Term
| When does assessment begin? |
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Definition
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Term
| What is general survey? What should you look at? |
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Definition
OVerall impression of the client.
-Appearance/behavior
-Grooming hygiene
-Body type/posture
-Mental state
-Speech
-Vital Signs
-Height/Weight |
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Term
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Definition
| A means of assessing vital or critical physiological function. |
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Term
| What does variations in vital signs reflect? |
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Definition
| A person's state of health and/or functional ability of body systems. |
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Term
| What is the frequency of monitoring vital signs determined by? |
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Definition
-Physician order and/or nurse's judgement
-Client's condition
-Facility standards |
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Term
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Definition
| The degree of heat maintained by the body. |
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Term
| What is the average core temperature? Is it warmer or colder than skin temperature? |
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Definition
97.0 -100.8 F
36.1 - 38.2 C
Usually 1-2 degrees warmer than skin temperature. |
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Term
| How do you obtain a surface temperature? |
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Definition
| Use oral or axillary method |
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Term
| What is Pyrexia? Another word for it? |
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Definition
| The state of having a fever. Febrile. |
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Term
| What is the temperature for a fever? |
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Definition
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Term
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Definition
| Occurs in response to pyrogens. Induce the secretions of prostaglandins that reset the hypothalamic thermostat at a higher temperature. |
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Term
| What is hyperexia? What is the range for it? What can it cause? |
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Definition
| A fever that is 105.8 or higher. Can cause seizures. |
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Term
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Definition
| Core temperature below 95. Caused by extended exposure to cold. |
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Term
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Definition
| Your heart rate. The "wave" that begins when the left ventricle contracts and ends when the ventricles relax. |
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Term
| How is your pulse rate measured? |
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Definition
| Beats per minute. Obtained by placing hand on radial artery. |
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Term
| What is the normal range for adults? The average? |
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Definition
NORMAL - 60-100
AVERAGE - 70-80 |
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Term
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Definition
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Term
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Definition
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Term
| What does an S3/S4 sound indicate? |
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Definition
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Term
| What is the most accurate place to take someone's pulse rate? |
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Definition
| Apical w/ use of stethoscope |
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Term
| Where is the apical pulse? |
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Definition
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Term
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Definition
| Between midline and side of neck. Used to assess circulation of head. |
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Term
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Definition
| Medially in antecubital space |
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Term
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Definition
| Laterally on the anterior wrist (thumb side) |
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Term
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Definition
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Term
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Definition
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Term
| Where is the dorsalis pedis? |
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Definition
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Term
| Where is the posterior tibial? |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| What can rates be classified as? |
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Definition
- Regular or irregular
- Bounding or thready |
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Term
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Definition
| The quantity of blood pumped out by each contraction of the Left ventricle |
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Term
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Definition
Stroke volume X pulse/HR
Normal adult = 5,000 L |
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Term
| What causes pallor and cyanosis? |
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Definition
| Poor profusion/circulation |
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Term
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Definition
| Paleness of skin when compared to another part of the body |
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Term
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Definition
| A blueish/greyish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood. |
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Term
| What is apical-radial pulse deficit? What causes it? |
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Definition
| Greater than 2 BPM difference in the rates of apical and radial pulses. Insufficient circulation. |
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Term
| If you're checking an 88 year old dorsalis pedis and the pulse is thready and the feet are cool - what do you do? |
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Definition
| Assess the popliteal and then the femoral pulse. If it's all the way up her leg, it's a major problem. |
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Term
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Definition
| The exchange of oxygen and carbon dioxide in the body. |
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Term
| What is mechanical respiration? |
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Definition
| Inspiration and expiration. |
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Term
| What is chemical respiration? |
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Definition
| Receptors that are in the brain sensitive to CO2 levels. Pulmonary and circulatory system work together to bring O2 to the tissues and take away wastes and CO2 back to the lungs. |
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Term
| What does the diaphragm do during inspiration? |
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Definition
| Diaphragm contracts/moving down |
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Term
| What does the diaphragm do during expiration? |
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Definition
| Diaphragm relaxed/moving up. |
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Term
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Definition
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Term
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Definition
| Normal breathing (12-20 breaths/minute) |
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Term
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Definition
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Term
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Definition
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Term
| What are the 3 depths of breathing? |
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Definition
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Term
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Definition
| About to die. Gradual increase in depth of respirations followed by gradual decrease and then a period of apnea. |
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Term
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Definition
| Irregular respirations of variable depth, alternating with periods of apnea. |
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Term
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Definition
| Labored breathing/short of breath. |
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Term
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Definition
| Inability to breathe when horizontal. |
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Term
| What are the 5 variations in breath sounds? |
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Definition
1.) Wheeze
2.) Ronchi
3.) Crackles
4.) Stridor
5.) Stertor |
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Term
| HIgh pitched, continuous musical sounds, usually heard on expiration is? |
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Definition
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Term
| Low-pitched continuous sounds caused by secretions in the large airways are? |
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Definition
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Term
| Piercing high pitched sounds heard primarily during inspiration is? |
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Definition
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Term
| Labored breathing that produces a snoring sound is? |
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Definition
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Term
| What is hyperventilation? |
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Definition
| Abnormally fast or deep respiration, which results in the loss of carbon dioxide from the blood, thereby causing a fall in blood pressure, tingling of the extremities, and sometimes fainting. |
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Term
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Definition
| too shallow or too slow breathing, which does not meet the needs of the body. If a person hypoventilates, the body's carbon dioxide level rises. |
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Term
| What are arterial blood gasses? |
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Definition
| Used to directly measure the partial pressure of oxygen, co2 and blood pH. |
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Term
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Definition
| Noninvasive method of monitoring respiratory status. Uses a finger monitor that measures oxygen saturation. |
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Term
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Definition
| The pressure of blood on the artery walls as it is pushed against them during cardiac contraction. How much pressure is being put on the vessels of the body with a certain heart rate. |
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Term
| What is systolic pressure? |
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Definition
| Peak pressure exerted against arterial walls as the ventricles contract and eject blood. |
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Term
| What is diastolic pressure? |
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Definition
| Pressure on arterial walls when the heart is relaxed? |
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Term
| Is 110/70 normal, high, low? |
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Definition
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Term
| What is a BP of 120/80 considered? |
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Definition
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Term
| What is the range of BP for hypertensive stage one? |
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Definition
Systolic - 140-159
Diastolic - 90-99 |
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Term
| What is the range for stage 2 hypertensive? |
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Definition
Systolic - greater than 160
Diastolic - greater than 100 |
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Term
| What is the unit of measurement of BP? |
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Definition
| Milliliters of mercury (mmHg) |
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Term
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Definition
| The difference between systolic and diastolic |
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Term
| What are the 3 reasons for fluctuation in bp? |
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Definition
1.) Cardiac fxn
2.) Peripheral vascular resistance
3.) Blood volume |
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Term
| If there is higher peripheral resistance, what does this do to BP? |
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Definition
| Raises it. It can't get through so the pressure increases |
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Term
| How is volume related to BP? |
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Definition
High blood volume = high BP
Low blood volume = low BP |
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Term
| What are some factors that affect BP? |
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Definition
-Sex
-Fam history
-Lifestyle
-Exercise
-Body position
-Stress
-Pain
-Race
-Obesity
-Diurnal Variations
-Medications
-Diseases |
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Term
| What is an indirect way of measuring someone's BP? |
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Definition
Sphygmomanometer. The bladder of cuff goes over the artery.
If cuff is incorrect size, can effect your reading. too small, can increase BP. Too big, can decrease BP. |
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Term
| What sounds do you listen for when taking a BP? |
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Definition
1st sound - onset sound is systolic BP
5th sound - silence is diastolic BP |
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Term
| What is primary or essential hypertension? |
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Definition
| Diagnosed when there is no know cause for the increase in BP. Accounts for 90% of all cases of hypertension. |
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Term
| What effect does hypertension have on the body? |
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Definition
Increases stress on heart and blood vessels, can lead to heart attack, failure, peripheral vascular disease, kidney damage, or stroke.
Severity is directly related to degree of elevation. The higher the BP, the harsher it is on the body. |
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