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Patient Nursing Care Fundamen > Chapter 21 > Flashcards

Chapter 21 Flashcards

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1
Q

Information given from the viewpoint of the patient or some in the patient’s life

A

Subjective data

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2
Q

sign: information directly observed by the health care provider

A

Objective data

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3
Q

Label if they are subjective or objective:
1)Blood sugar level:__
2) Numbness/tingling sensation:___
3)Pain:___
4)Blood pressure:___
5)Bowel sound is normal active in 4 quadrant:____
6)Family stated patient has history of hypertension: __
7)Right leg is red and swelling: __

A

1) Objective
2) Subjective
3) subjective
4) objective
5)objective
6)Subjective
7) objective

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4
Q

Are clinical measurements that include blood pressure, pulse, body temperature, respiration, and oxygen saturation.

A

Vital signs

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5
Q

What are the 6 vital signs?

A

1) Temperature
2) blood pressure
3) heart rate(Pulse)
4) respiratory rate
5) oxygen saturation
6) Pain

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6
Q

Clinical measurements that indicate the state of ________ of the body

A

Essential functions

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7
Q

What is the normal range for temperature?

A

Normal ranges: 97.5F-99.5F (36.4 C- 37.5C)

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8
Q

What is the temperature range for pyrexia (Fever)?

A

> 100.2 or 100.4F (37.9C- 38C)

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9
Q

What are the symptoms of hyperthermia?

A

-flushed appearance, moist skin, chill, HR & RR ↑
-Compensation: diaphoresis
-Complications: dehydration, delirium, convulsions
-T > 105.8 F (41 C) – damage to body cells, esp. central nervous system.

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10
Q

What is the signs and symptoms of hypothermia?

A

-T < 95 F (35 C)
- sleepiness, coma

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11
Q

How would you take a rectal temperature?

A

Let patient be in sims position, Grab gloves and apply lube. Insert one full finger into the wall of the rectum.

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12
Q

How do you insert a rectal temp?

A

Insert 1 ½ inches toward the direction of umbilicus

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13
Q

Finish this statement:
Rectal temp - 1F(0.5C) _____ then oral

A

Higher

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14
Q

Finish the statement:
Axillary temp- 1F (0.5) ____ than oral

A

Lower

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15
Q

What is external factors can cause an inaccurate reading or affect temperature:
Temporal

A

Sweat

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16
Q

What is external factors can cause an inaccurate reading or affect temperature:
Tympanic

A

Ear wax

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17
Q

What is external factors can cause an inaccurate reading or affect temperature:
Oral

A

Swallow hot or cold foods, liquids, smoking or chewing gum. We wait 15-30 mins

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18
Q

What is external factors can cause an inaccurate reading or affect temperature:
Axillary

A

Sweat

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19
Q

What is external factors can cause an inaccurate reading or affect temperature:
Rectal

A

Stool and constipation

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20
Q

Location: Over temporal bone of head, above and lateral to eye
Rationale for selection: Easily accessible site used to assess pulse in children

A

Temporal

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21
Q

Location: Along medial edge of sternocleidomastoid muscle in neck
Rational for selection: Easily accessible site used during physiological shock, cardiac arrest, or when other sites are not palpable

A

Carotid

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22
Q

Location: fourth to fifth intercostal space at left midclavicular line
Rational for selection site used to auscultate

A

Apical

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23
Q

Location: Groove between biceps and triceps muscles at antecubital fossa
Rational for selection: site used to assess status of circulation to lower arm and to auscultate blood pressure

A

Brachial

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24
Q

Location: Radial or thumb side of forearm at wrist
Rational for selection: common site used to assess character or pulse peripherally and status of circulation to hand

A

Radial

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25
Location: little finger side of forearm at wrist Rational for election: Site used to assess status of circulation to hand; also used to perform an Allen's test
Ulnar
26
Location: Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine Rational of selection: Site used to assess character of pulse during physiological shock or cardiac arrest when other pulses are not palpable; used to assess status of circulation to leg
Femoral
27
Location: Behind knee in popliteal fossa Rational of selection: site used to assess status of circulation to lower leg
Popliteal
28
Location: Along top of foot, between extension tendons of great and first toe Rational of selection: Site used to assess status of circulation to foot
Dorsalis pedis
29
Location: Inner side of ankle, below medial malleolus Rational of selection: Site used to assess status of circulation to foot
Posterior tibial
30
What is a normal pulse
-HR: 60-100 bpm -Regular rhythm -Strong 2+
31
What is the pulse for tachycardia
HR > 100bpm
32
What is the pulse for bradycardia?
HR < 60 bpm
33
What is the breathing pattern: Rate- 12-20 breaths/ min Causes- Regular inspiration & expiration
Eupnea (normal)
34
What is the breathing pattern: Rate- <12 breaths/min Causes- Opioids, hypothyroidism, head injury, heart attack
Bradypnea
35
What is the breathing pattern: Rate- >20 breaths/ min Causes- sepsis, infection, acidosis, COPD
Tachypnea
36
What is the breathing pattern: Rate- Periods of zero (0) respirations Causes- obesity, smoking, narrowed airway, sleep apnea
Apnea
37
What is the breathing pattern: Rate- periods of inspiration & expiration w/ periods of apnea causes-end of life (brain tumors, TBI's and ICP)
Cheyne-strokes
37
What is the breathing pattern: Rate- Increased rate & depth (trying to blow off CO2) Causes- anxiety attacks, extreme exertion, fears, acidosis, etc
Hyperventilation
38
What is the breathing pattern: Rate- Deep, rapid, breathing pattern Causes- Diabetic ketoacidosis (DKA)
Kussmauls
39
Finish this pain Numonics of "PQRSTU"
P= palliating/ participating factors Q= Quality R=Radiation or pattern S=Severity or site T= temporal nature U= You!
40
Finish the Numonic "WHATS UP"
W= Where is it? H=How does it feel? A=Aggravating & alleviating factors? T=Timing, when did it start U=Useful other data P=Patient perception of the problem
41
Elevated temperature
Fever
42
Agents that cause fever
Pyrogens
43
_____ is the rate at which heat is produced when the body is at rest
Basal metabolic rate (BMR)
44
What is another word for fever?
Pyrexia
45
State of insufficient oxygen
hypoxia
46
Insufficient oxygen to the brain
Cerebral hypoxia
47
___ is the volume of blood pushed into the aorta with each heartbeat.
Stroke volume
48
_____ is the amount of blood pumped by the left ventricle in 1 minute
Cardiac output
49
________ is the exchange of oxygen and carbon dioxide in the lungs and tissues and is initiated by the act of breathing
Respiration
50
Excessive fluid volume
Overhydration
51
eardrum
Tympanic membrane
52
Temperature taken in the armpit
Axillary temperature
53
Is the temperature of the deep tissues of the body
Core temperature
54
Above normal body temperatures
Hyperthermia
55
Sensations of cold and shaking of the body
Chilis
56
Abatement of fever
Defervescence
57
___ stage is the body temperature rises to the new set point established by the hypothalamus and remains there until the cause of the fever resolves
Febrile
58
Abrupt decline in fever
Crisis
59
Gradual return to a normal temperature, when applied to fever
Lysis
60
Subnormal body temperature
Hypothermia
60
_____ refers to a pulse greater than 100 beats per minute
Tachycardia
61
Irregular pulse
arrhythmia
61
The pointed end of the heart
Apex
61
indicates a pulse that is less than 60 bpm
Bradycardia
62
Bluish discoloration
Cyanosis
63
Difficult and labored breathing
Dyspnea
64
Increased or rapid breathing
Tachypnea
65
Slow and shallow breathing
Bradypnea
66
Decreased levels of oxygen in the blood
Hypoxemia
67
Is a pattern of breathing in which there is an increase in the rate the depth of breaths and carbon dioxide is expelled causing the blood levels of carbon dioxide to fall
Hyperventilation
68
Have an increased rate and depth with panting and long, grunting exhalation
Kussmaul respirations
69
Are four or five breaths of equal depth alternating with irregular periods of apnea
Biot registrations
70
absence of breathing
Apnea
71
Consist of a pattern of dyspnea followed by a short period of apnea
Cheyne-strokes respirations
72
Abnormal, nonmusical sound heard on auscultation of the lungs during inspirations; formally called rales
Crackles
73
Low pitched wheezes. Continuous, dry rattling sounds heard on auscultation of the lungs caused by partial obstruction
Gurgles
74
Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Stertor
75
Crowing sound on inspiration caused by obstruction of the upper air passages, as occurs in croup or laryngitis
Stridor
76
Whistling sound of air forced past a partial obstruction, as found in asthma or emphysema
Wheeze
77
Measurment of oxygen
Oximetry
78
Machine that measures oxygen in the blood
Oximeter
79
While measuring blood pressure, you may hear certain sounds that relate to the effect of blood pressure
Korotkoff sounds
80
Pressure consistently above 130 systolic and/ or 80 diastolic is called ______. Also known as high blood pressure.
Hypertension
81
low blood pressure and is below 90/60 mm Hg
Hypotension
82
Circulatory collapse
Shock
83
A normal, relaxed breathing pattern
Eupnea

Patient Nursing Care Fundamen (13 decks)

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