chap 8 Flashcards
1
Q
who created AIDET?
A
Studor group
2
Q
AIDET is a
A
evidence based communication tool
3
Q
AIDET
A
- acknowledge
- introduce
- duration
- explanation
- thank you
4
Q
acknowledge
A
- show enthusiasm
- eye contact
- smile & greet
- “10/5” rule
5
Q
introduce
A
- complete any time change responsibilities
- job title
- certification/licensure
- experience
- number of procedures
6
Q
duration
A
- how long you will be w/ pt
- if any delays/interruptions may occur
7
Q
explanation
A
- what you will be doing/why
- what pt/family should expect
- what might be nxt steps
8
Q
thank you
A
- you enjoyed working w/ them
- thank for time
- shake hand
9
Q
how do you prepare for general survey?
A
observe
- skin color
- dress
- hygiene
- posture/gait
- physical development
- body build
- apparent age
- gender
10
Q
general survey
A
- physical development
- gender/sexual development
- apparent age
- skin condition/color
- dress/hygiene
- posture/gait
- LOC
- behaviors, body movements, affect
- facial expressions
- speech
- vital signs
11
Q
VS
A
- temp
- pulse
- respirations
- BP
12
Q
VS provide data on
A
status of
- cardiovascular
- neurologic
- peripheral vascular
- respiratory
- pain
13
Q
is physical examination subjective/objective?
A
objective
14
Q
equipment for physical exam
A
- thermometer
- disposable covers
- BP cuff
- stethoscope
- watch w/ second hand
15
Q
order of VS
A
- temperature
- pulse
- respirations
- BP
- pain
16
Q
factors that affect temperature
A
- dinural cycle
- ovulation/mensuration
- strenuous exercise
- age
- stress
- exposure to cold/heat
- illness
17
Q
tympanic temp range
A
98-100.9 F
18
Q
oral temp range
A
96.6-99.5 F
19
Q
axillary temp range
A
95.6-98.5 F
20
Q
temporal temp range
A
97.4-100.3 F
21
Q
rectal temp range
A
97.4-100.3 F
22
Q
standard temp range
A
96-99.5 F
23
Q
hyperthermia
A
> 100 F
24
Q
hypothermia
A
< 96 F
25
shock wave
produced when heart contracts & pumps blood out of ventricles into aorta
26
peripheral pulses
- carotid
- radial
- brachial
- pedal
27
characteristics of peripheral pulse
- rate
- rhythm
- amplitude/contour
- elasticity
28
normal adult BPM
60-100 beats/min
29
tachycardia
- rapid
| - > 100 beats/min
30
when could tachycardia occur?
with fever, certain medications, stress, abnormal states
31
bradycardia
- slow
| - < 60 beats/min
32
when could bradycardia occur?
- sitting/standing for long periods
| - heart block or dropped beats
33
sinus arrhythmia
- common in children/young adults
| - rhythm speed up (inspiration) & slows with expiration
34
amplitude
- 3+ bounding
- 2+ normal
- 1+ weak, thready
- 0 absent
35
normal respiration rate
12-20 breaths per minute
36
depth of respiration
- unlabored/labored
- shallow/deep
- use of accessory muscles
37
systolic BP
measurement of pressure of blood in the arteries when ventricles are contracted
38
diastolic BP
measurement of pressure of blood in arteries when ventricles relaxed
39
normal BP
120/80 or less
40
factors affecting BP
- cardiac output
- elasticity of arteries
- blood volume
- blood velocity (heart rate/thickness)
41
BP cuff size
80% of arm circumference
42
normal systolic
< 120-129 mmHg
43
normal diastolic
< 80-84 mmHg
44
prehypertension
120-139/80-89
45
orthostatic hypotension
low BP that occurs upon standing up
46
orthostatic hypotension measures
drop of > 20 mmHg when standing up
47
hypertension
> 140/90
48
stage 1 hypertension
140-159/90-99
49
stage 2 hypertension
>160/>100
50
stage 3 hypertension
> 180/110
51
expected findings for oxygen saturation
upper 90s
52
infants/pediatrics considerations w/ measurements
- weight
- length
- head circumference
53
what age should you take BP?
begin @ 3 years old
54
infants/pediatrics considerations w/ temp
- tympanic -> toddlers
| - oral -> begin age 5/6
55
RC
risk for complications
56
nursing diagnoses when analyzing data
- health promotion diagnoses
- risk diagnoses
- actual diagnoses
57
BP follow up normal
recheck in 2 years
58
BP follow up prehypertension
recheck in 1 year
59
BP follow up stage 1 hypertension
confirm w/in 2 months
60
BP follow up stage 2 hypertension
evaluate w/in 1 month
61
korotkoff phase 1
tapping (systolic pressure)
62
korotkoff phase 2
muffled, whooshing, swishing sound
63
korotkoff phase 3
return of distinct louder
64
korotkoff phase 4
muffling
65
korotkoff phase 5
all sounds disappearing
66
normal pulse pressure
30-50
67
hyperthermia can indicate
- bacterial/viral/fungal infection
- inflammatory process
- malignancies
- trauma
- blood/endocrine/immune disorders
68
hypothermia can indicate
- exposure to cold
- hypoglycemia
- hypothyroidism
- starvation
- neurologic dysfunction/shock
69
high point
systole
70
low point
diastole
71
ventricles relaxed
diastole
72
ventricles contracted
systole
73
isolated systolic hypertension
condition commonly seen in older adults when systolic pressure is > 140 mmHg and diastolic is normal
74
infants/pediatrics considerations w/ pulse
- apical < 2 years old
- radial > 2 years old
- count 1 full minute
