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Fundamentals of Nursing > Module 2(Part A & E) > Flashcards

Module 2(Part A & E) Flashcards

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1
Q

What are pressure ulcers?

A

-They are impairment of skin integrity related to unrelieved, prolonged pressure.

Note: Also known as pressure sore, decubitus ulcer and bedsore.

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2
Q

What kind of injury are pressure ulcers?

A

They are localised injury to the skin and other underlying tissue usually over a body prominence.

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3
Q

What causes pressure ulcers?

A
  • A result of pressure.
  • Pressure in combination with shear or friction.
  • Pressure in combination with shear and friction.
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4
Q

What are the risk factors for pressure ulcer formation?

A
  • Pressure is the major cause
  • Factors that interferes with blood flow
  • illnesses
  • People over 70 years are particularly vulnerable
  • Poor mobility
  • Aging skin
  • Poor nutrition
  • Plaster casts
  • Intensive care
  • Circulation problem
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5
Q

Pressure is the major element in the cause of pressure ulcers. What are the 3 pressure related factors that contribute to pressure ulcer development?

A
  • Pressure intensity
  • Pressure duration
  • Tissue tolerance
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6
Q

How is classification of pressure ulcers made?

A

By the pressure ulcer depth at the point of assessment.

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7
Q

What is the first stage of pressure ulcer development?

A

Nonblanchable Redness of Intact Skin.

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8
Q

What is the second stage of pressure ulcer development?

A

Partial-thickness Skin Loss or Blister.

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9
Q

What is the third stage of pressure ulcer development?

A

Full-thickness Skin Loss(Fat visible).

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10
Q

What is the fourth stage of pressure ulcer development?

A

Full-thickness Tissue Loss(Muscle/Bone Visible).

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11
Q

What are the sites to assess for risk of pressure ulcer development?

A
  • Occiput(Back of the head)
  • Shoulder
  • Elbow
  • Base of spine
  • Hip
  • Sacrum(tailbone)
  • Buttocks area
  • Ankle
  • Heel
  • Toes
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12
Q

What is blood pressure?

A

Blood pressure is the force/pressure exerted by the circulating blood on the wall of the arteries.

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13
Q

What is systolic pressure?

A

It is the highest point of pressure on the arterial walls when the ventricles contract and push blood through the arteries at the beginning of systole.

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14
Q

What is diastolic pressure?

A

It is the lowest pressure present on the arterial walls during diastole.

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15
Q

The measurement of blood pressure is in?

A

Millimeters of mercury(mm Hg)

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16
Q

The numerator is the _____________; the denominator is the ____________.

A

systolic pressure; diastolic pressure

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17
Q

What should we do to get an accurate assessment of blood pressure?

A
  • We should know what equipment to use.
  • We should know which site to use.
  • We should know how to identify the sounds we hear.
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18
Q

What are korotkoff sounds?

A

A series of sounds for which to listen when assessing blood pressure.

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19
Q

What are the most common sites used to assess blood pressure?

A

The brachial artery and popliteal artery.

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20
Q

Why do we estimate the systolic pressure?

A

To prevent inaccurate readings in the presence of an auscultatory gap( a pause in the auscultated sounds).

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21
Q

What are the equipment used when assessing for blood pressure?

A
  • Stethoscope
  • Sphygmomanometer
  • Blood pressure cuff of appropriate size
  • Pencil or pen
  • Paper or flowsheet
  • Alcohol swab
  • PPE as indicated
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22
Q

When should a body part or region not be used when taking blood pressure?

A
  • Presence of a cast
  • Arteriovenous shunt
  • Injured or disease limb
  • Breast or Axilla surgery (BP should not be taken on the side of the body corresponding to the arm used)
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23
Q

What are the factors that can affect blood pressure reading?

A
  • Patient’s age
  • Exercise
  • Position
  • Weight
  • Fluid balance
  • Smoking
  • Medication
  • Pain
  • Stress
  • Caffein or Energy drinks
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24
Q

What are the types of BP?

A
  • Lying
  • Sitting
  • Standing
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25
Q

What is intra-arterial blood pressure?

A
  • It is a monitoring technique that is commonly used in the Intensive Care Unit(ICU) and Operating Theatre.
  • This technique involves direct measurement of arterial pressure by inserting a cannula needle in a suitable artery.
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26
Q

Blood pressure is recorded as a ________.

A

fraction

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27
Q

What is the average blood pressure of a healthy adult?

A

120/80 mm Hg

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28
Q

The blood pressure of an elderly ranges from:

A

140-160 systolic

70-90 diastolic

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29
Q

The blood pressure of an adult ranges from:

A

90- 132 systolic

60- 85 diastolic

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30
Q

Define hypertension?

A
  • It is defined as a blood pressure higher than normal.
  • Also known as High Blood Pressure(HBP)

Note: This is based on the average of two or more accurate blood pressure measurements during two or more consultations with the healthcare provider.

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31
Q

What are the classifications of hypertension?

A
  • Prehypertension
  • Stage 1 Hypertension
  • Stage 2 Hypertension
  • Hypertensive Emergency
32
Q

Define prehypertension?

A
  • Blood pressure that is higher than normal but it doesn’t quite reach the level of high blood pressure.
  • It is defined as a systolic pressure from 120–139 millimeters of mercury (mm Hg) or a diastolic pressure from 80–89 mm Hg.

Note: We won’t be diagnosed with hypertension or prehypertension until it is high on several occasions.

33
Q

Define Stage 1 hypertension?

A

Stage 1 hypertension is defined as persistent blood pressure levels in which the systolic pressure ranges from 130 to 139 mmHg and the diastolic pressure ranges from 80 to 89 mmHg.

34
Q

When is a patient is said to have stage 2 hypertension?

A

Consistent blood pressure readings when the systolic pressure is already more than or equal to 140 mmHg and the diastolic is more than or equal to 90 mmHg.

35
Q

What is a hypertensive emergency?

A

It is an emergency situation where there is a severe increase in blood pressure that is, a measurement higher than 180/120 mm Hg.

36
Q

Define hypotension?

A

A reading of less than 90/60mmHg.

Note: Hypotension does not always cause symptoms, but treatment may be needed if there are.

37
Q

What causes hypotension?

A
  • Dilation of the arteries
  • Hemorrhage
  • Myocardial infarction
38
Q

What are the types of hypotension?

A
  • Orthostatic hypotension

- Postprandial hypotension

39
Q

What is orthostatic hypotension?

A

It is the drop in blood pressure that occurs when you transition from sitting or lying down to standing.

Note: It is common in people of all ages.

40
Q

What is postprandial hypotension?

A

It is a drop in blood pressure that occurs right after eating.

41
Q

Define body temperature?

A

Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment.

42
Q

What are the types of temperatures?

A
  • Core temperature (temperature of the deep tissues of the body)
  • Surface body temperature
43
Q

What are the different alterations in body temperatures?

A
  • Hyperthermia (Body temperature above normal range)
  • Hyperpyrexia (Very high fever, 41ºC(105.8 F) and above)
  • Hypothermia (Subnormal temperature)
44
Q

What are the sites for temperature measurement?

A
  • Oral
  • Rectal
  • Axillary
  • Tympanic membrane
  • Skin
  • Temporal artery
45
Q

What are the temperature ranges for a normal adult?

A

Oral: 36.5 –37.5 ºC
Axillary: 35.8 – 37.0 ºC
Rectal: 37.0 – 38.1 ºC
Tympanic: 36.8 – 37.9ºC

46
Q

What are the types of thermometer?

A
  • Mercury-in-glass Thermometer
  • Electronic Thermometer
  • Chemical Disposal Thermometer
  • Temperature-sensitive Tape
  • Infrared Thermometer
47
Q

What are the factors that affect body temperature?

A
  • Age
  • Diurnal variations(circadian rhythms)
  • Exercise
  • Hormones
  • Stress
  • Environment
48
Q

List some heat promoting centers?

A
  • Vasoconstriction
  • Sympathetic Stimulation
  • Skeletal Muscles
  • Thyroxine
49
Q

Name some body temperature abnormalities?

A
  • Fever/hyperthermia/hyperpyrexia
  • Heat cramps and Heat exhaustion
  • Heat Stroke(Due to fluid and electrolytes loss)
  • Hypothermia
50
Q

What is a pulse?

A

It is a wave of blood created by contraction of the left ventricle of the heart.

51
Q

What is the normal pulse rate?

A
  • 1 year : 80-140 beats/min
  • 2 years : 80- 130 beats/min
  • 6 years : 75- 120 beats/min
  • 10 years : 60-90 beats/min
  • Adult : 60-100 beats/min
52
Q

What is tachycardia?

A

A pulse rate of above 100 beats/min.

53
Q

What is Bradycardia?

A

A pulse rate below 60 beats/min.

54
Q

What is an Irregular pulse?

A

It is a pulse that has an uneven time interval between beats.

55
Q

What are the factors affecting pulse rate?

A
  • Age
  • Sex
  • Exercise
  • Fever
  • Medications
  • Hemorrhage
  • Stress
  • Position changes
56
Q

What are the characteristics of a normal pulse?

A
  • Normal Rate(This is the number of pulse beats per minute (70 to 80 beats/min in the adult)).
  • Normal Pulse rhythm(This is the pattern of the beats and the intervals between the beats.)
  • Normal Pulse volume(It refers to the force of blood with each beat. It can range from absent to bounding.)
57
Q

What are the sites for pulse rate assessment?

A
  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Femoral
  • Popliteal
  • Poserior tibial
  • Pedal (dorsalis pedis)
58
Q

What are the methods used in assessing the pulse?

A

Palpation and auscultation.

59
Q

When assessing respiration, what do we assess?

A

Respiratory Rate
Ventilatory Depth
Ventilatory Rhythm
Respiratory quality/character

60
Q

What is respiratory rate?

A

A cycle of full inspiration and expiration.

61
Q

What is ventilatory depth?

A
  • The depth of respirations by observing the degree of excursion or movement in the chest wall.
  • It is generally described as deep, normal, or shallow.
62
Q

What is ventilatory rhythm?

A
  • This refers to the regularity of the expirations and the inspirations.
  • Normal respirations are evenly spaced.
  • Respiratory rhythm can be described as regular or irregular.
63
Q

What is respiratory quality/character?

A
  • This refers to those aspects of breathing that are different from normal, effortless breathing.
  • It is the amount of effort a client must exert to breathe.Usually, breathing does not require noticeable effort.
  • The sound of breathing(Normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse’s ear.)
64
Q

What are the factors influencing character of respirations?

A
  • Exercise
  • Acute pain
  • Anxiety
  • Smoking
  • Body position
  • Medications
  • Neurological injury
  • Hemoglobin function
65
Q

What are the acceptable ranges of respiratory rate?

A 
Newborn: 35-40(BREATHS/MIN)
Infant (6 months): 30-50(BREATHS/MIN)
Toddler (2 years): 25-32(BREATHS/MIN)
Child: 20-30(BREATHS/MIN)
Adolescent: 16-20(BREATHS/MIN)
Adult: 12-20(BREATHS/MIN)
66
Q

What are the alterations in Breathing Pattern?

A
  • Bradypnea
  • Tachypnea
  • Hyperpnea
  • Apnea
  • Hyperventilation
  • Hypoventilation
  • Cheyne-Stokes respiration
  • Kussmaul’s respiration
  • Biot’s respiration
67
Q

What is bradypnea?

A

It is a condition where the rate of breathing is regular but abnormally slow (less than 12 breaths/min).

68
Q

What is tachypnea?

A

It is a condition where the rate of breathing is regular but abnormally rapid
(greater than 20 breaths/min).

69
Q

What is hyperpnea?

A
  • It is a condition where respirations are labored, increased in depth, and increased in rate ( > than 20 breaths/min)
  • Occurs normally during exercise.
70
Q

What is apnea?

A

It is when respirations cease for several seconds.

Note: Persistent cessation results in respiratory arrest.

71
Q

What is hyperventilation?

A

It is a condition where the rate and depth of respirations increase.

72
Q

What is hypoventilation?

A

It is a condition where respiratory rate is abnormally low, and depth of ventilation is depressed.

73
Q

What is Cheyne-Stokes respiration?

A
  • It is a condition where respiratory rate and depth is irregular, characterized by alternating periods of apnea and hyperventilation.

Note:- Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth.
-The pattern reverses; breathing slows and becomes shallow, climaxing in apnea before respiration resumes.

74
Q

What is Kussmaul’s respiration?

A

It is a condition where respirations are abnormally deep, regular, and increased in rate.

75
Q

What is Biot’s respiration?

A

It is a condition where respirations are abnormally shallow for two to three breaths followed by irregular period of apnea.

Fundamentals of Nursing (1 decks)

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