Exam 1 Flashcards
What is a general survey? - includes objective parameters and gives overall impression
- gender/race
- age
- signs of distress
- body type
- posture
- gait
- body movements
- hygiene/grooming
- dress
- body odor
- affect/mood
- speech
- client abuse
- substance abuse
What are the 5 vital signs?
- body temperature
- pulse
- respiration/oxygen saturation
- blood pressure
- pain (the 5th vital sign)
How do you measure vital signs?
- circulatory
- respiratory
- neural
- endocrine
- establish baseline
- understand and interpret values
- communicate/document findings
What is body temperature and what areas can you take it?
- heat produced/lost
- 96.8 to 100.4 F or 36 to 38 C
- areas:
oral
skin
axillary (armpit)
rectal (butt)
tympanic (ear)
temporal artery (across forehead)
esophageal (tube leading to stomach)
pulmonary artery (carry oxygen from the right side of your heart to lungs) bladder
What factors affect body temperature?
- age
- exercise
- hormonal level
- circadian rhythm
- environment
- temperature alterations - fever/pyrexia, heatstroke, heat exhaustion
What is pulse?
- Indicates circulatory status
- electrical pulses come from SA node (sinoatrial)
- cardiac output = HR x stroke volume
What is apical pulse?
Use a stethoscope to hear the heart better
For adults located on the fifth intercostal space
For children located on the fourth intercostal space
Always measured on the left where the heart is
What is systolic and diastolic?
Systolic is when the heart contracts
Diastolic is when the heart rests/relaxes
What factors influence blood pressure?
- age
- stress
- ethnicity/ genetics
- gender
- daily variation
- medications
- activity/weight
- smoking
What is hypertension aka high blood pressure?
- more common than hypotension
- thickening of walls
- loss of elasticity
- family history
- risk factors
What is hypotension aka low blood pressure?
- less than 90/60 mmHg - 90 is systolic (contracts) and 60 is diastolic (rests)
- mm = millimeters and Hg = mercury
- dilation of arteries
- loss of blood volume
- decrease of blood flow to vital organs
- happens when you stand up too quickly from sitting down or lying down (orthostatic/postural)
What are the ranges of blood pressure?
Normal: systolic: less than 120 mm Hg
diastolic: less than 80 mm Hg
Prehypertension: systolic: 120–139 mm Hg
diastolic: 80–89 mm Hg
Hypertension: systolic: 140 mm Hg or higher
diastolic: 90 mm Hg or higher
What is ADPIE? Nursing process
- Assess = gather info about the patients condition
- Diagnose= identify the patient’s problems no medical just nursing diagnosis
- Plan= set goals of care and desired outcomes and identify appropriate nursing actions SMART GOALS specific measurable achievable relevant and time bound
- Implement= perform the nursing actions identified in planning verb words giving them medicine, walking them
- Evaluate= determine if goals and expected outcomes are achieved reassessment by the nurse
What is critical thinking when it comes to patient care and safety?
- essential in nursing process
- knowing as much of the patient as possible
- sort information into patterns to clarify problems, recognize changes, and make appropriate care decisions
- essential for safe, efficient, and skillful nursing intervention
- improves patient outcomes
what is PQRST?
Provokes - what provoked the pain? What makes it worse? What makes it better? Did the pain occur at rest or during exertion?
Quality - what does the pain feel like? is the pain sharp, squeezing, dull, pressure, aching, pounding
Radiate/region- where is the pain located? does the pain move anywhere, ask to point where they feel pain common in heart attack
Severity - rate scale from 1-10
Time- when did it start? How long has it lasted? Is it the same as previously or the same as last time? Does it come and go?
