unit 2 learning objectives Flashcards
Review the assessment and normal values of temperature, pulse, and respiration across the lifespan.
Newborn
temp 97-100
pulse 120-160
respiration 30-60
teen
temp 97-100
pulse 60-100
respiration 12-20
adult
temp 97-100
pulse 60-100
respiration 12-20
Determine the cuff size and location most appropriate for the measurement of blood pressure, in the client, based on age and illness variables.
The bladder of width of 40% , length of 80% of arm circumference
use brachial artery
some illnesses like CVD might cause fluid buildup, and using bp cuff could cause fluid to build up and cause damage
Explain the procedure to the client.
Educate patient about risks for hypertension. People with family history of hypertension, premature heart disease, lipidemia, or renal disease are at significant risk
prevention of hypertension includes lifestyle modifications (e.g., lose weight, exercise daily, reduce sodium and saturated fat intake
Define the terms systolic and diastolic.
systolic blood pressure, measures the pressure in your arteries when your heart beats.
The second number, called diastolic blood pressure, measures the pressure in your arteries when your heart rests between beats.
Utilize the American Heart Association standards when determining blood pressure.
normal <120 and <80
elevated 120-129 and <80
HBP stg1 130-139 or 80-89
HBP stg 2- 140 + or 90+
Crisis 180+ and/or 120+
Describe factors that cause variations in vital signs.
temp;
Age Circadian rhythms Exercise Hormones Stress Environment Illness/ infection
pulse
age exercise stress illness temp medications fluid volume position sympathetic stimulation
respiation
age exercise acid-base balance nuerolpcal injury altitude chronic rest disease anemia anxiety medication pain/illness
blood pressure
age exercise stress ethnicity gender medications weight cicadianrythmm smoking position
Define hypertension and describe the procedure for referral.
high blood pressure 140/90+
Report immediately to health care provider any irregularities in heart function and indications of impaired arterial blood flow.
- Report to health care provider changes in peripheral circulation, which may indicate circulatory compromise, which may result in permanent nerve damage or tissue death if untreated.
- Refer patient (if appropriate) to resources available for controlling or reducing risks (e.g., nutrition counseling, exercise class, and stress-reduction programs).
Perform a pain assessment appropriate for the client’s developmental stage.
pain assessments are done on a 1-10 scale, and are subjective data said by the patient
Identify anatomical landmarks used to assess the cardiovascular system.
Angle of Louis- below sternal notch
Aortic-right of sternum
Pulmonic left of sternum
Erb-move down on sternum
Tricuspid-near sternal border
mitral-near nipple-moving lateral from tricuspid
Describe how to locate the PMI (Point of Maximum Impulse).
Locate PMI by palpating with fingertips along the fifth ICS in midclavicular line (see illustration). Note light, brief pulsation in area 1 to 2 cm (1⁄2–1 inch) in diameter at the apex.
Usually right under nipple
Assess apical and peripheral pulses for rate, rhythm, and amplitude.
apical-short, gentle tap
short,nomrally only first half of systole
peripheral-ones like on wrist-should be 60-100 and medium amplitude(1-3)
Auscultate and differentiate between heart sound variations (S1, S2, S3, S4 murmurs and rubs).
s1-lub
s2-dub
s3-abnomral -lub dub ee
s4-abnormal see lub dub
murmur-blowing/swooshing sound-extra heartbeat graded from 1-6 on loudness
Differentiate absence or presence of peripheral edema and documentation.
edema is when fluid stays in spot on body
1-mild pitting-slight indentation no swelling
2-moderate pitting-indent sub used rapidly
3 deep pitting- indent remains for short time-leg swollen
4- very deep pitting-indent last for a very long tome
Distinguish between normal and abnormal cardiovascular assessment data and documentation.
cap refill
nail clubbing
hair
edema
apical pulse
Jvd
color
chest vibrations
peripheral pulse grading
Compare and contrast how age may affect the assessment of the cardiovascular system.
Pediatric / Infants
◦ Circumoral cyanosis
◦ Transient acrocyanosis
◦ Murmurs may be normal (innocent/functional murmurs)
◦ HR – Infants (100-180) after birth, then (120-140)
◦ PDA (patent ductus arteriosus closes after 2-3 days)
- Geriatric
◦ Foot/leg edema
◦ Peripheral vascular - Pregnant women
- Leg edema
- More blood volume
Identify anatomical landmarks to be used when auscultating breath sounds.
1 2
4 3
5 6
8 7
9 10
1 starts on top of lungs
slowly go in snake line down to bottom
Differentiate between vesicular, bronchovesicular, and bronchial breath sounds.
V- low nd soft
BV– moderate
B– High, loud
Describe adventitious breath sounds and the terms used to describe each.
Crackles-cracking noises-heard in short, medium or coarse
Rhonchi-loud low pitched continuous sound, like blowing air through fluid w/straw
Wheeze-high pitched musical sounds
Determine how quality of cough, skin color, oxygen saturations, and respiratory rate all contribute to data collection for respiratory assessment.
all of those determine how well you are getting air into body
if low air quality in, cough is weak, skin turns blue, oxygen saturation is low and repository rate is higher
Distinguish between normal and abnormal data during chest and respiratory assessment.
skin color
skin, nails
mucous membranes
nasal flaring
ribs
tripod positioning
pigeon chest
funnel chst
barrel chest
Compare and contrast how age may affect the assessment of the respiratory assessment.
Pediatric
* Rounded chest
* Breath more with
diaphragm
* RR may be
irregular (infant)
- Elderly
- Fatigue easier
- Spine shape
Define the terms “hypoxia and hypoxemia” and describe how to assess the client for the need for oxygen therapy.
Hypoxemia- a decrease in the partial pressure of oxygen in the blood
hypoxia is defined by reduced level of tissue oxygenation.
use pulse oximetry- gets oxygen levels in blood
Compare and contrast oxygen delivery systems across the lifespan, including safety aspects, and indicate when/how each would be used.
Nasal cannula-Oxygen tank connected to pronged into nares–Used because easy and inexpensive
non-rebreather–mask attached to a simple bag–used to deliver high levels of oxygen
simple-Fits over mouth and nose-with side on face that allows expiration - used in moderate situations
rebreather-similar to nonrebreather mask, but no one way valves so patients exhaled air mixes w/inhaled air
Venturi-used for patents who need specific amount % of air with COPD
face tent-provides controlled concentration of oxygen and increase moisture
Indicate procedures to maintain mucous membrane and skin integrity during oxygen administration.
Assessing the patient’s external ears, nares, and nasal mucosa for breakdown at least once per shift.
Frequent assessment is a priority and will help the nurse identify early signs of skin breakdown
Describe other actions/techniques (C&DB, peak flow meter, IS, percussion, positioning) to improve oxygenation and when they would be utilized in client care.
Explain what a pulse oximeter measures, the normal results, and how results are used to monitor oxygen therapy.
the saturation of oxygen carried in your red blood cells.
95-100
is used to determine how much/what type of oxygen therapy is needed
Identify factors that can interfere with the accuracy of a pulse oximeter.
poor circulation,
skin pigmentation,
skin thickness,
skin temperature,
current tobacco use,
and use of fingernail polish.
Describe assessment data that would indicate the client is receiving adequate oxygenation.
pulse oximetry is 95-100
skin is normal color
no edema
cap refil
Identify anatomical landmarks and techniques used to assess the abdomen.
LUQ
Stomach
spleen
LLQ
large intestines
RUQ
liver
gall bladder
RLQ
intestines
appendix
Differentiate between normal and abnormal abdominal assessment data (including bowel sounds) and document.
Character, frequency
* Normal
* Active in all 4 quadrants
*
Abnormal
* Hyperactive
* Hypoactive
* No bowel sound
Compare and contrast how age-related variations may affect assessment of the abdomen.
Pediatric (Jarvis-p 176)
* Inspection: shape of abdomen; umbilical cord
* History
* Jaundice
* Pain
* Fussiness
* Intense crying
* Projectile vomiting
* Variations:
Geriatric (Jarvis-p178)
* Inspection: contour
* Auscultation:
* Check for decreased peristalsis
* Check aorta for possible bruit
