CNUR 107

what is the normal range of tympanic temperature

+/- 0.2 of oral

what is the 3 point scale of a pulse

0 - absent, 1-weak, 2-normal, 3-bounding

what is the normal range of rectal temperature

0.4 to 0.5 higher than oral

what is the normal range of axillary temperature

0.6 lower than oral

how long is an apical pulse taken

1 full minute

how long do you count for a irregular pulse

1 minute

what is the normal range for respiration

10-20 per minute

what is the normal range for pulse in a baby

120 - 160 per minute

what is a normal blood pressure

120/80

how long do you count for a regular pulse

30 seconds

how long do you count respirations

30 seconds

what is the normal range of pulse pressure

30-50

what is the normal range of oral temperature

35.8 to 37.3

what is stroke volume per minute

4 to 6L

what is the normal range for pulse in an adult

60-100 per minute

what is bradypnea

<10 breaths per minute

what is tachypnea

>20 breaths per minute

what is the normal range for oxygen saturation

>95%

what is the acronym for mental status examination

ABCT

what is acronym used for pain assessment

PQRSTU

what is orthostatic hypotension

a drop in blood pressure once you stand up, low resting blood pressure

what are ADL;s

activities of daily living

what factors affect blood pressure

age, gender, weight, exercise, emotions, stress

what is ABC

airway, breathing, circulation

what is mental illness characterized by

alteration in thinking, mood, behaviour, or distress in daily function

what are the steps to inspected neck vessels

angle of jaw, midcervical, base of neck

what are the steps to auscultating the heart

aortic, pulmonic, eras point, tricuspid, mitral

what do you look for when palpating precordium

apex, left sternal border, base, feeling over the valves

what does ABCT stand for

appearance, behaviour, cognition, thought process

what is cultural sensitivity

be sensitive to individual beliefs and values

where does the heart extend to

between 2nd and 5th intercostal space

what are some prevention health screening available for adults

blood pressure, height, weight, pap test, mammogram, depression, visual, hearing, fall prevention, prostate, etc.

what is bruit

blowing, swishing sound indicating turbulent blood flow

which colour of temperature probe is used for what

blue for oral or axillary, red for rectal

what is blood pressure determined by

cardiac output, volume of blood, vascular resistance, viscosity of blood

define etiology

cause

what past health is important to ask about when taking patient history

childhood illnesses, accidents, chronic illness, hospitalizations, operations, obstetric history, allergies, medications, and last examination date

what is S1

closing of AV valves, beginning of systole

what is S2

closing of pulmonic and aortic valves, end of systole

define role of assessment

collection of data on patients state of health

what do you look for when inspecting precordium

colour, check for pulsations

what are you assessing for during a skin assessment

colour, temperature, moisture, texture, thickness, mobility, bruising, lesions, edema

what is pulse equality

comparing pulses bilaterally

what are the four types of clinical situations

complete, problem, follow up, emergency

the bottom number of blood pressure is known as what

diastolic

what is dyspnea

difficulty breathing

what is a medical diagnosis concerned with

etiology of disease

what is an emergency clinical situation

fast diagnosis, gather data quickly

what is tachycardia

fast heart rate >100

what is pyrexia

fever

what part of the hand do you use to assess shape and consistency of mass or organ

fingers and thumb

what part of the hand do you use to assess texture, pulsations, lumps, and swelling

fingertips

what is a complete clinical situation

full physical exam

what is included in obstetric history

gravida, term, preterm, abortions, living

high blood pressure is known as

hypertension

what does HTN stand for

hypertension

low blood pressure is known as

hypotension

what can cause a decreased temperature

hypothermia, UTI, babies if body is shutting down, anesthesia, environment, ovulation

what is a nursing diagnosis concerned with

impact of health challenges on the whole person

what can cause an increased temperature

infection or dehydration

what can cause a pulse to be >100

infection, pain, anxiety, exercise

define objective data

information physical assessments, patient record, and lab results

define subjective data

information provided my patient

what can nurses teach

injury prevention, diet, exercise, sexual behaviour, dental health, immunization, substance abuse

what is the order of physical assessment techniques for the integumentary system

inspection, palpation, percussion, auscultation

what is oxygen saturation

measures how much hemoglobin in the blood is carrying oxygen

what is anti-pyretic

medication for a fever

what is a follow up clinical situation

monitor status of identified problem

what is delayed cap refill

more than 1 to 2 seconds

what are hard plates of keratin

nails

what are the checkpoints considered before taking a blood pressure

no speaking, feet flat on floor, no smoke or drink within 30 minutes, arm supported at heart level, on bare skin

what is a problem clinical situation

one problem and short term

what can cause respirations to be >20

pain, anxiety, fear, asthma

what are the 4 areas of the general survey

physical appearance, body structure, mobility, behaviour

systolic measures what

pressure in the arteries when the heart is contracting

diastolic measures what

pressure in the arteries when the heart is resting

afterload

pressure that heart has to overcome to eject blood to rest of the body

during a pain assessment what does P stand for and what questions do you ask

provocation/palliation, does the pain increase with movement? Have any previous treatments been effective?

during a pain assessment what does Q stand for and what questions do you ask

quality, what does your pain feel like? What words describe your pain?

what is assessed what taking a pulse

rate, rhythm, force, and equality

what is cultural safety

realize social, economic, political and historical positions in society

during a pain assessment what does R stand for and what questions do you ask

region/radiation, where is your pain? does the pain radiate to other areas?

during a pain assessment what does S stand for and what questions do you ask

severity, how you would rate your pain on a scale of 0 to 10

what can cause a pulse to be <60

shock, medications, electrolyte balance

what is orthopnea

shortness of breath

what is bradycardia

slow heart rate <60

what can cause respirations to be <8

street drugs and brain issues

what does pulse force show

strength of stroke volume

what is the equation for cardiac output

stroke volume x rhythm

the top number of blood pressure is known as what

systolic

what is febrile

temperature

what is cultural competence

the application of knowledge, skills, and attitudes required by nurses

define precordium

the area on the anterior chest overlying the heart and great vessels

how is pulse pressure determined

the difference between the systolic number and diastolic number

what is considered when assessing

the stage of life development, infancy to late adulthood

what is it called if you feel a palpable vibration

thrill

during a pain assessment what does T stand for and what questions do you ask

timing, when did the pain start? Is it constant?

what is the purpose of assessment

to make a diagnosis and determine priority level for patient

during a pain assessment what does U stand for and what questions do you ask

understanding, what do you think is causing the pain? What medications are you using? What medications have worked for you in the past? What is an acceptable comfort level

preload

volume of blood returned to ventricles