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82 Cards in this Set

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Which type of auscultation do you use a stethoscope?
indirect


direct is using your ear only
What are some things to document in regard to sound?
intensity
pitch
duration
quality
location
When you are doing an initial assessment, what are you looking at during the general survey of the patient?
.physical presence
.psychological presence
.distress
When you are looking at a patient's physical appearance/physical presence during a general survey, what are you looking at?
- stated age vs. aparent age
- general appearance (symmetrical body?)
- body fat
- stature
- motor activity
- body and breath odors
What does this fall under?

tremors

frail

bad breath
tremors - motor activity
physical presence
general survey

frail - body fat, physical presence general survey

bad breath - body odors, physical presence general survey
Other than physical presence, what else do you look for in general survey?
psychological presence

signs of distress
What is included in psychological presence?
clothing, grooming, hygiene

self esteem, dementia, homelessness, neglect

mood and manner

speech - clear and understandable

facial expressions - tremors and twix are abnormal
What does this signal?

labored breathing, wheezing during general survey?
distress
What does this signal?

bleeding, wounds, crying, nervous, avoidance of eye contact
distress - general survey
Respiration

what is normal range of respiration?
12-20 bpm
What is considered tachypnea?
if greater than 20 bpm
How do you count respirations?
respiration cycles in one minute

(inspiration and expiration in one minute is a respiration cycle)
What is defined as bradypnea?
Less than 12 breaths per minute
What is apnea?
Absent for greater than 10 seconds...no breath sounds
How do you determine pulse?
palpate it
What three things constitute pulse?
1. rate
2. rhythm
3. volume
How do you determine pulse rate?
measure number of pulse beats in one minute
What part of the body controls the pulse?
s/a node
Which one (sympathetic or parasympathetic) results in a lower pulse?
parasympathetic
What detects bp changes?
barioreceptors
Lower blood pressure will affect heart rate, how?
it will increase it
What actually is rhythm in regard to heart rate?
rhythm is the pattern of pulses between pulses. It can be regular or irregular
What is rhythm not?
Rhythm is not the heart rate.
What is heart rate?
beats per minute
This is defined as the amplitude or pulse strength.
volume
What are some descriptive words for volume?
strong, weak, thready, bounding
What type of scale do you use to describe volume?
3 or 4 point scale

Bounding on a 3 point scale is 3

Bounding on a 4 point scale is 4
What is normal on a three point scale?
2 is normal

1 is thready

0 is absent pulse11
What is normal on a four point scale?
2 is normal

3 is increased

4 is bounding

***2 is normal on both scales. Carly, this will be on test as: patient's pulse is 2/4. Is this normal? The 2 is the reading of pulse and the /4 means out of a four scale. No one else will get this....You are welcome. love you.
What should you do if radial pulse is irregular?
Take apical for 60 seconds
What is normal pulse rate?
60-100 bpm
What is the average pulse rate?
72
Define tachycardia
Pulse over 100
Define bradycardia
Pulse under 60
What is asystole?
Without a heart beat. No co, no blood flow. dead. No contraction and can't be stimulated to contract, because it is already fully contracted.
What is a pulse deficit?
apical rate greater than radial rate
What are the things that can cause tachycardia?
low potassium
trauma
blood loss
anemia
infection
shock
fever
fear
pain
hypterthyroid
anxiety
What are some drugs that can cause bradycardia?
digoxin (memorize this, cuz it is on tests in both classes...think dig overdose, or side effect of dig is brady)
beta blockers
What establishes body temperature?
blood profusing to hypothalamus
When is temperature lowest?
in early morning just before wakening.
What amount of change in temperature is normal?
1-2 degrees
Why are children more sensitive to environmental temperatures...and why are elderly more sensitive?
Kids are because their thermo regulation is not yet developed.

Elderly do not have working temperature regulation any longer
What does stress do to body temperature?
stress raises body temperature because it stimulates sympathetic nervous system
What is the normal range for oral temperature?
96.8 to 100.4
What is the normal range for rectal temperature?
98 to 100.4
What is the normal range for auxillary temperature?
95.8 to 99.4
What is pyrexia or hyperthermia defined as?
101.5 or higher
What are some signs of pyrexia?
increased respirtory rate

increased pulse

shivering, palor, thirst
What is hypothermia defined as?
93.2 and lower
What is blood pressure a reflection of?
The forces exerted from flowing blood....look up
What number is on top in bp?
systolic
What has to happen for bp to be reported as hyptertension?
bp is 140/90 on three separate occasions
What causes hypertension?
.vascular disease
.kidney disease
.arteriosclerosis
.fluid overload
What causes hypotension?
.dehydration
.hypovolumia
.shock
.medications
What is pulse pressure?
difference between diastolic and systolic
What is blood pressure?
The force exerted by the flow of blood pumped into the large arteries.
What is the definition of pain?
An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Where does nociceptive pain arise from?
somatic or visceral stimulation
What part of the brain perceives pain?
cerebrum (cortex and limbic systmes perceive the pain)
What is nociception?
pain perception
What are the steps of pain?
transduction (cell damage stimulates an action potential that moves to the spinal cord via the afferent nerve fibers)

Transmission (pain impulse is carried via the spinothalamic tract to the brain)

Perception of pain (cortex and limbic systems perceive the pain)

Modulation (the inhibition of nociceptor impulses)
What are the types of pain?
cutaneous

somatic

visceral
What is cutaneous pain?
Pain that arises from the stimulation of cutaneous nerves
What does cutaneous pain feel like?
burning quality
What is somatic pain?
Pain that originates from bone, tendons, ligaments, muscles and nerves. It is frequently caused from musculoskeletal injury.
What is visceral pain?
Pain that arises from the organs.
Appendicitis is an example of this type of pain.
Visceral
What is referred pain?
pain that is perceived in a location other than where the pathology is occuring.
Why is the location of the referred pain significant?
because it is the dermatome of the spinal cord that is innervating the affected viscera and where the organ was located in its embryonic stage
How would you group pain by its duration?
acute
chronic malignant
chronic nonmalignant
How long would pain have to be present for it to be called chronic malignant?
more than 6 months - for example a patient with cancer
Acute pain is described as:
sudden onset
short duration
self limiting
What is the difference between chronic malignant and chronic nonmalignant pain?
chronic non malignant can occur with and without an identifiable cause. It can remain even after an initial injury is healed
Give two examples of chronic non malignant pain.
fibrymyalgia

back pain
What variables affect pain?
sex
age
previous experience with pain
cultural expectations
What are some physiological responses to pain?
tachycardia
tachypnea
hyptertension
diaphoresis (excessive sweating)
dilated pupils
altered immune response
What are the first 5 characterisitcs of a chief complaint?
Location
Radiation
Quality
Quantity
Associated Manifestations
What are the last 5 characteristics of a chief complaint?
Aggravating Factors
Alleviating Factors
Setting
Timing
Meaning and Impact
What is similar with all devices that help the nurse assess pain?
The client is in control over each of his own pain assessments.
What is the primary goal of standard precautions?
to prevent the exchange of blood and body fluids.
What is the order of physical assessment?
inspection
palpation
percussion
auscultation

***except when assessing abdomen, then auscultation is performed before palpation and percussion.
Inspection includes two things:
1. vision
2. smell