Module 2(Part A & E) Flashcards
1
Q
What are pressure ulcers?
A
-They are impairment of skin integrity related to unrelieved, prolonged pressure.
Note: Also known as pressure sore, decubitus ulcer and bedsore.
2
Q
What kind of injury are pressure ulcers?
A
They are localised injury to the skin and other underlying tissue usually over a body prominence.
3
Q
What causes pressure ulcers?
A
- A result of pressure.
- Pressure in combination with shear or friction.
- Pressure in combination with shear and friction.
4
Q
What are the risk factors for pressure ulcer formation?
A
- Pressure is the major cause
- Factors that interferes with blood flow
- illnesses
- People over 70 years are particularly vulnerable
- Poor mobility
- Aging skin
- Poor nutrition
- Plaster casts
- Intensive care
- Circulation problem
5
Q
Pressure is the major element in the cause of pressure ulcers. What are the 3 pressure related factors that contribute to pressure ulcer development?
A
- Pressure intensity
- Pressure duration
- Tissue tolerance
6
Q
How is classification of pressure ulcers made?
A
By the pressure ulcer depth at the point of assessment.
7
Q
What is the first stage of pressure ulcer development?
A
Nonblanchable Redness of Intact Skin.
8
Q
What is the second stage of pressure ulcer development?
A
Partial-thickness Skin Loss or Blister.
9
Q
What is the third stage of pressure ulcer development?
A
Full-thickness Skin Loss(Fat visible).
10
Q
What is the fourth stage of pressure ulcer development?
A
Full-thickness Tissue Loss(Muscle/Bone Visible).
11
Q
What are the sites to assess for risk of pressure ulcer development?
A
- Occiput(Back of the head)
- Shoulder
- Elbow
- Base of spine
- Hip
- Sacrum(tailbone)
- Buttocks area
- Ankle
- Heel
- Toes
12
Q
What is blood pressure?
A
Blood pressure is the force/pressure exerted by the circulating blood on the wall of the arteries.
13
Q
What is systolic pressure?
A
It is the highest point of pressure on the arterial walls when the ventricles contract and push blood through the arteries at the beginning of systole.
14
Q
What is diastolic pressure?
A
It is the lowest pressure present on the arterial walls during diastole.
15
Q
The measurement of blood pressure is in?
A
Millimeters of mercury(mm Hg)
16
Q
The numerator is the _____________; the denominator is the ____________.
A
systolic pressure; diastolic pressure
17
Q
What should we do to get an accurate assessment of blood pressure?
A
- We should know what equipment to use.
- We should know which site to use.
- We should know how to identify the sounds we hear.
18
Q
What are korotkoff sounds?
A
A series of sounds for which to listen when assessing blood pressure.
19
Q
What are the most common sites used to assess blood pressure?
A
The brachial artery and popliteal artery.
20
Q
Why do we estimate the systolic pressure?
A
To prevent inaccurate readings in the presence of an auscultatory gap( a pause in the auscultated sounds).
21
Q
What are the equipment used when assessing for blood pressure?
A
- Stethoscope
- Sphygmomanometer
- Blood pressure cuff of appropriate size
- Pencil or pen
- Paper or flowsheet
- Alcohol swab
- PPE as indicated
22
Q
When should a body part or region not be used when taking blood pressure?
A
- Presence of a cast
- Arteriovenous shunt
- Injured or disease limb
- Breast or Axilla surgery (BP should not be taken on the side of the body corresponding to the arm used)
23
Q
What are the factors that can affect blood pressure reading?
A
- Patient’s age
- Exercise
- Position
- Weight
- Fluid balance
- Smoking
- Medication
- Pain
- Stress
- Caffein or Energy drinks
24
Q
What are the types of BP?
A
- Lying
- Sitting
- Standing
25
What is intra-arterial blood pressure?
- It is a monitoring technique that is commonly used in the Intensive Care Unit(ICU) and Operating Theatre.
- This technique involves direct measurement of arterial pressure by inserting a cannula needle in a suitable artery.
26
Blood pressure is recorded as a ________.
fraction
27
What is the average blood pressure of a healthy adult?
120/80 mm Hg
28
The blood pressure of an elderly ranges from:
140-160 systolic
| 70-90 diastolic
29
The blood pressure of an adult ranges from:
90- 132 systolic
| 60- 85 diastolic
30
Define hypertension?
- It is defined as a blood pressure higher than normal.
- Also known as High Blood Pressure(HBP)
Note: This is based on the average of two or more accurate blood pressure measurements during two or more consultations with the healthcare provider.
31
What are the classifications of hypertension?
- Prehypertension
- Stage 1 Hypertension
- Stage 2 Hypertension
- Hypertensive Emergency
32
Define prehypertension?
- Blood pressure that is higher than normal but it doesn’t quite reach the level of high blood pressure.
- It is defined as a systolic pressure from 120–139 millimeters of mercury (mm Hg) or a diastolic pressure from 80–89 mm Hg.
Note: We won't be diagnosed with hypertension or prehypertension until it is high on several occasions.
33
Define Stage 1 hypertension?
Stage 1 hypertension is defined as persistent blood pressure levels in which the systolic pressure ranges from 130 to 139 mmHg and the diastolic pressure ranges from 80 to 89 mmHg.
34
When is a patient is said to have stage 2 hypertension?
Consistent blood pressure readings when the systolic pressure is already more than or equal to 140 mmHg and the diastolic is more than or equal to 90 mmHg.
35
What is a hypertensive emergency?
It is an emergency situation where there is a severe increase in blood pressure that is, a measurement higher than 180/120 mm Hg.
36
Define hypotension?
A reading of less than 90/60mmHg.
Note: Hypotension does not always cause symptoms, but treatment may be needed if there are.
37
What causes hypotension?
- Dilation of the arteries
- Hemorrhage
- Myocardial infarction
38
What are the types of hypotension?
- Orthostatic hypotension
| - Postprandial hypotension
39
What is orthostatic hypotension?
It is the drop in blood pressure that occurs when you transition from sitting or lying down to standing.
Note: It is common in people of all ages.
40
What is postprandial hypotension?
It is a drop in blood pressure that occurs right after eating.
41
Define body temperature?
Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment.
42
What are the types of temperatures?
- Core temperature (temperature of the deep tissues of the body)
- Surface body temperature
43
What are the different alterations in body temperatures?
- Hyperthermia (Body temperature above normal range)
- Hyperpyrexia (Very high fever, 41ºC(105.8 F) and above)
- Hypothermia (Subnormal temperature)
44
What are the sites for temperature measurement?
- Oral
- Rectal
- Axillary
- Tympanic membrane
- Skin
- Temporal artery
45
What are the temperature ranges for a normal adult?
Oral: 36.5 –37.5 ºC
Axillary: 35.8 – 37.0 ºC
Rectal: 37.0 – 38.1 ºC
Tympanic: 36.8 – 37.9ºC
46
What are the types of thermometer?
- Mercury-in-glass Thermometer
- Electronic Thermometer
- Chemical Disposal Thermometer
- Temperature-sensitive Tape
- Infrared Thermometer
47
What are the factors that affect body temperature?
- Age
- Diurnal variations(circadian rhythms)
- Exercise
- Hormones
- Stress
- Environment
48
List some heat promoting centers?
- Vasoconstriction
- Sympathetic Stimulation
- Skeletal Muscles
- Thyroxine
49
Name some body temperature abnormalities?
- Fever/hyperthermia/hyperpyrexia
- Heat cramps and Heat exhaustion
- Heat Stroke(Due to fluid and electrolytes loss)
- Hypothermia
50
What is a pulse?
It is a wave of blood created by contraction of the left ventricle of the heart.
51
What is the normal pulse rate?
- 1 year : 80-140 beats/min
- 2 years : 80- 130 beats/min
- 6 years : 75- 120 beats/min
- 10 years : 60-90 beats/min
- Adult : 60-100 beats/min
52
What is tachycardia?
A pulse rate of above 100 beats/min.
53
What is Bradycardia?
A pulse rate below 60 beats/min.
54
What is an Irregular pulse?
It is a pulse that has an uneven time interval between beats.
55
What are the factors affecting pulse rate?
- Age
- Sex
- Exercise
- Fever
- Medications
- Hemorrhage
- Stress
- Position changes
56
What are the characteristics of a normal pulse?
- Normal Rate(This is the number of pulse beats per minute (70 to 80 beats/min in the adult)).
- Normal Pulse rhythm(This is the pattern of the beats and the intervals between the beats.)
- Normal Pulse volume(It refers to the force of blood with each beat. It can range from absent to bounding.)
57
What are the sites for pulse rate assessment?
- Temporal
- Carotid
- Apical
- Brachial
- Radial
- Femoral
- Popliteal
- Poserior tibial
- Pedal (dorsalis pedis)
58
What are the methods used in assessing the pulse?
Palpation and auscultation.
59
When assessing respiration, what do we assess?
Respiratory Rate
Ventilatory Depth
Ventilatory Rhythm
Respiratory quality/character
60
What is respiratory rate?
A cycle of full inspiration and expiration.
61
What is ventilatory depth?
- The depth of respirations by observing the degree of excursion or movement in the chest wall.
- It is generally described as deep, normal, or shallow.
62
What is ventilatory rhythm?
- This refers to the regularity of the expirations and the inspirations.
- Normal respirations are evenly spaced.
- Respiratory rhythm can be described as regular or irregular.
63
What is respiratory quality/character?
- This refers to those aspects of breathing that are different from normal, effortless breathing.
- It is the amount of effort a client must exert to breathe.Usually, breathing does not require noticeable effort.
- The sound of breathing(Normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse’s ear.)
64
What are the factors influencing character of respirations?
- Exercise
- Acute pain
- Anxiety
- Smoking
- Body position
- Medications
- Neurological injury
- Hemoglobin function
65
What are the acceptable ranges of respiratory rate?
```
Newborn: 35-40(BREATHS/MIN)
Infant (6 months): 30-50(BREATHS/MIN)
Toddler (2 years): 25-32(BREATHS/MIN)
Child: 20-30(BREATHS/MIN)
Adolescent: 16-20(BREATHS/MIN)
Adult: 12-20(BREATHS/MIN)
```
66
What are the alterations in Breathing Pattern?
- Bradypnea
- Tachypnea
- Hyperpnea
- Apnea
- Hyperventilation
- Hypoventilation
- Cheyne-Stokes respiration
- Kussmaul’s respiration
- Biot’s respiration
67
What is bradypnea?
It is a condition where the rate of breathing is regular but abnormally slow (less than 12 breaths/min).
68
What is tachypnea?
It is a condition where the rate of breathing is regular but abnormally rapid
(greater than 20 breaths/min).
69
What is hyperpnea?
- It is a condition where respirations are labored, increased in depth, and increased in rate ( > than 20 breaths/min)
- Occurs normally during exercise.
70
What is apnea?
It is when respirations cease for several seconds.
Note: Persistent cessation results in respiratory arrest.
71
What is hyperventilation?
It is a condition where the rate and depth of respirations increase.
72
What is hypoventilation?
It is a condition where respiratory rate is abnormally low, and depth of ventilation is depressed.
73
What is Cheyne-Stokes respiration?
- It is a condition where respiratory rate and depth is irregular, characterized by alternating periods of apnea and hyperventilation.
Note:- Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth.
-The pattern reverses; breathing slows and becomes shallow, climaxing in apnea before respiration resumes.
74
What is Kussmaul’s respiration?
It is a condition where respirations are abnormally deep, regular, and increased in rate.
75
What is Biot’s respiration?
It is a condition where respirations are abnormally shallow for two to three breaths followed by irregular period of apnea.
