Week 1 Flashcards
Vital Signs (BP and pulse)
Nursing process steps
Assessment
Analysis/Diagnosis
Planning
Implementation
Evaluation
Primary survey includes checking:
ABCs= Airway, Breathing, Circulation
Disability
Exposure
Level of consciousness
Alert and oriented
Confused and disoriented
lethargic
obtunded
unconscious
What is first level priorities
life threatening, requires urgent action
what is second level priorities
may lead to clinical deterioration, needs prompt action
what is third level priorities
non urgent, but needs addressing (ex:educating clients)
Intervention types
effective
ineffective
unrelated
contraindicated
what is focused assessment
Specific to a health concern, reason for seeking care
Complete health assessment
Full overview of client’s health status
What is head to toe assessment
Cephalocaudal “head to toe” approach, provides overview of client’s current health status
what type of level of consciousness: altered in consiousness
confused and disoriented
what type of level of consciousness:slow and sluggish
lethargic
what type of level of consciousness: significant impairment without stimuli they will return back to sleep
obtunded
Diff types of health promotion
behavioural = focus on lifestyle
relational = focus on the person’s relationships (things around the patient)
structural = focus on policies
locations of pulses
radial
brachial
carotid
apical pulse
where is brachial pulse found?
Look for the pulse in the brachial artery in the antecubital fossa
where is apical pulse found?
Auscultate the apical pulse at the 2nd-5th intercostal space, midclavicular line.
when describing pulse what do you have to mention
Rate
Rhythm
Force
Equality (bilateral)
when describing pulse rhythm you use either
Regular = even tempo with equal intervals
Irregular
- regularly irregular
- irregularly irregular
when describing pulse force you use
3+ Full, bounding
2+ Normal/strong
1+ Weak, diminished, thready
0 Absent/non-palpable
three regular pulse beats and one missed and this is repeated. what type of Irregular is it?
- regularly irregular
- irregularly irregular
regularly irregular
there is no rhythm to the irregularity. what type of Irregular is it?
- regularly irregular
- irregularly irregular
- irregularly irregular
normal pulse range
60-100 BPM = adults
+15 = in pregnant women
100-175 BPM = newborn/children
what is bradycardia
slow BPM, below 60 bpm
tachycardia is
elevated heart rte, above 100bpm
what is sinus arrhythmia
Irregular heart rhythm = pulse fluctuates with breathing
Higher during inspiration
lower during expiration
what is Atrial fibrillation (Arrhythmia)
when atria quivers (beat irregularly)
what is auscultatory gap
brief period during blood pressure measurement when Korotkoff sounds disappear and then reappear
orthostatic hypotension is
a person’s BP decrease when moving
orthostatic tachycardia
increased BPM of a person when they move
Hypertension is
elevated BP (140/90 or higher)
Hypotension is
decreased BP (less than 95/60)
Aneurysm
blood vessels ballon bec of weak walls
