Unit 3-Nurses Flashcards
pulse
pressure of blood pushing against wall of an artery as the heart beats and rests
pulse points
most easily felt in arteries that are close to skin and can be pressed against bone by fingers
antecubital space
bend of elbow
- where brachial pulse is found
palpate
feeling a pulse
- use first 3 fingers
Auscultate
heading a pulse
- use stethoscope
Rate
measured as number of beats per minute (BPM)
rhythm
pattern of heartbeats
- charted as “regular” or “irregular”
Arrhythmia
irregular pulse
- assess irregular pulse for 1 minute
volume
strength/intensity of pulse
absent
unable to detect (0)
thready/weak
difficult to palpate (+1)
strong/normal
easily found (+2)
bounding/full
pushed forcefully against fingertips (+3)
apical pulse
-assessed at apex of heart
-use stethoscope
used?= irregular heartbeat, before certain meds, peripheral pulse too weak, assessing infants
respiration
exchange of oxygen and carbon dioxide
- patient shouldn’t be aware of assessment
respiratory rate
- adult= rise and fall of chest
* children= rise and fall of abdomen
rhythm
pattern should be regular
quantity
refers to depth and character of respiration
- deep
- shallow
- labored
- unlabored
blood pressure
measurement of pressure blood exerts as it pulsates throughly arteries
• mmHg
• uses sphygmomanometer
3 types of sphygmomanometer
- mercury
- aneriod
- electronic
mercury
usually hung on wall
- most accurate
- OSHA discourages their use
aneriod
calibrated dial
electronic
digital display
BP measurement
records as fraction
- systolic = occurs when heart is contracting (top #) - diastolic = present when heart is at rest (bottom #)
causes of hypertension
- stress
- anxiety
- obesity
- kidney diease
causes of hypotension
- heart failure
- dehydration
- depression
- severe burns
- shock
normal range of BP
systolic = <120 diastolic = <80
hypotension
systolic = <90 diastolic = <60
prehypertension
systolic = 120-139 diastolic = 80-89
hypertension
systolic = 140+ diastolic= 90+
temperature
measurement of heat loss and heat produced
causes of increased temperature
- infection
- exercise
- excitement
- high temperature environment
causes of decreased temperature
- starvation/fasting
- decreased muscle fine
- mouth breathing
- exposure to cold environment
hypothermia
below 95
-death = below 93
hyperthermia
above 104
- death= 106+
febrile
running a fever (100+)
afebrile
without a fever
oral temperature
taken in mouth
rectal (R)
taken in rectum
- runs 1 degree higher
Axillary (AX)
taken in armpit
- runs 1 degree lower than oral
aural (A)
taken in ear
temporal (TA)
taken across forehead
health history
- follow check list of questions
- active listening
- silence
- opened ended questions
- protect privacy
valuables list
must be documented and sent to holding
• jewelry
• watches
-clothing = kept in closet
client comfort
• starts with psycho-social comfort
-client is nervous/scared
• provide supplies for daily needs
• introduce roommate
• put call-bell in reachinstructions of polices/procedures
- patient = anxiety
- inform client of:
• meal schedule
• visitor policy
• what to expect now they are here
work environment
- large area of work
- nurses can travel anywhere there’s a shortage of nurses
how to become a nurse
• min = associates degree
- 2 years
• max = bachelors degree
- 4 years
• diploma = nursing right away but not paidqualities
- compassionate
- empathetic
- hardworking
- comfortable with touch
advancement
- beginner nurse = start as staff nurse (work in hospital)
- after bachelors you can get masters
pay
- average nurse in DE = $70,000
* most money you can earn will be in the hospital setting
