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Patient Nursing Care Fundamen > Chapter 21 > Flashcards

Chapter 21 Flashcards

1
Q

Information given from the viewpoint of the patient or some in the patient’s life

A

Subjective data

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2
Q

sign: information directly observed by the health care provider

A

Objective data

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3
Q

Label if they are subjective or objective:
1)Blood sugar level:__
2) Numbness/tingling sensation:___
3)Pain:___
4)Blood pressure:___
5)Bowel sound is normal active in 4 quadrant:____
6)Family stated patient has history of hypertension: __
7)Right leg is red and swelling: __

A

1) Objective
2) Subjective
3) subjective
4) objective
5)objective
6)Subjective
7) objective

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4
Q

Are clinical measurements that include blood pressure, pulse, body temperature, respiration, and oxygen saturation.

A

Vital signs

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5
Q

What are the 6 vital signs?

A

1) Temperature
2) blood pressure
3) heart rate(Pulse)
4) respiratory rate
5) oxygen saturation
6) Pain

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6
Q

Clinical measurements that indicate the state of ________ of the body

A

Essential functions

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7
Q

What is the normal range for temperature?

A

Normal ranges: 97.5F-99.5F (36.4 C- 37.5C)

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8
Q

What is the temperature range for pyrexia (Fever)?

A

> 100.2 or 100.4F (37.9C- 38C)

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9
Q

What are the symptoms of hyperthermia?

A

-flushed appearance, moist skin, chill, HR & RR ↑
-Compensation: diaphoresis
-Complications: dehydration, delirium, convulsions
-T > 105.8 F (41 C) – damage to body cells, esp. central nervous system.

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10
Q

What is the signs and symptoms of hypothermia?

A

-T < 95 F (35 C)
- sleepiness, coma

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11
Q

How would you take a rectal temperature?

A

Let patient be in sims position

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12
Q

How do you insert a rectal temp?

A

Insert 1 ½ inches toward the direction of umbilicus

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13
Q

Finish this statement:
Rectal temp - 1F(0.5C) _____ then oral

A

Higher

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14
Q

Finish the statement:
Axillary temp- 1F (0.5) ____ than oral

A

Lower

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15
Q

What is external factors can cause an inaccurate reading or affect temperature:
Temporal

A

Sweat

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16
Q

What is external factors can cause an inaccurate reading or affect temperature:
Tympanic

A

Ear wax

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17
Q

What is external factors can cause an inaccurate reading or affect temperature:
Oral

A

Swallow hot or cold foods, liquids, smoking or chewing gum. We wait 15-30 mins

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18
Q

What is external factors can cause an inaccurate reading or affect temperature:
Axillary

A

Sweat

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19
Q

What is external factors can cause an inaccurate reading or affect temperature:
Rectal

A

Stool and constipation

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20
Q

Location: Over temporal bone of head, above and lateral to eye
Rationale for selection: Easily accessible site used to assess pulse in children

A

Temporal

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21
Q

Location: Along medial edge of sternocleidomastoid muscle in neck
Rational for selection: Easily accessible site used during physiological shock, cardiac arrest, or when other sites are not palpable

A

Carotid

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22
Q

Location: fourth to fifth intercostal space at left midclavicular line
Rational for selection site used to auscultate

A

Apical

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23
Q

Location: Groove between biceps and triceps muscles at antecubital fossa
Rational for selection: site used to assess status of circulation to lower arm and to auscultate blood pressure

A

Brachial

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24
Q

Location: Radial or thumb side of forearm at wrist
Rational for selection: common site used to assess character or pulse peripherally and status of circulation to hand

A

Radial

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25
Q

Location: little finger side of forearm at wrist
Rational for election: Site used to assess status of circulation to hand; also used to perform an Allen’s test

A

Ulnar

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26
Q

Location: Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine
Rational of selection: Site used to assess character of pulse during physiological shock or cardiac arrest when other pulses are not palpable; used to assess status of circulation to leg

A

Femoral

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27
Q

Location: Behind knee in popliteal fossa
Rational of selection: site used to assess status of circulation to lower leg

A

Popliteal

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28
Q

Location: Along top of foot, between extension tendons of great and first toe
Rational of selection: Site used to assess status of circulation to foot

A

Dorsalis pedis

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29
Q

Location: Inner side of ankle, below medial malleolus
Rational of selection: Site used to assess status of circulation to foot

A

Posterior tibial

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30
Q

What is a normal pulse

A

-HR: 60-100 bpm
-Regular rhythm
-Strong 2+

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31
Q

What is the pulse for tachycardia

A

HR > 100bpm

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32
Q

What is the pulse for bradycardia?

A

HR < 60 bpm

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33
Q

What is the breathing pattern:
Rate- 12-20 breaths/ min
Causes- Regular inspiration & expiration

A

Eupnea (normal)

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34
Q

What is the breathing pattern:
Rate- <12 breaths/min
Causes- Opioids, hypothyroidism, head injury, heart attack

A

Bradypnea

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35
Q

What is the breathing pattern:
Rate- >20 breaths/ min
Causes- sepsis, infection, acidosis, COPD

36
Q

What is the breathing pattern:
Rate- Periods of zero (0) respirations
Causes- obesity, smoking, narrowed airway, sleep apnea

37
Q

What is the breathing pattern:
Rate- periods of inspiration & expiration w/ periods of apnea
causes-end of life (brain tumors, TBI’s and ICP)

A

Cheyne-strokes

37
Q

What is the breathing pattern:
Rate- Increased rate & depth (trying to blow off CO2)
Causes- anxiety attacks, extreme exertion, fears, acidosis, etc

A

Hyperventilation

38
Q

What is the breathing pattern:
Rate- Deep, rapid, breathing pattern
Causes- Diabetic ketoacidosis (DKA)

39
Q

Finish this pain Numonics of “PQRSTU”

A

P= palliating/ participating factors
Q= Quality
R=Radiation or pattern
S=Severity or site
T= temporal nature
U= You!

40
Q

Finish the Numonic “WHATS UP”

A

W= Where is it?
H=How does it feel?
A=Aggravating & alleviating factors?
T=Timing, when did it start
U=Useful other data
P=Patient perception of the problem

41
Q

Elevated temperature

42
Q

Agents that cause fever

43
Q

_____ is the rate at which heat is produced when the body is at rest

A

Basal metabolic rate (BMR)

44
Q

What is another word for fever?

45
Q

State of insufficient oxygen

46
Q

Insufficient oxygen to the brain

A

Cerebral hypoxia

47
Q

___ is the volume of blood pushed into the aorta with each heartbeat.

A

Stroke volume

48
Q

_____ is the amount of blood pumped by the left ventricle in 1 minute

A

Cardiac output

49
Q

________ is the exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing

A

Respiration

50
Q

Excessive fluid volume

A

Overhydration

51
Q

eardrum

A

Tympanic membrane

52
Q

Temperature taken in the armpit

A

Axillary temperature

53
Q

Is the temperature of the deep tissues of the body

A

Core temperature

54
Q

Above normal body temperatures

A

Hyperthermia

55
Q

Sensations of cold and shaking of the body

56
Q

Abatement of fever

A

Defervescence

57
Q

___ stage is the body temperature rises to the new set point established by the hypothalamus and remains there until the cause of the fever resolves

58
Q

Abrupt decline in fever

59
Q

Gradual return to a normal temperature, when applied to fever

60
Q

Subnormal body temperature

A

Hypothermia

60
Q

_____ refers to a pulse greater than 100 beats per minute

A

Tachycardia

61
Q

Irregular pulse

A

arrhythmia

61
Q

The pointed end of the heart

61
Q

indicates a pulse that is less than 60 bpm

A

Bradycardia

62
Q

Bluish discoloration

63
Q

Difficult and labored breathing

64
Q

Increased or rapid breathing

65
Q

Slow and shallow breathing

66
Q

Decreased levels of oxygen in the blood

67
Q

Is a pattern of breathing in which there is an increase in the rate the depth of breaths and carbon dioxide is expelled causing the blood levels of carbon dioxide to fall

A

Hyperventilation

68
Q

Have an increased rate and depth with panting and long, grunting exhalation

A

Kussmaul respirations

69
Q

Are four or five breaths of equal depth alternating with irregular periods of apnea

A

Biot registrations

70
Q

absence of breathing

71
Q

Consist of a pattern of dyspnea followed by a short period of apnea

A

Cheyne-strokes respirations

72
Q

Abnormal, nonmusical sound heard on auscultation of the lungs during inspirations; formally called rales

73
Q

Low pitched wheezes. Continuous, dry rattling sounds heard on auscultation of the lungs caused by partial obstruction

74
Q

Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi

75
Q

Crowing sound on inspiration caused by obstruction of the upper air passages, as occurs in croup or laryngitis

76
Q

Whistling sound of air forced past a partial obstruction, as found in asthma or emphysema

77
Q

Measurment of oxygen

78
Q

Machine that measures oxygen in the blood

79
Q

While measuring blood pressure, you may hear certain sounds that relate to the effect of blood pressure

A

Korotkoff sounds

80
Q

Pressure consistently above 130 systolic and/ or 80 diastolic is called ______. Also known as high blood pressure.

A

Hypertension

81
Q

low blood pressure and is below 90/60 mm Hg

A

Hypotension

82
Q

Circulatory collapse

Patient Nursing Care Fundamen (8 decks)

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