Vital Signs
Describe three characteristics of a pulse and what they each mean.
Rate - a numerical value or numerical finding
Rhtym - regular or irregular heartbeat
Amplitude - the force (absent, weak/thready, regular, bounding/strong)
The time of day, caffeine or nicotine intake, exercise, emotions, pain, and temperature.
Desribe how to calculate respirations.
Define Bradypnea
Define Tachypnea
If breathing is normal, count for 30 seconds and multiply x 2
If breathing is abnormal, count for a full 60 seconds
Bradypnea - < 8-12 breaths/min
Tachypnea - > 24 breaths/min
How could you perform a dietary assessment on someone from a different cultural background?
Ask them the following:
1. Are there any foods you commonly eat?
2. Do you have any special routines for eating?
3. Are there any foods that are restricted?
4. Do you eat certain foods to keep you healthy?
How can religion and spirituality benefit clients?
1. Improves their sense of well-being.
2. Improves their ability to cope with end-of-life issues.
3. Increases compliance
What are the first two components of performing a health assessment?
General Survey
V/S: Temperature, pulse, respirations, and blood pressure
What is a normal oral temperature?
What is a normal tympanic temperature?
Oral 96.6-99.5
Tympanic 98.0-100.9
What is a normal oxygen saturation?
Define hypoxia.
Define cyanosis
A normal oxygen saturation should be > 92
Hypoxia - < 92
Cyanosis - abnormal color changes associated with hypoxia - bluish color or ashen gray in African Americans
The nurse states, "all Asians refuse pain medications." This is an example of ____________.
Stereotyping
Describe Spirituality
A search for meaning and purpose in life while understanding life's ultimate questions in relation to the sacred.
Describe the normal sequence for performing a health assessment?
Inspection
Palpation
Percussion
Auscultation
How do you calculate a pulse?
Define Bradycardia
Define Tachycardia and list possible causes
If normal count for 30 sec and multiply x 2
If abnormal, count for a full 60 seconds
Bradycardia - a heart rate < 60 bpm
Tachycardia - a heart rate > 100 bpm; can be caused by underlying disease process, fever, and pain
List some important things to consider when checking a manual blood pressure.
Why is it important to assess for orthostatic hypotension
Give the client a few min to relax before checking, feet should be flat on the floor, use the right cuff size for the weight of the patient, inflate the cuff 30mm above where the radial pulse disappears. Consider external influences and always take the blood pressure in both arms if one arm is elevated.
To determine if the patient's blood pressure drops when standing to initiate safety precautions (i.e., fall precautions).
The nurse should consider which factors when assessing someone's pain from a different cultural background?
Their beliefs about the causes of pain, their expectations, and developmental level.
How can a nurse support the spiriual needs for a client?
1. Silence and meditation
2. Prayer
3. Offer hospital pastoral or chaplain services.
What is the purpose of performing a general survey?
To get an overall impression of the client which leads to clues about their health status.
To identify normal variations and to determine if the client is in distress.
Modifiable risk factors for heart disease
Reducing sodium, saturated fats, and cholesterol
Smoking cessation
Alcohol intake
Weight loss
Nonverbal indicators of pain
Facial expression, grimacing, crying, changes in vital signs
How can one's culture influence their non-verbal behavior?
How does an elderly persons temperature differ from a young adult?
They have lower body temperature; therefore, a slight elevation above 96.9 could indicate a fever.
Describe how a young athletes vital signs might differ from a middle-age-adult.
You would expect a young athlete to have a lower blood pressure and a lower heart rate.
Describe the COLDSPA acronym and what is it used for.
C - characteristics (Describe how something feels i.e., sharp, aching, dull, knifelike)
O - onset (when did you notice the symptoms)
L - location (where is the pain)
D - duration (how long does it last)
S - severity (how bad is the pain)
P - pattern (what makes it better or worse)
A - alleviating factors (what helps with the pain)
Give three examples of cultural norms.
Pain - some cultures believe pain is punishment for wrongdoing. Some cultures refuse pain medications, whereas other cultures are receptive to pain medications.
Temperature of food - some cultures prefer for their food and beverages to be served warm and they are not receptive to eating or drinking things that are cold.
Some cultures the "man is considered the head of the home and makes all decisions, including healthcare decisions for the family."