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Nursing Concepts > Test 2 > Flashcards

Test 2 Flashcards

1
Q

Define vital signs.

A

Vital signs: Measurements that indicate the effectiveness of the circulatory, respiratory, neural and endocrine body functions.

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2
Q

Identify times when vital signs may be assessed. (4)

A
  1. On admission to obtain baseline vitals
  2. Evaluating responses to interventions
  3. Monitoring a patient’s condition
  4. Identifying health problems
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3
Q

Identify the normal range variations in body temperature, pulse, respirations, pulse oximetry and blood pressure.

A

Temperature: 36-38 degrees C

Pulse: 60-100bpm

Respirations: 12-20 rpm

BP:
Sys: 120-139 mmHg
Dia: 80-89 mmHg

O2: 95-100%

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4
Q

Define febrile and afebrile.

A

Febrile: The medical term for temperature > 38°C ie. fever

Afebrile: The medical term for a normal temperature; often used when fever breaks

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5
Q

Define fever (pyrexia).

A
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6
Q

Define hypothermia and hyperthermia.

A

Hypothermia:

Hyperthermia:

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7
Q

Identify factors to be assessed prior to taking vital signs and related rationale. (4)

A
  1. Intake of hot or cold liquid or food
  2. Smoking
  3. Ambient temperature
  4. Resting state, or having just exercised
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8
Q

Define thermoregulation, and explain how it works.

A

Thermoregulation: The balance between heat lost and heat produced.

  • Regulated by physiological and behavioural mechanisms - neurological and cardiovascular mechanisms
  • As long as heat production and heat loss are properly balanced, body temperature remains constant
  • e.g., Shivering, Sweating
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9
Q

Differentiate between core temperature and surface temperature.

A

Core Temperature: Deep tissue of the body, temperature remains relatively constant

  • e.g., Rectal, tympanic, temporal artery

Surface Temperature: Temperature of the skin/subcutaneous tissue

  • e.g., Skin, mouth, axilla
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10
Q

Routes of Temperature measurement (5)

A
  1. Axillary -SURFACE
  2. Oral - SURFACE
  3. Rectal - CORE
  4. Tympanic - CORE
  5. Temporal Artery - CORE
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11
Q

What is a pulse? Differentiate between radial and apical pulse.

A

Pulse: The bounding of arterial blood flow that is palpable at various points on the body; an indicator of circulatory status

Radial Pulse: Located along the radial side of the inner wrist

Apical Pulse: Located at the 5th intercostal space at midclavicular line; the heart sounds heard at the apex (base) of the heart

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12
Q

Factors that impact HR (7)

A
  • Exercise
  • Temperature
  • Emotions
  • Pain
  • Medication
  • Hemorrhage
  • Postural changes
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13
Q

Characteristics of pulse.

A
  1. Strength - Normal finding would be strong (3+)
  2. Rhythm - Normal finding would be regular
  3. Rate - Normal finding would be between 60-100 bpm
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14
Q

Characteristics of respirations.

A
  1. Rate - Normal finding would be 10-20 rpm
  2. Depth - Normal finding would be normal depth
  3. Rhythm - Normal finding would be regular
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15
Q

Define tachypnea and bradypnea.

A

Tachypnea: Rate greater than 20 rpm

Bradypnea: Rate less than 10 rpm

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16
Q

Define apnea and dyspnea.

A

Apnea: Cessation of breathing (counted in seconds)

Dyspnea: The subjective feeling of being short of breath

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17
Q

Factors that impact respirations.

A
  • Fever
  • Pain
  • Anxiety
  • Exercise
  • Chest or head injury etc.
18
Q

How does an oximeter work? And what are it’s limitations?

A

Works by estimating the percent of oxygen bound to hemoglobin (SpO2)

Limitations:

Light transmission

  • Carbon Monoxide absorbs and reflects light like O2
  • Nail Polish
  • Dark skin
  • Outside light
  • Jaundice etc.

Arterial pulsation

  • Peripheral vascular disease
  • Hypotension
  • Peripheral edema etc.
19
Q

Differentiate between systolic and diastolic.

A

Systolic: Contraction of the ventricles

Diastolic: Ventricles are at rest; lower pressure present at all times

20
Q

Differentiate between hypertension and hypotension

A

Hypertension

  • Sys: Greater than or equal to 140 mmHg
  • Dia: Greater than or equal to 90 mmHg

Hypotension

  • Sys: Less than or equal to 90 mm Hg
21
Q

Define orthostatic hypotension, and how can you prevent it (3)?

A

When BP falls when patient sits or stands.

Prevention:

  • Get patients moving as soon as possible in hospital
  • Change position slowly
  • Sit at the side of the bed for a few min before standing
22
Q

4 steps when placing a BP cuff.

A
  1. Width of the cuff should be 40% of limb circumference
  2. Bladder should encircle 80-100% of limbs circumference
  3. Check tightness should not be able to slide around
  4. Placed above the antecubital fossa, allowing for placement of stethoscope
23
Q

The point at which you hear the first sound when auscultating a BP is the ____. The point at which you hear the last sound is the ____.

A

The point at which you hear the first sound when auscultating a BP is the SYSTOLIC PRESSURE. The point at which you hear the last sound is the DIASTOLIC PRESSURE.

24
Q

Define Arteriosclerosis, and what is its significance?

A

Arteriosclerosis: Vessels become more rigid with age

Causes an increase in systolic BP and pulse pressure.

25
Q

What are the 3 main functions of the heart?

A
  1. Delivering oxygen and nutrients to the body
  2. Removing metabolic waste
  3. Maintaining adequate perfusion of the organs and tissues
26
Q

What are the steps of a cardiac assessment?

A
  1. Subjective data collection
  2. Inspection
  3. Palpation
  4. Auscultation
27
Q

What vitals signs do you assess during a cardiac assessment?

A
  • BP
  • Pulse
  • O2
  • Respirations
28
Q

When palpating the anterior chest, what are you feeling for and where?

A

Palpate for heaves, lifts or thrills over precordium (5 places)

  1. Aortic area (Rt 2nd intercostal space
  2. Pulmonic area (Lt 2nd intercostal space)
  3. Right ventricular area (Lt sternal boarder)
  4. Left ventricular area (apex)
  5. Epigastric region
29
Q

Characteristics to note when palpating the Apical Pulse…

A
  1. Size - 1-2 cm
  2. Amplitude - Short, gentle tap
  3. Duration - 1/2 of a systole
30
Q

When palpating the auscultating the heart, what are you listening for and where?

A

Listen for:

  • Rate - 60-100 bpm
  • Rhythm - Regular
  • S1 S2 (lub dub)

Listen in 5 areas:

  1. Aortic area (rt 2nd intercostal space)
  2. Pulmonic area (lt 2nd intercostal space)
  3. Erb’s point (lt 3rd intercostal space)
  4. Tricuspid area (lt 4th intercostal space)
  5. Mitral area (lt 5th intercostal space)
31
Q

List the arteries of the arm.

A
  • Brachial
  • Ulnar
  • Radial
32
Q

What are the 3 types of veins found in the legs and give examples of each.

A

Deep veins
- Femoral
- Popliteal

Superficial veins
- Great saphenous
- Small saphenous

Perforators (connecting veins)

33
Q

List the arteries in the leg.

A
  • Femoral
  • Popliteal
  • Dorsalis pedis
  • Posterior tibial
34
Q

What are you inspecting for during a Peripheral Vascular Assessment? How do you do this assessment?

A

Assessing for blood flow to the extremities.

Asses by examining:

  • Capillary refill
  • Hair growth
  • Colour
  • Peripheral pulses - strong, regular and equal bilaterally
    -Temperature
35
Q

What are the stages of a fever?

A
  1. Plateau phase: feeling warm, dry
  2. Initiation phase: body temperature, rises, chills, shivering
  3. Febrile phase: heat loss responses - sweating, warm, flushed skin, diaphoresis
  4. Afebrile phase: fever breaks
36
Q

How do you calculate a pulse deficit?

A

Pulse deficit is the difference between the apical rate, and the radial rate

37
Q

Why might an older person find it difficult to cope with extreme temperatures?

A
  1. Poor vasomotor control.
  2. Reduction of subcutaneous tissue.
  3. Poor temperature control mechanisms.
38
Q

When should an electronic blood pressure cuff not be used?

A

Electronic blood pressure cuff should not be used when the patient has:

  • Seizures
  • Shivering
  • Irregular heart rate
  • Severe hypertension
39
Q

Which techniques should nurses keep in mind regarding accurate blood pressure measurements?

A
  • The cup with should be 20% more than the diameter of the midpoint of the limb were the cuff is placed
  • The cuff with should be 40% of the arm circumference of the midpoint of the limb where it is applied
  • The inflatable rubber bladder of the cuff should cover 80% of the upper arm
40
Q

What should nurses keep in mind when taking the blood pressure of somebody experiencing orthostatic hypotension?

A
  • measurement of blood pressure should not be delegated in the situation
  • Blood pressure should be obtained in supine, sitting and standing positions
    Blood pressure should be obtained one to three minutes after changing the patient’s position

Nursing Concepts (2 decks)

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