Week 2 Lecture

What type of data does a nurse get when they interview the paitient during initial assessment

Subjective data

What type of data does a nurse get from a physical assesment

Objective data

When. isa comprehensive assesment performed

Upon admission to a new helathcare faciltity

When is a ongoing partial assesment performed

Throughout the shift at regular intervals

What is the point of a ongoing partial health assessment

Promotes Continuity in care throughout the shift routine check broad

When is a focused health assesment performed

When there is a specific problem that needs to be assessed.

When is an emergency assesment performed

Take a broad history and assesment while maintain vital functiosn as the concern

Airway, respirtoary and all dat

Why is subjective data known as symptoms

Because symptoms are only felt by patients and can;t be verified scientifically

Paitent reports this

Why is objective data known as signs

Signs are observable and measurable through exams and testing

What is normal data?

Normal limits with paitent, there are no clinical mishaps

What is abnormal data with expected finding

Data is out of normal range, however this number is expected due to the patients condition

What is abnormal data with unexpected finding

Data is out of normal range, this data cannot be explained

When a nurse records abnormal data what should they do

Compare the finds to the normal baseline data of the paitent

Look at other factors that can cause it

Report

How often are vitals rechecked

Q 4h

What are some physiological factors that can caused increase blood pressure?

CV disease

Hypertension

Coronary Heart Disease

Obesity

Genetics

What are factors not related to physio that can caused increase BP

Anxiety

White Coat Syndrom

Sympathic Stimluation

BP cuff too small causes ___ BP

High

BP cuff too big causes __ BP

Low

What are some physio factors that cause low BP

Volume Loss Dehydration

Emesis

Fection Sepsis spetic shock

What is orthostatic hypotension

Decrease of BP after quickly getting up from a resting position

After someone stood up from getting up how long should you wait to take them BP

2 min

What is considered stroke level BP

BP > 180/120

What is normal blood pressure

120/80

What is normal heart rate

60-100 bpm

What are factors that can make HR elevate (tachycardia)

Infection

Stress, Pain

Volume Loss

Side effects of drus

Aniemia (Low RBC)

Hyperthyroidism

What HR is considered Tachycardia

Over 100

What HR is considerd Bradycardia low HR

HR < 60

What are the causes of Bradycardia

Beta Blocker medication

Hypothermia

Rest

Hypothyroidism

What is normal respiratory rates

12-20

What are the causes low RR<12

Drug Overdose

Sleep Apnea

Head Injuries

What are the causes of high RR > 20

Anxiety

Fever

Heart Diseases

Dehydration

What are the normal ranges for SPo2

95-100 %

What causes high oxygen satuation

Proper Oxygen

Hyperventilation

What causes low oxygen saturation

Hypotension

Poor circulation

Lung disease

Hypoventilation

High Altitudes

What is normal temperature for humans

97.5

What is Level of Consciousness

Aware of person, self, enviroment, and enviormental reponse

What is the AVPU scale for loc

Alert

Voice

Pain

Unresponsive

Explain each part of the AVPU scale for LOC

A: Alert to respond immediately to stimuli and is aware of enviorment

V: Only responds to voice

P: Does not repond to voice but reponds to painful stimuli

U: Unresponsive, does not respojnd to anyhing

What is lethargic

Drowniesss that can only be awaken with some type of stimuli

What is obtunded

A more severe lethargic

What is stuperous

Deep sleep, only aroused by continous vigouours stimili

Verbal responses are incromphensibel

What is comatose

Cannot be aroused

What are the Alter and orientation X 4 Requimrents

Person, place, time event

What is the PERRLA assesment

An assessment performed on the pupil to check ordinary function

What does PERRLA stand for

Pupils

Equal

Responsive

ROund

Light

Accommodation

WHat is the size of normal pupils

2-6 mm

What shape should pupils be?

Round

How should normal pupils react to light shined on them?

Both pupils should constrict

What does normal accommodation look like for pupuls

If objec tis being brought to the nose the pupils should diverse inwards

During a physical assessment what is the order of technique for anything besides teh abdominal area

Inspection

Palpation

Percussions

Ausucation

What is the order of physical assesment techniques in a abdominal assesment

Inspection

Ausucation

Percussion

Palpation

What happens during the inspection phase of a phsyical assesment

Accesses size color shape position

When happens during the ausculation of a physical assessment

LIstening to sound, pitch, loudness, quality and duraction

What happens during palpation

Access temper, turgor, texture, moisture

If a paitent is using accessory muscles what does that indicate

It means the paitent is not gettign enough air through their normal respirtory muscles

Indicates something is causing an issue

What is the alveoli

Functional unit of respirtoay system

Site of gas exchange

What is the pores of Kohn

THey are tubes that connect different alveoli together for air to pass

Does gas exchange happen in the teachea and bronchi?

NO it is a anatomical dead space

What is the cause of fine crackles for respiratory sounds

Collapsed small airayws that pop during inspiration

What is the cause of coarse crackles for respiratory sounds

Air passing thorugh fluid muscus secretions

What is the cause of wheezes in respiratory sounds

Air passing thorugh narrow or contricted pathways

WHat is the cause of strider sounds

Airway contriction

What is the cause of a pleural fraction rub

Pleural surfaces rubbing together

What is skin turgor

The skins ability to return and snap back to shape

What is Cyanosis

Blue skin, sign of decreased oxygen

HOw do you check for cyanosis for poeple with darker skin

Look at lips or oral mucosa

What is Pallor?

Pale of the skinn

Cause of anemia

What is Erythemia/ Flushing

Redness of the skin to incerase blood flow

Inflammation

Fever

What is Jaundice?

Excess Bilirubin (yellow pigment from the breakdown of old RBC)

Liver issues

What does PMI mean for apical pulse

Point of Maximal impulse

Why is it important to assess the apical pulse for one min when giving medication

To seeif the medication will do more harm than good

What is a 0 pulse

NO pulse, not palpable

What is a +1 Pulse

Weak pulse, can easily be obliterated with mild pressure

What is a +2 pulse

Normal pulse, can be obliterated with the firm pressure

What is a +3 pulse

Strong pulse that is hard to be oblitedated

What is a +4 pulse

Very strong Bounding pulse that cannot be obliterated

What pulse rating is this

+1

What is a normal time for capillary refill

Cap refill < 2

What is the normal blood glucose range

70-90 mg/dl

What are some signs and symptoms of hypoglycemia

Blood glucose < 70 mg

Cold, numbness

Tachycardia

Headache, Faint, Dizzy, Unsteady, slurred speak

Hunger

What are some signs and symptoms of hyperglycemia?

Blood Glucose > 70 mg

Increase Urination

Dehydration

Glycosuria

Hot and Dry

If a paitent has sings of bowel obstruction waht should a nurse do?

Place them on NPO

Measure abdominal girth

If a patient has hyperactive bowel sounds what should the provider do?

Place them on NPO

Administer antidiarrheal medication

If a patient has a full palpable bladder over symphysis pubic what shoudl be done?

Bladder Scan

Encourgine Fouding

If a paitent has no bowel sounds what should be done?

Listen for 3 full minutes

Report it

If a paitent has black or tarry stool what should be don

Check if its blood

Report

WHat is an ostomy

Surgical opening to allow for elimation

What does garbled mean

Difficult to understand

What is dysphasia

Impairment in production of speech

Stroke

What is Aphasia

Full loss of language

What is dysphagia

Trouble swallowing

What is Aspiration

Fluids enter lungs instead of stomach

What are the main components of a therapeutic relationship