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N321: Nursing Assessment of Clients > Module 4 > Flashcards

Module 4 Flashcards

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1
Q

Vital Signs

A

Temperature
Pulse
Respiration
Blood Pressure
O2 Saturation
(Pain is often included but not necessarily)

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2
Q

Vital Signs reflect…

A

the health of a person

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3
Q

When should vitals be taken?

A
  • to get a baseline with pre/post medications or pre/post vitals
    -upon admission
    -based on institutional policy/procedure
  • before and after activity that increases risk, surgery, or medication administration affecting cardio/resp.
    -when physician orders it
    -WHENEVER YOU FEEL YOU NEED TO DO THEM
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4
Q

Can you take just one vital sign?

A

Absolutely Not

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5
Q

Who can take vitals?

A

People who are delegated healthcare personnel, but it is the nurses responsibility to assure its correct

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6
Q

We need to have a what for vital comparison?

A

Baseline vitals

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7
Q

“Close the Loop”

A

Responsibility of the nurse to follow up on delegation of vitals - the nurse has the responsibility if someone else is told to do it

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8
Q

Thermoregulatory center is in …

A

the hypothalamus

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9
Q

Primary source of body heat production?

A

metabolism

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10
Q

What things increase metabolism and heat production?

A

-hormones (EP and NEP), muscle movements, and exercise

-NEP and EP are released and alter metabolism which leads to energy production decreases and heat production increases

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11
Q

Sources of Heat Loss

A

-Skin (primary source)
-evaporation of sweat
-warming and humidifying inspired air
-eliminating urine and feces

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12
Q

Physical Processes Transferring Body Heart to External Environment?

A
  1. Radiation
  2. Convection
  3. Evaporation
  4. Conduction
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13
Q

Radiation

A

the diffusion or dissemination of heat by electromagnetic waves (ex: not having a hat)

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14
Q

Convection

A

transference of heat by motion between areas of unequal density

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15
Q

Evaporation

A

conversion of a liquid to a vapor (lose heat)

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16
Q

Conduction

A

transference of heat to another object during direct contact (ex: ice pack)

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17
Q

Factors Affecting Body Temperature

A
  1. Circadian Rhythm
  2. Age and Gender
  3. Environmental Temperatures
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18
Q

How does core temperature fluctuate during the day?

A
  1. core temperature is lowest in the morning
  2. body temperature highest in the alte afternoon (4-8 pm)
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19
Q

How does Age and Gender influence core body temperature?

A
  • Older and Younger people have less adaptable ability (from things like less sweat glands or less muscle mass)

-Men and Woman have hormone changes differing body temperature (Female Progesterone leads to more fluctuation)

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20
Q

Types of Fever

A
  1. Intermittent - Temp returns to normal once every 24 hours
  2. Remittent - fluctuating a few degrees
  3. Sustained/Continuous - stays stable at the same temperature
  4. Relapsing - returning to normal for 1+ days with fever for several days reoccurring
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21
Q

FUO

A

Fever of unknown origin - a fever greater than 38 Celsius lasting more than 3 weeks with no identifiable cause

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22
Q

Methods of Taking Temperature

A

Blue Oral
Blue Axillary
Red Rectal
Tympanic Membrane
Temporal Arterial
Temperature Sensitive (invasive)
Single Use Thermometer
Mercury Glass Thermometer
Infrared Thermometer

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23
Q

Sites for Temperature Assessment

A

Forehead
Orallly
Axillary
Rectal
Temporal Artery

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24
Q

Contraindications for Oral Temperature

A

Vomiting
Cognition issues
Eating or Drinking
Oxygen Use
Smoking
Age
Seizure Status
Open Sores
Age (<4 is too young to cooperatre)
Recent Oral Surgery

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25
Q

Contraindications for Rectal Temperature

A

Cardiac Issues (Vagus nerve stimulation lowers HR)
Rectal Surgery
Thrombocytopenia
Neutropenia
Age
Cognitive Issues

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26
Q

Contraindications of Tympanic Temperature

A

Pain
Infection
Scar Tissue
Cerumen Excess
Age (Under 3 can perforate the E tubes)

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27
Q

What might alter Temporal Artery Temperature?

A

Hair, Scarring, Cranial Surgery

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28
Q

Oral Normal Temperature

A

37 C / 98.6 F

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29
Q

Rectal Normal Temperature

A

37.5 C / 99.5 F

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30
Q

Axillary Normal Tempearture

A

36.5 C / 97.7 F

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31
Q

Tympanic Normal Temperature

A

37 C / 98.6 F

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32
Q

Forehead Normal Temperature

A

34.4 C / 94 F

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33
Q

Temporal Arterial Normal Temperature

A

37.5 C / 99.5 F

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34
Q

What temperatures are about a degree above and below Oral?

A

Above: Rectal, Temporal Arterial
Below: Axillary

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35
Q

Core Temperatures

A

Rectal, (possibly tympanic)

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36
Q

Routine newborn temperature is taken…

A

Axillary

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37
Q

Important thing to do when taking Tympanic Temperature?

A

in an adult, pull back on the ear

In a child above age 3/4 y/o you pull down and back

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38
Q

When taking a rectal temperature you must use what 2 things?

A

Gloves and Water Soluble Lubricants

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39
Q

Pulse is regulated by the ____ through _____

A

ANS through pacemaker (cardiac sinoatrial node)

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40
Q

What is the heart’s pacemaker?

A

Cardiac Sinoatrial Node

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41
Q

Parasympathetic stimulation does what to heart rate

A

decreases it (Sympathetic increases it)

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42
Q

What is Pulse Rate?

A

number of contractions over a peripheral artery for one minute

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43
Q

Physical Effects of Fever?

A

Anorexia
Headache
Diaphoresis
Thirst
Dehydration
Muscle Aches
Elevated Respiration
Elevated pulse Rate Due to Fluid Deficiency
Possibly Seizures

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44
Q

Hypothermia

A

Temperatures below 95/93.2 F or 34C

45
Q

Febrile

A

100.4 F or 38.3 C

46
Q

Peripheral Pulse

A

throbbing sensation that can be palpated over peripheral arteries (due to a pump of blood being put into circulation by the contraction of the left ventricle)

47
Q

When taking pulse you are on the look out for what 3 things?

A

Rate, Amplitude/Quality, Rhythm

48
Q

Tachycardia

A

Increased heart rate 100-180 bpm in adults

49
Q

Bradycardia

A

Decreased heart rate (below 60 bpm) in adults

50
Q

How to record pulse amplitude/quality?

A

0,+1,+2,+3 scale with 0 being absent, 1 being weak, 2 being normal, and 3 being bounding

51
Q

Normal Adult Heart Rate?

A

60 to 100 bpm

52
Q

Ways to Measure Pulse?

A
  1. Palpate peripheral arteries
  2. Auscultate apical pulse with stethoscope
  3. Assessing apical-radial pulse
53
Q

Methods of Assessing Pulse?

A
  1. Inspection
  2. Palpation (2-3 middle fingers lightly over the pulse)
  3. Doppler Ultrasound
  4. Stethoscope and Apical Pulse
54
Q

When palpating pulse, never use your…

A

thumb

55
Q

The apical pulse is located…

A

on the left side, mid-clavicular, 5th intercostal space

56
Q

Areas of Peripheral Pulses

A

Temporal
Carotid
Brachial
Radial
Ulnar
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibial

57
Q

Which peripheral pulse is checked only during an emergency for RATE?

A

Carotid

58
Q

Never do what with carotid pulse?

A

take both sides at the same time

59
Q

Pulse/Apical Deficit

A

Difference between the apical and radial pulses

Do not want this to occur, and the radial pulse will never be higher than the apical

Requires two people to learn

60
Q

Stroke Volume

A

the volume of blood ejected from the left ventricle with each heartbeat(contraction)

61
Q

Cardiac Output

A

the amount of blood ejected per minute

62
Q

Cardiac Output Equation

A

Stroke Volume * Heart Rate

63
Q

Dysrhythmia

A

irregular heart rate

64
Q

Decent Cardiac Output Range?

A

3.5 to 8 Liters of blood per minute

65
Q

Typical Child Pulse Rate

A

80-100 bpm

66
Q

Typical Infant Pulse Rate

A

100-160 bpm

67
Q

Typical Older Adult Pulse Rate

A

low 70s - 60 bpm

68
Q

Pulmonary Ventilation

A

movement of air in (inhalation) and out (exhalation) of the lungs

69
Q

Respiration involves what three things?

A

Ventilation, Diffusion, and Perfusion

70
Q

While heart rate is controlled by ANS, what controls respiration?

A

ANS and External Control

71
Q

External Respiration (Diffusion)

A

the exchange of oxygen and carbon dioxide between the alveoli and circulating blood

72
Q

Internal Respiration (Perfusion)

A

the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells

73
Q

Respiratory Centers controlling Rate and Depth of Breathing are located in..

A

the Medulla and Pons

74
Q

What stimulation causes activation of breathing?

A

stimulation of peripheral chemo receptors detecting oxygen OR pH

75
Q

The most powerful respiratory stimulant is…

A

an increase in CO2

76
Q

Factors Affecting Respiration

A

Exercise
Respiratory and Cardiovascular Disease
Alterations in Fluid, Electrolyte, and Acid Balances
Medications
Trauma
Infection
Pain
Anxiety

Diabetic Ketoacidosis increasing resp to get rid of ketones (and cause a sweet smell)

Low Carb/High protein diet increasing resp to get rid of ketones (and cause a sweet smell)

Medications like opioids suspend/decrease drive for respiration

Medications like EP and Caffeine increase drive for respiration

77
Q

Ways to Assess Respiration?

A

Pulse Oximeter

Auscultate with Stethoscope

Inspection

Monitoring Arterial Blood Gas Results

78
Q

Things to look for when Inspecting Respirations?

A

Rate

Depth

Rhythm

Ease of Breathing

Use of accessory muscles of the neck

color of skin

blanching of nail bed within 3 seconds is good circulation, longer is concerning

79
Q

Tachypnea

A

increased respirations

80
Q

Bradypnea

A

decreased respirations

81
Q

Minimal time to count respiration/pulse is…

A

30 seconds (multiply by 2) (sometimes can do 15 seconds for pulse and multiply by 4)

But, first time should always be done for 60 seconds

82
Q

Apnea

A

periods with no breathing (greater than 4-6 minutes leads to brain death)

83
Q

Dyspnea

A

means rapid breathing or shallow breathing

84
Q

Blood Pressure

A

the force of blood against the arterial walls

85
Q

Blood pressure rises when and falls when?

A

Rises when the ventricle contracts (Systolic) and falls when the heart relaxes (Diastolic)

86
Q

Pulse Pressure

A

Differences between systolic and diastolic pressure (S-D = PP)

87
Q

Equipment for BP

A

Stethoscope

Sphygmomanometer (with right cuff size)

Doppler Ultrasound

Electronic or automated devices

88
Q

Too small a BP cuff can lead to…

A

false high reading

89
Q

Too small a BP cuff can lead to…

A

false low reading

90
Q

Average adult breathing rate?

A

12-20 BPM

91
Q

Contraindications for Blood Pressure

A

IV placement on arm

AV Fistula

Birth control implant in arm

Any healthcare device in arm indicates to use the other

Mastectomy leading to lymphoedema potential

BP cuff being made of latex could cause allergies

hypo/hypervolemia

wounds in upper extremities

92
Q

Korotkoff sounds?

A

First noise is the systolic pressure, fifth/final is diastolic

Aucultatory gap between the first and second sounds

93
Q

Basic BP Pressure Reading Procedure

A
  1. pick correct cuff and wash hands
  2. Assume sitting position with arm horizontal to heart and find brachial artery pulse
  3. Expose arm and place cuff
  4. palpate radial pulse and inflate until extinction, note number and add 30 mmHg
  5. pump to that number after putting stethoscope diaphragm over brachial pulse a minute later
  6. allow deflation of 2-3 mmHg per second and note first and final sounds
  7. remove, clean equipment and hands, mark recordings
94
Q

Systolic

A

highest amount of pressure (working phase of heart)

95
Q

Diastolic

A

lowest amount of pressure (resting phase of heart)

96
Q

How is BP written?

A

Systolic/Diastolic

97
Q

How is Pulse Pressure written?

A

Systolic - Diastolic

98
Q

Factors that Influence BP?

A

Age, Gender, Race
Circadian Rhythm
Food Intake
Exercise
Weight
Emotional State
Body Position
Drugs/Medications
Peripheral Resistance
Blood Volume
Viscosity of Blood

99
Q

Standard “Normal” BP in Adults

A

below 120/80

100
Q

Hypertension

A
  • Diagnosis after 3 readings above normal limit (140/90)
    -Prehypertension, stage 1, and stage 2 stages
101
Q

Prehypertension Average

A

120-139/80-89

102
Q

Stage 1 Average

A

140-159/90-99

103
Q

Stage 2 Average

A

Greater or Equal to 160/100

104
Q

Hypotension

A

below the lower limit of normal for blood pressure

105
Q

Orthostatic Hypotension

A

temporary fall in BP related to postural changes (standing up) that can lead to falls

106
Q

What can lead to False BP Highs

A

Uncalibrated Sphygmomanometer

Assessing BP after exercise

A narrow Cuff

Releasing the valve too slowly

Reinflating the bladder during auscultation

107
Q

What can lead to False BP Lows

A

hearing deficit in nurse

noise in environment

viewing the meniscus from above eye level

applying too wide a cuff

crack stethoscope

misplacing the bell instead of the diaphragm

failing to pump cuff 30 mmHg above the disappearance of the pulse

108
Q

Abnormalities in Vitals as titled by Nursing Diagnosis

A

Risk for Altered Body Temperature
Hypothermia
Hyperthermia
Ineffective Thermoregulation

Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Inability to Sustain Spontaneous Ventilation

109
Q

Rectal thermometers are what color?

A

Red (and only rectal thermometers ared red, while oral is blue)

N321: Nursing Assessment of Clients (18 decks)

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