NSE103 Vital Signs Quiz Flashcards
What does ADPIE stand for?
Assessment
Diagnosis
Planning
Implementation
Evaluation
Define Clinical Judgement
The observed outcome of critical thinking and decision-making, it is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.
What are the ABCDEs of the Primary Survey?
Airway: is it blocked? is there wheezing?
Breathing: is breathing shallow, or interrupted?
Circulation: what is their pulse and heart rate? urine output?
Disability: is their confusion? weakness on one side? sudden loss of sight?
Exposure: is the person hypothermic? is there an excessive loss of fluids?
What are the four health promotion interventions?
- Effective: an evidence-based treatment that results in optimal health outcomes (i.e., cpr with compressions)
- Ineffective: non-evidence based treatment that will not result in optimal health outcomes (i.e., cpr without compressions)
- Unrelated: possibly evidence-based by unrelated to the client’s current health situation (i.e., calling employer)
- Contraindicated: will result in negative health outcomes (i.e., waiting for physician)
Define behavioral health promotion
choice-centered, focuses on the client’s behavior in relation to their health outcomes; does not factor in environmental or social determinants (i.e., client needs to quit smoking)
Define relational health promotion
understands and includes the relationship between people, places, environments, etc. for a client’s health outcomes (i.e., mental health issues contribute to a client’s habitual smoking - eases anxiety)
Define structural health promotion
institutional and historical contexts of health outcomes (i.e., client started smoking at a young age as they grew up in a minority, low-income, and at-risk community that contributes to poor mental health and high anxiety)
What are the 5 levels of consciousness?
- Alert and oriented
- Confused and disoriented
- Lethargic
- Obtunded
- Unconscious
What are the levels of orientation?
- Place
- Time
- Person
- Self
What are some examples of a trauma-informed approach?
Introducing self/role, explaining why you are there, asking permission to touch, giving the client choices, explaining the procedure, providing privacy
Define anterior
Front side or further to the front
Define posterior
backside or further to the back
Define medial and lateral
the midline of the body - lateral refers to moving further away from this line
Define proximal and distal
nearest the trunk or center of the body, distal refers to further away from the trunk of the body
Define inspection
Is the technique of purposeful and systematic observation of the client
Define palpation
Is the technique of using your hands/fingers to assess the client based on your sensation of touch. It provides useful information to assess and evaluate findings related to temperature, texture, moisture, thickness, swelling, elasticity, contour, lumps/masses, consistency, organ location and size, pulsatility, crepitation, and presence of pain.
Define percussion
Percussion involves tapping the body to elicit sounds and determining whether the sounds are appropriate for a particular organ or area of the body
Define auscultation
involves your sense of hearing while listening to areas of the body with a stethoscope
Why is tympanic temperature higher than oral?
The tympanic membrane is fed by the same artery as the hypothalamus
What is normal temperature range?
36.5-37.5. However, a wider temperature range is accepted in infants and children as their heat control mechanisms are less effective. Older adults tend to have lower body temperatures.
What is Oxygen Saturation?
Refers to the percentage of hemoglobin molecules saturated with oxygen. Oxygen saturation provides information about how much hemoglobin is carrying oxygen, compared to how much hemoglobin is not carrying oxygen. Normal ranges are 97-100%. Slightly lower is accepted in older adults.
What is included in the mental status examination?
- Appearance
- Behavior
- Cognition
- Thinking
What is a first-level priority?
A life-threatening condition requiring urgent action
What is a second-level priority?
Addressed after a first-level priority; may lead to clinical deterioration and requires prompt action
What is a third-level priority?
Non-urgent, but needs addressing
Where might you hear flatness when percussing? Dullness? Resonance? Tympany?
Flatness can be heard over bones, dullness over dense organs (i.e., liver, heart), Resonance will be heard over lungs, and Tympany will be heard over abdominal areas (i.e., intestines or stomach)
What does pulse rhythm refer to
Normal pulse rhythm is regular, meaning that the frequency of pulsation felt by your fingers follows and even tempo with equal intervals between pulsations
What is sinus arrhythmia?
It is a common condition in children, adolescents, and young adults. It involves an irregular pulse rhythm in which the pulse rate varies with the respiratory cycle: the heart rate increases at inspiration and decreases back to normal upon expiration. The underlying physiology of sinus arrhythmia is that the hear rate increases to compensate for the decreased stroke volume from the heart’s left side upon inspiration.
What is an important point to consider with an irregular rhythm?
Is it regularly irregular or is it irregularly irregular? Irregularly irregular pulse rhythm is highly specific to atrial fibrillation and is more concerning.
What are you measuring in pulse?
Rhythm, rate, force, equality
Which pulse should be taken prior to administration of a beta blocker?
Apicial
What is blood pressure?
Blood pressure is the force of blood exerted against the arterial walls, and is reported in mm Hg
What is systolic pressure?
It is the maximum pressure on the arteries during left ventricular contraction (systole)
What is the diastolic pressure?
It is the resting pressure on the arteries between each cardiac contraction when the heart’s chambers are filling with blood (diastole)
What is stroke volume?
It is the amount of blood ejected from the left ventricle in a single contraction. It provides information about the functioning of the heart. Typical range is 5-80 mL.
How can you measure the stroke volume indirectly?
This involves assessing the pulse pressure, which is the difference between the systolic and diastolic values and signifies the force required by the heart each time it contracts. A higher pulse pressure can be indicative of arterial stiffness or aortic valvular insufficiency. A lower pulse pressure can be a marker of poor heart function, where cardiac output is decreased.
Where is the brachial artery?
About 2cm medial to the bicep tendon and about 2-3cm above the antecubital fossa
Define bradycardia
A slow heart rate, typically below 60 beats per minute in adults
Define tachycardia
A fast heart rate, typically above 100 beats per minute at rest
What is Cardiac Output, how it is measured?
The quantity of blood pumped by the heart in a given period of time, typically measured in liters per minute using the equations CO = SV x HR
What are the five factors contributing to blood pressure?
- Cardiac Output
- Peripheral Vascular Resistance
- Viscosity
- Volume of Circulating Blood
- Elasticity
What is Orthostatic Hypotension?
A sudden drop in blood pressure of more than 20 mm Hg or an increase of pulse of more than 20 bpm
Hypertension is considered when blood pressure is measured at what value?
> 140/90 but is contextual, generally
Hypotension is considered when blood pressure is measured at what value?
<95/60 but contextual, generally
What are the BMI ranges?
- Underweight: <18.5
- Normal weight: 18.5-24.9
- Overweight: 25.0-29.9
- Obese Class I: 30.0-34.9
- Class II: 35.0-39.9
- Class III: >40.0
What are the breathing rates over the various age groups?
- Adults and older adult: 10-20
- 12-18: 12-22
- 7-11: 18-30
- 2-6: 22-36
- 6mo-1yr: 26-40
- New born-6mo: 30-60
What are warning signs of respiratory distress?
Wide eyes, nasal flaring, tracheal tugging, intercostal tugging
What do you record when taking a blood pressure?
Systolic and diastolic in even numbers, the position, and which arm was used
Define Acute pain
Short, limited in duration and is caused by something specific (i.e., labor, menstruation, headache, fever, etc.) may be accompanied by changes in vital signs
Define Chronic pain
Recurring pain with a duration longer than 3-6 months, can be associated with an injury (i.e., cancer, arthritis) may not be accompanied by increased vitals as the body adjusts over time
Define Nociceptive pain
Associated with mechanical, thermal, or chemical causes (i.e., strain a muscle, touch a hot surface, exposed to noxious chemicals)
Define Neuropathic pain
Somatosensory nervous system injury, may be described as ‘burning’ or ‘tingling’ (i.e., diabetic neuropathy, carpal tunnel syndrome) associated with lesions to the nervous system
Define Nociplastic pain
Unclear evidence of injury, however, pain is evident (i.e., stubbing a toe)
Define Referred pain
Pain that is felt in a different location than it’s origin (i.e., feeling jaw pain when the heart muscle is injured)
Define Idiopathic pain
Pain of unknown origin (i.e., fibromyalgia, IBS)
What is the PQRSTU mneumonic?
Provocative/Palliative
Quality/Quantity
Region/Radiation
Severity
Timing/Treatment
Understanding
Define Pruritus
Generalized itchiness
Define Nevi
Moles; inspect for ABCDE
Break down the ABCDEs of screening potentially cancerous moles
Asymmetry
Border irregularity
Color
Diameter (more than 6mm)
Evolving
What are the 4 stages of pressure ulcer formation?
Stage 1: non-blanching, reddened area
Stage 2: partial thickness
Stage 3: full thickness, subcutaneous tissues are visible
Stage 4: full thickness tissue loss, cartilage, tendon, ligaments, and sometimes bone are visible
When choosing a pain tool diagnostic, what factors should you consider?
Reason for assessing, developmental stage, health status, institution/unit, culture
What are some examples of unidimensional pain assessment tools?
Numeric rating scale, visual analog scale, verbal descriptor tool
FACES pain scale, sun-cloud pain scale
What are some examples of multidimensional pain assessment tools?
PQRSTU, Brief pain inventory, pain scales related to cognitive impairment (Abbey Pain Scale, PAIC-15), FLACC pain tool, behavioral pain scale, critical care pain observation tool
What does the Behavioral Pain Scale measure?
facial expression, upper limb movement, compliance with ventilation
What are some priorities of care?
Angina, significant increases, inadequately managed post-operative pain, pain upon movement with suspected fracture, back pain associated with potential spinal cord compression
What are the roles of the integumentary system?
Thermoregulation, fluid balance, protective barrier, immune defense against barriers, sensory functions
What is the difference between a viral skin infection and a bacterial skin infection?
Common characteristics of a bacterial infection are inflammation, exudate (i.e., pus), erythema, swelling, pain, and odour. Common characteristics of a viral infection are grouping/cluster of lesions, generally asymmetrical (one side of the body), and specific regions of the body (i.e., mouth, nose, hands, feet)
Define Erythema
a reddening/darkening of the skin, typically due to increased blood flow to the capillaries
Define Brawny
a brown-reddish discoloration, typically associated with venous insufficiency. Red blood cells accumulate in the interstitial spaces and can cause hemosiderin staining from the blood leaking out of capillaries.
What 6 areas are used to screen clients with the Braden scale?
- Sensory perception (1-4)
- Skin moisture (1-4)
- Activity (1-4)
- Mobility (1-4)
- Friction and shear (1-3)
- Nutritional Status (1-4)
What are the score ranges for the Braden scale?
Mild risk: 15-18
Moderate risk: 13-14
High risk: 10-12
Severe risk: less than 9
Which side should you always assess first in a patient?
The unaffected side - the best control for a patient is their own body!
What is the scale of manual muscle testing?
0: No contraction, MMT cannot be performed
1: Flicker or trace of contraction, no gravity (body part is supported by a bed or a table)
2: Active movement, with gravity eliminated
3: Active movement, against gravity
4: Active movement, against gravity and resistance
5: Normal power, full resistance
What should you do when a fracture is suspected?
- Immobilize the area and do not attempt you realign the bones
- Monitor vital signs frequently (particularly respiration, pulse, and blood pressure) and perform a primary survey
- Assess circulation and sensation distal to the injury including skin temperature, sensations, and pulses: cool temperature, numbness/tingling, and decreased or absent pulses
- Report findings to the physician or nurse practitioner
When should you NOT conduct ROM or MMT?
If the subjective assessment and/or inspection and palpation suggest trauma to the neck or back, or a bone fracture
When should you use the dorsal aspect of your hands when palpating?
When you are assessing for temperature, because it is most sensitive to temperature changes
What is the difference between assisted and active ROM?
Assisted active ROM is when you are providing some assistance to help the client with ROM; passive ROM is when a healthcare provider or equipment/machine moves the clients through ROM positions for a specific joint
Describe the ROM of the neck
Flexion: 60 degrees
Extension: 75 degrees
Lateral flexion: 45 degrees
Rotation: 80 degrees
Describe the ROM of the shoulders
Flexion: 180 degrees
Extension: 50-60 degrees
Abduction: 180 degrees
Adduction: 50 degrees
External rotation: 90 degrees
Internal rotation: 70-90 degrees
Describe the ROM of the elbows
Flexion: 140-150 degrees
Extension: 0 degrees
Pronation: 80 degrees
Supination: 80 degrees
Describe the ROM of the wrists
Palmar flexion: 60-80 degrees
Dorsiflexion: 60-70 degrees
Ulnar deviation: 30 degrees
Radial deviation: 20 degrees
Describe the ROM of the lumbar spine
Flexion: 65-90 degrees
Extension: 25 degrees
Lateral flexion: 25 degrees
Rotation: 30 degrees
Describe the ROM of the hips
Flexion: 100-120 degrees
Extension: 30 degrees
Abduction: 40-45 degrees
Adduction: 20-30 degrees
External rotation: 45-50 degrees
Internal rotation: 40-45 degrees
Describe the ROM of the knee
Flexion: 150 degrees
Describe the ROM of the ankle
Dorsiflexion: 20-30 degrees
Plantarflexion: 20-50 degrees
Inversion: 35 degrees
Eversion: 15 degrees
