Chapter 13 Flashcards
Apical pulse
The pulse on the left side of the chest, just below the nipple
Apnea
The absence of breathing
BPM
The medical abbreviation for beats per minute
Brachial pulse
The pulse inside the elbow; about the 1 to 1 1/2 inches above the elbow
Bradycardia
Slow hear rate, under 60 beats per minute
Celsius
The centigrade temperature scale in which the boiling point of water is 100 degrees and the freezing point of water is 0 degrees
Cheyenne-Strokes respiration
Alternating periods of slow, irregular respiration’s and rapid shallow respiration’s, possibly along with periods of apnea
Diastolic
Second measurement of blood pressure; phase when the heart relaxes
Dilate
To widen
Dyspnea
Difficulty breathing
Eupnea
Normal respirations
Expiration
The process of exhaling air out of the lungs
Fahrenheit
A temperature scale in which the boiling point of water is 212 degrees and the freezing point of water is 32 degrees
Hypertension
High blood pressure, measure ing 140/90 mm Hg or higher
Hypotension
Low blood pressure, below 90/60 mm Hg
Hypothermia
Sever sub-normal body temperature; body temperature drops below the level required for normal functioning
Inspiration
The process of inhaling air into the lungs
Orthopnea
Shortness of breath when lying down that is relieved by sitting up
Orthostatic hypotension
A sudden drop in blood pressure that occurs when a person sands or sits up; also call postural hypotension
Prehypertension
A condition which a person has a systolic measurement of 120-139 mm Hg and a diastolic measurement of 80-90mm Hg
Radial pulse
The pulse on the inside of the wrist, where the radial artery runs just beneath the skin
Respiration
The process o inhaling air into the lungs and exhaling air out of the lungs
Sphygmomanometer
A device that measures blood pressure
Stethoscope
An instrument used to hear sounds in the human body, such as the heartbeat or pulse, breathing sounds, or bowel sounds
Systolic
First measurement of blood pressure; phrase when the heart is at work,contracting and pushing blood out of the left ventricle
Tachycardia
Rapid heart rate, over 100 beats per minute
Tachypnea
Rapid respirations, over 20 breaths per minute
Thermometer
A device used for measuring the degree of heat or cold
Vital signs
Measurements-body temperature, pulse, respirations, blood pressure, and pain level-that monitor the functioning of the vital organs of the body
What do vital signs consist of?
1) Measuring temperature
2) Counting pulse
3) Counting rate of respirations
4) Measuring blood pressure
5) Observing and reporting pain level
What is often the first indication that someone is ill?
A change in vital signs
What is a normal mouth (oral) temperature?
- 6-99.6 Degrees Fahrenheit
36. 5-37.5 degrees Celsius
What is an normal Rectum temperature?
- 6-100.6 degrees Fahrenheit
37. 0-38.2 degrees Celsius
What is regular Armpit (axillary) temperature?
- 6-98.6 degrees Fahrenheit
36. 0-37.0 degrees Celsius
What is the normal ear (tympanic) temperature?
- 6-99.7 degrees Fahrenheit
35. 8-37.6 degrees Celsius
What is Normal Temporal Artery temperature?
- 2-100.1 degrees Fahrenheit
36. 2-37.8 degrees Celsius
What is normal blood pressure?
Systolic: 119 or lower
Diastolic: 79 or lower
What is a low blood pressure rate?
Below 90/60
Prehypertensive
Systolic:120-139
Diastolic:80-89
What is a high blood pressure rate?
140/90 or above
What is a normal pulse rate?
60-100 beats per minute
What is a normal respiratory rate?
12-20 respirations per minute
List the factors can affect body temperature
1) age
2) amount of exercise
3) Circadian rhythm
4) Stress
5) Illness
6) Environment
What are the signs of hypothermia?
1) Temperature below 97 degrees Fahrenheit
2) Shivering
3) Numbness
4) Quick and shallow breathing
5) Slow movements
6) Mild confusion
7) Changes in mental status
8) Pale and cyanotic skin
What are the five sites for measuring temperature?
1) Mouth
2) Rectum
3) Armpit
4) Ear
5) Temporal artery
What can Mercury-free thermometers be used for?
Taking an oral, rectal, or axillary temperature
What color are mercury-free oral thermometers usually?
Green
What color are mercury-free rectal thermometers usually?
Red
What are digital thermometers commonly used for?
Oral, rectal, and axillary temperatures
Digital thermometers require what to cover the probe?
Sheath
What are electronic thermometers commonly used for?
Oral, rectal, and axillary temperatures
Electronic thermometers require to cover the probe?
A cover that must be discarded after a single use
What are disposable thermometers used for?
Taking oral or axillary temperatures
What happens to disposable thermometers after they are used?
The are discarded after one use. They do not require a disposable sheath
Typmpanic thermometers are what?
Fast and accurate
How are Temporal artery thermometers used?
They are moved across the forehead and are non-invasive
Do not take an oral temperature on a person who…
1) Is unconscious
2) is using oxygen
3) Is confused or disoriented
4) Is paralyzed
5) Has facial trauma
6) Is likely to have a seizure
7) Has a nasogastic or orogastric tube
8) Is younger than five years old
9) Has sores, redness, swelling, or pain in the mouth
10) Has an injury to the face or neck
When should you not take an oral temperature?
After a resident has smoked, eaten or drank fluids, chewed gum, or exercised within the last
How do you use a mercury-free thermometer?
Hold the thermometer by the stem. Before inserting it in the resident’s mouth, shake thermometer down to below the lowest number. To shake thermometer down, hold it at the end opposite the bulb with the thumb and two fingers. With a snapping motion of the wrist, shake the thermometer. Stand away from furniture and walls while doing so.
How do you use a digital thermometer?
Put on disposable sheath. Turn on thermometer. Wait until “ready”sign appears.
Process for using an oral mercury-free thermometer
Put on disposable sheath if available. Gently insert bulb end of thermometer into resident’s mouth, under tongue and one side.
Process for using a digital oral thermometer
Insert the end of digital hero meter into resident’s mouth, under tongue and to one side.
Process for using and electronic oral thermometer
Insert the end of electronic thermometer into resident’s mouth, under the tongue and to one side
What should the resident do for all thermometers?
The resident should hold the thermometer in his mouth with his lips closed. He should breathe through his nose, and he should not bite down or talk.
How long should a mercury-free thermometer be left in the mouth?
At least Three minutes
How long should you leave a digital thermometer in a resident’s mouth?
Until the thermometer blinks or beeps
How long should you leave an electronic thermometer in a resident’s mouth?
Leave in place until you hear atone or see a flashing or steady light
Guidelines for taking rectal temperature
1) Rectal temperatures are most accurate
2) The NA must explain what he will do before starting
3) The NA should be reassuring
4) The NA must hold onto the thermometer at all times
5) Gloves must be worn
6) Thermometer must be lubricated for this procedure
7) The privacy of the resident is important
8) Thermometer must be held the entire time it is in the rectum
How far will a tympanic thermometer go into the ear of a resident?
The tip will only go into the ear 1/4 to 1/2 inch
Important points about axillary temperatures
1) Axillary temperatures are not as accurate as the sites
2) Axillary arena must be clean and dry when temperature is measured
What position do you put a resident in for a rectal temperature?
The left-lying (sims) position
What part of the resident must you expose when taking a rectal temperature?
Only the rectal area
Before using a rectal Mercury-free thermometer what do you do?
Hold thermometer by the stem. Shake thermometer down to below the lowest number. Put on disposable sheath.
Before using an electronic rectal thermometer what do you do?
Remove probe from base unit. Put on probe cover.
What do you do before using a digital rectal thermometer?
Put on disposable sheath. Turn on thermometer and wait until ready sign appears.
How far do you put in a rectal thermometer?
1/2-1 inch
How do you insert a rectal thermometer?
Separate the buttocks. Gently insert thermometer into rectum on-half to one inch. Stop if you meet resistance. Do not force the thermometer into the rectum.
How does the mercury-free thermometer stay inside the rectum?
At least three minutes
How do you insert a tympanic thermometer?
Position the resident’s head so that the ear is in front of you. Straighten the ear canal by gently pulling up and back on the outside edge of the ear. Insert the covered probe into the ear canal.
How do you use an axillary mercury-free thermometer?
Hold thermometer in place, with the arm close against the side, for eight to ten minutes
List the factors that can affect pulse rate
1) age
2) gender
3) exercise
4) stress
5) hemorrhage
6) medications
7) fever and illness
Important points about pulse rate
1) pulse is the number of heartbeats per minute. Normal rate is 60-100 beats per minute for adults
2) NA should observe for the overall pattern of the pulse and the quality or type of the pulse
Important points about respiration
1) NA should do the Counting immediately after taking the pulse
2) it is important not to let the resident know that NA is counting breaths
3) normal rate is 12-20 breaths per minute
4) NA should observe for the overall pattern of the respiration and the quality or type of breathing
Where is the radial pulse found?
Typically on the wrist
What types of breathings would you observe when counting respirations?
Normal breathing- smooth and quiet
Irregular breathing- troubled, shallow, or noisy
What is normally the same as the radial pulse?
The apical pulse
How do you find the apical pulse?
Place the flat metal diaphragm on the left side of the chest, just below the nipple. Listen for the heartbeat.
What is the difference between the apical pulse and another pulse?
The pulse deficit
Ex: if the apical pulse is is 80 beats per minute, and the radial pulse is 68 beats per minute, the pulse deficit is 12
List the factors that can affect blood pressure
1) age
2) exercise
3) stress
4) race
5) heredity
6) obesity/unhealthy diet
7) alcohol
8) tobacco products
9) time of day
10) illness
The different types of sphygmomanometer
1) An aneroid sphygmomanometer has a round gauge that is portable or is attached to the wall. It my also hook to clothing
2) a Digital sphygmomanometer automatically inflates and deflates to measure blood pressure. In addition to blood pressure, it may also measure other vital signs. The use of a stethoscope is not required with digital sphygmomanometer
Important points about blood pressure
1) Brachial pulse is used to measure blood pressure
2) the cuff must first be completely deflated before measuring blood pressure
When should an NA not take blood pressure?
1) an intravenous line (IV) is present
2) the cuff does not fit the arm properly
3) the arm has a cast
4) burns or injuries are present
5) the arm is being used for dialysis
6) the arm or side has had recent trauma
7) the arm or side is paralyzed due to stroke
8) an amputation has been performed
9) the side has had a mastectomy (or any other surgery or incision)
Additional points about blood pressure
1) cuff must be correct size
2) observe for normal readings and the quality or type of sounds
3) other sites for measuring blood pressure are forearm, thigh, and calf. Other sites may be required due to the size of the upper arm or blood pressure cuff or due to recent surgeries or conditions
Where do you place the blood pressure cuff on the person?
Snugly on the resident’s arms. The center of the cuff with sensor/arrow placed over the brachial artery (1-1 1/2 inches above the elbow toward the inside of the elbow)
After placing the blood pressure cuff on the resident’s arm, what do you do?
Locate brachial pulse with fingertips, place the diaphragm of then stethoscope over the brachial artery
Points about pain
1) it is as important to monitor as vital signs
2) it is uncomfortable and an individual experience
3) NAs must take complaints of pain seriously
4) NAs should ask questions to get accurate information
List the signs and symptoms of pain to observe and report
1) increase pulse, respirations, and blood pressure
2) sweating
3) nausea and vomiting
4) tightening the jaw
5) squeezing eyes shut
6) holding or guarding a body part
7) frowning
8) grinding teeth
9) increases restlessness
10) Agitation or tension
11) change in behavior
12) crying
13) sighing
14) groaning
15) breathing heavily
16) difficulty moving or walking
What measurements should NAs take to reduce pain?
1) Report complaints of pain or unrelieved pain promptly to the nurse
2) Check on the resident often and ask if the pain has been relieved
3) Give back rubs frequently if allowed
4) Assist in frequent changes of position. Use pillows to properly support the body. Be careful when moving, lifting, or transferring the resident in pain
5) offer warm baths or showers
6) assist the resident to the bathroom or commode or offer the bedpan or urinal
7) encourage slow, deep breathing
8) be patient, caring, gentle, empathetic, and responsive to residents who are in pain.
