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76 Cards in this Set
- Front
- Back
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Two most common communication sources the nurse relies on
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client's record and reports
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Basic guidelines for effective documentation and reporting
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Be factual, descriptive, accurate, concise.
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True or False: There is an increased risk of unauthorized individuals gaining access to computer information.
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True
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PIE
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Problem, Intervention, Evaluation (a problem oriented system using progress notes)
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DAR
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Data, Action, client Response (used in focused charting a way to make progress notes more concise)
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SOAP
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Subjective data, Objective data, Assessment or analysis, Plan
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Where are oral shift-reports given?
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either in a conference room or during walking rounds with nurses from both shifts
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What are the vital signs?
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Temperature
Pulse Respirations Blood Pressure Pain is considered the 5th vital sign. It is fequently the symptom that leads clients to seek health care. Oxygen saturation is an additional vital sign |
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How is oxygen saturation obtained?
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through pulse oximetry that reflects ability of the cardiac and respiratory system to maintain adequate oxygenation.
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Normal ranges for temperature
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36-38* C 98.6-100.4* F
Oral/tympanic: 37* C, 98.6* F Rectal 37.5*C, 99.5* F Axillary 36.5* C, 97.7* F |
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Normal ranges for Pulse
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Adult: 60-100 beats per minute, strong and regular
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Normal ranges for Respirations
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Adult: 12-16 breaths per minute, deep and regular
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Normal ranges for Blood Pressure
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Systolic: less than 120 mm Hg
Diastolic: less than 80 mm Hg Average blood pressure 120/80 mm Hg |
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define bounding
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describes a pulse that is very strong
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define words like weak, feeble, and theady in regards to pulse
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descriptive words for a pulse of low volume that are difficult to palpate
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The pulse is a palpable bounding of blood flow caused by pressure wave transmission from the ______ ____ to the ____, large arteries, and _____ arteries
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left ventricle, aorta, peripheral arteries
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Scale for measuring pulses
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measures pulse strength (amplitude)
4+ bounding 3+ full 2+ normal 1+ weak 0 absent |
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What is the most accurate, noninvasive measure of heart rate and rhythm?
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the apical pulse
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Temperature fluctuates in a 24 hour cycle, being lowest between _____am and ____am, rising steadily throughout the day, and peaking at about ___pm
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lowest between 1am-4am
peaks at 6pm |
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What are the most reliable sites for body temperature?
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rectal, tympanic, esophageal, pulmonary artery, and urinary bladder. Those that are not so affective are the skin, oral, and axillary sites.
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How/where is the apical pulse auscultated ?
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place the diaphragm over the point of maximum impulse at the 5th intercostal space on the left midclavicular line.
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Movement of air through the lungs involves 3 interrelated processes:
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ventilation, diffusion, perfusion
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Define ventilation
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mechanical movement of air in and out of the lungs
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Define diffusion
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the movement of respiratory gases between the alveoli and RBC's
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Define perfusion
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distribution of blood through the pulmonary capillaries
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How long does it take to get a reading from a tympanic thermometer?
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2-5 seconds
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How long does it take to get a reading from an axillary thermometer?
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3 minutes
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Healthy men and children usually demonstrate _________ breathing
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diaphragmatic (concentration and relaxation of the diaphragm and is most visible in abdomen)
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Women breathe more with the _____, most apparent in the chest.
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thorax
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A longer expiratory phase is evident when the outward flow of air is ______.
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obstructed, such as in asthma
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Blood pressure is the _____ exerted by the blood against the ______ walls.
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force, arterial
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________ pressure is the peak pressure occurring during the heart's ________ as blood is forced under high pressure into the ______
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Systolic
contraction, aorta |
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The ______ pressure is the pressure present when the ventricles are ________ and when there is minimal pressure exerted against the arterial wall.
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diastolic,
relaxed |
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What is pulse pressure?
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the difference between the systolic and diastolic pressure
Ex- if BP is 120/80 the pulse pressure is 40 |
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What are some things that could cause low blood pressure?
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A decreased cardiac ouput related to CHF or a low blood volume related to dehydration
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What are some things that could increase blood pressure?
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stress or arteriosclerosis (loss of elasticity of vessel walls)
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Factors that increase risk of hypertension
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obesity, increased sodium intake, smoking, lack of exercise, family history, age (over 50), alcohol consumption, having Diabetes Mellitus, low socioeconomic status, sedentary lifestyle, stress, elevated serum lipid levels, ethnicity (2x more prevalent in African Americans)
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The diaphragm of the stethoscope is used for ....
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higher-pitched heart sounds, bowel sounds, and lung sounds
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The bell of the stethoscope is used for...
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lower-pitched heart sounds and vacular sounds
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What are the 2 methods for obtaining blood pressure?
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auscultatory (manual) and oscillometric (electric)
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Blood pressure cuffs require routine maintenance for _______.
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calibration
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The inflatable rubber bladder of the BP cuff should encircle ___% of the arm of an adult and the cuff width should be at least __% greater then the arm circumferance.
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80,
40 |
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Ranges for Normal Blood Pressure (for adults 18+)
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Systolic <120 or diastolic < 80
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Ranges for Prehypertension
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Systolic 120-139 or
Diastolic 80-89 |
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Ranges for Stage 1 hypertension
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Systolic 140-159 or
Diastolic 90-99 |
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Ranges for Stage 2 hypertension
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Systolic >160
or Diastolic <100 |
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True or False: One blood pressure recording qualifies as a diagnosis of hypertension
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False. A diagnosis is made when an average of two or more readings on two subsequent visits indicate prehypertension or a stage of hypertension.
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Critical areas of potential error involving measuring BP that need to be reviewed routinely
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cuff selection, extremity positioning, inflation/deflation rate, rounding off, and detection of Korotkoff sounds
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Blood pressure can drop ____ to ____ % during nighttime sleep
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10-20%
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Fever is more accurately assessed between ____pm and ____pm
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5pm and 7pm
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Blood pressure varies throughout the day, with lower blood pressure during ______, highest blood pressure in the _____, a ______ in the evening, and in increase beginning at ____ to ___am.
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Blood pressure varies throughout the day, with lower blood pressure during SLEEP, highest blood pressure in the AFTERNOON, a DECREASE in the evening, and an increase beginning at 4am to 6am.
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Anxiety can raise blood pressure as much as ____
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30 mm Hg
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Smoking and intake of hot or cold food/fluid can affect ____ temperature
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oral
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True or false: Caffeine and nicotine decrease pulse rate.
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False, they increase pulse rate
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Coffee icreases blood pressure within ____ minutes and can last as long as ___ hours
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15 minutes, 3 hours
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_____ and _____are immediately influenced by smoking, which lasts as long as 15 minutes
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blood pressure and pulse rate
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Talking to a client when blood pressure is assessed increased readings from ____ to _____%
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10-40% !!!
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_____blood pressure is associated with rapid IV infusion of fluids or blood producs, increased intracranial pressure, cardiovascular disease, and renal disease
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High
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____ blood pressure is associated with rapid vasodilation, shock, hemorrhage, and dehydration
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Low
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A WBC count greater than _______in a nonpregnant adult suggests the presence of infection
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12,000/mm3
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A WBC count less than _____ suggests that the body's ability to fight infection is compromised, which can lead to ineffective thermoregulation
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5,000/mm3
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Low values of hemoglobin, hematocrit, and RBC count are associated with ____oxygen transport to tissues and ____.
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decreased
hypoxia |
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____ levels reflect adequacy of oxygenation and ventilation
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ABG
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Low hemoglobin levels, decreased oxygenation, and decreased ventilation can _____ pulse rate, blood pressure readings, and respiratory rate
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increase
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____________ is assessed by observing any circumoral, nail bed, or mucous membrane cyanosis, tachycardia, dizziness, and mental confusion
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Lowered oxygen level
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What should you do if a tympanic temperatire is abnormal?
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Repeat measurement in other ear or wait 2-3 minutes to repeat in same ear.
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What position should client be in for assessing rectal temperature?
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side-lying Sim's position with upper lex flexed.
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Dip rectal thermometwe into lubricant covering ____inches for an adult. Gently insert thermometer into anus in direction of umbillicus ____ for adult
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1- 1.5 inches (2.5-3.5 cm)
1.5 inches (3.5 cm) |
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It takes ____ to determine if a pulse is regular in rhythm
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30. If irregular, count rate for 60 seconds
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If pulse is irregular, assess for a pulse deficit. Count apical pulse while colleague counts radial pulse. Begin apical pulse, initiating counting by a signal to simultaneously asess pulses for a full minute. If polse count differs by more than ____ beats per minute, a pulse _____ exists, which may indicate alteration in _______.
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2
deficit cardiac output |
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If rhythm of respirations is regular count number of respirations in ____ seconds and multiply by ___
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30, 2
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If rhythm of respirations are irregular, count for ____.
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a full minute
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When inflating BP cuff, inflate cuff rapidly to ____ mm Hg above palated systolic pressure. Slowly release pressure bulb valve, and allow needle to fall at rate of __- ___ mm Hg/sec
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30
2-3 mm Hg /sec |
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Before obtaining blood pressure, client should be seated or lying in a quiet environment, free from termperature extremes, for at least ___ minutes.
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5
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Position BP cuff ___ inch above site of brachial pulsation
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1 inch (2.5 cm)
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Position manometer ______ at eye level. Observer should be no farther than ____ away.
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vertically
one meter or approximately one yard |
