health occs chapter 10 hartman

What is patient rounding?

Visiting patients at scheduled intervals (typically every hour) to assess progress, check bathroom needs, pain levels, comfort/repositioning, and equipment function.

What are the benefits of consistent patient rounding?

It helps reduce falls and pressure injuries, minimizes call light use, decreases patient anxiety, and helps identify early changes in condition.

What are the four main vital signs?

Body temperature, pulse rate, respiratory rate, and blood pressure.

What do vital signs indicate?

How well vital organs such as the heart and lungs are functioning.

What are baseline vital signs?

Measurements that are normal for a specific individual, which are essential for detecting early signs of physiological distress.

When should vital signs be reported to a nurse immediately?

When measurements fall outside normal adult ranges or show significant deviations from a patient's baseline.

What is the normal adult oral temperature range?

97.6°F to 99.6°F (36.4°C to 37.6°C).

What is the normal adult rectal temperature range?

98.6°F to 100.6°F (37.0°C to 38.1°C).

What is the normal adult axillary temperature range?

96.6°F to 98.6°F (35.9°C to 37.0°C).

What is the normal adult tympanic (ear) temperature range?

96.6°F to 99.7°F (35.9°C to 37.6°C).

What is the normal adult temporal artery temperature range?

97.2°F to 100.1°F (36.2°C to 37.8°C).

Which temperature measurement site is considered the most accurate?

Rectal.

Which temperature measurement site is considered the least accurate?

Axillary.

What is hypothermia?

Low body temperature below 95°F (35°C) measured rectally.

What is hyperthermia or pyrexia?

Fever or elevated body temperature, usually above 101°F.

What temperature above which can quickly lead to convulsions, brain damage, and death?

106°F (41.1°C).

What does afebrile mean?

The absence of a fever.

What is diaphoresis?

Excessive sweating, which may be caused by fever or pain, or be a sign of a heart attack.

What is cyanosis?

A blue or gray color around the lips, nail beds, or inside the mouth/nose, signaling decreased blood oxygen.

What is pallor?

Unusually pale skin indicating poor circulation or illness.

What is flushing?

Skin appearing red or darker than normal due to fever, heat, or pain.

What is the normal pulse rate range for healthy adults?

60 to 100 beats per minute (BPM).

What is tachycardia?

A pulse rate over 100 beats per minute in adults.

What is bradycardia?

A pulse rate under 60 beats per minute in adults.

What are the three main characteristics to note when taking a pulse?

Rate, rhythm, and volume/strength.

What is the most common site for monitoring pulse in adults and children 6 and older?

Radial pulse on the inside of the wrist.

What is the apical pulse?

A pulse measured by listening directly over the apex of the heart using a stethoscope.

Where is the apical pulse located?

On the left side of the chest, in the 5th intercostal space just below the nipple.

Why should respirations be counted immediately after counting the pulse?

Because people tend to breathe more quickly if they know they are being observed.

What is the normal respiratory rate range for adults?

12 to 20 breaths per minute.

What is the normal respiratory rate range for infants?

30 to 40 breaths per minute.

What is dyspnea?

Difficulty or labored breathing.

What is apnea?

The absence of breathing.

What is tachypnea?

Rapid respiratory rate above 25 breaths per minute.

What is bradypnea?

Slow respiratory rate, usually below 10 breaths per minute.

What is orthopnea?

Shortness of breath when lying down that is relieved by sitting up.

What is Cheyne-Stokes breathing?

Alternating periods of slow, irregular respirations and rapid, shallow respirations followed by short periods of apnea.

What are rales?

Bubbling, crackling, or noisy breath sounds caused by fluids or mucus in the air passages.

What is wheezing?

High-pitched whistling or sighing sounds during expiration due to difficulty breathing.

What is the normal pulse oximetry (blood oxygen saturation) range for adults and children?

95% to 100%.

What is hypoxia?

A shortage of oxygen in the body's tissues.

What is systolic blood pressure?

The top number in blood pressure representing the pressure in artery walls when the left ventricle contracts.

What is diastolic blood pressure?

The bottom number in blood pressure representing the constant pressure in artery walls when the heart is at rest between contractions.

What is normal adult blood pressure?

Less than 120 mm Hg systolic and less than 80 mm Hg diastolic.

What is hypertension?

Consistently high blood pressure.

What is hypotension?

Abnormally low blood pressure with readings below 90/60 mm Hg.

What are the four uncontrollable risk factors for hypertension?

Age, race, gender, and genetics.

What instrument is used to measure blood pressure?

Sphygmomanometer.

What is the orthostatic (postural) blood pressure measurement protocol?

Measuring blood pressure sequentially in three positions: lying down, sitting (after waiting 2 minutes), and standing (after waiting 2 minutes).

Why must patient weight be recorded in kilograms in hospital settings?

To prevent serious medication errors, as medication doses are based on metric units (1 kg = 2.2 lbs).

How is Body Mass Index (BMI) calculated?

By dividing a person's weight in kilograms by the square of their height in meters.

What is informed consent?

A process in which a person, with the help of a doctor, makes informed healthcare decisions and signs a consent form after learning risks, benefits, and options.

What does NPO stand for and mean?

Nothing by mouth; a medical order disallowing food, water, and ice chips.

What are sequential compression devices (SCDs)?

Sleeve-like inflatable garments placed on lower legs connected to a machine that promotes circulation and prevents blood clots.

What is the primary goal of postoperative care?

To prevent infections, promote healing, and return the person to a state of health.

What are compression stockings (antiembolic stockings)?

Elastic stockings that gently squeeze the legs to increase blood flow, reduce swelling, and prevent blood clots/embolisms.

What is surgical asepsis (sterile technique)?

Making an object or area completely free of all microorganisms, not just pathogens.

How long must a surgical scrub be performed?

For at least 5 minutes per hand/forearm, keeping fingertips pointed upward.

What is the outer border of a sterile field considered?

Nonsterile (specifically the outer 1-inch border).

What is a Mayo stand?

A portable stainless-steel tray and holder commonly used to set up a sterile field.

What is the drop method used for?

Adding small, soft items to a sterile field by opening a package and holding it downward to fall onto the field.

What are the "rights" of medication administration?

Right patient, right medication, right time, right route, right dose, and right documentation.

What is anaphylaxis?

A severe, potentially deadly allergic reaction where the body's immune system overreacts to a drug.

What is diversion in healthcare?

The illegal stealing or misuse of controlled medications by healthcare workers.

What factors can affect vital signs?

Age, medical condition, medications, mental state, room temperature, and noise levels.

What factors affect body temperature?

Environment, meals, emotions, activity, baths, infection/illness, and time of day.

What is arrhythmia?

An irregular or abnormal heart rhythm.

What is eupnea?

Normal respirations.

What are common symptoms of low blood oxygen?

Rapid breathing, shortness of breath, and a rapid pulse rate.

On what arm should blood pressure NOT be measured?

An arm with an IV, dialysis shunt, cast, burns, recent trauma, paralysis from stroke, or on the side of a recent mastectomy.

What is a stadiometer?

A device used to measure height.