Exam 1 Review Flashcards
Week 1-4 (243 cards)
1
Q
what is controlled acts
A
performed only by qualified individuals or if delegated to you
2
Q
Primary survey includes checking:
A
ABC = airway, breathing, circulation
Disability
Exposure
3
Q
Level of unconciousness
A
Alert and oriented
confused and disoriented
Lethargic
Obtunded
Unconscious
4
Q
Lethargic means
A
Tired andSlow/sluggish
5
Q
Confused and disoriented aka
A
altered cognition
6
Q
obtunded means a patient
A
needs constant stimulation, if not they will go back to sleep
7
Q
What to assess/ask when checking for level of orientation
A
Place
Time
Person
Self
8
Q
What do you look at when examining mental status
A
Appearance
Behaviour
Cognition
Thinking
9
Q
Firs level priority are
A
life threatening and needs urgent action
10
Q
second level priority is when
A
it can lead to clinical deterioration, needs prompt action
11
Q
third level priority is
A
non urgent, but needs to be addressed (EG: teaching/educating)
12
Q
what do you have to consider when prioritizing care (aside from the patient’s assessed data)
A
what is most important to the client
13
Q
When should mental health be a priority instead of first, second or third level priority
A
When a person has a plan (when and where)
14
Q
Types of interventions
A
Effective
Ineffective
Unrelated
Contraindicated
15
Q
Types of care people are receiving that determines their health assessment frequency
A
Primary care
Long term care
Acute care
16
Q
Types of health assessments
A
Primary Survey
Focused assessment
Head to toe (Abbreviated)
Complete health assessment
17
Q
Another term for Head to toe assessment
A
Cephalocaudal approach
18
Q
Diff types of health promotion
A
Behavioural = lifestyle
Relational = their environment
Structural = hospital policies
19
Q
Health promotions and interventions allow patients to
A
enable them to increase control over their health
20
Q
Stroke volume (SV) refers to
A
About 5-80 ml of blood that is being pumped with each contraction of left ventricle
21
Q
Peripheral pulse means
A
refers to the feeling of blood moving away from the heart traveling to the body
22
Q
What pulse location do you use when taking Vital signs
A
Radial pulse
23
Q
Where is radial pulse located
A
bone close to flexor of wrist.
Radial artery
24
Q
Where is carotid pulse located
A
medial to sternomastoid muscle in middle third of neck
25
T or F should you palpate carotid artery one at a time only? why?
Yes, you should only palpate carotid artery one at a time to not block the brain completely of blood
26
Where is brachial pulse located
in the antecubital fossa in the bicep tendon
27
What do yo u assess for when taking pulse
Rate
Rhythm
Force
Equality
28
Normal pulse (BPM) for adult
60-100 BPM
29
Normal pulse for newborn
100-175 BPM
30
Bradycardia is when
Pulse is lower than 60 BPM = Low Pulse
31
Tachycardia is when
Pulse is higher than 100 BPM = High pulse
32
what is Sinus arrhythmia
Irregular heart rhythm.
Abnormal health rhythm that shows your heart is HEALTHY
33
Diff level of pulse force
0 = Absent
1= weak/thready
2= normal
3 = bounding/strong
34
What is Equality or bilateral assessment?
Checking both sides of the body
35
Changes in Blood pressure is based on whether the heart is:
Contracting (systolic)
Resting (Diastolic)
36
Blood pressure refers to
the force of blood exerted against arterial wall
37
Systolic refers to
Contraction of left ventricle of the heart.
Maximum force on artery wall
38
Diastolic refers to
when left ventricle is at rest/filling
39
is systolic or diastolic takes longer period of time?
Diastolic takes longer
40
If BP doesn't fall within the normal range what should you do
Inform the nurse
check for equality (other side)
compare to client's personal base line
41
Pulse pressure refers to
the diff between systolic and diastolic.
Measuring the force ur heart generate when it contracts
42
Cardiac output (CO) refers to
volume of blood pumped in 1 min
43
Cardiac output formula
cardiac output = Stroke volume X Heart rate
44
Stroke volume formula
SV = EDV - ESV
stroke volume = end diastolic volume - end systolic volume
45
Peripheral vascular resistance
Opposition to blood flow
46
Factors affecting one's Blood pressure
Cardiac output
Peripheral vascular resistance
Viscosity
Volume of circulating blood
Elasticity of vessel walls
47
Modifiable risk factor affecting BP include:
Sedentary lifestyle/exercise
Diet/alcohol intake
Emotions/stress
Disease processes
Dysglycemia & dyslipidemia
Non adherence to treatment plans
48
Non modifiable risk factor affecting BP
Age
> Age 55 years and older increased risk of HTN
Sex
Ethnicity
Family history of CV disease
Diurnal rhythm
Smoking
Weight/obesity
49
What is Diurnal rhythm
Type of circadian rhythm.
Diurnal rhythm is the natural daily pattern of changes in the body, like sleeping at night and being awake during the day. It follows a 24-hour cycle and is controlled by light and darkness.
49
What is Dysglycemia
Dysglycemia = abnormal blood sugar levels
focus on the glycemia part of the name
50
What is Dyslipidemia
Dyslipidemia = abnormal level of lipids in the bloodstream
focus on lipid on the name
51
Methods of taking BP measurements (4)
Manual
automatic
Arterial catheters
Cellular phone apps
52
what is arterial catheters
Invasive BP monitoring, by inserting inside the body, usually on the wrist
53
Width of BP cuff should equal __% of the circumference of patient’s arm
40%
54
What happens if the BP cuff is not the right size
gives false reading
if the cuff is too small, its gonna show a higher BP than it actually is
55
What is auscultatory gap
abnormal finding, period of silence between korotkoff sounds
56
What is orthostatic hypotension
drop in systolic BP of more than 20
and diastolic of 10
this may include increase of pulse more than 20
so basically when someone moves and when their BP drops and their heart rate spikes
57
common cause of orthostatic hypotension
Prolonged bedrest
older age
dehydration
58
What is considered hypertension in older adults. when it reaches
More than 140/90 BP
59
What is considered hypotension is older adults
Less than 95/60
60
List of common BP errors (just read)
Anxiety
Arm position and leg position
Inaccurate cuff size
Failure to palpate radial artery
Poor inflation of cuff
Pressing stethoscope too hard
Deflating cuff
Pausing during descent
Failure to wait adequate time between measures
Observer error
61
What is COPD – Chronic obstruction pulmonary disease
lung disease that restricts airflow and breathing
62
What is focused assessment
focus on the patients reason for seeking care/ specific health concern
63
what is primary survey
checks ABC, exposure and disability
64
head to toe assessment vs complete health assessment
head to toe = overview of client's CURRENT health status
Complete health assessment = overview of client's health status overall
65
what is atrial fibrillation
When atria quivers
66
Higher Cardiac output
High Peripheral vascular resistance
High Volume of circulating blood
High Viscosity of blood
> Results in low/high BP?
High BP
67
Low Cardiac output
Low Peripheral vascular resistance
Low Volume of circulating blood
Low Viscosity of blood
> Results in low/high BP?
Low BP
68
If vessel walls are more elastic does it result in higher or lower BP?
If its more elastic its lower BP
69
Difference of about 10 mm Hg decrease in BP and increase in pulse of 10-15 bpm is normal or abnormal from lying to standing?
Normal
Abnormal if its more than 20 BP and BPM
70
Orthostatic tachycardia is
(tachyCARDIA)
increase in pulse of 20 BPM when moving
Pulse not BP
71
What is aneurysm
may be a result of hypertension, when blood vessels ballon cause of weak walls
72
What is peripheral arterial disease?
result of hypertension, obstruction of vessels
73
when assessing for respiration what do you check?
Rate
Rhythm
Quality (are they using their accessory muscles?)
Note of any respiratory distress
74
What position should you be wary of when checking for the patient's respiratory
tripod position -> leaning forward and holding things for support
- Tracheal tugging
- wide eyes
- nasal flaring
- intercostal tugging
75
Normal range of respiratory for older adults
10-20
Higher for younger individuals
76
normal O2 saturation range
97-100%
92-100% acceptable for older adults
77
influencing factors of O2 sat findings
Age
Obesity or certain diseases
smoking and anemia
78
alternative sites for pulse oximeter placement if fingers are not possible
Earlobe
Forehead
79
What part of the brain controls temp
hypothalamus
80
what is the core temps for adults
36.5-37.5 celcius
81
core temps for infants or children
35.5-37.7 celcius
higher than adults
82
influencing factors for temp
age
stress
diurnal cycle
menstruations
pregnancy
exercise
hyperthermia
hypothermia
83
normal range of temp for oral
35.8 - 37.3 celcius
84
normal range of temp for axillary
34.8 - 36.3 celcius
85
what is the normal temp for tympanic
36.1- 38.9 celcius
86
what is the normal temp for rectal
36.8 - 38.2 celcius
87
who do you use rectal temp to and when?
usually for infants if they have a fever, it can be dangerous
but it cal also be done for older adults in special circumstances
88
T or F weight can change on the time of day
Yes True
89
BMI: underweight, normal weight, overweight, obese
less than 18.5
underweight
90
BMI: underweight, normal weight, overweight, obese
18.5 - 24.9
normal
91
BMI: underweight, normal weight, overweight, obese
25.0 - 29.9
Overweight
92
BMI: underweight, normal weight, overweight, obese
more than 30
Obese
93
Calculating BMI, what are the 2 formulas
Kg/(metres^2)
(Lbs/ (inch^2) ) X 703
94
Conversion of Kg and Lbs
X or / by 2.2
1 Kg is 2.2Lbs
95
Conversion of metres to inches
X or / by 39
1metres is 39 inch
96
downside of BMI
doesn't account for individual differences such as ethnicities
97
Wasted/stunded in context of weight/BMI refers to
severely underweight/stunded height
98
What waist and hip circumference measurements indicate increased risk for men and women?
Men: ≥ 102 cm (40 in)
Women: ≥ 88 cm (35 in)
99
What is the Waist-to-Hip Ratio, and what values indicate increased risk?
Waist-to-Hip Ratio = Waist ÷ Hip
Increased risk:
Men: ≥ 0.90
Women: ≥ 0.85
100
What is the Waist-to-Height Ratio, and what value indicates increased risk?
Waist-to-Height Ratio = Waist ÷ Height
Increased risk: Ratio ≥ 0.5
101
Apnea refers to
pauses in breathing
102
is oxygen considered medication? are nurses able to give them?
oxygen is a medication, nurse practitioner can give them if needed.
Nurses can only give in emergency situation = dips bellow 92%
103
is fevers helpful? why?
yes, it can fight off infection in the body
104
are anthropometric body measurements used as diagnostic tools?
no its for screening tools only, to see a person's overall health
105
why is it a risk if an individual has higher measurements for their anthropometric body measurements?
because carrying adipose tissue can be hard for the heart
106
Match with the correct normal respiratory rate range
7-11 years
2-6 years
Adults and Older Adults
12-18 years
Newborn to 6 months
6 months to 1 year
10-20
22-36
30-60
18-30
26-40
12-22
Adults and older adult: 10-20
12-18yrs: 12-22
7-11 yrs: 18-30
2-6 yrs: 22-36
6 month-1 year 26-40
Newborn-6 month: 30-60
107
what should the quality of a respiratory be when you are assessing for it?
relaxed and silent
108
What does IPPA stand for when doing an objective assessment
Inspection
Percussion
Palpation
Auscultation
109
What should you do/ask the patient to do before objective assessment?
if they need to go to the bathroom
prepare the environment
privacy and warmth
body positioning and mechanics (for u and patient)
developmental considerations (how much they have to move, especially for older adults)
care partners
110
when doing an objective assessment, if there are no precautions needed do you wear gloves or use bare skin?
bare skin
only wear gloves if theres precautions or skin breakdown,etc
111
What does "Cranial" mean in terms of anatomical location?
Cranial refers to towards the head or the skull.
112
What does "Caudal" mean in terms of anatomical location?
Caudal means towards the tail or lower part of the body.
113
What does "Posterior" mean in terms of anatomical location?
Posterior refers to the back or behind of the body.
114
What does "Dorsal" mean in terms of anatomical location?
Dorsal refers to the back of the body, often used for animals or in reference to the back side.
115
What does "Anterior" mean in terms of anatomical location?
Anterior refers to the front or towards the front of the body
116
What does "Ventral" mean in terms of anatomical location?
Ventral refers to the front or belly side of the body.
117
What does "Superior" mean in terms of anatomical location?
Superior means above or towards the head.
118
What does "Inferior" mean in terms of anatomical location?
Inferior means below or towards the feet.
119
What does "Distal" mean in terms of anatomical location?
Distal refers to further away from the point of attachment or trunk of the body.
120
What does "Proximal" mean in terms of anatomical location?
Proximal means closer to the point of attachment or the trunk of the body.
121
What does "Lateral" mean in terms of anatomical location?
Lateral means away from the midline of the body, towards the sides.
122
What does "Medial" mean in terms of anatomical location?
Medial means towards the midline of the body.
123
inspection in IPPA means1 full respiratory cycle is
one inhale and exhale
124
oxygen saturation means
% of hemoglobin saturated with oxygen
each can attach to 4 oxygen
125
hypoxemia refers to
insufficient oxygen in the blood
126
anemia refers to
less hemoglobin to carry oxygen in your blood
127
vasoconstriction refers to
narrowing of blood vessels = reduced blood flow to peripheries (limbs/body)
128
can you use the same arm when taking Bp and O2 saturations?
no, use a diff arm
129
what can cause O2 saturation to show an inaccurate reading?
nail polish
patient is cold
anything below 75%
130
hyperthermia refers to
elevated body temp
131
hypothermia refers to
decrease body temp
132
lead to cell damage, hypothermia or hyperthermia?
hyperthermia
133
lead to unconsciousness, hypothermia or hyperthermia
hypothermia
134
when palpating a patient what do you use
use hand/fingers/back of hand (esp for temp)
135
when palpating for body temp what do you use?
back of hand is more sensitive to temp
136
when do you use your fingertips when palpating?
texture
thickness
moisture
swelling & massess
pain/tenderness
location,size,density
pulsatility
crepitus
137
when do you use cupping of hands motion or grasping of fingers/thumbs when palpating?
Bones and muscles (and associated deformities) as well as the trachea and testicles are often assessed using a gentle grasping motion of the fingers and thumbs.
Crepitation is an abnormal grating or crunching sound or sensation felt and heard over joints at the location where bones meet.
138
what is crepitation and where does it occur
grating/crunching sound or sensation at joints (where bones meet)
139
when do you use ulnar surface of hand when palpating?
pulsatility in a patient
140
what is vibration (tactile fremitus) refering to
shaking motion over the lungs
141
what is pulsatility referring to
abnormal pulsation felt over the heart "thrills" (like a purr of a cat)
142
when do you use metacarpophalangeal joints or side of hands when palpating?
checking for vibrations or tactile fremitus over lungs
143
what is Percussion do in IPPA
tapping body to elicit a sound
144
sound of percussion in the body depends on
the underlying structure, is it air filled, fluid filled or dense
145
what is indirect percussion technique
use of non dominant middle finger and using dominant hand to tap your other finger
146
what should you hear when doing percussion over bones (clavicle, ribs, sternum)
flatness
147
what should you hear when doing percussion over adult lungs
resonance
148
what should you hear when doing percussion over child lungs
hyperresonance
149
what should you hear when doing percussion over dense organs (liver, spleen, heart)
dullness
150
what should you hear when doing percussion over abdominal area (intestines and stomach)
tympany
151
what is auscultation do in IPPA
listening to body with stethoscope
152
what do you use diaphragm or bell when listening to high pitched sounds
diaphragm
153
what do you use diaphragm or bell when listening to low pitched sounds
bell
154
dimensions of pain
subjective
physiological
behavioural
cognition
psychological and social
reactive = how it interferes with ADL
155
the use of diff type of pain assessment tool depends on
reason for assessment
developmental stage
health status
institutions / unit
culture
156
list of diff types of pain assessment tool
numerical rating scale
visual analogue scale
verbal description tool
FACES pain scale
sun cloud pain scale
PQRSTU mnemonic
ABBEY pain scale
157
P in PQRSTU
Proactive
Palliative
what makes it better/worse
158
Q in PQRSTU
quality
quantity
what does it feel like? (eg: dull)
159
R in PQRSTU
region
radiation
where is it located, does it radiate?
160
S in PQRSTU
Severity
From 0-10 how much does it hurt?
161
T in PQRSTU
Timing
Treatment
When did it occur? have you taken any medication for it? is it worse in the day or when you stand?
162
U in PQRSTU
understanding
what do you think caused it?
163
when is abbey pain scale used?
for dementia patients or non verbal patients or cognitive impairement
164
abbey pain scale measure what categories
vocalization
facial expression
change in body language
behavioural change
psychological change
physical change
165
Abbey pain scale, when score is 0-2 its:
no pain, mild, moderate, severe
no pain
166
Abbey pain scale, when score is 3-7 its:
no pain, mild, moderate, severe
mild
167
Abbey pain scale, when score is 8-13 its:
no pain, mild, moderate, severe
moderate
168
Abbey pain scale, when score is 14 and up its:
no pain, mild, moderate, severe
severe
169
downside of pain assessment tools
can't differentiate between pain or other distressing state/cause
170
Angina
chest pain caused by reduced blood flow to the heart
171
Does IPPA happen in order?
no, it depends on the situation
172
does subjective or objective assessment come first?
subjective assessment, use the objective assessment to confirm the subjective assessment
173
what does it mean to collect collateral information?
gathering secondary history of patient from people around the patient or their charts
174
T or F. if abdomen is full it can create a dull sound
true
175
Erythema refers to
redness of skin
176
sepsis refers to
body damages itself by fighting off an infection
177
how long do you assess the client again after giving pain medication
about half an hour after
178
is it normal or abnormal to hear the sound of blood "woosh"?
it is abnormal, it can indicate clotted artery
blood is normally quiet
ask the patient to hold their breath so you don't mistake that sound to air coming through their lungs
179
what type of pain is: acute
short, and caused by something specific
usually subsides after cause of pain is resolved
180
what type of pain is: chronic
pain is present for about 3-6 months
even after expected healing time
181
Type of chronic pain: secondary chronic pain refers to
pain brought upon as a result of a disease/condition/treatment
182
type of chronic pain: primary chronic pain refers to
pain that can't be accounted for by other causes
not associated with an underlying, identifiable medical condition that directly causes it. It is considered a condition in itself, not just a symptom of something else.
183
fibromyalgia (type of primary chronic pain) refers to
chronic condition that causes pain, fatigue and discomfort all over the body
184
what type of pain is: referred pain
pain felt from a diff site of the origin of the pain
185
what type of pain is: idiopathic
Mystery pain = no one knows why
pain from unknown origin, no obvious pathology (no clear medical explanation)
186
what type of pain is: nociplastic pain
Faulty body pain system = body overreacting
caused by dysfunctional nociception (body recognition of pain).
no obvious tissue damage
187
what type of pain is: neuropathic pain
Messed up nerves
sensitive to touch and temp.
Pain caused by disease in somatosensory nervous system (body's sensory nervous system)
188
what type of pain is: Nociceptive
"Real/visible(?)" injury
involves noxious stimulus (harmful stimulus) that activates nociceptor
189
Type of nociceptive pain: somatic pain refers to
pain originating from peripheral tissues
190
Type of nociceptive pain: visceral pain refers to
pain originating from inside of the organs
191
what is opioid usually used for
narcotic substance for pain management
192
spasticity
abnormal muscle tightness dur to prolonged muscle contraction
193
Tangential lighting is when you use....
direct penlight to shine on an area you are inspecting
194
what do you inspect?
body position and posture
gait (balance/movement)
symmetry
skin
behaviour
dress and hygiene
195
when palpating why should you avoid staccato taps?
can be difficult for patients to anticipate
196
what is diaphoresis
excessive perspiration
197
when palpating for swelling and masess and pain and tenderness what do you use?
fingertips/fingers
198
subcutaneous crepitus refers to
when air is trapped in tissues
199
what type of sound do you hear when doing percussion that may indicate a mass?
Flatness
200
tool facilitated percussion
using instrument to tap the body
201
direct percussion
using one finger to directly tap with fingertips
202
Ischemia refers to
deficit of blood flow (oxygen) in tissues/other body parts
203
list of roles of integumentary system
thermoregulation
fluid balance
protective barrier
immune defense against foreign bodies
sensory functions
204
Necrotizing fascitis refers to
Flesh eating disease
skin infection that spreads throughout the body
Very Critical finding
205
Necrosis refers to
tissue death
(common on toes and feet)
206
Pruritus aka
itching skin
207
Nevi aka
moles
208
Alopecia aka
unexpected hair loss
209
when doing skin inspection in older adults what do you make sure to assess?
bony Prominences which is commonly overlooked (eg: ear)
210
Skin inspection: pallor means
paler skin that other body parts
211
Skin inspection: erythema means
redness
212
Skin inspection: cyanosis means
bluishness in other parts of skin (sometimes due to lack of oxygen)
213
Skin inspection: brawny means
Brawny tone to skin
214
Skin inspection: jaundice means
yellowish skin (focus on the liver when jaundice occurs)
215
Skin inspection: virtiligo means
development of lighter skin tones
216
Nevi inspections: ABCDE stands for
Asymmetry
Border irregularity
Colour
Diameter
Evolving
217
Skin inspection, what does contusions mean
bruising
218
Braden scale measures what categories
sensory perception
skin moisture
activity
mobility
friction and shear
nutritional status
mild risk 15-18
moderate 13-14
high risk 10-12
severe - less than 9
219
Skin palpation: skin turgor refers to
elastic rebound of skin when its tugged, dehydration results in less turgor
220
List of signs of dehydration
dry mouth
chapped/cracked lips
dry skin
no tear production
dark urine
dry cough
dry wrinkle skin
headache
delirium
fatigue
lightheadedness
poor skin turgor
constipation
221
Nail clubbing refers to
when nails seem swollen / appear wider
222
Capillary refill refers to
how long your blood goes back to your nail bed when you pinch it
normal - about 3 sec
223
what should you assess when you notice clubbing of nails
assess heart/lungs, it usually happens cuz of chronic low oxygen
224
avulsion refers to
tearing off of skin or other part of body
225
subungual hematoma refers to
collection of blood collecting under nails
226
nail laceration is
cut in the nail bed under the nail
227
skin maceration refers to
skin breakdown due to prolonged exposure to moisture
228
diabetic neuropathy refers to
Low sensation on their foot/leg -> may get hurt often without realizing -> can lead to skin ulcer breakdown
229
compound break refers to
break in bone poking through skin
230
discrete rash vs confluent rash
discrete rash = rash not touching each other
confluent rash = multiple and are touching/on top of each other
231
Primary vs secondary skin lesions
secondary lesion is caused by primary lesion
232
what should you assess when looking at blisters
if they are fluid filled or if they are dense
233
When inspecting Nevi using ABCDE what findings are abnormal?
Irregular shape
irregular border (no symmetry)
variation in colour
larger then 6mm
evolving
234
you inspect bony prominences because it is a risk for
pressure ulcers
235
T or F. if a patient is cold, their capillary refill will take longer
True
236
Cullen's sign refers to
a bruising and edema of fatty tissue around belly button .
can be a sign of internal bleeding or pancreatic trauma
237
T or F measles require airborne precautions
True
238
measles refers to
small flat red spots on face and spread to body
239
Keloid is
a thick raised scar on skin
240
T or F. Linea nigra and striae are normal findings on pregnant patients
TRUE
241
Dyspnea refers to
difficulty breathing
242
