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119 Cards in this Set
- Front
- Back
Radiation is?
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The Transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays. *keeping fabric on the body will reduce radiate heat loss
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The ranges for tempertures are?
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96.8 degrees F. - 100.4 degrees F
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The ranges for pulse are?
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60 to 100 beats per min.
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The ranges for respiration are?
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12 to 20 breaths per min
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The normal ranges for blood pressure is?
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100/60 to 120/80
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Prehypertension ranges are?
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121/81 to 139/89
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Hypertension ranges are?
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140/90 or greater
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When are vital signs taken?
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-upon admissions and at schedule times
-before and after surgical procedures -before and after an invasive procedures -before and after cardiac or respiratory medications -deterioration of condition or change -before an intervention that influences Vital Signs - At any sign of distress |
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Temperature is?
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is the difference between the amount of heat produce by the body and the amount of heat lost to the environment
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Conduction is?
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The transfer of heat from one object to another with contact. The body losses heat though the air though conduction.
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Convection is?
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The loss of heat through air movement such as a fan or when the skin is moisten and comes with contact with moving air.
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Evaporation is?
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Tranformation of heat from a liquid to a gas. Evaporation causes heat loss as water istransfer into the air. Such as diaphoresis(sweating)during a fever.
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The four ways in which the body losses heat.
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Radiation
Conduction Convection Evaporation |
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The five factors affecting the body's temperature
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Age
Diurnal Variations-Time of Day Emotionals/Stress- Exercise Hormones Environment Food,Fluids,Smoking |
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The nine pulse sites are?
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Temporal
Carotid Apical Brachial Radial Femoral Popiteal Posterior tibial Dorsalis pedis |
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What are the uses of the Temporal pulse?
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Used when radial pulse is not accessible
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What are the uses of the Carotid pulse?
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Used during cardiac arrest/shock in adults
Used to determine circulation to the brain |
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What are the uses of the Apical pulse?
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Routinely used for infants and children up to the 3 years in age
Used to determin discrepancies with the radial pulse Used in conjunction with some medications |
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What are the uses of the Brachial pulse?
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Used to measure blood pressure
Used during cardiac arrest for infants |
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What are the uses of the Femoral pulse?
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Used in cases of cardiac arrest/shock
Used to determine circulation to a leg |
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What are the uses of the popliteal?
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Used to determine circulation to the lower leg
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What are the uses of the Posterior tibial pulse?
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Used to determine circulation to the foot
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What are the uses of the Dorsal pedal pulse?
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Used to determine circulation to the foot
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The Body's temperature regulating system is?
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In the brain the hypothalamus regulates the production and loss of heat for example shivering, sweating, and vasoconstriction
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Oral
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A-acessible and convenient
D-themometers can break if bitten. Inaccurate if client has just ingested hot or cold food or fluid or smoked. Could injure the mouth following oral surgery |
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Rectal
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A--Reliable measurement- most reflective of the core body temperture
D--Incovenient and more unpleasant for clients; difficult for client who cannot turn to the side. Could injure the rectum following rectal surgery. Presence of stool ma interfere with thermometer placement. If the stool is soft, the thermometer may be embedded in stool rather than against the wall of the rectum. **rectal is used to check hypothermic accuracy and is .9 degrees higher than oral |
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Axillary
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A--Safe and noninvasive
D--The thermometer must be left in place a long time to obtain an accurate measurement ** reflected of surface temperature and is .9 degree lower than lower |
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Tympanic membrane
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A--Readily accessible; relects the core temperature. Very fast.
D--Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far. Repeated measurements may vary. Right and left measurements can differ. ** reflects core body temperature .9 degrees higher than oral |
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Temporal artery
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A--safe and noninvasive; very fast
D-- Requires electronic equipment that may be expensive or unavailable; variation in technique needed if the client has perspiration in the forehead. |
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Four types of fever are?
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Intermittent
Remittent Relasping Constant |
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Intermittent fever is?
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The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures.
Example is with the disease malaria |
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Remittent fever is?
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Fever such as with a cold or influenza, a wide range of temperature fluctuations(more than 2 degrees C {3.6 degrees F} occurs over the 24-hour period, all of which are above normal
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Relasping fever is?
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Short febrile periods of a few days are interspersed with periods of 1 to 2 days
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Constant fever
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The body temperature fluctuates minimally but always remains above normal. This can occur with typhoid fever.
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Pyrexia
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greater than 100 degrees F
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Hyperpyrexia
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greater than 106 F
** will monitor their neural status, tempature can cause seizures |
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Febrile
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Patient with a fever
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Afebrile
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Patient has no fever
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Clinical S/S Onset of a fever are?
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Chills with gooseflesh
Shivering/cold skin Pallid skin Increased HR and resp rate C/O feeling cold No sweating |
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Apical-Radial Pulse
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Assess for pts with cardiovascular disorders. Normally these rates are identical. But if the apical pulse is larger this could indicate PVD. Discrepancy is called the pulse deficit. PROCEDURE: 2 nurses- radial nurse is time keeper- start- count for one minute- stop and compare rates.
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Apical Pulse
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only pulse that is auscultated, place stethoscope on the 5th ICS on the midclavicular line.
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Characteristics that should be included when assessing the pulse are:
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Rate (BPM), Rhythm (regular or irregular), and volume- 1+, 2+ etc.
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The mechanics of respiration are:
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External: alveoli and blood exchange oxygen. Internal: taking of the oxygenated blood and CO2 at the tissue level. The stimulus to breathe is an increase in CO2. *Except COPD pts the stimulus to breathe is O2.
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The characteristics to be included in the respiratory assessment are:
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Rate, depth(shallow deep etc), rhythm (reg or irreg), character(labored/unlabored), and the sounds.
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Eupena
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Normal breathing pattern of 12-20 resp per min.
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Bradypnea
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less than 12 breaths/min
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Tachypnea
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more than 20 breaths/min
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Systole
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-Contration phase of the heart
-the top number of a blood pressure reading -the first sound heard -LUB -mitral and tricuspid valve close |
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Diastole
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-relaxation phase/ heart at rest
-filling period -lower number of a BP reading -DUB -aortic and pulmonic valves closed |
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Pulse pressure
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the difference of systole and diastole. the norm range is 30-40 mmHg.
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Delegation
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DO not delegate unless pt is stable and the UAP is resposible and accountable.
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Palpation
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use of hands and sense of touch for texture, moisture, temp, pain etc. pads of fingers for tactile discrimination. light (one hand) and deep (two hand) palpation
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Percussion
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this is an advanced technique of striking the body with a plexor onto the pleximitor.
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Ausculation
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listening to sounds in the body
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Inspection
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Purposeful observation
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Elements of the nursing health history
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Past medical/surgical history/allergies, family history, current medical status/ chief complaint, lifestyle/social/psychologic status/
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OPQRST
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-onset
-provoke/palliate -quality/quantity -region/radiation -severity/scale -timing |
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Bell of the stethoscople
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low pitch sounds
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Diaphram of the stethoscope
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high pitched sounds
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Correct sequence of the physical exam
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1. inspection
2. palpation 3. percussion 4. auscultation |
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Correct sequence of the GI exam
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1. inspection
2. auscultate 3. palpation 4. percussion |
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Macule
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flat primary skin lesion less than 1 cm "freckle"
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Papule
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elevated primary skin lesion less than 1 cm "skin tag"
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Nodule or Tumor
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elevated hard mass greater than 1 cm
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Vesicle
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translucent fluid filled mass less than 0.5 cm ex "a cold sore, chicken pox, herpes zoster"
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Bulla
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translucent fluid filled mass larger than 0.5 cm "burn blister"
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Pustule
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pus filled vescile or bulla "pimple"
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Wheal
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reddened localized area of edema "big burn. hives, TB PPD reaction"
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Club nails
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hypoxia over a long period of time can cause this.
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S/S During Course of Fever are?
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-C/O head ache
-Flushing of skin- skin feels warm -Irritability or restlessness -Glassy-eyed appearance -Disorientation, confusion- seizures -Anorexia, N/V, thirst -Generalized weakness, aches |
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S/S During Termination of Fever
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-Diaphoresis
-Decreased shivering -Reddening of skin due to vasodilation, flushed and feels warm -Possible dehydration * they will be wet from Sweat |
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Nursing Interventions for a Febrile Patient
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--Chills- Blankets, note onset and duration
--Diaphoresis-Increase air circulation & change blankets frequently --Encourage fluids/ Oral hygiene --Frequent V/S --Bathe with tepid water- No alcohol --Decrease activity- Provide O2 if ordered --Provide sufficiednt calories due to increase BMR ***Nurses respnsibilities is to monitor temp. Q 2 hours, monitor hydration*** |
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Adventitious Lung Sounds
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Abnormal lung sounds
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Crackles
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heard on inspiration and are not cleared by cough. can sound like hair rubbed between 2 fingers near the ear.
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Rhonchi
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sonorous wheezes, sounds like snores and may clear with cough
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Wheezes
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sibilant wheezes musical sounds on inspiration and expiration
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Pallor
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pale
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Cyanosis
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blueish color of the skin
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Jaundice
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yellow color of the skin
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Erythemia
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red color of the skin
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Ecchymosis
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Bruises
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Supine
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laying flat on the back
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Dorsal recumbent
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back lying with knees flexed, for foley, peri care
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Lithotomy
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stirrups, for vaginal/rectal exam
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Sims
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how Julie sleeps, side lying with lower most arm behind body, leg flexed, position for enemas or vaginal/rectal exams.
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Prone
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lying face down
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Purposes of the Physical Examination
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-obtain baseline data
-supplement, confirm, or refute data from the history -help establish nursing diagnoses and plans of care -evaluate physiologic outcomes and make clinical judgements -identify areas for health promotion and prevention |
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To convert C to F
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1.8 times X +32
x= the C temp |
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To convert F to C
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X-32/1.8
x= the F temp |
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alopecia
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hair loss
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Blanch test
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CRT test. You press a nail and count the seconds until color comes back. Normal is under 3 secs.
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myopia
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nearsightedness
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hyperopia
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farsightedness
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presbyopia
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loss of elasticity of the lens
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astigmatism
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un uneven curve of the cornea
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Mydriasis
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constricted pupils
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miosis
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constructed pupils
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orthopnea
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dyspnea when laying down
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hemoptysis
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bloody sputum
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Barrel chest
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anterioposterior ratio is 1 to 1 vs the normal 2 to 1 due to empyhsema
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bruit
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a blowing or swishing sound created by the turbulence of blood flow due to a narrowed lumen.
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thrill
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a vibrating sensation in an artery that feels like a purring cat
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Factors affecting Respirations
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Pain, body position, environment, exercise, medications, increased intracranial pressure.
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Tachycardia
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greater than 100 BPM
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Bradycardia
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less than 60 BPM
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Sinus Rhythm
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60-100 BPM
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Factors affecting blood pressure
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peripheral resistance, vasoconstriction, vasodilation, blood volume, cardiac output, blood viscosity, elasticity of the vessels.
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Factors influencing BP
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-age
-SNS -Meds -Diurnal Variations -Activity -emotions -exercise -foods/weight |
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Primary Hypertension
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cause unknown, accounts for over 90% of cases
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Secondary Hypertension
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Known cause 10% of cases. renal diseases, diabetes
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Hypotension
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low BP that causes symptoms such as dizziness, fainting, clammy skin, or pallor.
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Patient Teaching
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*Encourage breast self exam (
-Monthy @ age 20 -Mamography q 1 year 40+ -CBE over 40 annually *Testicular self exams *Skin Self Exams |
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What is the importance of understanding cultural diversity?
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To better provide care for your pts in a way that is respectful of their beliefs.
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Tremor
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an involuntary trembling of a limb or body part
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Intention Tremor
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a tremor that is more apparant when a pt tries a voluntary movement
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Resting Tremor
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more apparant when the client is at rest and diminished activity
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hernia
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protrusion of the intestine through the inguinal wall or canal.
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Arteriosclerosis
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This is when the elastic and muscular tissues of the arteries are replaced with fibrous tissue and the arteries lose much of their ability to constrict and dilate.
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Orthostatic Hyoptension
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Is a blood pressure that falls when the client sits or stands.
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