Unit 1 Flashcards

1
Q

how can we assess circulation?

A

Pulse and blood pressure

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2
Q

How can we assess respiratory system?

A

Respiratory rate and oxygen

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3
Q

How can we assess the endocrine system?

A

Temperature

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4
Q

How can we assess nervous system?

A

Respiratory rate

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5
Q

What are the 6 vital signs?

A

Pulse, respiratory rate, temperature, oxygen, blood pressure, pain

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6
Q

What is the average temp range?

A

36c to 38 c
96.8-100.4 F

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7
Q

Where are the 6 sites where we can take body temperature?

A

Oral
Tympanic
Rectal
Skin
Temporal artery
Axillary

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8
Q

Inspiration and expiration
Which one is active process and passive process?

A

Inspiration- active process
Expiration-passive process

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9
Q

What are the three processes and how do they relate to the respiratory system?

A

Ventilation-breathing
Diffusion- exchange of CO2 and O2 to the alveoli
Perfusion-exchange of O2 to red blood cells

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10
Q

What is the normal breaths per minute - adults

A

12-20 breaths per minute

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11
Q

What factors could influence Respiration?

A

Medication, anxiety, activity, medical condition (CPOD), smoking

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12
Q

What is the normal bpm?

A

60-100 for adult

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13
Q

What number is systolic, and what is diastole

A

Systole- peak 120
Diastole- minimal 80

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14
Q

What is the normal range for systolic and diastolic?

A

Systolic (90-119)
Diastolic (60-79)

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15
Q

What is considered orthostatic hypotension?

A

Systolic drops by 20 or more

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16
Q

When shouldn’t we take a BP on an arm?

A

Port, mastectomy, fistula, edema

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17
Q

How is pulse, RR, and BP differ than adults?

A

Pulse and RR is higher in infants and children
BP is lower in infants and children

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18
Q

How often should we monitor a patient?

A

Frequency of monitoring is dependent on patient condition

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19
Q

T/F chronic pain is pain that has been constant for a year

A

False
Chronic pain is 3-6 or more months

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20
Q

What is idiopathic pain?

A

Pain of an unknown cause

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21
Q

Is pain a normal part of aging?

A

No! While chronic pain is more prevalent in older adults, it is not a normal part of aging.

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22
Q

What does PQRST stand for in pain assessment?

A

P-precipitating (what makes your pain worse or better)
Q-quality of pain (Can you describe your pain)
R- region and radiation (where is the pain)
S- severity (What is your pain 0-10)
T-(Does it come and go)

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23
Q

Before you treat a child in pain you need to know…?

A

Pain history
Developmental age
Cultural background
Child’s temperament
Parent’s response to child’s pain

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24
Q

What are some pain scales?

A

Wong-Baker faces pain rating scale
0-10 numeric pain intensity scale
Verbal pain intensity scale
Visual analogue scale

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25
How do we assess neonatal pain. What scale?
NPASS neonatal pain agitation and sedation scale Irritable or crying, consolable—— high pitched cry, inconsolable Restless sleep——constantly awake Intermittent pain expression——- continual pain expression Intermittent clenched fists, body is not tense——-continual clenched fists, body is tense
26
What are the 3 analgesic groups?
Nonopioid Opioid Adjuvant
27
What are three examples of nonopioid analgesics
Acetaminophen Non selective NSAIDs(ibuprofen, naproxen) COX-2 selective NSAIDs (celecoxib)
28
What are 4 opioid analgesics
Morphine, Fentanyl, hydromorphone, oxycodone
29
What are 3 adjuvant analgesics
Local anesthetics—lidocaine Anticonvulsants—gabapentin Antidepressants—-desipramine
30
What are three nonpharmacological interventions for patient with pain?
Positioning —proper body alignment, pillows, etc Thermal measures—— heat and cold therapies Mind-body therapies—prayer, deep breathing, meditation, relaxation, pet therapy
31
What are the factors influencing patient safety
Patient’s developmental level Mobility, sensory, cognitive status Medical and physical status Lifestyle choices Knowledge and understanding Environment
32
What entails a workplace culture?
Individual Environmental Organizational
33
What are the levels of errors?
Adverse effect-unanticipated event Near miss- catching a mistake before it being serious Sentinel event- unexpected occurrence involving death
34
What do nurses bring to the table?
Knowledge Skills Attitudes Critical thinking
35
What are the types of errors?
Diagnostic errors Treatment errors Preventative errors Communication failure
36
What are three areas to prevent patient falls?
Fall risk screening Universal Fall precautions Patient-specific Interventions
37
What are the 4 requirements for restraints?
1. Only use when absolutely necessary for safety 2. Try alternatives first if possible 3. Require provider order 4. Always use the least restrictive available
38
How frequent does the nurse need to assess a violent patient and a non violent patient?
Every 15 minutes for violent patient Every 2 hours for nonviolent patient
39
What 5 of the potential complications of restraints?
Pressure injuries Pneumonia Constipation Incontinence Loss of self esteem Humiliation Agitation
40
How would a patient describe “normal Pain”, somatic pain, and neuropathic pain
Normal pain- aching, cramping Somatic pain- Sharp pain in localized area Neuropathic pain -burning, neuropathy, shooting
41
What is general adaption syndrome?
GAS desxriples the physiological changes a body endures in response to stress. -Alarm is the fight or flight, cardiovascular and sympathetic NS takes over, immune system is suppressed -Resistance is where the mechanisms of the body are implemented -exhaustion is where the body breaks down the mechanisms and causes wear and tear on the organs
42
What are the short term and long erm effects of general adaption syndrome?
Short term- since the immune system is suppressed, the body is more susceptible to illness. Long term- wear and tear on the organs, chronic hypertension, stroke, depressions, heart disease.
43
When is it appropriate to get vital signs ?
• On admission to a health care agency • When assessing a patient during home care visits • In a clinic setting before a health care provider examines the patient and after any invasive procedures • In a hospital on a routine schedule according to the health care provider’s order • Before, during, and after a surgical procedure or invasive diagnostic/treatment procedure • Before, during, and after a transfusion of any type of blood product • Before, during, and after the administration of medication or therapies • Before, during, and after nursing interventions influencing a vital sign • When a patient reports nonspecific symptoms of physical distress (e.g., feeling “funny” or “different”) • When a patient’s general physical condition changes
44
What are examples of situational, maturational, and sociocultural factors of stress and coping?
Situational- getting divorced, losing a job, illness Maturational- peer pressure, transition to adulthood, facing retirement Sociocultural factors—economy, discrimination, community support
45
What are the 5 patient centered assessment a nurse needs to ask about safety to the patient?
1) a patient’s own perceptions of risk factors, (2) a patient’s values and beliefs about safety, (3) a patient’s concerns about being in a health care setting, (4) a patient’s knowledge of how to adapt to safety risks, and (5) information about a patient’s previous experience with accidents. Consult with family caregivers when appropriate.
46
If an infectious disease can be transmitted directly from one person to another, it is a: 1. Susceptible host 2. Communicable disease 3. Port of entry to a host 4. Port of exit from the reservoir
Communicable disease If it transmitted from person to person, it doesn’t need a reservoir
47
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. 1. Illness stage 2. Convalescence 3. Prodromal stage 4. Incubation period
Prodromal stage The prodromal stage is the interval between entrance of a pathogen into the body and appearance of first symptoms.
48
What factors cause variation in vital signs?
Age, physical activity, stress, body position, medications, hormones, infections, endocrine disorders
49
How is clinical judgement is essential when assessing and analyzing vital signs?
Contextual understanding: -patient history—medical history, medications, symptoms -clinical presentation-appearance, mood, affect, general survey Pattern recognition -trends—viral signs over time, can indicate worsening or improving conditions -comparison—current vs baseline status
50
What is the difference between average temperature of rectal and axillary compared to average temperature range (36-38C)?
Average rectal—37.5 Axillary—36.5 Oral—37
51
What is the normal SpO2?
95%
52
What is the average pulse pressure (not BP)
30 to 50mm Hg
53
What does Fatigue do to pain coping skills?
Heightens perception of pain and decreases coping skills
54
What are the nurse guidelines for administering analgesics?
1.) know the patients previous response to analgesics 2.) select proper medication when more than one is ordered 3.) know accurate dosage 4.) access right time and interval for admission
55
Identify barriers to effect pain management.
Patient barriers -fear, anxiety, communication barriers, suffering in silence Healthcare provider barriers -inadequate pain assessment skills, no pain management protocols, not believing patients time constraints Healthcare system barriers -concerns with addicts, mail-order pharmacy restrictions, poor pain policies, inadequate access to pain clinics
56
What main scales are used on infants
CRIES- Crying, RR O2, Increased vitals, Expression on face, Sleep NPASS— neonatal pain agitation sedative and sleep FLACC— faces, legs, activity, crying, consolability 0-12months
57
What ages do we use the Wong-baker face scale and oucher pain scale
3-5 years Adolescents are also used
58
Compare and contrast the use of pharmacological and nonpharmacological pain management
Pharmacological—directs target pain, often rapid, potential for side effects effective for acute pain Non Pharmacological—alters perception of pain, may take time to develop, fewer side effects, effective for chronic pain
59
What are some examples of intrinsic and extrinsic factors?
Intrinsic factors: behavior, altered cognition, altered mobility, sensory deficit, medications, toileting issues. Extrinsic factors: communication issues, education issues, physical hazards, competency
60
An infection occurs in a cycle that depends on the presence of what elements? And what would be an act to break that chain of infection
-agent or pathogen: hand hygiene -reservoir/source: proper food storage -a port of exit: wearing a mask/covering coughs -mode of transmission: PPE -port of entry:skin integrity/functioning immune system -susceptible host: maintaining healthy/nutrition
61
What is a systemic infection?
An infection that affects the entire body instead of use a single organ
62
What is the body system’s natural defenses?
Skin-barrier, shedding of cells Mouth- saliva(enzymes) Eyes-tears and blinking Respiratory- cilia and mucus Urinary-flushing action of urine flow GI-acidic, rapid peristalsis
63
What are the events in the inflammatory response?
Vascular and cellular response- injury causes chemical mediators to increase permeability of small cells Inflammatory exudate—accumulation of fluid, dead cells, and WBCs-clear through lymphatic drainage Tissue repair—damaged cells eventually are replaced with new healthy cells, which gradually mature
64
What are condition that promote the transmission of healthcare-associated infections?
Multi drug resistant organisms Unsterile technique Open drainage systems Failure to clean properly Poor aseptic technique Contamination
65
How does stress in the workplace affect nurses?
Compassion fatigue Second victim syndrome Burnout
66
How does stress in the workplace affect nurses?
Compassion fatigue Second victim syndrome Burnout