Exam 1 Study Guide Flashcards
What are the vital signs?
(TPR & BP) Temperature Pulse Respirations Blood Pressure and Pain *Keep in mind Pain is Subjective*
Where are the Pulse sites?
- Temporal (At the Temples of the Head)
- Carotid (Both Sides of Neck) – never check pulse rates on both carotid arteries at the same time
- Apical (Heart) – over the heart and taken with a stethoscope
- Brachial (Crooks of Elbows) – typically used during blood pressure checks
- Radial (Wrists, under thumb) – used most often, easy to reach, easy to find, used for routine vital signs
- Femoral (Groin)
- Popliteal (Behind knee)
- Pedal (Top of Feet) – used to check circulation of the leg
When documenting Blood Pressure make sure to notate…
whether it was taken on the Left Arm or Right Arm.
When documenting Respirations make sure to…
label the reading as “resp” or “RR”.
When documenting Heart Rate (Pulse) make sure to…
label the reading as “HR”, “Heart Rate” or “Pulse” AND note which Pulse Site was used.
Pain is the only vital sign that is…
Subjective.
Subjective Data
information provided by the resident (what they Say)
Objective Data
information collected by the nurse aide’s senses (what is Observed)
IWIPE
Introduce yourself Wash your hands Identify patient Provide privacy Explain procedure and gather Equipment
Respirations
The process that supplies oxygen to the cells and removes carbon dioxide from cells.
What are the Blood Pressure Sites?
- Brachial: right or left upper arm (The brachial artery is most often used by the nurse aide when checking blood pressure)
- Radial: right or left wrist
What are the Blood Pressure Nevers?
- Do not take blood pressure on an arm with an IV, dialysis shunt graft catheter, or other medical device in place
- Avoid taking blood pressure on a side that has been injured or burned, is paralyzed, has a cast, or has had a mastectomy
What is Orthostatic Hypotension?
Abnormal low blood pressure that occurs when the resident suddenly stands up; complaints of feeling weak, dizzy, faint and seeing spots before the eyes.
NOTE: hyPO = LOW
Hypertension
High Blood Pressure: consistent elevated systolic or diastolic values
HYPERTENSION: STAGE 1 o Systolic (top number) - 130 to 139 mm Hg o Diastolic (bottom number) - 80 to 89 mm Hg
HYPERTENSION: STAGE 2 o Systolic (top number) - 140 mm Hg or Higher o Diastolic (bottom number) - 90 mm Hg or Higher
HYPERTENSIVE CRISIS o Systolic (top number) - 180 mm Hg or Higher o Diastolic (bottom number) - 120 mm Hg or Higher (Call 911)
NOTE: HY = HIGH
What is a graduate?
• Accurate measuring device for fluids when resident is on Intake and Output (I&O)
What is the importance of I&O?
- Used to evaluate fluid balance
- Used to evaluate kidney function
- Assists in planning and evaluating medical treatment
- Assists with carrying out special fluid orders
- Used to help prevent or detect complications from fluid intake
- Fluid intake is one factor that reflects the resident’s nutritional status
Which fluids are considered input?
- Liquids that the resident drinks
- Semi-liquid foods that are eaten
- Other fluids including intravenous (IV) fluids and tube feedings that nurse is responsible for maintaining and measuring
Which fluids are considered output?
- Urine
- Vomit
- Diarrhea
- Wound drainage
- Gastric suction material
Which devices collect output?
- Catheter bag
- Urinal
- Commode hat
- Emesis basin
What is the importance of recording accurate weight?
Important indicator of Health Status and Nutrition also tells medical staff how much medication to prescribe.
What are all of the aspects of Hand Hygiene?
INFECTION PREVENTION
• CDC defines hand hygiene as washing hands with
o soap and water or
o alcohol-based hand rubs (gels, rinses, or foams that do not need water to use)
What are the different types of PPE?
• PPE includes o Gloves: protect skin on hands o Gown: protects skin and clothes o Masks: protect mouth and nose o Goggles: protect eyes face shields that protect o Whole Face Mask
What are the Fall Prevention steps?
Components:
o Assessing residents for risk of falling
o Identifying/implementing interventions to minimize risk of sustaining an injury as a result of a fall
BEFAST
Signs a Stroke is Occurring o Balance – loss of balance; dizziness o Eyes – blurred vision o Face – one side of face is drooping o Arms – arm (or leg) weakness o Speech – speech difficulty o Time – time needs to be documented AND time to call 911 or notify supervisor if the resident in a health care facility
What do you do in the event of a seizure?
MAIN GOAL – keep resident safe
• Note time of start and stop of seizure
• Send for supervisor, but do not leave resident alone
• Put on gloves
• Cradle head to protect it
• Loosen clothing to assist with breathing
• Do Not attempt to restrain resident
• Do Not force anything in resident’s mouth between teeth
• Do Not give resident food or liquids
• If no injuries are suspected (head, neck, spine), turn resident on side when seizure is over to prevent aspiration (choking on saliva or vomitus)
RACE
Used in case of Fire
• Remove residents from danger
• Activate alarm
• Contain the fire by closing all doors and windows, if possible
• Extinguish the fire, or fire department will extinguish
PASS
o Pull the pin
o Aim at the base of the fire when spraying
o Squeeze the handle
o Sweep back and forth at the base of the fire
HIPAA
(Health Insurance Portability and Accountability Act) – law that protects the privacy and security of a person’s health information
What are the 3 Skills?
o Basic skills – essential skills required of nurse aides to deliver competent care to residents in health care settings
o Personal care skills – tasks that deal with a person’s body, appearance, and hygiene, typically done on a daily basis
o Interpersonal skills – in a health care setting, generally refers to a health care provider’s ability to get along with others while getting the job done
Fluid for I&O is measured and documented in…
milliliters (mL)
How do you measure fluid in a graduate?
at eye-level on flat surface.
What should you do if both intake and output are being measured?
Use two separate graduates that are and labelled.
PPE
Personal Protective Equipment
Why is PPE worn?
INFECTION PREVTION
Keeps blood, urine, stool, saliva, and other body liquids off skin and clothes.
What is the number one way to stop the transmission of infection?
Handwashing
Standard Precautions
1st of Two Levels of Infection Prevention Precautions; all body fluids, non-intact skin, and mucus membranes are treated as if they were infected
Transmission Based Precautions
2nd of Two Levels to Infection Prevention Precautions; specific tasks and measures that health care workers must do when caring for residents who are infected or may be infected with specific types of infections
What are types of Transmission Based Precautions and what PPE is worn for each?
o Contact Precautions
• PPE – follow Standard Precautions, plus wear Gown and Gloves
• Examples – Methicillin-Resistant Staphylococcus Aureus (MRSA) infection (is the bacteria known for causing skin infections in addition to many other types of infections)
o Droplet Precautions
• PPE – follow Standard Precautions, plus wear a Mask and Gloves
• Examples – influenza, meningitis, and whooping cough
o Airborne Precautions
• PPE – follow Standard Precautions, plus wear a Respirator, depending on specific disease
• Examples – tuberculosis (or TB), chicken pox, measles
Maslow’s Hierarchy of Needs
a theory, developed by Abraham Maslow, researcher of human behavior, that explains the necessity of meeting an individual’s physical needs before meeting psychosocial needs
P.S. BE SAfe
P• Physiological Needs: nutrition (water and food), elimination (toileting), breathing/circulation (vital signs), sleep, sex, shelter, and exercise
S• Safety and Security: injury prevention (call lights, hand hygiene, fall precautions, assistive devices, close observation); build trust (communication, reassurance, empathy); ensure clean, safe environment (free from harm, recognition and alleviation of fears) and resident and family education
B• Belonging and Love: supportive relationships free from social isolation, therapeutic communication skills, meaningful relationships
S• Self-Esteem: acceptance into a community or facility, personal achievement, sense of control or empowerment, accepting one’s physical appearance and mental capabilities
A• Self-Actualization: empowering environment, spiritual growth, ability to recognize other’s point of view, reaching one’s maximum potential
(f and e are not used)
Nursing Process 5 Steps
o Assessment – collecting information about a resident
o Diagnosis – describes a health problem that can be treated using nursing measures
o Planning – setting priorities and goals for a resident
o Implementation – performing or carrying out nursing measures that impact resident care
o Evaluation – time when nurses look at nursing care plans and see if plan worked in solving health issues and if interventions were effective
Afebrile
without a fever
Febrile
with a fever
Temperature Sites
o Mouth (oral) o Rectum (rectal) – most accurate; never let go of rectal thermometer while checking temperature o Armpit (axillary) – least accurate o Ear (tympanic) o Temporal artery (forehead)
Do Not take oral temperature when…
- Recent is unconscious
- Recent facial or mouth surgery
- Recent injury to face
- Has sores, redness, or mouth pain
- Is confused or agitated
- History or seizure
- Is using oxygen
- Is mouth-breather
- Has a feeding tube
Do Not take rectal temperature when…
- Has diarrhea
- Has rectal problem
- Has heart disease
- Recent rectal surgery
- Is confused or agitated
After Shaking Non-mercury, liquid-filled glass thermometers how long do you take the temperature for the reading be complete?
3 Minutes for Rectal
5 Minutes for Oral and Axillary
How do you position a patient to take a rectal temperature?
Lying down on LEFT side (due to heart, want to avoid stimulating vagus nerve)
How far do you stick in a rectal thermometer?
2”
What is the most accurate way to take temperatures?
Rectal
What colors are Non-mercury, liquid-filled glass thermometers?
Rectal - RED
Oral & Axillary - BLUE or GREEN
What are the types of thermometers?
- Digital – oral, rectal, axillary
- Electronic – oral, rectal, axillary
- Tympanic – ear
- Temporal – forehead
- Non-mercury, liquid-filled glass
What are the Baseline and Normal Ranges for temperatures at the different sites?
• Oral, Tympanic, & Temporal (The Head) o Baseline – 98.6 F o Normal range – 97.6 F to 99.6 F • Rectal o Baseline – 99.6 F o Normal range – 98.6 F to 100.6 F • Axillary o Baseline – 97.6 F o Normal range – 96.6 F to 98.6 F
ADL
Activities of Daily Living – term used in health care to describe everyday things that a resident routinely does, such as hygiene and grooming, dressing, eating, toileting, and transferring
Nurse Aide I in the State of NC
a valued, unlicensed member of the health care team, responsible for providing delegated nursing tasks, within a defined range of function, for residents (patients/clients), in a variety of settings, and who is listed on the NC Nurse Aide I Registry
Body Fluids
- Blood
- Pus (liquid from sores)
- Spit
- Saliva
- Tears
- Urine
- Stool
- Droplets (from Sneezes and Coughs)
- Emesis
- Sputum (mucous coughed up from lungs)
Mucus Membranes
Linings of the body such as eyes, nose, mouth, rectum.
How long should you wait before taking the oral temperature of a client who has just had a drink or has eaten?
20 minutes
List the correct steps to Orthostatic Hypotension Process.
• Nurse aide may be asked to take an orthostatic blood pressure measurement; process includes:
o BP checked while lying down, record in note pad
o Have resident sit up, wait 2 minutes, check BP, record in notepad
o Have resident stand up, wait 2 minutes, check BP, record in notepad
o Record and report findings to nurse
• Throughout process, nurse aide should check to see if resident is feeling weak, dizzy, faint, or seeing spots
When changing a soiled dressing you should wash your hands…
before, during, and after the procedure.
List the correct steps to Orthostatic Hypotension Prevention.
• Per care plan and directive from nurse
o Increase activity in stages:
1. Bed rest
2. then Sitting on side of bed (while sitting on side of bed with feet dangling, have resident cough/deep breathe and move legs back-and-forth in circles, 1 to 5 minutes)
3. then Standing and walking
o Ask resident to report weakness, dizziness, faintness, or seeing spots
Who is the regulatory body that provides list of tasks that fall within the range of function for nurse aides in North Carolina?
North Carolina Board of Nursing
It is call the The North Carolina Board of Nursing Administrative Code
The North Carolina Board of Nursing Administrative Code is…
a list made by the North Carolina Board of Nursing which defines range of function for nurse aides in North Carolina
North Carolina Health Care Personnel Education and Credentialing Section
section of the State of North Carolina that provides services for unlicensed health care workers, their employers, and their instructors and maintains the NC Nurse Registry
North Carolina Nurse Aide I Registry
a registry of all people who meet state and federal training and testing requirements to perform Nurse Aide I tasks in the State of North Carolina
Cognition
the manner in which messages from the five senses are collected, stored in memory, recovered from memory, and later used to answer questions, respond to requests, and perform tasks; the ability to think logically and clearly
Delegation
the process of assigning part of one’s responsibility to another qualified person in a specific situation; transferring responsibility for the performance of an activity or task while retaining accountability for the outcome
Analog Watch
a watch that has moving hands and typically marked from numbers 1 through 12
Aneroid Manometer
that part of the sphygmomanometer (BP cuff) that includes the dial that indicates the systolic and diastolic pressures during blood pressure checks
Apnea
no breathing
Atria
(right and left) two upper chambers of the heart
Body temperature
how much heat is in the body and balances the heat created by the body and heat lost to the environment
Bradycardia
a pulse rate less than 60 beats per minute
NOTE: “Brady” = Low
Bradypnea
a respiratory rate less than 12 breaths per minute
NOTE: “Brady” = Low
“pnea” = Respiratory
Cardiovascular System
also called the circulatory system and is the continuous movement of blood though the body
Cheyne-Stokes
alternating periods of slow, irregular breathing and rapid, shallow breathing, plus short periods of absent breathing
Stethoscope Chest Piece
part placed against the body to listen to heart sounds, lung sounds, and the brachial pulse during blood pressure checks; made up of the
Bell - used for low frequency sounds
AND
Diaphragm - used for high frequency sounds
Diastole
the resting phase of the heart when the heart fills with blood; the bottom number of a blood pressure reading (diastolic)
Dyspnea
painful or difficult breathing
NOTE: “pnea” = Respiratory
Eupnea
normal breathing aka normal respirations
NOTE: “pnea” = Respiratory
Expiration
aka Exhalation - breathing out of carbon dioxide through the nose and mouth; the chest falls
Inspiration
aka Inhalation - breathing in of oxygen through the nose; chest rises
Millimeters of Mercury
(mm Hg) the unit of measure for Blood Pressure
Define Pulse Force, Rate, and Rhythm
Pulse Force – the strength of the pulse and should be easy to feel
Pulse Rate – the number of heart beats (or pulses) per minute
Pulse Rhythm – the regularity of the heart beats (pulses) and should be the same interval between beats
Sphygmomanometer
aka Blood Pressure cuff; is the equipment used to check a person’s blood pressure
Stethoscope
instrument used to listen to heart sounds, lung sounds, and the brachial pulse during blood pressure checks
Systole
the working phase of the heart when the heart is pumping blood to the body; the top number of a blood pressure reading (systolic)
Tachycardia
a pulse rate more than 100 beats per minute
Tachypnea
a respiratory rate more than 20 breaths per minute
NOTE: “pnea” = Respiratory
Ventricles
(Right and Left) – two lower chambers of the heart
Edema
when fluid intake is more that fluid output and body tissues swell with water
Gastric Suction Material
stomach contents that are suctioned out using a nasogastric tube
Nothing by Mouth (NPO)
a doctor’s order that states that a resident is not to eat or drink anything
Aerobic
requires oxygen to survive
Anaerobic
does not need oxygen to survive
Aseptic
clean
HAI
Healthcare-associated infection – an infection that a resident gets while staying or living in a health care setting
Norovirus
a contagious gastrointestinal illness
Reservoir
place where harmful germs live, grow, and increase in numbers
Systemic Infection
an infection that affects an entire body part, or entire body system
Localized Infection
an infection found in one part of the body with symptoms noted at that one part of the body
Cerebrovascular Accident
(CVA or Stroke) – occurs when blood supply to a part of the brain is blocked or a blood vessel leaks/breaks in a part of the brain
Elopement
when a resident leaves a health care facility without the staff’s knowledge
Seizure
involuntary contractions of muscles involving small area or entire body; caused by abnormal electrical activity in the brain
Kardex
a type of card file that includes information important to the care of residents and includes drugs, treatments, diagnoses, routine care measures, and special needs
Self-esteem vs. Self-Actualization
Self-esteem - confidence in one’s own worth or abilities; self-respect
Self-Actualization - the realization or fulfillment of one’s talents and potentialities, especially considered as a drive or need present in everyone
What is the normal Pulse range?
60 to 100
What is the CC to mL conversion?
1 CC = 1 mL (They are the same)
What fluids are considered Liquids?
- Water
- Milk
- Coffee
- Tea
- Juices
- Soups
- Soft drinks
Convert Milliliters to Ounces?
30 mL = 1 oz
When should you weigh a pt?
when they’re first admitted and at the same time every day
Convert Kg to lbs?
2.2 lbs = 1 Kg (take the weight in lbs and then divide by 2.2 to get the Kg)
How long do you wash your hands?
20 seconds
5 essential times you need to preform hand washing?
- arriving at work
- after using the rest room
- before and after eating
- before and after putting on gloves
- leaving work
How many lobes are in each lung?
Left Lung has 2 Lobes
Right Lung has 3 Lobes
Hypoventilation
slow, shallow breathing that may be irregular
NOTE: hyPO = LOW
What are the breathing abnormalities?
- Apnea – none (apnea)
- Bradypnea – less than 12 breaths per minute
- Tachypnea – more than 20 breaths per minute
- Dyspnea – painful or difficult breathing
- Hypoventilation – slow, shallow breathing that may be irregular
- Hyperventilation – rapid, deep breathing
- Cheyne-Stokes – alternating periods of slow, irregular breathing and rapid, shallow breathing, plus short periods of apnea
What makes up the transportation system of the cardiovascular (circulatory) system?
o Veins – carry blood with waste products Away from the Cells and To the Heart
+ Veins carry the blood back to the heart. They’re similar to arteries but not as strong or as thick. Unlike arteries, veins contain valves that ensure blood flows in only one direction. (Arteries don’t require valves because pressure from the heart is so strong that blood is only able to flow in one direction.) Valves also help blood travel back to the heart against the force of gravity.
o Arteries – carry blood with oxygen and nutrients Away from the Heart and To the Cells
+Arteries carry oxygenated blood away from the heart. They’re tough on the outside but they contain a smooth interior layer of epithelial cells that allows blood to flow easily. Arteries also contain a strong, muscular middle layer that helps pump blood through the body.
What are genetic factors that affect BP?
o Age (BP increases with age) o Gender (women’s BP usually lower) o Race (black residents BP higher than white)
What is the normal BP ranges for an adult?
o Systolic (top number)
– 90 mm Hg to 119 mm Hg
o Diastolic (bottom number)
– 60 mm Hg to 79 mg Hg
Hypotension
Low Blood Pressure: too low systolic and/or diastolic values o Systolic (top number) – less than 90 mm Hg o Diastolic (bottom number) – less than 60 mm Hg
NOTE: hyPO = LOW
What are Elevated BP ranges?
ELEVATED o Systolic (top number) - 120 to 129 mm Hg o Diastolic (bottom number) - 80 mm Hg or Less
What fluids are considered semi-liquids?
- Milkshakes
- Ice cream
- Sherbet
- Custard
- Pudding
- Gelatin
- Popsicles
What are the stages of Blood Pressure?
NORMAL o Systolic (top number) - 90 to 119 mm Hg o Diastolic (bottom number) - 60 to 79 mm Hg
ELEVATED o Systolic (top number) - 120 to 129 mm Hg o Diastolic (bottom number) - 80 mm Hg or Less
HYPERTENSION: STAGE 1 o Systolic (top number) - 130 to 139 mm Hg o Diastolic (bottom number) - 80 to 89 mm Hg
HYPERTENSION: STAGE 2 o Systolic (top number) - 140 mm Hg or Higher o Diastolic (bottom number) - 90 mm Hg or Higher
HYPERTENSIVE CRISIS o Systolic (top number) - 180 mm Hg or Higher o Diastolic (bottom number) - 120 mm Hg or Higher (Call 911)
