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45 Cards in this Set

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List/recognize the admission protocol
1.Advance directives
2.Bill of rights
3.Admission assessment-RN only in specified time.
4.Legible ID band
5.Consent formed by mentally complete adult/gaurdian
Who is responsible for admission assessment and why?
The RN is responsible per the requirement of JCAHO.
3 ways to ensure accuracy of Wt.
1.Same scale each time
2.void before weighing
3.wearing same type of clothing
3 ways to ensure accuracy of ht.
1.Stand erect
2.Lshaped bar on top of head
3.Stand so back is facing balance bar
Role of Nurse if client wants to leave AMA.
-notify MD asap
-ask client why leaving
-Explain MD reasons to stay
-Explain risks of leaving
-offer AMA form and get sig, RN to cosign
-for refusal sig, note on form and witness, form in client chart,escort client,notify relatives if safety issues.
APEX
pointed end of a come shaped part or organ.
APNEA
ABSENCE OF BREATHING
AXILLA
ARMPIT
BRADYCARDIA
PULSE RATE BELOW 60 BPM
CARDIO
PERTAINING TO THE HEART
DIASTOLE
PERIOD WHEN HEART DILATES AND FILLS WITH BLOOD; PERIOD OF RELAXATION
HEART RYTHM
TIME INTERVAL BETWEEN HEARTBEAT
HYPERPNEA
ABNORMAL INCREASE IN DEPTH/RATE OF BREATHING.
HYPERTENSION
BP CONSIDERED HIGHER THAN NORMAL RANGE
HYPERTHERMIA
UNUSUALLY HIGH BODY TEMP
HYPOTHERMIA
BODY TEMP BELOW AVERAGE NORMAL RANGE.
NORMAL PULSE RATE
-SMOOTH ROUNDED SHARP INCREASE STROKE TO DECREASE STROKE.
-PROVIDE INFO ON CARDIAC STATUS/BLOOD VOL.
-CORRELATES WITH CARIAC CONTRACTION.
PALPATE
TO EXAMINE BY TOUCH,FEEL
PERIPHERAL
PERIPHERY, AWAY FROM CENTRAL STRUCTURE
PULSE DEFICIT
HEART RATE COUNTED AT APEX BY AUSCULTATION GREATER THAN RATE BY PALPATION OF RADIAL PULSE. PULSE WAVE NOT TRANSMITTED TO PERIPHERY TO PRODUCE PALPABLE RADIAL PULSE.
PULSE PRESSURE
DIFF BTWEN SYSTOLIC/DIASTOLIC PRESSURE.
PYROGEN
ANY SUBSTANCE THAT PRODUCES FEVER.
SET POINT
BODY'S NORMAL CORE TEMP
SHOCK
INADEQUATE TISSUE PERFUSION RESULTING FROM CIRC FAILURE B/C OF MANY FACTORS.
-IDENTIFIED BY VARIOUS S&S.
SPHYGMOMANOMETER
DETERMINES ARTERIAL BP.
TACHYCARDIA
HR GREATER THAN 100 BPM
TACHYPNEA
RESP RATE ABOVE 24 BPM. RATE REMAINS REG BUT SHALLOW IN PATTERN.
VALSALVA'S MANEUVER
FORCIBLY EXHALE WTIH GLOTTIS,NOSE,MOUTH CLOSED.
INCREASED INTRATHORACIC PRESSURE
INFO TEMP PROVIDES
BALANCE BTWEEN HEAT GAIN/LOSS
INFO PULSE PROVIDES
OVERALL IMPRESSION OF HEARTS ACTION.
INFO RESP PROVIDES
DATA ON CLIENTS ENTIRE BREATHING PROCESS
INFO BP PROVIDES
COND OF HEART,ARTERIES,VESSEL RESISTENCE,ARTERIOLES,CARDIAC OUTPUT,CV STATUS
INFO PAIN LEVEL PROVIDES
HOMEOSTASIS,QUALITY OF LIFE. PAIN LOCATION, INTESITY,OUTCOMES OF RELIEVE MEASURES.
FACTORS THAT INFLUENCE VS
AGE,GENDER,RACE,HEREDITY,LIFESTYLE,ENVIRON,PAIN,EXERCISE,
ANXIETY,STRESS,METABOLISM,
CIRCADIAN RYTHMN,HORMONES
S&S OF FEVER
PERSPIRATION OVER BODY,BODY WARM TO TOUCH,CHILLS/SHIVERS,
FLUSHED FACE,HOT/COLD FLASHES,
INCREASEDPULSE/RESP,MALAISE/FATIGUE,PARCHED LIPS/DRY SKIN,CONVULSIONS
CONDITIONS ALTERING FEVER
DISEASE,INFLAMMATION,BRAIN LESIONS,PYROGENS,DEGENERATING TISSUE
NORM ORAL TEMP
97-99.5F
36-37.5C
NORMAL RECTAL TEMP
1 DEGREE HIGHER THAN ORAL: 98-100.5F
NORMAL AXILLARY TEMP
96-98.5F 1 DEGREE LOWER THAN ORAL
NORMAL EAR TEMP
98.5-99.5F 0.5 DEGREES HIGHER THAN ORAL
FACTORS THAT ALTER CORE TEMP
EATING,DRINKING,GUM,SMOKING,
EXERCISING
WAIT TIME AFTER ALTERING FACTORS OF CORE TEMP
20-30 MINUTES ORALLY
HOW DO TEMPS VARY THROUGHOUT THE DAY
CIRCADIAN THERMAL RYTHMN
WHEN TO AVOID ORAL TEMP
UNCONSCIOUS,MOUTH BREATHER,FACIAL,NUERO,PROBLEMSOPENING MOUTH,LOW ORAL TEMP NO CAUSE
PLACEMENT OF ELEC. THERMOMETER,ORAL
UNDER TONGUE,ALONG GUMLINE IN SUBLINGUAL POCKET