Skills Lecture 2 Flashcards
1
Q
Normal range for temp
A
96.8-100.4
2
Q
Normal range for heart rate
A
60-100
3
Q
Normal range for respirations
A
12-20
4
Q
Normal range for blood pressure
A
> 90/60 - <120/80
5
Q
Normal range for oxygen
A
Greater than or equal to 94%
6
Q
What can affect vital sign values
A
Age, exercise, stress, trauma, illness, infection, disease, medications
7
Q
What part of the brain is temperature regulated by?
A
Hypothalamus
8
Q
Circadian rhythm of temperature
A
6am - lowest
4pm - highest
9
Q
What’s the balance between heat production and heat loss?
A
Thermoregulation
10
Q
If a patient has an o2 saturation reading of 47% but is clearly not showing signs of sob or o2 deficiency what should you do?
A
Check to make sure equipment is working properly
11
Q
What are the vital signs?
A
Temp, o2, pulse, respirations, blood pressure and pain
12
Q
A patient has a temp of 102.8 and a blood pressure of 148/98 what do you do with these findings?
A
Assessment and ask questions to find out what’s going on with patient
13
Q
What are the two types of temperature?
A
Core and surface temperature
14
Q
Sites of temperature measurement
A
Oral, rectal, tympanic, temporal, axillary
15
Q
What can occur when using different devices for temperature checks?
A
Invalid data due to every device measuring differently
16
Q
Heat loss occurs through what?
A
Sweating, inhibition of heat production, and vasodilation of vessels
17
Q
Heat conservation occurs through what?
A
Vasoconstriction, voluntary muscle contractions, and muscle shivering
18
Q
Vasodilation
A
Widening of blood vessels which sends blood to surface vessels to promote heat loss
19
Q
Vasoconstriction
A
Narrowing of the vessels to reduce blood flow to the skin and extremities thus reducing heat loss
20
Q
An older adult is more likely at risk for hypothermia because of what factors?
A
They lose body fat with aging and temp lowers
21
Q
Factors that affect body temperature
A
Age, exercise, hormone level, circadian rhythm, stress and environment
22
Q
Pyrexia
A
Fever- temp greater than 100.4 thermoregulation cannot keep up with heat production
23
Q
Hyperthermia
A
Overload of thermoregulation mechanisms body cannot reduce heat
24
Q
Hypothermia
A
Heatloss during prolonged exposure to cold
25
A patient has a temp of 102.8 what other vital signs can expected to be elevated and lowered?
Heart rate and respirations elevated
o2 lowered requiring supplemental o2
26
A patient is diagnosed with an infection. How does this affect vital signs?
Increased temp, heart rate and respirations o2 drops
27
A patient has a temp of 101.2 what would you do after getting this info?
wait 30 minutes and reassess
28
A patient has just drank coffee for breakfast and is now due for oral temp check what would the nurse do about temp?
Wait 30 minutes then take oral temp
29
tachycardia
fast heart rate
30
bradycardia
slow heart rate
31
dysrhythmia
irregular heart rate
32
As the nurse assess a patient she notices the arterial pulse has an irregular rate and rhythm what is the appropriate next step?
nurse she auscultate the apical pulse for one minute
33
Apical pulse is also known as what
The point of maximal impulse (PMI)
34
Where can you find the apical pulse?
The apex (bottom) of the heart
35
You notice that a teenager has an irregular pulse. The best action you should take includes:
Assessing the apical pulse for one full minute
36
What part of the brain controls breathing?
Medulla oblongata
37
What mechanisms are involved in respirations?
Ventilation - gasses going in and out
Diffusion - co2 and o2 moving between red blood cells in the aveoli
Perfusion - o2 going to the tissues
38
Mechanics of breathing
Inspiration is an active process
expiration is a passive process
39
A postoperative patient is breathing rapidly. You should immediately:
Count the respirations
40
Where can you assess oxygen saturation on the body?
Digit
forehead
earlobe
foot
41
A patient with parkinson's disease is getting vitals done. What problems might the nurse encounter?
Inaccurate oxygen saturation reading due to tremors
42
A patient is being seen in the ED during a winter storm. When getting vitals the nurse is having trouble getting an o2 reading what would be the nurses next step?
attempt to warm up fingers
43
What is blood pressure?
The force exerted on the walls of an artery by the pulsing blood under pressure from the heart
44
Systolic pressure
The peak of maximum pressure when blood ejection from the heart occurs.
When the heart forces blood out into the body using pressure
45
Diastolic pressure
Minimal pressure exerted against the arterial walls at all times.
When the heart relaxes and fills with blood
46
Bottom number on blood pressure
Diastolic
47
Top number on blood pressure
Systolic
48
Physiology of arterial blood pressure
cardiac output
peripheral resistance
blood volume
viscosity
elasticity
thickened arteries or blood can cause it to be high
49
Factors influencing blood pressure
Age
stress
ethnicity and genetics
gender
daily variation
medications
activity and weight
smoking
50
What is pulse pressure
Difference between systolic and diastolic pressure.
The force that the heart generates with each contraction
51
Concerns with orthostatic hypotension
Blood pressure dropping when standing up causing safety concerns and fall issues
52
decreased of blood flow to vital organs and tissues
hypotension
53
A patient currently on hypertension medications presents with a blood pressure of 150/100 what are the likely causes of this?
Patient not taking medication, nervous or stressed, underlying issue, wrong medication dose
54
Blood pressure cuff width should be _____% of the arm circumference
40
55
The inflatable bladder of the blood pressure cuff should encircle at least ____% of the upper arm.
80
56
A patients blood pressure has to be taken on the lower extremity, what can the nurse expect to be different than on an upper extremity?
Systolic reading will be increased by about 10 mmHg (or more)
57
Which vital sign is subjective?
Pain
58
non-pharmocological interventions for pain
Compress
range of motion
reposition
therapeutic interventions
distraction
59
Where in the brain is pain stimulated?
Cerebral cortex
60
Physiological changes caused by pain
changes in vital signs
61
behavioral changes caused by pain
expressions
crying
sometimes no emotions
62
body's stress response from pain stimulates the what system?
autonomic nervous system
63
autonomic nervous system includes:
sympathetic nervous system
parasympathetic nervous system
64
low to moderate intensity and superficial pain will elicit what system?
sympathetic nervous system
65
Continuous, severe, and/or deep pain involving visceral organs elicit what system?
parasympathetic nervous system
66
A patient has kidney stones. What nervous system is involved with the pain??
parasympathetic nervous system
67
nociceptive pain
type of pain felt when tissue in the body is damaged. the pain signal starts in the pain receptors, or nociceptors, which are located in the skin and the internal organs, and which register pain
68
Inflammatory pain
Inflammation leads to the secretion of substances that lower the pain threshold and amplify pain. Occurs temporarily when tissue is damaged, and can be chronic in illnesses such as rheumatism.
69
Neuropathic pain
Caused by injury or disease in the nervous system. Both direct damage to the nerve and pressure on the nerve can lead to pain. Can develop as a result of slipped disc, DM, stroke, ect
70
Acute/transient pain
Protective
Identifiable cause
Short duration
Limited tissue damage and emotional response
common after acute injury, disease or surgery
injury heals - pain resolves
treated aggressively because it has a predictable ending
71
chronic pain
not protective, serves no purpose
affects quality of life
can impact persons daily activities
greater than 6 months of pain
decreases quality of life if medication is not given around the clock
72
symptoms of chronic pain
fatigue
insomnia
anorexia
weight loss
apathy
hopelessness
depression
anger
73
factors impacted by pain
quality of life
self-care
work
social support
74
Characteristics of pain
onset, duration, pattern
location
quality
severity using pain scale
aggravating and alleviating factors
relief measures
baseline pain level
75
onset, duration, pattern of pain
When did the pain start?
how long have you had the pain?
intermittent, constant?
76
location of pain
Where is the pain located?
point to pain with one finger
77
quality of pain
can you describe the pain?
dull, aching, throbbing, sharp, stabbing, burning
78
severity of pain using pain scale
educate patient on the pain scale being used
identify patients perception of pain intensity
79
aggravating and alleviating factors of pain
what makes pain worse?
what makes it better?
80
relief measures of pain
how does the pt relieve their pain?
81
patients baseline pain level
if pain is chronic what is their baseline pain level?
what level is acceptable to live with/function at?
not always realistic to completely get rid of pain but it can be tolerable for the pt
82
assessment of pain
encourage pts self report of pain
focused physical exam
behavioral effects
impact adls
83
Patient reports 0/10 pain on pain scale but has facial grimacing and guarding of area. What should the nurse do?
ask more questions to determine pain, document what patient reports and also nonverbal signs of pain
84
On admissions assessment patient reports 0/10 pain. Two hours into shift patient states they are now in pain what are the next steps?
Reassess for changes
85
most common pain scales
numerical rating scale (0-10)
Wong-Baker faces pain rating scale (ages 3 and older)
86
less common pain scales
verbal descriptive scale
visual analog scale
87
A non-verbal patient is in the ED for pain. How could you assess this patients pain level?
you can have them point to the pain level on the scale
they can write their pain score or show you with their hand
88
how would you assess pain in a cognitively impaired patient?
Use nonverbal cues, body language and behaviors
various tools published, use of tool depends on policy of facility
89
When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true?
A. Chronic pain is psychological in nature
B. Patients are the best judges of their pain
C. Regular use of narcotics analgesics leads to drug addictions
D. Amount of pain is reflective of actual tissue damage
Answer: b
90
When treating pain, what should you consider when talking to the patient?
Use measures that the patient believes are effective for them
91
non-pharmacological pain-relief interventions
relaxation and guided imagery
distraction
music
repositioning
cutaneous stimulation - heat/cold
massage
breathing techniques
environmental modifications
92
Pharmacological pain therapies
analgesic medication
93
Routes of analgesics for pain
By mouth (PO)
Intravascular (IV)
Intramuscular (IM)
Subcutaneous (SQ)
Topical (creams, gels, sprays, transdermal patches)
94
acetaminophen
Tylenol - moderate pain
can be combined with opioids
can cause hepatotoxicity
95
Acetaminophen maximum dose
24 hour dose in a healthy individual is 4 grams
older adult or patient with liver disease 3 grams
96
NSAIDS characteristics
non-steroidal anti-inflammatory drugs
actionn of medication is to inhibit the enzyme required to make prostaglandins; prostaglandins are responsible for causing pain
NSAIDS reduce inflammation
increase gastrointestinal irritation
do not give on empty stomach
can reduce blood flow to the kidneys and cause kidney related issues, avoid administering NSAIDS to older adults (they already have decreased kidney function) NEPHROTOXIC
97
medications that are considered NSAIDS
Aspirin
Ibuprofen
Naproxen
98
Most common Opioids (narcotics)
Tramadol
oxycodone
hydrocodone
morphine
fentanyl
ect
99
short acting opioids
provide relief for about 4 hours
100
long acting form of opioids
relief for longer periods of time
101
opioids are given in what circumstances
episodes of acute pain
chronic pain (dependent on situation)
102
Which routes can opioids be administered?
PO
IV
Transdermal patch
103
What type of patient is typically given a transdermal fentanyl patch?
Cancer patient
104
What medication depresses the central nervous system?
Opioids
105
If a nurse is administering pain medication what should they do before and after?
Vital signs
assess pain level
assess mental status
106
Common side effects of opioids
N/V
constipation
CNS changes
respiratory depression
107
What patient group is more likely to have adverse reactions to opioids and why?
Older adults because their body cannot filter our toxins normally anymore
108
A patient has just undergone an appendectomy and is in severe pain when discussing with the patient several pain-relief interventions the most appropriate recommendation would be:
A. transdermal fentanyl patch B. tylenol C. ibuprofen D. Oxycodone
D. Oxycodone
109
Physical dependence of a drug
The body becomes physically dependent on the drug because it has
adapted to it
Normal responses to ongoing exposure to pharmacologic agents
manifested by withdrawal syndrome when the drug is abruptly
decreased
Physical dependency does not imply addiction
to avoid withdrawal, drug should be tapered
110
Drug tolerance
Need for increased dose to maintain same degree of pain control
Drug tolerance does not imply addiction
Rotate drug type if tolerance develops, as increasing dose could
contribute to hyperalgesia
111
Addiction
Characterized by behaviors arising from a drive to obtain and take
substances for reasons other than the prescribed therapeutic value
Tolerance and physical dependence are not indicators of addiction
112
A postoperative patient is receiving PRN pain medication. You will evaluate the effectiveness of the medication when:
A. you compare assessed pain w/baseline pain B. body language is incongruent with reports of pain relief C. family members report that pain has subsided D. vital signs have returned to baseline
A. you compare assessed pain w/baseline pain
113
What are the three P's when doing rounding?
Pain
Potty
Position
114
If interventions for pain were performed what do we need to do next?
Think ADPIE - reassess in 30 minutes to an hour to follow up to see if interventions worked
115
Continue to follow up on pain at least every ____ hours if not sooner
two
116
Ventilatory rhythm
pattern of breathing it is even or uneven and is there pauses in breathing
117
ventilatory depth
is it labored or unlabored
labored uses accessory muscles - pulling of neck and muscles around ribs
