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The "Fun" class > Skills Exam 2 > Flashcards

Skills Exam 2 Flashcards

1
Q

-Location
-Severity
-Quality
-Duration
Are?

A

Questions that should be asked and documented when the patient reports pain during an assessment.

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2
Q

If interventions for pain were performed, then how long should you wait to reassess the pain?

A

30 minutes to 1 hour

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3
Q

How often after a patient reports pain, and after interventions were performed should you continue to follow up on the pain?

A

At least every two hours if not sooner.

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4
Q

Basic assessment that can tell us so much information about what is going on with our patient

A

Vital Signs

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5
Q

what is the first assessment that you would perform if there is a change in a patients condition?

A

Vital signs

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6
Q

What are things that should be done before going to asses a patients vital signs?

A
  • Assess equipment is working correctly.
  • Select the appropriate equipment for the patient.
  • Know the patient’s usual range of vital signs.
  • Know the patient’s health history, therapies, and prescribed and over-the-counter medications.
  • Control environmental factors and be organized.
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7
Q

what should be done after performing a vital sign assesment?

A
  • Verify and communicate significant changes.

- Provide patient teaching about your findings.

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8
Q

what are you going to asses in vital signs

A
  • Body Temperature
  • Pulse
  • Respirations
  • Blood Pressure
  • Oxygen Saturation
  • Pain
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9
Q

what is the normal range for Temperature?

A

96.8 - 100.4F

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10
Q

What is the normal range for Heart Rate?

A

60 beats per minute - 100 beats per min

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11
Q

What is the normal range for Respirations?

A

12 breaths per min – 20 breaths per min

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12
Q

What is the normal range for Blood Pressure?

A

> 90/60 mmHg – <120/80 mmHg

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13
Q

What is the normal range for Oxygen Saturation?

A

≥ 94%

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14
Q

What can affect vital sign values?

A

-Age
-Exercise
-Stress
-Trauma
-Illness
-Infection
-Disease
-Mediations
And more

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15
Q

What would you have to do if there are vital signs outside of normal range?

A

Perform additional assessments and ask questions to try to determine what is going on, unless those ranges are the patients baseline.

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16
Q

Temperature is regulated by…

A

The Hypothalamus

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17
Q

Heat produced minus Heat lost =

A

Body Temperature

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18
Q

Core Temperature is….

A

The temperature of the deep tissues, and the most constant true temperature

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19
Q

Surface Temperatures…

A

vary depending on blood flow to the skin and the amount of heat lost to the external environment

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20
Q

Factors that determine temperature

A
  • The site of temperature measurement (oral, rectal, tympanic, temporal, axillary, etc.)
  • Time of day temperature is taken (lowest temperature is at 0600, highest temperature is at 1600)
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21
Q

Can the temperature change if using different devices?

A

yes, which is why it is important to use the same device on the patient.

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22
Q

Balance between heat production and heat loss

A

Thermoregulation

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23
Q

What controls the temperature?

A

Hypothalamus

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24
Q

If heat inside the body rises above the “set point” the Hypothalamus will send signals to reduce it, What happens next…

A

Heat loss will occur through sweating, inhibition of heat production, and vasodilation (widening) of blood vessels, which sends blood to surface vessels to promote heat loss.

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25
Q

If heat inside the body lowers below the “set point” the Hypothalamus will send signals to increase it, What will happen next….

A
  • Heat conservation will occur through vasoconstriction (narrowing) of vessels to reduce blood flow to the skin and extremities, thus reducing heat loss.
  • The body will also compensate with this change by producing heat through voluntary muscle contractions (i.e. movement) and muscle shivering
  • Shivering begins when vasoconstriction is ineffective in preventing additional heat loss
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26
Q

Factors Affecting Body Temperature

A
  • Age
  • Exercise
  • Hormone level
  • Circadian rhythm
  • Stress
  • Environment
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27
Q

Temperature alterations

A
  • Fever (Pyrexia)
  • Hyperthermia
  • Hypothermia
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28
Q
  • Palpable bounding of blood flow in a peripheral artery

- Indicator of circulatory status

A

Pulse

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29
Q

Number of pulsing sensations in 1 minute

A

Pulse rate

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30
Q

Common locations to find a pulse

A
  • Radial
  • Carotid
  • Brachial
  • Femoral
  • Dorsalis Pedis
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31
Q

If the pulse rate or rhythm is found to be irregular, the nurse must further assess

A
  • If rate is elevated (> 100 bpm), tachycardia is present
  • If rate is slow (< 60bpm), bradycardia is present
  • The nurse is required to auscultate the apical pulse for one minute
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32
Q

Which of the pulse locations is the most commonly used?

A

Radial Pulse

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33
Q

Pulse deficit

A

Inefficient contraction of heart that fails to transmit a pulse wave to peripheral pulse site

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34
Q

what is often associated with abnormal heart rhythm

A

Pulse Deficit

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35
Q

Breathing

A

is controlled by the medulla oblongata

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36
Q

Respiration involves

A
  • Ventilation
  • Diffusion
  • Perfusion
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37
Q

active process

A

Inspiration

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38
Q

passive process

A

Expiration

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39
Q

Ventilatory depth

A

Unlabored or labored

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40
Q

Ventilatory rhythm

A

Pattern even or uneven

41
Q

When may SpO2 readings be inaccurate?

A
  • Anemia
  • Edema
  • Carbon Monoxide Poisoning
  • Tremors
  • Cold extremities
  • Nail Polish
42
Q

Force exerted on the walls of an artery by the pulsing blood under pressure from the heart

A

Blood Pressure

43
Q

what happens if blood pressure is out of range?

A
  • Without enough pressure, tissues won’t receive blood

- With too much pressure in the system, the small vessels within the tissues may rupture

44
Q

How is blood pressure supposed to be noted?

A

Systolic Blood Pressure/Diastolic Blood Pressure

45
Q

What is Systolic pressure?

A

Heart forces blood out into the body using pressure

46
Q

What is Diastolic Pressure?

A

When the heart is relaxes and filling with blood

47
Q

Physiology of arterial blood pressure

A
  • Cardiac output 
  • Peripheral resistance 
  • Blood volume 
  • Viscosity
  • Elasticity 
48
Q

Factors influencing blood pressure

A

Age, stress, ethnicity and genetics, gender, daily variation, medications, activity and weight, smoking

49
Q

What is Pulse Pressure?

A

Difference between systolic pressure and diastolic pressure

50
Q
  • Blood pressure 130/80 mm Hg or higher
  • Patients usually asymptomatic
  • Thickening of arterial walls
  • Loss of elasticity of arterial walls
  • Heart must exert more force to push blood out into system, thus increasing pressure
A

Hypertension

51
Q

(Systolic <90 mm Hg
Diastolic <60 mm Hg)
-Decrease of blood flow to vital organs and tissues
-Orthostatic/postural changes

A

Hypotension

52
Q

When you assess the patient, if the blood pressure reading is elevated ask questions

A
  • Do they have a history of hypertension?
  • If so, did they take their medications today?
  • Are they nervous? Sick? Stressed?
53
Q

How long should you wait before taking another blood pressure in the same arm?

A

you should wait at least 2 minutes to avoid arterial occlusion, numbness, and tingling

54
Q

Avoid using an extremity with the following present when taking blood pressure

A
  • Dressing
  • Cast
  • Peripheral IV
  • Fistula
55
Q

How much will the systolic reading be increased by if using a lower extremity to asses blood pressure?

A

10 mmhg or more

56
Q

Safety Guidelines for Nursing Skills when taking blood pressure

A
  • Clean devices between patients to decrease the risk for infection.
  • Rotate sites during repeated measurements of BP and pulse oximetry to decrease the risk for skin breakdown.
  • Analyze trends for vital signs and report abnormal findings.
  • Determine the appropriate frequency of measuring vital signs based on the patient’s condition.
  • Determine a patient’s status before delegating a vital sign skill.
57
Q

Where should you document any abnormal vital signs?

A

in narrative charting along with additional assessment findings (whether normal or abnormal)

58
Q

what is known as the sixth vital sign?

A

Pain

59
Q

Is pain considered subjective or objective?

A

pain is a subjective finding

60
Q

where is the pain stimulus sent to be interpreted by the brain?

A

to the cerebral cortex

61
Q

what does the Autonomic Nervous system include?

A

Sympathetic Nervous System and Parasympathetic

Nervous System

62
Q

What happens if the SNS is stimulated?

A

Increased heart rate, increased blood pressure, increased respiratory rate

63
Q

The SNS is stimulated due to

A

Low to moderate intensity and superficial pain

64
Q

The PNS is stimulated due to

A

Continuous, severe and/ or deep pain ( these types of pain involves visceral organs- such as kidney stones)

65
Q

If a patient says that they are in pain can you confirm with vital signs

A

No you would not be able to because, vital signs may or may not change with pain

66
Q

Acute/transient pain

A

-Protective
-Identifiable cause
-Short duration
Limited tissue damage and emotional response
-Common after acute injury, disease, and/or surgery
-After the injured area heals, the pain usually resolves
-Acute pain is usually treated aggressively (with interventions) because it has a predictable ending

67
Q

chronic pain

A
  • Chronic pain affects more than 50 million American adults
  • Not protective, serves no purpose
  • Has a dramatic effect on a person’s quality of life
  • Defined when pain lasts longer than 3 to 6 months
  • Can impact psychological and physical disability
68
Q

what are symptoms of Chronic Pain

A

fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, depression, anger

69
Q

what are some assumptions that nurses have about patients in pain?

A
  • Limit ability to offer pain relief
  • Do not believe if patient does not appear in pain
  • Must accept a patient’s report of pain
  • View experience through the patient’s eyes
70
Q

what are physiological factors that influence pain?

A
  • Age
  • Fatigue
  • Genes
  • Neurological Function
71
Q

What are Social factors that influence pain?

A
  • Previous experience
  • Family and social network
  • Spiritual factors
72
Q

-Attention
-Anxiety and fear
-Coping style
are classified as what kind of factors that influence pain?

A

Psychological Factors

73
Q

-Meaning of pain and ethnicity are what kind of factors that influence pain?

A

Cultural factors

74
Q

What are factors that are impacted or changed due to pain?

A
  • Quality of life
  • Self-care
  • Work
  • Social support
75
Q

What should you be looking for when asses a patients pain?

A

you should be observant of the patients actions and reactions for example facial grimacing, Guarding, Etc.

76
Q

What questions should you ask when asses pain?

A
  • Onset, duration and pattern
  • Location
  • Quality
  • severity using pain scale
  • aggravating and alleviating factors
  • Relief measures
  • what their baseline is
77
Q

what is the most commonly used pain scale?

A

Numerical rating scale( 0-10) followed by the Wong-Baker Faces Pain Rating Scale( ages 3 and older)

78
Q

Less common pain scales

A
  • Verbal descriptive scale

- Visual analog scale

79
Q

What should you do to asses the pain of a non verbal patient?

A
  • You can have them point to the pain level on the scale

- They can write their pain score or show you with their hand

80
Q

what should you do to asses pain in a cognitively impaired patient?

A
  • Use nonverbal cues, body language, behaviors

- Various tools published, use of tool depends on policy of facility

81
Q

Nonpharmacological interventions

A

are ways that the nurse can act independently to help relieve pain

82
Q

Nonpharmacological intervention

A

can decrease a patient’s pain and reduce/eliminate the need for analgesic medications

83
Q

Nonpharmacological pain-relief interventions

A

-Relaxation and guided imagery
-Distraction
-Music
-Repositioning
-Cutaneous stimulation
(Heat
Cold)
-Massage
-Breathing techniques
-Environmental modifications

84
Q

What is the most common and effective method to relieve pain

A

Analgesics

85
Q

What can help maximize pain relief?

A

Providing analgesic medication around the clock, or at scheduled times, rather than PRN

86
Q

Non-opioids

A

are usually given to treat mild to moderate pain

87
Q

Acetaminophen (Tylenol)

A
  • One of the most tolerated and safest analgesics available
  • Action of medication is to inhibit the enzyme required to make prostaglandins; prostaglandins are responsible for causing pain
88
Q

To much Acetaminophen(Tylenol) can cause…

A

Hypatotoxicity

89
Q

NSAIDS (Non-steroidal anti-inflammatory drugs)

A

Aspirin, ibuprofen, naproxen

90
Q

NSAIDS

A
  • Action of medication is to inhibit the enzyme required to make prostaglandins; prostaglandins are responsible for causing pain
  • NSAIDS also reduce inflammation
91
Q

Opioids

A

also known as narcotics, are used to treat moderate to severe pain

92
Q

what is the goal of Opioids?

A

a reduction in pain intensity to a level of acceptable comfort

93
Q

what kind of patients are transdermal patches given to?

A

Cancer or patients with chronic pain

94
Q

should a nurse asses a patient before and after administering opioid medications?

A

Yes, Vital signs, Pain level, and Mental status

95
Q

Common side effects of Opioids

A

N/V, Constipation, CNS changes, respiratory depression

96
Q

Physical dependence

A

The body becomes physically dependent on the drug because it has adapted to it

97
Q

Drug tolerance

A

Need for increased dose to maintain same degree of pain control

98
Q

Addiction

A

Characterized by behaviors arising from a drive to obtain and take substances for reasons other than the prescribed therapeutic value

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