Unit 1 Flashcards
how can we assess circulation?
Pulse and blood pressure
How can we assess respiratory system?
Respiratory rate and oxygen
How can we assess the endocrine system?
Temperature
How can we assess nervous system?
Respiratory rate
What are the 6 vital signs?
Pulse, respiratory rate, temperature, oxygen, blood pressure, pain
What is the average temp range?
36c to 38 c
96.8-100.4 F
Where are the 6 sites where we can take body temperature?
Oral
Tympanic
Rectal
Skin
Temporal artery
Axillary
Inspiration and expiration
Which one is active process and passive process?
Inspiration- active process
Expiration-passive process
What are the three processes and how do they relate to the respiratory system?
Ventilation-breathing
Diffusion- exchange of CO2 and O2 to the alveoli
Perfusion-exchange of O2 to red blood cells
What is the normal breaths per minute - adults
12-20 breaths per minute
What factors could influence Respiration?
Medication, anxiety, activity, medical condition (CPOD), smoking
What is the normal bpm?
60-100 for adult
What number is systolic, and what is diastole
Systole- peak 120
Diastole- minimal 80
What is the normal range for systolic and diastolic?
Systolic (90-119)
Diastolic (60-79)
What is considered orthostatic hypotension?
Systolic drops by 20 or more
When shouldn’t we take a BP on an arm?
Port, mastectomy, fistula, edema
How is pulse, RR, and BP differ than adults?
Pulse and RR is higher in infants and children
BP is lower in infants and children
How often should we monitor a patient?
Frequency of monitoring is dependent on patient condition
T/F chronic pain is pain that has been constant for a year
False
Chronic pain is 3-6 or more months
What is idiopathic pain?
Pain of an unknown cause
Is pain a normal part of aging?
No! While chronic pain is more prevalent in older adults, it is not a normal part of aging.
What does PQRST stand for in pain assessment?
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)
Before you treat a child in pain you need to know…?
Pain history
Developmental age
Cultural background
Child’s temperament
Parent’s response to child’s pain
What are some pain scales?
Wong-Baker faces pain rating scale
0-10 numeric pain intensity scale
Verbal pain intensity scale
Visual analogue scale
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
What are the 3 analgesic groups?
Nonopioid
Opioid
Adjuvant
What are three examples of nonopioid analgesics
Acetaminophen
Non selective NSAIDs(ibuprofen, naproxen)
COX-2 selective NSAIDs (celecoxib)
What are 4 opioid analgesics
Morphine, Fentanyl, hydromorphone, oxycodone
What are 3 adjuvant analgesics
Local anesthetics—lidocaine
Anticonvulsants—gabapentin
Antidepressants—-desipramine
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
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
What entails a workplace culture?
Individual
Environmental
Organizational
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
What do nurses bring to the table?
Knowledge
Skills
Attitudes
Critical thinking
What are the types of errors?
Diagnostic errors
Treatment errors
Preventative errors
Communication failure
What are three areas to prevent patient falls?
Fall risk screening
Universal Fall precautions
Patient-specific Interventions
What are the 4 requirements for restraints?
- Only use when absolutely necessary for safety
- Try alternatives first if possible
- Require provider order
- Always use the least restrictive available
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
What 5 of the potential complications of restraints?
Pressure injuries
Pneumonia
Constipation
Incontinence
Loss of self esteem
Humiliation
Agitation
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
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
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.
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
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
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.
If an infectious disease can be transmitted directly from one person to another, it is a:
- Susceptible host
- Communicable disease
- Port of entry to a host
- Port of exit from the reservoir
Communicable disease
If it transmitted from person to person, it doesn’t need a reservoir
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection.
- Illness stage
- Convalescence
- Prodromal stage
- Incubation period
Prodromal stage
The prodromal stage is the interval between entrance of a pathogen into the body and appearance of first symptoms.
What factors cause variation in vital signs?
Age, physical activity, stress, body position, medications, hormones, infections, endocrine disorders
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
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
What is the normal SpO2?
95%
What is the average pulse pressure (not BP)
30 to 50mm Hg
What does Fatigue do to pain coping skills?
Heightens perception of pain and decreases coping skills
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
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
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
What ages do we use the Wong-baker face scale and oucher pain scale
3-5 years
Adolescents are also used
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
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
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
What is a systemic infection?
An infection that affects the entire body instead of use a single organ
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
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
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
How does stress in the workplace affect nurses?
Compassion fatigue
Second victim syndrome
Burnout
How does stress in the workplace affect nurses?
Compassion fatigue
Second victim syndrome
Burnout
