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NUR211 > Module 4 part 1 > Flashcards

Module 4 part 1 Flashcards

General Survey and vital signs

1
Q

page 152

A

Ch 6

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2
Q

Does general survey come before or after vitals?

A

before.

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3
Q

What is included in general survey?

A
  • do they look ill?
  • how old do they look?
  • Hygiene, dress, body odors
  • Body structure (symmetry, short, thin, muscular, tall)
  • Behavior
  • Mental status (eye contact, speech, calm/restless?)
  • LoC (alert, oriented)
  • Mood/Affect
  • Mobility
  • Pain
  • Distress.(ABC or GI)
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4
Q

What is cachetic?

A

thin, frail, wasting syndrome

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5
Q

SV?

A

stroke volume is amount of blood forced out of heart each beat

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6
Q

how long to assess respirations

A

one full minute

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7
Q

RR is controlled by

A

medulla oblongata and pon in the brain stem.

control the rate and depth of respirations

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8
Q

CO?
equation?

A

cardiac output is volume of blood pumped in 1 minute
CO=SVxHR

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9
Q

What is viscosity?

A

thickness of blood. causes incr. peripheral resistance

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10
Q

What is standard temp route for adults

is it core or non core

A

oral

core

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11
Q

‘thermostable’ adult alt. temp routes and core/noncore

A
  • disposable digital therm.
  • temporal artery
  • axillary

noncore

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12
Q

Contraindications for blood pressure

A
  • caffeine, cigs, exercise in the last 30 minutes
  • sitting for less than 5 minutes
  • legs crossed
  • bladder not emptied
  • Clothing still on arm
  • back not supported by chair
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13
Q

What happens to BP when someone is leaning forward in their chair

A

diastolic raises by 6 mmhg

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14
Q

C to F

A

multply by 9/5 THEN add 32

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15
Q

F to C

A

subtract 32 FIRST
then multply by 5/9

If your at F your subtract 32 First

5 looks like F and C is inside of 9

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16
Q

Body temp circadian rhythem

A

Can change 1°F to 2°F (0.5°C to 1°C)
* Lowest in the morning (2 to 4 a.m.) while resting and is warmest in the afternoon (4 to 6 p.m.) while active.

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17
Q

is it ok to use mercury thermometer

A

NO

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18
Q

Measurement of BP cuff

A

The inflatable part (bladder) of the BP cuff length should cover about 80 percent of the circumference of your upper arm. The cuff width should cover two-thirds (40%) of the length from your elbow to your shoulder

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19
Q

Where can you take a BP reading

A

Upper arm
Forearms
Thigh

are all most common

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20
Q

contraindications for oral temp

A
  • cannot follow directions,
  • has decreased mentation,
  • is unable to keep mouth closed
  • breathes through his or her mouth.
  • eaten anything cold or hot in the last 30 minutes (wait another 30 if they have until taking it)
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21
Q

Where do you put an oral therm

A

Inside the sublingual pocket and have them close their mouth

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21
Q

Normal therm oral

A

97.5°F to 99.5°F or 36°C to 37.5°C Daily fluctuations may be 1° F or 2° F

singing 97.5 is when you feel alive
97.5 +1 or +2 is 99.5

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22
Q

Fever (pyrexia) oral therm

A

greater than 100°F or 37.8°C.

0 to a hunded real quick song comes from the mouth

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23
Q

Tympanic temp mechanism

A

infrared radiation and a thermopile detector at the TIP of the instrument to measure the infrared energy given off from the patient’s eardrum

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24
Q

Tympanic ear temp contraindications

A
  • ear pain
  • ear drainage, or a large amount of wax in the ear.
  • small ear canal (can’t get to tympanic membrane)
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25
Q

What should you remember to do when taking an ear temperature

A

pull the pinna up and back

(down and back for a child)

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25
Q

Ear temp normal findings, and fever

A

normal is
98.2°F to 100°F or 36.8°C to 37.8°C

A tympanic temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature (closer to inside of body than mouth)

an ear looks like an 8
the ear is superior to the mouth

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26
Q

Temporal thermometer procedure

A
  1. Explain the procedure to the patient.
  2. Attach a clean disposable sensor probe cover.
  3. Place the sensor head of the temporal artery thermometer at the center of the forehead midway between the eyebrow and the hairline. press button and hold.
  4. Slowly slide the thermometer straight across the forehead toward the top of the ear maintaining direct contact with the skin. stop at the hairline.
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27
Q

Temporal therm normal

A

A forehead (temporal) scanner is usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature (the skin is cool)

98.7°F to 100.5°F or 37.1°C to 38.1°C

shares the same numbers as rectal

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28
Q

Assessing Rectal Temp benefits

A

You can get core body temp with rectal probe

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29
Q

Risks of using rectal probe

A

could stimulate the vagus nerve in the rectum (causes someone to faint)

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30
Q

Rectal temp contraindications

A
  • rectal surgery, rectal disease
  • low WBC, or clotting disorder (risk of infection or bleeds)
  • Neurological disorders (vagus nerve problem)
    * cardiac disease (because of possible vagus nerve lowering BP)
  • diarrhea
  • hemorrhoids
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31
Q

What should you do with the rectal thermometer first

A

Lube the TIP of the probe cover

1” max

and put on gloves with patient on their side (could be Sims)

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32
Q

Rectal temp normal

A
  • A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature (inside body cavity where its warm)
  • normal is 98.7°F to 100.5°F or 37.1°C to 38.1°C
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33
Q

Important considerations with temperature

A
  • Compare to baseline
  • Axillary is NOT recommended in ADULTS
  • stick with same site of measurement when possible
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34
Q

What is documented after temperature

A

Time, site, and last admin of antipyretics

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35
Q

Two key areas to assess heart rate

A

Apical pulse (apex of heart)
Radial pulse

remember apex of heart is most inferior

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36
Q

What do you document for pulse

A

RRR
amplitude

regular rate and rhythm. amp means 0 to + 3

normal is +2. No pulse is 0

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37
Q

How long do you count HR

A

one full minute but especially one minute if its irregular

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38
Q

What do you do when you find an irregular pulse

A

ALWAYS take an apical pulse for 60 seconds

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38
Q

Apical Pulse HR procedure

A
  1. wipe steth with at least 70% alcohol
  2. Use steth over 5th left intercostal at midclavicular line
  3. Count for 60 seconds

always document site, rate, rhythm

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39
Q

If you find a weak radial pulse, what do you do?

A

Assess both the radial and apical pulse to determine if there is a pulse deficit

deficit is apical MINUS radial

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40
Q

What does a pulse deficit mean

A

rate of blood pumping to peripheral artery is less than the blood pumping at the heart. indicates inability of heart to push blood to the peripheral.

could be a tunnel prob, could be a pump prob

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41
Q

What is the biggest indicator of patient deterioriation

A

RR abnormal

b/c RR is related to pH, pain, exercise, stress, intoxication, illness, conditions, medications, and body positioning

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42
Q

Does RR go up or down when temperature is elevated by one degree F

A

RR goes up. More CO2 to blow off. (higher metabolism)

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43
Q

How does body position impact RR

A

Fowlers, semi fowlers, or standing is the best for respiratory depth (lungs were designed to have apex at top w/ air floating to the apex)

Lyding down in prone reduces respiratory depth

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44
Q

What is best timeto take RR

A

right after the pulse. leave fingers on pulse and assess RR while patient is resting.

b/c RR becomes voluntary if pt is aware of breathing

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45
Q

Documentation of RR

A

Depth - deep/shallow
Rhythm
Effort

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45
Q

How long to count the respirations

A

60 seconds

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46
Q

You are struggling to see respirations. What now?

A

place the diaphragm of the stethoscope over the trachea, and auscultate to the breath sounds.

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47
Q

Like temperature flucuates, how does BP fluctuate?

A

Body position
Stress
Medications
Disease
Pain
Exercise
Gender
Age
HTN fmly his
Diet
Alcohol
Obesity
Diurnal variations

47
Q

Common sites to take BP

A

Upper arm
Forearms
Thigh

48
Q

BP cultural consideration

A

In US, highest in AA males and females

48
Q
A
49
Q
A
50
Q

What is the effect of gender on blood pressure?

A

Men have slightly higher BP than women of comparable age.

After menopause, women’s BP increases possibly due to a decrease in estrogen.

51
Q

How does age affect blood pressure?

A

Blood pressure increases with age.

This trend is observed across different populations.

52
Q

What family history factor increases the risk of hypertension?

A

Family history of hypertension increases the risk for developing hypertension.

Genetics can play a significant role in blood pressure regulation.

53
Q

Name two lifestyle factors that can affect blood pressure.

A
  • Diets high in sodium
  • Alcohol consumption of three or more drinks per day
  • Obesity increases risk for high BP

Lifestyle modifications can significantly impact blood pressure levels.

54
Q

What are diurnal variations in relation to blood pressure?

A

BP changes related to a person’s schedules and routine.

Blood pressure may fluctuate throughout the day.

55
Q

What effect does regular exercise have on blood pressure?

A

Regular exercise decreases BP.

Exercise is a crucial component of lifestyle modification for hypertension management.

56
Q

How does body position affect blood pressure?

A

BP is higher with standing.

Readings are also affected by arm position and leg position (e.g., dangling or crossed).

57
Q

What psychological factors can increase blood pressure?

A
  • Fear
  • Worry
  • Excitement
  • Other stressors

These factors contribute to temporary increases in blood pressure.

58
Q

What is ‘white coat hypertension’?

A

BP rises when being examined by a healthcare provider.

This phenomenon is common among patients with anxiety related to medical settings.

59
Q

How does acute pain affect blood pressure?

A

Acute, short term pain increases BP.

Prolonged severe pain can have the opposite effect, potentially decreasing BP.

60
Q

What types of substances can alter blood pressure?

A
  • Over-the-counter medications
  • Herbs
  • Illicit drugs
  • Prescription medications

It’s important to consider all substances that may influence blood pressure.

61
Q

Which diseases can affect blood pressure?

A

Diseases of the circulatory, renal, liver, and other major organs may affect BP.

Chronic conditions often require careful monitoring of blood pressure.

62
Q

Reasons to not take BP right now

A

Exercise, smoked, or caffeine in the last 30 minutes. Wait another 30 if yes.

63
Q

How to posture the patient when sitting for BP

A

If sitting, seat the patient comfortably with back supported, legs
uncrossed, and palm facing up, the arm resting at the level of the fourth intercostal space (heart level) and not tensed

63
Q

How to posture patient when supine for BP

A

place the arm flat with
palm facing up on a pillow so that the arm is at heart’s level

64
Q

When do you measure arm circumference

A

Every time

@ circumference of the midpoint of the upper arm between the shoulder and th elbow

65
Q

22 to 26 cm

A

small adult

65
Q

27 to 34 cm

A

adult size

66
Q

35 to 44 cm

A

large adult size

67
Q

Cuff size abnormal- problems for too small or too big?

A

abnormal reading from both too small and too big

67
Q

45 to 52 cm

A

adult THIGH size

68
Q

How to check if BP cuff is too tight?

A

able to fit ONE finger under the BP cuff

69
Q

How much do you inflate to bypass the auscultory gap

A

30 mmHg past the point where patients pulse stopped being palpable

69
Q

if you don’t know the palpable systolic value?

A

If the palpable systolic value is unknown, you can inflate the cuff to 160 to 180 mm Hg. If pulse sounds are heard right away at these values, inflate to a higher pressure. It is also good practice to review the patient’s record for previous readings.

70
Q

How to deflate cuff

A

Slowly release the manual valve (2 to 3 mm/sec) to deflate the BP cuff, and listen for the first rhythmic Korotkoff sounds heard as blood begins to flow through the artery; this first sound is the systolic reading.

71
Q

Auscultory gap defined

A

a silent gap, is the interval of pressure where the Korotkoff sounds become diminished or absent. The presence of an auscultatory gap is frequently associated with increased vascular stiffness. With an auscultatory gap, the Korotkoff sounds temporarily become inaudible between phase 2 and phase 3 prior to the Korotkoff sounds reappearing

Record the location in the reading where you hear an auscultatory gap

72
Q

What if BP too high?

A

always reassess.

wait for one to two minutes to allow return of trapped blood. Then retake the BP in the opposite arm. Document the higher of the two BP readings

73
Q

What if BP cuff doesn’t fit their upper arm?

A

When patients’ upper arms are not accessible and/or when cuffs do not fit large upper arms (i.e., a patient who is obese), the forearm site is often used for BP measurement

74
Q

How long should they be sitting before you take BP MEASUREMENT?

A

If the patient is ambulatory, have the patient sit in a chair with his or her feet flat on the floor for 5 minutes.

75
Q

procedure for BP

A
  • Using a measuring tape, measure the forearm in centimeters at the widest point closest to the elbow: choose a correctly sized BP cuff.
  • Wrap the deflated cuff around the patient’s upper forearm about 2.5 cm (1 inch) below the brachial artery; make sure the artery marker is pointing down toward the radial artery.
  • Have the patient support the bare arm on the exam table or in your arm at the patient’s heart level; patients in supine position should have their arm resting on a pillow at heart level.
76
Q

When would you take thigh BP?

A

upper arm > lower arm> thigh

if arms arent accessible

77
Q

Assessing Blood Pressure in the Thigh

A

Place the patient preferably in the prone position; if patient
cannot lie on his or her stomach, place the patient in the supine position with the knee slightly flexed.
3. Measure the thigh in centimeters between the knee and the hip; choose the correct size cuff.
4. Wrap the deflated cuff around the patient’s thigh about 2.5 cm (1 inch) above the popliteal artery; making sure the artery marker is pointing down toward the popliteal artery
5. Turn the manual valve clockwise on the BP cuff to close it.
6. Palpate the popliteal artery and continue to feel for the pulsation of this artery.
7. Start squeezing the bulb at the end of the rubber tube attached to the BP cuff, inflating the BP cuff until you no longer feel the pulsation of the popliteal artery. (This is the palpable systolic BP.) Make note of this number on the sphygmomanometer. Release the manual valve to deflate the BP cuff.

  1. Place the bell or the diaphragm of the stethoscope on the popliteal artery, and inflate the BP cuff 30 to 40 mm Hg above the palpable systolic BP number (Anderson, 2009).
  2. Slowly release the manual valve to deflate the BP cuff, and listen for the first rhythmic low-frequency Korotkoff sounds heard as blood begins to flow through the artery. This is the patient’s systolic pressure; this first sound is the systolic reading.
  3. Continue to listen as the BP cuff pressure is released, for the last Korotkoff sound that you are able to hear; this last sound is the diastolic reading.
  4. Document the location and BP reading.
77
Q

Thigh BP is higher or lower?

A

Values obtained from thigh measurement may be higher than arm pressures due to increased hydrostatic pressure related to the lower position of the thigh

78
Q

define Orthostatic hypotension

A

Orthostatic hypotension is an abnormal fall in blood pressure of at least 20 mm Hg systolic and 10 mm Hg diastolic within three minutes of standing upright.

Assess only the supine and sitting positions if the patient is unable to safely stand.

79
Q

What is the first Korotkoff sound?

A

A tapping sound that occurs during systole, corresponding to the pulse (systolic BP)

The first sound indicates the onset of blood flow as the cuff is deflated.

80
Q

What characterizes the second Korotkoff sound?

A

A soft, swishing sound caused by blood turbulence

swish like 2 drinking buddies

This sound occurs as the cuff is further deflated.

81
Q

Describe the third Korotkoff sound.

A

A sharp, rhythmic, tapping sound that begins midway through the BP measurement

This sound indicates a more pronounced flow of blood.

82
Q

What is the fourth Korotkoff sound like?

A

Similar to the third sound, but softer and fading

This sound indicates a transition towards diastole.

83
Q

What does the fifth Korotkoff sound signify?

A

Silence, corresponding with diastole (diastolic BP)

This marks the end of the audible sounds during the blood pressure measurement.

84
Q

What is the systolic blood pressure range for ‘Normal’ blood pressure in adults?

A

Less than 120

This category indicates optimal blood pressure levels.

85
Q

What systolic blood pressure range is classified as ‘Elevated’?

A

120-129

Individuals in this category are at risk of developing hypertension.

86
Q

What is the systolic blood pressure range for ‘Hypertension Stage 1’?

A

130-139

This stage indicates a higher risk for cardiovascular issues.

87
Q

What is the diastolic blood pressure range for ‘Hypertension Stage 1’?

A

Less than 80

Hypertension Stage 1 can occur even with normal diastolic pressure.

88
Q

What is the systolic blood pressure range for ‘Hypertension Stage 2’?

A

140 or higher

This stage requires more intensive treatment.

89
Q

What is the diastolic blood pressure range for ‘Hypertension Stage 2’?

A

90 or higher

Hypertension Stage 2 indicates a significantly elevated risk of health complications.

90
Q

What is the blood pressure classification for a ‘Hypertensive crisis’?

A

systolic Higher than 180 And/Or diastolic Higher than 120

This condition requires immediate medical attention.

91
Q

What is the measurement unit for blood pressure?

A

Millimeters of mercury, or mm Hg

92
Q

What defines isolated systolic hypertension?

A

Systolic number is greater than 130 and diastolic number is less than 80

93
Q

What health risks can isolated systolic hypertension lead to?

A
  • Stroke
  • Heart disease
  • Kidney disease
94
Q

What is considered normotensive?

A

Systolic reading is less than 120; diastolic reading is less than 80

95
Q

What is hypotension?

A

Blood pressure that is below normal limits

96
Q

What is hypertension defined as?

A

Blood pressure greater than or equal to 140 systolic or greater than or equal to 90 diastolic

97
Q

What blood pressure should patients with chronic kidney disease or diabetes maintain?

A

Less than 130/80 mm Hg

98
Q

Assessing Orthostatic Vital Signs procedure

A
  1. Place the patient in the supine position for 5 to 10 minutes prior **to the first BP **and pulse assessment.
  2. Take the patient’s pulse and BP in the left arm (Fig. 6-11A).
  3. Do not remove the BP cuff.
  4. Document the site, the pulse, and BP readings in the supine position.
  5. Ask the patient to stand up.
  6. Have the patient stand for three minutes. Retake the patient’s pulse and BP while standing (Fig. 6-11B).
  7. Document the site, the pulse, and BP readings in the standing position.
99
Q

ABNORMAL FINDINGS Orthostatic Vital Signs

A

Pulse rate increases by 20 or more bpm
Systolic BP decreases by 20 or more mm Hg
Diastolic BP decreases by 10 or more mm Hg
Patient becomes dizzy or loses consciousness (Witting & Hydorn, 2013)

100
Q

What is the preventive care goal of Healthy People 2030?

A

Help people get recommended preventive health care services

ODPHP, 2020

101
Q

What should patients be taught regarding monitoring their health?

A

Basics about taking their own temperature, pulse, and BP, and awareness of normal and abnormal findings

AHA, 2020

102
Q

What is the prevalence of high blood pressure (BP) among adults in the United States?

A

About one in three adults has high BP.

103
Q

Why is high blood pressure often referred to as ‘the silent killer’?

A

It usually has no warning signs or symptoms.

104
Q

What can high blood pressure damage over time?

A

Heart, blood vessels, kidneys, and other parts of the body

National Institute on Aging, 2018

105
Q

What should all patients be educated about regarding heart disease?

A

The risk factors of heart disease and high BP.

106
Q

Is high blood pressure a modifiable risk factor?

A

Yes, it can be modified through lifestyle changes.

107
Q

What is one lifestyle modification for managing high blood pressure?

A

Lose weight if overweight

Losing 10 pounds (4.5 Kg) can lower BP by 10 points.

108
Q

What is the recommended alcohol limit for men to manage high blood pressure?

A

Two drinks per day.

109
Q

What is the recommended alcohol limit for women to manage high blood pressure?

A

One drink per day.

110
Q

What is the recommended alcohol limit for older people (> 65) to manage high blood pressure?

A

One drink per day.

111
Q

How much exercise is recommended for managing high blood pressure?

A

At least 30 minutes preferably on all days.

112
Q

What lifestyle change is advised regarding smoking to manage high blood pressure?

A

Stop smoking.

113
Q

What dietary changes should be made to manage high blood pressure?

A

Reduce sodium, saturated fats, and cholesterol.

114
Q

hypothermia

A

Hypothermia is a body temperature below 95°F (35°C) (Venes, 2021).

115
Q

hyperpyrexia

A

Hyperpyrexia is fever above 105.8°F (41.0°C). Hyperpyrexia is dangerous and requires intervention

116
Q

what to do if you see a temp that makes you suspect hyperthermia or hypothermia

A

Hypothermia and hyperthermia should be confirmed by temperature readings at two different core locations

NUR211 (12 decks)

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