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NURS 221 Foundations- Nursing Practice > WEEK 1 > Flashcards

WEEK 1 Flashcards

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1
Q

What is a normal blood pressure?

A

Normal: Less than 120/80 mm Hg

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2
Q

What is elevated blood pressure?

A

Elevated: Systolic between 120-129 and diastolic less than 80

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3
Q

What is considered Stage 1 hypertension?

A

Systolic between 130-139 or diastolic between 80-89

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4
Q

What is considered Stage 2 hypertension?

A

Systolic at least 140 or diastolic at least 90 mm Hg

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5
Q

What is considered hypertensive crisis (sudden/ severe increase in BP) ?

A
  • Systolic over 180 and/or diastolic over 120
  • With patients needing prompt
    changes in medication if there are no other indications of problems, or immediate
    hospitalization if there are signs of organ damage
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6
Q

What is the systolic reading?

A

How much pressure is pushing on your blood vessel walls as your heart contracts and pumps out blood to your body.

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7
Q

What is your diastolic reading?

A

The pressure on your blood vessel walls when your heart relaxes between contractions.

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8
Q

What can affect a blood pressure reading?

A
  • Exercise
  • Meals
  • Bathroom: full bladder can give you an elevated reading
  • Alcohol, Caffeine, Tobacco
  • Cuff size
  • Clothing: don’t put cuffs over clothing
  • Temperature: if you’re cold you might get a higher reading than expected
  • Position
  • Stress
  • Talking
  • Age
  • Ethnicity
  • Gender
  • Daily variation
  • Medications
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9
Q

How should a patient be positioned when obtaining blood pressure?

A

o Should be seated with back and arms supported
o Feet on floor uncrossed
o Arm at heart level
o If laying- arm at heart level
NOTE: Patient should be in a seated position for at least 5 minutes for most accurate measurement

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10
Q

Why would you NOT use a particular limb to obtain blood pressure?

A

o Trauma
o Casted or bandaged
o Blood cot
o Lymph nodes removed (radical mastectomy)
o Presence of fistula (used for hemodialysis in renal failure)

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11
Q

Is the blood pressure measured in the leg higher or lower than in the arm?

A

Normally higher (lower could signal Peripheral vascular disease (PVD)

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12
Q

Where is the stethoscope placed when obtaining blood pressure in the arm? Where is the cuff
placed?

A

1)- Locate the brachial or radial artery as appropriate and place the stethoscope’s diaphragm over it below the bottom of the cuff.
- Do not let the chest piece touch the
cuff or clothing.
- Do not place the diaphragm under the cuff or place excessive pressure
on the stethoscope head

2) Position the cuff in the antecubital space. Apply the cuff above the artery by centering
the arrows marked on the cuff over the artery so that the end of the cuff is 2 to 3 cm
above the antecubital fossa to allow room for placement of the stethoscope.

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13
Q

Why is blood pressure sometimes measured by the 2-step method?

A

To establish the patient’s baseline blood pressure- inflating the cuff too tight or many times
because you didn’t inflate enough the first time can lead to inaccurate readings

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14
Q

What is Hypertension?

A

Blood pressure that is higher than normal

  • More common than hypotension
  • Thickening of walls
  • Loss of elasticity
  • Family history
  • Risk Factors
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15
Q

What is Hypotension?

A

Low blood pressure

  • Dilation of arteries
  • Loss of blood volume
  • Decrease of blood flow to vital organs
  • Orthostatic/postural
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16
Q

So what does blood pressure determine?

A

Determines if a patient has hypotension, hypertension, or orthostatic hypotension which can be defining characteristics of the following diagnoses

  • Activity Intolerance
  • Anxiety
  • Decreased cardiac Output
  • Risk for Injury
  • Acute Pain
  • Ineffective Peripheral Tissue Perfusion
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17
Q

What is a normal temperature reading in degrees Fahrenheit and Celcius?

A

Normal: 96.8 F (36C) to 99F (37.2C)

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18
Q

What is considered a fever?

A

100.4 F or 38 C

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19
Q

Temperature sites for patients?

A
  • Oral
  • Rectal( most accurate, used for babies)
  • Axillary
  • Tympanic Membrane
  • Temporal Artery
  • Esophageal
  • Pulmonary artery
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20
Q

What factors affect body temperature?

A
  • Age
  • Exercise
  • Hormone level
  • Cardiac rythm
  • Stress
  • Enviroment
  • Temperature alterations
21
Q

What are temperature alterations?

A
  • Fever(pyrexia)
  • Heat-loss mechanisms are unable to keep pace with excessive heat production
  • Febrile( FEVER)
  • Afebrile( NO FEVER)
  • Hyperthermia(high body temp)
  • Heatstroke
  • Heat exhaustion
  • Hypothermia(low body temp)
22
Q

What are some types of body temperature regulation?

A
  • Neural and vascular control
  • Heat production
  • Heat loss
  • Behavioral control
  • Skin temperature regulation
23
Q

What is the Nursing Process?

A
  • Assessment
  • Nursing diagnosis
  • Planning
  • Implementation
  • Acute care
  • Evaluation
24
Q

What is a pulse?

A

Palpable bunding of blood flow noted at various points on the body

25
Q

How do you assess pulse? What is the character of the pulse?

A

Sites include

  • Temporal
  • Carotid
  • Apical
  • Brachial
  • Radial
  • Ulnar
  • Femoral
  • Popliteal
  • Posterior Tibial
  • Dorsalis pedis

Character of pulse

  • Rate
  • Rhythm
  • Strength
  • Quality
26
Q

What can a pulse determine?

A
  • Activity intolerance
  • Anxiety
  • Acute pain
  • Decreased cardiac output
  • Deficient/ excess fluid volume
  • Impaired gas exchange
  • Ineffective peripheral tissue perfusion
27
Q

What is the normal respiratory rate for an adult? How do you asses it?

A

12-20 breaths/min
Must be an inhale and exhale for 1 full breath
- They can either be deep, normal, or shallow

28
Q

How do you assess diffusion and perfusion?

A
  • Measure oxygen saturation of the blood

- Measurement of arterial oxygen saturation

29
Q

What is diffusion? What is perfusion?

A
  • Movement of oxygen and carbon monoxide between alveoli and red blood cells
  • Distribution of red blood cells to and from the pulmonary capillaries
30
Q

What is a normal oxygen saturation for an adult?

A

94-100%

31
Q

What factors could affect oxygen saturation?

A
  • COPD (emphysema/bronchitis)
  • asthma
  • anemia
  • heart disease
  • PE
  • covid-19
  • pneumonia
  • pneumothorax
  • sleep apnea
  • congenital heart defects
  • interstitial lung disease
  • ARDS
32
Q

Factors that increase the risk of contracting an infection?

A 
o Age
        o Young and old
• Breaks in skin integrity or alteration in other mechanisms that protect against 
infection (see #2)
• Antibiotic use
• History of infections 
• Decreased immune system 
       o Immunocompromised patients
        o Multiple comorbidities 
        o Poor nutrition 
        o Recent illness
         o Immunosuppressant medications
• Indwelling medical devices 
• Hospital/ healthcare settings
33
Q

Identify body mechanisms against infection

A 
• Skin
• Mucous membranes
• Tears
• Earwax
• Stomach acid 
• Normal flow of urine 
• WBCs and immune responding cells 
          o Inflammation
          o Tissue repair
          o Vascular response 
           o Exudates
34
Q

Define nosocomial, iatrogenic, endogenous infections

A

• Nosocomial
o Hospital or healthcare-acquired infection
• Iatrogenic
o a type of HAI that results from a diagnostic or therapeutic procedure
• Endogenous
o The patient’s own flora becomes altered and an overgrowth results

35
Q

What is the medical asepsis/clean technique? When is this used?

A

Medical asepsis, or clean technique, includes procedures for reducing the number
of organisms present and preventing the transfer of organisms.

o Hand hygiene 
o Alcohol swabs
o Personal protective equipment 
o Standard precautions apply to contact with blood, body fluid, nonintact skin, 
and mucous membranes from all patients
36
Q

What is the surgical asepsis/Sterile technique? When is this used

A

• Technique that is considered free of microorganisms and minimizes risk of
contamination
• The OR/ IR, labor and delivery rooms, invasive procedures, when the integrity of
the skin is accessed, impaired, or broken

37
Q

When is soap and water hand hygiene preferable to alcohol-based hand sanitizers? Are there
organisms that are not killed by hand sanitizer?

A

• When visibly dirty, soiled with blood or body fluids, before eating, after using the
bathroom
• Cdiff and Bacillus anthracis

38
Q

How often should you wash your hands in a hospital setting?

A
  • Before and after every contact with patient
  • Before eating
  • After bathroom
  • When dirty
38
Q

How often should you wash your hands in a hospital setting?

A
  • Before and after every contact with patient
  • Before eating
  • After bathroom
  • When dirty
  • Between changing gloves
39
Q

How long should you use lather hands when using soap and water?

A

20 seconds

40
Q

Principles of proper body mechanics

A

Stable Center of Gravity
Wide Base of Support
Proper Body Alignment

41
Q

What is Fowler’s position?

A

A bed positioned where the head and trunk are raised b/w 40-90 degrees

Often used for patients who have cardiac issues, trouble breathing, or nasogastric tube in place

42
Q

What is lateral position?

A

Involves the patient lying on either her right or left side. A pillow is often placed b/w legs for comfort

43
Q

What is a Lithotomy position?

A

Patient is lying flat on her back with legs elevated at hip level or above

Commonly used for gynecological procedures and childbirth

44
Q

What is Prone position?

A

The patient lies on their stomach with their head turned left or right

Position allows for drainage of the mouth after oral or neck surgery

45
Q

What is Sim’s position?

A

A prone/lateral position in which the patient lies on his side with his upper leg flexed and drawn in towards the chest and upper leg flexed at the elbow

Useful for administrating enemas, perineal examinations, and comfort in pregnancy

46
Q

What is a Supine position?

A

A position where the patient is flat on his back. Considered most natural at rest position

Often used for abdominal, facial, and extremity procedures.

47
Q

Define activity tolerance/intolerance. What should be monitored before, during, and after
ambulation for a weak or debilitated patient?

A

Physiologic tolerance of activities of daily living.

Activity intolerance is generalized weakness
and debilitation secondary to acute or chronic illness. Symptoms include weakness, dizziness, or pain with ambulation; increased HR, RR, changes in blood pressure; dyspnea/shortness of
breath

Vital signs; ask patients to report pain, dizziness, weakness

48
Q
  1. On which side do you stand when ambulating a patient with a weak side
A

Weak side

NURS 221 Foundations- Nursing Practice (1 decks)

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