Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

321 assessment of clients > Test 1 > Flashcards

Test 1 Flashcards

1
Q

Two components of health assessment

A

Health history ( interviewing)
Physical assessment ( hands on)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Type of health assessments

A

Comprehensive, ongoing partial, focused, emergency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Comprehensive assessment

A

Obtained on admission to the health care facility
- get info, write everything down, ask questions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Ongoing partial assessment

A

Obtained at regular intervals
- After admission, assess in morning and at a time interval later (ex: every 4 hours)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Focused assessment

A

Assess a specific problem
- ex: cardiac, respiratory, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Emergency assessment

A

Assess life- threatening or unstable conditions
- in need of immediate attention, ex: gun shot wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Subjective data

A

Anything the patient tells you that you cannot directly observe
- ex: symptoms, feeling, preferences, ideas, values, personal info

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Interviewing

A
  • requires professional, interpersonal, interviewing skills
  • 2 focuses: establishing rapport and trusting relationship and gathering info
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

types of info gathered during interview

A

Developmental, psychological, physiologic, sociocultural, spiritual status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Phases of interview

A

Pre-introductory, introductory, working and summary/closing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Pre-introductory phase

A

-review medical records
- reveals information to help assess current needs
- reveals special considerations
- guide nurse in obtaining necessary info

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Introductory phase

A
  • introduce self
  • ask them name and DOB
  • tell types of questions you will ask
  • explain why taking notes, sitting and looking at computer
  • confidential
  • make sure comfortable and private
  • develop trust and rapport
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Working phase

A
  • biographical data (life, kids, married, gender)
  • reason for seeking care (chief complaint)
    History of present concern
  • past history
  • fam history
  • review of body systems (ROS) ask pain head to toe
    -lifestyle and health practices and dev level
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Summary and closing phase

A
  • summarize info obtained during working phase
  • validate problems and goals
  • ask if any other concerns or questions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Objective data

A

Data directly observed during interaction with the client
- info elicited through physical exam techniques

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Collecting objective data (basic knowledge)

A
  • types of operation of equipment needed
  • preparing self and client for exam
  • properly performing techniques
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Performance techniques

A

Inspection
Palpation
Percussion
Auscultation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Non-verbal communication

A

Presentable appearance
Demeanor
Facial expression
Attitude
Listening
AVOID:
Excessive/insufficient eye contact
Distraction and distance
Standing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Verbal communication

A

Open-ended questions
Close ended questions
Validating
Clarifying
Reflective
Sequencing
Directing
AVOID:
Biased or leading questions
Rushing through the interview
Reading off questions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Considerations during interview

A

Gerontologic variation: age (older adults hearing and sight)
Cultural variation
Emotional variation: depressed, anxious, etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Analysis Pain

A

COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated factors
PQRST
Provocative
Quality
Radiates
Severity
Timing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Supine position

A

Laying on back
- for skin and abdomen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Standing position

A

For neuro assessments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Sitting position

A

Heart and lung exams

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Sims position

A

Laying on left side with right leg bent
- rectum and uterus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Dorsal recumbent position

A

Laying on back knees up arms up
-vaginal, pelvic, childbirth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Knee-chest position

A

On knees pull chest to knees
- OBGYN (reposition fetus), some surgeries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Prone position

A

Laying flat on stomach
-acute respiratory distress syndrome (ARDS), surgery,infants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Lithotomy

A

On back with legs in stirrups
- OBGYN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Physical assessment inspection

A
  • vision, smell, hearing
  • comfortable temp
  • lighting
  • look/observe before touching
  • expose part being examined not rest
    -compare symmetric parts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Physical assessment palpation

A

Light (palms of fingers) or deep (hands)
Feeling for:
Texture
Temp
Moisture
Mobility
Consistency
Strength of pulses
Size
Shape
Tenderness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Palpation finger pads

A

Pulse, texture, size, consistency, shape, crepitus (rice crispy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Palpation ulnar or palmar surface

A

Vibrations
Shrills/thrills
Fremitus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Palpation dorsal surface

A

Temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Physical assessment Percussion

A

DO NOT USE ON CARDIAC
Seeing if they are having pain, masses, reflexes
Assessments:
Eliciting pain
Determine loco, size and shape
Determine density
Detecting abnormal masses
Eliciting reflexes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Types of percussion

A

Direct
Blunt: one hand down and hit with other
Indirect or mediate: hand to chest hit fingers with 2 other fingers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Sounds elicited by percussion

A

Resonance (respiratory)
Hyperresonance
Tympany (stomach)
Dullness
Flatness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Physical assessment auscultation

A

Requires stethoscope
Classify sounds:
- intensity
- pitch
- duration
- quality
Diaphragm for high pitch bell for low pitch

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Vital signs

A

A measure of the body’s most basic functions
- Temp, Pulse, respirations, blood pressure, sometimes pain, sometimes oxygen sat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

When do assess vital signs

A
  • on admission
  • before invasive procedures (baseline)
  • after procedures (came back to baseline)
  • before some meds
  • activities after surgery (first time standing after hip replacement)
  • LOC lose/level of consciousness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Normal oral temp

A

35.8-37.5 Celsius or 96.4-99.5 F

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Normal pulse

A

60-100 bpm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Normal respiration rate

A

12-20 breaths/min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Normal blood pressure

A

120/80 or less

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Temperature

A

Reflects the balance between heat the body produces and heat lost from the body to the environment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Core temperature sites

A

Rectum, tympanic membrane, temporal artery, pulmonary artery, esophagus and urinary bladder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Surface temperature sites

A

Oral, axillary, temporal, tympanic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Primary source of metabolism

A

Heat production

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

What increases metabolism

A

Hormones, muscle movements, exercise

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What is released when additional heat is required

A

Epinephrine and norepinephrine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Conduction

A

Transfer of heat from the body directly to another surface

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Convection

A

Dispersion of heat by air currents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Evaporation

A

Dispersion of heat through water vapor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Radiation

A

Transfer of heat from one object to another without contact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Diaphoresis

A

Visible perspiration on the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Normal rectal temp

A

97.4-100.5 F or 36.6-38.1 C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Normal axillary temp

A

95.6-98.5 F or 35.4-36.9 C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Normal temporal temp

A

98.7-100.5 F or 36.3-38.1 C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Normal tympanic temp

A

98.2-100.9 F or 36.8-38.3 C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Age and temperature

A
  • Newborns have a larger surface to mass ratio so they loose heat rapidly to environment making it higher
  • older clients could have more adapose (fat) making it higher
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Hormonal changes and temp

A
  • ovulation and menses
  • menopause
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Exercise/activity and dehydration and temp

A

On tribute to hyperthermia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Illness and injury and temp

A
  • can cause elevations
  • fever
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Food/fluid and smoking and temp

A

Can change the accuracy of oral temp wait 15-30

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Circadian rhythms, stress, envi and temp

A

Can effect temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Hypothermia

A

Below 95 F (35 C)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Hyperthermia

A

Above 104 F (40 C)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Contraindications of Oral temp taking

A
  • under age of 6
  • confused/comatose
  • on oxygen
  • trauma to mouth or favce
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Contraindications of rectal temp taking

A
  • constipation/diarrhea
  • heart conditions (VEGAS NERVE)
  • less than 3 months old
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

How to take rectal temp

A
  • lay in left lateral sims position
  • 1 1/2 inch for adults
  • no more than 1 inch for children
  • 1/2 inch for infants
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

Contraindications of axillary temp taking

A
  • sweating
  • operator not knowing correct way
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

Contraindications of tympanic temp taking

A
  • operator
  • drainage
  • ear infection
  • scars
  • tubes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Contraindications of temporal temp taking

A
  • operator
  • anything covering head
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Afebrile

A

Without fever

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Pyrexia

A

With fever (febrile)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Autonomic nervous system

A

Controls heart rate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

Parasympathetic nervous system

A

Lowers the heart rate
(Rest and digest)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

Sympathetic nervous system

A

Raises heart rate
(Fight or flight)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

Pulse

A

Measure of heart rate and rhythm
- bounding of blood flowing through various points in the circulatory system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Tachycardia

A

Greater than 100 bpm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

Bradycardia

A

Lower than 60 bmp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

Strength scale of pulse

A

0 - absent
1 - diminished, weaker than expected
2 - brisk, expected
3- bounding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

Dysrhythmia

A

An irregular heart rhythm, generally with an irregular radial pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

Pulse deficit

A

The difference between the apical rate and the radial rate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

Regular pulse outside of adults

A

Newborn: 95-170
Infant: 85-170
Toddler: 70-150
Children: 65-130
Adolescent: 60-115

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

Peripheral pulses

A

Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

Ventilation

A

The exchange of oxygen and co2 in the lungs through inspiration and expiration
- measure through rate, rhythm and depth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

Diffusion

A

The exchange of oxygen and co2 between the alveoli and the RBC
- measure with pulse oximetry

89
Q

Perfusion

A

The flow of RBCs to and from the pulmonary capillaries
- measure with pulse oximetry

90
Q

Rate of respiration

A

The number of full inspiration and expiration in 1 minute

91
Q

Depth of respiration

A

The amount of chest wall expansion that occurs with each breath (shallow or deep)

92
Q

Rhythm of respiration

A

The observation of breathing intervals
Expect regular with an occasional sign (adults)

93
Q

Normal respiration with age

A

Newborn: 30-60
Infant: 30-50
Toddler: 20-40
Child: 15-25
Adolescent: 12-20

94
Q

Diaphragmatic breathers

A

Breathing with diaphragm and abdomen
Abdominal movements are more pronounced
Males and children

95
Q

Thoracic breathers

A

Chest breathing
Chest movements are more pronounced
Women

96
Q

Considerations of respirations

A

Pain, anxiety, smoking, body position, medications, neurological injury, illness

97
Q

Bradypnea

A

Regular breathing with a rate less than 12/min

98
Q

Hypoventilation

A

Shallow breathing pattern with an abnormally low rate

99
Q

Apnea

A

Periods where there is no breathing
Ongoing spells can lead to respiratory arrest

100
Q

Tachypnea

A

Regular breathing pattern with a rather higher than 20/min

101
Q

Hyperventilation

A

Deep breathing pattern with an increases, leads to decreased levels of CO2 and hyperoxygenation

102
Q

Hyperpnea

A

Rate, depth and work of breathing increases
Common during exercise

103
Q

Cheyenne-strokes respiration

A

Irregular rate and depth of respiration that follow a cyclical pattern (shallow to normal, increased rate to slowing again) ending with an apnea period

104
Q

Kussmaul respiration

A

Increased respiratory rate, regular pattern but excessively deep

105
Q

Normal pulse oximetry range

A

90-100

106
Q

Pulse oximetry

A

Measures oxygen saturation of the blood (the percent of hemoglobin that is bound with oxygen in the arteries is the precent of saturation of hemoglobin)

107
Q

Blood pressure

A

Reflects the force of the blood exerts against the walls of the arteries during cardiac muscle contractions (systole) and relaxation (diastole)

108
Q

Systolic BP

A

The peak pressure in the artery at the end of the cardiac cycle while the ventricles are contracting

109
Q

Diastolic BP

A

During ventricular diastole, when the ventricles relax and exert minimal pressure against arterial walls
Represents the minimum amount of pressure exerted on the arteries

110
Q

Principal determinants of BP

A

Cardiac output and systemic (peripheral) vascular resistance
BP = CO X SVR

111
Q

Determinants of cardiac output

A

the amount of blood pumped by the heart in one minute

Heart rate
Contractility
Blood volume
Venous return
And increase in any increase CO and BP and vis versa

112
Q

Systemic vascular resistance SVR

A

The amount of constriction or dilation of the arteries and diameter of blood vessels
Increase SVR increase BP and vis versa

113
Q

Elevated BP

A

120-129 SBP and less than 80 DBP

114
Q

Stage 1 hypertension

A

130-139 SBP and 80-89 DBP

115
Q

Stage 2 hypertension

A

Greater than or equal to 140 SBP and greater than or equal to 90 DBP

116
Q

Orthostatic hypotension

A
  • results from an inadequate physiologic response to postion change
  • causes by dehydration, blood loss, neuro, cardiovascular, or endocrine problems,
117
Q

Hypotension

A

< 90/60 mmHg
- result of disease
- side effect of meds
- inability of body to maintain or return pressure to normal

118
Q

Pulse pressure

A

Difference between systolic and diastolic B

119
Q

Considerations while taking blood pressure

A

Age, circadian rhythms, stress, exercise, ethnicity, obesity, family history, sex, meds

120
Q

Infectious agent

A

Bacteria, fungi viruses

121
Q

Reservoir

A

Natural habitat of the organism

122
Q

Portal of exit

A

Point of escape for the organism

123
Q

Means of transmission

A

Direct contact, indirect contact, airborne route

124
Q

Portal of entry

A

Point at which organism enters a new host

125
Q

Susceptible host

A

Must overcome resistance mounted by host’s defenses

126
Q

Bacteria

A

Most significant and prevalent infectious agent in hospital settings
- treat with antibiotics

127
Q

Virus

A

Smallest of all microorganisms
- treat with antivirals

128
Q

Fungi

A

Plant-like organisms present in air soil and water
- athletes food and parasites

129
Q

Classifications of bacteria

A
  • shape: spherical (cocci), rod (bacilli), corkscrew (spirochetes)
  • gram pos or neg
  • aerobic or anaerobic
130
Q

Factors affecting potential to produce disease

A
  • number of organisms
  • virulence
  • competence of persons immune system
  • length and intimacy of contact
131
Q

Possible reservoirs

A

Other people
Animals
Soil
Food,water, milf
Inanimate objects

132
Q

Common portals of exit

A
  • respiratory
  • gastrointestinal
  • genitourinary tracts
  • breaks in skin
  • blood and tissue
133
Q

Incubation period

A

Organism growing and multiplying

134
Q

Prodromal stage

A

Person is most infectious, vague and nonspecific signs

135
Q

Full stage of illness

A

Presence of specific signs and symptoms

136
Q

Convalescent period

A

Recovery from the infection

137
Q

Factors affecting host susceptibility

A

Intact skin and mucus membrane
Normal pH
WBC
Age, sex, race, hereditary
Immunization
Fatigue, climate, nutritional and general heath
Stress
Invasive or indwelling medical devices

138
Q

Cardinal signs of acute infection

A

Redness
Heat
Swelling
Pain
Loss of function

139
Q

Lab data indicating infection

A
  • elevated WBC count (norm: 5,000-10,000)
  • increase in specific WBC
  • elevated erythrocyte sedimentation rate
  • presence of pathogens in urine, blood, sputum or draining cultures
140
Q

Five moments for hand hygiene

A
  • before touching a patient
  • before a clean or aseptic procedure
  • after a body fluid exposure risk
  • after touch a patient
  • after touching patients surroundings
141
Q

Transient bacterial floral

A

Attached loosely on skin, removable with relative ease

142
Q

Resident bacterial flora

A

Found in creases in skin, require friction with brush to remove

143
Q

4 categories of HAIs

A
  • catheter- associates urinary tract infection CAUTI
  • surgical site infection SSI
  • central-line associated bloodstream infection CLABSI
  • ventilator associated pneumonia VAP
144
Q

Risk factors for vancomycin- resistant enterococci VRE

A
  • compromised immune system
  • recent surgery
  • invasive devices
  • prolonged antibiotic use
  • prolonged hospitalization
145
Q

Body’s defenses against infection

A
  • body’s normal flora
  • inflammatory response
  • immune response
146
Q

Factors determining use of sterilization and disinfection methods

A
  • nature of organism present
  • number of organisms present
  • type of equipment
  • intended use of equipment
  • available means
  • time
147
Q

Personal protection equipment PPE

A

Gloves gowns masks and protective eyewear

148
Q

Standard precautions

A
  • used in care of all hospitalized patients
  • apply to blood, body fluids, secretions and excretions (not sweat), nonintact skin, mucous membranes
149
Q

Transmission based precautions

A
  • in addition to standard for patients with suspected infections with pathogens that can be transmitted by airborne, droplets or contact routes
  • use PPE whenever entering room
150
Q

Aseptic technique

A

Includes all activities to prevent or break the chain of infection
Medical asepsis: clean technique
Surgical asepsis: sterile technique

151
Q

Factors effecting safety

A

Developmental considerations
Lifestyle
Social behavior
Environment
Mobility
Sensory perception
Knowledge
Ability to communicate
Physical/psych health state

152
Q

Focus of safety assessments

A
  • the person
  • the environment
  • specific risk factors ( everyone’s different)
153
Q

Safety history

A
  • history of falls or accidents
  • assistive devices
  • history of drug or alcohol abuse
  • family support systems and home envi
154
Q

Safety physical exams

A
  • mobility status
  • ability to communicate
  • level of awareness
  • sensory perception
  • identify potential hazards
  • domestic violence or neglect?
155
Q

Factors that contribute to falls

A
  • lower body weakness
  • poor vision
  • balance issues
  • feet and shoe problems
  • psychoactive meds
  • postural dizziness
  • home hazards
156
Q

Risk factor assessments

A

Falls
Fires
Poisoning
Suffocation and choking
Firearm injuries

157
Q

Safety devices to prevent falls

A
  • Guard rails in beds ( are a unless asked for so cannot be up without dr order and must be renewed every 24 hrs and checked every hour)
  • breaks on beds
  • sticky socks
158
Q

RACE

A

R- rescue anyone in immediate danger
A - active the fire code and notify appropriate person
C - confine the fir by closing doors and windows
E - evacuate patients and others to safe area

159
Q

Safety event reports

A
  • must be completed after any accident or incident
  • describe the circumstances
  • details of patients response
  • completed y nurse immediately after
  • not part of medical record and should not be mentioned in documentation
160
Q

Physical hazards associated with restraints

A
  • Increased poss for serious injury due to fall
  • skin breakdown
  • contractures (weakened muscles and stiffness)
  • incontinence (hard to get to BR)
  • depression
    -delirious
  • anxiety
    Aspiration
  • death
161
Q

Factors influencing mobility

A
  • developmental considerations
  • physical/mental health
    -lifestyle
  • attitude/values
  • fatigue/stress
  • external factors
162
Q

Physical assessment for mobility

A
  • general ease of movement and gait
  • alignment
  • joint structure and function
  • muscle mass, tone, strength
  • endurance
163
Q

Fowler position

A

semi sitting position
30 degrees 90 degrees
High Fowler: eating

164
Q

Protective supine position

A

Lying on back

165
Q

Protective side-lying or lateral position

A

On the side

166
Q

protective sims position

A

Left side right leg bent up arms behind back

167
Q

Protective prone position

A

Laying on stomach

168
Q

Lathotomy position

A

Feet in stirrups (OBGYN)

169
Q

Pericardium

A

Outermost later of the heart

170
Q

Epicardium

A

Thin outermost layer of the heart

170
Q

Myocardium

A

Thick muscular middle layer of the heart

170
Q

Endocardium

A

The innermost layer of the heart

170
Q

Upper chambers of the heart

A

Right and left atria at the base of the heart
- thin walled, reservoirs for returning blood from the veins

170
Q

Lower chambers of the heart

A

Right and left ventricle at the apex of the heart
- thick walled and pumps the blood to the lungs and throughout the body

170
Q

Cardiac septum

A

Blood tight partition that divides the left and right heart

170
Q

Atrioventricular valves

A

Tricuspid (right) Mitral (left)

171
Q

Semilunar valves

A

Between ventricles and great vessel, organ system
regulate blood flow between the ventricals and arteries
- pulmonic: between the right ventricle and the pulmonary artery
- aortic: between the left ventricle and the aorta

172
Q

Arteries

A

Carries oxygenated blood from the heart to the body
Carries blood AWAY from heart

173
Q

Veins

A

Carry deoxygenated blood TOWARDS the heart

174
Q

Pulmonary circulation

A

Right heart pumps deoxygenated blood to the lungs

175
Q

Systematic circulation

A

Left heart pumps oxygenated blood to rest of the body

176
Q

Path through heart

A

Inferior and superior Vena cava - right atrium - tricuspid valve - right ventricle - pulmonary valve - pulmonary artery - lungs - left atrium - mitral valve - left ventricle - aorta - rest of body

177
Q

Two phase cardiac cycle

A

Ensures proper circulation by heart contracting and relaxing rhythmically

178
Q

Systole

A

Ventricles contract causing blood to eject from the left ventricle into the aorta and from the right ventricle into the pulmonary artery
APEX “lub”

179
Q

What closes/opens during systole

A

Mitral and tricuspid valves close
Aortic and pulmonic valves open (bloods ejected into arteries

180
Q

Diastole

A

Ventricles dilate ( energy required effort) drawing blood into them as the atria contract, moving blood from the atria to the ventricles
BASE “dub”

181
Q

What opens/closes during diastole

A

Mitral and tricuspid valves open
Aortic valve is closed
Atria contacts as ventricle almost filled

182
Q

First heart sound

A

Mitral and tricuspid valves closing

183
Q

Second heart sound

A

Aortic and pulmonic valves closing

184
Q

Third heart sound

A

Blood moves from atria to ventricles

185
Q

Fourth heart sound

A

Complete emptying of atria

186
Q

Electrical conduction of the heart

A

Sinoatrial node (SA node) Pacemaker
Atrioventricular node (AV node)
Bundle of His
Purkinje fibers

187
Q

Cardiovascular health history complaints

A

Pain (leg arm or chest)
Dyspnea (SOB)
Palpitations (pounding)
Dizziness
Medications
Edema
Nocturnal (sleep schedule)

188
Q

Pallor

A

unusual lightness of skin
Look for in inspection phase (cardiac)

189
Q

Cyanosis

A

Blueness of skin
Look for in inspection (cardiac)

190
Q

Inspection for Cardiac exam

A

Neck vessels, pain, discomfort, cough, fatigue, SOB

191
Q

Positions of cardiac exam

A

Sitting, supine (on back with head to 30-45 angle), left lateral recumbent

192
Q

Auscultation areas for heart

A

Aortic, pulmonic, erbs point, tricuspid, mitral

193
Q

Murmurs

A

Turbulent blood flow with a swooshing or blowing sound

194
Q

Conditions contributing to murmurs

A
  • increased blood velocity
  • structural valve defects
  • valve malfunction
  • abnormal chamber openings
195
Q

Neck vessels

A

Carotid artery and jugular veins
- carotid artery pulse: ventricular systole

196
Q

Electrocardiogram

A

Cardiac evalution

197
Q

Electrolyte lab values

A

Cardiac evaluation
Usually look for K bc associated with heart

198
Q

Troponin

A

Cardiac eval
- protein found in heart (if elevated signifies a problem)

199
Q

CBC

A

Cardiac eval (complete blood count)
WBC increase infection
Someone low in hemoglobin or RBC or anemic will have hard time breathing

200
Q

Cholesterol levels

A

Cardio eval
Cause blockage in heart

201
Q

Heart catheterization

A

Heart eval
Can see arteries and veins and possible blockages

202
Q

Myocardial infarction

A

(MI) occlusion of arterial blood flow causing tissue damage

203
Q

Congestive Heart Failure

A

(CHF) congestion in pulmonary and or systemic circulation related to inadequate pumping

204
Q

Thrombus

A

Blood clot

205
Q

Fluid volume defect (hypovolemia)

A

Isotonic fluid loss
Fluid becomes hypertonic drawing fluid from cells in interstitial space leaving them depleted ad unable to function
Causes BP to decrease HR to increase

206
Q

Fluid volume excess (hypervolemia)

A

Excess of isotonic fluid
Kidney malfunction and infective heart pumping may cause, results in the accumulation of fluids in lungs and dependent parts of body
Causes BP increase HR increase and cough, SOB, fluid in lungs

207
Q

Signs of bad vascularity

A

Pallor
cold
wounds not healing
Lack of hair on lower extremities

208
Q

Neuropathic

A

Numbness and tingling

209
Q

Varicosities

A

Enlarged veins, alter flow

210
Q

Identifying varicosities

A

Circulation (capillary refill on toes greater or less than 3 sec) mobility (wiggle toes) sensation (identify toe you are touching without looking)

211
Q

Where to use compression

A

Venous ulcers NOT arterial

212
Q

Edema

A

Pitting vs non pitting
Pressing with finger to see if limb “bounces back”

213
Q
A

321 assessment of clients (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions