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Basic Nursing Skills > Unit 3: Chapters 12 & 13 > Flashcards

Unit 3: Chapters 12 & 13 Flashcards

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1
Q

Vital signs

A
  • temperature
  • pulse
  • respirations
  • blood pressure
  • pain
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2
Q

When should you take vital signs?

A
  • admission
  • according to medical orders
  • once per day if pt is stable
  • every 4 hrs when 1 or more vital signs are abnormal
  • every 5 to 15 min when pt is unstable
  • when there is a significant difference from previous measurement
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3
Q

What produces temperature in the body?

A

hypothalamus

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4
Q

Shell temperature

A

warmth at the skin surface

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5
Q

Core temperature

A

warmth at deeper sites within the body (heart, brain)

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6
Q

Factors that affect body temperature

A
  • age
  • gender
  • exercise
  • time of day
  • emotions
  • illness
  • drugs
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7
Q

Normal body temperature

A

96.6 - 99.3 degrees F

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8
Q

Sites for assessing body temp

A
  • temporal artery
  • oral
  • rectal equivalent
  • axillary equivalent
  • tympanic membrane
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9
Q

Different types of thermometers

A
  • electronic
  • infrared
  • infrared temporal artery
  • glass
  • chemical
  • digital
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10
Q

Fever

A

elevated body temperature 99.3

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11
Q

Signs/symptoms associated with elevated temp

A

flushed skin, restlessness, irritability, poor appetite, glassy eyes, increased perspiration, headache, above normal pulse, disorientation, convulsions, fever blisters

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12
Q

Phases of the fever

A
  • prodromal phase
  • onset or invasion phase
  • stationary phase
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13
Q

Prodromal phase

A

nonspecific symptoms just before temp rises

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14
Q

Onset or invasion phase

A

obvious mechanisms for increasing body temp

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15
Q

Stationary phase

A

fever is sustained

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16
Q

Resolution

A

temp returns to normal

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17
Q

Pulse

A

sensation felt as the heart forces blood into the arteries,causing arterial walls to expand and distend

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18
Q

Pulse rate

A

of pulsations palpated in 1 minute

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19
Q

Factors affecting the pulse rate

A
  • age
  • circadian rhythm
  • gender
  • body build
  • exercise
  • stress/ emotions
  • elevated body temp
  • blood volume and components
  • drug
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20
Q

Tachycardia

A

100 to 150 bpm

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21
Q

Palpation

A

awareness of ones own heart contraction

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22
Q

Bradycardia

A

less than 60 bpm

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23
Q

Pulse rhythm

A

pattern of the pulsations and the pauses between them

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24
Q

Arrhythmia or dysrhythmia

A

irregular pattern of heartbeats

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25
Q

Pulse volume

A

quality of palpated pulsations

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26
Q

Apical pulse

A

of ventricular contractions per minute

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27
Q

Landmark for locating the apical pulse

A

apex

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28
Q

Process of taking an apical-radial pulse

A

separate nurses at the same time using one watch or clock

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29
Q

Pulse deficit

A

difference between the radial and apical rates

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30
Q

When it is difficult to hear/feel/find a pulse what can you use?

A

Doppler ultrasound device

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31
Q

Respiration

A

exchange of oxygen and carbon dioxide

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32
Q

Ventilation

A

movement of air in and out of the chest

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33
Q

Normal adult respiratory rate

A

Men: 14-18
Women: 16-20

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34
Q

Bradypnea

A

slower that normal respiratory rate

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35
Q

Hyperventilation

A

rapid and or deep breathing

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36
Q

Hypoventilation

A

diminished breathing

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37
Q

Dyspnea

A

difficult or labored breathing

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38
Q

Orthopnea

A

breathing facilitated by sitting up or standing

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39
Q

Apnea

A

absence of breathing

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40
Q

Stertorous breathing

A

noisy ventilation

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41
Q

stridor

A

high pitched sound heard on inspiration when there is laryngeal obstruction

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42
Q

Blood pressure

A

force that the blood exerts within the arteries

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43
Q

Preload

A

volume of blood that fills the heart and stretches the heart muscle fibers during its resting phase

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44
Q

Cardiac outputs

A

volume of blood ejected from the left ventricle per minute

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45
Q

Afterload

A

force against which the heart pumps when ejecting blood

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46
Q

Factors that affect blood pressure

A
  • age
  • circadian rhythm
  • gender
  • exercise
  • emotions and pain
  • miscellaneous factors
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47
Q

Blood pressure is written as a

A

fraction

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48
Q

Systolic pressure

A

pressure within the arterial system when the heart contracts

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49
Q

Diastolic pressure

A

pressure within the arterial system when the heart relaxes and fills with blood

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50
Q

Pulse pressure

A

difference between systolic and diastolic blood pressure measurements

51
Q

Assessment sites for blood pressure

A
  • popliteal artery behind the knee

- lower arm use radial artery

52
Q

Equipment needed to measure blood pressure

A
  • sphygmomanometer
  • inflatable cuff
  • stethoscope
53
Q

Korotkoff sounds

A

sounds that result from the vibrations of blood within the arterial wall or changes of blood flow

54
Q

Average adult blood pressure

A

120/80

55
Q

Palpating blood pressure

A
  • apply blood pressure cuff

- position fingers over the artery while releasing cuff pressure ( instead of a stethoscope)

56
Q

Doppler stethoscope

A

helps to detect sounds created by the velocity of blood running through a blood vessel

57
Q

automatic blood pressure monitoring

A
  • blood pressure cuff attached to a microprocessing unit

- diagnosis unusual fluctuations in blood pressure

58
Q

Hypertension

A

high blood pressure

59
Q

White coat hypertension

A

blood pressure is elevated when taken by a health care provider but normal at other times

60
Q

Diseases associated with hypertension

A
  • anxiety
  • obesity
  • vascular diseases
  • stroke
  • heart failure
  • kidney diseases
61
Q

Hypotension

A

low blood pressure

62
Q

Postural hypotension

A

temporary drop in blood pressure when rising from a reclining position after 3 to 5 minutes of rest

63
Q

Where do you document vital signs?

A
  • medical record for analysis of patterns and trends

- clients record

64
Q

Physical assessment

A

systematic examination of body structures

65
Q

Purposes of physical assessment

A
  • evaluate client’s current physical condition
  • detect early signs of developing health problems
  • establish baseline
  • evaluate the clients responses to medical and nursing interventions
66
Q

Inspection

A

purposeful observation

67
Q

Percussion

A
  • least used assessment technique

- striking or tapping with finger tips to produce vibratory sounds

68
Q

Palpation

A

lightly touching or applying pressure to the body

69
Q

light palpation

A

using the fingertips, the back of the hand, or the palm of the head

70
Q

Deep palpation

A

depressing tissue approximately 1 inch with the forefingers of one or both hands

71
Q

Auscultation

A

listening to body sounds

72
Q

Equipment

A

gloves, examination gown, cloth or paper towels, scale, stethoscope, sphygmomanometer, thermometer, pen light, tongue blade

73
Q

Environment

A

assessment location

74
Q

Drape

A

sheet of soft cloth or paper

75
Q

Head-to-toe approach

A

assessing the client from the top of the body to the feet

76
Q

Body systems approach

A

assessing the client according to the functional systems of the body

77
Q

Mental status assessment

A

technique for determining the level of a pts cognitive function

78
Q

Opthalmoscope

A

tool used to examine structures within the eye

79
Q

Visual acuity

A

ability to see both near and far

80
Q

Snellen eye chart

A

tool for assessing far vision

81
Q

Jaeger chart

A

visual assessment tool with small print or newsprint with varying sides

82
Q

What is the size of each pupil measured in under normal light conditions?

A

millimeters

83
Q

Pupil shape

A

normal pupils are round and equal in size

84
Q

Consensual response

A

a brisk,equal, and simultaneous constriction of both pupils when one eye and then the other is stimulated with light

85
Q

accommodation

A

ability to constrict when looking at a near object and dilate when looking at an object in the distance

86
Q

PERLA

A

pupils equally round and react to light and accommodation

87
Q

Extraocular moments

A

eye movements

88
Q

Visual field examination

A

assessment of peripheral vision and continuity in the visual field

89
Q

Cerumen

A

ear wax

90
Q

hearing acuity

A

ability to hear and discriminate sound

91
Q

Weber test

A

determining equality or disparity of bone-conducted sound

92
Q

Rinne test

A

comparing air versus bone conduction of sound

93
Q

Audiometry

A

measures hearing acuity at various sound frequencies

94
Q

Smelling acuity

A

ability to smell and identify odors

95
Q

Wound

A

break in the skin

96
Q

Ulcer

A

open, crater-like area

97
Q

abrasion

A

area that has been rubbed away by friction

98
Q

Laceration

A

torn, jagged would

99
Q

Fissure

A

crack in the skin (especially on or near mucus membranes )

100
Q

Macule

A

freckles

101
Q

Papule

A

wart

102
Q

Vesicle

A

blister

103
Q

Wheal

A

hives

104
Q

Pustule

A

boil

105
Q

Nodule

A

enlarged lymph node

106
Q

Cyst

A

tissue growth

107
Q

Turgor

A

resiliency of the skin (fullness or lack thereof )

108
Q

Lordois

A

exaggerated natural lumbar curve

109
Q

Kyphois

A

increased thoracic curve

110
Q

Scoliosis

A

lateral curvature of the spine

111
Q

Two normal heart sounds

A

-S1 and S2

“lub dub”

112
Q

Capillary refill time

A

the time it takes blood to resume flowing in the base of the nail bed

113
Q

Tracheal sounds

A
  • loud and coarses

- equal in length and separated by a brief pause

114
Q

Bronchial sounds

A
  • heard over the upper sternum anteriorly & between the scapulae posteriorly
  • harsh and loud
  • shorter on inspiration than expiration
  • pause between them
115
Q

Bronchovesicular sounds

A
  • either side of the central chest or back
  • equal in length during inspiration and expiration
  • no noticeable pause
116
Q

Vesicular sounds

A
  • periphery of all the lung sounds
  • longer on inspiration than expiration
  • no bause between
117
Q

Normal capillary refill time

A

2 seconds or less

118
Q

Assessing the abdomen

A

always inspect and then auscultated

119
Q

Assessing bowel sounds

A
  • place diaphragm lightly in the right lower quadrant

- move the chest piece over all four quadrants in clockwise pattern

120
Q

Normal bowel sounds

A

resemble clicks or gurgles and occur 5 to 34 times a minute

121
Q

frequent bowel sounds

A

hyperactive

122
Q

hypoactive

A

if bowel sounds occur after long intervals of silence

123
Q

Absent

A

if no bowel sound is heard for 2 to 5 minutes

Basic Nursing Skills (6 decks)

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