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108 Cards in this Set
- Front
- Back
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Diastolic pressure |
Measurement of the pressure excerpted by the blood on the artery walls while the heart ventricles are not contracting ( at rest); the lower of the two pressures; the bottom number of the b/p |
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Systolic pressure |
Measurement if the pressure exerted by the blood on the artery walls while the heart ventricles are contracting; the hugest of the two pressures; the top number of the b/p |
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Hypertension |
The systolic BP consistently over 140 mm Hg or the diastolic BP consistently over 90 Hg |
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Hypotension |
The BP suddenly falls 20 mm Hg to 30 mm Hg below the persons Nirmal BP or falls below the low normal 90/60 mm Hg |
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Orthostatic hypotension or postural hypotension |
When the position changes, it results in systolic pressure drop of 15 to 25 mm Hg or the diastolic pressure falls 10 mm Hg |
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Pulse pressure |
Measurement of the difference between systolic and diastolic pressures, normally a 30-50 point difference |
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Afebrile |
Without fever |
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Febrile |
Fever |
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Hyperthermia |
Fever |
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Hypothermia |
Temperature below normal |
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Pyrexia |
Fever, commonly above 105 degrees F |
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S1 |
As the ventricular contraction begins, the tricuspid and bicuspid valves (AV valves) slam shut; the first heart sound; the linger, lower-priced sound; the lub lub-dub |
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S2 |
As the ventricles begin relaxation, the pulmonary and aortic valves (semi lunar valves) close; a shorter, sharper sound; the dupp of lubb dupp |
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Bradycardia |
Heart rate below 60 bpm |
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Tachycardia |
Heart rate above 100 bpm |
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Pulse deficit |
The difference between the apical and radial pulse when the radial pulse is slower than the apical pulse |
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Eupnea |
Evenly spaced respiration of normal depth, between the rate of 12 and 20 breaths per minute |
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Apnea |
Respiration cease or are absent |
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Bradypnea |
Respiratory rate below 12/minute |
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Tachypnea |
Respiratory rate above 20/minute |
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Dyspnea |
Labored or difficult breathing |
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Stertorous |
Noisy, snoring, labored respirations that are audible without a stethoscope |
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Hypoxemia |
Decreased oxygen level in blood |
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Hypoxia |
Decreased oxygen level in tissues |
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Orthopnea |
Difficulty breathing unless in upright position |
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Stridor |
An audible high-pitched crowing sound that results from partial obstruction of the airways |
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Six vital signs |
Blood pressure (BP) Temperature (T) Pulse (P) Respiration (R) Oxygen saturation (SpO2) Pain |
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Why are vital signs significant? |
Reveal how systems are functioning, provide data of overall conditon,provide a baseline against sublets changes can be measured |
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What can affect the reading of a body temperature? |
Environment, time of day, physical activity and exercise, medications, food or drink, smoking, illness |
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Routes used for taking temperature are: |
Oral Tymoanic Auxiliary Skin Temporal artery Rectal |
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What are factors used to assess for respiratory rate? |
Rate per minute, depth, rhythm, pattern, respiratory effort |
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What are some abnormal breath sounds that are discussed in the chapter. |
Adventitous, wheeze, crackles or rates, rhonchi, stridor |
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Normal Sp02 level is? And where are the spots it can be taken? |
96%-100% Clip senior for fingertip, earlobe, bridge of nose, toe |
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When to reassess vital signs? |
After administering IV medications, changed level of consciousness, unstable postoperative condition, uncontrolled bleeding, pale, cold, clam my skin, suspect any change, serious condition suspected, instinct |
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4 circulatory qualities |
Strength of hearts contraction, blood thickness, blood volume, peripheral vascular resistance |
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Normal percentage of RBC in plasma (ages) |
Newborn: 49-54 Children: 35-49 Adult females: 37-47 Adult males: 40-54 Test to measure percentage: hematocrit |
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Korotkoff sounds |
First sound: clear, rhythmic tapping sound Second: soft, swishing, murmuring sound Third: sharper, crisper rhythmic sound Fourth: softening or muffling of rhythmic sound Fifth sound: silence |
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Effects of hypertension; and what are some risks |
-Gradual loss of elasticity in arterial walls -Heart works harder
Genetics, smoking, stress, alcohol,obesity, elevated cholesterol |
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Untreated hypertension causes |
Brain: stroke Heart: heart attack Kidneys: kidney failure Retina: loss of vision |
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Temporal pulse |
Used when radial not accessible |
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Carotid pulse |
Used in cardiac arrest |
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Brachial pulse |
Measures BP |
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Radial pulse |
Used for pulse rate assessment |
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Femoral pulse |
Determines leg circulation |
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Popliteal pulse |
Determines leg circulation |
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Posterior tibialis pulse |
Determines foot circulation |
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Dorsal Pedia pulse |
Determines foot circulation |
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Adventitous sounds |
Abnormal sounds heard by listening to lungs with a stethoscope, includes wheezes, rales or crackles, rhonchi, and stridor |
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Wheezes |
Musical, whistling sounds that may be audible without stethoscope |
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Rales or crackles |
Short, choppy, popping, snapping, raspy sounds that may resemble rubber band sounds between index finger and thumb |
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Rhonchi |
Low pitched rattling or bubbling, snoring, or sonorous wheezing sounds |
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Peripheral pulse sites |
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Peripheral pulse assessment |
Strength -absent or 0 -weak or 1+ ( may be thready) -Strong or 2+ -Bounding or 3+ Equality -equal strength bilateral lyrics - weaker than opposite side |
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How does the brain regulate vital signs? |
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What is needed to know for pain assessment? |
Site Location Characteristics (sharp,dull,stabbing,aching) Severity of pain (pain scale) |
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Thermogenesis |
Way human body produces heat is through the processes occurring after ingestion of food |
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Basal metabolic rate (BMR) |
Amount of heat the body produces at total rest |
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Thermoregulation |
Regulation of body temperature controlled by the hypothalamus |
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Circadian rhythm |
Body's "time clock" |
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Oral temp advantage/disadvantage |
Advantage: more accurate, convenient, simple, no position change Disadvantage: risk body fluid exposure, affected by smoking, drinking liquids,not for children/confused/unconscious patients |
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Skin temperature advantage/disadvantage |
Advantage: convenient, safe, comfortable route, good for newborns, unaffected by eating/drinking/smoking Disadvantage: affected by perspiration, reflect surface rather than core temperature, affected by severe environmental temperature |
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Typanic membrane advantage/ disadvantage |
Advantage: Convenient, easy route, quick (5 sec), preformed without disturbing sleep, comfortable, unaffected by eating/ drinking/smoking Disadvantage:inaccurate if probe not pointed to Tymoanic membrane, correct placement is difficult in children, can't be used with someone with ear infections, higher cost |
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Temporal artery temp. Advantage/disadvantage |
Quick (less than 5 sec) easy, comfortable, can use with chikdren, does not require positioning, not affected by eating/drinking/smoking Affected by perspiration, thick hair on artery gives inaccurate reading, high cost |
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Axillary temp advantage/disadvantage |
Safe, can be used on unconscious patient Temple 1° less than core temperature, changes in Temple are slower to be reflected |
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Rectal temp advantage/ disadvantage |
Most accurate, provides core temperature, reflect temp quick Embarrassment, positioning required, risk body fluid exposure, risk rectum perforation, can't have diarrhea, heroics, rectal surgery |
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Internal catheter probe temp advantage/ disadvantage |
Most accurate, core temo, continual monitoring Most invasive, require sterile technique, risk vessel perforation and infection |
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Uncontrolled hypertension can cause perminately damage to what organ? |
Heart |
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health assessment |
comprehensive assessment of the physical, mental, spiritual, socioeconomic, and cultural status of a individual, group, or communtiy |
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nursing assessments focus on.... |
the clients functional abilities and physical responses to illness and other stressors |
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what are the purposes of a physical assessment? |
to obtain base line data, to identify collaborative problems, to figure out nursing diagnosis and wellness diagnosis, to monitor the status of identified problem, and to screen for health problems |
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where would you do a comphrehensive assessment? |
annual physical, outpatient appointment, inpatient setting, admission onto unit |
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what is a focused physical assessment? |
pertains to a particular topic, body part, or functional ability rather than an overall health status. gets added to database of the comprhensive assessment |
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what is a specific system assessment? |
limited to one body system |
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what is an ongoing assessment? |
performed as needed, after the initial database is completed, and idealing after EVERY interaction with a patient |
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what is an head to toe approach? |
starts at the head and neck and progresses down the body |
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what is a body systems approach? |
examines each system in a predetermined order (musculoskeletal, cardiovascular, neurological |
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before approaching a patient ___________ yourself with the situation |
familiarize |
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when to avoid doing an assessment? |
when the client is...-hungry-tired-anxious-unwilling to cooperate with assessment |
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palpation is.... |
the use of touch to gather dataused to assess temperature, skin texture, moisture, anatomical landmarks (edema, masses, areas of tenderness) |
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percussion is... |
tapping your fingers on the skin using short strokesuseful when assess lung sounds and abdominal issues |
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ausculation means... |
the use of hearing to gather data |
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direct auscultation means... |
listening without using an instrumentexample: hearing wheezing without the use of a stethoscope |
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indirect auscultation means... |
listening with the help of an instrumentexample: listening to lung sounds |
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olfaction means... |
the use of the sense of smell to gather data |
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if a clients breath has a fruity or acetone smell, what does that mean? |
ketoacidosis! which may accompany diabetes! assess the urine for ketones |
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when assessing older adults, remember SPICES which stands for... |
means the typical issues that require nursing intervention.s=sleep problemsp=problems with eating or feedingi=incontinencec=confusione=evidence of fallss=skin breakdown |
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mongolian spots |
benign, blue black birthmarks found on the lower back and butt of some african american, hispanic, native american, and asian babies. usually fade by age 2 but can still persist until adolscence |
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capillary hemangiomas |
"stork bites", small, irregular pink-red areas that are usually on the face and nape of neck in newborns. diasppear in infancy and can last until 5 years old |
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use the __________ of the _______ to assess skin temperature |
dorsum, hand/finger |
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when assessing the skin, the nurse is checking for these four things....? MTTT |
moisture, texture, turgor, temperature |
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primary skin lesions are.... |
result from disease of irritation. example: acne |
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secondary skin lesions are... |
develop from primary skin lesions as a result of continued illness, exposure, injury, infectionexample: crusts that form from pimples |
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exceptionally dry hair may mean... |
HYPOthyroidism |
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exceptionally smooth (very fine, silky) hair may mean.... |
HYPERthyroidism |
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How to assess the head, acroynm: |
HEENThead, eyes, ears, nose, throat |
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what is the weber test? |
assesses the sound vibrations of nerve impulses from CN VIII. placing the vibrating tuning fork on the center of the clients head-should be able to sense the vibration in both ears. |
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what is the rinne test? |
uses the tuning fork to compare air conduction and bone conduction. used to assess the type of hearing problem |
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what is the romberg test? |
the patient should be standing feet together and eyes closed, with minimal swaying. test neurological issues as well as ear imbalances |
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an enlarged thyroid may be associated with either.... |
hyper/hypothyroidism |
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pulmonary circulation means... |
oxygen depleted blood circulates from the heart into the lungs and back into the heart |
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systemic circulation means... |
pumping it throughout the body |
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coronary circulation means... |
circulates blood through the heart itself |
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bruit means.. |
turbulent blood flow through the cartoid artery producing a whooshing sound |
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carotid stenosis means... |
narrowing from plaque, increased cardiac output secondary to fluid overload, use of stimulants, and hypothyroidism |
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Glasgow coma scale |
grades eye movement, motor, and verbal responses. relies heavily on verbal and vision interaction and doesn't evaluate brainstem reflexes |
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lethargic |
appears drowsy, easily drifts off to sleep |
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stuporous |
requires vigorous stimuli before responding |
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comatose |
does not respond to verbal or painful stimuli |
