Exam 2; Chapters 29 & 44 Flashcards
1
Q
What are vital signs?
A
A basic assessment that can tell the nurse important information about what is going on with the patient
2
Q
If a patient has a change in status, what will the nurse assess first.?
A
The vital signs
3
Q
What are the guidelines for measuring vital signs.?
A
- Select appropriate equipment
- Assess equipment is working properly
- Know the patients health history
- Know the patients normals
- Control environmental factors & be organized
- Verify & communicate major changes
- provide patient EDU. About findings
4
Q
What are the 6 vital signs.?
A
- Body temperature
- pulse
- respirations
- BP
- oxygen saturation
- pain
5
Q
What is the normal range for body temperature.?
A
98.6-100.4 degrees Fahrenheit
6
Q
What is the normal range for heart rate.?
A
60-100bpm
7
Q
What is the normal rate for respirations.?
A
12-20 breaths per minute
8
Q
What is the normal range for Blood pressure.?
A
120/80mmHg
9
Q
What is the normal range for oxygen saturation.?
A
More than or equal to 94%
10
Q
What factors can affect vital signs.?
A
•age •excersice •stress •trauma •illness •infection •disease •meds and more.!
11
Q
If vital signs are outside of normal ranges what should you do.?
A
Assess the patient.!
12
Q
What are the parts of a stethoscope.?
A
- earpieces
- binaurals
- tubing
- bell chest peice
- diaphragm chest peice
13
Q
How do you ensure the stethoscope is working.?
A
Place the earpieces in your ears properly & gently tap the chest piece(s)
14
Q
What regulates temperature.?
A
The hypothalamus
15
Q
How do we find body temperature.?
A
Heat produced-heat loss= body temperature
16
Q
What is core temperature.?
A
Temperature of the deep tissues
17
Q
What is the most constant, true temperature.?
A
Core temperature
18
Q
What is the normal temperature range in celsius.?
A
36-38
19
Q
What factors determine temperature
A
- the site of temperature taken
* the time of day temperature is taken
20
Q
When is temperature the lowest.?
A
0600
21
Q
When is temperature highest.?
A
1600
22
Q
What is thermoregulation.?
A
The balance between heat production & heat loss
23
Q
How does the body keep an acceptable/constant range of temperature.?
A
By constantly producing and releasing heat
24
Q
What signals are sent out by the hypothalamus to reduce body temperature.? (What actions=heat release)
A
•sweating
•inhibition of heat production
•vasodilation (widening of blood vessels)
-vasodilation sends blood to surface vessels to promote heat loss
25
What signals does the hypothalamus send out to promote heat conservation.?
•vasoconstriction (narrowing blood vessels)
-reduces blood flow to surface
vessels
•voluntary muscle contractions (movement)
•muscle shivering (occurs when vasoconstriction is inefficient)
26
Skin regulates body temperature through what.?
Insulation with subcutaneous fat
27
What are factors that affect body temperature.?
* age
* exercise
* hormone level
* circadian rhythm
* stress
* environment
28
What are the 6 temperature measurement sites.?
* oral
* temporal
* axillary
* tympanic
* rectal
* infared/electronic
29
What is pulse rate.?
The number of pulsing sensations in 1 minuet
30
What does pulse indicate.?
Circulatory status
31
Most common location for pulse assessment
Radial pulse
32
What finger is never used to palpate pulse.? Why.?
The thumb, because it contains its own pulse
33
If pulse is found to be irregular what is done next.?
Auscultate the apical pulse
34
>100bpm is known as what.?
Tachycardia
35
<60bpm is known as what.?
Bradycardia
36
An irregular heart rate is known as what.?
Dysrhythmia
37
What is a pulse deficit.?
Apical pulse - radial pulse= pulse deficit
38
Pulse deficits are associated with what.?
Abnormal heart rhytms
39
What controls breathing.?
Medulla oblongata
40
Respiration involves what.?
* ventilation
* diffusion
* perfusion
41
Inspiration is a(n) ________ process
Active
42
Expiration is a(n) ________ process
Passive
43
When assessing respiration, what should you NOT do.?
Tell the patient you are counting their respirations
44
Ventilatory depth
Labored or unlabored
45
Ventilatory rhythm
Even or uneven pattern
46
What does oxygen saturation measure.?
Percentage of hemoglobin saturated with oxygen
47
What does a pulse ox measure.?
* oxygen saturation
| * heart rate
48
What should you avoid when measuring oxygen saturation.?
Taking BP on same arm as pulse ox
49
What to always include when reading the pulse ox.?
* Unit of measure (%)
| * oxygen source
50
What causes inaccurate pulse ox readings.?
•tremors
•cold fingers
•dark nail polish
& more.!
51
What is blood pressure.?
The force exerted on the walls of an artery by the pulsing blood under pressure from the heart
52
What will happen if there isn’t enough pressure in the vascular system.?
Tissues and extemities will not recieve blood
53
What does mmHg mean.?
Millimeters of mercury
54
What is systolic pressure.?
* The peak of maximum pressure when blood ejection from the heart occurs;
* heart forces blood out into the body using pressure;
* top number
55
What is diastolic pressure.?
* Minimal pressure exerted against the arterial walls at all times;
* When the heart is relaxed and filling with blood;
* Bottom number
56
What factors influence blood pressure.?
* age
* stress
* ethnicity/genetics
* daily variation
* meds
* activity/weight
* smoking
57
What is pulse pressure.?
Systolic pressure - diastolic pressure= pulse pressure
58
Characteristics of hypertension.?
* BP 130/80 or higher
* thickening of arterial walls
* loss of elasticity in arterial walls
* heart exerts more force which results in more pressure
59
Characteristics of hypotension
* systolic <90mmHg
* diastolic <60mmHg
* decreased blood flow
* orthostatic/postural changes
60
The nurse is assessing a patient and their BP comes back abnormally high, what questions should he/she ask the patient.?
* do they have a history of hypertension.?
* if so, have they taken their medications today.?
* are they nervous.? Sick.? Stressed.?
61
What are the parts of a sphygmomanometer.? What is their purpose.?
* knob- allows for air retention and release
* bulb- inflates cuff when squeezed
* dial- gives readings, measured in 2 mmHg
62
Where should the patients arm be when measuring BP.?
Heart level; supported by a table, or held by the nurse
63
What locations can BP be measured.?
* upper arm (brachial artery)
* forearm (radial artery)
* upper thigh (popliteal artery)
* calf (dorsalis pedis artery)
64
What can be expected when measuring BP on a lower extremity.?
Systolic reading will be increased by 10mmHg or more
65
What is considered the 6th vital sign.?
Pain
66
Nurses are legally & ethically responsible for what.?
Assessing and managing pain
67
Low to moderate intensity and superficial pain will stimulate what.?
The sympathetic nervous system
* increased heart rate
* increased BP
* increased respiratory rate
68
Continuous, severe and/or deep pain stimulates what.?
The parasympathetic nervous system
* pallor
* N/V
69
Characteristics of acute/transient pain
* protective
* Identifiable cause
* short duration
* pain resolves after injury heals
* treated aggressively
* when unrelieved progresses to chronic pain
70
Characteristics of chronic pain
* not protective/serves no purpose
* affects quality of life
* lasts 3-6+ months
* impacts physiological & physical ability
71
S/S of chronic pain
* fatigue
* insomnia
* anorexia
* weight loss
* apathy
* hoplessness
* depression
* anger
72
What physiological factors influence pain.?
* age
* fatigue
* genes
* neurological function
73
What social factors influence pain.?
* previous experience
* family/social network
* spiritual factors
74
What psychological factors influence pain.?
* attention
* anxiety & fear
* coping style
75
What cultural factors influence pain.?
* meaning of pain
| * ethnicity
76
What factors are impacted by pain.?
* quality of life
* self-care
* work
* social support
77
What are the commonly used pain scales.?
* numerical pain scale; 0-10
| * Wong-Baker faces pain rating scale (ages 3+)
78
What are the uncommonly used pain scales.?
* verbal descriptive scale
| * visual analog scale
79
What are some non-pharmacological pain relief interventions.?
* relaxation & guided imagery
* distraction
* music
* repositioning
* cutaneous stimulation
* massage
* breathing techniques
* environmental modification
80
What type of intervention is providing pharmacological pain therapies.?
Dependent intervention; requires an order from the physician
81
What are analgesics.?
Pain medications
82
What are the routes of analgesics.?
* by mouth (PO)
* intravascular (IV)
* intramuscular (IM)
* subcutaneous (SQ)
* topical
83
[True or false]
| Response to analgesics is the same across the board.
False.!
| A patients response to an analgesic is highly individualized
84
What are the types of non-opiod analgsics.?
* Acetominophen (Tylenol)
* Aspirin (NSAID)
* ibuprofen (NSAID)
* naproxen (NSAID)
85
Characteristics of Acetaminophen
* most tolerated & safest analgesics available
* inhibits enzyme required to make prostaglandins (responsible for pain)
* can be paired with opiods to lower dosage
* Max 24hr dose is 4g in healthy individuals, 3g in older adults/patients with liver disease
* can cause hepatotoxicity
86
Characteristics of NSAIDS
* inhibits enzyme required to make prostaglandins
* reduce inflammation
* increase GI irritation (take w food)
* can reduce blood flow to kidneys
* should be avoided in older adults
87
What are the types of opioids.?
```
•Tramadol
•oxycodone
•hydrocodone
•morphine
•fentanyl
Etc.
```
88
What are health professionals most worried about when prescribing opioids.?
Risk for addiction/dependence
89
Opioids are prescribed to treat what type of pain.?
Moderate to severe pain
90
What forms are opiods made available in.?
* short-acting form (~4hrs)
| * long-acting form (~ 8-12hrs)
91
Opiods are prescribed to aggresively treat which type of pain.?
Acute pain
92
How long can transdermal patches stay in place.?
Up to 72hrs
93
Opioids act how.?
By binding to opiate receptors in the brain in order to modify perception of pain (depress CNS)
94
When should the nurse assess the patient when administering opioids.? What assessments should the nurse do.?
* Before and after administering the medication
* Vital signs
* pain level
* mental status
95
[True or False]
| If a patient is not expressing typical behaviors associated with pain, they are not truly experiencing pain
False.!
There are many factors that affect how an individual responds to pain. Each individual will respond differently, and this should be taken into consideration when rendering treatment.
