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Concepts Ch 15 & 17
Concepts of nursing chapters 15 & 17
| Term | Definition |
|---|---|
| Routinely Scheduled Care | Early Morning (early a.m.) Care, Morning (a.m.) Care, Afternoon (p.m.) Care, Bedtime (h.s.) Care |
| Hygiene | a term used to describe keeping oneself clean and well groomed |
| Activities of Daily Living (ADL) | When each of us prepares for the day, the activities involved—such as bathing, washing and styling hair, brushing and flossing teeth, dressing, and shaving |
| Benefits of Bathing Patients | Cleanses the skin, Provides an opportunity for skin assessment, increases circulation, increases sensation, provides comfort and relaxation, provides improved self-esteem, contributes to the establishment of the nurse-patient relationship |
| Maceration | softened skin caused by continuous exposure to moisture |
| Excoriation | Scrapes on the skin, that may be the result of scratching or that may occur during care |
| Venous Return | wash from distal to proximal to improve blood return from the extremities back to the heart |
| Mottling | a purplish blotching of the skin when circulation slows greatly |
| Types of care | Self-care, assisted care, and total care |
| types of baths | Complete bed bath, complete bed bath using a commercially prepared bathing product, assisted or help bath, partial bath, tub bath, shower, therapeutic bath, commercially-prepared bathing product |
| Bath Blanket | A large lightweight flannel blanket, during the bath to prevent exposure |
| Special Mouth Care | The term used for oral care for patients whose conditions result in a need for more frequent care and who need assistance for this care |
| Environmental concerns | Noise, Odors, Clutter, Equipment |
| Unoccupied bed | The bed is considered unoccupied when the patient is out of the bed while linens are changed |
| Open bed | This type of bed is made with the top linens fanfold to the foot of the bed so that the patient can easily slip into the bed and pull them up |
| Surgical bed | This type of bed is made with the top linens fanfold to the side of the bed (the side away from the door) |
| Closed bed | In acute care, the closed bed is only used when the patient is discharged. The room is terminally cleaned and the bed is made with fresh linens. The top linens are spread to the head of the bed to keep the bed clean. |
| Occcupied bed | The bed is considered occupied if the linens are changed while the patient remains in the bed. This is done when the patient is unable to be out of bed. |
| Draw sheet | Turn sheet are applied to the bed up to where the patient is lying |
| Flat | Used for resting or sleeping and after certain procedures such as lumbar punctures and back surgery. |
| Fowlers | Knees slightly elevated to prevent sliding down; used when patients want to sit up to watch TV or converse with visitors |
| Semi-Fowlers | Used for patients on continuous tube feedings to prevent aspiration and for comfort when patient does not wish to be completely flat. |
| Trendelenburg | Used for patients who have very low blood pressure (shock) to return blood to the brain and vital organs. Keeping the head of the bed flat with the feet elevated is the preferred bed position for patients with breathing difficulty or head injury. |
| Reverse Trendelenburg | Used to elevate the patient’s head without bending at the waist for patients who have returned from procedures requiring that the legs be kept straight at the groin, such as a cardiac catheterization. |
| The Six Vital Signs | Temperature (T), Pulse (P), Respirations (RR), Blood Pressure (BP), Oxygen saturation (SpO2), Pain (subjective measurement) |
| Body Temperature | the difference between the amount of heat the body produces and the amount of heat that is gained or lost to the external environment. |
| Core Temperature | he most important measurement to maintain, as it determines the conditions in which the brain, heart, and other internal organs must survive. |
| Thermogenesis | The production of heat |
| Basal Metabolic rate | The amount of heat produced by the body when at total rest |
| Factors influencing heat production | The hormones thyroxine, epinephrine and norepinephrine, and adenosine triphosphate |
| Thermoregulation | The regulation of body temperature, is primarily controlled by the part of the brain known as the hypothalamus. |
| Set point | When the hypothalamus functions correctly, it maintains a comfortable core temperature |
| diaphoresis | When sweat production is high enough to be seen on the skin |
| Factors affecting body temperature | Environment, Time of day, Sex, Physical Activity and Exercise, Medications, Food intake, stress, and illness |
| Types of Thermometers | Nonmercury Thermometer, Tympanic Thermometer, Electronic Thermometer, Digital-tape or other paper-strip thermometer, and Noncontact infrared Thermometer |
| Oral route | more accurate, convenient and easily accessible, simple |
| Skin route | Does not require position change. Convenient, safe, easily accessible, and comfortable for patient. Provides continual assessment to reflect changes quickly. Good for use with newborns. Unaffected by eating, drinking, or smoking. |
| Tympanic Membrane | Convenient, easily accessible, and comfortable for the patient Good for use with newborns Quick (less than 5 seconds) Good for patients with difficulty breathing or on supplemental oxygen Unaffected by eating, drinking, or smoking |
| Temporal Artery | Quick (less than 5 seconds) Easy, noninvasive, and comfortable for the patient Good for use with small children Does not require positioning Unaffected by eating, drinking, or smoking |
| Axillary | Safe and noninvasive Can be used with unconscious patient |
| Rectal | Most accurate Provides core temperature Reflects temperature changes quickly |
| Noncontact infrared Thermometer (NCIT) | Convenient, easily accessible, and comfortable for the patient Safe and noninvasive Easy and comfortable for the patient Easy to disinfect Quick (less than 5 seconds) |
| Internal Catheter Probe | Most accurate Provides core temperature Continual Monitoring |
| Febrile | Indicate having a fever |
| Afebrile | Indicate the state of being without fever |
| Hypothermia | Commonly used to describe serious elevations above 105 degrees Fahrenheit (40.5 degrees Celsius) |
| Phagocytes | specialized white blood cells whose purpose is to ingest the invaders |
| Signs and Symptoms of Fever | Flushed face, Dry/hot skin, Dry mucous membranes, Elevated pulse rate & rapid respirations, Glassy/droopy eyes, Increased irritability/restlessness, Photophobia, Thirst, Headache |
| Children with viruses | No Aspirin |
| Hypothermia | a core temperature below 95 degrees Fahrenheit (35 degrees Celsius), slows body metabolism |
| Stroke Volume | The amount of blood discharged from the left ventricle with each contraction |
| Pulse | This arterial fluid wave can be palpated as a gentle pulsing, tapping, or throbbing sensation at various points over the body |
| Cardiac Output | he volume of blood pumped from the heart in 1 minute |
| Apical Pulse | The central or primary pulse site located over the the apex of the heart where the contraction is the strongest |
| Apex of the heart | The cone-shaped end of the left ventricle, actually touches the anterior chest wall at or near the fifth intercostal space. |
| Point of Maximum Impulse (PMI) | located 3 to 4 inches to the left of the sternum, generally in the fifth intercostal space, at the midclavicular line. The PMI is the site over which you will place your stethoscope to auscultate, or listen to, the apical pulse. |
| Distinct or Strong | If both the S1 and S2, or lubb-dupp, sounds are heard clearly and distinctly, the volume or strength of the apical pulse is described as distinct or strong. |
| Distant or Muffled | If both heart sounds cannot be heard distinctly |
| Pulse Deficit | When the radial pulse is slower than the apical pulse |
| Peripheral Pulse sites | Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Posterior Tibialis, Dorsalis Pedis |
| Auscultate | Listen attentively |
| Pulse Assessment | Rate, Rhythm, Volume (strength) |
| Bradycardia | A pulse less than 60 bpm |
| Tachycardia | A pulse greater than 100 bpm |
| Regular Rhythm | All beats are evenly spaced |
| Irregular Rhythm | If there are differences in the interval lengths |
| Perfusing | If peripheral pulses are palpated with each cardiac contraction, the blood fluid wave is reaching the pulse points |
| Strong or 2+ | If the palpated pulse is easily detected, |
| Weak or 1+ | a pulse that is faint and difficult to feel |
| Thready/Feeble | the pulse is so weak that slight fingertip pressure on the pulse site results in the pulse disappearing |
| Obliterates | a thready pulse disappears due to an inadequate volume of blood is being ejected from the heart with each contraction |
| Bounding or 3+ | A pulse that is very strong and does not disappear, even with moderate pressure |
| Absent/O | a pulse is not detectable by palpation |
| Capillary Refill Time | Assessed by gently squeezing nailbed to empty the capillaries of blood. The nailbed will turn pale until you remove the pressure then it should return to a pink color as the capillaries refill with blood. Normally this will occur within 3-5 seconds |
| Factors Affecting Pulse Rate | Age, Emotions, hormones, stress, medications, caffeine and nicotine, exercise, meditation, rest and sleep, circadian rhythm, blood volume decreased, blood volume increased, body temperature, hypoxia, cardiovascular disease, increased intracranial pressure |
| Respiration | The exchange of oxygen and carbon dioxide between the atmosphere and the body |
| External Respiration | the exchange of these gases between the lungs’ alveoli and the blood found in the capillaries that surround the alveoli. |
| Internal Respiration | the process of exchanging gases between the circulating blood and the tissue cells that make up the body. |
| Ventilation | The movement of air into and out of the lungs |
| Inhalation/Inspiration | The mechanics of respiration involve the act of breathing in |
| Exhalation/Expiration | The act of breathing out |
| Carotid Body | a section of the carotid artery wall |
| Aortic Body | a section of the aortic arch wall |
| Hypoxemia | decreases in the blood oxygen level |
| Assessing Respiration | Rate per minute, depth, rhythm, pattern, and respiratory effort |
| Eupnea | When the rate, depth, rhythm, pattern, and respiratory effort fall within normal parameters |
| Bradypnea | a respiratory rate below 12 respirations per minute |
| Tachypnea | when the rate exceeds 20 respirations per minute |
| Apnea | When respirations cease or are absent |
| Factors Affecting Respiratory Rate | Age, smoking, environmental temperature, exercise and exertion, rest, sleep and meditation, pain, anxiety, stress and fear, medications, drug overdose, respiratory diseases, metabolic acidosis, metabolic alkalosis, and increased intracranial pressure |
| Tidal Volume | he average amount of air inhaled in one breath is between 300 and 500 mL |
| dyspnea | An individual who is having labored or difficult breathing |
| Hypoxemia | The term used to denote a decreased oxygen level in the blood |
| Hypoxia | Decreased delivery of oxygen to the tissues and cells |
| Orthopnea | find it too difficult to breathe unless positioned in an upright position, such as sitting or standing |
| Breathing Characteristics | Stertorous, Adventitious Sounds, Wheezes, Crackles/Rales, Coarse/Rhonchi, and Stridor |
| Cheyne-Stokes Respirations | Respirations begin shallow, gradually increase in depth and frequency to a peak, and then begin to decrease in depth and frequency until slow and shallow; this is followed by a period of apnea lasting from 10 to 60 seconds. Pattern is repetitious. |
| Kussmaul Respirations | Respirations are increased in rate and depth, with long, strong, blowing, or grunting exhalations. |
| Biot Respirations | Respirations are grouped as several shallow breaths followed by variable-length periods of apnea. |
| Blood Pressure | The measurement of the pressure or tension of the blood pushing against the walls of the arteries in the vascular system. |
| Stroke volume | The amount of blood ejected from the heart in one contraction |
| Cardiac Output | The volume of blood pumped from the heart in a full minute |
| Arteriosclerosis | hardening of the arteries |
| Factors Affecting Blood Pressure | Age, race, exertion/exercise, rest, circadian rhythm, anxiety, stress, and emotions, medications, nicotine and caffeine, obesity, level of hydration, hemorrhage, and increased intracranial pressure |
| Systolic Pressure | he measurement of the force exerted by the blood against the walls of arteries during contraction of the heart ventricles. This time during which the ventricles are contracted is known as systole and is the time when the pressure is the highest. |
| Diastolic Pressure | the measurement of the pressure exerted by the blood on the artery walls while the heart ventricles are not contracting. This is the lower of the two pressures. The time during which the ventricles are at rest is known as diastole. |
| Pulse Pressure | he measurement of the difference between the systolic and diastolic pressures (subtract the smaller number, the diastolic, from the larger number, the systolic) and normally is between 30 and 50 points. |
| Hypertension | The term used to describe a systolic reading consistently above 130 or a diastolic reading consistently over 80 |
| Sphygmomanometer | Blood pressure cuff |
| Assessment site | BP is normally assessed with the cuff around the upper arm and the stethoscope over the brachial artery at the antecubital site, on the inner aspect of the elbow. |
| Korotkoff Sounds | first sound, second sound, third sound, fourth sound, and fifth sound |
| Auscultatory Gap | the silence and return of sound |
| Primary Hypertension/Essential Hypertension | Rise in BP due to the loss of elasticity in arterial walls that causes the heart to work harder to pump blood |
| Secondary Hypertension | When there is a renal or endocrine disease process that results in elevation of BP |
| Risk Factors for Hypertension | positive family history of hypertension, smoking, chronically high stress levels, moderate to heavy alcohol consumption, obesity, and elevated cholesterol levels in the blood |
| Hypotension | When BP suddenly falls 20 mm Hg to 30 mm Hg below the patient’s normal BP or falls below the low normal of 100/60 mm Hg |
| Orthostatic Hypotension/Postural Hypotension | When position changes result in a systolic pressure greater or equal to 15 mm Hg or the diastolic pressure falls 10 mm Hg |
| Modified Trendelenburg | A supine position in which the feet are elevated above the level of the heart |
| Full Trendelenburg Position | The head is lower than heart level |
| Acute pain | pain that has a sudden onset, may have severe symptoms, and runs a shorter course |
| Chronic pain | which is of longer duration or is ongoing with little change or progression |
| Characteristics of Pain | Site or location, characteristics, severity based on a specified pain scale |
| Documenting Vital Signs | Vital signs are generally documented on a flow sheet designed solely for this purpose. Most facilities also require that vital signs be documented in the nurse’s notes. |
Created by:
makiyas
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