Data that may be revealed by what the client says about himself.
Define objective Data
Data inferred through individuals behavior which is observed by the nurse. Data includes nurses observations, vital signs, and data from the health assessment (general survey, physical exam)
What are the 8 critical characteristics of client symptoms?
Character or Quality
Quantity or Severity
Aggravating or Relieving Factors
When is it important to asses vital signs?
Right at the beginning of the appointment to get a baseline. After surgery to monitor progress. Before giving medications to watch for possible adverse effects.
What is the normal oral temperature in a resting person?
How does the rectal temperature differ from the oral temperature?
The rectal temperature measures 0.7 to 1 F higher than the oral temperature.
How does the hypothalamus regulate body temperature?
The hypothalamus balances heat production (from metabolism, exercise, food digestion, external factors) with heat loss ( through radiation, evaporation of sweat, convection, conduction).
When does the "trough" of daily body temperature occur?
In the early morning
When does the "peak" of daily body temperature occur?
Late afternoon/early evening
How does menstruation effect body temperature?
Progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° to 1.0° F rise in temperature that continues until menses.
Fever, is caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown such as the following myocardial infarction, trauma, surgery, or malignancy. Neurologic disorders (e.g., a cerebral vascular accident, cerebral edema, brain trauma, tumor, or surgery) also can reset the brain's thermostat at a higher level, resulting in heat production and conservation.
Hypothermia is usually due to accidental, prolonged exposure to cold. It also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation, or gastrointestinal hemorrhage.
What is an advantage to the electric thermometer?
The electronic thermometer has the advantages of swift and accurate measurement (usually in 20 to 30 seconds) as well as safe, unbreakable, disposable probe covers.
Which type of thermometer is not currently suggested for use with a critically ill patient?
tympanic membrane thermometer (TMT)
What is the average stroke volume of an adult?
With every beat, the heart pumps an amount of blood—the stroke volume—into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.
What is the average adult heart rate?
In the adult at physical and mental rest, clinical evidence shows the normal heart range at 50 to 90 beats per minute (bpm).
How does heart rate vary from infants to adults?
The rate normally varies with age, being more rapid in infancy and childhood and more moderate during adult and older years.
How does heart rate differ between genders?
The rate also varies with gender; after puberty, females have a slightly faster rate than males.
In the adult, a heart rate less than 50 bpm is bradycardia.
Who will commonly develop bradycardia?
This occurs normally in the well-trained athlete whose heart muscle develops along with the skeletal muscles. The stronger, more efficient heart muscle pushes out a larger stroke volume with each beat, thus requiring fewer beats per minute to maintain a stable cardiac output.
A more rapid heart rate, over 90 bpm, is tachycardia
When does tachycardia typically develop?
It occurs normally with anxiety or with increased exercise to match the body's demand for increased metabolism. Tachycardia occurs with fever, sepsis, and following myocardial infarction.
What is one irregularity commonly found in the heart rate rhythm of children?
Sinus arrhythmia. Here the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. Inspiration momentarily causes a decreased stroke volume from the left side of the heart; to compensate, the heart rate increases.
A “weak, thready” pulse reflects...
a decreased stroke volume (e.g., as occurs with hemorrhagic shock)
A “full, bounding” pulse denotes ...
an increased stroke volume (e.g., as with anxiety, exercise, and some abnormal conditions).
Describe the pulse force scale
The pulse force is recorded using a three-point scale: 3+—Full, bounding 2+—Normal 1+—Weak, thready 0—Absent
Define blood pressure
Blood pressure (BP) is the force of the blood pushing against the side of its container, the vessel wall. The strength of the push changes with the event in the cardiac cycle.
What is the name for the maximum pressure felt on the artery during left ventricular contraction ?
Systolic BP (systole)
What is the name for the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction?
Diastolic BP (diastole)
Define pulse pressure.
The pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume
Define Mean Arterial Pressure (MAP)
The mean arterial pressure (MAP) is the pressure forcing blood into the tissues, averaged over the cardiac cycle. This is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer. Rather, it is a value closer to diastolic pressure plus one-third the pulse pressure.
Name some factors that affect blood pressure
Blood pressure is determine by what 5 factors?
1. Cardiac output 2. Peripheral vascular resistance 3. Volume of circulating blood 4. Viscosity 5. Elasticity of vessel walls
How does a blood pressure cuff that is too narrow, affect the final reading?
The cuff size is important; using a cuff that is too narrow yields a falsely high BP because it takes extra pressure to compress the artery.
Which step always comes first in the general survey?
Inspection is the use of vision and hearing to distinguish normal from abnormal findings.
Palpation involves the use of the hands to touch body parts to make sensitive assessments.
Percussion involves tapping the body with the fingertips to produce a vibration that travels through body tissues.
Direct vs Indirect Percussion
Direct is using one hand Indirect is using two hands – most common
Auscultation involves listening to sounds the body makes to detect variations from normal. You are able to hear some sounds without assistance but will need a stethoscope for most sounds.
If a patients arm is held above heart level, how will that effect the final BP measurement?
It will read falsely low
If a patients arm is held below heart level, how will that effect the final BP measurement?
It will read falsely high.
If a patient crosses their legs during a blood pressure reading, how will it affect the final reading?
It will read falsely high .
Which patients should not have their BP taken at their arm, but rather their upper thigh?
Patients who have undergone matectomies, trauma to extremity, or CVA.
Define acute pain
Short term, self limiting, eases after injury
Define chronic pain
Continues for 6 months or longer, can last for years
Describe an annular lesion
Circular, begins in center and spreads to periphery (e.g., tinea corporis or ringworm, tinea versicolor, pityriasis rosea).
Describe confluent lesions
Lesions run together (e.g., urticaria [hives])
Describe discrete lesions
Distinct, individual lesions that remain separate (e.g., acrochordon or skin tags, acne).
Describe grouped lesions
Clusters of lesions (e.g., vesicles of contact dermatitis).
Describe gyrate lesions
Twisted, coiled spiral, snakelike.
Describe target lesions
Or iris, resembles iris of eye, concentric rings of color in the lesions (e.g., erythema multiforme).
Describe a linear lesion
A scratch, streak, line, or stripe.
Describe a polycyclic lesion
Annular lesions grow together (e.g., lichen planus, psoriasis).
Describe zosteriform lesions
Linear arrangement along a unilateral nerve route
What is defined as "Solely a color change, flat and circumscribed, of less than 1 cm?"
Freckles, petechiae, and measles are all examples of ?
Macules that are larger than one cm are known as ?
A lesion you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis, is known as ?
When papules coalesce to form surface elevation wider than 1 cm. A plateau-like, disk-shaped lesion, they are known as ?
Describe a nodule
Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule.
Describe a tumor
Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although “tumor” implies “cancer” to most people.
A mosquito bite is an example of?
A Superficial, raised, transient, and erythematous lesion; slightly irregular shape due to edema is know as ?
Hives are also known as
When Wheals coalesce to form extensive reaction and are intensely pruritic they are known an?
Decribe a vesicle
Elevated cavity containing free fluid, up to 1 cm
A blister is an example of ?
What is defined as larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily?
What is a cyst?
Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin.
Give one example of a pustule
What is defined as a lesion with turbid fluid (pus) in the cavity. Circumscribed and elevated.
Describe the ABCDE rule of skin lesions
A—asymmetry B—border C—color D—diameter E—elevation and enlargement
What are the four central concepts of interest to the discipline of nursing are
The four central concepts of nursing are also known as?
The Nursing Metaparadigm
What are the 5 steps of the nursing process?
Assess Diagnose Plan Implement Evaluate
What are the SMMART Expected Outcomes?
S-Specific to patient, nursing diagnosis, content and time M-Mutual (patient and nurse) M-Measurable A-Achievable R-Realistic T-Time-limited
What is transferrin?
Transferrin: protein that regulates iron absorption
What is the purpose of a Total lymphocyte count ?
A total lymphocyte count easures immune function and visceral protein status
What is Albumin?
Albumin is formed in liver. It transports nutrients, blood and hormones. Indicator of visceral protein status
When you measure serum glucose, what are you measuring?
You are measuring the body’s ability to metabolize glucose
If you are testing hematocrit levels, what are you testing?
You are measuring the percentage of red blood cells per volume of whole blood
A BMI of <18.5 indicates
A BMI of 18.5-24.9 indicates ?
18.5-24.9 Normal weight
A BMI of 25.0-29.9 indicates?
A BMI of 30.0-39.9 indicates?
A BMI OF ≥40 indicates?
≥40 Extreme obesity
A current percent body weight of what indicates mild malnutrition?
A current weight of 85% to 95% of usual body weight indicates mild malnutrition;
Which percent body weight indicates moderate malnutrition?
75% to 84%, moderate malnutrition; .
Less than 75% usual body weight indicates?
What is an anthropometric measure?
These measures evaluate growth, development, and body composition. The most commonly used anthropometric measures are height, weight, triceps skinfold thickness, elbow breadth, and arm and head circumferences.
What waist-to-hip ratio is an indicator of upper body obesity in men and women?
A waist-to-hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper body) obesity and increasing risk for obesity-related diseases and early mortality.
What is the purpose of the skinfold thickness test?
Skinfold thickness measurements estimate the body fat stores or the extent of obesity or undernutrition.
Which test estimates skeletal muscle mass and fat stores?
Mid–upper arm circumference (MAC)
What are the four phases of the nurse-client relationship?
Pre-Interaction Orientation Working Termination
What are some examples of the bridges of the nurse-client relationship?
Caring Respect Trust Presence (being there, conveys hope) Mutuality (both parties committed) Empathy (I understand something about your world) Authenticity (being real, honest) Confidentiality
65% of the information received from face to face conversation comes from ?
The Theory of interpersonal relationships is related to which nurse theorist ?
Who dscribes the nurse-client relationship as the foundation of nursing practice?
Which nurse theorist talks about the value of talking about painful experiences?
Psychosocial development was created by which nurse theorist?
Abraham Maslow created?
Progressive stages of personal growth also known as Maslow’s Hierarchy of Needs
The basis of Maslow’s Hierarchy of Needs is?
The physiological needs
What are the 7 elements of communication?
Referent Sender and receiver Message Channel Feedback Interpersonal variable Environment
Define the nursing process
The nursing process is “the systematic approach to reduce or eliminate the individuals health problem” The nursing process consists of assessment, diagnosis, planning, implementation and evaluation.
What are the 4 components to assess during general survey?
Physical Appearance Body Structure Mobility Behavior
When might a full mental status be necessary?
Full mental status is necessary when: You find any abnormality in affect or behavior Family members are concerned about changes Brain lesions Aphasia Symptoms of any psychiatric illness
What are two examples of Derived anthropometric measures ?
Derived anthropometric measures:
Mid-upper arm muscle circumference (MAMC) MAMC = MAC – (p × TSF)
Mid-arm muscle area (MAMA) MAMA = (MAC – MAMA)2 4π
Arm span or total arm length
Frame size by elbow breadth
What disorder is due to inadequate intake of protein and calories or prolonged starvation.
What is Kwashiorkor?
Kwashiorkor (protein malnutrition) is due to diets high in calories but contain little or no protein, e.g., low-protein liquid diets, fad diets, and long-term use of dextrose-containing IV fluids.
Pigmented keratotic scaling lesions resulting from a deficiency of niacin. are known as?
What disorder is a sign of vitamin D and calcium deficiencies in children ?
Which theory focuses on self efficacy?
Social Learning Theory /Social Cognitive Theory
Which nurse theorist is responsible for the Social Learning Theory /Social Cognitive Theory?
Describe the 6 stages of the Transtheoretical Model of Change ?
Precontemplation: no intention (6 mos) Contemplation: considering change (6) Planning: seriously thinking to change (1) Action: behavior change for (6) period Maintenance: sustaining Self Efficacy
Piaget is responsible for which develpomental theory?
Who is responsible for the psychosocial development theory?
Which theorist is responsible for the moral developmental theory?
What 4 things must be present in an objective?
Audience: Who are your learners? Behavior: What do you expect them to do? This should be an overt , observable behavior. Condition: Under what circumstances will learning occur? Degree: How well must the behavior be done?
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