NURS 110 Exam 1

When should a patient's vital signs be measured?

1) Admission to the hospital

2) Beginning of a shift

3) Visit to the HCP office

4) Before, during, and after procedures

5) To monitor effects of meds or activities

6) When the patient's condition changes

How often should a patient's vital signs be taken in the hospital?

Every 4-8 hours

How often should a patient's vital signs be taken in a home health or clinic setting?

Each visit

Average oral temperature in adults?

98-98.6°F

Average rectal temperature in adults?

99-99.6° F

Normal range for pulse in adults?

60-100 bpm

Normal respirations in adults?

12-20 breaths/min

Normal blood pressure in adults

120/80 mmHg

Elevated blood pressure in adults?

120-129/

Hypertension stage 1?

130-139/80-89 mmHg

Hypertension stage 2?

≥140/≥90 mmHg

Hypertensive crisis?

>180 and/or >120

Vasoconstriction

increases body temperature

Vasodilation

decreases body temperature

Hyperthyroidism

increase in thyroxine that increases BMR

Hypothyroidism

decrease in thyroxine that decreases BMR

Body temperature begins to ________ from early childhood to adulthood.

stabilize

What factors influence body temperature?

1) Developmental level

2) Environment

3) Sex

4) Emotions/Stress

5) Circadian rhythm

6) Exercise

How does developmental level influence body temperature?

Infants lose a lot of heat through their heads so they are at risk of decreased body temp; stays stable afterwards and until late adulthood where older people have trouble maintaining body heat.

How does sex influence body temperature?

Female body has a higher body temp than male due to hormones

How do emotions and stress influence body temperature?

Stress, anxiety, excitement, nervousness, all increase body temperature

How does circadian rhythm influence body temperature?

Lowest in early morning, highest in late afternoon early evening

Pyrexia

fever

When is the dorsalis pedis pulse measured?

assessing peripheral circulation to the feet and legs

When is the femoral artery pulse measured?

to determine circulation to legs and for children

When is the popliteal pulse measured?

When assessing the status of circulation to the lower leg or as an alternative means of assessing blood pressure with a large leg cuff

Bradycardia

rates below 60 beats per minute

Tachycardia

rates over 100 beats per minute

Weak or thready quality pulse?

A pulse that can barely be felt is readily obliterated with pressure from fingers

Normal quality pulse?

easily palpated, not weak or bounding

Bounding pulse?

unusually strong pulse

Bilateral equality

useful in determining whether the blood flow to a body part is adequate; record which side is weaker if inadequate

Eupnea

normal respiration; equal rate and depth; 12-20 per min

Bradypnea

slow respirations;

Trachypnea

fast respirations; >24 breaths/min; usually shallow in depth

Kussmaul Respirations

Regular pattern but abnormally deep & increased in rate

Biot Respirations

irregular respirations varying in depth and interrupted by intervals of apnea that lacks repetitive pattern

Cheyne-Stokes Respiration

gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea

Deep breath

abdomen fully expands

Dyspnea

difficult or labored breathing

Orthopnea

difficulty breathing when lying down

What factors influence respirations?

1) Developmental stage

2) Exercise

3) Pain

4) Stress

5) Smoking

6) Fever

7) Hemoglobin

8) Disease

9) Medications

10) Position

How does developmental stage effect respirations?

Newborns have higher respiratory rates

How does pain effect respirations?

Increased rate, decreased depth

How does stress influence respirations?

increases rate

How does smoking influence respirations?

increased resting respiratory rate

How does fever influence respirations?

respiratory rate increases usually 4 breaths/min per 1 degree

How does hemoglobin influence respirations?

respiratory rate and depth decrease due to anemia

How do medications influence respirations?

CNS depressants (anesthetics, morphine) can cause slower, deeper respirations; caffeine & atropine can cause faster shallow breaths

How do positions influence respirations?

1) Standing up maximizes respiratory depth, while laying down minimizes it

2) Slumping prevents chest expansion

How does developmental stage influence pulse rate?

newborns have a rapid pulse rate; it stabilizes in childhood and gradually slows

How does sex influence pulse rate?

females have a slightly higher pulse rate than males

How does exercise influence pulse rate?

athletic people have lower heart rates; muscle activity increases pulse rate

How does food intake influence pulse rate?

Ingestion of a meal causes a slight increase in pulse rate for several hours.

How does stress influence pulse rate?

increases pulse rate and strength

How does fever influence pulse rate?

The pulse rate tends to increase about 10 beats/min for each degree Fahrenheit of temperature elevation.

What diseases influence pulse rate?

Heart disease, hyperthyroidism, respiratory diseases, infections ---> increase pulse rate

Hypothyroidism ----> decreases pulse rate

How does blood loss influence pulse rate?

pulse rate increases to compensate for lost blood

How does position change influence pulse rate?

Standing and sitting positions cause a temporary increase in pulse rate due to blood pooling in the feet and legs

How do medications influence pulse rate?

1) Stimulants (epinephrine for example) increase pulse rate

2) Cardiotonics (digitalis), opiods (narcotic analgesics), and sedatives decrease pulse rate.

How does sex influence blood pressure?

Male individuals have a slightly higher blood pressure than females around the same age

What lifestyle choices influence blood pressure?

1) sodium intake

2) smoking

3) consumption of 3+ alcoholic drinks per day

^ all elevate BP

How does exercise influence blood pressure?

Increased activity increases blood pressure

How does body position influence blood pressure?

Blood pressure is higher when standing than when sitting or lying down; readings will be higher if the patient's arm is unsupported or below the heart level; if a patient's feet are crossed or dangling rather than flat on the floor the reading will be higher

How does stress influence blood pressure?

causes BP to rise

How does pain influence blood pressure?

it increases it

How does race influence blood pressure?

Black individuals have a higher hypertension rate

How does obesity influence blood pressure?

obesity causes an increase in BP

How do diurnal variations influence blood pressure?

BP is lower while the person is sleeping and upon awakening, rises during the day, drops again towards nighttime

What medications influence blood pressure?

Antihypertensive medications and pain medication

How do diseases influence blood pressure?

Diseases that affect the circulatory system or any major organs may influence BP

When a patient has shortness of breath, how should you intervene?

Raise the head of the bed

You should have a ______ base of support.

Wide

When lifting, you should _____.

Squat

When using body mechanics, you should avoid ______ & _______.

Bending and twisting

When moving a patient, the bed should be at what height?

Waist to hip level

What are some hygienic activities of daily living (ADLs)?

Taking a bath/shower, washing hair, brushing & flossing teeth, promoting comfort, improving self-image, & decreasing infection and disease.

How do personal preferences influence hygiene practices?

Some people prefer baths to showers or vice versa, some people prefer to bathe/shower in the morning rather than night or vice versa, people have soap & shampoo preferences

How does culture & religion or spirituality influence hygiene practices?

Many people consider daily bathing, use of deodorant, and brushing the teeth necessary to eliminate body odors, whereas other people may find a weekly bath sufficient; some people may not be able to receive hygiene care from the opposite sex

How does socioeconomic status influence hygiene practices?

Inadequate bathing facilities or lack of money for hygiene supplies (e.g., lack of access to running water or soap) can influence how often a person bathes. People living in poverty must focus on meeting basic needs for food and shelter before they can spend money and energy on hygiene.

How does developmental stage influence hygiene practices?

1) Parents and other caregivers perform hygiene care for infants and young children. Older children learn practices that become habits, such as brushing and flossing the teeth.

2) As older children begin to perform their own hygiene, they are influenced by media and societal norms. For example, some preteens may avoid water and bathe only under parental duress, but teenagers, who are typically very self-conscious, may begin to take several showers a day. Many teenagers have oily skin and can tolerate frequent bathing.

3) As we age, the oil-producing sebaceous glands become less active. Frequent bathing and the use of deodorant soap further dry the adult skin. Older adults may find it necessary to bathe only every 2 or 3 days, use less soap, and increase the use of skin moisturizers.

How does knowledge and cognitive level influence hygiene practices?

Patient teaching is an important part of your hygiene care because even if they are ill at the moment, most people will eventually be responsible for their own personal hygiene.

How does pain influence self-care ability?

The pain itself, limited mobility caused by the pain, and drowsiness from analgesics used to manage the pain may all contribute to a self-care deficit.

What are some examples of limited mobility that influence self-care ability?

Joint and muscle problems, casts or traction, injury, weakness, fatigue, surgery, prescribed bedrest, or pain

How do sensory deficits influence hygiene practices?

Sensory deficits diminish a person's ability to perform hygiene measures safely and independently. For example, someone with hearing loss taking an anticoagulant needs to be taught the importance of using an electric razor.

What are some examples of cognitive impairment that influence hygiene practices?

Patients with conditions such as dementia, delirium, psychoses, stroke, Alzheimer disease, or traumatic brain injury may be unable to initiate their own grooming

How can emotional or other mental health disturbances influence hygiene practices?

Patients with conditions such as dementia, delirium, psychoses, stroke, Alzheimer disease, or traumatic brain injury may be unable to initiate their own grooming

Hourly rounds (comfort or safety rounds)

consist of seeing the patient every hour, on schedule, to offer help with self-care needs (e.g., pain relief, positioning, and toileting). Hourly rounding improves patient safety and greatly reduces call light use.

Early morning care

Provided soon after the patient awakens to prepare the patient for breakfast or other activities, such as diagnostic tests. As needed, assist with toileting, washing the face and hands, giving mouth care, and providing comfort measures.

Hygiene care

Can occur anytime during your shift at a time that is convenient for both you and the patient. Depending on the patient's self-care ability, assist with toileting, bathing, oral hygiene, skin care, hair care (including shaving if needed), dressing, and positioning or helping the patient transfer to a chair. Change or straighten bed linens, according to agency policy, and tidy the room.

H.S. (hour of sleep) care

given before the patient goes to sleep. Offer the same care as given during the bath, adding a back massage to help the patient relax. Also, place the call light, water glass, urinal, or anything else the patient may need during the night within easy reach. Turn off lights and TV and close the door before leaving the room (according to patient needs and preferences).

Puritis

itching; may lead to scratching breaks in the skin

Dry skin & common cause?

tends to crack, burn, or itch; can be caused by dehydration

Maceration

softening of tissue by prolonged moisture

Excoriation

Skin sore or abrasion produced by scratching or scraping

Abrasion

a rubbing away of the epidermal layer of the skin, especially over bony areas or prominences, is often caused by friction or shearing forces that occur when a patient moves or is moved in bed.

Pressure injury

lesions caused by tissue compression and inadequate perfusion

When going to perform hygiene care on a patient, what all should you ask them first?

1) Past and current skin concerns

2) Prescription and over-the-counter (OTC) or herbal remedies used to treat any skin concerns

3) Allergic skin reactions to food, medications, plants, skin care products, and so on

4) History of diseases or other factors that are known to cause skin issues

Pallor

paleness

Erythema

redness of the skin