unit 2 learning objectives

Question 1

Review the assessment and normal values of temperature, pulse, and respiration across the lifespan.

Answer 1

Newborn
temp 97-100
pulse 120-160
respiration 30-60

teen
temp 97-100
pulse 60-100
respiration 12-20

adult
temp 97-100
pulse 60-100
respiration 12-20

Question 2

Determine the cuff size and location most appropriate for the measurement of blood pressure, in the client, based on age and illness variables.

Answer 2

The bladder of width of 40% , length of 80% of arm circumference

use brachial artery

some illnesses like CVD might cause fluid buildup, and using bp cuff could cause fluid to build up and cause damage

Question 3

Explain the procedure to the client.

Answer 3

Educate patient about risks for hypertension. People with family history of hypertension, premature heart disease, lipidemia, or renal disease are at significant risk

prevention of hypertension includes lifestyle modifications (e.g., lose weight, exercise daily, reduce sodium and saturated fat intake

Question 4

Define the terms systolic and diastolic.

Answer 4

systolic blood pressure, measures the pressure in your arteries when your heart beats.

The second number, called diastolic blood pressure, measures the pressure in your arteries when your heart rests between beats.

Question 5

Utilize the American Heart Association standards when determining blood pressure.

Answer 5

normal <120 and <80

elevated 120-129 and <80

HBP stg1 130-139 or 80-89

HBP stg 2- 140 + or 90+

Crisis 180+ and/or 120+

Question 6

Describe factors that cause variations in vital signs.

Answer 6

temp;
Age Circadian rhythms Exercise Hormones Stress Environment Illness/ infection

pulse
age exercise stress illness temp medications fluid volume position sympathetic stimulation

respiation
age exercise acid-base balance nuerolpcal injury altitude chronic rest disease anemia anxiety medication pain/illness

blood pressure
age exercise stress ethnicity gender medications weight cicadianrythmm smoking position

Question 7

Define hypertension and describe the procedure for referral.

Answer 7

high blood pressure 140/90+

Report immediately to health care provider any irregularities in heart function and indications of impaired arterial blood flow.

• Report to health care provider changes in peripheral circulation, which may indicate circulatory compromise, which may result in permanent nerve damage or tissue death if untreated.
• Refer patient (if appropriate) to resources available for controlling or reducing risks (e.g., nutrition counseling, exercise class, and stress-reduction programs).

Question 8

Perform a pain assessment appropriate for the client’s developmental stage.

Answer 8

pain assessments are done on a 1-10 scale, and are subjective data said by the patient

Question 9

Identify anatomical landmarks used to assess the cardiovascular system.

Answer 9

Angle of Louis- below sternal notch

Aortic-right of sternum

Pulmonic left of sternum

Erb-move down on sternum

Tricuspid-near sternal border

mitral-near nipple-moving lateral from tricuspid

Question 10

Describe how to locate the PMI (Point of Maximum Impulse).

Answer 10

Locate PMI by palpating with fingertips along the fifth ICS in midclavicular line (see illustration). Note light, brief pulsation in area 1 to 2 cm (1⁄2–1 inch) in diameter at the apex.

Usually right under nipple

Question 11

Assess apical and peripheral pulses for rate, rhythm, and amplitude.

Answer 11

apical-short, gentle tap
short,nomrally only first half of systole

peripheral-ones like on wrist-should be 60-100 and medium amplitude(1-3)

Question 12

Auscultate and differentiate between heart sound variations (S1, S2, S3, S4 murmurs and rubs).

Answer 12

s1-lub
s2-dub
s3-abnomral -lub dub ee
s4-abnormal see lub dub
murmur-blowing/swooshing sound-extra heartbeat graded from 1-6 on loudness

Question 13

Differentiate absence or presence of peripheral edema and documentation.

Answer 13

edema is when fluid stays in spot on body
1-mild pitting-slight indentation no swelling

2-moderate pitting-indent sub used rapidly

3 deep pitting- indent remains for short time-leg swollen

4- very deep pitting-indent last for a very long tome

Question 14

Distinguish between normal and abnormal cardiovascular assessment data and documentation.

Answer 14

cap refill
nail clubbing
hair
edema
apical pulse
Jvd
color
chest vibrations

peripheral pulse grading

Question 15

Compare and contrast how age may affect the assessment of the cardiovascular system.

Answer 15

Pediatric / Infants
◦ Circumoral cyanosis
◦ Transient acrocyanosis
◦ Murmurs may be normal (innocent/functional murmurs)
◦ HR – Infants (100-180) after birth, then (120-140)
◦ PDA (patent ductus arteriosus closes after 2-3 days)

• Geriatric
  ◦ Foot/leg edema
  ◦ Peripheral vascular
• Pregnant women
• Leg edema
• More blood volume

Question 16

Identify anatomical landmarks to be used when auscultating breath sounds.

Answer 16

1 2
4 3
5 6

8 7
9 10

1 starts on top of lungs
slowly go in snake line down to bottom

Question 17

Differentiate between vesicular, bronchovesicular, and bronchial breath sounds.

Answer 17

V- low nd soft

BV– moderate

B– High, loud

Question 18

Describe adventitious breath sounds and the terms used to describe each.

Answer 18

Crackles-cracking noises-heard in short, medium or coarse

Rhonchi-loud low pitched continuous sound, like blowing air through fluid w/straw

Wheeze-high pitched musical sounds

Question 19

Determine how quality of cough, skin color, oxygen saturations, and respiratory rate all contribute to data collection for respiratory assessment.

Answer 19

all of those determine how well you are getting air into body

if low air quality in, cough is weak, skin turns blue, oxygen saturation is low and repository rate is higher

Question 20

Distinguish between normal and abnormal data during chest and respiratory assessment.

Answer 20

skin color

skin, nails
mucous membranes
nasal flaring
ribs
tripod positioning

pigeon chest
funnel chst
barrel chest

Question 21

Compare and contrast how age may affect the assessment of the respiratory assessment.

Answer 21

Pediatric
* Rounded chest
* Breath more with
diaphragm
* RR may be
irregular (infant)

• Elderly
• Fatigue easier
• Spine shape

Question 22

Define the terms “hypoxia and hypoxemia” and describe how to assess the client for the need for oxygen therapy.

Answer 22

Hypoxemia- a decrease in the partial pressure of oxygen in the blood

hypoxia is defined by reduced level of tissue oxygenation.

use pulse oximetry- gets oxygen levels in blood

Question 23

Compare and contrast oxygen delivery systems across the lifespan, including safety aspects, and indicate when/how each would be used.

Answer 23

Nasal cannula-Oxygen tank connected to pronged into nares–Used because easy and inexpensive

non-rebreather–mask attached to a simple bag–used to deliver high levels of oxygen

simple-Fits over mouth and nose-with side on face that allows expiration - used in moderate situations

rebreather-similar to nonrebreather mask, but no one way valves so patients exhaled air mixes w/inhaled air

Venturi-used for patents who need specific amount % of air with COPD

face tent-provides controlled concentration of oxygen and increase moisture

Question 24

Indicate procedures to maintain mucous membrane and skin integrity during oxygen administration.

Answer 24

Assessing the patient’s external ears, nares, and nasal mucosa for breakdown at least once per shift.

Frequent assessment is a priority and will help the nurse identify early signs of skin breakdown

Question 25

Describe other actions/techniques (C&DB, peak flow meter, IS, percussion, positioning) to improve oxygenation and when they would be utilized in client care.

Question 26

Explain what a pulse oximeter measures, the normal results, and how results are used to monitor oxygen therapy.

Answer 26

the saturation of oxygen carried in your red blood cells.

95-100

is used to determine how much/what type of oxygen therapy is needed

Question 27

Identify factors that can interfere with the accuracy of a pulse oximeter.

Answer 27

poor circulation,
skin pigmentation,
skin thickness,
skin temperature,
current tobacco use,
and use of fingernail polish.

Question 28

Describe assessment data that would indicate the client is receiving adequate oxygenation.

Answer 28

pulse oximetry is 95-100

skin is normal color

no edema

cap refil

Question 29

Identify anatomical landmarks and techniques used to assess the abdomen.

Answer 29

LUQ
Stomach
spleen

LLQ
large intestines

RUQ
liver
gall bladder

RLQ
intestines
appendix

Question 30

Differentiate between normal and abnormal abdominal assessment data (including bowel sounds) and document.

Answer 30

Character, frequency
* Normal
* Active in all 4 quadrants
*
Abnormal
* Hyperactive
* Hypoactive
* No bowel sound

Question 31

Compare and contrast how age-related variations may affect assessment of the abdomen.

Answer 31

Pediatric (Jarvis-p 176)
* Inspection: shape of abdomen; umbilical cord
* History
* Jaundice
* Pain
* Fussiness
* Intense crying
* Projectile vomiting
* Variations:

Geriatric (Jarvis-p178)
* Inspection: contour
* Auscultation:
* Check for decreased peristalsis
* Check aorta for possible bruit