Clinical skills Flashcards
(37 cards)
Factors to assess when taking tympanic temp:
Otitis media, impacted cerumen, inflammation, recent ear surgery
Factors that can affect pulse rate and rhythm:
Medical history, disease process, age, exercise, and medications
How to rate strength of pulse:
Bounding, full or strong, barely palpable or diminished;; or absent
For a regular pulse-
Count rate for 30 secs and multiply by 2
For irregular pulse-
Count rate for 60 secs
Normal pulse rate:
60-100 BPM
How to locate PMI/apical impulse:
Over the apex of the heart in the 5th intercostal space at the left midclavicular line
Color of probe when taking rectal temp:
Red
Placement of tympanic thermometer probe:
Gently tug the pinna backward, up, and out before inserting the probe.
How to tale temporal artery temperature:
Place the sensor flush on the patient’s forehead.
What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?
Assess pt for pulse deficit
Inadequate oxygenation to the body will cause the radial pulse to become:
Tachycardic
Which action would take priority if a patient’s apical pulse has an irregular rhythm?
Reassess pulse for 1 full min
Factors that cause pulse deficit:
Irregular heart rate, dyspnea, fatigue, chest pain, orthopnea, palpitations
How to find a pulse deficit:
Subtract the radial rate from the apical rate. If the difference is more than 2 BPM, a pulse deficit exists.
F/u care for a pt with a pulse deficit:
Signs or sxs of decreased cardiac output, such as edema, cyanosis or pallor of the skin, and dizziness or syncope.
Factors that can affect respiratory rate:
Exercise, anxiety, acute pain, smoking, and medications
Normal respiratory rate:
12-20 breaths per minute
What to note as you count respiratory rate:
The depth of the respiration as shallow, normal, or deep by observing chest wall movement.
F/u care after checking respiratory rate:
Compare respirations with the pt’s previous baseline, usual rate, depth, and rhythm. Correlate the pt’s respiratory rate, depth, and rhythm with pulse ox and arterial blood gas measurements.
Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?
Assess respiration after measuring the pulse.
The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?
Encourage the patient to rest for 10 minutes before assessing respiration.
During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?
Continue to count the patient’s breaths for a full 60 seconds.
Where should the BP cuff lie on the arm?
2-3 cm above anticubital fossa
