Term
| What do vital signs indicate? |
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Definition
| baseline health status, change in health status, response to intervention |
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Term
| What are the physical assessment skills used? |
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Definition
| inspection, palpation, and auscultation |
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Term
| What variables affect the temperature? |
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Definition
| diurnal, menstrual cycle, exercise, age |
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Term
|
Definition
| daily fluctuation (of temperature) - high in evening, low in morning |
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|
Term
| What is a blue tip thermometer used for? red tip? |
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Definition
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Term
| What is the normal oral temperature? |
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Definition
| 37 degrees C or 98.7 degrees F |
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Term
| Describe the procedure to take oral temperature. |
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Definition
| shake down to 35.5 degrees C (96 degrees F), leave in 3-4 minutes if afebrile (up to 8 min if febrile), wait 15 minutes after eating hot/cold food or fluid, wait 2 minutes after smoking |
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Term
| Who should you not take the oral temp of? |
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Definition
| seizure disorder patients |
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Term
| What is the normal temperature for axillary/inguinal areas? |
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Definition
|
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Term
| Who do you take an axillary/inguinal temperature on? |
|
Definition
| children because they move around (don't want to damage ear) |
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Term
| Describe the procedure for axillary/inguinal temp. |
|
Definition
| 5.5 min for axillary and 3-5 min for inguinal |
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|
Term
| What is the normal temp for a rectal reading? |
|
Definition
|
|
Term
| Who do you take a rectal temp of? |
|
Definition
| infants, unconscious, seizure patients, face/head surgery or trauma, shock, oxygen.nasogastric tube or no TMT equipment |
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Term
| Describe the procedure for taking rectal temp for an adult? infant? |
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Definition
| adult: insert 2-3 cm for 2.5 min; infant: insert 2.5 cm for 3 min |
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|
Term
| What is important to remember when counting pulses? |
|
Definition
|
|
Term
| What is normal pulse rate? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| What is a sinus arrhythmia? |
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Definition
| pulse rate increases with inspiration and decreases with expiration (wrong pattern, but there is a pattern) |
|
|
Term
| What is atrial fibulation? |
|
Definition
|
|
Term
| What do you record for pulse? |
|
Definition
| date/time, location, rate and rhythm, force and strength |
|
|
Term
| What is an apical pulse? How long do you auscultate it for? |
|
Definition
|
|
Term
| What does it mean if the radial pulse is higher than the apical pulse? |
|
Definition
|
|
Term
| What do you document for respirations? |
|
Definition
| rate and rhythm, date and time, any alteration in breathing pattern (shallow, labored, use of acessory muscles, tripod position) |
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|
Term
| What is the tripod position? |
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Definition
| person is sitting, putting elbows in front of them, and leaning forward |
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|
Term
|
Definition
| force of blood pushing against vessel wall |
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|
Term
| What is systolic blood pressure? diastolic? |
|
Definition
| max pressure (top number), rest pressure (bottom number) |
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|
Term
|
Definition
| difference between systolic and diastolic |
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|
Term
| What variables affect BP? |
|
Definition
| age, sex, race, diurnal rhythm, weight, exercise, emotions, stress |
|
|
Term
| What determines blood pressure? |
|
Definition
| cardiac output (stroke volume x heart rate), peripheral vascular resistance, circulating blood volume, blood viscosity, vessel wall elasticity |
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|
Term
| What happens to BP when we add more blood? |
|
Definition
|
|
Term
| What does cuff inflation do? |
|
Definition
| compresses brachial artery and occludes blood flow |
|
|
Term
| What does cuff deflation do? |
|
Definition
|
|
Term
| What are the Korotkoff sounds of each phase? |
|
Definition
| phase 1: clear tapping (systolic), phase 2: tapping and murmuring (swooshing), phase 3: louder sharper tapping (knocking), phase 4: muffling, phase 5: sound stops (diastolic) |
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|
Term
| What is the auscultatory gap? who is it most common in? |
|
Definition
| a period when the Korotkoff's sounds stop between phases 1 and 2, people with hypertensioin |
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Term
| Why is the bell best to be used when taking BP? |
|
Definition
|
|
Term
| What should the size od the BP cuff be? |
|
Definition
| width: 40% of arm circumference, length: 80% of arm circumference |
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|
Term
| When should you record phase 4 of BP? |
|
Definition
| when there is a difference of more than 10 between phases 4 and 5 |
|
|
Term
| What happens to BP when you get older? |
|
Definition
| your systoliic pressure increases |
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|
Term
|
Definition
|
|
Term
| What is hypotension? hypertension? |
|
Definition
|
|
Term
| Why should you calm a crying child? How many minutes before? |
|
Definition
| crying raises BP by 30-50 mmHg; 5-10 minutes prior to taking BP |
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|
Term
| How much higher should the BP be if you take it at the thigh? |
|
Definition
| systolic should be 10-40 mmHg higher than brachial |
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|
Term
| How should the forearm BP differ from brachial BP? |
|
Definition
| systolic should be 7 mmHg lower, diastolic should be 14 mmHg higher |
|
|
Term
| What is orthostatic hypertension? |
|
Definition
| when there is a decrease in the systolic pressure when the patient stands up (20 mmHg is significant) |
|
|
Term
| is pain subjective or objective |
|
Definition
|
|
Term
|
Definition
| unpleasant sensory and emotional experience with actual or potential tissue damage |
|
|
Term
| What variables affect pain? |
|
Definition
| age, gender, culture, type of pain |
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|
Term
| What is important about aging adults and pain? |
|
Definition
| they have decreased sensation, so there may be more pain then they report |
|
|
Term
| What is the difference between men and women in regards to pain? |
|
Definition
| women are more likely to express pain |
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|
Term
|
Definition
| short term, self-limiting, decreases as injury heals |
|
|
Term
|
Definition
| continues for 6 months or longer, fluctuates with course of disease, doesn't necessarily stop when the injury heals |
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|
Term
| What is important to assess for pain? |
|
Definition
| signs, symptoms, stressor development |
|
|
Term
| What can give us a sense of the severity of the pain? |
|
Definition
| PA and lab findings, pain scale, behavioral clues |
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|
Term
| What is the trend for BP change in older adults? |
|
Definition
| systolic pressure increases |
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