CP: POD #1 Flashcards
Blood Pressure
The force exerted on the walls of the arteries by the pulsing blood under pressure from the heart
factors that can affect temperature
-age
-environment
-exercise
-stress
-circadian rhythm
factors that can affect heart rate
-exercise
-temperature
-meds
-pain
-hemorrhage
-postural changes
quality/strength (pulse)
volume of blood ejected against the arterial wall with each heart contraction
depth (respiratory)
amount of movement in the chest wall during breathing
-deep, normal, shallow
factors that affect respiratory rate
-smoking
-exercise
-anxiety
-acute pain
-meds
-body position
-neurological injury
-hemoglobin
rhythm (respiratory)
-regular or irregular breathing problems
-observe the chest or abdomen (contraction and relaxation of the diaphragm)
systolic BP
-peak of max pressure when ejection occurs
-100-139 mmHG
pulse oximetry (oxygen saturation)
detects amount of hemoglobin in arterial blood that is saturated with O2
what are the sites you can measure termperature
-oral (mouth-under tongue)
-tympanic (ear)
-rectal (anus)
-axillary (armpit)
what are the 5 principles of body mechanics?
-use of correct muscles to complete
-prevents unnecessary strain on muscle and joints
-to maintain body alignment, balance, posture assessment?
-reduce risk of injury to nurse and client during assessment
-reduce muscle fatgue
hypotension
-low blood pressure
-less than SBP100/DBP60
pulse pressure
-difference between systolic and diastolic pressure
what are the benefits of oral care?
-maintains healthy stage of mouth
-decrease gum inflammation
-decrease risk of aspiration pneumonia
-removes food, plaque, and bacteria
what are some factors that affect oxygen saturation readings?
-black nail polish/fake nails
-poor/impaired blood circulation
-juandice
-dark pigmentation
-carbon monoxide poisoning
-anemia
-activity
-moisture
-light transmission interference
what is the hospital standard for SpO2 (oxygen saturation) reading?
-adult with co-morbidities/acute health challenge > 92%
-healthy adults 95-100%
-COPD: 88-92%
-life threatening: < 70%
Hypertension
-high blood pressure
-higher than SBP139/DBP90
what safety check need to be done for patients and their environment?
-check pts ABCCs
-look for cognitive risk factors (behaviours)
-environmental risk factors (clutter,sharps)
-patient position bed
-bed rails (min 1,max 3)
-bed brakes on
-bed in lowest position
-bed/chair alarm on
-safety belt on in chair
what are gloves used for?
-contact with mucous membrane
-blood/bodily fluids
-environmental surfaces that may be contaminated with blood or body fluids
when should hand hygiene be performed (5 cases)
-after body fluid exposure risk
-before touching patient
-after touching patient
-after touching patient surroundings
-before clean/aseptic procedure
what are the benefits to hand sanitizers/alcohol-based antiseptics?
- improves hand hygiene practices
- protects health care workers hands
- reduces transmission of pathogens to patients and personnel
- quicker than hand washing with soap and water
how long should you wash with soap and water?
- minimum 15 s
- total 40-60 s
- more if hands visibility soiled
what are the 6 bed positions used for performing activities of daily living?
- fowlers: 45-60 degrees
- high fowlers: 60-90 degrees, prevents aspiration and feeding and oral care
- semi-fowlers: 30-45 degrees, easy for breathing or just comfort
- trendelenburg: help move patient up in bed (head down and feet up)
- reverse trendelenburg
- flat: usually for sleeping
what do you need to clean dentures?
- lukewarm water
- enclosed container with tepid water: prevents breakage and warping (drying)
- assess oral mucosa for lesions, pain, and bleeding
- remove at night
- moisten to put back in to help with suction
what is optimum temperature for a healthy adult?
36-38 degrees
what is the normal range for respiratory rate for a person?
- 12-20 breaths per minute
- measured by listening for 30 s or 1 than x2
bradypnea
slow breathing rate, less than 12 breaths per minute
apnea
- periodically stop breathing then start up again
orthopnea
- shortness of breath when lying down
dyspnea
- shortness of breath
how do you count respiratory rate?
- place arm on client’s abdomen and count for 30 s or 1 min for irregular rhythm
febrile vs afebrile
febrile: with fever
afebrile: no fever
what does the bell of the stethoscope listen to?
listens to more specific areas and picks up lower frequency sounds
what is normal oxygen saturation for a healthy adult?
95-100%
what is oxygen saturation for someone with COPD?
88-92%
what are 4 places for pulse oximetry?
- finger
- toes
- nose
- earlobe
core temperature
temp of structures deep within the body
heart rate
number of pulsing sensations counted in a minute
rhythm (pulse)
interval that occurs between each heart beat
rate (respiratory)
both inspiration and exhalation counted as 1 breath
orthostatic hypotension
- BP drops after standing or
- sit to stand, wait 1-3 mins
- drops more than SBP 20/DBP10 mmHG
- heart rate more than 30 bpm
what is oxygen saturation for someone with co morbidities/acute health challenge?
> 92%
Diastolic BP
60-89 mmHg
- min pressure exerted against the arterial walls when the ventricles relax
-5th kortokoff sound
what safety checks need to be down for bedside equipment?
- suction meter density (suction water, liner, plastic
- oxygen meter testing (O2 meter, white nipple)
- nasal prongs, simple O2 mask, suction catheter
what is the normal diastolic BP for a healthy person?
60-89 mmHg
what is a normal systolic BP for a healthy person?
100-139 mmHg
complete bed bath vs partial bed bath
Complete:
- for totally dependent patients
- cleaning all areas including perineal area
Partial:
- for mere independent patients
- only body parts that cause discomfort or odour or not easily reached
tachypnea
- fast breathing rate
- greater than 20 breathe per minute
tachycardia
- fast heart rate
- greater than 100 bpm
what does the diaphragm of the stethoscope listen to?
wider area of the body and picks up higher frequency sounds
what are 3 reasons for bathing?
- increase blood circulation
- decrease risk of infection
- decrease skin breakdown
- removes bacteria
- promotes hygiene
bradycardia
- slow heart rate
- slower than 60 bpm
pyrexia
high body temperature
2 common sites (heart rate)
radial and apical
when to assess respiratory rate
after measuring pulse while hand remains on patient’s wrist
