Test 1

Cards (146)

  • Afebrile
    Without fever
  • Pyrogens
    Substances that cause fever
  • Hyperthermia
    High body temperature
  • Hypothermia
    Low body temperature
  • Tachycardia
    Rapid heart rate
  • Bradycardia
    Decreased heart rate
  • Tachypnea
    Increased respiratory rate
  • Bradypnea
    Decreased respiratory rate
  • Apnea
    Periods when no breathing occurs
  • Dyspnea
    Difficult or labored breathing
  • Orthopnea
    Changes in breathing when sitting or standing
  • Hyperventilation
    Increased rate and depth (extreme exercise, fever)
  • Hypoventilation
    Decreased rate and depth (irregular, overdose of narcotics)
  • Cheyne-stokes
    Alternating periods of deep, rapid breathing followed by periods of apnea (typically seen in dying patient, drug overdose, heart failure)
  • Dysrhythmia
    Irregular pattern of heartbeats (must report immediately)
  • When to Assess Vital Signs
    • On admission
    • Based on policy
    • Any time change in patients condition/ loss of consciousness
    • Before/after surgical or invasive procedure
    • Before/after activity that may increase risk, such as ambulation after surgery
    • Before/after administration of meds that affect heart and respirations
  • Delegation
    • As nurse cannot delegate teaching of a patient
    • When delegating: must make sure person (UAP) knows skills
    • If patient is unstable or change in vitals- CANNOT delegate vitals
    • Nurse's responsibility to ensure accuracy or the data, and report abnormal findings
  • Medical diagnosis
    What brings patient to the hospital
  • Patients level of acuity
    How sick patient actually is
  • Interventions for fever
    1. Light clothing
    2. Antipyretics (need order)
    3. Increase fluids
  • Signs of fever
    • Shivering
    • Dehydration
    • Sweat
    • Body's natural response to reduce temperature
  • How does patient with fever present
    • Loss of appetite
    • Headache
    • Hot/ dry skin
    • Flushed in face
    • Thirst
    • Fatigue
    • Muscle aches
    • Increased respiration
    • Pulse rate
    • In older adult: delirium or delusion, confusion
    • In younger children: seizures
  • Vital Signs
    • Body Temperature 96.7-100.5
    • Pulse Rate 60-100 (newborns have higher pulse rate/ older adults have lower pulse rates)
    • Respirations 12-20
    • Blood Pressure 120/80
    • Pulse Ox 95-100%
  • Circadian rhythm
    24 hour sleep cycle, typically temperature is lowest in the morning
  • Body temperature in older adults
    Maybe lower due to impaired thermoregulation response
  • Pulse amplitude
    • 0 Absent
    • +1 Diminished, Weaker than expected
    • +2 Brisk, expected, normal
    • +3 Bounding
  • Sites for Pulses
    • Temporal
    • Carotid- Neck
    • Brachial- pinky side, elbow
    • Radial- thumb side
    • Femoral- groin
    • Popilteal- behind knees
    • Posterior tibial- inside ankle
    • Dorsalis pedis- on top of foot
  • Oral and rectal route
    NOT preferred for child under 5/ older confused patient/ or someone who just had oral surgery
  • Rectal temperature
    Thermometer probe into the anus about 1.5 in in an adult or no more than 1 in in a child
  • Oral temperature
    Sublingual; use protective probe, make sure patient can hold probe under tongue, close lips [if patient had something to eat or drink; wait 15-30 minutes after]- AVOID glass thermometers
  • Axillary temperature
    The armpit; place in middle of axilla - most common for neonates
  • Temporal temperature
    Swiped over the skin; forehead and back of ear
  • Tympanic temperature
    Ear; can be used on adults/children for child pull down and back… for adult pull up and back on pinna [large wax deposit/ smaller canal/ wrong position could affect accuracy of temperature]
  • Rhythm
    Regular or irregular
  • Amplitude/ quality
    Strong or weak
  • Apical pulse
    Found on left mid clavicular line, fifth intercostal space, listen for 1 minute
  • Pulse deficit
    Difference between apical and radial pulse; which indicates that all of the heartbeats are not reaching in the peripheral arteries or are too weak to be palpated [need 2 nurses] assess the apical and radial pulse together for 1 minute
  • Eupnea
    Normal/ unlabored breathing
  • Listening Korotkoff sounds
    • Systolic (measurement of contraction of ventricles) typically 100-140- can be affected with emotional state
    • Diastolic (relaxation of ventricles) typically 60-90
  • Pulse pressure
    Difference between systolic and diastolic pressure