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Concepts of Nursing
Chapter 17
| Question | Answer |
|---|---|
| Afebrile | Without fever |
| Febrile | With Fever |
| Tachycardia | Pulse greater than 100 bpm |
| Bradycardia | Pulse below 60 bpm |
| Diastole | the time at which the ventricles are at rest |
| Systole is | the time which the ventricles of the heart contract |
| Bradypnea | Resp rate below 12 resp per 12 min |
| Dyspnea | labored or difficulty breathing |
| Eupnea | the resp effort, rate, pattern, rhythm, depth, all fall within normal rate |
| Orthopnea | too difficult to breathe unless positioned in an upright position such as sitting or standing |
| Tachypnea | Respiration rate exceeds 20 resp per min |
| Hypertension | Elevated blood pressure (systolic consistently above 130 or diastolic consistently over 80) |
| Hypotension | Low blood pressure that falls below 100/60 |
| Hypothermia | A core temp below 95 degrees (slows body metabolism down) |
| Auscultatory Gap is | the silence and return of sound |
| Pulse Deficit | is when the radial pulse is slower than the apical pulse |
| Pulse Pressure | the measurement of the differences between systolic and diastolic pressures (less than 30 but greater than 50 is abnormal) |
| Sphygmomanometer | used to assess the blood pressure (blood pressure cuff) |
| Stridor is | An audible high pitch crowing sound that results from partial obstruction of the airways |
| Cheyne-Stokes Respirations | Respiration begins shallow that get deeper then apnea |
| Biot Respirations | Respirations are grouped as several shallow breaths followed by variable length periods of apnea |
| A stethoscope has a sound-transmitting chest piece consisting of | A bell and a diaphragm |
| What are the 5 objective vital signs? | Temperature, Pulse, Respirations, Blood Pressure, Oxygenation Saturation (provides data regarding the patient's overall condition) |
| What is the 6th subjective vital sign? | Pain (serves as a warning that tissues are being injured or about to be injured) |
| What does Objective mean? | Observed by the nurse of the patient |
| What does Subjective means? | Said to the nurse from the patient |
| Your gut will never steer you wrong? | True |
| Thermogenesis is the production of heat | True |
| The basal metabolic rate is what? | The amount of heat produced by the body when at total rest |
| Thermoregulation is what | The regulation of the body temp controlled by the hypothalamus |
| Vasoconstriction is what? | Blood vessels tightening up (shrinking); helps redirect blood flow to the vital organs (brain and heart) |
| Factors Affecting Body Temp are? | Environment, Time of day, Sex (gender), Physical Activity and Exercise, Medications, Food Intake, Stress, Illness, |
| Types of thermometers are? | Strip, tympanic, temporal, oral, rectal, nonmercury, electronic, non-contact infrared thermometer (NCIT) |
| A patient with a heart problem should not use what type of thermometer? | Rectal |
| What nerve is near the rectum? | Vagas Nerve |
| Oral temp is the best noninvasive route with an accurate reading | True |
| Rectal thermometer is invasive but most accurate | True |
| Hyperthermia means what? | An elevated fever above 105F degrees or 40.5C degrees |
| Phagocytes are | Specialized white blood cells that ingest invaders in the body; they secrete pyrogens that stimulate secretion of the prostaglandin hormones. |
| Temp elevation above 105 degrees can result in what? | Damage to body cells |
| When body temp raises quickly the body will react by doing what? | Seizing (esp. in infants or children) |
| The amount of blood contracted from the left ventricle of the heart is? | Stroke Volume |
| Point of Maximal Impulse (PMI) | The most accurate pules because it comes straight from the heart at the Apex of the heart in the 5th intercoastal space at the midclavicular line |
| S1 and S2 (Lub Dub) sounds represent | one complete heartbeat |
| Pulse pressure is between what? | Diastolic and Systolic |
| +3 pulse is called? | bounding (strong) |
| +2 pulse is called? | normal |
| Threading pulse Is? | weaker than a weak pulse |
| Peripheral Pulse Sites are what? | Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Posterior Tibialis, Dorsalis Pedis (are used to assess the heart rate) |
| The most difficult pulse to find is which one? | Popliteal |
| What is capillary refill? | gently squeezing a nailbed of the finger to empty the capillaries of blood (3 seconds in adults; 5seconds in older adults) if no return there is a circulatory issue |
| External resp | exchange of gas between the alveoli and the capillaries that surround the alveoli |
| Internal resp | the circulating blood of the tissues |
| Respiration system is controlled by what? | medulla oblogata |
| Hypoxemia (blood) | low oxygen in the blood |
| Hypoxia (tissue) | low oxygen in the tissue |
| Respirations are assessed for one minute | True |
| Apnea (silent) | when respirations cease or are absent |
| Blood Pressure is the measurement of ? | the assessments of the Systolic and Diastolic pressure (and is measured in ml) |
| 4 circulatory qualities are | rate (number of pulse beats per minute), rhythm (regular or irregular), strength (strong or weak), equality (same strength on both sides) |
| Cardiac Output | the volume of blood pumped from the heart in a full minute |
| High blood pressure is known as? | The silent killer |
| B/P cuff goes upper 2/3's of the arm | True |
| Korotkoff Sounds | sounds heard when pumping up b/p cuff to releasing cuff |
| Arteriosclerosis is a | gradual loss of elasticity in the arterial walls resulting in less stretch and recoil |
| Primary Hypertension is | Heart has to work harder to pump the blood through the cardiovascular system |
| Secondary Hypertension is | caused by an endocrine or renal problem |
| Normal Spo2 rate is | 96-100 |
| Acute pain happens | now; is less than 6 months |
| Chronic pain is | of long duration and is ongoing with little change or progression |
| What is a pain scale | numbers from 0-10 that are used when assessing a patient's pain level (o is the lowest and 10 is highest) |
| Adult ear assessing is | Back and up |
| Children ear assessing is | Back and down |
| FLACC sale is what? | a behavioral pain assessment tool for pediatric patients ranging from 2months to 7years old or individuals who cannot communicate using FACES or 0/0 pain scale (or with developmental delays) |
| What is the Wong-Baker FACES Pain Rating Sale? | consists of a picture of a series of faces that show varying degrees of comfort (smiling, frowning, crying) the child or patient can point to their level of pain |
| What are vital signs? | measurements of life signs that include 5 objective and 1 subjective measurement; one the most important and frequent assessments made |
| Most vital sign routine are performed when? | Q8hrs unless provider orders differently or nurse determines to do more frequently due to sufficient reasoning |
| Celsius temp is | temp regulated by the hypothalamus |
| Fahrenheit temp is | the body temp |
| Converting Fahrenheit to Celsius is | c= (f-32) / 1.8 |
| Converting Celsius to Fahrenheit | F= (C) 1.8 +32 |
| Thermoregulation is the | regulation (production of heat) body temperature; is controlled by the hypothalamus |
| Body heat is the byproduct of metaboloism | true |
| More heat is produced as metabolism speeds up | True |
| The basal metabolic rate is the amount of heat produced by the body when at | Rest |
| Shivering is an involuntary skeletal muscle that can raise heat production to 4 to 5 times normal | True |
| Muscle contraction normally produces .... of body heat in resting state | 25% |
| Factors that influence heat production include | hormones thyroxine, epinephrine and norepinephrine, and adenosine triphosphate |
| Thyroxine is produced by the thyroid gland | True |
| Epinephrine and norepinephrine are both secreted by the adrenal medulla | True |
| Adenosine triphosphate is an energy source produced in all cells during cell respiration | True |
| The liver is always metabolically active and produces .... of body heat in resting state | 15% to 20 % |
| Older adults have a difficult time maintaining normal body temp because | of the limited amount of subcutaneous fat cells avail to insulate their internal organs |
| The Set Point is | a comfortable core body temp |
| When the set point is exceeded is does what | sends signals causing the body to sweat and blood vessels to dilate |
| Vasodilation brings more blood to the skins surface for increased heat loss through radiation resulting in | a reduction of temp |
| Sweat helps reduce | temp through evaporation |
| The body's "time clock" is called what | Circadian Rhythm (blood pressure normally lowers during sleep, increases when waking until peak is reached in the afternoon then begins to lower during the evening |
| Women have a slight body temp raise over men because ovulation and that causes progesterone to rise | True |
| Progesterone is the hormone that prepares the uterus for pregnancy | True |
| What medication will lower an elevated temperature | Tylenol |
| Noncontact Infrared Thermometer (NCIT) less than 5 min reading but | position can alter, length of hair or hair covering, affected by severe environment temps, can all affect the reading |
| Internal Catheter Probe thermometer is the most invasive and requires sterile technique | True |
| Normal oral temp is | 98.6 |
| Normal tympanic temp is | 98.6 |
| Normal rectal temp is | 99.6 |
| Normal axillary temp is | 97.6 |
| If a fever persists over 102 then healthcare providers will intervene otherwise, they will allow the fever to fever | True |
| Myalgia is | muscle aches |
| No Aspirin for children with viruses | True |
| Medications used for children with fever are | Ibuprofen and Acetaminophen |
| Reyes Syndrome is | an acute and potentially fatal childhood disease affecting the nervous system and liver that has been ass. with children with fevers taking Aspirin |
| Blood pumped from the heart in 1 min is known as | Cardiac Output |
| The average adult heart pumps approx. 5 liters per min | True |
| The central of the primary pulse site is | Apical Pulse located over the apex of the heart where contraction is the strongest |
| You may find the PMI in a child in the | 4th or 5th intercoastal space |
| You will place your stethoscope over the | PMI site to auscultate (listen) the apical pulse |
| The rate of the hearts contraction is regulated by the | medulla oblongata, located in the brainstem of the central nervous system |
| Auscultate means to | listen attentively |
| Temporal pulse is located | over the temporal bone on the sides of the head; is assessed when the radial cannot be assessed |
| Carotid pulse is located | on the sides of the neck between the trachea and sternocleidomastoid muscle |
| Brachial pulse is located | in the medial elbow crease of each arm (antecubital space) |
| Radial pulse runs | parallel the radius bone on the thumb side of the wrist |
| Femoral pulse can be palpated | along the groin crease at the top of the thigh |
| Popliteal Pulse is the most difficult location | found behind the knee |
| To feel the dorsalis pedis pulse first have the patient do what | slightly flex the knee then place fingertips between the big toe and second toe |
| The posterior tibialis is located | by laying fingertips on the medial aspect of the ankle directly behind the medial malleolus bone |
| Palpating carotid pulses at the same time can cause | drop in pulse and blood pressure and could cause fainting |
| 3 characteristics of pulse are | rate, rhythm, and volume (strength) |
| Normal pulse range in an adult is | 60-100 bmp |
| If the pulse rhythm (intervals between beats) is evenly spaced, it is called | regular |
| If there are differences in the interval lengths of the pulse it is called | irregular |
| Blood fluid wave reaching the pulse points it is called | perfusing |
| +1 pulse is considered | weak |
| No detectable pulse is considered | absent or rate of 0 |
| Increased intercranial pressure will | typically lower the pulse rate and may cause it to be irregular |
| Doppler ultrasound machine is a device | that uses sound waves to determine whether blood flow is present |
| Diastolic pressure is | is pressure exerted by the blood on the artery walls while the heart ventricles are not contracting |
| Systolic pressure is | the force exerted by the blood against the walls of the arteries during contraction of the heart ventricles |
| Factors affecting blood pressure are | Age, Race, Exercise, Rest, Cardiac rhythm, Anxiety, Stress, Emotion, Nicotine, Medication, Caffeine, Obesity, Level of hydration, Hemorrhage, Increased Intracranial pressure |
| Stage 2 Hypertension is | systolic 140 or higher or diastolic 90 or higher |
| A blood pressure cuff too big for the patient will give an inaccurate reading of | low reading |
| A blood pressure cuff too small for the patient will read an inaccurate reading of | too high |
| The bell of the stethoscope is | to auscultate the lower pitched sounds such as the heart |
| The diaphram of the stethoscope is | to auscultate higher pitched sounds such as the lungs, blood pressure, and stomach (bowel sounds) |
| When there is a renal or endocrine disease process that results in the elevation of the blood pressure it is called | Secondary Hypertension |
| Untreated hypertension can lead to | Brain stroke, Heart failure/attack, Kidney failure, Retinas of the eyes/ loss of vision |
| Treatment for hypertension | Stop smoking, weght loss |
| Syncope (fainting) is a | temporary loss of consciousness |
| orthostatic hypotension is | when position changes resulting in systolic pressure greater or equal to 15mm /Hg or diastolic pressure falls 10mm Hg |
| If a patient faints due to orthostatic pressure, you must | lay the person in a modified Trendelenburg's position (feet are elevated to above the level of the heart |
| Oxygen saturation should be | 96%-100% (on the finger) and is read in less than 30seconds (on the ear) it is read in less than 15 seconds if results are lower than 90% contact RN supervisor |
| Blood Pressure 4 circulatory qualities are | strength of the heart's contractions, blood thickness, blood volume, and peripheral vascular resistance |
| Respirations are the interchange of oxygen (o2) and carbon dioxide (co2) between the atmosphere and the body | True |
| Kussmaul Respirations are | increased respirations in rate and depth with long, strong, blowing, or grunting exhalations |
| Hematocrit is a measurement of what | the concentration of the red blood cells in the plasma |
| When there is a higher proportion of red blood cells to blood plasma, the viscosity of the blood is increased, which causes what to rise? | Blood Pressure |
| Before assessing a blood pressure at the antecubital site be sure patient does not have what conditions? | Amputation, Mastectomy, Shunt, Casts, Brace, Dressings, recent vascular surgery or trauma, IV infusion on the selected arm |
| Vital signs are documented on a | flow sheet (electronic flow sheet/chart) |
| Adventitious abnormal sounds include | wheezes, crackles, rales, stridor, and rhonchi (heard with stethoscope) |
| Coarse or Rhonchi sounds are | low-pitched rattling or bubbling snoring caused by partial obstruction of the large airways (tumors) |
| Stertorous | noisy snoring labored respirations heard without stethoscope |
| Crackle sounds are | short and choppy popping snapping or raspy (rubbing strands of hair) air moving over secretions in the lungs |
| Wheezing sounds are | musical whistling (can be heard with or without stethoscope) |
| Inhalation and Exhalation is | ventilations |
| Tidal Volume is | 300-500ml |
| Diaphoresis | sweat is high enough to be seen on the skin |
Created by:
Daarina Jones