Unit 3 Review (Exam 2) Flashcards
What are Vital Signs?
Known to be the first place to discover what is wrong with your patient.
5 Types of Vital Signs
T - Temperature P - Pulse R - Respiration BP - Blood Pressure P - Pain
Temperature is controlled by which part of the brain?
Hypothalamus
Average Adult Temperature
98.6
Factors that Influence Body Temperature
- Age
- Gender
- Exercise and Activity
- Time of Day
- Emotions
- Illness
- Drugs
Pyrexia, Febrile, Afrebrile are all known as ____?
Fever
HYPERthermia
High tempterature; Up to 105.8 degrees
HYPOthermia
Low temperature; 95 degrees and below
True/False: You should check vitals before giving meals.
TRUE
True/False: You should check vitals when a patient is complaining.
TRUE
True/False: You should check vitals before/after surgery.
TRUE
True/False: Newborns & Elderly have the most trouble getting temperature.
TRUE
Signs & Systems of Fever
- Flushed skin
- Warm to touch
- Thirst
- Restless and Irritable
- Poor Appetite
- Glassy Eyes
- Increased perspiration
- Headache
- Elevated pulse and respiration
- Disorientation and confusion
- Convulsions
- Fever Blisters
Phases of Fever
- Prodromal Phase
- Onset Phase
- Stationary Phase
- Resolution Phase
Signs & Symptoms of Subnormal Temperature
- Pale, cool skin
- Listlessness
- Decrease pulse and respirations
- Decreased ability to solve problems
- Diminished ability to feel pain and other sensations
What are the 4 sites for taking temperatures?
- Oral
- Rectal
- Axillary (under arm)
- Tympanic
What are the 4 assessment sites?
- Oral
- Rectal
- Axillary
- Ear
Types of Thermometers
- Glass
- Electronic
- Infrared (tympanic)
- Chemical
- Digital
- Automated Monitoring Devices
- Continuous Monitoring Devices
Define Pulse
The sensation felt a the heart forces blood into the arteries walls to expand and distend.
Define Pulse/Heart Rate
The number of pulsations palpated in 1 minute.
Factors that Influence Pulse Rates
- Age
- Circadian Rhythm (fast during the day, slow at night)
- Gender
- Body Build
- Exercise and Activity
- Stress and Emotions
- Elevated Body Temperature
- Blood Volume and Components
- Drugs
What is the average adult pulse?
80
What is Tachycardia?
Fast Heart Rate (100-150 bpm)
What is Bradycardia?
Slow Heart Rate (Less than 60 bpm)
What is Dysrhythmia?
Irregular Heart Rate
What is Arrhythmia?
Pattern of pulsations and pauses (normal heart rate)
What is Pulse Volume?
The quality of pulsations
What are the 5 pulse volumes?
- Absent (No Pulse)
- Thready (Faint to No Pulse)
- Weak (Light Pulse)
- Normal (Pulse is present and clear)
- Bounding (Strong Pulse)
What are the 8 Pulse Sites?
- Temporal (Temple)
- Carotid (Neck)
- Femoral (Pelvic Region)
- Doralis Peds (Foot)
- Brachial (Bicep Region)
- Radial (Wrist)
- Popliteal (KneeCap)
- Posterior Tibal (Back Foot)
When taking a pulse, count for ____ seconds, and multiply times ____.
30 seconds; x 2
What pulse is the most accurate pulse?
Apical
Where is the apical pulse located?
Midclavicular, 5th Intercostal Space
How do you calculate a Pulse Deficit?
Apical Pulse Rate (-) Radial Pulse Rate
What is Respiration?
Exchange of oxygen and carbon dioxide.
What is Tachypnea?
Fast respirations
What is Bradypnea?
Slow respirations
What are Adventitious Lung Sounds?
Abnormal lung sounds.
What is Blood Pressure?
Force exerted by blood within the arteries.
Why do we check blood pressure?
To assess the efficiency of the heart.
What is Systole?
Working phase of the heart; heart contracts.
What is Diastole?
Resting phase of the heart; heart relaxes and refills.
How is Blood Pressure written?
As a fraction.
Systolic/Diastolic
What is the average adult blood pressure?
120/80
What is Arterio/sclerosis?
Arteries lose elasticity.
What is Athero/sclerosis?
Arteries become narrowed w/ fat deposits.
What is Hypertension?
High Blood Pressure; 140/90 bpm
What is Hypertension?
Low Blood Pressure; 96/60 bpm
How do you calculate Pulse Pressure?
Systolic BP (-) Diastolic BP = Pulse Pressure
What equipment is needed to check blood pressure?
- Stethoscope
- Sphygmomanometer
- Read the meter at eye level
- Maintain the arm at the level of the heart.
Who admit patients to facility?
Physicians
What are 3 things a Nurse must do when admitting a patient?
- Prepare room
- Welcome patient
- Orient Patient (show where everything is)
Safegaurding valuables and clothing, helping the patient undress, compiling the data base, having medical admission responsibilities, and providing common responses to admission are all apart of what process?
Admission
True/False: A patient’s personal values should be sent home when being admitted.
TRUE.
True/False: If responsible for a patient’s personal values, you should document it, envelope it, label it, provide yours and the patient’s signature and put it in a safe.
TRUE.
What does it mean when you are discharging a patient?
You are in process of releasing them out of the facility.
True/False: Discharge begins at admission.
TRUE.
True/False: You must have discharge orders to discharge a patient.
TRUE.
What does “Leaving Against Medical Advice” consist of?
- A patient leaving before being discharged
- When patient is unhappy
- Negotiating the patient to stay
- Having the patient sign AMA form
- Document the “AMA” action.
What is needed to complete during Discharge Planning?
- Improve client outcomes
- Post discharge needs
- Coordinating community resources
- Special considerations
What are the proper discharge instructions?
M.E.T.H.O.D.
What does M.E.T.H.O.D. represent?
M - Medication E - Environment T - Treatments H - Health Teaching O - Outpatient referral D - Diet
What is the proper procedure when discharging a patient?
- Gather belongings
- Arrange transportation
- Escorting the Client
- Writing a discharge summary
- Terminal cleaning
Where are some places patients are transferred?
- Extended Care Facilities
- Basic Care Facilities
- Nursing Homes
- Home Health Care
Why do we assess patients?
To see a baseline of a patient’s condition.
What are the techniques for a Physical Assessment?
I - Inspection (observe)
P - Percussion (Tapping/Striking Fingeretips)
P - Palpation (Feel organs)
A - Auscultation (Listen to heart, lungs, abdomen)
True/False: Before performing a Physical Assessment on a patient, you must have the room clean, warm, private, and have good lighting.
TRUE.
What does PQRSTU represent?
P - Provactative, Pallative Q - Quality, Quantity R - Region, Radiation S - Severity T - Timing U - Understanding
Who performs a Complete Assessment?
RN - Registered Nurse
Who performs a Focused Assessment?
LVN - Licensed Vocational Nurse
LPN - Licensed Practical Nurse
As a LVN, what type of approach will you provide during an physical assessment?
Head-To-Toe
Why is it important to perform a Head-To-Toe assessment?
- Prevents overlooking data
- Requires fewer positions
- Takes less time
What does Data Collection include during an assessment?
- Head/Neck
- Chest
- Extremities
- Abdomen
- Genitalia
- Anus & Rectum
What is the purpose of assessing the Head/Neck?
To retrieve patient’s mental status
What is the main procedure done on eyes during physical assessment?
P.E.R.R.L.A
P - Pupils E - Equal R - Round R - Responsive L - Light A - Accommodation
What test is performed to detect bone conduction during physical assessment?
EARS-Weber Test
What test is performed to detect air & bone conduction during physical assessment?
EARS-Rinne Test
What is the purpose of performing a “Skin Turgor” on a patient?
Allows the skin to repel back to its original state as it will confirm patient’s hydration status.
When assessing skin, what can be determined from a patient with Ecchymosis?
Purple, bruised skin.
What pattern is performed for a Chest Auscultation?
Zig-Zag (10 moves)
What are the 4 Normal Lung Sounds?
- Tracheal Sounds
- Bronchial Sounds
- Bonchovesicular Sounds
- Vesicular Sounds
What does “Tracheal Sounds” sound like?
- Loud & Coarse
- Equal
- Brief Pause
What does “Bronchial Sounds” sound like?
- Harsh & Loud
- Shorter Respiration
- Pause
What does “Bronchovesicular Sounds” sound like?
- Medium Range
- Equal
- No Pause
What does “Vesicular Sounds” sound like?
- Soft, rustling
- Longer inspiration
- No pause
What does “Adventitious” mean?
Abnormal lung sounds.
As a Nurse, what do you assess when a patient’s lung is sounding adventitious?
Cough & Sputum
What are the 4 Auscultating Heart Sounds?
- Aortic
- Pulmonary
- Tricuspid
- Mitral
What is a Capillary Refill?
Pressure is applied to nail bed until it is turned white, then blood is removed to tissue after 3 seconds.
What is the shape of “clubbed” fingernails?
Heart-Shaped
What is Edema?
Excessive fluid in legs and feet.
What are the 5 stages of Edema?
+ 1 Pitting = Little fluid present
+2 Pitting = Adequate amount of fluid present
+3 Pitting = larger amount of fluid present
+4 Pitting = Excessive fluid present
+5 Brawny = Leg/Feet extremely enlarged
True/False: Pain is the 5th vital sign.
TRUE.
What is the process of Pain?
- Transduction
- Transmission
- Perception (Pain threshold/tolerance)
- Modulation
What is one Pain Theory?
Gate Control Theory
What are Endogenous Opioids?
Natural Morphine-like subtance
What are the 5 types of pain?
- Cutaneous (Skin, burning)
- Visceral (Organs)
- Neuropathic (Phantom Limb)
- Acute (Less than 6 mo.)
- Chronic (6 mo. and longer)
True/False: Pain is subjective in nature. Pain assessment looks at onset, quality, intensity, location, and duration.
TRUE.
What are some assessment tools to detect pain?
- Pain Scale (0-10)
- Pain Scale with descriptive words
True/False: Always assess pain before and 30 minutes after administering pain medication.
TRUE.
When providing drug therapy, you must start ____, and go ____.
low; slow
What is a placebo?
Mind body interactions (addiction)
What are Korotkoff sounds?
Vibrations of blood within the arterial wall or changes in blood flow.
What are the 5 Phases of Korotkoff sounds?
Phase I - Faint Tapping Phase II - Swishing Phase III - Loud knocking Phase IV - Muffled Phase V - Silence
