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NUR 230 Exam 1 > chap 8 > Flashcards

chap 8 Flashcards

1
Q

who created AIDET?

A

Studor group

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2
Q

AIDET is a

A

evidence based communication tool

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3
Q

AIDET

A
  • acknowledge
  • introduce
  • duration
  • explanation
  • thank you
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4
Q

acknowledge

A
  • show enthusiasm
  • eye contact
  • smile & greet
  • “10/5” rule
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5
Q

introduce

A
  • complete any time change responsibilities
  • job title
  • certification/licensure
  • experience
  • number of procedures
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6
Q

duration

A
  • how long you will be w/ pt

- if any delays/interruptions may occur

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7
Q

explanation

A
  • what you will be doing/why
  • what pt/family should expect
  • what might be nxt steps
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8
Q

thank you

A
  • you enjoyed working w/ them
  • thank for time
  • shake hand
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9
Q

how do you prepare for general survey?

A

observe

  • skin color
  • dress
  • hygiene
  • posture/gait
  • physical development
  • body build
  • apparent age
  • gender
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10
Q

general survey

A
  • physical development
  • gender/sexual development
  • apparent age
  • skin condition/color
  • dress/hygiene
  • posture/gait
  • LOC
  • behaviors, body movements, affect
  • facial expressions
  • speech
  • vital signs
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11
Q

VS

A
  • temp
  • pulse
  • respirations
  • BP
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12
Q

VS provide data on

A

status of

  • cardiovascular
  • neurologic
  • peripheral vascular
  • respiratory
  • pain
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13
Q

is physical examination subjective/objective?

A

objective

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14
Q

equipment for physical exam

A
  • thermometer
  • disposable covers
  • BP cuff
  • stethoscope
  • watch w/ second hand
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15
Q

order of VS

A
  • temperature
  • pulse
  • respirations
  • BP
  • pain
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16
Q

factors that affect temperature

A
  • dinural cycle
  • ovulation/mensuration
  • strenuous exercise
  • age
  • stress
  • exposure to cold/heat
  • illness
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17
Q

tympanic temp range

A

98-100.9 F

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18
Q

oral temp range

A

96.6-99.5 F

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19
Q

axillary temp range

A

95.6-98.5 F

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20
Q

temporal temp range

A

97.4-100.3 F

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21
Q

rectal temp range

A

97.4-100.3 F

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22
Q

standard temp range

A

96-99.5 F

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23
Q

hyperthermia

A

> 100 F

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24
Q

hypothermia

A

< 96 F

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25
Q

shock wave

A

produced when heart contracts & pumps blood out of ventricles into aorta

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26
Q

peripheral pulses

A
  • carotid
  • radial
  • brachial
  • pedal
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27
Q

characteristics of peripheral pulse

A
  • rate
  • rhythm
  • amplitude/contour
  • elasticity
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28
Q

normal adult BPM

A

60-100 beats/min

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29
Q

tachycardia

A
  • rapid

- > 100 beats/min

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30
Q

when could tachycardia occur?

A

with fever, certain medications, stress, abnormal states

31
Q

bradycardia

A
  • slow

- < 60 beats/min

32
Q

when could bradycardia occur?

A
  • sitting/standing for long periods

- heart block or dropped beats

33
Q

sinus arrhythmia

A
  • common in children/young adults

- rhythm speed up (inspiration) & slows with expiration

34
Q

amplitude

A
  • 3+ bounding
  • 2+ normal
  • 1+ weak, thready
  • 0 absent
35
Q

normal respiration rate

A

12-20 breaths per minute

36
Q

depth of respiration

A
  • unlabored/labored
  • shallow/deep
  • use of accessory muscles
37
Q

systolic BP

A

measurement of pressure of blood in the arteries when ventricles are contracted

38
Q

diastolic BP

A

measurement of pressure of blood in arteries when ventricles relaxed

39
Q

normal BP

A

120/80 or less

40
Q

factors affecting BP

A
  • cardiac output
  • elasticity of arteries
  • blood volume
  • blood velocity (heart rate/thickness)
41
Q

BP cuff size

A

80% of arm circumference

42
Q

normal systolic

A

< 120-129 mmHg

43
Q

normal diastolic

A

< 80-84 mmHg

44
Q

prehypertension

A

120-139/80-89

45
Q

orthostatic hypotension

A

low BP that occurs upon standing up

46
Q

orthostatic hypotension measures

A

drop of > 20 mmHg when standing up

47
Q

hypertension

A

> 140/90

48
Q

stage 1 hypertension

A

140-159/90-99

49
Q

stage 2 hypertension

A

> 160/>100

50
Q

stage 3 hypertension

A

> 180/110

51
Q

expected findings for oxygen saturation

A

upper 90s

52
Q

infants/pediatrics considerations w/ measurements

A
  • weight
  • length
  • head circumference
53
Q

what age should you take BP?

A

begin @ 3 years old

54
Q

infants/pediatrics considerations w/ temp

A
  • tympanic -> toddlers

- oral -> begin age 5/6

55
Q

RC

A

risk for complications

56
Q

nursing diagnoses when analyzing data

A
  • health promotion diagnoses
  • risk diagnoses
  • actual diagnoses
57
Q

BP follow up normal

A

recheck in 2 years

58
Q

BP follow up prehypertension

A

recheck in 1 year

59
Q

BP follow up stage 1 hypertension

A

confirm w/in 2 months

60
Q

BP follow up stage 2 hypertension

A

evaluate w/in 1 month

61
Q

korotkoff phase 1

A

tapping (systolic pressure)

62
Q

korotkoff phase 2

A

muffled, whooshing, swishing sound

63
Q

korotkoff phase 3

A

return of distinct louder

64
Q

korotkoff phase 4

A

muffling

65
Q

korotkoff phase 5

A

all sounds disappearing

66
Q

normal pulse pressure

A

30-50

67
Q

hyperthermia can indicate

A
  • bacterial/viral/fungal infection
  • inflammatory process
  • malignancies
  • trauma
  • blood/endocrine/immune disorders
68
Q

hypothermia can indicate

A
  • exposure to cold
  • hypoglycemia
  • hypothyroidism
  • starvation
  • neurologic dysfunction/shock
69
Q

high point

A

systole

70
Q

low point

A

diastole

71
Q

ventricles relaxed

A

diastole

72
Q

ventricles contracted

A

systole

73
Q

isolated systolic hypertension

A

condition commonly seen in older adults when systolic pressure is > 140 mmHg and diastolic is normal

74
Q

infants/pediatrics considerations w/ pulse

A
  • apical < 2 years old
  • radial > 2 years old
  • count 1 full minute

NUR 230 Exam 1 (7 decks)

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