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101 LEC > TEST 2 > Flashcards

TEST 2 Flashcards

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1
Q

What do we check when taking vital signs?

A

Temp
Pulse
Respiration
BP
Pain
Oxygen saturation

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2
Q

What is the normal range for temp?

A

35.9-38 C
96.7-100.5 F

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3
Q

What is the normal range for pulse?

A

60-100bpm

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4
Q

What is the normal range for respirations?

A

12-20 breathes per min

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5
Q

What is the avg bp?

A

120-80 mmHg

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6
Q

What is the pulse pressure?

A

30-50 mmHg difference between systolic and diastolic

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7
Q

What is the bodys primary source of heat?

A

Metabolism

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8
Q

What is basal metabolic rate?

A

Occurs at rest, heat is still being produced

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9
Q

What are the factors affecting temp?

A

-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

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10
Q

What is hyperthermia
What is hypothermia

A

hyperthermia -elevated temp
hypothermia - lower temp

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11
Q

What is pyrexia (febrile)
What is afebrile?

A

pyrexia (febrile) - fever
afebrile - no fever

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12
Q

What are the sites we can assess temp?

A

Oral - glass for contact precaution
Axillary
Tympanic
Rectal
Forhead - temporal

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13
Q

What is cardiac output?

A

Volume of blood pumped by heart each minute

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14
Q

How do we calculate the cardiac output?

A

SV X Heart rate = CO

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15
Q

What is the min blood volume available before heart speeds up contractions to make up for it?

A

4-6 liters

Increased volume = heart rate slower
Decreased volume = heart rate faster

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16
Q

What is the pulse rate?

A

number of beats felt in 1 min

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17
Q

What are the numbers for bradycardia and tachycardia?

A

Bradycardia - >60
Tachycardia - <100

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18
Q

What are the sites to check for a pulse?

A

Temporal
Carotid - Emergecy
Apical - 4-5 intercostal space and mid left calvicular
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

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19
Q

What 3 scenarios do you need to check the apical pulse

A

Giving cardiac meds, abnormal heart rythum, history of cardiac issue

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20
Q

Diaphragm pick up what frequency sounds?
Bell picks up?

A

Diaphragm - high frequencey
Bell - low

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21
Q

Characteristics of pulse
Rhythm
Force/strength

A

Rhythm - regular or irregular
(dysrhythmia/arrhythmia)

Force - 0 - no pulse
1+ barely/weak
2+ normal
3+ bounding

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22
Q

What part of the brain controls our respirations?

A

Medulla oblongata - sensitive to opioids

*Regulated by levels of carbon dioxide, oxygen & hydrogen Ion concentration in the blood

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23
Q

What does
Bradypnea
Tachypnea
Apnea
Dyspnea

A

Bradypnea - slow breathing
Tachypnea - fast breathing
Apnea –no breathing
Dyspnea - difficulity breathing

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24
Q

What does the oxygen saturation measure?

A

% of hemoglobin bound to oxygen in arteries

**how saturated your hemoglobin is with oxygen

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25
Q

What is COPD?

A

Lacking in o2 molecules/ normal is lower 80-90’s

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26
Q

What can result in abnormal results for oxygen saturation?

A

Anemia -lacking in hempglobin
Nail polish
Impeding blood flow while taking BP

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27
Q

What does the BP meausre?

A

amount of force by blood against walls of artery

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28
Q

What does systolic and diastolic pressure measure?

A

Systolic - period of heart muscle contraction
Diastolic - period of heart muscle relaxation

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29
Q

What are the risks for hypertension

A

Family history
Obesity
Smoking
heavy alcohol
High sodium
Sedentary lifestyle
stress
diabetes
Elderly african amerian
high cholestrol

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30
Q

WHat are the metrics for stage 2 hypertension?

A

Systolic => 140
Diastolic => 90

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31
Q

What are the ranges in normal that determines orthostatic hypotension?

A

Systolic decrease >20mm HG when changing positions

Diastolic decreased > 10 mm Hg when changing positions

HR increase 10% when changing positions

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32
Q

What are the risk factors for orthostatic hypotension?

A

Volume depletion
Dehydration
anemia
prolonged bedrest
anti-hypertensive meds

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33
Q

What is transduction?

A

Nociceptors stimulated and release chemicals

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34
Q

What is transmission?

A

Pain impulses travel from peripheral nerve fibers

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35
Q

What is perception?

A

Brain interprets pain

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36
Q

WHat is modulation?

A

Inhibition of pain impulse by neuromodular compounds

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37
Q

What is nociceptive pain?

A

Normal due to injury

38
Q

WHat is

Cutaneous
Somatic
Visceral pain?

A

Cutaneous - superficial, paper cut, laceration
Somatic - deep tissue, muscle bone
Visceral - internal organs

39
Q

What is neuropathic pain?

A

Abnormal/ no obvious injury

*diabetic neuropathy

40
Q

What is idiopathic pain?

A

No idea whats causing it

41
Q

What is PQRSTU

A

Provactive?
Quality
Region
Severity
Timing
Understand; any other symptoms

42
Q

What are non-pharmacological pain relief options?

A

Relaxation, distraction, excerise, biofeedback, cutaneous stimulation

43
Q

What is the clincal judgement model?

A

Recognize Cues
Analyze cues
Prioritize hypotheses
Generate solutions
Take action
evalute outcomes

44
Q

What is a
Initial assessment
Focused assessment
Time lapsed assessment

A

Initial assessment - 1st & thorough
Focused assessment - 1 area, complaint
Time lapsed assessment - pain level assessemnt, wound assess, follow up

45
Q

What is the physical assessment technique?

A

I- Inspection - look at area
P - Palpation - touch
P - Percussion - tapping
A - Auscultation - listen with stetho

46
Q

How is the abdominal IPPA different?

A

I - inspect
A - Auscultation
P - Percusion
P - palpate *last to not create false sounds or pain

47
Q

What is the proper format to write a nursing diagnosis?

A

Diagnosis label, related to, AEB

48
Q

What are the 3 types of nursing diagnosis?

A

Actual
Risk
Readiness for enchanced (health promotion/wellness)

49
Q

How to develop an outcome statement?

A

Specific - patient will
Measureable - #’s details
Attainable
Realistic
Time-bound - when to accomplish goal

50
Q

For breast assessment what do you do first?

A

Ask subjective data
1. Pain
2. Lumps? Discharge? Swelling?
3. Surgery? Trauma/injury
4. History of disease?
5. Do you practice self-checking?

51
Q

When you inspect the breasts what are you looking for?

A

Symmetry - (left will be slightly bigger)
Color/lesions
Peau d orange
Venous networks - both breasts
Dimpling, retracting

52
Q

Where are most cancerous tumors found in the breast

A

Tail of spence

53
Q

What do you write when demonstrating breast masses?

A

Location - quad & cm from the nipple
Size - length & width, cm
Tenderness - discomfort
Mobility - fixed or movable
Retraction - which quad

54
Q

The frontal lobe is associated with?

A

Personality & behavior
Emotions & intellectual function
Motor cortex - voluntary movement

*brocas area - Motor speech area

55
Q

What is expressive aphasia?

A

Cannot talk or talk clearly

56
Q

What is the parietal lobe responsible for?

A

Process data from -touch, sight, smell, hearing, taste

*Proprioception

57
Q

What is proprioception?

A

Body positioning, awareness of body parts w/out looking

58
Q

What is the occipital lobe responsible for?

A

Vision center

59
Q

What is the temporal lobe responsible for?

A

Auditory reception center

60
Q

What is receptive aphasia

A

Cant understand what people are saying or writing

61
Q

What is the cerebellum responsible for?

A

Coordinates movement, equilibrium, muscle tone, balance and posture

62
Q

What is the first thing you ask on a neurological assessment?

A

Subjective data
Past history
Headache & injury
Dizziness, Seizure, Tremors, weakness
Loss of coordination, numbness
difficultly swallowing

63
Q

What are the 5 parts of the neurological assessment after subjective?

A
  1. Mental status
  2. Cranial nerves
  3. Proprioception & cerebellar function
  4. Sensory function
  5. Reflexes
64
Q

how do you assess mental status?

A

-Awake & alert?
-Orientated to person, place and time?
-Clear speech

65
Q

What number on the glasgow coma scale is a coma?

A

7 or >

66
Q

How do you test the olfactory nerve?

A

Patient close eyes
Close one nostril & present a smell to see if they can identify it
-do same on other nostril

67
Q

How do you test cranial nerve 2 - optic nerve?

A

Cover one eye and move your finger to test peripheral
50, 90 and 70 degrees

68
Q

How do you test cranial nerves 3,4,5

A

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

69
Q

How do you do a corneal light reflex

A

Shine a light in center of head and see the reflection in both eyes

70
Q

How do you test the cranial nerve 5 motor function?

A

Palpate temporal & masseter muscles as person clenches teeth and try to separate jaw by pushing down on chin

71
Q

How do you test cranial nerve 5 sensory function?

A

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

72
Q

How do you test the cranial nerve 7?

A

Have patient
Smile
Frown
Close eyes tightly
lift eye brows
show teeth
Puff cheeks
*check for mobility & symmetry

73
Q

How do you test the cranial nerve 8?

A

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

74
Q

How to test cranial nerve IX and X

A

Depress tounge, have patient say ahhhh
Note pharyngeal movement
-Uvula & soft palate should rise in midline
-Tonsillar pillars should move medially

75
Q

How to test cranial nerve 11?

A

Examine sternomastoid & trapezius muscles for equal size
-patient rotate head against resistance
-Patient shrug shoulders against resistence

76
Q

How to assess cranial nerve 12?

A

Patient stick out tounge, inspect tongue for tremors
Ask patient to say “light tight and dynamite”

77
Q

How to test balance?

A

Have patient walk 10-20 ft, turn and return
Have patient walk heel-to-toe
Romberg test- feet together & hold for 20 sec

78
Q

What is the romberg test?

A

Have patient start with feet together and arms at sides for 20 secs with eyes closed

79
Q

How do you test for coordination and killed movements?

A
  1. rapid alternating movements
  2. Alternating fingers
  3. Finger to finger
  4. Finger to nose
  5. Heel to shin
80
Q

How to test the sensory system?

A

Eyes closed
-Test symmetry
-Sharp/dull
-Light touch
-Vibration
-Kinesthesia
-Stereognosis - id object w/ eyes closed
-Graphesthesia - id what was written on hand

81
Q

How do you test the plantar reflex?

A

With reflex hammer light stroke up lateral side of sole
_flexion - abnormal
-inversion - normal

82
Q

How to test bicep reflex?

A

Support patients forarm, place your thumb on bicep tendon and strike a blow

83
Q

How to test triceps?

A

hold patients arm as it goes limp, strike triceps tendon
-Normal = extensions of forearm/elbow

84
Q

How to test brachioradialis reflex?

A

Hold patients thumb to suspend forarm
Strike forearm
-normal = flexion and supination

85
Q

How to test quadriceps reflex?

A

Strike tendon directly below patella
Normal = extension

86
Q

How to test achilles reflex?

A

Hold foot and strike achille tendon
-normal = flex

87
Q

What are the disorders of CNS?

A

Seizure
Cerebrovascular accident
abnormal positioning

88
Q

What are the 2 abnormal positioning?

A

decorticate rigidity - cerebral cortex
decerebrate rigidity - brainstem damage

89
Q

What is the abnormal positioning with arms at chest

A

Decorticate

90
Q

What is the abnormal positioning with arms at sides?

A

Decerebrate

91
Q

What are the disorders of the PNS?

A

Trigeminal Neuralgia
Bells palsy
Peripherl neuropathy

101 LEC (15 decks)

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