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82 Cards in this Set
- Front
- Back
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Which type of auscultation do you use a stethoscope?
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indirect
direct is using your ear only |
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What are some things to document in regard to sound?
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intensity
pitch duration quality location |
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When you are doing an initial assessment, what are you looking at during the general survey of the patient?
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.physical presence
.psychological presence .distress |
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When you are looking at a patient's physical appearance/physical presence during a general survey, what are you looking at?
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- stated age vs. aparent age
- general appearance (symmetrical body?) - body fat - stature - motor activity - body and breath odors |
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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 |
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Other than physical presence, what else do you look for in general survey?
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psychological presence
signs of distress |
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What is included in psychological presence?
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clothing, grooming, hygiene
self esteem, dementia, homelessness, neglect mood and manner speech - clear and understandable facial expressions - tremors and twix are abnormal |
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What does this signal?
labored breathing, wheezing during general survey? |
distress
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What does this signal?
bleeding, wounds, crying, nervous, avoidance of eye contact |
distress - general survey
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Respiration
what is normal range of respiration? |
12-20 bpm
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What is considered tachypnea?
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if greater than 20 bpm
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How do you count respirations?
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respiration cycles in one minute
(inspiration and expiration in one minute is a respiration cycle) |
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What is defined as bradypnea?
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Less than 12 breaths per minute
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What is apnea?
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Absent for greater than 10 seconds...no breath sounds
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How do you determine pulse?
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palpate it
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What three things constitute pulse?
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1. rate
2. rhythm 3. volume |
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How do you determine pulse rate?
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measure number of pulse beats in one minute
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What part of the body controls the pulse?
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s/a node
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Which one (sympathetic or parasympathetic) results in a lower pulse?
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parasympathetic
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What detects bp changes?
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barioreceptors
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Lower blood pressure will affect heart rate, how?
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it will increase it
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What actually is rhythm in regard to heart rate?
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rhythm is the pattern of pulses between pulses. It can be regular or irregular
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What is rhythm not?
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Rhythm is not the heart rate.
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What is heart rate?
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beats per minute
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This is defined as the amplitude or pulse strength.
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volume
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What are some descriptive words for volume?
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strong, weak, thready, bounding
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What type of scale do you use to describe volume?
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3 or 4 point scale
Bounding on a 3 point scale is 3 Bounding on a 4 point scale is 4 |
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What is normal on a three point scale?
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2 is normal
1 is thready 0 is absent pulse11 |
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What is normal on a four point scale?
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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. |
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What should you do if radial pulse is irregular?
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Take apical for 60 seconds
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What is normal pulse rate?
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60-100 bpm
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What is the average pulse rate?
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72
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Define tachycardia
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Pulse over 100
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Define bradycardia
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Pulse under 60
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What is asystole?
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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.
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What is a pulse deficit?
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apical rate greater than radial rate
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What are the things that can cause tachycardia?
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low potassium
trauma blood loss anemia infection shock fever fear pain hypterthyroid anxiety |
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What are some drugs that can cause bradycardia?
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digoxin (memorize this, cuz it is on tests in both classes...think dig overdose, or side effect of dig is brady)
beta blockers |
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What establishes body temperature?
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blood profusing to hypothalamus
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When is temperature lowest?
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in early morning just before wakening.
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What amount of change in temperature is normal?
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1-2 degrees
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Why are children more sensitive to environmental temperatures...and why are elderly more sensitive?
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Kids are because their thermo regulation is not yet developed.
Elderly do not have working temperature regulation any longer |
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What does stress do to body temperature?
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stress raises body temperature because it stimulates sympathetic nervous system
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What is the normal range for oral temperature?
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96.8 to 100.4
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What is the normal range for rectal temperature?
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98 to 100.4
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What is the normal range for auxillary temperature?
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95.8 to 99.4
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What is pyrexia or hyperthermia defined as?
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101.5 or higher
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What are some signs of pyrexia?
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increased respirtory rate
increased pulse shivering, palor, thirst |
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What is hypothermia defined as?
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93.2 and lower
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What is blood pressure a reflection of?
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The forces exerted from flowing blood....look up
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What number is on top in bp?
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systolic
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What has to happen for bp to be reported as hyptertension?
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bp is 140/90 on three separate occasions
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What causes hypertension?
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.vascular disease
.kidney disease .arteriosclerosis .fluid overload |
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What causes hypotension?
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.dehydration
.hypovolumia .shock .medications |
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What is pulse pressure?
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difference between diastolic and systolic
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What is blood pressure?
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The force exerted by the flow of blood pumped into the large arteries.
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What is the definition of pain?
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An unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
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Where does nociceptive pain arise from?
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somatic or visceral stimulation
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What part of the brain perceives pain?
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cerebrum (cortex and limbic systmes perceive the pain)
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What is nociception?
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pain perception
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What are the steps of pain?
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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) |
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What are the types of pain?
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cutaneous
somatic visceral |
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What is cutaneous pain?
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Pain that arises from the stimulation of cutaneous nerves
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What does cutaneous pain feel like?
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burning quality
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What is somatic pain?
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Pain that originates from bone, tendons, ligaments, muscles and nerves. It is frequently caused from musculoskeletal injury.
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What is visceral pain?
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Pain that arises from the organs.
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Appendicitis is an example of this type of pain.
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Visceral
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What is referred pain?
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pain that is perceived in a location other than where the pathology is occuring.
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Why is the location of the referred pain significant?
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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
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How would you group pain by its duration?
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acute
chronic malignant chronic nonmalignant |
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How long would pain have to be present for it to be called chronic malignant?
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more than 6 months - for example a patient with cancer
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Acute pain is described as:
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sudden onset
short duration self limiting |
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What is the difference between chronic malignant and chronic nonmalignant pain?
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chronic non malignant can occur with and without an identifiable cause. It can remain even after an initial injury is healed
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Give two examples of chronic non malignant pain.
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fibrymyalgia
back pain |
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What variables affect pain?
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sex
age previous experience with pain cultural expectations |
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What are some physiological responses to pain?
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tachycardia
tachypnea hyptertension diaphoresis (excessive sweating) dilated pupils altered immune response |
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What are the first 5 characterisitcs of a chief complaint?
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Location
Radiation Quality Quantity Associated Manifestations |
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What are the last 5 characteristics of a chief complaint?
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Aggravating Factors
Alleviating Factors Setting Timing Meaning and Impact |
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What is similar with all devices that help the nurse assess pain?
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The client is in control over each of his own pain assessments.
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What is the primary goal of standard precautions?
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to prevent the exchange of blood and body fluids.
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What is the order of physical assessment?
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inspection
palpation percussion auscultation ***except when assessing abdomen, then auscultation is performed before palpation and percussion. |
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Inspection includes two things:
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1. vision
2. smell |
