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119 Cards in this Set

  • Front
  • Back
Radiation is?
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
The ranges for tempertures are?
96.8 degrees F. - 100.4 degrees F
The ranges for pulse are?
60 to 100 beats per min.
The ranges for respiration are?
12 to 20 breaths per min
The normal ranges for blood pressure is?
100/60 to 120/80
Prehypertension ranges are?
121/81 to 139/89
Hypertension ranges are?
140/90 or greater
When are vital signs taken?
-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
Temperature is?
is the difference between the amount of heat produce by the body and the amount of heat lost to the environment
Conduction is?
The transfer of heat from one object to another with contact. The body losses heat though the air though conduction.
Convection is?
The loss of heat through air movement such as a fan or when the skin is moisten and comes with contact with moving air.
Evaporation is?
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.
The four ways in which the body losses heat.
Radiation
Conduction
Convection
Evaporation
The five factors affecting the body's temperature
Age
Diurnal Variations-Time of Day
Emotionals/Stress-
Exercise
Hormones
Environment
Food,Fluids,Smoking
The nine pulse sites are?
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popiteal
Posterior tibial
Dorsalis pedis
What are the uses of the Temporal pulse?
Used when radial pulse is not accessible
What are the uses of the Carotid pulse?
Used during cardiac arrest/shock in adults
Used to determine circulation to the brain
What are the uses of the Apical pulse?
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
What are the uses of the Brachial pulse?
Used to measure blood pressure
Used during cardiac arrest for infants
What are the uses of the Femoral pulse?
Used in cases of cardiac arrest/shock
Used to determine circulation to a leg
What are the uses of the popliteal?
Used to determine circulation to the lower leg
What are the uses of the Posterior tibial pulse?
Used to determine circulation to the foot
What are the uses of the Dorsal pedal pulse?
Used to determine circulation to the foot
The Body's temperature regulating system is?
In the brain the hypothalamus regulates the production and loss of heat for example shivering, sweating, and vasoconstriction
Oral
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
Rectal
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
Axillary
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
Tympanic membrane
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
Temporal artery
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.
Four types of fever are?
Intermittent
Remittent
Relasping
Constant
Intermittent fever is?
The body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures.
Example is with the disease malaria
Remittent fever is?
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
Relasping fever is?
Short febrile periods of a few days are interspersed with periods of 1 to 2 days
Constant fever
The body temperature fluctuates minimally but always remains above normal. This can occur with typhoid fever.
Pyrexia
greater than 100 degrees F
Hyperpyrexia
greater than 106 F
** will monitor their neural status, tempature can cause seizures
Febrile
Patient with a fever
Afebrile
Patient has no fever
Clinical S/S Onset of a fever are?
Chills with gooseflesh
Shivering/cold skin
Pallid skin
Increased HR and resp rate
C/O feeling cold
No sweating
Apical-Radial Pulse
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.
Apical Pulse
only pulse that is auscultated, place stethoscope on the 5th ICS on the midclavicular line.
Characteristics that should be included when assessing the pulse are:
Rate (BPM), Rhythm (regular or irregular), and volume- 1+, 2+ etc.
The mechanics of respiration are:
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.
The characteristics to be included in the respiratory assessment are:
Rate, depth(shallow deep etc), rhythm (reg or irreg), character(labored/unlabored), and the sounds.
Eupena
Normal breathing pattern of 12-20 resp per min.
Bradypnea
less than 12 breaths/min
Tachypnea
more than 20 breaths/min
Systole
-Contration phase of the heart
-the top number of a blood pressure reading
-the first sound heard
-LUB
-mitral and tricuspid valve close
Diastole
-relaxation phase/ heart at rest
-filling period
-lower number of a BP reading
-DUB
-aortic and pulmonic valves closed
Pulse pressure
the difference of systole and diastole. the norm range is 30-40 mmHg.
Delegation
DO not delegate unless pt is stable and the UAP is resposible and accountable.
Palpation
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
Percussion
this is an advanced technique of striking the body with a plexor onto the pleximitor.
Ausculation
listening to sounds in the body
Inspection
Purposeful observation
Elements of the nursing health history
Past medical/surgical history/allergies, family history, current medical status/ chief complaint, lifestyle/social/psychologic status/
OPQRST
-onset
-provoke/palliate
-quality/quantity
-region/radiation
-severity/scale
-timing
Bell of the stethoscople
low pitch sounds
Diaphram of the stethoscope
high pitched sounds
Correct sequence of the physical exam
1. inspection
2. palpation
3. percussion
4. auscultation
Correct sequence of the GI exam
1. inspection
2. auscultate
3. palpation
4. percussion
Macule
flat primary skin lesion less than 1 cm "freckle"
Papule
elevated primary skin lesion less than 1 cm "skin tag"
Nodule or Tumor
elevated hard mass greater than 1 cm
Vesicle
translucent fluid filled mass less than 0.5 cm ex "a cold sore, chicken pox, herpes zoster"
Bulla
translucent fluid filled mass larger than 0.5 cm "burn blister"
Pustule
pus filled vescile or bulla "pimple"
Wheal
reddened localized area of edema "big burn. hives, TB PPD reaction"
Club nails
hypoxia over a long period of time can cause this.
S/S During Course of Fever are?
-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
S/S During Termination of Fever
-Diaphoresis
-Decreased shivering
-Reddening of skin due to vasodilation, flushed and feels warm
-Possible dehydration
* they will be wet from Sweat
Nursing Interventions for a Febrile Patient
--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***
Adventitious Lung Sounds
Abnormal lung sounds
Crackles
heard on inspiration and are not cleared by cough. can sound like hair rubbed between 2 fingers near the ear.
Rhonchi
sonorous wheezes, sounds like snores and may clear with cough
Wheezes
sibilant wheezes musical sounds on inspiration and expiration
Pallor
pale
Cyanosis
blueish color of the skin
Jaundice
yellow color of the skin
Erythemia
red color of the skin
Ecchymosis
Bruises
Supine
laying flat on the back
Dorsal recumbent
back lying with knees flexed, for foley, peri care
Lithotomy
stirrups, for vaginal/rectal exam
Sims
how Julie sleeps, side lying with lower most arm behind body, leg flexed, position for enemas or vaginal/rectal exams.
Prone
lying face down
Purposes of the Physical Examination
-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
To convert C to F
1.8 times X +32

x= the C temp
To convert F to C
X-32/1.8

x= the F temp
alopecia
hair loss
Blanch test
CRT test. You press a nail and count the seconds until color comes back. Normal is under 3 secs.
myopia
nearsightedness
hyperopia
farsightedness
presbyopia
loss of elasticity of the lens
astigmatism
un uneven curve of the cornea
Mydriasis
constricted pupils
miosis
constructed pupils
orthopnea
dyspnea when laying down
hemoptysis
bloody sputum
Barrel chest
anterioposterior ratio is 1 to 1 vs the normal 2 to 1 due to empyhsema
bruit
a blowing or swishing sound created by the turbulence of blood flow due to a narrowed lumen.
thrill
a vibrating sensation in an artery that feels like a purring cat
Factors affecting Respirations
Pain, body position, environment, exercise, medications, increased intracranial pressure.
Tachycardia
greater than 100 BPM
Bradycardia
less than 60 BPM
Sinus Rhythm
60-100 BPM
Factors affecting blood pressure
peripheral resistance, vasoconstriction, vasodilation, blood volume, cardiac output, blood viscosity, elasticity of the vessels.
Factors influencing BP
-age
-SNS
-Meds
-Diurnal Variations
-Activity
-emotions
-exercise
-foods/weight
Primary Hypertension
cause unknown, accounts for over 90% of cases
Secondary Hypertension
Known cause 10% of cases. renal diseases, diabetes
Hypotension
low BP that causes symptoms such as dizziness, fainting, clammy skin, or pallor.
Patient Teaching
*Encourage breast self exam (
-Monthy @ age 20
-Mamography q 1 year 40+
-CBE over 40 annually
*Testicular self exams
*Skin Self Exams
What is the importance of understanding cultural diversity?
To better provide care for your pts in a way that is respectful of their beliefs.
Tremor
an involuntary trembling of a limb or body part
Intention Tremor
a tremor that is more apparant when a pt tries a voluntary movement
Resting Tremor
more apparant when the client is at rest and diminished activity
hernia
protrusion of the intestine through the inguinal wall or canal.
Arteriosclerosis
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.
Orthostatic Hyoptension
Is a blood pressure that falls when the client sits or stands.