Nursing Skills Quiz 2

vital signs include

blood pressure, temperature, heart rate, respiratory rate

when to take vital signs

admission, any changes with the patient, before and after surgery, before and after medications, nursing interventions, medical interventions

sites for body temperature

oral, rectal, axilla, tympanic, temporal

pyrexia

temp above normal

afebrile

no fever

hypothermia

below 96.4

hyperthermia

above 105.8

pulse deficit

apical pulse - radial pulse

pulse pressure

the difference between systolic and diastolic, normal is 40 mmHg

syncope

fainting

thrills

vibration

heaves

heavy/hard thrusting

pulse assessment

0+ no pulse, +1 weak/thready, +2 normal, +3 bounding/strong

pulse locations

temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal

bruit

turbulant blood flow, swishing/blowing sound

semilunar valves

pulmonic and aortic

atrioventricular valves

tricuspid and mitral

cardiac auscultation 5 places

aortic 2nd intercostal to the right of the sternum

pulmonic 2nd intercostal space to the left of the sternum

erbs 3rd intercostal space to the left of the sternum

tricuspid 4th intercostal space to the left of the sternum

mitral 5th intercostal space to the left of the sternum

S1

lub part of “lub dub”, loudest at apex of heart, AV valves close

S2

dub part of “lub dub”, loudest at base of heart, SV valves close

S3

lub dub ee

S4

dee lub dub

circumoral cyanosis

circulation around lips

transient acrocyanosis

one side of body looks more blue

peripheral vascular disease

decrease circulation in lower extremities

subcutaneous emphysema

aire gets into subcutaneous tissue

vesicular

over entire lung

bronchovesicular

over bronchi

bronchial

over trachea

normal sounds for respiratory

vesicular, bronchovesicular, bronchial

cackles/rales

fluid in lungs

rhonchi

brochitis, upper respiratory, low pitched sound

friction rub

inflammation of pleura

wheezes

continuous high pitch sound, asthma

stridor

croup, high pitched

absent

no breathing

scoliosis

S or C shape

chiphosis

hump back

loredosis

go backwards, compensation when pregnant

tachypnea

fast HR

bradypnea

slow HR

apnea

absense of breathing

kussmaul

metabolic acidosis, slow-fast-slow-fast, back n forth

cheyne-stokes

deep, shallow terminal ill patients

orthopnea

positional breathing

dyspnea

shortness of breathing

hypoxia

decrease levels of 02 in blood

hypoxemia

labs run

cyanosis

blue tint from lack of 02

simple mask

flow rate 6-8L

partial rebreather mask

flow rate 8-11L

nonrebreather mask

12L

venturi mask (COPD patient)

flow rate 4-10L

LUQ

stomach and spleen

LLQ

large intestines

RUQ

liver and gallbladder

RLQ

intestines and appendix

umbilicus

infected or have an odor

ascites

fluid builds up, veins become pronounced, liver failure

striae

stretch marks from rapid weight gain

rebound tenderness

push on RLQ and release, if patient has pain then appendicitis

jaundice

bilirubin isn’t being excreted through bowel movements