral temp range
96.6-99.5 F
axillary temp range
95.6-98.5 F
temporal temp range
97.4-100.3 F
rectal temp range
97.4-100.3 F
standard temp range
96-99.5 F
hyperthermia
> 100 F
hypothermia
< 96 F
shock wave
produced when heart contracts & pumps blood out of ventricles into aorta
peripheral pulses
- carotid
- radial
- brachial
- pedal
characteristics of peripheral pulse
- rate
- rhythm
- amplitude/contour
- elasticity
normal adult BPM
60-100 beats/min
tachycardia
- rapid
- > 100 beats/min
when could tachycardia occur?
with fever, certain medications, stress, abnormal states
bradycardia
- slow
- < 60 beats/min
when could bradycardia occur?
- sitting/standing for long periods
- heart block or dropped beats
sinus arrhythmia
- common in children/young adults
- rhythm speed up (inspiration) & slows with expiration
amplitude
- 3+ bounding
- 2+ normal
- 1+ weak, thready
- 0 absent
normal respiration rate
12-20 breaths per minute
depth of respiration
- unlabored/labored
- shallow/deep
- use of accessory muscles
systolic BP
measurement of pressure of blood in the arteries when ventricles are contracted
diastolic BP
measurement of pressure of blood in arteries when ventricles relaxed
normal BP
120/80 or less
factors affecting BP
- cardiac output
- elasticity of arteries
- blood volume
- blood velocity (heart rate/thickness)
BP cuff size
80% of arm circumference
normal systolic
< 120-129 mmHg
normal diastolic
< 80-84 mmHg
prehypertension
120-139/80-89
orthostatic hypotension
low BP that occurs upon standing up
orthostatic hypotension measures
drop of > 20 mmHg when standing up
hypertension
> 140/90
stage 1 hypertension
140-159/90-99
stage 2 hypertension
> 160/>100
stage 3 hypertension
> 180/110
expected findings for oxygen saturation
upper 90s
infants/pediatrics considerations w/ measurements
- weight
- length
- head circumference
what age should you take BP?
begin @ 3 years old
infants/pediatrics considerations w/ temp
- tympanic -> toddlers
- oral -> begin age 5/6
RC
risk for complications
nursing diagnoses when analyzing data
- health promotion diagnoses
- risk diagnoses
- actual diagnoses
BP follow up normal
recheck in 2 years
BP follow up prehypertension
recheck in 1 year
BP follow up stage 1 hypertension
confirm w/in 2 months
BP follow up stage 2 hypertension
evaluate w/in 1 month
korotkoff phase 1
tapping (systolic pressure)
korotkoff phase 2
muffled, whooshing, swishing sound
korotkoff phase 3
return of distinct louder
korotkoff phase 4
muffling
korotkoff phase 5
all sounds disappearing
normal pulse pressure
30-50
hyperthermia can indicate
- bacterial/viral/fungal infection
- inflammatory process
- malignancies
- trauma
- blood/endocrine/immune disorders
hypothermia can indicate
- exposure to cold
- hypoglycemia
- hypothyroidism
- starvation
- neurologic dysfunction/shock
high point
systole
low point
diastole
ventricles relaxed
diastole
ventricles contracted
systole
isolated systolic hypertension
condition commonly seen in older adults when systolic pressure is > 140 mmHg and diastolic is normal
infants/pediatrics considerations w/ pulse
- apical < 2 years old
- radial > 2 years old
- count 1 full minute
