Exam #2 Class Flashcards
Factors to consider when measuring pulse
- rate
- rhythm
- quality/strength
- equality ( same pulse on the left and right side)
Normal adult pulse rate
60-100bpm
For how long you should count the pulse
- regular: 30s then X2
- irregular: 60s
Describe how to locate PMI
PMI: point of maximal impulse
Apex of the heart
- on the left
- between the 5th and 6th rib
- mid clavicules line - MCL
Pulse deficit
- 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
Arrhythmia/dysthymia
Abnormal heart rhythm
// - // - //___/// —// ___ // -
Bradycardia (rate + factors that can affect_)
Slow pulse rate
- pulse rate < 60bpm
Factors
- athlete
- emotions
- extreme cold
- medication
- horizontal position - sleeping
Tachycardia (rate + factors that can affect)
Fats heart rate
- pulse rate > 100bpm
Factors
- exercice
- fever
- environment
- emotion
- pain
- medication
- hemorrhage
- lack of O2
What is blood pressure BP
Force created by blood pushing against the artery walls
- Normal adult range BP
90 - 139 systolic
———-
60-89 diastolic
BP hypertension
> 140 - 159 systolic
90 - 99 diastolic
Orthostatic hypotension + symptoms
- 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
Hypotension
< 90 systolic
< 60 diastolic
Major causes for changes in blood pressure measurements
- 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
3 process of oxygenation
- VENTILATION : breathing
- breathing = expansion of the lungs or inspiration = active process
- contraction of the lungs or expiration = passive process - 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 - 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
Hemoglobin
A protein composed of iron in the RED BLOD CELLS (RBC’S) blinds with O2 and releases it in tissues
Normal respirator rate
Normal: 10-20 B/MIN
Bradypnea
Respiratory rate: <10 B/MIN
Tachypnea
Respiratory rate: > 24 B/MIN
Apnea
Short periods with NO BREATHING
Respiratory arrest
Long periods with NO BREATHING
Respirator rhythm
Normal rhythm can be described as:
- rhythmic, even chest wall movements
- effortless
- equal intervals between cycles
Depth of respiration
Described as:
- shallow
- normal
- deep
How can you asses the depths of respiration
Using a inspirometer or pulmonary function test
Breath sounds (auscultation)
Described as:
- clear
- swish or breezy
- adventitious sounds
- absence of any abnormalities
How does DYSPNEA feels
-difficulty breathing
- SIB
- chest pain
- ‘’ can’t catch my breath’’
- hard/small amount of air = dizzy
Capillary refill (time and purpose)
< 3seconds to return to normal Color
Tells how well the tissues are being perfumed with blood
Reason of fainting
Decrease of O2 in the brain
O2 sat + normal value + factors that can cause an inaccurate reading
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
Possible blood test
CBC: complete blood count = hemoglobin and RBC’s
ABG: arterial blood count and complete blood count = O2 & CO2
Effect of nutrition (oxygenation/respiratory)
- decrease in iron = decrease in hemoglobin
- high fat diet = obesity - fat tissues is less vascular - less O2 can be carried to tissues
Effect of Fluid and electrolyte (oxygenation/respiratory)
- dehydration or decrease blood volume = decrease circulating RBC’s = decrease O2 carrying capacity of blood
Effect of skin integrity (oxygenation/respiratory)
- 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
Effect of activity & rest (oxygenation/respiratory)
- 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
Effect of emotions (oxygenation/respiratory)
Anxiety, stress, excitement increase respiratory rate = increase O2 demands
Effect of medication (oxygenation/respiratory)
- digitalis(drug) = increase cardiac output = increase O2 supply
Effect of age (aging adult) (oxygenation/respiratory)
- 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
What is self-concept
- The composite of beliefs and feelings that a person holds about one’s self at a given time.
What are some common problems clients experience with self concept?
- anxiety
- disturbed body image
- ineffective coping
- fear
- hopelessness
- powerlessness
- low self esteem
- spiritual distress
5 sub-components of self concept + description + assessing
- 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…)
4 foundations of nursing
- person
- environment
- health
- nursing
foundations of nursing (PERSON)
- we all have values and beliefs
- we all interacts with people, family, groups and our communities as well as the environment
foundations of nursing (ENVIRONMENT)
The person’s surroundings:
- psychosocial
- political
- spiritual
- cultural
foundations of nursing (HEALTH)
- adaptation to multiple environmental factors
foundations of nursing (NURSING)
- 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.
7 goals of nursing
- nurse client partnership
- health promotion
- prevention of illness, accidents, social problems, suicide
- therapeutic process
- functional rehabilitation
- quality of life
- professional commitment
The following activities in the practice of nursing are reserved to nurses:
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.
What is the nursing act?
Defines the scope of practice of nurse as outlined in law
