Unit 2 Exam Flashcards
How is body temp regulated?
Hypothalamus acts as thermostat and controls body temp by feedback mechanism
Nursing interventions to reduce fever
Encourage large fluid intake
lower room temp
increase air circulation w/ fan
remove bed covers/clothing items
control/reduce body activity
Pyrexia
Fever, above 100.2 F
Normal temp
97.5-99.5 F
Stroke volume
Volume of blood pushed into aorta with each heartbeat (affects character of pulse, weak pulse may indicate fall in stroke volume)
Normal pulse range
60-100 bpm
Tachycardia
Over 100 bpm
Bradycardia
< 60 bpm
Arrhythmia
Irregular pulse. Has a period of normal rhythm broken by periods of irregularity or skipped beats. Can occur from emotional stress, fright. Continuing arrhythmia may indicate heart disease or medicine side effects.
Pulse 1+
Weak & irregular (even beats with poor force)
Pulse 2+
Strong and regular (even beats with moderate force)
Pulse 3+
Full and bounding (even with strong force)
Irregular pulse
Both strong and weak beats within 1 min
Thready pulse
Weak and may be irregular
Absent pulse
No pulse palpable or heard
Blood Pressure (BP)
Pressure exerted on arterial wall
Systolic pressure
Maximum pressure exerted during left ventricular contraction (working)
Diastolic pressure
Lower pressure exerted on artery when heart is resting between contractions (rest)
Average healthy adult BP
120/80 mm Hg
Pulse pressure
Difference between systolic (120) and diastolic (80) = 40 (e.g.)
Normal BP
<120, <80
Elevated BP
120-129, <80
Stage 1 Hypertension
130-139, or 80-89
Stage 2 Hypertension
140 or higher, or 90 or higher
Hypertensive crisis
Over 180, and/or over 120
Factors that influence BP
Age- BP increases with age. Highest in older adult b/c of decrease in elasticity of vessels.
Stress/emotions- Increases BP by releasing hormones and stimulating SNS, leading to vasoconstriction and increased heart rate. Regular exercise can lower stress levels.
Medications.
Diurnal variation (time of day)- BP low at night with sleep, increases during day with increased activity, peaks mid afternoon.
Sex (gender)- At puberty men tend to have higher BP. Women’s BP increases after menopause.
Exercise- BP increases with activity and exercise as SNS responds to increased need for oxygen.
Body position- lower lying down, higher standing
R vs L arm- 1/4 of population has slight difference between R&L arms. 10 (+-5) mm Hg. 10 mm Hg not significant.
Vasodilation- Increased blood vessel diameter, lower BP may happen to warm temp, fever, relaxation.
Vasoconstriction- Decreased blood vessel diameter, increase BP in cold temp.
Head injury- increased BP and pulse pressure.
Reduced blood volume- Decreased BP
Increased blood volume- Increased BP
ADLs
Activities of daily living
Ascites
Abnormal accumulation of serous fluid within the peritoneal cavity
Bruit
Abnormal sound heard on auscultation; a kind of swishing sound
Cognitive
Relating to the mental process of knowing, remembering, and relating; connected thinking
Cyanosis
A bluish tinge to the skin, nail beds, or mucous membranes, indicating low oxygen
Ecchymosis
Blue or purplish patch on the skin or mucous membrane that is not elevated; bruising
Erythema
Redness of the skin caused by congestion of the capillaries in the lower layers of the skin that occurs with any skin injury, infection, or inflammation
Fissure
A narrow slit
Guaiac
A test for blood in the stool
Gurgles
Low-pitched wheezes. Wet sounds heard when auscultating the lungs; newer term for rhonchi; gurgle sounds also occur in the bowel
Inspection
Visual examination for detection of abnormal signs or qualities
Integument
Skin covering the body
Jaundice
Yellowness of the skin, sclera, mucous membranes, and excretions resulting from hyperbilirubinemia and deposition of bile pigments; icterus
Jugular venous distention (JVD)
Visible protrusion of the jugular veins when the patient is positioned sitting in bed at 15-35 degrees; assessed as a sign of heart failure or over-hydration.
Lethargy
Abnormal drowsiness or stupor
Murmur
Periodic sound of short duration of cardiac or vascular origin
Ophthalmoscope
Lighted instrument used for viewing interior of eye
Orientation
Awareness of ones environment with the reference to person, place, time, and event
Otoscope
Lighted instrument for visualizing tympanic membrane and interior ear canal.
Pallor
Paleness of skin
Papanicolaou (Pap) Smear
Microscopic lab exam used to determine presence of malignant cells from body secretions (respiratory, genitourinary, or digestive tract)
Patent
Freely open (e.g., a patent drain)
Petechiae
Pinpoint, round, purplish red spots that are not raised, caused by intradermal or submucosal hemorrhage; a significant sign for various diseases
Protoscopic examination
Examination of the rectum with a lighted instrument
Pigmentation
Deposition of coloring matter in skin
Rinne test
A test to compare bone and air conduction of sound; performed with a tuning fork
Sanguineous
Bloody
Scar
A mark remaining after healing a wound
Serosanguineous
Composed of serum and blood
Sigmoidoscopy
Examination of the sigmoid colon using a lighted instrument
Sign
Any objective evidence of disease or dysfunction
Sore
Painful lesion of the skin or mucous membrane
Speculum
Short, funnel-like tube for examining canals, such as nasal canal and vaginal canal
Sputum
Mucous secretions of the lungs ejected through the mouth
Symptom
Any indication of disease perceived by the patient; subjective info
Tinnitus
Noise in the ears such as ringing, buzzing, roaring
Tuning fork
Forked metal instrument used to test hearing and sense of vibration
Vertigo
Sensation of rotation or whirling movement; dizziness
Weber test
Test of bone conductions of sound performed with a tuning fork placed in the center of the forehead
Wheeze
A high pitched respiratory sound that often indicated narrowed airways; it is common in patients with asthma
Wound
Bodily injury caused by physical means with disruption of the skin or other structures
Supine Position
Laying face up
Lithotomy position
Stirrups hold the patients feet in an elevated position. (Pelvic examination, female genitalia examination)
Knee-chest position
Facing down, with knees to chest (rectal examination)
Lateral/Sims position
Most often lying on the left side.
Left leg on bottom is straight
Right leg on top is bent
Left arm on bottom rests behind the body with the torso tilted
Right arm on top rests in front, bent at the elbow and shoulder
Important to cushion knee, head and elbow with pillows or padding
Administering enema, pregnancy and childbirth
Prone position
Laying face down
RNS HOPE
Rest and activity
Nutrition, fluids, and electrolytes
Safety and security
Hygiene and grooming
Oxygenation and circulation needs
Psychosocial and learning
Elimination
Basic need assessment
Factors affecting the environment
Temperature- different for older or younger patients, certain patients require special temp conditions
Ventilation- fresh air
Humidity- 30-50% is normally comfortable
Lighting- sunny, cheerful room lifts spirits. Adequate lighting for tasks to prevent injury or accidents
Odor
Noise
Type A fire extinguisher
Water-under-pressure extinguisher used for paper, wood, or cloth fires
Type B fire extinguisher
Contains carbon dioxide and is used for gasoline, oil, paint, fat, and flammable liquid fires
Type C fire extinguisher
Contains carbon dioxide but is used for electrical fires
ABC combination extinguisher
Can be used on any kind of fire
RACE
Rescue any patients in immediate danger by removing them from the area
Activate the fire alarm system
Contain the fire by closing all doors and windows
Extinguish the flames with an appropriate extinguisher or Evacuate
