Exam 2 Flashcards
aging and mobility, vital signs, physical assessment, documentation
What are some of the reasons why people in the stage of late adulthood might not have healthy nutrition?
finances, poor diet education, chronic diseases, low resources
Name the American Hospital Association’s (AHA’s) seven goals to prevent heart disease.
healthy diet
exercise
avoid increase weight
no smoking
blood pressure
cholesterol
blood sugar
Heart disease
Cause: weak pulse, high blood pressure, chest pain.
Nursing action: improve circulation, lower blood pressure, and administer medication.
Type 2 Diabetes
Cause: polyuria, polydipsia, polyphagia, dry skin, blurred vision.
Nursing action: encourage exercise and a healthy diet.
Osteoporosis
Cause: bones become porous and more susceptible to fractures.
Nursing action: increase calcium and vitamin D intake, eat foods with high calcium, limit sodas or colas
Alzheimer’s
Agnosia- unable to recognize
Anomia- unable to name objects
Aphasia- unable to comprehend
Apraxia- unable to perform task
Amnesia- memory loss
Nursing action: educate family and patient on medications and encourage a strict routine.
Rotation
moving lengthwise
Circumduction
moving in a circular fashion
Extension
straightening the arm
Eversion
moving the palm of the hand to face downward
Pronation
turning soles outward
Adduction
moving closer to the midline
Abduction
moving away from the midline
Flexion
bending the joint and decreasing the angle between bone
Inversion
turning the sole of the foot toward the midline
What is a mobility assessment?
An objective assessment
Immobility effects
degradation of cardiovascular, respiratory, gastrointestinal, and musculoskeletal functions
Risk for impaired mobility
falls, poor ROM, pressure ulcers, blood clots, and pneumonia
Capillary refill check and time
fingers and toes
less then 3 seconds
Systole
period of contraction the ventricles of the heart that occurs between the first and second heart sounds to the cardiac cycle
Diastole
period of relaxation of the heart muscle, accompanied by the filling of the chamber with blood
Cardiac Output
the amount of blood pumped by the heart
Stroke Volume
the volume of blood that is pumped out of the heart’s left ventricle during each systolic cardiac contraction.
Viscosity
the resistance of a fluid movement when forces are applied to it.
Peripheral Vascular Resistance
the resistance in the circulatory system that is used to create blood pressure, the flow of the blood and is also a component of cardiac function.
Contractility
the capability or quality to shrink or contract.
Preload
the stretch of the myocardium or end-diastolic volume of the ventricles.
Korotkoff sounds
generated when a blood pressure cuff changes the flow of blood through the artery.
Hypertension
when the pressure in your blood vessels is too high (140/90mmHg or higher)
Hypotension
a decrease in systemic blood pressure below accepted low values. (90/60 mmHg or lower)
Pulse deficit
occurs when the heart is contracting, and the pulse is not reaching the periphery.
Cheyne-stroke
an atypical pattern of breathing involving deep breathing followed by shallow breathing.
Kussmaul respirations
fast, deep breathing that occurs in response to metabolic acidosis.
Dyspnea
a sensation of running out of air and of not being able to breathe fast enough of deeply enough.
Hypoxia
low levels of oxygen in your body tissues.
Cutaneous stimulation
simulation of nerves vis skin contact in an effort to reduce pain impulses to the brain.
ROM
the movement potential of a joint from full extension to full flexion.
Gait
a pattern of running or walking
Posture
the position of the body in space.
Arthritis
inflammation/degeneration of joints.
Orientation
a person’s level of awareness to self, place, time, and situation.
Focused assessment
a detailed nursing assessment of specific body system(s) related to the presenting problem or other current concern(s).
Affect
a patient’s immediate expression or emotion.
Costal margin
the lower edge of the chest (thorax) formed by the bottom edge of the rib cage.
Venous distention
the bulging of the major veins in your neck.
Vascular ulcer
wounds on your skin that develop because of problems with blood circulation.
PMI
the point where there is a maximal impulse against the chest that can be felt.
Nasogastric
NG
No known allergies
NKA
No known drug allergies
NKDA
Nothing by mouth
NPO
Nausea and vomiting
N&V
Oxygen
O2
Out of bed
OOB
Through or by
thru
By mouth
PO
As needed
PRN
Q
each or any
r/o
rule out
Rx
prescription
Stat
right now
TID
three times a day
Tx
treatment
UA
urinalysis
Wt
weight
Normal SBP range
120 to 139 mmHg
Normal DBP range
80 to 84 mmHg
Normal temperature range
96.8 to 100.4
Normal RR
12 to 20 bpm
Normal SAT
95% to 100%
Best auscultated apical pulse
60 to 100
Temperature sites
temporal, oral, tympanic, axillary, and rectal
