Chapter 16-19 Flashcards
A pts or residents room, also referred to as a ____, will vary in the way it is set up according to the type of facility and the needs of the person
unit
Serves as the central base of operation for the nursing staff
nurses station
Used to store meds and the supplies for administering meds
medication room
Used to store clean and sterile supplies
clean utility room
Where dirty items are handling and stored
soiled utility room
Soiled utility rooms often have a _____, a sink like fixture that flushes like a toilet, used for cleaning bed pans and rinsing soiled linen
hopper
Where snacks and beverage are stored and prepared for pts and residents
nourishment room
The aspects of residents environment is regulated by ____
OBRA
Essential for controlling the spread of infection and odors
cleanliness
Ways to help with minimize ____:
- keep lids down on laundry and waste containers
- empty and clean emesis basins, urinals, bedside commodes, and bedpans
- air freshner
- assist your pt with routine personal care
- pay attention to your personal hygiene
odor
Provides fresh air and keeps air circulating
- carries away odor
- keeping air from becoming stale
- keeps room from getting stuffy
ventilation system
People who are ill, elderly, or relatively inactive may prefer a ____ room temp
warmer
Provides overall illumination _____
Directs bright light toward a specific area ____
general lightning
task lighting
Ways to minimize ____:
- headphones
- answer phone promptly
- report loud equipment
- be aware of your voice volume
noise
_____ commonly referred to as a hospital bed, is used in most health care settings
adjustable bed
The mattress platforms of most adjustable beds have joints at the hip and knees, which allow the mattress to break or bend, these joints are called _____
gatches
Foot of the mattress is raised so that the persons head is lower than her feet
-used for people in shock to get blood flow to the heart
trendelenburgs position
Head of the mattress is raised so the persons head is higher than their feet
-used for spinal cord, back injury, and traction
reverse trendelenburgs position
A _____ is useful for residents who may roll out of bed or get out of bed without calling for assistance
low bed
Fits over the bed or chair and can be raised or lowered as needed
over-bed tables
Used for pts to alert a staff member that they need help
call light
Branch of medicine that specializes in the tx of obesity
bariatrics
The official entry of a person into a health care setting
- time for orientation for new pt and health care team
- can be stressful for both pt and family as they adjust to change
admission
____ for long term care:
- most do not choose to be admitted
- admitted after a crisis
- may require a quick decision when choosing facility
- family may realize no longer able to provide care
- physically, emotionally, and financially draining
- feeling of guilt from family
concerns
The ____ process
- orders are written by the doctor
- the admissions coordinator or admission nurse helps the person to complete an admission sheet
- person is escorted to their room
- nurses complete the nursing hx
- nursing assistant takes vital signs and helping the person to become oriented to the room
admission
Gathers information about the person such as, name, address, date of birth, social security number, gender, insurance and employment information, and advanced directive information
admission sheet
Making a new pt feel _____:
- prepare room before arrival
- greet person warmly and introduce yourself
- help person settle into new home
- practice good communication skills
welcome
Gathers information about a persons preference, abilities, disabilities, and habits
nursing history
Document that list and briefly describes all the residents personal belongings
resident inventory sheet
A _____ occurs whenever a pt is moved within or between health care settings:
- from one room to another
- one unit to another
- one health care facility to another
- can be necessary due to changes in persons medical condition
transfer
A _____ must be safe
- pt and belongings must be treated with respect
- nurse is usually responsible for reporting information to accepting RN
- if going to a long term facility, you may report personal care information to the receiving nursing assistant
transfer
_____ is the official release of the person from a health care facility back home
discharge
When a person leaves health care setting without a doctors order, the person is said to leave _____
against medical advice (AMA)
Used by the members of the health care team to help prepare a pt or resident to leave the facility
- the process that helps identify the needs of a person after his discharge and makes arrangements for meeting these needs
- begun at the time of admission
discharge planning
The _____ responsibilities during discharge:
- helping pt pack personal items
- having the person ready to leave on time
- assisting person out of the facility
nursing assistant
- promote comfort and well-being of pt
- important for infection control
- helps with skin breakdown and pressure ulcer formation
- a neat well-made bed is a sign of capable,competent care by the facility
bedmaking
Think layer of padding that is placed on the mattress to help make the bed more comfortable for the pts and to protect the mattress from moisture and soiling
mattress pads
Small, flat sheet that is placed over the middle of the bottom sheet covering the area of the bed from above the persons shoulders to below the buttocks
draw sheets
A draw sheet that is used to help lift or reposition a person in bed
lift sheet
A square of quilted absorbent fabric backed with waterproof material
- approximately 3 ft by 3 feet
- it can be disposable or laundered
- used for pts that are incontinent or have draining wounds
- sometimes this is the only thing that needs to be changed
bed protector
Lightweight cotton blanket or flannel sheet that is used provide modesty and warmth during a bed bath
bath blanket
Placed on top of the regular mattress to help prevent skin breakdown for pts that stay in bed for a long period of time
-some can be filled with air or water
pressure relieving mattress
Piece of wood that is placed under the mattress to provide extra support
- keeps the mattress from sagging and keeps body aligned
- most common in long term care
bed board
A padded board that is placed upright at the foot of the bed
-keeps the feet in proper alignment
foot board
_____ that are commonly used:
- mattress pad
- bottom and top sheets
- draw sheets
- bed protectors
- blankets
- bedspreads
- pillow and pillowcases
- bath blankets
linens
Other equipment and supplies are used depending on the persons ____:
- pressure relieving mattress
- bed board
- bed cradle
- footboard
needs
Has elasticized sides that wrap around and underneath the mattress, holding the pad securely to the mattress
fitted mattress pad
Pad is not secured to the mattress
flat (non-fitted) mattress pad
Bed is made with \_\_\_\_\_ sheets: Bottom sheet may be -flat, or non fited -fitted The top sheet is a flat sheet -can be white or colored
two
A ____ adds the finishing touch to a well made bed and can add a decorative touch to a persons room
-allowing a person to use their own from home is one way to foster a sense of independence and individuality
bedspreads
Metal frame that is placed between the bottom and top sheets to keep the top sheet, the blanket, and the bedspread away from persons feet
- used for people with burns to keep top sheet from touching the pt
- used for pts at risk for pressure sores
bed cradle
Do not hold linens ____ to your uniform
close
Wear gloves when removing used linens from a bed
-roll the linens _____ the center of the bed to confine the soiled area inside
toward
____ is a way of folding and tucking the sheet so that it lies flat and neat against the mattress
mitering
When the top sheet, blanket, and bedspread of a closed bed are turned back, or fanfolded, the closed bed becomes an _____ or a bed ready to receive a pt
-the bed wheels should always be locked and in lower position
open
A closed bed that has been opened to receive a pt who will be arriving by stretcher
surgical bed
Some conditions make it difficult for a person to get out of bed for a linen change, when this is the case, it is necessary to change the linens while the person is still in bed, this is called an _____
occupied bed
Always place linens so that the seams are ____ from pts face and skin
away
Key measurements that provide essential information about overall health status
- how fast heart is beating, internal temp of body, and rate of breathing
- indicates how well the body is functioning
- if indicates change, person may be in or have an injury
vital signs
Vital signs are taking when specified on ____ or ____:
- long term care facility: once daily or weekly, and as needed
- hospital: every shift or every few hours, and as needed
nursing care plan or doctors orders
____ is important: many people rely on these measurements to make decisions about the persons care
-report an abnormal measurement immediately
accuracy
It is the difference between heat produced and heat lost by the body
- body heat is produced as a normal process of metabolism
- regulated by thermoregulatory center located in the brain
body temperature
The physical and chemical changes that occur when the cells of the body change the food that we eat into energy
metabolism
- physical or emotional stress
- environmental temperature
- time of the day
- age
- gender
Factors affecting _____
body temperature
Measured in either degrees Fahrenheit or Celsuis
- mouth: oral
- rectum: rectal
- armpit: axillary
- ear: tympanic
- forehead: temporal
These are measurements of _____
body temperature
- glass
- electric
- tympanic
- temporal
These are types of ____
thermometers
Adult oral temperature is _____
97.6-99.6 F
Normal body temp ranges from ____ to ____ above or below the range considered normal
0.5-1 F
Increased body temperature
- person is said to be febrile
- doctor may order an antipyretic (fever reducing) drug
pyrexia
When the heart beats, it sends a wave, or ____ of blood through the arteries
- look for rate and a rhythm
- pulse amplitude
pulse
Irregular pulse rhythm is called _____
dysrhythmia
- physical activity (increases the bodys need for O2 and nutrients
- anger and anxiety, illness, pain, fever, and excitement
- certain meds
Are factors that can affect _____
pulse
The force or quality of the pulse
pulse amplitude
Taken by placing fingers over the radial artery (inside the wrist)
radial pulse
Taken by listening over the apex of the heart with a stethoscope
apical pulse
The difference between the apical pulse and the radial pulse, requires two team members pulse at both locations at same time
pulse deficit
Always measure for a _____ in children younger than 12
full minute
- temporal
- carotid
- apical
- brachial
- radial
- femoral
- dorsalis pedis
- posterior tibial
- popliteal
These are all _____
pulse points
Places where the arteries run close to the surface of the skin, allowing the pulse to be felt
pulse points
A rapid heart rate, or pulse rate of more than 100 beats per minute for an adult
tachycardia
A heart rate that is slower than normal, that is a pulse rate of less than 60 beats per minute
-may be normal in some people
bradycardia
Normal pulse rate for adult _____
60 to 100
Is accomplished through ventilation
respiration
_____ is inhalation of O2 and exhalation of carbon dioxide
ventilation
When measuring ____ look for:
- rate
- rhythm
- depth
- abnormal sounds
respiration
Number of times person breathes in 1 minute (one breath is one inhalation and exhalation
-best to count after pulse with fingers still on wrist because its easier for pt to control breathing
respiration rate
Regularity with which a person breaths
respiration rhythm
The quality of each breath
depth of respiration
Normal respiratory rate is called ____
- ____ to ____ times a minute for adults
- higher for infants and children
eupnea
12 to 20
- tachypnea
- bradypnea
- dyspnea
- hyperventilation
- hypoventilation
Are abnormal _____
respiratory pattern
Respiratory rate that is higher than normal (greater than 24 breaths)
tachypnea
Respiratory rate that is lower than normal (less than 10 breaths)
bradypnea
Labored or difficult respirations
dyspnea
The force that the blood exerts against the arterial walls
- two pressure levels: systolic and diastolic
- measured in mm or mercury and recorded in fraction
blood pressure
The difference between systolic and diastolic is ____
pulse pressure
- cardiac output
- blood volume
- resistance to blood flow
- age
- gender
- race
Are factors that affect ____
blood pressure
Amount of blood that the heart is able to pump with each beat
cardiac output
The amount of blood in the vessel at any given time influences the blood pressure
blood volume
How hard it is for the blood to flow through the vessels
resistance to blood flow
- faint but clear sounds, first tapping is systolic
- last sound heard before continuous silence is diastolic
korotkoff sounds
_____ can move up and down within a range of normal during the course of the day and activity level of the individual
Abnormal ranges
- hypertention
- hypotention
- orthostatic hypotension
blood pressure
Blood pressure for normal adult _____
- influenced by chronic condition or medication
- increased tendency for fluctuation due to postural changes, physical exertion, and illness
120/80
Measure pulse and respiration ____ in children 5 yrs and younger
first
Sudden decrease in blood pressure that occurs when a person stands up from sitting or lying position
orthostatic hypotention
A persons _____
- provides insight into overall health and nutritional status
- often used to calculate medication dosage
Measure ___ on admission and on transfer or discharge
Measure ____ on admission and at regular intervals
weight
height
weight
____ is measured in feet and inches or centimeters
____ is measured in pounds or kilograms
Ways of measurement:
- upright scale
- chair scale
- tape measure and sling scale
height
weight
- always measure at the same time of day
- always measure with same type of clothes on and no shoes
- always measure with empty bladder
When monitoring ____
weight
