Clinical skills Flashcards
Factors to assess when taking tympanic temp:
Otitis media, impacted cerumen, inflammation, recent ear surgery
Factors that can affect pulse rate and rhythm:
Medical history, disease process, age, exercise, and medications
How to rate strength of pulse:
Bounding, full or strong, barely palpable or diminished;; or absent
For a regular pulse-
Count rate for 30 secs and multiply by 2
For irregular pulse-
Count rate for 60 secs
Normal pulse rate:
60-100 BPM
How to locate PMI/apical impulse:
Over the apex of the heart in the 5th intercostal space at the left midclavicular line
Color of probe when taking rectal temp:
Red
Placement of tympanic thermometer probe:
Gently tug the pinna backward, up, and out before inserting the probe.
How to tale temporal artery temperature:
Place the sensor flush on the patient’s forehead.
What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?
Assess pt for pulse deficit
Inadequate oxygenation to the body will cause the radial pulse to become:
Tachycardic
Which action would take priority if a patient’s apical pulse has an irregular rhythm?
Reassess pulse for 1 full min
Factors that cause pulse deficit:
Irregular heart rate, dyspnea, fatigue, chest pain, orthopnea, palpitations
How to find a pulse deficit:
Subtract the radial rate from the apical rate. If the difference is more than 2 BPM, a pulse deficit exists.
F/u care for a pt with a pulse deficit:
Signs or sxs of decreased cardiac output, such as edema, cyanosis or pallor of the skin, and dizziness or syncope.
Factors that can affect respiratory rate:
Exercise, anxiety, acute pain, smoking, and medications
Normal respiratory rate:
12-20 breaths per minute
What to note as you count respiratory rate:
The depth of the respiration as shallow, normal, or deep by observing chest wall movement.
F/u care after checking respiratory rate:
Compare respirations with the pt’s previous baseline, usual rate, depth, and rhythm. Correlate the pt’s respiratory rate, depth, and rhythm with pulse ox and arterial blood gas measurements.
Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?
Assess respiration after measuring the pulse.
The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?
Encourage the patient to rest for 10 minutes before assessing respiration.
During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?
Continue to count the patient’s breaths for a full 60 seconds.
Where should the BP cuff lie on the arm?
2-3 cm above anticubital fossa
How to indicate systolic BP:
- Slowly release the pressure bulb valve, allowing the manometer needle to fall slowly and continuously at a rate of 2-3 mm Hg per second
- Observe the point on the manometer at which the first Korotkoff sound is heard= systolic BP value
How to indicate diastolic BP:
Point at which all Korotkoff sounds disappear
For greater accuracy on taking BP and to decrease patients anxiety:
Take pt’s BP again in 2 minutes
If it’s the pt’s first BP reading:
Take BP on both arms, then use arm with higher pressure
F/u care after checking blood pressure:
Teach the patient how to prevent HTN by: exercising daily, weight loss, stopping smoking, reducing sodium and saturated fat intake, and maintaining good potassium and calcium intake.
Normal BP in adults:
Systolic: less than 120 mm Hg
Diastolic: less than 80 mm Hg
Normal BP in patients with elevated BP:
Systolic: 120-129 mm Hg
Diastolic: less than 80 mm Hg
Normal BP in patients with stage 1 HTN:
Systolic: 120-129 mm Hg
Diastolic: 80-89 mm Hg
Normal BP in patients with stage 2 HTN:
Systolic: 140 mm Hg
Diastolic: 90 mm Hg
What does the systolic measurement represent?
The pressure exerted against the arterial wall
2 step BP method:
- Palpate brachial artery with fingers while inflating cuff then note where pulse reappears (systolic) and disappears (diastolic) then…
- Take BP with stethoscope as normal
Using a blood pressure cuff that is too wide would cause:
BP to be low
Using a blood pressure cuff that is too loose would cause:
BP to be high
