Nurs 125 Quiz 1 Flashcards
what levels should nurses asses health on?
- psychosocial
- physical
- physiological
- developmental
- emotional
- emotional
- mental
- spiritual
- cultural
- nutritional
how do nurses promote health and prevent illness?
- teaching during wellness visits
- promoting regular health screenings
- asisting patients with long-term health challnges to maintian optimal functioning
how is safety defined?
minimization of risk of harm to pateints and providers through both system of effectivness and indivual performances
what are the seven primary nursing values in the code of ethics?
- providing safe, compassionate, competent, and ethical care- prmoting health and well-being
- promoting and respecting informed decision - amiing
- honouring dignity
- mainatianing privacy & confidentiality
- prmoting justice
- being accountable
what are the roles of Registered nurse?
what is health assessment?
collection off subjective and objective data to develop a database about a patient’s health status, health concerns, and usual coping mechanism to develop an individualized care plan
what is health history?
interviewing to collect a patient’s current symptoms - history of the present conerns, past medical, surgical, personal, social and family history
what does comprehensive health history include?
nutritional, developmental, mental and spiritual dimensions. also adresses safety issues, risk factors, health promotion and functional abilities
what data is collected during emergency?
information needed to pinpoint the source of the challenging issues and treat presenting concerns
what is wellness?
a reality, a lived experience, to wich people aspire to
what are examples of social determinants of health?
income, culture, education, age, gender, social support, work conditions and environment influences an individual’s coping mechanisms and health practices
what are the 3 levels of intervention?
- primary
- secondary
- tertiary
what is the purpose of primary intervention?
strategies aimed at preventing health concerns - immunizations, health teaching, safety precautions, and nutrition counselling
what is the focus of secondary intervention?
early diagnosis of health issues and prompt tretment - includes vision screening, pap smears, BP screening, hearing testing, tuberclin skin test
what does the tertiary prevention focus on?
prevents complications of existing disease or condition - diet teaching for diabetic patients, exercise programs
what is the nursing process?
systemic problem solving approach to identifying and treating
what are the phases of nursing process?
A = assesing
D = diagnosis
P = planning
I = intervention
E = evaluating
what does the assessment component include?
collcetion of data
what does analysing entail during nursing process?
purpose and end result of assessment - may also called diagnostic phase
make informed judgement of the subjective and objective data
what is the 7 step process of analyis?
- identifying abnormal (unexpected) findings
- cluster data
- draw inferences
- propose possible nursing diagnosis
- check for presence of defining charateristics
- confirm or rule out nursing diagnosis
- document conclusions
what are nurisng interventions?
actions that you perform based on your clinical judgements and nursing knowledge to enhance patient outcomes
what does care planning include?
determingin resopurces, selecting nursing interventions, and writing the plan of care
when does the general survey begin?
during the interview phase of health assesment
what elements are included in vital signs?
temperature, pulse, repirations, blood pressure (BP) and pain
what is the sixth element?
functional ability
what are indicators of urgent situation?
extreme anxiety, acute distress, pallor, cyanosis and a change in mental status
what is the unexpected range of respirations?
less than 10 breaths/min and or greater than 32 breaths/min
what is the unexpected range of oxygen saturation?
less than 92%
what is the unexpected range of pulse?
less than 55 beats/min (bpm) or greater than 120 bpm
what is the unexpected range of systolic BP ?
less than 100 or greater than 170
what is the unexpected range of temperature?
less than 35 or greater than 39
what are examples of primary prevention?
lifestyle modifications - such as weight loss, regular exercise, dietary modifications, cessation of smoking, reduction of stress, and reduction of saturated fats, sugars and sodium in diet.
what does the patient need to do prior to vital signs assessment?
rest quietly for 5 minutes
what is in initial survey?
mental notes of overall behavior, physical appearance and mobility
how do you introduce yourself to the patient?
shake hands if appropriate - note the hand strength, if he make eye contact or smile
what are the general indicators of of overall health?
what are the anthropometric measurements?
various measurements of the human body, including height and weight
what are the baseline measurements you take when you meet with a patient?
height and weight
what are the frequency of vital signs?
- upon admission to a facility
- before and after any surgical procedure
- before, during and after administration of medications that affect vital signs
- per the institution’s policy or physician orders.
- any time the patient’s condition changes.
- before and after any procedure affecting vital signs.
how do you convert from fahrenheit to celsius & vice versa?
- C = (F − 32) × 5/9
- F = (C × 9/5) + 32
what is the variation of physical activity called?
diurnal or circadian cycle
how does the oral route work?
sublingual pockets under the tongue are rich in blood supply that responds quickly to changes in the core temperature
how does the axillary route work?
it can be used with infants and young children
disadvantage - wait 30 mins after washing the axilla
how does the tympanic membrane route work?
uses infrared sesnsors to detect heat the tympanic membrane produces
how does the temporal artery route work?
quick, safe - no contact with mucous membranes
how does the rectal route work?
considered most accurate - taken when other routes are not practical core
what is the techniqiue of taking oral temperature?
wait 15-30 after hot or cold drink
place the thermometer in the sublingual area at the base of the tongue
close the lips tightly - hold the probe until it beeps
what is the method of taking axillary temperature?
place the electronic thermometer in axillary fold hold it in place closer to the body
what is the method of taking tympanic temperature?
turn the unit on and wait for the ready signal.
in adult - pull the pinna up, back
What is a pulse?
Contraction of the heart wwhich causes blood flow forward which creates a pressure wave
Where can pulse be palpated?
Over the peripheral artery
Where can pulse be ausecultated?
Over the apex of the heart
What does the pulse reflect?
The amount of blood ejected with each beat of the heart, which is the stroke volume
What is heart rate?
The number of pulsations occuring in 1 minute
How do you assess pulse?
Palpate the arterial pulse points (usually radial artery)
What should you note when assesing the pulse?
The rate
The rhythm
Strenght (amplitude)
Elasticity of the vessel
What is the expected heart rate for an adult?
60 to 100 beats per minute
What is tachycardia?
Heart rate over 100 bpm
Trauma, anemia, blood loss, hyperthyroidism can cause this
What is bradycardia?
Heart rate under 60 beats perr minute
Medications like digoxin & beta-blocekers can cause decrease in heart rate
What is asystole?
Absence of a pulse
Can be caused by cardiac arrest
What is pulse rhythm?
The interval between beats
What are the 2 types of pulse rhythms and their descriptions?
Reglar = occurs at evenly spaced intervals
Irregular = varied interval between beats
What should you do if a pulse if irregular rhythm?
Auscultate an apical pulse for 1 min
What is sinus dysrhythmia?
Aka sinus arrhythmia speeding up during inspiration and slowing with expiration
What is a pulse deficit?
Difference that exists between the apical and radial pulse rates - indicates the heart’s ability/inability to provide adequate blood flow to the body (perfusion)
How do you assess for pulse deficits?
Assess the peripheral and the apical pulse rates at the same time or count the two simultaneously
What is the amplitude?
The strenght of the pulse or amplitude indicates the volume of blood flowing through the vessel
How is the amplitude scale evaluated?
0 = non-palpable/absent
1+ = weak, diminished, and barely palpable
2+ = expected strenght
3+ = full, increased
4+ = bounding
What does elasticity of the pulse mean?
The smooth, straight , and resilient feeling of healthy artery
Where is the temporal pulse located?
Superior and laterla to the eye, anterior to the ear, over the temporal bone
In infants
Where is the carotid pulse located?
Medial edge of the sternocleiodomastoid muscle lateral to the trachea
During shock and cardiacc arrest
Where is the apical pulse located?
Fifth intercostal space, medial to left mid-clavicular line
Asseses pulse deficit and auscultation of heart
Where is the brachial pulse located?
Procimal to the antecubital fossa, in the groove between the biceps and triceps muscles
With cardiact arrest in infants, auscultate blood pressure
Where is the radial pulse located?
Thumb side of the forearm, at the wrist
Routinely assess heart rate in adults
Where is the ulnar pulse located?
Ulnar side of the forearm, at the wrist
To assess ulnar circulation in the hand and when performing Allen test
Where is the femoral pulse located?
Inferior to the inguinal ligament in the groin
To assess circulation in lower extremeties andd during cardiac arrest
Where is the popliteal pulse located?
Behind the knee in the popliteal fossa, midline
Assess circulation in the lower extremeties and to auscultaate leg BP
Where is the dorsalis pedis pulse located?
Lateral and parallel with the extensor tendon of the great toe
Assess circulation in the feet
Where is the posterior tibial pulse located?
Behind the medial malleoulus
Assess circulation in the feet
How do you assess pulse?
Use the pads of your index and middle fingers
Press the artery against the underlying bone and muscle till you feel pulsation
How do you do calculation for regular pulse rhythm?
Count the beats for 30 seconds and multiply by 2
How do you calculate for irregular rhythm?
Auscultate the apical pulse for 1 min and assess for pulse deficit
How do you assess the apical pulse?
Place the diaphgram of a stethescope at the left fifth intercostal sspace, medial to the midclavicular line, and ausculatate for 1 full min
What is tachypnea?
Rapid, persistent respiratory rate over 20 breaths/min
What is bradypnea?
Persistent respiratory rate under 12 breaths/min
What is dyspnea?
Difficult breathing
What is hypernea?
Deeper and more rapid respiration
What is apnea?
Absence of spontaneous respiration for more than 10 secs
What is hyperventilation?
Deep, rapid respiration
May result frim anxiety, or metabolic acidosis
What is hypoventilation?
Shallow, slow respiration
What are the accessory muscless?
Sternomastoid
Rectus abdominis
Internal intercostals
What is oxygen saturation?
Percent to whicch hemoglobin is saturated with oxygen - meaured with pulse oximetry
What can affect pulse oximetry?
Nail polish - earlobe or bridge of nose maybe considrered as an alternative
What is the approximate measurement for pulse oximetry?
92% to 100%
What is blood pressure?
Measurement of the force exerted by the flow of blood against the arterial walls
When is the maximum pressure exerted?
Contraction of the left ventricle at the begininning of systole
Aka systolic pressure
When does the lowest pressure occur?
Occurs when the left ventricle relaxes between beats
What is the standard unit of measurin blood pressure?
Millimetres of mercury (mm Hg)
How is Blood pressure recorded?
Recorded as a fraction
Numerator = systolic blood pressure - ussually less than 140 mm Hg
Denominator = diastolic blood pressure - usually less than 90 mm Hg
What are factors contributing to blood pressure?
Cardiac output - BP increases during exercise
Peripheral vascular resistance - circulatory disorders increase BP
Circulating blood volume - increase in volume increases BP
Viscocity - thicker blood will increase pressure in blood vessels
Elasticity of vessel walls - increase in stiffness increases BP
How is blood pressure measured?
Using sphygmomanometer & stethescope
What is the measurement of the width of the cuff?
⅔ of the lenght of the upper arm, 40% of the circumference of the upper arm, or more than 20% of the diameter of the upper arm
What should the patient do before taking blood pressure?
Be sure the patient is calm and relaxed and has not smoked, exercised for 30 mins prior to measurement - allow patient to rest for at least 5 mins before assesing
How shoudl he arm be supported when taking BP?
Patient maybe supine or sitting
Support the bare arm aat heart level with palm upward, supported on a table, feet flat on the floor and the back supported
Legs should not be crossed
How do you estimate the systolic blood pressure (SBP)?
Palpate the brachial artery above the antecubital fossa and medial to the bicep tendon
Centre the deflated cuff ~2.5 cm above the antecubittal crease
Line up the arrow on the cuff with the brachial artery
Estimate the SBP by palpating the radial rteyr and inflating the cuff until the pulsation dissapears
Squeeze the bulb to pump air into the bladder
Continue feeling the pulse, and identify when it disappears
Pump the cuff to 30 mmHG above where the pulse stopped
Slowly open the valve by turning it toward you to deflate the cuff
Feel fo the pulse - noting the number when the pulsation is palpable again - then quickly deflate the cuff completely =gives you the estimated SBP
How do you find the korotkoff sounds?
Wait 15-30 seconds before reinflating the cuff to allow trapped blood in the veins to dissipate
Position the earpieces of the stethoscope in your ears - place the diaphragm or bell of the stethoscope over the brachial artery
You will ot heat he tapping of the pulse until the cuff is inflated - inflating the BP cuff alters the flow of blood through artery which generates korotkoff sounds
Quickly inflate the cuff to 30 mmHg aboe the estimated SBP
Then deflate cuff slowly~2mm Hg while listening for pulse sounds (korotkoff sounds)
The korotkoff (I)coincides with the patient’s SBP
Korotkoff (IV) is the last pulse sound
Korotkoff (V) is when the pulse dissappears - used to define the DBP
What is auscultatory gap?
Period in which there are no Korotkofff sounds during auscultation - estimating the SBP will prevent missing this gap
The gap occurs between the first and second korotkoff sounds
What is the pulse pressure?
The difference between the SBP and the DBP = reflects the stroke volume
Usually ~40 mmHG
What is the mean arterial pressure?
Calculated by adding ⅓ of the SBP and ⅔ of the DBP
Usually around 60 mmHG needed for tissue perfusion
what is a sign?
measurable and objective (perceived by the observer)
what is the purpose of evaluation?
make judgement about the patient’s progress, analyze the effectiveness of nursing care - monitor the quality of care
what are the 6 dimensions of critical thinking dimensions?
- knowledge
- comprehension
- application
- analysis
- sysnthesis
- evaluation
what is symptoms?
subjective (percieved by the patient)
what are 3 types of health assessments?
- Urgent assessment
- comprehensive assessment
- focused assessment
what is the purpose of urgent assessment?
performed in a life -threatening or unstable situation
what is the mnemoninc used to determine the acuity of level of urgent care required?
A = airway
B = breathing
C = circulation
D = disability
E = exposure
what is the comprehensive assessment include?
complete health history and phsycal examination - includes the patient’s perception of health, methods of coping and support systems
what does the complete physical examination include?
all body systems and regions - usually in head to toe format
what does focused assessment include?
only involves one, two or more body systems or narrower scope pf comprehensive assessment
a general survey - with selected vital signs
what is priority setting?
the most important of issues in a list of issues
what is the guideline in priotizing?
first adress the life-threatening issues - tend C A B formula
what is the frequency of health assessment?
it varies with the patients needs, the purpose of data collection, and healthcare setting
what does cultarally competent care include?
knowledge, attitudes and skills that support nurses to care for or work with people across different cultures and languages
what is cultural safety?
degree of assimilation into the dominant culture an the extent to which one identifies with the ethnic community - considering dress, food, religion, symptoms
who is the primary source in subjective data collection?
the patient
what is subjective data?
pateint’s experiences and perceptions - feelings, sensations
what is the objective data?
measurable - assess vital signs, examine the skin, listen to heart, lungs
how is subjective and objective data analyzed?
S = subjective
O = objective
A = analysis
P = Plan
E = evaluation
what are the 3 major organizing frameworks for health assessment?
- functional health patterns - sexuality and reproductive, nutrition and elimination
- head to toe system - head and neck, eyes and ears
- body systems - nuerological, respiratory, cardiovascular
