Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
63 Cards in this Set
- Front
- Back
|
Factors Affecting Body Temp
|
developmental level
environment temp hormones emotions and stress circadian rhythm |
|
|
Febrile
|
having a fever 100.4 or above
|
|
|
Afebrile
|
no fever normal body temp 96.2 to 100.4
|
|
|
Hypothermia
|
body temp below norm 96.8
|
|
|
Pyrexia
|
fever or abnormal high temp 100.4
|
|
|
Hyperthermia
|
having a fever or temp above 100.4
|
|
|
Variation in Temp Developmentally
|
older adults run low
infants and children run higher both more susceptible to environment temp |
|
|
Factors affecting pulse
|
age
sex- adult female higher exercise food- eating raises stress- fight or flight fever- 10 bpm for each degree disease blood loss- raises position medication |
|
|
Tachy pulse
|
> 100bpm
|
|
|
Brady pulse
|
< 60bpm
|
|
|
Intermittent pulse
|
rhythm is inconsistent
|
|
|
Pulse deficit
|
difference between apical and radial
|
|
|
9 Pulse sites
|
temporal
carotid brachial radial ulnar femoral popliteal posterior tibial dorsalis pedis |
|
|
Variations in HR through development
|
newborns are more rapid
older slows down normal 60 to 100 bpm |
|
|
Factors affecting respiration
|
exercise
pain stress smoking fever pulse rate- R:P 1:4 hemoglobin- if low ^depth and rate disease medications position |
|
|
Apnea
|
absence of breathing
|
|
|
Dyspnea
|
labored breathing
|
|
|
Hyperpnea
|
fast breathing
|
|
|
Hypoventilation
|
ex. COPD
CO2 retained decrease in depth and rate |
|
|
Hyperventilation
|
loss of CO2 ^rate and depth
|
|
|
Orthopnea
|
cant breathe laying down
|
|
|
Variations in respiration throughout development
|
newborns rapid 40 to 90 breaths pm
gradual decrease to 12 to 20 breaths pm |
|
|
Factors affecting B/P
|
age
sex family Hx lifestyle exercise position stress pain race AA have higher B/P obesity diurnal variation medication disease |
|
|
Systolic
|
peak pressure exerted against arterial walls as ventricals contract
|
|
|
Diastolic
|
minimum pressure exerted against arterial walls between cardiac contractions when heart is at ret
|
|
|
Pulse pressure
|
the difference between systolic and diastolic should be no greater than 1/3 of the systolic pressure
|
|
|
Hypotension
|
Dx as systolic B/P lower than 100
|
|
|
Hypertension
|
persistantly higher B/P 140/90 recorded twice
|
|
|
Variations in B/P throughout development
|
newborns have systolic of 40 and it increases gradually throughout childhood systolic and diastolic both increase with age due to decreased arterial compliance
|
|
|
Factors affecting O2 saturation
|
age
environment- stress/air/altitude/temp lifestyle- pregnancy/occup/smoke/fat medications pathophysiological cond.-hypoxemia |
|
|
Hypoxemia
|
low arterial blood O2 levels caused by poor O2 diffusion into blood across the alveolar capillary membrane
|
|
|
Assessing O2
|
use pulse oximeter reflects % of hemoglobin molecules carrying O2
normal value is 95 to 100% |
|
|
Purpose of I and O assessment
|
plan to monitor a clients fluid status. kidneys produce urine at a rate of 60 mL per hour or 1500 mL per day
|
|
|
Nature of pain
|
can cause sleep loss, irritability, functional impairment and immobility.
|
|
|
Intractable
|
both chronic and highly resistant to relief
|
|
|
Cutaneous
|
superficial pain that arises on skin or subcu tissue
|
|
|
Referred
|
pain occurring in an area distant from original site
|
|
|
Somatic
|
originates in the ligaments tendons and nerves/ more diffuse and lasts longer
|
|
|
Visceral
|
caused by stimulation of deep internal pain receptors
|
|
|
Pain Threshold
|
point at which the brain recognizes and defines stimulus as pain
|
|
|
Physiology of pain
|
transduction- nociceptors are activated by chemical thermal or mechanical stimuli in periphery
transmission- peripheral nerves carry pain message to dorsal horn of spinal cord along two types of fibers A delta (lg and myelinated)and Csm and unmyelinated) |
|
|
Factors affecting Pain
|
emotions- fear guilt anger
developmental stage- preemies more sensitive injury in youth affects response later sociocultural factors- reactions to pain learned through family and culture communication/cognitive impairments |
|
|
Assessing Pain
|
understand pt. perception by reviewing the Hx, assess as fifth VS
|
|
|
Interventions for pain
|
dependent-get Px from MD
interdependent-get CNA to massage independent-listen to pt.report |
|
|
Evaluate effectiveness of pain mngmnt
|
are pain scores getting better?
accd to pt what is quality of life? reassess pain regularly use pain flow sheet |
|
|
Normal Movement
|
mobility depends on interaction between skeleton muscles and nerves
|
|
|
Changes in MS system due to IM
|
inactivity causes 7 to 10% loss of muscle strength, causes stiff joints and contractures
|
|
|
Changes in Metabolism due to IM
|
increase level of serum lactic acid and decrease ATP concentrations cause drop in metabolic rate. cause glucose intolerance and muscle mass loss
|
|
|
Changes in Cardio System due to IM
|
increased workload of the heart and venous stasis. blood pools in periphery, thrombus formation
|
|
|
Changes in Urinary due to IM
|
inhibits drainage of urine leads to stagnant urine and increases risk for infection
|
|
|
Changes in GI due to IM
|
slows peristalsis which leads to constipation and gas, could cause paralytic ileus (cessation of peristalsis)
|
|
|
Changes in Respiratory due to IM
|
decrease strength in chest muscles, secretions pool in the airways, risk of pneumonia
|
|
|
Changes in Skin due to IM
|
compress capillaries in skin obstructing circulation and cause ischemia and necrosis
|
|
|
Assessing mobility
|
-pt who is obese MS concern or bed bound
-nursing Hx -physical assess alignment, joints , gait and activity tolerance |
|
|
Interventions for IM
|
bed bound- positioning and passive ROM vinadine boots
mobility issues- promote execise and limit injury in exercise |
|
|
Principles in Body Mechanics
|
stand in alignment
wide base squat to lift objects close to body adjust hght of bed |
|
|
Factors influencing Hygiene
|
personal preference
culture/religion/spirituality economic status/living situation developmental level knowledge level |
|
|
Hygiene given by nurses
|
bathing
oral care perineal care grooming |
|
|
Purpose of Bathing
|
removes perspiration and bacteria to prevent odor
increases circulation provides sensory input good time to assess prevent pressure ulcer |
|
|
Assessment during bathing
|
assess self care abilities
assess skin through inspection assess feet/nails/eyes/mouth |
|
|
Factors affecting Skin Integrity
|
age- infants and elderly have thin skin
immobility- pressure cause skin break diet- skin reflects status nutrition sensory-tactile sense prone to break bad circulation- tissue metabolism medications- side effects moisture- leads to maceration fever- leads to sweat infection- around wound prevent heal lifestyle- tanning/smoking/piercing |
|
|
Assessment for pressure ulcers
|
ischemia occurs (lack of O2) skin will be cool and relieve pressure to find increase redness (reactive hyperemia) if red doesnt disappear quickly then tissue damage occurred. use of PUSH tool to assess ulcers--surface area, exudate and type of wound tissue are scored
|
|
|
Interventions for pressure ulcers
|
provide skin care/inspect every 8 to 12 hours
provide nutrition frequent positioning using assistive devices |
