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Nursing Practice > Test 3 > Flashcards

Test 3 Flashcards

(107 cards)

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1
Q

What is the centre for controlling body temperature?

A

Hypothalamus

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2
Q

What are the factors that affect body temperature?

A

Basal Metabolic Rate | Peripheral vasodilation | Lack of sweat glands | Diaphoresis | Fever | External environment

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3
Q

Which factors tend to elevate body temperature?

A

Exercise | Sex | Circadian Rhythm | Stress | Environment | Fever | Hyperthermia | Heatstroke

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4
Q

Which factors tend to lower body temperature?

A

Age, newborns | Sex | Environment | Hypothermia | Shock | Frostbite | Infections - septicemia

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5
Q

What is the formula for converting Centigrade to Fahrenheit

A

F=1.8(C)+32

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6
Q

What is the formula for converting Fahrenheit to Centigrade?

A

C=(F)-32/1.8

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7
Q

Identify the three (3) types of thermometers that can be used to measure body temperature.

A
  • Tympanic
    • Rectal
    • Axilla
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8
Q

How would you choose a glass thermometer for oral use versus rectal use?

A

The rectal thermometers are colour coded and also have a more shallow rounded end.

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9
Q

Identify the 5 sites for taking temperature.

A
  1. Tympanic Membrane
  2. Rectum
  3. Mouth
  4. Axilla
  5. Skin
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10
Q

advantage and disadvantage of tympanic temperature

A

+The site is easily accessible

-Measurement is more variable with this device than with other core temperature devices

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11
Q

advantage and disadvantage of rectal temperature

A

+more reliable

-Requires special positioning

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12
Q

advantage and disadvantage of oral temperature

A

+Measurement at this site is comfortable for clients

-carries risk of exposure to body fluids

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13
Q

advantage and disadvantage of axilla temperature

A

+Measurement at this site is safe and noninvasive

-Measurement time is long

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14
Q

advantage and disadvantage of skin temperature

A

+Continuous reading

-Adhesion can be impaired

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15
Q

What variations occur in temperature depending on the site used?

A

Average oral/tympanic: 37 C
Average rectal: 37.5 C
Average axillary: 36.5 C

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16
Q

What client positions would you use to take a rectal temperature? Why?

A
  • Side laying
    • Sims Position
      Because of the position of the colon
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17
Q

What additional safety considerations are needed with taking of a rectal temperature? Identify comfort considerations.

A
  • Lubricant
    • Ask client to breathe slowly and relax OR “pant”, relaxation of the anus will minimize any injuries
    • Never force thermometer
    • Insert Gently
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18
Q

Pyrexia

A

Fever, occurs because heat-loss mechanisms are unable to keep pace with excess heat production.

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19
Q

Hypothermia

A

Heat loss during prolonged exposure to cold overwhelms the body’s ability to produce heat, causing hypothermia.

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20
Q

Hyperthermia/hyperpyrexia

A

body temperature that is elevated as a result of the body’s inability to promote heat loss or reduce heat production.

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21
Q

Febrile

A

White blood cell production is stimulated. Increased temperature reduces the concentration of iron in the blood plasma, supressing the growth of bacteria Fever also fights viral infections by stimulating production of interferon, the body’s natural virus fighting substance.

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22
Q

Afebrile

A

The skin becomes warm and flushed because of vasodilation. Diaphoresis assists in evaporative heat loss. When the fever “breaks,” the person becomes afebrile.

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23
Q

Define pulse

A

Bounding of blood flow that is palpable at various points on the body. Blood flows through the body in a continuous circuit. The pulse is an indicator of circulatory status.

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24
Q

What is the purpose of measuring a pulse?

A

Indicator of circulatory status

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25
Identify factors that affect pulse rate.
Emotional reasons - Stress - Caffeine - Exercise - Alcohol - Smoking - Medications - Shock - Fever - Valsalva Maneuver - Beta Blockers - Depressants
26
Which factors tend to elevate pulse rate?
Emotional reasons - Stress - Caffeine - Exercise - Alcohol - Smoking - Certain medications - Shock - Fever
27
Which factors tend to lower pulse rate?
* Valsalva Maneuver * Certain medications * Beta Blockers * Depressants
28
State the rationale for assessing emotional and activity level prior to taking a client's pulse:
* exercise increase pulse rate | * emotions increase pulse rate
29
State the rationale for assessing colour and warmth if taking pedal pulse
indicators of circulation in the foot
30
State the rationale for assessing facial pallor and cyanosis
* pale or dusky looking * blue skin * indicates oxygen levels
31
In addition to rate, what other factors are assessed when measuring a pulse?
* Rhythm * Strength * Equality
32
What is pulse deficit? How is it checked?
* the difference between the heart rate and the pulse rate in atrial fibrillation * difference in heart rate and peripheral pulse * Checked by one person measures apical pulse with stethoscope; Second person measures pulse at radial site at same time
33
Tachycardia
abnormally fast heart rate, more than 100 beats per minute in adults
34
Bradycardia:
is a slow heart rate, less than 60 beats per minute in adults.
35
Pulse Amplitude
pulse amplitude is the magnitude of a pulse parameter, such as the voltage level, current level - full volume or thready
36
Pulse Contour
The shape of the arterial pulse
37
Dysrhythmia:
disturbance of rhythm
38
What are the centres that control respirations?
The brain stem regulates the involuntary control of respiration
39
What is the purpose of measuring respirations?
* To measure and determine oxygen saturation | * gives you an idea of respiratory system
40
What factors are noted when assessing a client's respirations?
* Respiratory Rate * Respiratory Depth * Respiratory Rhythm
41
Explain the usual difference in respirations between males and females?
females breathe faster - smaller
42
How does exercise affect respiration?
Increases respiratory rate and depth to meet body's need for additional O2 and to rid body of CO2
43
How does Acute Pain affect respiration?
Pain alters rate and rhythm of respiratory; breathing becomes shallow. Client inhibits or splints chest wall movement when pain is in the area of chest or abdomen
44
How does Anxiety affect respiration?
Increases respiratory rate and depth as a result of sympathetic stimulation
45
How does Smoking affect respiration?
Chronic smoking changes pulmonary airways, resulting in increased rate of respirations at rest when the person is not smoking
46
How does Body Position affect respiration?
A straight, erect posture promotes full chest expansion. A stooped or slumped position impairs ventilatory movement. Lying flat prevents full chest expansion
47
How does medication affect respiration?
Narcotics, cocaine may increase respiratory rate and depth.
48
How does Neurological Injury affect respiration?
Injury to the brain stem impairs the respiratory centre and inhibits respiratory rate and rhythm.
49
How does Hemoglobin Function affect respiration?
Reduce O2 carrying capacity of the blood
50
Ventilatory Pattern
breathing pattern
51
Hyperventilations:
state of breathing faster or deeper than normal
52
Hypoventilation
occurs when ventilation is inadequate
53
Tachypnea
Fast breathing
54
Bradypnea
Slow Breathing
55
Eupnea
normal, good, unlabored ventilation
56
Dyspnea
Irregular, labored ventilation
57
Orthopnea
Shortness of breath, they have to sit up to breathe better
58
Apnea
Brief pauses in breathing
59
What is the purpose in assessing a patient's pulse oximetry/oxygen saturation levels?
looking at oxygen saturation levels
60
What factors affect oxygen saturation?
smoking, low body temperature
61
What are unexpected outcomes and what will be your intervention?
* postoperative - low saturation - wake them up and get them to take deep breaths * assessment - congestive heart failure - get them on oxygen
62
What is blood pressure?
the force exerted on the walls of an artery by the pulsing blood under pressure from the heart. Blood flows throughout the circulatory system because of pressure changes. It moves from an area of high pressure to an area of low pressure.
63
What is the purpose of assessing blood pressure?
blood pressure is a good indicator of cardiovascular health
64
What is the standard unit for measuring blood pressure?
the standard unit for measuring blood pressure is millimetres of mercury (mm Hg).
65
What is the difference between systolic blood pressure and diastolic blood pressure?
* diastolic: pressure exerted by the blood remaining in arteries when the ventricles relax * systolic: peak of maximum pressure when ejection occurs from the heart
66
How does age affect BP
BP is lower in children than in adult and tends to increase with advancing age
67
How does gender affect BP
* boys and girls do not have clinically significant differences in BP. After puberty, boys tend to have higher blood pressure levels. After menopause, women tend to have higher levels of BP than men do of similar ages
68
How does ethnicity affect BP
hypertension is higher among ethnic groups such as South Asian, Aboriginal, and Black Canadians
69
How does daily variation (diurnal rhythm) affect BP
BP varies over the course of a day. typically lowest during sleep, and then between 0300 - 0600 BP rises steadily. BP surges when client awakens and is highest between 1000 - 1800 hours.
70
How does weight affect BP
obesity is a factor in hypertension
71
How does exercise affect BP
BP can be reduced for several hours following a period of exercise
72
How does smoking affect BP
BP rises when a person is smoking and returns to baseline 15 minutes after smoking ceases
73
How does stress affect BP
anxiety, fear, pain and emotional stress result in stimulating the sympathetic nervous system, which increases heart rate, cardiac output, and peripheral vascular resistance - all of which increase blood pressure. anxiety can raise blood pressure as much as 30 mm Hg
74
Explain the differences in technique for taking blood pressure with an aneroid versus a mercury manometer.
* The mercury manometer, considered to be the gold standard for blood pressure measurement, measures the height of a column of mercury, giving an absolute result without need for calibration, and consequently not subject to the errors and drift of calibration which affect other methods. The use of mercury manometers is often required in clinical trials and for the clinical measurement of hypertension in high risk patients, including pregnant women. * The aneroid manometers have the advantages of being safe, lightweight, portable and compact but requires calibration prior to use. Before you use the aneroid model, make sure the needle is pointing to zero and that the manometer is correctly calibrated.
75
Identify situations when a blood pressure would not be measured on a client's arm or leg.
* when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. also, avoid applying the cuff to extremity that has been traumatized, diseased, or requires a cast or bulky bandage.
76
State the rationale for the following nursing actions: | * Place client's arm at heart level, palm up
Inappropriate site selection results in poor amplification of sounds, causing inaccurate readings.
77
State the rationale for the following nursing actions: | Palpate the brachial artery. Position cuff 2.5 cm above the brachial pulse. Centre cuff above artery.
Inflating bladder directly over artery ensures that proper pressure is applied during inflation. Loose-fitting cuff causes false high readings.
78
State the rationale for the following nursing actions: | After inflating the cuff to find point at which brachial pulse disappears, wait 30 seconds before re-inflating the cuff.
Completely deflating cuff prevents venous congestion and false high readings.
79
State the rationale for the following nursing actions: | Inflate cuff to 30 mm Hg above palpated systolic pressure
Rapid inflation ensures accurate measurement of systolic pressure
80
What is auscultatory gap?
a period in which sound is not heard in the auscultatory method of sphygmomanometry.
81
When might you, as a nurse, decide to take blood pressure on the client's thigh? How do blood pressure readings taken on the thigh vary from those taken on the arm?
* use the lower extremities when the brachial arteries are inaccessible * the popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation. the cuff must be wide enough and long enough to allow for a larger girl the the thigh. placing the client in prone position is best. position cuff 2.5 cm above client's popliteal artery with the bladder over the posterior aspect of the mid thigh.
82
What is white coat hypertension?
elevated blood pressure in a clinical setting
83
Systolic pressure
Blood pressure when the heart contracts (beats).
84
Diastolic pressure:
Blood pressure when the heart is resting between beats.
85
Pulse pressure:
the difference between systolic and diastolic pressures.
86
Korotkoff's sounds
sounds heard during auscultatory determination of blood pressure in humans, thought to be produced by vibratory motion of the arterial wall as the artery suddenly distends when compressed by a pneumatic blood pressure cuff. Origin of the sound may be within the blood passing through the vessel or within the wall itself.
87
Antecubital space:
space in front of the elbow
88
Hypotension:
Hypotension is the medical term for low blood pressure.
89
Hypertension:
Hypertension is high blood pressure.
90
Orthostatic hypotension
abnormal decrease in blood pressure when a person stands up. This may lead to fainting
91
Postural hypotension:
same thing as orthostatic hypotension
92
1. What is the purpose in assessing height and weight?
To monitor growth, development, relationship to nutrition and fluid intake and change over time.
93
What factors affect weight?
* Age * Diseases * Pregnancy
94
What is the conversion factor for converting kilograms to pounds
lbs. / 2.2=Kg
95
What is the conversion factor for converting pounds to kilograms
Kg x 2.2=Lbs.
96
Normal range for oral temperature
37 C
97
Normal range for rectal temperature
37.5 C
98
Normal range for axillary temperature
36.5 C
99
Normal range for tympanic temperature
37 C
100
Normal range for infant pulse rate
120 - 160
101
Normal range for child pulse rate
80 - 140
102
Normal range for adolescent pulse rate
60 - 90
103
Normal range for adult pulse rate
60 - 100
104
Normal range for infant BP
40 (newborn) - 85/54
105
Normal range for child BP
95/65 - 105/65
106
Normal range for teen BP
110/65 - 120/75
107
Normal range for adult BP
120/80

Nursing Practice (2 decks)

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