module 7 and 10

Question 1

the metric system

Answer 1

Referred to as the International System of Units
* Based on base units such as meters and grams
* Uses prefixes and a decimal system
* Used in healthcare in the US

Question 2

Weight

Answer 2

Measured in pounds or kilograms
* 1 kilogram = 2.2 pounds

Question 3

Weight using a bed scale

Answer 3

if resident cannot stand or sit up to use wheelchair scale you can use a bed scale
ask resident not to move and zero it out
back away from the bed

Question 4

how can weight be obtained?

Answer 4

Upright scale
* Wheelchair scale
* Bed scale
* Mechanical lift

Question 5

Weight using a mechanical lift

Answer 5

cannot stand or sit up to use wheelchair scale and if bed has no scale use a mechanical lift
Traditional lift:400 lbs or less
Bariatric lift: > 400 lbs
butt/heels are no loner touching bed, zero scale out, pt does not move, do not touch pt while recording weight

Question 6

Length (height)

Answer 6

Most often documented using feet and inches (imperial system)
* Can use an upright scale with height rod or a stadiometer
* May need to be obtained while resident is in bed

Question 7

Measuring using smaller units

Answer 7

Most often documented using metric system
* Examples: pressure injuries, lacerations, bruises

Question 8

What is the base volume measurement in the metric system?

Answer 8

Liter and 1 ounce = 30 ml= 30 cc

Question 9

Fluid intake

Answer 9

calculated during meals and snacks
any liquid should be recorded
All calculations in centimeter or milliliter
intake is never calculated in ounces

Question 10

Military time

Answer 10

Used for documentation and
communication purposes
* Helps eliminate errors
* Based on a 24-hour cycle
* Examples:
* 2:00 am = 0200
* 2:00 pm = 1400
* 4:30 am = 0430
* 4:30 pm = 1630

Question 11

LTC and hospital vital

Answer 11

LTC: once every week
hospital: every 2 hours

Question 12

vital signs

Answer 12

Upon admission as a baseline
* Typically on resident’s bath day
* At least once per shift during hospital stay
* Once per shift for 72 hours after a fall, or per facility protocol
* During illness
* As directed by the nurse

Question 13

Vital signs- Infection control

Answer 13

Clean equipment with alcohol after use
* Use probe covers
* Keep a set of vital sign equipment in isolation rooms
* When isolation precautions are no longer needed, remove equipment from
room and disinfect completely
* Always perform hand hygiene before and after each resident contact

Question 14

Temperature: ensurinh

Answer 14

When taken orally, ensure resident is not chewing gum and has not had anything to eat or drink for last 15−20 minutes
* When using temporal artery scanner, remove hat and wait about a minute
before taking temp; do not swipe resident’s bangs

Question 15

When taking pulse what do ask resident to do?

Answer 15

Ask resident to remain still

Question 16

Before taking resp what should you do?

Answer 16

Do not tell patient you are doing this
ask for permission before doing so

Question 17

Blood pressure: facts

Answer 17

Do not take on same arm of mastectomy: can cause lymphedema
Do not do on the same arm as an IV
Relaxed state
No feet crossed
Be still and do not talk
be able to place 1 finger and it is overlapped
either roll up sleeve or remove arm from sleeve

Question 18

Normal vital ranges

Answer 18

Temp: 97.6-99.6
pulse: 60 to 100 beats per minute
respirations: 12-20 breaths per minute
blood pressure 120/80

Question 19

oral temp

Answer 19

probe is placed under the tongue. Most often a digital model is used

Question 20

Axillary

Answer 20

Probe is placed under the resident’s arm, in the center and deepest fold of axilla.
Preferable for residents with dementia or cognitive disabilities

Question 21

Tympanic- ear

Answer 21

Probe is placed into ear canal. Invasive and can be uncomfortable.
Least accurate method due to user error or buildup of cerumen

Question 22

Temporal Artery Scanner

Answer 22

Less invasive and most accurate as rectal thermometer. Professional and
home models available; follow manufacturer’s directions

Question 23

Rectal

Answer 23

Most invasive and accurate. can cause ham

Question 24

non-contact infrared thermeter (NICT)

Answer 24

least invasive since there is no contact with resident. Reduces risk of cross-contamination. Follow manufacturer’s directions

Question 25

Pulse (producer)

Answer 25

- have resident sitting Use the index and middle fingers to find the resident’s radial pulse * Radial pulse is found in the natural groove of the wrist, on the thumb side * Heartbeat is counted for 60 seconds * Apical pulse is obtained by using a stethoscope

Question 26

respiration (measurement)

Answer 26

Counted by observing the rise and fall of the resident’s chest or abdomen * 1 rise and 1 fall = 1 breath if resident coughs wait until their done

Question 27

BP measurment

Answer 27

place cuff around upper arm and line up with brachial artery * Cuff is inflated to apply pressure to arm and then slowly released * Manual cuff requires use of stethoscope to listen for first and last heartbeats * Wrist cuffs are available and convenient but often the least accurate

Question 28

Extra step bP

Answer 28

if you hear the pluse right away deflate the valuve and let the residetn arm rest for 1 to 2 minutes, reinflates the cuff 30 mmHG higher than pluse left

Question 29

Korotkoff sound

Answer 29

heart rate heard via stethoscope while taking BP

Question 30

what to do when you know their usual BP

Answer 30

inflate and add 20 mmHG to average measurement

Question 31

Temp- factd

Answer 31

too low: hairs rise for a thermal blanket too high: produce sweat Affecting factors: environment, smoking, exercise, stress Body temperature is a balance between amount of heat produced and amount lost by the body. * Thermometers measure temperature. * Fahrenheit (F) and centigrade (C) scales are used

Question 32

pulse- facts

Answer 32

expansion of artery with every beat of heart affecting factors: fitness level, chronic illness, age, stress The pulse is the beat of the heart felt at an artery as a wave of blood passes through the artery. * Carotid pulse is taken during CPR and other emergencies. * The apical pulse is felt over the heart. * This pulse is taken with a stethoscope.

Question 33

Respiration: facts

Answer 33

Respiration means breathing air into (inhalation) and out of (exhalation) the lungs. * Oxygen enters the lungs during inhalation. * Carbon dioxide leaves the lungs during exhalation. * The chest rises during inhalation. * The chest falls during exhalation. affecting factors: age, exercise, medication, pain, and emotions

Question 34

Systolic and diastolic and their ranges

Answer 34

systolic pressure—the pressure in the arteries when the heart contracts * Diastolic pressure—the pressure in the arteries when the heart is at rest * Systolic pressure— 90 mm Hg or higher but lower than 120 mm Hg * Diastolic pressure— 60 mm Hg or higher but lower than 80 mm H

Question 35

hyper/hypotension: ranges

Answer 35

Hypertension—when the systolic blood pressure is 140 mm Hg or higher (hyper) or the diastolic blood pressure is 90 mm Hg or higher * Report any systolic measurement at or above 120 mm Hg. * Report any diastolic pressure at or above 80 mm Hg. * Hypotension—when systolic blood pressure is below (hypo) 90 mm Hg or the diastolic blood pressure is below 60 mm Hg * Report a systolic pressure below 90 mm Hg. * Report a diastolic pressure below 60 mm Hg

Question 36

brady/tachycardia

Answer 36

Bradycardia: a low heart rate; can mean heart is not working properly or there is a medication problem * Tachycardia: a high heart rate; can indicate atrial fibrillation, medication problem, stimulant use, pain, anxiety, or cardiac disease

Question 37

Brady/tachypnea

Answer 37

Bradypnea: slow breathing; usually caused by medication, narcotic drugs, or alcohol * Tachypnea: fast, shallow breathing; often caused by respiratory infection or disease, an imbalance of resident’s pH, pain, or fever

Question 38

BP ranges

Answer 38

Hypertension: * Stage 1: 130–139/80–89 * Stage 2: higher than 140/90 * can result in heart attack, stroke, kidney disease or failure, or congestive heart failure * Hypotension: * lower than 90/60 * can result in falls and injurie

Question 39

After taking vital

Answer 39

* Document in the patient chart * Update nurse if results do not follow resident’s trending normal values * Orally report any vital signs that are outside of normal limits or do not follow the resident’s normal value trend

Question 40

If unsure about vitals

Answer 40

if unsure about any vitals let resident rest arm for 5 minutes than repeat

Question 41

what it the vital signs order?

Answer 41

1: temp, 2: pulse 3: respiration 4: blood pressure

Question 42

Brady/tachycardia ranges

Answer 42

brady: less 60 Tachy: more than 100

Question 43

Oral Axillary Rectal Tympanic Temporal Artery RANGES

Answer 43

O: 98.6 A: 97.6 R: 99.6 T:97.6 TA: 99.6

Question 44

What is a sphygmomaneter and what types are there?

Answer 44

It is a cuff measuring device - electronic type -wrist cuff -aneroid types - mercury type