Midterm

Question 1

Why do we make vital sign assessments?

Answer 1

it provides:
-information of pt.'s health status
-baseline status
-monitoring a patient's condition
-identifying problem
evaluating the pt.'s response to intervention

Question 2

How do we make vital sign assessments?

Answer 2

pulse
-palpate for apical, carotid, radial or brachial pulsations
respiration
-inhalation and exhalation counts ass one breath
-breathing can be seen through the chest (women) and abdomen (men)
blood pressure
- the measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole
oxygen saturation
temperature
pain
- P (protective or palliative)
- Q (quality or quantity)
- R (region or radiation)
- S (severity scale)
- T (timing)
- U (understand patients perception of the problem

Question 3

Physiology of normal regulation of body temperature

Answer 3

body temperature (thermoregulation) is regulated by:

• neural and vascular control
• heat production (regulated by posterior hypothalamus); heat is produced as a by-product of metabolism via BMR [basal metabolic rate], voluntary movements, shivering, non-shivering thermogenesis [neonates with brown fat]
• heat lost (regulate by anterior hypothalamus); heat is lost through: radiation (transfer of heat from one surface to another without direct contact, conduction (transfer of heat but using direct contact), convection heat moved away by air movement), evaporation (lost heat/fluid [600-900 mL] through sweat [diaphoresis] which occurs through the skin or breathing.

Question 4

Physiology of normal regulation of pulse

Answer 4

it is affected by stroke volume (it is the amount of blood your heart pushes into the artery every time it contracts), cardiac output and compliance (how elastic an artery is which allows blood to flow more easily.

Question 5

Physiology of normal regulation of respiration

Answer 5

involves three processes:

• ventilation: the mechanical movement of gases in and out of the lungs
• diffusion: the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
• perfusion: the distribution of red blood cells to and from the pulmonary capillaries

Question 6

Physiology of normal regulation of blood pressure

Answer 6

regulated through:

• cardiac output: the amount of blood coming from heart
• peripheral vascular resistance: resistance of blood flow
• blood volume: circulating volume
• blood viscosity: thicker blood causes more pressure to be made which increases blood pressure
• artery elasticity or “compliance”

Question 7

Physiology of normal regulation of oxygen saturation

Answer 7

accuracy is dependent upon light transmission and adequate arterial pulsations

Question 8

Normal vital signs

Answer 8

temperature
- 36-38 degree Celsius (96.8-100.4 degree Fahrenheit)
pulse 
- 60-100 bpm
respiration
- 12-20 bpm
blood pressure
- <80
oxygen saturation
- 95-100%
pain
- absence of pain

Question 9

Abnormal vital signs

Answer 9

temperature
- hypothermia (mild 93.2-96.8; moderate 86-93.2; severe 105 degree Fahrenheit
- frostibite
pulse
- tachycardia > 100 bpm
- bradycardia < 60 bpm
- dysrhythmia, bounding, weak, thread, unequal, absent
respiration
- bradypnea < 9 bpm
tachypnea > 24 bpm
- hyperpnea, apnea, hyperventilation, hypoventilation [shallow], cheyne-stokes, kussmaul’s (hyperventilation), biot’s respiration
oxygen saturation
- < 95%
blood pressure
- hypotension (a systolic blood pressure of < 90 mmHg)
- orthostatic hypotension (a symptomatic drop in BP with change in position
- hypertension (associated with thickening and loss of elasticity in arterial walls; decreased blood flow to vital organs

Question 10

Abnormal vital sign interventions

Answer 10

• review, analyze, decide if further investigation is necessary/notify the physician
• proper functioning equipment
• equipment appropriate for pt.
• know the pt.’s baseline; educate pt. to know their baseline
• medical Hx and medications
• have a routine for taking vital signs
• frequency of measurement dependent on diagnosis
• indication for medication administration
• analyze and interpret significant changes
• communicate significant changes

Question 11

Factors that affect temperature measurement

Answer 11

• age
• exercise
• hormone level
• circadian rhythm
• stress
• environment

Question 12

Factors that affect pulse measurement

Answer 12

• exercise
• temperature
• emotions
• drugs
• hemorrhage
• postural changes
• pulmonary conditions

Question 13

Factors that affect respiration measurements

Answer 13

• exercise
• acute pain
• anxiety
• smoking
• bod position
• medications
• neurologic injury
• hemoglobin

Question 14

Factors that affect blood pressure measurements

Answer 14

• age
• stress
• ethnicity
• gender
• daily variation
• medications
• activity and weight
• smoking
• caffeine
• diet

Question 15

Various aspect of hygiene care

Answer 15

• skin hygiene
• oral hygiene
• bathing skin care
• perineal care
• hair care
• eye care
• feet and nails

Question 16

Interventions to prevent the spread of infection

Answer 16

Hand hygiene before and after all pt. contact
- When to use hand hygiene: Before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a pt., after touching pt. surroundings
- Alcohol-based hand sanitizer: 20-30 seconds
- Soap and water: 40-60 seconds
Visibly soiled
Coming into contact with a pt. that has spore-forming microorganisms
Proper use of supplies
Proper disposal of certain supplies
Good technique of donning and removing PPE
Critical thinking
Artificial nails (don’t have, get them)

Question 17

Proper procedure for applying alcohol-based hand sanitizer

Answer 17

For 20-30 seconds:

• Apply a palm-full in a cupped hand, covering all surfaces.
• Rub hands palm to palm.
• Right palm over left dorsum with interlaced fingers and vice versa.
• Palm to palm with fingers interlaced.
• Backs of finger to opposite palms with fingers interlocked.
• Rotational rubbing of left thumb clasped in right palm and vice versa.
• Rotational rubbing, backwards and forwards with clasped fingers of right hand in let palm and vice versa.
• Once dry, your hands are safe.

Question 18

Proper procedure for using soap and water

Answer 18

for 40-60 seconds:

• wet hands with water
• Apply enough soap to cover all hand surfaces
• Rub hands palm to palm
• Right palm over left dorsum with interlaced fingers and vice versa.
• Palm to palm with fingers interlaced.
• Backs of finger to opposite palms with fingers interlocked.
• Rotational rubbing of left thumb clasped in right palm and vice versa.
• Rotational rubbing, backwards and forwards with clasped fingers of right hand in let palm and vice versa
• Rinse hands with water
• Dry hands thoroughly with a single use towel
• Use towel to turn off faucet
• your hands are now safe

Question 19

Types of isolation

Answer 19

Tier I
- Standard precautions: Don gloves when in contact with bodily fluids or mucous membranes
Tier II
- Contact precautions Ie. Rhino virus, c. diff., MRSA, VRE, MDRO (multi-drug resistant organisms); Don gown and gloves
- Droplet precautions Ie. Pneumonia, bacterial meningitis, shingles, influenza; Don gloves, gown, face mask
- Air-borne precautions Ie. Chicken-pox, tuberculosis; All PPE + N95 mask (Mask is specifically fitted to fit an individual’s face)

Question 20

Donning and removing PPE

Answer 20

Donning
- Gown
- Mask
- Goggles
- Gloves
Removing
- Gloves
- Cap
- Goggles
- Gown
- Mask

Question 21

Medical asepsis

Answer 21

• Clean technique
• Practices/procedures that assist in reducing the number of organisms present and prevent the transfer or organisms
• Used when coming into contact with mucous membranes or skin Ie. Bedpans, food utensils, blood pressure cuffs, endotracheal tubes

Question 22

Surgical asepsis

Answer 22

• Sterile technique
• Procedures used to eliminate all microorganism (pathogens & spores) from an object or area
• Used when there will be intentional perforation of the pt.’s skin Ie. IV insertion, catheters

Question 23

Purpose of body mechanics

Answer 23

to maintain coordinated efforts of the musculoskeletal and nervous system to maintain balance, posture, and body alignment
to facilitate activities of lifting, bending, moving, and performing ADL’S
to achieve balance via a relatively low center of gravity balanced over a wide base of support

Question 24

proper body mechanics

Answer 24

equilibrium maintained as long as center f gravity aligns with base of support
facing direction of movement prevents abnormal twisting of the spine
balanced use of arms and legs reduced risk of back injury
leverage, rolling, and turning and pivoting requires less work than lifting
less friction equals less force needed to move an object
alternating period of rest and activity helps to reduce fatigue and injury

Question 25

therapeutic positioning

Answer 25

patients with impaired nervous or musculoskeletal system functioning, increased weakness, or restricted to bed rest benefit from therapeutic positioning for immobile patients, maintain them in the 30-degree lateral position which keeps their arms and legs supported and keep them off bony prominence's

Question 26

repositioning patients

Answer 26

patients who require therapeutic positioning should be repositioned as needed: - at least every 2 hours if they are in bed - every 20-30 minutes if they are sitting in a chair

Question 27

devices used for positioning

Answer 27

``` foot boots/splints trochanter rolls wedge pillow side rails trapeze bar hand rolls/splints pillow bed boards ```

Question 28

assessment of mobility

Answer 28

``` range of joint motion gait activity tolerance - exercise - activity body alignment pain associated with activity ```

Question 29

examples of nursing assessment questions on mobility

Answer 29

describe changes you've noticed in the ability to ambulate or care for yourself. are you experiencing any stiffness, swelling, pain, or difficulty moving? have you noticed you've become short of breath? describe your daily activities. what do you normally eat in a day? do your days and nights seem long? have you noticed any changes in your skin? have you noticed any problems with urination or defecation?

Question 30

nursing interventions on mobility

Answer 30

musculoskeletal system - perform ROM exercises to improve strength skin integrity - perform skin assessment, turn patient q2h elimination system - keep pt. hydrated via either drinking or IV fluids gastrointestinal - provide a high-fiber diet, it encourages digestive movement psychosocial problems - encourage social interactions, regulate sleep-wake cycles developmental changes - maintain normal development (young) - prevent falls via strength build-up, encourage cognitive function (elder) respiratory system - promote expansion of the chest and lungs -- use incentive spirometer - prevent stasis of pulmonary secretions metabolic system - increase intake of protein and vitamins - consider tube-feeding for pt.'s with a lack of appetite cardiovascular system - monitor pulse, blood pressure (especially before performing movements) - encourage pt. to breath out during movement -- discourages valsalva maneuver which leads to syncope prevent blood clots - encourage movement - increase circulating fluids - administer blood-thinners - promote circulation with SED's or ted stockings

Question 31

oxygen level of room air

Answer 31

21% O2 on room air

Question 32

nasal cannula

Answer 32

``` 1L = 24 O2 on nasal cannula 2L = 28 3L = 32 4L = 36 5L = 40 6L = 44 humidification may be added for comfort (prevents nares drying) may only administer 6L or less ```

Question 33

simple mask

Answer 33

5-6L = 40% O2 on simple mask 7-8L = 50 10L = 60 ranges exist because the pt. is breathing in room air as well as the prescribed oxygen

Question 34

partial rebreather mask

Answer 34

6-10L = 40-70% O2 on partial rebreather should not run below 5L the reservoir bag should never be fully collapsed

Question 35

non rebreather mask

Answer 35

delivers 60-80% O2 on non rebreather should not run below 10L the reservoir bah should never be fully collapsed

Question 36

venturi mask

Answer 36

delivers a specific amount of oxygen

Question 37

airway maintenance tecchniques

Answer 37

``` hydration - 1500-1600 mL/day (unless contraindicated) humidification - add sterile water to the O2 supply nebulization - adds medication to the humidification chest physiotherapy - removes secretions or mobilizes them through: -- postural drainage -- chest percussion -- chest vibration coughing techniques artificial airways - oropharyngeal - nasopharyngeal - endotracheal - tracheostomy suctioning techniques - oropharyngeal - nasophaaryngeal - orotrahceal - nasotracheal - traccheostomy ambulation - ROM positioning - at a 45 degree semi-fowler's position chest tubes - removes air or fluid from pleural space ```

Question 38

history assessment on skin

Answer 38

``` review of systems skin diseases previous bruising general skin condition skin lesions usual healing of sores nutritional status ```

Question 39

inspection and palpation of skin

Answer 39

``` skin color distribution skin turgor presence of edema characteristics of any skin lesions particular attention paid to areas that are most likely to break down hyperemia - areas of redness - perform blanching of that area -- if it turns white then back to red, that is normal and indicates short-term injury it is abnormal if it remains red which indicates long-term injury and the first stage of a pressure ulcer incontinence skin around dressings ```

Question 40

untreated wounds assessment

Answer 40

``` location extent of tissue damage wound depth, length, width bleeding foreign bodies associated injuries last tetanus toxoid injection ```

Question 41

treated wounds asssessment

Answer 41

``` appearance size drainage presence of swelling pain status of drains or tubes wound base ```

Question 42

pressure site assessment

Answer 42

inspect pressure areas for discoloration and capillary refill or blanch response inspect pressure areas for abrasions or excoriations palpate the surface temperature over the pressure area sites palpate bony prominences and dependent body areas for presence of edema

Question 43

interventions to prevent skin breakdown

Answer 43

``` provide nutrition - fluid intake - protein, vitamins, zinc - dietary consult - weight/lab data monitoring maintaining skin hygiene - mild cleansing agents avoid hot water - moisturizing lotions/skin protection -- moisture barrier cream for stage I ulcers to prevent further ulcerification - reduce irritants - reducing pain avoiding skin trauma - smooth, firm surfaces - semi-fowler's position - frequent weight shifts - exercise and ambulation - lifting devices - reposition q2h - turning schedule providing supportive devices - mattresses, beds - wedges, pillows prevent entry of microorganisms prevent transmission of pathogens ```

Question 44

interventions to prevent skin breakdown

Answer 44

``` minimize direct pressure over bony prominences improve circulation schedule and record position changes provide devices to reduce pressure areas clean and dress the ulcer using medical asepsis never use alcohol or hydrogen peroxide around wounds to minimize irritation - use saline obtain C&S, if infected teach the pt. provide ROM exercise nutrition check for blanching prevent infection/treat infection color guide for wound care - if it is red, protect - if it is yellow, cleanse - if it is black, debride ```

Question 45

hemorrhage

Answer 45

an escape of blood through ruptured or unruptured vessel walls

Question 46

infection

Answer 46

invasion off the body by organisms that have the potential to cause disease

Question 47

dehiscence

Answer 47

a bursting open, splitting, or gaping long natural or sutured lines

Question 48

evisceration

Answer 48

protrusion of underlying content through a lesion caused by intentional ie. surgical incision) or unintentional trauma