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200 Cards in this Set
- Front
- Back
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High Blood Pressure Reading
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140/90
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Hypo Blood Pressure Reading
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90/60
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Pre Hypertension Reading
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129/89
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Normal Blood Pressure Reading
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120/80
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Leg Blood Pressure
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Use Popliteal (back of knee)
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Special Considerations When Taking Blood Pressure
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Women with Mastectomy ( Lymphadema - Swelling of the arm)
IV Lines - will blow line Fistula for Dialysis - |
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Pulse Volume Varia tions
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0 - None felt
1+ Thready Pulse - Difficult to feel 2+Weak Pulse - Somewhat stronger than thready 3+Normal Pulse Easily Felt 4+ Bounding - Feels full and strong |
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Pulse
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rhythmic beating or vibrating movement
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Adult Pulse Rate
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between 60 to 100
average is 80 |
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tachychardia
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pulse faster than 100 beats per minute
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brachychardia
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pulse is lower than 60 beats per minute
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drysrhythmia
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amount between beats varies - it is an irregular heart beat
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auscultate
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listen for sounds in the body to evaluate the condition of the heart, lungs, intestines, or other organs or to detect fetal heart tones
gi, bowel , heart |
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Stethoscope (Bell)
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Low Pitch
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Stethoscope (Diaphragm)
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High Pitch Sounds
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Acute Pain
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6 months or less - only last through expected recovery period
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Chronic Pain
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Last more than 6 months- last beyond typical healing period
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Intractable Pain
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Pain that persist despites all the therapeutic interventions - still in pain
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Cutaneous Pain
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Skin pain or underlying tissues
ex. cut on arm |
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Somatic Pain
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Inter structure pain
ex. bone, ligaments, pulled hamstring |
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Visceral Pain
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Organ pain
ex. appendicitis, kidney infection |
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Radiating Pain
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Pain that spreads..
ex.. back pain but also felt down my leg |
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Referred Pain
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Felt at area of origination but also effects somewhere non adjacent
ex.. kidney infect effects the thigh |
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Neuropathic Pain
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Involves the nerve
feels like.. burning, stabbing, shooting, not dull |
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Phantom Pain
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Pain in a part that is no longer there. Amputation pain..
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JCAHO Standards
Joint Commission on Accreditation of Healthcare Orginization |
Policy and procedures in place for pain control therapies.
Have the right to assessment Must be treated Give pain meds as ordered Pain management part of discharge |
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Pain Assessment: PQRST Method
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P= Precipitating (cause / palliation (what makes it better)
Q= Quality (stabbing, burning) R= Region Radiation ( Where is it? does it spread ) S= Severity ( 1- 10 scale) rate the intensity T= Timing ( How often) ex. sudden, 3 weeks, intervals |
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Other Pain Assessments
<Non Verbal> |
Vital Signs,
Guarding (stomach Pain - holding stomach), Facial Expression Crying Restlessness Diaphoresis - (excessive sweating) Pallor - (Pale) |
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Non Pharmacological Pain Control
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Nurse client relationship
Back massage Hot or cold Packs Behavioral Techniques - therapeutic touch, guided imagery (meditation) |
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When documenting a client's blood pressure, Systolic Pressure is heard at what point
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The first Korotkoff sound is heard
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Nursing Assessment Examples
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Admission Assessment
Daily Assessment Prn (as needed) assessment |
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Assessment
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systematic process of of evaluating a patients condition
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The Interview
(Assessment) |
Physical assessment begins here
Introduce myself Say why I am there Give estimate of time Let them know info is confidential Good Eye contact LISTEN to patient with my body |
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Chief Complaint ( step 2 in assessment)
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Cheif Complaint -
document in clients owns words w/ quotation marks |
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objective data
(signs) |
can be seen, heard, measured, can be verified by more than one person
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subjective data
(symptom) |
cant see it
perceived by the client numbness, nausea, |
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page 65
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cultural and ethnic considerations on midterm study!!!!
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Focused assessment
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assessment focused on one area
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Head to Toe Assessment
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From Head to Toe Assessment... Full Body
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Admissions Assessment
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Before they are admitted
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Client preparation for assessment
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explain procedure
positioning (ex. supine) |
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Inspection - assessment
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To look with eyes
color, size, shape, symmetry ex. mucous color |
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Palpation Assessment
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to feel with hands
temperature texture distention - ex..bloating pulsation -ex. pulse presence of pain on palpation - ex-- stomach exam |
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A (alert) & O Oriented x 4
A and O x 4 |
person
place time purpose |
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Neurological System Assessment
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Level of Consciousness
(person, place, time, purpose) Orientation Speech Pain Assessment Pupils |
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Pupils
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3 to 7 mm
round equal on both sides |
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Direct Response
(pupil assessment) |
Dim light and come in from side, pupil should constrict (get smaller)
Light makes pupil constrict |
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Consensual response
(pupil assessment) |
both eyes should constrict along with the other eye
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Pupils dilate when object is moved away
constrict when it gets closer |
Accommodation (pupil assessment)
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PERRLA
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pupils
equal round reacting to light accommodation |
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non verbal. inability to communicate through speech and writing
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aphasia
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dysphasia
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difficulty with speaking
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Paresis
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weakness
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Plegia
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paralysis
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paralegia
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lower extremities paralysis
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Quadriplegia
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all four extremities paralysis
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Erythema
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redness
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Ecchymosis
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bruising
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Pruritis
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Itching
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Skin Integrity
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is skin in tack
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diaphoresis
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sweating
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capillary refill time
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should be less than 3 seconds-
ex. brisk, cap refill time 3 |
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Dehydration Signs
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Skin - will be cool, dry, poor skin turgor
Mucous membranes- look dry - in mouth Eyes- Will look sunken in Behavior- lethargic, tired, irritable Pulse- Rapid but weak Blood pressure - decreased- lack of circulating blood Respirations- rapid |
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Normal Respiratory Rate
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12 to 20
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Pitting Edema Scale
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1+ trace
2+ mild - rebounds 10 to 15 sec 3+ moderate - 30 sec to 1 minute 4+ severe 2-5 minutes before rebounding |
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Apical Pulse
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5th intercostal space, at or just medial to the left midclavicular
this area is at the apex of the heart |
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brachial
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arm
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femoral
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groin
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popliteal
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back of knee
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carotid
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neck
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pedal (dorsalis pedis)
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top of foot
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systolic
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pressure is higher and represents the higher number and represents ventricle contracting, forcing blood into the aorta and pulmonary arteries
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diastolic
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pressure within the artery beats
pressure when ventricles are at rest represents the lower number |
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5 Vital Signs
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temperature
pulse respirations blood pressure pain level |
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5 Times When vitals signs are needed
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admission
health status change before, after, during invasive procedure before after certain medications before after nursing interventions that could affect vital signs. |
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Temperature
(Vital) |
“Normal” ORAL body temperature:
97 to 99.6 degrees Fahrenheit (°F) |
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Body Temperature
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balance between heat produced and heat lost
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Hypothalamus
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Controls temperature regulation
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Temperature Methods (5)
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Oral
Rectal Axillary Tympanic Temporal |
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Oral Temperature
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Place to the right or left of frenulum in posterior sublingual pocket
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Rectal Temperature
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1 degree higher than oral.
ACCURATE insert 1-1.5” on adult Supine position Red end of the thermometer |
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Axillary Temperature
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Under armpit
LEAST accurate 1 degree F lower than oral Commonly used for newborns Blue end of thermometer |
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Tympanic Temperature
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Behind the ear
1 degree F higher than oral Pull ear up and back for a person 3 years and up Pull ear down and back for a child younger than 3 years |
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Temporal Scanner
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Quickest
1 degree higher than oral Accurate Any age Easily used on combative or unconscious patients |
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Febrile
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With fever
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(A)frebile
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without fever
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Hypothermia
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Low temp
Below 90 degrees Give warmth with room temp, warming pads, warm blankets, covering the head Make sure clothing is dry Keep limbs close to body Provide warm fluids |
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Hyperpyrexia
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Extremely high temperature
105 degrees and higher |
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Antipyretic
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medication that treats fever
ex. tylenol |
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Pulse
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60 to 100 beats a minute
heart pumps out blood and the artery contracts |
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Apical
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Pulse location bottom of heart
Located - 5th intercostal left mid clavicle women- lift up breast men - typically nipple line |
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Radial
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Wrist
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Temporal
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Temples
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Carotid
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Lower portion of the neck
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3 Pulse Characteristics
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rate - fast or slow
rhythm - missed beat volume - strength |
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Brachycardia
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heart rate below 60
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Tachycardia
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heart rate above 100
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Pulse deficit
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Apical Rate Minus (-) Radial (wrist) Rate
heart rate - wrist rate |
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Pulse volume (strengths) variations
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0= no pulse felt
1+= thready - very weak 2+= weak 3+= normal 4+= bounding - strong |
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Respirations
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Normal - 12 to 20 breaths per minute
The act of breathing Inhalation/inspiration Exhalation/expiration |
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Cheyne-Stokes
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abnormal breathing pattern
periods of apena and deep rapid breathing. starts with slow shallow breaths that become abnormally rapid and deep |
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Orthopnea
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person must sit or stand to breath comfortably
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Dyspnea
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uncomfortable breathing caused by activity like exercising
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Apnea
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absence of spontaneous respiration
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bradypnea
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low rate of breathing
lower than 12/min |
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tachypnea
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fast rate of breathing
higher than 20/ min |
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Blood Pressure is..
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Pressure exerted by circulating volume of blood on the arterial walls
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Pulse Pressure
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difference between systolic and diastolic pressures
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4 Phases
Listening to a blood pressure |
Korotkoff’s Sounds
Phase 1 Clear tapping or thumping Phase 2 Muffled “whoosh” or “swish” Phase 3 Softer but crisp thumping sound Phase 4 Becomes muffled; soft blowing quality Phase 5 Silence |
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Orthostatic hypotension
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Sudden drop in blood pressure when the client moves from a horizontal to a vertical position
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Effects of the wrong size
Blood Pressure Cuff |
Too small - False High reading
Too big - False low |
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Stethoscope Chest Piece
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Bell - Low Pitch sounds
Diaphragm - High Pitch sounds |
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Pulse Oximetry
"Pulse Ox" |
Pulse Ox should be in between
90% and 100% |
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Renal Calculi
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Kidney Stone
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Anorexia
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Decreased Appetite
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Active ROM
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Can achieve muscle strengthening
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Passive ROM
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No muscle strengthening
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Brady
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Slow
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de-
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from down or not
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ab-
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away from
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sub
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under
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PRN
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as needed
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ic
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pertaining
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Joesph Lister
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Father of Aseptic technique
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Tredelenburg
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for postural drainage
entire bed tilted downward |
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moving client
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bend knees and hips
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2 types of sterilization
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chemical (gas)
chemical solutions - Iodine, alcohol, and bleach |
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CDC Isolation Guidelines
(2) Tiers |
1st Care for all- Standard Precautions
2nd disease specific (contact precautions) |
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Types of Baths
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Complete
Partial Bag (no rinse) Tub Shower Sitz Bath |
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Myalgia
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Muscle Pain
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Diverticulitis
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inflammation of the diverticulum
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Myo-
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muscle
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Circum, peri
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around
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Surgical Asepsis
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absolutely free of organisms and spores
"sterile asepsis" |
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Medical Asepsis
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Inhibits growth and spread of pathogenic microorganisms
"clean technique" |
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Semifowler
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head of the bed raised
approx 30 degrees - promotes lung expansion |
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Remove Equipment
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gloves
goggles gown mask |
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putting on Protective Equipment
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gown
mask goggles gloves |
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SRD
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Safety Reminder Device
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ad-
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to toward near
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thromb
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clot
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nephroma
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tumor of kidney
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plasty
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surgical repair
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cynotic
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blue discoloration
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-ous
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pertaining to
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ven
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vein
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intra
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within
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therm
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temperature
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rhin
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nose
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gastrocopy
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visual examination of the stomach
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electr
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electricity
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oste
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bone
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pathy
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disease
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episitomy
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surgical incision of the perineum
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anti, contra
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against or opposed to
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a- , an
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without
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phelb
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vein
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veinoustasis
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blood pulling in leg vein
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PASS
Use fire Extinguisher |
P= pull pin
A= aim extinguisher S=squeeze handle S=sweep spray back and forth |
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Pressure Ulcers
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on bony prominence
skin breakdown |
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RACE
(Fire Procedure) |
R=rescue and remove
TOP PRIORITY A= activate C=contain E=extinguisher and evacuate |
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Infection Process
6 links |
1 infectious agent
2 reservoir (infected individual) 3 exit route- (urine, feces) 4 method of transmission (tissue) 5 entrance (mouth, skin break) 6 host - another person |
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nosocomial infection
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caught in health care facility
within first 12 hrs |
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infectious process
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1 incubation period (1st symptom appears)
2 prodromal stage (specific symptoms - fever) 3 illness signs manifest specific to the type of infection ( ex. sinus infection) 4 convalescence - symptoms disappear |
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infectious agent (4)
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bacteria
virus fungus protozoa |
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virulence
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the ability of any agent of infection to produce disease
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fomite
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vehicle is nonliving - scissors
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vector
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vehicle is living
ex. bacteria |
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osteoporosis
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loosing calcium demilitarization
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atrophy
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shrink or get smaller (muscle wasting)
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contractures
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permanent shortening of a muscle
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postural hypertension
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sudden drop of bp (sit up and laydown)
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thrombophelitis
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blood clot stuck in inflamed vessel
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embolism
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traveled blood clot
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macro
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large or long
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micro
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small
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oligo
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few or deficient
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pan
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all
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super or supra
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above or excessive
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ante, pre, pro
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before
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con, syn, sym
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together or with
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dys
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painful, or difficult
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eu-
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good or normal
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neo
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new
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Assessment
General Survey |
General appearance and behavior
Posture and position Body movement Hygiene Vital signs Height and weight Facial features |
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Assessment
Integumentary System |
Nail assessment
Capillary refill time Should be brisk (less than 3 seconds) Assessment of feet Surgical incisions, open wounds |
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Integumentary Assessment for Dehydration
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Skin
Mucous membranes Eyes Other assessments for dehydration Behavior Pulse Blood pressure Respirations |
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Assessment
Cardiovascular System |
Apical rate and heart sounds
Blood pressure Peripheral vascular system -Assessment of peripheral pulses Perfusion |
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Assessment
Respiratory System |
Respirations
--Rate, rhythm, depth, effort --Chest expansion Pulse ox Breath sounds --Normal (clear) --Adventitious (crackles, wheezing) |
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Adventitious Breath Sounds
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Crackles (rales)
--Fine crackles: high-pitched --Coarse crackles: louder and more bubbly Wheezes Pleural friction rub |
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Pleural friction rub
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inflammation of the pleural surface in the lung. viscereal and priteal are rubbing together
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Sibilant Wheeze
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high pitch wheeze- like after exercise
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Sonorous Wheeze
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continuous sounds - can be cleared through a cough
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emesis
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vomiting
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Assessment
Gastrointestinal System |
Nausea
Pain Appetite anorexia History of bowel movement patterns Dysphagia (difficulty swallowing) Vomiting (emesis) Diet-how much was eaten |
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Assessment
GI System |
Inspection--
Feeding tube Skin Distention Auscultation Bowel sounds 4 quadrants Diaphragm of stethoscope Palpation -Rigidity -Tenderness -Masses |
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Bowel Sounds
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Normal: “active x 4 quadrants”, sounds occur every 15-60 seconds (4-32 sounds per minute)
Hyperactive: more than 32 per minute Hypoactive: less than 4 per minute |
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Borborygmi
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extremely hyperactive bowel sounds, gurgling sound caused by hyperperistalsis.
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Assessment
Genitourinary System |
Inspect genitalia during peri care, noting any abnormalities
Urinary output (Color, amount, frequency, odor Continence, Catheter) |
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Assessment
Musculoskeletal System |
Gait
(Balance, Limping, Foot dragging Ataxia) Muscle strength (Strong and symmetrical, Hand grasps) ROM |
