Test 1 Flashcards
(121 cards)
0
Q
Rectal temp 1-3 y.o.
A
99 degrees
1
Q
Axillary temp for newborn
A
97 degrees
2
Q
Oral temp 6-adult
A
98 degrees
3
Q
Oral temp >70 y.o.
A
97 degrees
4
Q
Normal adult temps: Rectal Axillary Tympanic Forehead
A
R-99
A-97
T-99
F-94
5
Q
Pulse newborn
A
80-180 bpm
6
Q
Pulse 1-3 y.o
A
80-140 bpm
7
Q
6-8 y.o pulse
A
75-120 bpm
8
Q
10 y.o pulse
A
75-110 bpm
9
Q
Teen/adults/> 70 y.o pulse
A
60-100 bpm
10
Q
Tachycardia
A
Heart rate >100bpm adults
11
Q
Bradycardia
A
Heart rate <60 bpm adults
12
Q
SV
A
How much blood is pumped with each contraction
13
Q
CO
A
How much blood is pumped per minute
SV x HR
14
Q
Respiration newborn
A
30-80 breaths/min
15
Q
1-3 y.o respiration
A
20-40 breaths/min
16
Q
6-10 y.o respiration
A
15-25 breaths/min
17
Q
Teens respiration
A
15-20 breaths/min
18
Q
Adults respiration
A
12-20 breaths/min
19
Q
> 70 y.o respiration
A
15-20 breaths/min
20
Q
Definition of blood pressure
A
Force of blood moving through arterial walls
21
Q
Blood pressure newborn
A
73/55 mmHg
22
Q
1-3 y.o BP
A
90/55 mmHg
23
Q
6-8 y.o BP
A
95/75 mmHg
24
10 y.o BP
102/62 mmHg
25
Teen BP
102/80 mmHg
26
Adult BP
120/80 mmHg
27
> 70 y.o BP
120/80 mmHg
28
Short term BP regulators
Occurs quickly, such as standing.
| Targets Resistance by vasodilation/contraction
29
Long term regulators of BP
Kidneys regulate blood volume.
| The more blood volume, the higher the BP
30
Thermoregulation
The ability to keep temperature within certain boundaries.
| Regulate by hypothalamus.
31
How the body conserves temperature
Vasoconstriction, shunt blood to deep vital organs.
| Less radiating of heat by putting on layers.
32
Production of heat
Metabolism is primary source of heat.
Epinephrine/norepinephrine release=increase heat.
Shivering=reduces surface size.
33
Reduction of temperature
Skin is primary site of heat loss.
| -evaporation of sweat.
34
Heat transfer:
| Radiation
The body gives off heat from exposed areas of skin.
35
Heat transfer:
| Convection
Such as when a fan blows on you.
36
Heat transfer:
| Conduction
Transfer of heat with direct contact, such as sitting on metal chair
37
Intermittent fever
Fever, then back to normal
38
Remittent fever
Fluctuates but never goes back down to normal
39
Constant fever
Remains elevated
40
Relapsing fever
Normal temp for over a day, but comes back
41
Crisis fever
Returns to normal suddenly
42
Lysis fever
Returns to normal gradually
43
Hyperthermia range
>105.8 Degrees F
44
Pyrexia def
Fever
45
Methods to reduce fever
Antipyretic (Tylenol/ibuprofen)
Cool sponge bath
Cool packs
Hypothermia blanket
46
Pulse amplitude:
| 0
Absent pulse, no pulse felt despite deep pressure
47
Pulse amplitude
| +1
Thready: not easily felt, slight pressure make it disappear
48
Pulse amplitude:
| 2+
Weak pulse, light pressure cause it to disappear, but stronger than threads pulse
49
Pulse amplitude
| 3+
Normal pulse, palpating easily felt, moderate pressure for it to disappear
50
Pulse amplitude
| 4+
Bounding pulse, strong and doesn't disappear with moderate pressure
51
Pulse amplitude def
He full pulse is, shows strength of left ventricular contraction
52
Pulse rhythm def
The pattern of the pulses and the pauses between them
53
Dysthymia def
Irregular heart beat
54
Pulse deficit def
Difference between apical and radial pulses, indicate a blockage.
55
What's the most powerful respiratory stimulant
CO2
56
Nsg diagnosis of decreased CO (altered pulse)
Hx CHF, dysrhythmia
57
Nsg diagnosis of ineffective peripheral tissue perfusion (altered pulse)
Hx peripheral vascular disease with decreased popliteal pulses
58
Nsg diagnosis deficient fluid volume (altered pulse)
Exposure to high environmental temperature, increased age, tachycardia
59
Nsg diagnosis acute pain (altered pulse)
Day after postoperative sx, crying, tachycardia
60
Assess respiration's:
Depth
Rhythm
Depth: deep or shallow
Rhythm: regular or irregular
61
Nsg diagnosis:
| Ineffective breathing pattern
Anxiety, increased intracranial pressure after head injury, premature infant via c-section
62
Nsg diagnosis ineffective health maintenance (BP)
Lack of finances to seek care for HTN
63
Subjective data
From the subject, symptoms, feelings
64
Objective data
Observable data. Can be seen, smelled...
65
5 c's of an interview
```
What do u call up problem
What caused your problem
How do u cope
Who cares for you
What concerns do u have
```
66
Turgor
Elasticity of skin, when pt is dehydrated skins elasticity is decreased
67
Difficulty in lifting a skin fold may indicate what?
Edema
68
Amplitude of pulses
| 0
Absent
69
Amplitude of pulses
| 1+
Weak
70
Amplitude of pulses
| 2+
Normal
71
Amplitude of pulses
| 3+
Increased
72
Amplitude of pulses
| 4+
Bounding
73
Abnormal pulse such as absent, weak,thready may indicate
Decreased CO
74
Bounding pulse may indicate
HTN
75
RBC aka
Erythrocyte
76
CBC
RBC
M:
F:
M: 4.7-6.1
F: 4.2-5.4
77
CBC
| WBC
5-10,000
78
CBC
Hg
M:
F:
M: 14-18 g/dl
F: 12-16 g/dl
79
CBC
Ht
M:
F:
M: 42-62
F: 37-47
80
Electrolytes
Def
Usage
Def: inorganic substances that conduct electrical current
Usage: asses fluid balance, kidney function, endocrine function...
81
Electrolyte
| Na+
Sodium
| 135-145 mEq/L
82
Electrolyte
| K+
Potassium
| 3.5-5.0 mEq/L
83
Electrolyte
| Cl
Chloride 95-105 mEq/L
84
Electrolyte
| Ca
Calcium
| 4.5-5.5 mEq/L
85
Electrolyte
| P
Phosphate
| 1.8-2.6
86
Electrolyte
| Mg
Magnesium
| 1.5-2.5 mEq/L
87
```
UA
pH
Protein
Spec gravity
Glucose
Keytones
Blood
```
```
pH: 4.6-8.0
Protein: up to 10 mg/100ml
Spec grav: 1.003-1.030
Glucose: neg
Keytones: neg
Blood: up to 2 RBC's
```
88
```
Arterial blood gases
pH
PaCO2
PaO2
HCO3
SaO2
```
```
pH: 7.35-7.45
PaCO2: 35-45 mm HG
PaO2: 80-100 mm HG
HCO3: 22-26 mEq/L
SaO2: 95-98%
```
89
Sputum specimen usage
Determine infection, abnormal cell (cytology) acid fast bacillus
90
Arterial blood gases
Def
Usage
Def: assess adequacy of ventilation and oxygenation via arterial blood
Usage: measures respiratory and metabolic disturbances
91
Metabolic
Renal
92
PQRST
```
P: provoke, what causes pain/makes worse/better
Q: quality, sharp/dull/burning..
R: radiate, does pan travel
S: severity, 1-10 rate pain
T: timing, constant/intermittent
```
93
Assessment
Systematic, continuous collection, organization, validation, analysis and documentation of data
94
4 types of assessments:
Comprehensive
Ongoing partial
Focused
Emergency
95
Stages of an interview
Opening
Body
Closing
96
The opening stage of an interview
Sets tone for interview
| Establish rapport, orient client to the procedure
97
Body of the interview
Question/answer
98
Closing of the interview
Maintain rapport, finished
99
Generalization
Starting point for data
100
Stereotype
Ending point cuts off curiosity/knowledge
101
Africa American health problems
HTN, stroke, sickle cell, lactose intolerant, keloids
102
Asian/pacific islanders health problem
HTN, CA, lactose intolerance, thalassemia
103
Hispanic American health problems
Diabetes, lactose intolerant
104
3 ways to improve communication
- self awareness
- increased knowledge about communication process
- being more sensitive
105
Active listening
```
S: sit facing client
O: observe with open posture
L: lean forward
E: eye contact
R: relax, don't fidget
```
106
Active listening
Pay attention verbal/nonverbal cues.
| Eye contact, verbal remarks helping communication
107
Seeking clarification
Asking to elaborate, give example
108
Restating
Say in different words to make sure u understand/heard
109
Broad opening examples
Is there something u would like to talk about today?
110
Reflecting
Respond to a statement with a question to help identify their feelings
111
Summarizing
Review main points, make conclusions.
112
Offering self
Make yourself available, show interest/concern
113
Accepting
Nurse can follow and hears u
114
Giving recognition
Greet patient by name, note efforts/change the clients made
115
Focusing
Focus on one thing until its clear
116
Exploring
Further investigating into idea/subject
117
Presenting reality
State what's real/not without arguing
118
Suggest collaboration
Figure out things with the patient
119
Three phases of nurse /client relationship
- orientation
- working phase
- termination phase
120
S2 split
Normal for some, occurs at end of inspiration.
| Heard only in pulmonic valve
