Exam 1 Review Flashcards
Week 1-4
what is controlled acts
performed only by qualified individuals or if delegated to you
Primary survey includes checking:
ABC = airway, breathing, circulation
Disability
Exposure
Level of unconciousness
Alert and oriented
confused and disoriented
Lethargic
Obtunded
Unconscious
Lethargic means
Tired andSlow/sluggish
Confused and disoriented aka
altered cognition
obtunded means a patient
needs constant stimulation, if not they will go back to sleep
What to assess/ask when checking for level of orientation
Place
Time
Person
Self
What do you look at when examining mental status
Appearance
Behaviour
Cognition
Thinking
Firs level priority are
life threatening and needs urgent action
second level priority is when
it can lead to clinical deterioration, needs prompt action
third level priority is
non urgent, but needs to be addressed (EG: teaching/educating)
what do you have to consider when prioritizing care (aside from the patient’s assessed data)
what is most important to the client
When should mental health be a priority instead of first, second or third level priority
When a person has a plan (when and where)
Types of interventions
Effective
Ineffective
Unrelated
Contraindicated
Types of care people are receiving that determines their health assessment frequency
Primary care
Long term care
Acute care
Types of health assessments
Primary Survey
Focused assessment
Head to toe (Abbreviated)
Complete health assessment
Another term for Head to toe assessment
Cephalocaudal approach
Diff types of health promotion
Behavioural = lifestyle
Relational = their environment
Structural = hospital policies
Health promotions and interventions allow patients to
enable them to increase control over their health
Stroke volume (SV) refers to
About 5-80 ml of blood that is being pumped with each contraction of left ventricle
Peripheral pulse means
refers to the feeling of blood moving away from the heart traveling to the body
What pulse location do you use when taking Vital signs
Radial pulse
Where is radial pulse located
bone close to flexor of wrist.
Radial artery
Where is carotid pulse located
medial to sternomastoid muscle in middle third of neck
T or F should you palpate carotid artery one at a time only? why?
Yes, you should only palpate carotid artery one at a time to not block the brain completely of blood
Where is brachial pulse located
in the antecubital fossa in the bicep tendon
What do yo u assess for when taking pulse
Rate
Rhythm
Force
Equality
Normal pulse (BPM) for adult
60-100 BPM
Normal pulse for newborn
100-175 BPM
Bradycardia is when
Pulse is lower than 60 BPM = Low Pulse
Tachycardia is when
Pulse is higher than 100 BPM = High pulse
what is Sinus arrhythmia
Irregular heart rhythm.
Abnormal health rhythm that shows your heart is HEALTHY
Diff level of pulse force
0 = Absent
1= weak/thready
2= normal
3 = bounding/strong
What is Equality or bilateral assessment?
Checking both sides of the body
Changes in Blood pressure is based on whether the heart is:
Contracting (systolic)
Resting (Diastolic)
Blood pressure refers to
the force of blood exerted against arterial wall
Systolic refers to
Contraction of left ventricle of the heart.
Maximum force on artery wall
Diastolic refers to
when left ventricle is at rest/filling
is systolic or diastolic takes longer period of time?
Diastolic takes longer
If BP doesn’t fall within the normal range what should you do
Inform the nurse
check for equality (other side)
compare to client’s personal base line
Pulse pressure refers to
the diff between systolic and diastolic.
Measuring the force ur heart generate when it contracts
Cardiac output (CO) refers to
volume of blood pumped in 1 min
Cardiac output formula
cardiac output = Stroke volume X Heart rate
Stroke volume formula
SV = EDV - ESV
stroke volume = end diastolic volume - end systolic volume
Peripheral vascular resistance
Opposition to blood flow
Factors affecting one’s Blood pressure
Cardiac output
Peripheral vascular resistance
Viscosity
Volume of circulating blood
Elasticity of vessel walls
Modifiable risk factor affecting BP include:
Sedentary lifestyle/exercise
Diet/alcohol intake
Emotions/stress
Disease processes
Dysglycemia & dyslipidemia
Non adherence to treatment plans
Non modifiable risk factor affecting BP
Age
> Age 55 years and older increased risk of HTN
Sex
Ethnicity
Family history of CV disease
Diurnal rhythm
Smoking
Weight/obesity
What is Diurnal rhythm
Type of circadian rhythm.
Diurnal rhythm is the natural daily pattern of changes in the body, like sleeping at night and being awake during the day. It follows a 24-hour cycle and is controlled by light and darkness.
What is Dysglycemia
Dysglycemia = abnormal blood sugar levels
focus on the glycemia part of the name
What is Dyslipidemia
Dyslipidemia = abnormal level of lipids in the bloodstream
focus on lipid on the name
Methods of taking BP measurements (4)
Manual
automatic
Arterial catheters
Cellular phone apps
what is arterial catheters
Invasive BP monitoring, by inserting inside the body, usually on the wrist
Width of BP cuff should equal __% of the circumference of patient’s arm
40%
What happens if the BP cuff is not the right size
gives false reading
if the cuff is too small, its gonna show a higher BP than it actually is
What is auscultatory gap
abnormal finding, period of silence between korotkoff sounds
What is orthostatic hypotension
drop in systolic BP of more than 20
and diastolic of 10
this may include increase of pulse more than 20
so basically when someone moves and when their BP drops and their heart rate spikes
common cause of orthostatic hypotension
Prolonged bedrest
older age
dehydration
What is considered hypertension in older adults. when it reaches
More than 140/90 BP
What is considered hypotension is older adults
Less than 95/60
List of common BP errors (just read)
Anxiety
Arm position and leg position
Inaccurate cuff size
Failure to palpate radial artery
Poor inflation of cuff
Pressing stethoscope too hard
Deflating cuff
Pausing during descent
Failure to wait adequate time between measures
Observer error
What is COPD – Chronic obstruction pulmonary disease
lung disease that restricts airflow and breathing
What is focused assessment
focus on the patients reason for seeking care/ specific health concern
what is primary survey
checks ABC, exposure and disability
head to toe assessment vs complete health assessment
head to toe = overview of client’s CURRENT health status
Complete health assessment = overview of client’s health status overall
what is atrial fibrillation
When atria quivers
Higher Cardiac output
High Peripheral vascular resistance
High Volume of circulating blood
High Viscosity of blood
> Results in low/high BP?
High BP
Low Cardiac output
Low Peripheral vascular resistance
Low Volume of circulating blood
Low Viscosity of blood
> Results in low/high BP?
Low BP
If vessel walls are more elastic does it result in higher or lower BP?
If its more elastic its lower BP
Difference of about 10 mm Hg decrease in BP and increase in pulse of 10-15 bpm is normal or abnormal from lying to standing?
Normal
Abnormal if its more than 20 BP and BPM
Orthostatic tachycardia is
(tachyCARDIA)
increase in pulse of 20 BPM when moving
Pulse not BP
What is aneurysm
may be a result of hypertension, when blood vessels ballon cause of weak walls
What is peripheral arterial disease?
result of hypertension, obstruction of vessels
when assessing for respiration what do you check?
Rate
Rhythm
Quality (are they using their accessory muscles?)
Note of any respiratory distress
What position should you be wary of when checking for the patient’s respiratory
tripod position -> leaning forward and holding things for support
- Tracheal tugging
- wide eyes
- nasal flaring
- intercostal tugging
Normal range of respiratory for older adults
10-20
Higher for younger individuals
normal O2 saturation range
97-100%
92-100% acceptable for older adults
influencing factors of O2 sat findings
Age
Obesity or certain diseases
smoking and anemia
alternative sites for pulse oximeter placement if fingers are not possible
Earlobe
Forehead
What part of the brain controls temp
hypothalamus
what is the core temps for adults
36.5-37.5 celcius
core temps for infants or children
35.5-37.7 celcius
higher than adults
influencing factors for temp
age
stress
diurnal cycle
menstruations
pregnancy
exercise
hyperthermia
hypothermia
normal range of temp for oral
35.8 - 37.3 celcius
normal range of temp for axillary
34.8 - 36.3 celcius
what is the normal temp for tympanic
36.1- 38.9 celcius
what is the normal temp for rectal
36.8 - 38.2 celcius
who do you use rectal temp to and when?
usually for infants if they have a fever, it can be dangerous
but it cal also be done for older adults in special circumstances
T or F weight can change on the time of day
Yes True
BMI: underweight, normal weight, overweight, obese
less than 18.5
underweight
BMI: underweight, normal weight, overweight, obese
18.5 - 24.9
normal
BMI: underweight, normal weight, overweight, obese
25.0 - 29.9
Overweight
BMI: underweight, normal weight, overweight, obese
more than 30
Obese
Calculating BMI, what are the 2 formulas
Kg/(metres^2)
(Lbs/ (inch^2) ) X 703
Conversion of Kg and Lbs
X or / by 2.2
1 Kg is 2.2Lbs
Conversion of metres to inches
X or / by 39
1metres is 39 inch
downside of BMI
doesn’t account for individual differences such as ethnicities
Wasted/stunded in context of weight/BMI refers to
severely underweight/stunded height
What waist and hip circumference measurements indicate increased risk for men and women?
Men: ≥ 102 cm (40 in)
Women: ≥ 88 cm (35 in)
What is the Waist-to-Hip Ratio, and what values indicate increased risk?
Waist-to-Hip Ratio = Waist ÷ Hip
Increased risk:
Men: ≥ 0.90
Women: ≥ 0.85
What is the Waist-to-Height Ratio, and what value indicates increased risk?
Waist-to-Height Ratio = Waist ÷ Height
Increased risk: Ratio ≥ 0.5
Apnea refers to
pauses in breathing
is oxygen considered medication? are nurses able to give them?
oxygen is a medication, nurse practitioner can give them if needed.
Nurses can only give in emergency situation = dips bellow 92%
is fevers helpful? why?
yes, it can fight off infection in the body
are anthropometric body measurements used as diagnostic tools?
no its for screening tools only, to see a person’s overall health
why is it a risk if an individual has higher measurements for their anthropometric body measurements?
because carrying adipose tissue can be hard for the heart
Match with the correct normal respiratory rate range
7-11 years
2-6 years
Adults and Older Adults
12-18 years
Newborn to 6 months
6 months to 1 year
10-20
22-36
30-60
18-30
26-40
12-22
Adults and older adult: 10-20
12-18yrs: 12-22
7-11 yrs: 18-30
2-6 yrs: 22-36
6 month-1 year 26-40
Newborn-6 month: 30-60
what should the quality of a respiratory be when you are assessing for it?
relaxed and silent
What does IPPA stand for when doing an objective assessment
Inspection
Percussion
Palpation
Auscultation
What should you do/ask the patient to do before objective assessment?
if they need to go to the bathroom
prepare the environment
privacy and warmth
body positioning and mechanics (for u and patient)
developmental considerations (how much they have to move, especially for older adults)
care partners
when doing an objective assessment, if there are no precautions needed do you wear gloves or use bare skin?
bare skin
only wear gloves if theres precautions or skin breakdown,etc
What does “Cranial” mean in terms of anatomical location?
Cranial refers to towards the head or the skull.
What does “Caudal” mean in terms of anatomical location?
Caudal means towards the tail or lower part of the body.
What does “Posterior” mean in terms of anatomical location?
Posterior refers to the back or behind of the body.
What does “Dorsal” mean in terms of anatomical location?
Dorsal refers to the back of the body, often used for animals or in reference to the back side.
What does “Anterior” mean in terms of anatomical location?
Anterior refers to the front or towards the front of the body
What does “Ventral” mean in terms of anatomical location?
Ventral refers to the front or belly side of the body.
What does “Superior” mean in terms of anatomical location?
Superior means above or towards the head.
What does “Inferior” mean in terms of anatomical location?
Inferior means below or towards the feet.
What does “Distal” mean in terms of anatomical location?
Distal refers to further away from the point of attachment or trunk of the body.
What does “Proximal” mean in terms of anatomical location?
Proximal means closer to the point of attachment or the trunk of the body.
What does “Lateral” mean in terms of anatomical location?
Lateral means away from the midline of the body, towards the sides.
What does “Medial” mean in terms of anatomical location?
Medial means towards the midline of the body.
inspection in IPPA means1 full respiratory cycle is
one inhale and exhale
oxygen saturation means
% of hemoglobin saturated with oxygen
each can attach to 4 oxygen
hypoxemia refers to
insufficient oxygen in the blood
anemia refers to
less hemoglobin to carry oxygen in your blood
vasoconstriction refers to
narrowing of blood vessels = reduced blood flow to peripheries (limbs/body)
can you use the same arm when taking Bp and O2 saturations?
no, use a diff arm
what can cause O2 saturation to show an inaccurate reading?
nail polish
patient is cold
anything below 75%
hyperthermia refers to
elevated body temp
hypothermia refers to
decrease body temp
lead to cell damage, hypothermia or hyperthermia?
hyperthermia
lead to unconsciousness, hypothermia or hyperthermia
hypothermia
when palpating a patient what do you use
use hand/fingers/back of hand (esp for temp)
when palpating for body temp what do you use?
back of hand is more sensitive to temp
when do you use your fingertips when palpating?
texture
thickness
moisture
swelling & massess
pain/tenderness
location,size,density
pulsatility
crepitus
when do you use cupping of hands motion or grasping of fingers/thumbs when palpating?
Bones and muscles (and associated deformities) as well as the trachea and testicles are often assessed using a gentle grasping motion of the fingers and thumbs.
Crepitation is an abnormal grating or crunching sound or sensation felt and heard over joints at the location where bones meet.
what is crepitation and where does it occur
grating/crunching sound or sensation at joints (where bones meet)
when do you use ulnar surface of hand when palpating?
pulsatility in a patient
what is vibration (tactile fremitus) refering to
shaking motion over the lungs
what is pulsatility referring to
abnormal pulsation felt over the heart “thrills” (like a purr of a cat)
when do you use metacarpophalangeal joints or side of hands when palpating?
checking for vibrations or tactile fremitus over lungs
what is Percussion do in IPPA
tapping body to elicit a sound
sound of percussion in the body depends on
the underlying structure, is it air filled, fluid filled or dense
what is indirect percussion technique
use of non dominant middle finger and using dominant hand to tap your other finger
what should you hear when doing percussion over bones (clavicle, ribs, sternum)
flatness
what should you hear when doing percussion over adult lungs
resonance
what should you hear when doing percussion over child lungs
hyperresonance
what should you hear when doing percussion over dense organs (liver, spleen, heart)
dullness
what should you hear when doing percussion over abdominal area (intestines and stomach)
tympany
what is auscultation do in IPPA
listening to body with stethoscope
what do you use diaphragm or bell when listening to high pitched sounds
diaphragm
what do you use diaphragm or bell when listening to low pitched sounds
bell
dimensions of pain
subjective
physiological
behavioural
cognition
psychological and social
reactive = how it interferes with ADL
the use of diff type of pain assessment tool depends on
reason for assessment
developmental stage
health status
institutions / unit
culture
list of diff types of pain assessment tool
numerical rating scale
visual analogue scale
verbal description tool
FACES pain scale
sun cloud pain scale
PQRSTU mnemonic
ABBEY pain scale
P in PQRSTU
Proactive
Palliative
what makes it better/worse
Q in PQRSTU
quality
quantity
what does it feel like? (eg: dull)
R in PQRSTU
region
radiation
where is it located, does it radiate?
S in PQRSTU
Severity
From 0-10 how much does it hurt?
T in PQRSTU
Timing
Treatment
When did it occur? have you taken any medication for it? is it worse in the day or when you stand?
U in PQRSTU
understanding
what do you think caused it?
when is abbey pain scale used?
for dementia patients or non verbal patients or cognitive impairement
abbey pain scale measure what categories
vocalization
facial expression
change in body language
behavioural change
psychological change
physical change
Abbey pain scale, when score is 0-2 its:
no pain, mild, moderate, severe
no pain
Abbey pain scale, when score is 3-7 its:
no pain, mild, moderate, severe
mild
Abbey pain scale, when score is 8-13 its:
no pain, mild, moderate, severe
moderate
Abbey pain scale, when score is 14 and up its:
no pain, mild, moderate, severe
severe
downside of pain assessment tools
can’t differentiate between pain or other distressing state/cause
Angina
chest pain caused by reduced blood flow to the heart
Does IPPA happen in order?
no, it depends on the situation
does subjective or objective assessment come first?
subjective assessment, use the objective assessment to confirm the subjective assessment
what does it mean to collect collateral information?
gathering secondary history of patient from people around the patient or their charts
T or F. if abdomen is full it can create a dull sound
true
Erythema refers to
redness of skin
sepsis refers to
body damages itself by fighting off an infection
how long do you assess the client again after giving pain medication
about half an hour after
is it normal or abnormal to hear the sound of blood “woosh”?
it is abnormal, it can indicate clotted artery
blood is normally quiet
ask the patient to hold their breath so you don’t mistake that sound to air coming through their lungs
what type of pain is: acute
short, and caused by something specific
usually subsides after cause of pain is resolved
what type of pain is: chronic
pain is present for about 3-6 months
even after expected healing time
Type of chronic pain: secondary chronic pain refers to
pain brought upon as a result of a disease/condition/treatment
type of chronic pain: primary chronic pain refers to
pain that can’t be accounted for by other causes
not associated with an underlying, identifiable medical condition that directly causes it. It is considered a condition in itself, not just a symptom of something else.
fibromyalgia (type of primary chronic pain) refers to
chronic condition that causes pain, fatigue and discomfort all over the body
what type of pain is: referred pain
pain felt from a diff site of the origin of the pain
what type of pain is: idiopathic
Mystery pain = no one knows why
pain from unknown origin, no obvious pathology (no clear medical explanation)
what type of pain is: nociplastic pain
Faulty body pain system = body overreacting
caused by dysfunctional nociception (body recognition of pain).
no obvious tissue damage
what type of pain is: neuropathic pain
Messed up nerves
sensitive to touch and temp.
Pain caused by disease in somatosensory nervous system (body’s sensory nervous system)
what type of pain is: Nociceptive
“Real/visible(?)” injury
involves noxious stimulus (harmful stimulus) that activates nociceptor
Type of nociceptive pain: somatic pain refers to
pain originating from peripheral tissues
Type of nociceptive pain: visceral pain refers to
pain originating from inside of the organs
what is opioid usually used for
narcotic substance for pain management
spasticity
abnormal muscle tightness dur to prolonged muscle contraction
Tangential lighting is when you use….
direct penlight to shine on an area you are inspecting
what do you inspect?
body position and posture
gait (balance/movement)
symmetry
skin
behaviour
dress and hygiene
when palpating why should you avoid staccato taps?
can be difficult for patients to anticipate
what is diaphoresis
excessive perspiration
when palpating for swelling and masess and pain and tenderness what do you use?
fingertips/fingers
subcutaneous crepitus refers to
when air is trapped in tissues
what type of sound do you hear when doing percussion that may indicate a mass?
Flatness
tool facilitated percussion
using instrument to tap the body
direct percussion
using one finger to directly tap with fingertips
Ischemia refers to
deficit of blood flow (oxygen) in tissues/other body parts
list of roles of integumentary system
thermoregulation
fluid balance
protective barrier
immune defense against foreign bodies
sensory functions
Necrotizing fascitis refers to
Flesh eating disease
skin infection that spreads throughout the body
Very Critical finding
Necrosis refers to
tissue death
(common on toes and feet)
Pruritus aka
itching skin
Nevi aka
moles
Alopecia aka
unexpected hair loss
when doing skin inspection in older adults what do you make sure to assess?
bony Prominences which is commonly overlooked (eg: ear)
Skin inspection: pallor means
paler skin that other body parts
Skin inspection: erythema means
redness
Skin inspection: cyanosis means
bluishness in other parts of skin (sometimes due to lack of oxygen)
Skin inspection: brawny means
Brawny tone to skin
Skin inspection: jaundice means
yellowish skin (focus on the liver when jaundice occurs)
Skin inspection: virtiligo means
development of lighter skin tones
Nevi inspections: ABCDE stands for
Asymmetry
Border irregularity
Colour
Diameter
Evolving
Skin inspection, what does contusions mean
bruising
Braden scale measures what categories
sensory perception
skin moisture
activity
mobility
friction and shear
nutritional status
mild risk 15-18
moderate 13-14
high risk 10-12
severe - less than 9
Skin palpation: skin turgor refers to
elastic rebound of skin when its tugged, dehydration results in less turgor
List of signs of dehydration
dry mouth
chapped/cracked lips
dry skin
no tear production
dark urine
dry cough
dry wrinkle skin
headache
delirium
fatigue
lightheadedness
poor skin turgor
constipation
Nail clubbing refers to
when nails seem swollen / appear wider
Capillary refill refers to
how long your blood goes back to your nail bed when you pinch it
normal - about 3 sec
what should you assess when you notice clubbing of nails
assess heart/lungs, it usually happens cuz of chronic low oxygen
avulsion refers to
tearing off of skin or other part of body
subungual hematoma refers to
collection of blood collecting under nails
nail laceration is
cut in the nail bed under the nail
skin maceration refers to
skin breakdown due to prolonged exposure to moisture
diabetic neuropathy refers to
Low sensation on their foot/leg -> may get hurt often without realizing -> can lead to skin ulcer breakdown
compound break refers to
break in bone poking through skin
discrete rash vs confluent rash
discrete rash = rash not touching each other
confluent rash = multiple and are touching/on top of each other
Primary vs secondary skin lesions
secondary lesion is caused by primary lesion
what should you assess when looking at blisters
if they are fluid filled or if they are dense
When inspecting Nevi using ABCDE what findings are abnormal?
Irregular shape
irregular border (no symmetry)
variation in colour
larger then 6mm
evolving
you inspect bony prominences because it is a risk for
pressure ulcers
T or F. if a patient is cold, their capillary refill will take longer
True
Cullen’s sign refers to
a bruising and edema of fatty tissue around belly button .
can be a sign of internal bleeding or pancreatic trauma
T or F measles require airborne precautions
True
measles refers to
small flat red spots on face and spread to body
Keloid is
a thick raised scar on skin
T or F. Linea nigra and striae are normal findings on pregnant patients
TRUE
Dyspnea refers to
difficulty breathing
