TEST 2 Flashcards
What do we check when taking vital signs?
Temp
Pulse
Respiration
BP
Pain
Oxygen saturation
What is the normal range for temp?
35.9-38 C
96.7-100.5 F
What is the normal range for pulse?
60-100bpm
What is the normal range for respirations?
12-20 breathes per min
What is the avg bp?
120-80 mmHg
What is the pulse pressure?
30-50 mmHg difference between systolic and diastolic
What is the bodys primary source of heat?
Metabolism
What is basal metabolic rate?
Occurs at rest, heat is still being produced
What are the factors affecting temp?
-Elderly - lose muscle & fat
-Males - higher temp due to hormones
-Circadian rythm - temp 1-2 lower in AM & peak in afternoon/early evening
Environmental temps
What is hyperthermia
What is hypothermia
hyperthermia -elevated temp
hypothermia - lower temp
What is pyrexia (febrile)
What is afebrile?
pyrexia (febrile) - fever
afebrile - no fever
What are the sites we can assess temp?
Oral - glass for contact precaution
Axillary
Tympanic
Rectal
Forhead - temporal
What is cardiac output?
Volume of blood pumped by heart each minute
How do we calculate the cardiac output?
SV X Heart rate = CO
What is the min blood volume available before heart speeds up contractions to make up for it?
4-6 liters
Increased volume = heart rate slower
Decreased volume = heart rate faster
What is the pulse rate?
number of beats felt in 1 min
What are the numbers for bradycardia and tachycardia?
Bradycardia - >60
Tachycardia - <100
What are the sites to check for a pulse?
Temporal
Carotid - Emergecy
Apical - 4-5 intercostal space and mid left calvicular
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
What 3 scenarios do you need to check the apical pulse
Giving cardiac meds, abnormal heart rythum, history of cardiac issue
Diaphragm pick up what frequency sounds?
Bell picks up?
Diaphragm - high frequencey
Bell - low
Characteristics of pulse
Rhythm
Force/strength
Rhythm - regular or irregular
(dysrhythmia/arrhythmia)
Force - 0 - no pulse
1+ barely/weak
2+ normal
3+ bounding
What part of the brain controls our respirations?
Medulla oblongata - sensitive to opioids
*Regulated by levels of carbon dioxide, oxygen & hydrogen Ion concentration in the blood
What does
Bradypnea
Tachypnea
Apnea
Dyspnea
Bradypnea - slow breathing
Tachypnea - fast breathing
Apnea –no breathing
Dyspnea - difficulity breathing
What does the oxygen saturation measure?
% of hemoglobin bound to oxygen in arteries
**how saturated your hemoglobin is with oxygen
What is COPD?
Lacking in o2 molecules/ normal is lower 80-90’s
What can result in abnormal results for oxygen saturation?
Anemia -lacking in hempglobin
Nail polish
Impeding blood flow while taking BP
What does the BP meausre?
amount of force by blood against walls of artery
What does systolic and diastolic pressure measure?
Systolic - period of heart muscle contraction
Diastolic - period of heart muscle relaxation
What are the risks for hypertension
Family history
Obesity
Smoking
heavy alcohol
High sodium
Sedentary lifestyle
stress
diabetes
Elderly african amerian
high cholestrol
WHat are the metrics for stage 2 hypertension?
Systolic => 140
Diastolic => 90
What are the ranges in normal that determines orthostatic hypotension?
Systolic decrease >20mm HG when changing positions
Diastolic decreased > 10 mm Hg when changing positions
HR increase 10% when changing positions
What are the risk factors for orthostatic hypotension?
Volume depletion
Dehydration
anemia
prolonged bedrest
anti-hypertensive meds
What is transduction?
Nociceptors stimulated and release chemicals
What is transmission?
Pain impulses travel from peripheral nerve fibers
What is perception?
Brain interprets pain
WHat is modulation?
Inhibition of pain impulse by neuromodular compounds
What is nociceptive pain?
Normal due to injury
WHat is
Cutaneous
Somatic
Visceral pain?
Cutaneous - superficial, paper cut, laceration
Somatic - deep tissue, muscle bone
Visceral - internal organs
What is neuropathic pain?
Abnormal/ no obvious injury
*diabetic neuropathy
What is idiopathic pain?
No idea whats causing it
What is PQRSTU
Provactive?
Quality
Region
Severity
Timing
Understand; any other symptoms
What are non-pharmacological pain relief options?
Relaxation, distraction, excerise, biofeedback, cutaneous stimulation
What is the clincal judgement model?
Recognize Cues
Analyze cues
Prioritize hypotheses
Generate solutions
Take action
evalute outcomes
What is a
Initial assessment
Focused assessment
Time lapsed assessment
Initial assessment - 1st & thorough
Focused assessment - 1 area, complaint
Time lapsed assessment - pain level assessemnt, wound assess, follow up
What is the physical assessment technique?
I- Inspection - look at area
P - Palpation - touch
P - Percussion - tapping
A - Auscultation - listen with stetho
How is the abdominal IPPA different?
I - inspect
A - Auscultation
P - Percusion
P - palpate *last to not create false sounds or pain
What is the proper format to write a nursing diagnosis?
Diagnosis label, related to, AEB
What are the 3 types of nursing diagnosis?
Actual
Risk
Readiness for enchanced (health promotion/wellness)
How to develop an outcome statement?
Specific - patient will
Measureable - #’s details
Attainable
Realistic
Time-bound - when to accomplish goal
For breast assessment what do you do first?
Ask subjective data
1. Pain
2. Lumps? Discharge? Swelling?
3. Surgery? Trauma/injury
4. History of disease?
5. Do you practice self-checking?
When you inspect the breasts what are you looking for?
Symmetry - (left will be slightly bigger)
Color/lesions
Peau d orange
Venous networks - both breasts
Dimpling, retracting
Where are most cancerous tumors found in the breast
Tail of spence
What do you write when demonstrating breast masses?
Location - quad & cm from the nipple
Size - length & width, cm
Tenderness - discomfort
Mobility - fixed or movable
Retraction - which quad
The frontal lobe is associated with?
Personality & behavior
Emotions & intellectual function
Motor cortex - voluntary movement
*brocas area - Motor speech area
What is expressive aphasia?
Cannot talk or talk clearly
What is the parietal lobe responsible for?
Process data from -touch, sight, smell, hearing, taste
*Proprioception
What is proprioception?
Body positioning, awareness of body parts w/out looking
What is the occipital lobe responsible for?
Vision center
What is the temporal lobe responsible for?
Auditory reception center
What is receptive aphasia
Cant understand what people are saying or writing
What is the cerebellum responsible for?
Coordinates movement, equilibrium, muscle tone, balance and posture
What is the first thing you ask on a neurological assessment?
Subjective data
Past history
Headache & injury
Dizziness, Seizure, Tremors, weakness
Loss of coordination, numbness
difficultly swallowing
What are the 5 parts of the neurological assessment after subjective?
- Mental status
- Cranial nerves
- Proprioception & cerebellar function
- Sensory function
- Reflexes
how do you assess mental status?
-Awake & alert?
-Orientated to person, place and time?
-Clear speech
What number on the glasgow coma scale is a coma?
7 or >
How do you test the olfactory nerve?
Patient close eyes
Close one nostril & present a smell to see if they can identify it
-do same on other nostril
How do you test cranial nerve 2 - optic nerve?
Cover one eye and move your finger to test peripheral
50, 90 and 70 degrees
How do you test cranial nerves 3,4,5
PERRLA - find pupils and watch as you shine a light
*pupils equal round reactive to light and accommodation
-Accommodation - hold an object and bring it closer to patient
How do you do a corneal light reflex
Shine a light in center of head and see the reflection in both eyes
How do you test the cranial nerve 5 motor function?
Palpate temporal & masseter muscles as person clenches teeth and try to separate jaw by pushing down on chin
How do you test cranial nerve 5 sensory function?
Have patient close eyes & get a cotton ball and test all 3 areas of nerve
Ophthalmic, Maxillary, Mandibular
Tell patient to tell you “now” when they feel it
How do you test the cranial nerve 7?
Have patient
Smile
Frown
Close eyes tightly
lift eye brows
show teeth
Puff cheeks
*check for mobility & symmetry
How do you test the cranial nerve 8?
Test hearing in 1 ear at a time, shield your lips
Stand 1-2feet from patients ear and wispher 2 syllable words: Armchair, baseball
Have patient repeat word
How to test cranial nerve IX and X
Depress tounge, have patient say ahhhh
Note pharyngeal movement
-Uvula & soft palate should rise in midline
-Tonsillar pillars should move medially
How to test cranial nerve 11?
Examine sternomastoid & trapezius muscles for equal size
-patient rotate head against resistance
-Patient shrug shoulders against resistence
How to assess cranial nerve 12?
Patient stick out tounge, inspect tongue for tremors
Ask patient to say “light tight and dynamite”
How to test balance?
Have patient walk 10-20 ft, turn and return
Have patient walk heel-to-toe
Romberg test- feet together & hold for 20 sec
What is the romberg test?
Have patient start with feet together and arms at sides for 20 secs with eyes closed
How do you test for coordination and killed movements?
- rapid alternating movements
- Alternating fingers
- Finger to finger
- Finger to nose
- Heel to shin
How to test the sensory system?
Eyes closed
-Test symmetry
-Sharp/dull
-Light touch
-Vibration
-Kinesthesia
-Stereognosis - id object w/ eyes closed
-Graphesthesia - id what was written on hand
How do you test the plantar reflex?
With reflex hammer light stroke up lateral side of sole
_flexion - abnormal
-inversion - normal
How to test bicep reflex?
Support patients forarm, place your thumb on bicep tendon and strike a blow
How to test triceps?
hold patients arm as it goes limp, strike triceps tendon
-Normal = extensions of forearm/elbow
How to test brachioradialis reflex?
Hold patients thumb to suspend forarm
Strike forearm
-normal = flexion and supination
How to test quadriceps reflex?
Strike tendon directly below patella
Normal = extension
How to test achilles reflex?
Hold foot and strike achille tendon
-normal = flex
What are the disorders of CNS?
Seizure
Cerebrovascular accident
abnormal positioning
What are the 2 abnormal positioning?
decorticate rigidity - cerebral cortex
decerebrate rigidity - brainstem damage
What is the abnormal positioning with arms at chest
Decorticate
What is the abnormal positioning with arms at sides?
Decerebrate
What are the disorders of the PNS?
Trigeminal Neuralgia
Bells palsy
Peripherl neuropathy
