Exam 1 Flashcards
What are the 6 vital signs?
Blood pressure, O2 saturation, Respiration, Temperature, Pulse, Pain.
Why are vital signs signifiant?
It regulates the organs and the body.
Provides data on the overall condition of the body.
Provides changes on the baseline against which you can measure.
When to asses?
Admission, routine visits, according to patient or policyholder, patients complaints or changes, when admin certain medication, procedures, If there is a major change in the VS.
Core temperature
Is the temperature of the deeper tissues and structures.
Thermoregulation.
The regulation of the body’s temperature controlled by the hypothalamus.
Normal body temperature:
98.6 F
Normal oral temperature range:
97.6-99.6
Normal tympanic temp range:
97.6-99.6 F
Normal rectal range
98.6-100.6 F
Normal axillary temp range:
96.6-98F
Hypothermia
When the body’s temperature falls below 95F.
Blood Pressure
Measurement of pressure or tension of blood pushing against the walls of the arteries in the vascular system.
Stoke volume
The amount of blood ejected in one contraction
Cardiac output
The amount of blood pumped from the heart in a full minute.
Pulse pressure
The difference between systolic and diastolic BP
Normal BP
Less than 120/80
Hypotension
Suddenly falls 20-30 mmHg
Falls below 100/60
Stage 1 hypertension BP
130-139/80-89
Stage 2 Hypertension
Greater than 140/90
Sphygmomanometer
BP cuff
Define auscultatory
The period which sound indicating true systolic pressure fade away and comes back in a weaker point.
How to avoid auscultatory gap?
Making sure to palpate while the cuff pressure is rapidly increased.
Define pulse
A rhythmic pulsing throbbing or the artery as blood goes through it.
Where is the apical pulse located? Why would you want to take an apical pulse?
Over the apex of the heart. 3-4 inches left of the sternum in the 5th intercostal space. Most accurate pulse. Atrial and ventricles information we ausculte (listen with stethoscope.) Full minute.
Define pulse deficit
pulse deficit is the difference between the systolic and diastolic rate.
3 factors of taking pulse
Rhytym, How many BPM, Strength (volume)
Pulse sites
Temporal: over the temporal bone. Carotid: side of the neck. Brachial: ante cubical Radial: wrist parallel to the thumb Femoral: Groin Popliteal: begins the knee Posterior tibialis: side of the ankle Dorsalis pedis: on top of the foot
Bradycardia
A pulse less than 60 bpm
Tachycardia
Greater than 100 bpm
Normal pulse range
60-100 bpm
Pulse range depending on age (bpm)
Newborns: 120-160
1-2: 90-120
3-18: 80-100
Adults: 60-100
Volume of pulse
3+ is bounding pulse is very full pulse, easy to feel, and bounding.
2+ is normal and easily directed but you can obliterate.
1+ pulse is weak and will obliterate with one
Thready very faint- very hard to feel.
0 absent- no pulse.
What is capillary refill time?
Indication if there is an adequate circulation. This is tested under the nail bed.
Normal: less than 3 secs on adults and children.
Within 5 secs in the elderly.
Respiration
Is interchange of oxygen and carbon dioxide.
Bradypnea
Respiratory rate below 12/minute
Tachypnea
Respiratory rate exceeds 20 respiration’s/minute
Describe external respiration
Breathe into the lungs and then the lung exchange gas with the heart.
Internal respiration
Exchange o2 between the tissues and the blood
Normal respiration range
12-20- Adult 30-60 newborn 20-40 infants 20-30 children 14-25 adolescence
Characteristics of respiratory rate besides rate:
Depth (shallow, normal, deep)
Effort (if it’s labored)
Rhythm (regular or irregular)
Common lung sounds
Normal: heart it coming in and out
Adventitious: anything other than normal breathe sound.
Wheezing: musical whistling
Crackles: some fluid or secretion in the lungs.
Rhonchi: low pitch sound.
the National Safety Goals established by?
The joint commission
Six factors that continue to unsafe patient setting:
Age Impaired mobility Communication Pain and discomfort Delay assistant Equipment
Strategies for preventing fall:
Morse fall scale
Timed get up and go scale
Restraint alternatives: leg monitor, bed monitor.
When to use RACE?
If the fire is in your area.
RACE stands for
Rescue
Alarm
Confine
Extinguished
When do you use PASS?
To extinguish small fire by a fire extinguisher.
PASS stands for
Pull
Aim
Squeeze
Sweep
Chain of infection
Infectious agent Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host
Vectors
Insects that transmits diseases such as ticks.
Primary defenses
Skin
Mucous membranes
Gastrointestinal system
Secondary defense
Inflammatory
Elevated temperature
Component cascade. (Complement)
Tertiary defense
Lymphocytes.
Standard precautions
Measures to prevent the spread of infection from bodily fluids.
Transmission-based precaution
Prevent the spread of known infection in patient or health-care staff.
Donning PPE
Gown, mask, googles, gloves
Removing PPE
Gloves, gown, googles, mask
Define pulse deficit
State where radial pulse is lower than the apical pulse.
Dyspnea
Labored breathing
Orthopnea
Labored breading while standing
Scope of practice
The limitations and allowances of what they can do as a nurse.
Transcultural nursing
Care that crosses or combine elements of more than one culture.
Cultural diversity
Differences between groups of people in one area.
Cultural awareness
Knowledge of various cultural beliefs as values.
Cultural competence
Providing care for the patient based on the cultural belief and values of the patient.
Barriers in heath care
Geography Economic Language Stereotyping prejudice and discrimination Education Misunderstanding
O2 normal saturation rate
96%-100%
MRSA precautious
Standard and contact
Superbug
multi resistant organism.
MDRO
Penicillin can treat this.
MRSA precaution
Standard precaution, Contact.
What is MRSA
Non-intact skin such as when when there are abrasions or incisions.
VRE
commonly lives in the intestine. It does not cost trouble until it travels to the blood steam or the urinary.
Diarrhea Infections
Clostridium Difficile C-Diff) causes infection in the lining of the intestinal that causes diarrhea.
Measures to prevent Health care-associated infections
Hand-washing, using tubes too long
Evidence-based hand hygiene guidelines
Alcohol-based hand gels for cleaning hands.
Example of contact precautions
MRSA, C-DIFF, VRE (wear gloves and gowns.
Example of droplets precautions
covid, flu, measles, whooping cough (wear surgical mask, gloves, gown.
Example of airborne precautions
Chicken pox, rubeola, TB (Gloves, googles, n-95) Must be in a negative pressure room.
Ways to protect yourself from radiation
Wear a lead apron during the procedure. Wear film badge.
Health occupations students of America (HOSA)
A national organization specifically for students in heath care education program.
National federation of LPN
The professional organization for LPN
Purpose of Critical thinking
Identify actions to take and information to consider when caring for a patient.
Caring for younger patient
Have a difficculty understanting what is going on and expressing their feelings during procedure.
Post conference connection
to help evaluate the clinical ecperience of caring for the patient in the clinical connection.
Quality and safety education for nurses
Patient-centered.
Heimlich maneuver
Action to relieve chocking.
CPR
Actions to restart the heart.
The joint comission
They evaluate and accredited healthcare organizations and programs in the U.S
Fall assesment scale
A form that gives a numerical rating for each patients risk fall.
Code team
A group of specially trained personnel designated to respond to codes.
Body mechanic
movement of the muscle of the body for balance and leverage.
Center of gravity
middle point of the body.
Base support
Feet and lower legs
The National patient safety goals are established by
The joint comission
Hypoxemia
A decreased blood level of oxygen
Stridor
A high-pitched crowing respiratory sound.
Hypoxia
Decreased lever of cellular oxygen
Ausculate
denote use of stetoscope
