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Fund Nurs 3
Fundamentals of Nursing Test 3
| Question | Answer |
|---|---|
| 4 Vital signs | 1 Body Temperature 2 Pulse 3 Respirations 4 Blood Pressure |
| Body Temperature 2 definitios | 1 Heat of Body in degrees 2 Difference between heat production and loss |
| Core temperature v Surface | Core temperature is higher |
| Where is the thermoregulatory center? | Hypothalamus |
| The primary source of heat production in the body | Metabolism- the sum of the chemical reactions of the body |
| The primary source of heat loss in the body? | The skin |
| Celcius to Fehrenheit conversion | C = 5/9 (F - 32) or F = 9/5 C + 32 |
| d Pulse | A wave of blood from pumping of the left ventricle |
| 3 characteristics of Pulse | 1 Rate 2 Quality of Amplitude 3 Rhythm |
| How is the pulse Rate measured? | bpm Beats per minute |
| How is the quality or amplitude of a pulse measured? 5 | 0 Absent 1+ Thready 2+ Weak 3+ Normal 4+ Bounding |
| How is the Rhythm measured? 4 | Regular Weak Bounding Irregular |
| The pulse is regulated by ( ) through ( ) | The autonomic nervous system through the cardiac sinoatrial node |
| Parasympathetic stimulation | Decreases the heart rate |
| Sympathetic Stimulation | Increases the heart rate |
| d pulmonary ventilation | Moving air in and out of the lungs |
| inspiration | breathing in |
| expiration | breathing out |
| External respiration | Exchange of Oxygen and carbon dioxide between the alveoli and circulating blood |
| Internal respiration | Exchange of oxygen and carbon dioxide between the circulating blood and the tissues |
| Respiratory centers in the (2) do what (2) | medulla and pons inhibit or stimulate respiratory muscles |
| The most powerful stimulant to breathe is ( ) | Carbon Dioxide |
| Can breathing be controlled voluntarily? If so how? | Yes, through the cerebral cortex |
| d. Blood Pressure | Force of blood through arterial walls |
| How is blood pressure recorded? | Measured as mm of Mercury (HG) |
| Systolic pressure | The highest pressure- left ventricle contracts |
| Diastolic pressure | The lowest pressure- heart rests between beats |
| Pulse pressure | Systolic minus Diastolic |
| Korotkoff Sounds | A series of sounds a nurse listens for when assessing blood pressure |
| KS Phase 1 | The first faint tapping sounds; the systolic pressure |
| KS Phase 2 | Swooshing sound called the ausculatory gap |
| KS Phase 3 | Distinct loud sounds |
| KS phase 4 | distinct abrupt muffling sound; first diastolic figure |
| KS phase 5 | Last sound heart; second diastolic measurement |
| 3 constant minor variations in blood pressure | 1 Peripheral Resistance 2 Neural and Humoral mechanisms 3 Cardic Output |
| Peripheral Resisance and BP | Contraction and Relaxation of Arterioles alters the BP |
| Neural and Humoral mechanisms and BP | Kidneys and Posterior Pituitary alter BP |
| Cardiac Output and BP | The amount of blood pumped per min varies and alters BP |
| Circadian Rhythm | Predictable repeated 24 hour fluctuations in physiologic processes |
| Time of day when temp is highest and lowest | Lowest in early morning, highest in late afternoon |
| 2 age groups most sensitive to environmental changes to body temperature | Old and young |
| Which gender has more body temp fluctuations? | Women |
| Hyperthermia | High body temperature |
| Hypothermia | Low body temperature |
| Pyrexia | Increased body temperature caused by upward tick in hypothalamic center set point |
| Febrile | Person with an increased temperature |
| Afebrile | Person with a normal temperature |
| TAchycardia | Pulse over 100 |
| Bradycardia | Pulse under 60 |
| Normal adult respirations | 12-20 |
| TAchypnea | Over 24 respitations per minute |
| Bradypnea | under 10 respirations per minute |
| Hyperventilation | Increased rate/ depth breathing |
| Hypoventilation | Decreased rate/ depth breathing |
| Cheyne-stokes | altered deep/ rapid breathing followed by apnea |
| Biots | Varying depth/ rate followed by period of apnea |
| 4 sites for assessing body temperature | Tympanic membrane Oral Rectal Axillary |
| 8 sites for assessing pulse | Radial (Wrist) Brachial (Arm) Coratid (neck) Temporal (Above ear) Femoral (Inner thigh) Popliteal (back of knee) Dorsalis pedis (instep of ankle) Posterior tibial (side of ankle) |
| 2 actions for assessing respirations | Inspection and Auscultation |
| 2 areas to assess BP | Brachial Artery and Popliteal Artery |
| Normal Temp C and F | 37 C and 98.6 F |
| Axillary temp newborn | 36.8 C |
| REctal temp age 1-3 | 37.7 C |
| Over age 70 C and F temp | 36 C and 96.8 F |
| Normal pulse teen and older | 60 - 100 |
| Pulse newborn | 80 - 180 |
| Pulse age 1 -3 | 80 140 |
| Pulse age 6-8 | 75 - 120 |
| Pulse age 10 | 75 - 110 |
| Respirations Newborn | 30 - 80 |
| Resp 1 - 3 | 20 - 40 |
| Resp 6 - 8 | 15 - 25 |
| REsp age 10 | 15 - 25 |
| Respirations Teen | 15 - 20 |
| Respirations Adult | 12 - 20 |
| Respirations Over 70 | 15- 20 |
| Blood Pressure Adult and Elderly | 120 / 80 |
| BP Teens | 102 / 80 |
| BP age 10 | 102 / 62 |
| BP age 6-8 | 95 / 75 |
| BP age 1 -3 | 90 / 55 |
| BP newborn | 73 / 55 |
| Adult Prehypertension | 120-139/ 80-89 |
| Adult Stage I Hypertension | 140- 159/ 90- 99 |
| Adult Stage II Hyperstension | Greater than 160/ Greater than 100 |
| Patient teaching for temperature (4) | 1) 30 min after eating or smoking 2) Under side of tounge with mouth closed 3) Leave in place 2-3 min 4) Wash thermometer |
| patient teaching for Pulse (3) | 1) May need to take before medication 2) Need a watch with second hand 3) Teach how to find pulse and count for 1 min |
| Patient teaching for BP (2) | 1) May need to check for medications 2) Teach about cuff size and placement |
| Normal pulse for a newborn | 120- 160 |
| Initial assessment when? | Shortly after arrival |
| Initial assessment Why? 2 | To establish a baseline and to identify problems |
| Focuses assessment looks at? | A specific problem or body system |
| 4 types of assessment | 1) Initial 2) Focused 3) Emergency 4) Time-lapsed |
| Emergency assessment identifies | Life-threatening problems |
| Time lapsed assessment | Compares curent status with a baseline |
| Medical assessment | Targets pathological conditions and their treatments |
| Nursing assessment | Target responses to health problems and diseases impact on the person |
| Objective data is (2) | observable and measureable |
| Objective data and others | It can be validated by another |
| Subjective data | Percieved only by the person affected |
| The 4 characteristics of Data | 1) Purposeful 2) Complete 3) Factual and Accurate 4) Relavent |
| 2 components of Nursing observation | 1) Nursing history 2) Physical assessment |
| Observation uses ( ) | The 5 senses |
| Interview skills are used in ? | The nursing history |
| 2 purposes of the nursing physical assessment | 1) Appraisal of health status 2) Identification of patient problems |
| Type of data used in the nursing physical assessment | Objective |
| What is the primary and best source of patient data? | The patient |
| Other than the patient name 4 sources of patient data | 1) Family and Significan others 2) the patient record 3) Other healthcare professionals 4) Nursing and other healthcare literature |
| The patient record provides information from ( ) | Different members of the health care team |
| Data Validation | The act of confirming and verifying data |
| The goal of data validation | Keep data free of error, bias, or misinterpretation |
| Invalid data may lead to ( ) | Inappropriate care |
| 2 times when data needs to be validated? | When there is a discrepancy between what the person is saying and what the nurse is observing and When data lacks objectivity |
| Significant patient data may lead to? | 1) Alerting other healthcare professionals of assessment changes 2) Increased frequency of assessment 3) Initiate changes in treatment |
| Critical changes require (time) | Immediate consultation |
Created by:
twininger1
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