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NURSING > Exam #2 Class > Flashcards

Exam #2 Class Flashcards

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1
Q

Factors to consider when measuring pulse

A
  • rate
  • rhythm
  • quality/strength
  • equality ( same pulse on the left and right side)
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2
Q

Normal adult pulse rate

A

60-100bpm

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3
Q

For how long you should count the pulse

A
  • regular: 30s then X2
  • irregular: 60s
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4
Q

Describe how to locate PMI

A

PMI: point of maximal impulse

Apex of the heart
- on the left
- between the 5th and 6th rib
- mid clavicules line - MCL

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5
Q

Pulse deficit

A
  • When heart is too weak to send blood to peripheral arteries
  • difference in rate between the apical pulse and radial pulse
  • one person count apical / one counts radial pulse
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6
Q

Arrhythmia/dysthymia

A

Abnormal heart rhythm
// - // - //___/// —// ___ // -

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7
Q

Bradycardia (rate + factors that can affect_)

A

Slow pulse rate
- pulse rate < 60bpm

Factors
- athlete
- emotions
- extreme cold
- medication
- horizontal position - sleeping

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8
Q

Tachycardia (rate + factors that can affect)

A

Fats heart rate
- pulse rate > 100bpm

Factors
- exercice
- fever
- environment
- emotion
- pain
- medication
- hemorrhage
- lack of O2

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9
Q

What is blood pressure BP

A

Force created by blood pushing against the artery walls

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10
Q
  • Normal adult range BP
A

90 - 139 systolic
———-
60-89 diastolic

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11
Q

BP hypertension

A

> 140 - 159 systolic
90 - 99 diastolic

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12
Q

Orthostatic hypotension + symptoms

A
  • occurs when a normotensive person (a person with normal blood pressure) develops symptoms of low blood pressure when rising to an upright position.

Symptoms
- dizziness
- lightheaded
- fainting

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13
Q

Hypotension

A

< 90 systolic
< 60 diastolic

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14
Q

Major causes for changes in blood pressure measurements

A
  • age: increase with age
  • emotion/stress: pain, fear, anxiety (white coat syndrome)
    -ethnicity: Asian, indigenous, African = higher BP
  • gender : minor variance
  • daily variations: lower during sleep, higher throughout the day
  • medications: cardiac meds, IV fluids, analgesics
  • other: smoking, obesity, exercice, hemorrhage, dehydration
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15
Q

3 process of oxygenation

A
  1. VENTILATION : breathing
    - breathing = expansion of the lungs or inspiration = active process
    - contraction of the lungs or expiration = passive process
  2. GAS EXCHANGE : O2 AND CO2
    - O2 from lungs - blood - tissues - cells
    - CO2 from blood - alveoli = exhaled
    - gas exchange occurs ont the alveoli capillary by diffusion
    Diffusion: movement of molecules from high concentration
    to low concentration
  3. TRANSPORT OF GASES
    - for O2 to be delivered to body tissues it id dependant on an intact and functioning cardiovascular system
    - heart and vessels (veins/artery) and sufficient blood flow
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16
Q

Hemoglobin

A

A protein composed of iron in the RED BLOD CELLS (RBC’S) blinds with O2 and releases it in tissues

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17
Q

Normal respirator rate

A

Normal: 10-20 B/MIN

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18
Q

Bradypnea

A

Respiratory rate: <10 B/MIN

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19
Q

Tachypnea

A

Respiratory rate: > 24 B/MIN

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20
Q

Apnea

A

Short periods with NO BREATHING

21
Q

Respiratory arrest

A

Long periods with NO BREATHING

22
Q

Respirator rhythm
Normal rhythm can be described as:

A
  • rhythmic, even chest wall movements
  • effortless
  • equal intervals between cycles
23
Q

Depth of respiration
Described as:

A
  • shallow
  • normal
  • deep
24
Q

How can you asses the depths of respiration

A

Using a inspirometer or pulmonary function test

25
Q

Breath sounds (auscultation)
Described as:

A
  • clear
  • swish or breezy
  • adventitious sounds
  • absence of any abnormalities
26
Q

How does DYSPNEA feels

A

-difficulty breathing
- SIB
- chest pain
- ‘’ can’t catch my breath’’
- hard/small amount of air = dizzy

27
Q

Capillary refill (time and purpose)

A

< 3seconds to return to normal Color
Tells how well the tissues are being perfumed with blood

28
Q

Reason of fainting

A

Decrease of O2 in the brain

29
Q

O2 sat + normal value + factors that can cause an inaccurate reading

A

Pulse oxygen measures the amount of O2 that hemoglobin is carrying or is saturated with

Normal value: 95% - 100%

Factors:
- cold fingers/shaking
- jaundice
- nail polish
- poor circulation
- fake nails

30
Q

Possible blood test

A

CBC: complete blood count = hemoglobin and RBC’s
ABG: arterial blood count and complete blood count = O2 & CO2

31
Q

Effect of nutrition (oxygenation/respiratory)

A
  • decrease in iron = decrease in hemoglobin
  • high fat diet = obesity - fat tissues is less vascular - less O2 can be carried to tissues
32
Q

Effect of Fluid and electrolyte (oxygenation/respiratory)

A
  • dehydration or decrease blood volume = decrease circulating RBC’s = decrease O2 carrying capacity of blood
33
Q

Effect of skin integrity (oxygenation/respiratory)

A
  • injury/surgery = increase risk for infection/fever = increase O2 demands because of increased metabolic demands d’or tissues repair and to fight microorganisms
  • hemorrhage - decrease blood volume = decrease O2
34
Q

Effect of activity & rest (oxygenation/respiratory)

A
  • as the level of activity increase the body’s O2 needs increase
  • physically fit = stronger heart muscle = increase cardiac output or blood flow with less effort than an unfit person
35
Q

Effect of emotions (oxygenation/respiratory)

A

Anxiety, stress, excitement increase respiratory rate = increase O2 demands

36
Q

Effect of medication (oxygenation/respiratory)

A
  • digitalis(drug) = increase cardiac output = increase O2 supply
37
Q

Effect of age (aging adult) (oxygenation/respiratory)

A
  • Decrease muscle strength
  • Costa; cartilage (joins the ribs to the sternum) more rigid = calcified
  • > 50 years tissues become less elastic = harder to inflate lungs = increase risk for DYSPNEA
38
Q

What is self-concept

A
  • The composite of beliefs and feelings that a person holds about one’s self at a given time.
39
Q

What are some common problems clients experience with self concept?

A
  • anxiety
  • disturbed body image
  • ineffective coping
  • fear
  • hopelessness
  • powerlessness
  • low self esteem
  • spiritual distress
40
Q

5 sub-components of self concept + description + assessing

A
  • IDENTITY: what makes one unique/distinguishes one from others (age, gender, social class, marital status, race, occupation. Ex: mother, volunteer, doctor)

Assessing: ‘’ how would you describe yourself? ‘’

  • SELF ESTEEM: an individual’s overall sense of self-worth, confidence, accomplishment. (feels like a loser)

Assessing: ‘’ how do you feel about yourself? ’’

  • SELF IDEAL: what one would like to be or do related to what one is capable of being or doing. (One’s hope, dreams, ambitions, regrets related to health)

Assessing: ‘’ what would you change yourself in terms of your health)

  • BELIEFS: a person’s belief system and an evaluation of who one is in relation to the universe. ( ex: my faith gives me the strength to get through this, god, Karan)

Assessing: ‘’ how would you describe your spiritual beliefs? // how do you measure up to your own standard of right living? // how do you evaluate yourself? ‘’

  • BODY IMAGE: attitude related to the physical appearance, structure, function of the body (appearance, masculinity, youthfulness, sexuality, vitality)

Assessing: ‘’ how do you feeling about your appearance? ‘’
PS: observe PT’s body language and posture (avoidance of a body part, level of personal hygiene…)

41
Q

4 foundations of nursing

A
  • person
  • environment
  • health
  • nursing
42
Q

foundations of nursing (PERSON)

A
  • we all have values and beliefs
  • we all interacts with people, family, groups and our communities as well as the environment
43
Q

foundations of nursing (ENVIRONMENT)

A

The person’s surroundings:
- psychosocial
- political
- spiritual
- cultural

44
Q

foundations of nursing (HEALTH)

A
  • adaptation to multiple environmental factors
45
Q

foundations of nursing (NURSING)

A
  • consists in assessing health, determining and carrying out the nursing care and treatment plan
  • providing nursing and medical care and treatment in order to maintain
  • restore the health of a person in interaction with his environment
  • prevent illness
  • providing palliative care.
46
Q

7 goals of nursing

A
  • nurse client partnership
  • health promotion
  • prevention of illness, accidents, social problems, suicide
  • therapeutic process
  • functional rehabilitation
  • quality of life
  • professional commitment
47
Q

The following activities in the practice of nursing are reserved to nurses:

A

1o assessing the physical and mental condition of a symptomatic person;

2o providing clinical monitoring of the condition of per- sons whose state of health is problematic, including monitoring and adjusting the therapeutic nursing plan;

3o initiating diagnostic and therapeutic measures, according to a prescription;

4o initiating diagnostic measures for the purposes of a screening operation under the Public Health Act (chapter S-2.2);

5o performing invasive examinations and diagnostic tests, according to a prescription;

6o providing and adjusting medical treatment, according to a prescription;

7o determining the treatment plan for wounds and alterations of the skin and teguments and providing the required care and treatment;

8o applying invasive techniques;

9o participating in pregnancy care, deliveries and
postpartum care;

10o providing nursing follow-up for persons with
complex health problems;

11o administering and adjusting prescribed medications or other prescribed substances;

12o performing vaccinations as part of a vaccination operation under the Public Health Act;

13o mixing substances to complete the preparation of a medication, according to a prescription; and

14o making decisions as to the use of restraint measures;

15o deciding to use isolation measures in accordance with the Act respecting health services and social services and the Act respecting health services and social services for Cree Native persons;

16o assessing mental disorders, except mental retardation, if the nurse has the university degree and clinical experience in psychiatric nursing care required under a regulation made in accordance

17o assessing a child not yet admissible to preschool education who shows signs of developmental delay, in order to determine the adjustment
and rehabilitation services required.

48
Q

What is the nursing act?

A

Defines the scope of practice of nurse as outlined in law

NURSING (2 decks)

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