lsua CN1 Theory Exam 1

Vital signs

BP, Pulse, respirations, pain, pulse ox, temp

Thermoregulation

-controlled by hypothalamus

-triggered by thermal receptors in skin

-sends sensory messages to hypothalamus

Oral temp

97.7 - 99.5°F

Axillary temp

96.7 - 98.5°F

Rectal temp

98.7 - 100.5°F

Tympanic temp

98.2 - 100°F

Temporal temp

98.7 - 100.5°F

Hyperthermia

Temperature greater than or equal to 101° F

Hypothermia

Temperature < 95 degrees

Convection

Heat transfer via movement of air/liquid

Radiation

Heat via electromagnetic waves

Evaporation

the conversion of a liquid to a vapor (sweating)

Conduction

transfer of heat through direct contact

Perfusion

the passage of oxygenated capillary blood through body tissue.

Perfusion requirements

normal functioning of both the respiratory and cardiac systems.

Cardiac contraction & relaxation requires

continuous, organized transmission of electrical impulses.

Pathways for electrical conduction in the heart

AV node

Bundle of His

Purkinje fibers

Sino-Atrial (SA) node

the normal pacer of the heart

Cardiac Cycle

Systole

Diastole

- Events in the right and left sides

Aortic area

2nd intercostal space, right sternal border

pulmonic area

2nd intercostal space, left sternal border

Erbs point

3rd intercostal space, left sternal border

tricuspid

3rd (or 4th) intercostal space, left sternal border

mitral area

Fifth intercostal space, left midclavicular line.

pulse sites

temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial.

assessing pulse

Rate, rhythm, amplitude

palpate and auscultate

tachycardia

rapid heart rate

greater than 100 beats per min

bradycardia

slow heart rate

less than 60 beats per min

Blood pressure

force of blood against arterial walls

systolic

pressure when the heart contracts

diastolic

pressure when the heart relaxes

BP regulation

Autonomic nervous system (ANS)

fluids pressure sensors (baroreceptors)

hormones (epinephrine/norepinephrine)

Amplitude

Strength of pulse

0 = absent

+1 = weak

+2 = normal/brisk

+3 = bounding

hypertension

high blood pressure

stage 1 - 130/80-139/89

stage 2 - 140/90 or greater

Crisis - 180/120 or greater

hypotension

low blood pressure

Oxygenation

Oxygenation refers to the process of providing cells with oxygen through the respiratory system and is accomplished by pulmonary ventilation, respiration, and perfusion.

Respirations

Pulmonary ventilation

Cycle - Inhalation/Exhalation

Rate

Depth

Patterns

hyperventilation

increased rate and depth of breathing

hypoventilation

decreased rate and depth of breathing

Pulse Oximetry

Measures concentration of oxygenation saturation in blood

Factors Affecting Rate and Depth

Changes in response to tissue demands

Controlled by respiratory centers in the medulla and pons

Activated by impulses from chemoreceptors

Increase in carbon dioxide is the most powerful respiratory stimulant

normal O2 sat range

94-100%

desat

desaturated oxygenation

Factors affecting pulse ox readings

Pt.'s fingers are cold

Poor circulation

Pt. is moving too much

titrate

going up/down on meds without calling the dr

Normal vital signs

Temp - 96.4 - 99.5

RR- 12-20

BP- 120/80

Pulse - 60-100 bpm

Skin

primary source of heat loss

hypothermia

abnormally low body temperature

hyperthermia

Abnormally high body temperature

pyrexia

fever

inspiration

breathing in (inhalation)

expiration

breathing out (exhalation)

ventilation

movement of air in and out of the lungs

diffusion

exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood

cheyne stokes

bursts of deep breaths, alternating with periods of apnea

apnea

absence of breathing

dispnea

difficulty breathing

orthostatic hypotension

low blood pressure that occurs upon standing up

SOB

shortness of breath

DOE

dyspnea on exertion

Hgb

hemoglobin

Hct

hematocrit

Safety

refers to being protected from potential or actual harm and is considered a basic human need. Responsibility of all health care providers, including nurses, and is a focus in all healthcare facilities as well as in the home, workplace and community.

Many of these concerns are universal for all age groups, but there are unique considerations for each developmental stage.

Factors that contribute to falls

Age >65

History of falls

Impaired vision or balance

Altered gait or posture, impaired mobility

Medication regimen

Postural hypotension

Slowed reaction time; weakness, frailty

Confusion or disorientation

Unfamiliar environment

bundle

small group of 3-5 practices and/or meds that work best together to treat a disease/illness.

Must be given together

Nurse rounding

during the day - every hour

At night - every two hours

Safety needs to be charted

patient outcomes/goals for saftey

pt. or caregiver will identify current and potential unsafe environmental situations

pt. will implement safety measures in the environment

pt. will incorporate accident prevention practices into ADLS

pt. will remain free of injury

goals = outcomes

Care plans = what we will do at the bedside

Adult restraints

Only when there is a dr orders (renewed every 24 hours and has to be in person)

Can use restraint without dr order if the situation is life threatening.

tie restraints on metal frame with quick release

Try at least 2 alternatives

Check restraints every hour and asses

check ROM every two hours for skin breakdown/bathroom

restraint hazards

Tissue damage

contractures

incontinence

aspiration and respiratory difficulties

Loss of extremity

death

RACE

Rescue anyone in immediate danger

Activate the fire code and notify appropriate persons

Confine the fire by closing doors and windows

Evacuate patients and other people to safe area

PASS

Pull

Aim

Squeeze

Sweep

Patient safety prevention measures

Regular vision/hearing screenings

non slip socks/shoes

no loose rugs or towels on the floor

have a clinical safety checklist.

safety event/ incident report

must be completed after unexpected accident/incident in a healthcare facility that compromises safety

described the circumstances of the accident or incident

documents patient's response to exam and treatment of the ot at the incident

completed by the nurse immediately after the incident

is not part of the medical record and should not be mentioned in documentation.

Incident reports is not a part of medicak record/charty but itis kept on file

Latex allergy

3 levels

irritant contactn - dry/irritated skin

allergic dermatitis - dry crust lessions (erupt ober 1-4 days), erythmea(red), Purities (itch)

Immediate hypersensitiy or real allergic reaction - systemic (all over the body), lessions, broncospapsm, shock

Dysphagia

difficulty swallowing