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Nurs 2500 > Lecture 2 Review > Flashcards

Lecture 2 Review Flashcards

1
Q

_____ are required for microbes that can travel >2m, requires a respirator mask (e.g. N95)

A

airborne precautions

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2
Q

_____ are required when pathogens are propelled in large droplets up to 2m

A

droplet precautions

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3
Q

A patient undergoing chemotherapy is immune-compromised and requires ____ precautions

A

reverse isolation

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4
Q

_____ are required when microbes can be transferred from direct (skin to skin) to indirect (through an object) contact

A

contact precautions

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5
Q

Lyme disease from wood ticks is an example of _____ transmission

A

vector born

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6
Q

_____ designed to contain pathogens in one area

A

transmission-based precautions

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7
Q

What is body mass index used for?

A

A practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

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8
Q

What is waist-to-hip ratio used for?

A

Reflects body fat distribution as an indicator of health risk

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9
Q

What is homeostasis?

A

Stability of systems that maintain life

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10
Q

What is allostasis?

A

Adaptation to changing external and internal environment

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11
Q

What are the systems in the pathophysiology map when there are stressors?

A

Central nervous system
Endocrine system
Immune system

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12
Q

Describe the pathophysiology pathway of stressors going through the immune system first

A

Stressors are detected by the CNS
CNS sends messages to immune system via neuropeptides
Immune system sends messages to endocrine system via cytokines
Endocrine sends signals to CNS via endocrine hormones

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13
Q

Describe the pathophysiology pathway of stressors going through the endocrine system first

A

Stressors are detected by the CNS
CNS sends messages to endocrine system via neuropeptides
Endocrine system sends messages to immune system via endocrine hormones
Immune system sends signals to CNS via cytokines

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14
Q

What are hemodynamics?

A

Hemodynamics refer to perfusion of oxygen in the body - this is determined by heart rate, blood pressure, and gas exchange

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15
Q

Cardiac output formula

A

CO = HR x SV

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16
Q

How can you increase cardiac output?

A
  • adding more fluid into body system to increase stroke volume
  • increased heart contraction force to increase stroke volume
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17
Q

What are the five vital signs?

A 
Blood pressure
Pulse
Respirations
Temperature
Oxygen saturation
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18
Q

What are the normal range and average of temperature?

A

35.8-37.3°C and an average of 37°C

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19
Q

What are common influences on true temperature?

A
  • infection and inflammation

- diurnal cycle, menstrual cycle, exercise, age

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20
Q

What commonly interferes with an accurrate measurement of temperature?

A
  • recent smoking (oral, wait 2-5 min)

- recent drinking/ eating hot/ cold (oral, wait 20 mins)

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21
Q

What are the interrelated concepts with thermoregulation?

A
  • infection
  • perfusion
  • tissue integrity
  • intracranial regulation
  • nutrition
  • fluid and electrolytes
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22
Q

How would you document that you measurerd 36.5°C taken with a thermometer in the mouth?

A

T 36.5°C. oral

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23
Q

What do you feel for when looking for a pulse?

A

You’re feeling the palpating artery and observing rate, rhythm, force, and location

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24
Q

What do you hear when looking for heart rate?

A

You’re hearing for the auscultate sound of the heart valves and observing rate and rhythm

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25
Q

What do you include in basic documentation of the pulse?

A

rate + location

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26
Q

What is a pulse deficit?

A

HR > pulse rate

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27
Q

What is the normal strength of a pulse?

A

Normal, strong (2+)

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28
Q

What is the normal rate of a pulse?

A

The normal rate is 60-100 beats per minute

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29
Q

What are the factors controlling blood pressure?

A
  • cardiac output
  • vascular resistance
  • volume
  • viscosity
  • elasticity of arterial walls
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30
Q

When do I know to take blood pressure?

A
  • the baseline bp is taken during a comprehensive exam or admission to the hospital
  • 5 mins rest, 3 measures 2 min apart, discard first and average second and third measure
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31
Q

What do you hear when listening to blood pressure in the arm?

A
  • Korotkoff I tapping
  • Korotkoff II swooshing
  • Korotkoff III knocking
  • Korotkoff IV abrupt muffling
  • Korotkoff V silence
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32
Q

What is an auscultatory gap?

A

An abnormal silence in which you only hear the first and last taps

33
Q

What is hypotension?

A

Low bp <95/60

Symptomatic hypotension means low perfusion

34
Q

What is hypertension?

A

High bp >140/90

35
Q

What are you observing when measuring respirations?

A

Rate, rhythm, and effort

36
Q

What is normal effort of respiration?

A

inspiration (active) < expiration (passive)

1:2 ratio

37
Q

How do you count respiration?

A

Count full inspiration + expiration for at least 30 seconds

38
Q

What is the healthy ratio of pulse to respiratory rate?

A

4:1

39
Q

What is tachypnea?

A

rapid respiratory > 20 breaths a minute

40
Q

What is dyspnea?

A

difficult or uncomfortable breathing

41
Q

What is bradypnea?

A

Less than 10 respirations a minute

42
Q

What is the normal range of O2 sats?

A

> 94%

43
Q

What is the critical value for O2 sats?

A

<90%

44
Q

What physiological skin changes result in for older adults?

A
  • decreased protection
  • decreased temperature regulation
  • delayed healing
45
Q

What are the leading increased risks from changes in skin for older adults?

A
  • wounds
  • heat stroke (reduced ability to sweat)
  • hypothermia (reduced adipose tissue)
  • greater risk for infection
46
Q

Definition of tissue integrity

A

4 types of tissue - muscle, neural, connective, and epithelial. This concept emphasizes structurally intact and physiological functioning epithelial tissues, such as the integument (skin and subcutaneous tissue) and mucous membrane.

47
Q

What are the kinds of abnormal findings in the integumentary system?

A
  • colour
  • lesions
  • edema
48
Q

What are the kinds of objective data in the integumentary system?

A 
A) Colour of patient's skin
B) Palpate the temperature
C) Moisture of skin
D) Texture of skin
E) Thickness of skin
F) Palpate for edema
G) Nail beds
H) oral cavity
I) palpate and inspect the scalp
49
Q

What is edema?

A

(swelling) fluid that accumulates in the intercellular spaces

50
Q

Pitting edema scale

A

1 to 4

51
Q

Pitting edema 1+

A

Mild pitting, slight indentation, no perceptible swelling of the leg

52
Q

Pitting edema 2+

A

Moderate pitting, indentation subsides rapidly

53
Q

Pitting edema 3+

A

Deep pitting, indentation reminds for a short time, swelling of the leg

54
Q

Pitting edema 4+

A

Very deep pitting, indentation lasts a long time, gross swelling and distortion of leg

55
Q

How do you assess moles?

A 
Asymmetry
Border irregularity
Colour variation
Diameter > 6mm
Evolution
56
Q

What are the kinds of objective data in the peripheral vascular system?

A

A) palpate/ compare the colour, warmth, sensation, movement (CWSM) of the arms and legs
B) Assess the capillary refill of the nails and toes
C) palpate the pulses

57
Q

SOAPIE

A 
Subjective
Objective
Assessment
Planning
Intervention
Evaluation
58
Q

AAPIE

A 
Assessment
Analysis
Planning
Intervention
Evaluation
59
Q

The general signs of decline in a patient

A
  • sudden change in level of consciousness
  • slow, fast, or absent heart rate
  • difficulty breathing, increased work of breathing, absence of breathing
  • decreasing or no urination
  • very low or very high blood pressure
  • cyanosis, low oxygen levels in the blood
  • chest pain or severe pain
  • blindness
  • hypo/hyperthermia
60
Q

What pulse site is used during CPR to assess circulation?

A

Femoral pulse

61
Q

What pulse site is used to assess the peripheral circulation of the lower extremities?

A

Dorsalis Pedis pulse

62
Q

What pulse site is commonly used to check HR when taking Vital Signs

A

Radial pulse

63
Q

What pulse site is used to measure blood pressure?

A

Brachial pulse

64
Q

Pallor definition

A

When red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the colour of connective tissue (collagen), mostly white

65
Q

Hypoxia definition

A

Oxygen deficiency

66
Q

Febrile definition

A

Having or showing signs of a fever

67
Q

Furrowed tongue definition

A

A tongue that looks like it has multiple cracks along the sides. Increases with age. Indication of dehydration

68
Q

Preload definition

A

Is the venous return that builds during diastole. It is the length to which the ventricular muscle is stretched at the end of diastole just before contraction.

69
Q

Cyanosis definition

A

Blueish, mottled discolouration that signifies decreased perfusion

70
Q

Hypercapnia definition

A

High levels of carbon dioxide in the body

71
Q

Pyrexia definition

A

Raised body temperature

72
Q

Skin turgor definition

A

Mobility of skin from pinching a fold of skin. Good skin turgor immediately returns to original position

73
Q

Afterload definition

A

The opposing pressure that the ventricle must generate to open the aortic valve against the higher aortic pressure

74
Q

Diurnal cycle definition

A

24-hour cycle

75
Q

Apnea definition

A

Temporary cessation of breathing; especially during sleep

76
Q

Mean arterial pressure (MAP) definition

A

The pressure forcing blood into tissues averaged over the cardiac cycle

77
Q

Erythema definition

A

Intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries

78
Q

Korotkoff sounds definition

A

The sounds are heard when the brachial artery is occluded by the blood pressure cuff in which there is no blood flow. The sounds are blood spurts into the artery.

79
Q

Diaphoresis definition

A

Profuse perspiration, accompanies an increase in metabolic rate, as occurs in strenuous activity fever

Nurs 2500 (16 decks)

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