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?
First phase, second phase, fourth phase, fifth phase
1st phase - data collection
2nd phase - identifying diagnoses
4th phase - intervention/implementation
5th phase - determine whether outcomes have been achieved
NANDA - North American nursing diagnosis association
Describes a patient’s response to a health problem that can be treated by nursing - nursing diagnosis
Urgent needs
Vital signs
Hygiene
Patient education
Emotional support
Objective vs subjective
Objective is age, sex, and skin color
Subjective anything that can have an opinion
Tachycardia -heart rate above 100 bpm too fast
Bradycardia - heart rate below 60 bpm below
Bradypnea - breathing rate below 12 breaths per minute lungs
Tachypnea - breathing rate too fast in lungs normal 12-20 anything above 22 anything below 12
Normal heart rate = 60 to 100 bpm
always use radial pulse for routine physical assessment and then apical pulse
ABC
Airway
Breathing
Circulation
Arm cuff size guideline
Width - 40% of the circumference of the person’s arm
Length - 80% of the circumference of the person’s arm
O2 - anything over 95 is normal
Slow breathing - neurological, overdose
Fast breathing - diabetic ketoacidosis, neurological
Orthostatic hypotension
Supine position retake in 3 min
Perfusion
Watering plants
Endogenous Infection
Another pathogen takes over
Exogenous infection
Apnea
Lungs
Precautions - airborne, contact, and droplet
Airborne- chickenpox also contact, measles, TB - 95 mask
Contact - c diff, eye infection, skin infection, wound infection - wear gloves
Droplet- flu, whooping cough - wear surgical mask and follow standard precautions
