Interventions Module 4

Front 1

baseline information

Back 1

what is there normal vital signs that can be used to compare with other levels when sick

Front 2

core body temperature range (Fahrenheit and celsius)

Back 2

97-99.5 F

36-37 C

Front 3

5 factors that can affect body temperature

Back 3

circadian rhythm (lowest body temperature in morning, highest in afternoon (possibly due to muscle activity and digestion)),

Age (in extremes of age (infants and elder) do not have the ability to regulate core body temperature as much)

Gender (women have greater temperature variability due to ovulation)

extreme environmental temp

increase in metabolic rate (exercise, stress, illness)

Front 4

febrile

Back 4

temperature above normal, possibly due to infection and increased immune function

Front 5

afebrile

Back 5

normal temperature

Front 6

hypothermia

Back 6

body temperature below normal range

Front 7

why is a fever not reliable for older adults and premature infants

Back 7

they do not have the same way of regulating their body temp, because of this, they don't have the same immune response. An infection could be very bad, and yet barely have a temperature of 100.

Front 8

why is a fever not reliable for immunocompromised status

Back 8

if their immune system is compromised, they can't initiate the same immune response so they can't create a fever.

could have infection without immune response and fever

Front 9

what temperature is indicative of an infection

Back 9

101F core temperature

Front 10

temperature differences between routes taken to obtain it

Back 10

+1 from oral for tympanic and rectal

-1 from oral for axillary

Forehead is -4.6 from oral (not temporal artery)

Front 11

when would you not want to use a tympanic thermometer

Back 11

if there is a lot of drainage or scarred tympanic membrane (probably hard of hearing on one side)(blood flow is not the same

okay if there is a lot of earwax or a possible ear infection

Front 12

when would you use axillary temperature

Back 12

pediatrics, takes a lot of time, though.

least accurate and least reliable

recommended for infants and children

Front 13

how to take rectal temperature

Back 13

put lube on the protective covering, tell them to take a deep breath, aim it up toward the umbilicus (people will try to push that out)

Front 14

when do you not use rectal thermometer

Back 14

when they have diarrhea, bowel surgery, disease of the rectum

neutropenic (immuno suppressed) (accidently puncture mucosa could lead to infection)

quadriplegics

cardiovascular surgery (stimulates parasympathetic nervous system leading to bradycardia which could cause them to faint)

Front 15

NANDA nursing diagnoses that nurses can choose from temperature

Back 15

hyperthermia, hypothermia, risk for imbalanced body temperature, ineffective thermoregulation

Front 16

characteristics of pulse

Back 16

rate, quality, and rhythm

Front 17

quality of pulse by amplitudes

Back 17

0 is pulse is absent, +1 is thready, +2 is weak, +3 is normal, +4 is bounding

Front 18

cardiac output

Back 18

heart rate x stroke volume

Front 19

factors affecting pulse rate

Back 19

age (as you age pulse gets slower) (infants have faster pulse rates)

autonomic nervous system (if sympathetic is activated, HR is increased. If parasympathetic NS is activated, HR is decreased)

medications (can decrease volume of blood, increase efficiency of heart contractions)

Front 20

what is the correlation between temp and pulse

Back 20

as temp goes up, pulse goes up because metabolic activity has increased

Front 21

tachycardia

Back 21

more than 100 BPM,

ventricle does not have enough time to fill, so stroke volume is also less

Low BP, high temp, poor oxygenation

exercise, very hot, pain- anything that activates sympathetic NS

Front 22

bradycardia

Back 22

less than 60 bpm

sleeping, men, older adults,

hypothermic, vagostimulation, severe pain (parasympathetic NS)

Front 23

dysrhytmia

regularly irregular

Back 23

discernible, predictable pattern when listening to someone's heart

Front 24

dysrhythmia

irregularly irregular

Back 24

no predictibility in pulse

cardiac disease, electrolyte imbalance

Front 25

NANDA nursing diagnoses with cardiac output

Back 25

acute pain, deficient fluid volume, ineffective tissue perfusion, decreased cardiac output

Front 26

factors that affect respirations

Back 26

age (as lung capacity increases, respiration decreases)(toddlers breath really fast, adults breath a lot slower)

gender (men have slower respiratory rate due to larger lung capacity)

stress, anxiety (initiates sympathetic NS causing it to go up)

exercise (tissue needs more oxygen so you breath faster)

acid-base balance (imbalances will lead to changes in respiration)

medications (narcotics and sedatives make it go down, amphetamine and bronchodilator makes it go up)

altitude (decreased oxygen content so increase in rate)

pain (increases)

anemia (decrease in hemoglobin carrying capacity so an increase in respiratory rate)

fever (increases metabolic rate so increases RR)

respiratory diseases (when lying down, lungs can't expand as well)

Front 27

eupnea

Back 27

breathing at a normal rate

Front 28

tachypnea

Back 28

breathing faster (more than 20)

Front 29

bradypnea

Back 29

slower than normal, less than 12

Front 30

apnea

Back 30

not breathing

Front 31

NANDA diagnoses for breathing

Back 31

ineffective breathing patterns, impaired gas exchange, risk for activity intolerance (not able to maintain a certain level of activity) (RR goes up, pulse goes up, BP goes up)

Front 32

sphygmomanometer

Back 32

blood pressure cuff

Front 33

factors that affect BP

Back 33

age (adults have normal range, older adults have higher (especially systolic))

circadian rhythm (lowest in morning, highest in afternoon)

gender (woman are lower than men until menopause)

food intake (higher after they eat)

exercise (systolic is higher after exercising)

weight (overweight means they normally have higher BP)

emotional state

body position (lowest when lying down, higher when standing)

race (hypertension is more prevalent in african americans)

medication (cardiac meds decrease amount of blood, and analgesics decrease BP)

Front 34

how does cuff size affect BP

Back 34

if the BP cuff is too wide for the person, it will give a false low, if too narrow, it will give false high

Front 35

how to take a blood pressure

Back 35

locate brachial artery, center cuff over the artery, palpate brachial artery while inflating cuff, at some point, pulse will go away, deflate cuff, put on stethoscope and reinflate cuff until 30 mmHg above the point that the pulse went away. Deflate cuff slowly and note when you hear the beat and when it disappears.

Front 36

what BP reading will you get with a doppler monitor

Back 36

systolic

Front 37

prehypertensive BP

Back 37

120-139

80-89

Front 38

mild hypertensive

Back 38

140-159

90-99

Front 39

what organs are at risk for damage by hypertension

Back 39

brain, heart, kidneys

Front 40

pulse pressure

Back 40

mathematical equation

systolic pressure- diastolic pressure

larger the pulse pressure (more difference between the two numbers), the more of an indication that the arteries are not compliant (little elasticity)

has more vascular resistance

Front 41

stroke volume and pulse pressure

Back 41

larger stroke volume gives a larger pulse pressure at any compliance

Front 42

orthostatic hypotension

Back 42

blood pressure drops when standing, get weak, feel faint

normally, when standing, changes in blood vessels, vasodilate and then quickly vasoconstrict and increase cardiac output

people with orthostatic hypotension do not get this change so quickly meaning that it is hard to get blood to the brain

people at risk: older adults, prolonged bed rest patients, dehydrated, blood loss, medications

Front 43

normal oxygen saturation

Back 43

above 96, below 93 means they need oxygen

Front 44

why would an anemic patient have a false high O2 stat

Back 44

they might give you a false high because there are not enough oxyhemoglobin receptors in their blood

Front 45

NANDA nursing diagnoses

Back 45

decreased cardiac output, ineffective health maintenance, effective therapeutic regimen management, risk for falls (orthostatic hypotension)

Front 46

xiphoid process

Back 46

bottom of sternum (cpr on patient)

Front 47

angle of louis

Back 47

on the second rib where the sternum and manubrium (top part of sternum) bones come together

Front 48

flow of blood through heart

Back 48

through vena cava into the right atrium, then through tricuspid valve into the right ventricle. from here it goes out the pulmonary valve into the pulmonary artery to the heart. from the heart it will return through pulmonary vein into the left atrium. From here it flows through the mitral valve into the left ventricle through the aortic valve into the aorta

Front 49

diastole is the period of time when

Back 49

the ventricles are passively filling. they just contracted and are now able to fill again.

Lub is S1, Dub is S2

period of time between S1 and S2 is diastole.

Front 50

systole is when what is happening

Back 50

ventricles are contracting to send blood to lungs or body, atrium are passively filling with blood.

systole is between S1 and S2 (between lub dub)

Front 51

lub is ______ dub is _______

Back 51

S1, S2

Front 52

what should you ask during general health assessment part of an interview for CV

Back 52

ask them about their fatigue and ask if it is unusual or persistent (are they always fatigued, does it go away) (could indicate not enough oxygen supply getting to organs and muscles)

signs of distress- do they look like they are leaning forward or having a hard time breathing, nausea and vomiting without being sick

chest pain, angina

Front 53

what should you ask during family history assessment part of an interview for CV

Back 53

family history of hypertension, diabetes, Cardiovascular disease, hyperlipidemia

Front 54

what should you ask during medication history assessment part of an interview for CV

Back 54

any current prescription drugs being taken (name of drug, dosage, how often, how long)

any current over the counter perscription (herbal supplements, vitamins, pain relief)

Front 55

what should you ask during activity level assessment part of an interview for CV

Back 55

amount of exercise that they get (30 minutes a day for several days a week)

periods of relaxation (how restful their sleep is, do they take naps, alcohol, caffeine)

Front 56

what should you ask during weight and diet assessment part of an interview for CV

Back 56

weight in relation to height (BMI) (overweight and obese is more likely to have hypertension)

what do they eat per day- do they follow a healthy diet, low cholesterol and triglyceride diet, do they actually eat a low sodium or fat diet or do they just think that they do

Front 57

what should you ask during lifestyle assessment part of an interview for CV

Back 57

are they anxious or stressed (type A personality), do they work somewhere stressful or somewhere with a lot of chemicals, is it very repetitive (leads to a lot more stress in their job if they are doing something repetitive)

Front 58

what should you ask during habits part of an interview for CV

Back 58

do they smoke (can decrease by 30-50% in the first year), drink alcohol excessively (women no more than 1, men no more than 2)

Front 59

anxiousness or restlessness could be a sign of

Back 59

central cyanosis, hypoxic, less oxygen getting to their brain,

Front 60

circumoral pallor

Back 60

lips blue and large circle around lips that is very pale

sign of central cyanosis

Front 61

central cyanosis in membranes of mouth

Back 61

would be pale or dusky bluish or grayish

Front 62

lower part of eye in central cyanosis

Back 62

pull down lower lid of eye. should be red, if it is pale, blue, or grayish, could be central cyanosis

Front 63

capillary refill

Back 63

test to assess oxygen content level in blood and to assess hydration status (is there enough circulation in blood)

pinch finger and then let go. should become white and then blood will return in less than two seconds and look normal

capillary refill would be slower if there isn't enough oxygen or dehydrated

Front 64

tripod position

Back 64

could be a sign of respiration issues or long standing cardiovascular disease

drop diaphragm and lean forward a bit.

helps them to breath better

(looks like how people look after they were running and need to catch their breath)

Front 65

finger clubbing

Back 65

late sign of cardiovascular disease and hypoxia

can use schamroth's test. put fingers together and should see triangle area of space between fingers, if you don't see that space, could be clubbed fingers

Front 66

using sternocleidomastoid muscle to breath could be a sign of

Back 66

having problems taking breath in and exhaling

can see muscle bulge out when they are breathing

Front 67

another muscle besides sternocleidomastoid that is used when people are having a hard time breathing is

Back 67

trapezius and intercostal muscles

Front 68

pmi

Back 68

point of maximal impulse

where you hear the pulse the best

Front 69

pulse deficit

Back 69

difference between the apical and radial pulse rate

Front 70

in a pulse deficit how is the radial pulse different from the apical pulse

Back 70

the radial pulse will be slower