Term
Hand washing
Gloves
Mask
Face Shield
Eye Protection
Blood Borne Pathogens Sharps containers Needles
Latex Allergy Irritant Contact Dermatitis Delayed Contact Dermatitis Systemic Reactions |
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Definition
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Term
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Definition
| Observation Continuous Gait Strength Body Habitus Body Language? Comfort Eye Contact |
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Term
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Definition
Use palmar surface of fingers and finger pads in a rolling or rocking motion to assess:
Position
Texture
Size
Consistency
Fluid
Crepitus
Structure of mass |
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Term
| Cool or cold can be a compensatory mechanism – |
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Definition
| pt in shock and peripheral circulation is diminished to preserve blood flow to the vital organs |
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Term
Use backs of fingers or hand to assess:
TEMPERATURE
Norm temp:
Warmth:
Cool or cold:
As with nearly all exams, compare left and right! |
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Definition
Use backs of fingers or hand to assess:
TEMPERATURE
Norm temp: suggests adequate
circulation
Warmth: suggests infection
Cool or cold: suggests
inadequate circulation
As with nearly all exams, compare left and right! |
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Term
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Definition
Sounds:
Tympany (gastric bubble)
Hyperresonance (hyperinflated lungs)
Resonance (healthy lungs)
Dullness (liver)
Flatness (muscle) |
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Term
stethescope- high pitched less directed
stethescope- low pitched directed (localized) |
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Definition
Diaphragm high pitched less directed
Bell low pitched directed (localized) |
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Term
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Definition
Intensity
Pitch
Duration
Quality |
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Term
| general considerations: vital signs |
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Definition
General Considerations:
Avoid ETOH, caffeine, tobacco, or exercise within 30 min
Patients sitting and comfortable
Arm at heart level |
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Term
Oral:
Rectal:
Axillary:
Tympanic:
Cutaneous: |
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Definition
Oral:
Glass/Digital
Rectal:
Glass/Digital
Axillary:
Glass/Digital
Tympanic: Ear (aural)
Digital
Cutaneous:
“Temp strips”
forehead |
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Term
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Definition
Normal temp:
~ 98.60F ~ 37.00C
Fever:
>100.50F oral
>38.50C oral |
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Term
| which is least and most accurate for temperature |
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Definition
| Of these, axillary is least accurate and rectal is most accurate |
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Term
Location
Character
Rhythm |
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Definition
Location Radial Brachial Carotid
Character Bounding Normal Weak
Rhythm Regular Regularly Irregular Irregularly Irregular |
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Term
| sounds that medical personnel listen for when they are taking blood pressure |
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Definition
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Term
| interval of pressure where Korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point during the manual measurement of blood pressure. The improper interpretation of this gap may lead to blood pressure monitoring errors: namely, an underestimation of systolic blood pressure and/or an overestimation of diastolic blood pressure |
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Definition
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Term
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Definition
Patient seated
Arm at heart level
Appropriate sized cuff |
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Term
| KOROTKOFF (BLOOD PRESSSURE) SOUNDS HAVE FIVE PHASES: |
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Definition
KOROTKOFF (BLOOD PRESSSURE) SOUNDS HAVE FIVE PHASES:
Phase 1: sharp thuds, start at systolic blood pressure
Phase 2: blowing sound; may disappear entirely (the auscultatory gap )
Phase 3: crisp thud, a bit quieter than phase 1
Phase 4: sounds become muffled
Phase 5: end of sounds -- ends at diastolic blood pressure |
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Term
| a point is reached where the cuff pressure equals the systolic blood pressure. As blood begins to spurt through the compressed artery, the turbulent flow is audible. The vibrations in the artery walls are called |
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Definition
| Korotkoff sounds. The sounds are divided into five phases based on the loudness and quality of the sounds. |
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Term
| bp cuff too lg v too small |
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Definition
Too large underestimates BP
Too small overestimates BP
Too Large? - Erroneously low Too Small?
- Erroneously high |
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Term
| The period during which Korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point; responsible for errors made in recording falsely low systolic blood pressure, especially in hypertensive patients, of up to 25 mm Hg, and avoided by pumping the cuff 30 mm Hg beyond palpable systolic pressure. |
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Definition
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Term
| The ONLY way to avoid an erroneous BP reading caused by an auscultatory gap is… |
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Definition
The first time you check a patients BP, check a palpable systolic pressure first.
Then you know approximately what the systolic BP will be before auscultating a systolic and diastolic BP |
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Term
| a sign where, on palpation of the pulse, a double peak per cardiac cycle can be appreciated |
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Definition
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Term
| a physical finding with arterial pulse waveform showing alternating strong and weak beats |
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Definition
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Term
| a descriptor for a heart arrhythmia in which abnormal heart beats occur every other concurrent beat |
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Definition
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Term
| an exaggeration of the normal variation in the pulse during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales. It is a sign that is indicative of several conditions including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease |
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Definition
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Term
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Definition
Blood Pressure and Pulse Supine Sitting Standing Used to assess volume status Supine is baseline BP and Pulse
Positive result: drop in diastolic BP of >10mmHg increase in pulse of >20
Also referred to as “tilt test” |
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Term
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Definition
Counted by inspection (do not inform patient)
# of breaths in 1 minute 15 seconds and multiply by 4
Normals Adults 14–20/min
Is breathing comfortable?
“accessory” muscle use?
Tachypnea
Hyperpnea
Bradypnea
Apnea
Cheyne-Stokes |
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Term
| gross lack of coordination of muscle movements |
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Definition
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Term
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Definition
Shoes off
Record in Feet and Inches or in cm You need to be able to convert inches to cm and cm to inches… (2.54cm=1”) |
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Term
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Definition
Shoes off
Gown only when practical
Record in pounds or kg
You must be able to convert pounds to kg and kg to pounds |
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Term
Your charting becomes a legal document.
Can you defend it?
More importantly, can you read it? |
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Definition
WRITE LEGIBLY
BE ACCURATE and COMPLETE! |
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