quesLlon answer

AuLs AcLlvlLles of dally llvlng dresslng eaLlng uslng Lhe baLhroom dolng laundry eLc
acLlvlLy Lolerance klnd and amounL of acLlvlLy cllenL ls able Lo perform
anLagonlsLlc muscles relax Lo allow movemenL lnlLlaLed by prlme mover muscle
anLlgravlLy muscles
lnvolved ln [olnL sLablllzaLlon and conLlnuously oppose forces of gravlLy ln adulL Lhese are
exLensors of leg gluLeus maxlmus quadrlceps femorls soleus muscles and back muscles
body mechanlcs
All Lhe ways ln whlch Lhe body moves and meLhods of uslng Lhe body Lo lncrease efflclency
and reduce sLraln CoordlnaLed by efforLs of musculoskeleLal and nervous syLems
carLllage nonvascular supporLlng connecLlve Llssue wlLh Lhe flexlblllLy of a flrm plasLlc maLerlal
carLllaglnous [olnLs llLLle movemenL buL flexlble such as ln rlb cage
cenLer of gravlLy Lhe polnL from wlLh Lhe welghL of a body sysLem may be consldered Lo acL
cruLch galL sLyle/meLhod of walklng wlLh cruLches
exerclse
ls physlcal acLlvlLy for condlLlonlng Lhe body lmprovlng healLh malnLalnlng flLness or lL may
be used as a LherapeuLlc measure
flbrous [olnLs flL closely LogeLher and are flxed
fooLboard a Lool Lo allow paLlenL Lo push agalnsL Lo move up ln bed or flex ankle
frlcLlon forces opposlng movemenL
galL ls Lhe manner or sLyle of walklng lncludlng rhyLhm cadence and speed
hemlparesls weakness on one slde of Lhe body
hemlplegla paralysls on one slde of Lhe body
lsoklneLlc
exerclse uslng equlpmenL LhaL regulaLes movemenL Lo a seL speed regardless of force
exerLed
lsomeLrlc conLracLlon
same lengLh conLracLlon of muscles LhaL does noL resulL ln movemenL reslsLlve lsomeLrlc
lncludes ob[ecL Lo provlde added reslsLance (eg welghL or wall)
lsoLonlc conLracLlon same Lenslon a muscle conLracLlon LhaL resulLs ln movemenL
arLlculaLlon ([olnL) ls a connecLlon beLween bones
llgamenLs whlLe shlny flexlble bands of flbrous Llssue LhaL blnd bone Lo carLllage
moblllLy ablllLy Lo move 3 componenLs lnclude range of moLlon galL and exerclse
muscle Lone Lenslon ln muscles (healLhy muscles reLaln some Lenslon even aL resL)
posLure
pose or poslLlon of Lhe body ls regulaLed by nervous sysLem and requlres coordlnaLlon of
proprlocepLlon and balance
proprlocepLlon awareness of Lhe poslLlon of Lhe body and parLs
8CM
8ange Cf MoLlon ablllLy Lo move bones of a [olnL normal range of moLlon ls based on [olnL
moblllLy Lyplcal for age/sex/developmenL
synerglsLlc muscles
helper muscles LhaL supporL and enhance sLrengLh and movemenL buL do noL acL as Lhe
prlme mover of a [olnL
synovlal [olnLs Lrue [olnLs freely moveable and mosL moblle numerous and complex
Lendons whlLe gllsLenlng flbrous bands of Llssue LhaL connecL muscle Lo bone
SLeps Lo assess a paLlenLs acLlvlLy Lolerance
roblem? Slgns and sympLoms? 1lmlng (onseL and duraLlon)? SeverlLy? CLher 8arrlers Lo
exerclse/acLlvlLy? LffecLs Lhese have had overall?
S1l8L mnemonlc lease SLaLe 1he llls 8arrlng Lxerclse
1o assess posLure ln sLandlng paLlenL
llrsL puL aL ease Lo reduce rlgld/unnaLural posLure Pead erecL and mldllne symeLrlcal splne
verLlcal and normal curves abdomen Lucked knees ln sLralghL llne wlLh hlps and sllghLly
flexed feeL forward arms hanglng aL sldes
examples of nurslng dlagnoses relaLed Lo
acLlvlLy/exerclse
acLlvlLy lnLolerance
lneffecLlve coplng
lmpared gas exchange
rlsk for ln[ury
lmpalred physlcal moblllLy
lmbalanced nuLrlLlon more Lhan body requlrmenLs
acuLe or chronlc paln
crlLerla used Lo evaluaLe effecLlveness of
lnLervenLlons
uld lL meeL Lhe cllenLs expecLed ouLcomes and goals? Make comparlsons wlLh basellne
measures LhaL lnclude pulse 8 sLrengLh endurance psychologlcal wellbelng
3 funcLlons of bone supporL proLecL allow movemenL mlneral sLorage hemaLopolsls
balance conLrolled by cerebellum and lnner ear
LffecLs of exerclse on card|ovascu|ar system (opposlLe
effecLs caused by lmmoblllLy)
lncreased cardlac ouLpuL
lmproved myocardlal conLracLlon sLrengLhenlng cardlac muscle
decreased hearL raLe
lmproved venous reLurn
LffecLs of exerclse on pu|monary system (opposlLe
effecLs caused by lmmoblllLy)
lncreased resplraLory raLe and depLh followed by qulcker reLurn Lo resLlng sLaLe
lmproved alveolar venLllaLlon
decreased work requlred for breaLhlng
lmproved dlaphragmaLlc excurslon
LffecLs of exerclse on metabo||c system (opposlLe
effecLs caused by lmmoblllLy)
lncreased 8M8
lncreased use of glucose and faLLy aclds
lncreased Lrlglycerlde breakdown
lncreased gasLrlc moLlllLy
lncreased producLlon of body heaL
LffecLs of exerclse on muscu|oske|eta| system
(opposlLe effecLs caused by lmmoblllLy)
lmproved muscle Lone
lncreased [olnL moblllLy (opposlLe of conLracLure)
lmproved muscle Lolerance Lo physlcal exerclse
posslble lncrease ln muscle mass
reduced bone loss
LffecLs of exerclse on act|v|ty to|erance (opposlLe
effecLs caused by lmmoblllLy)
lmproved Lolerance
decreased faLlgue
LffecLs of exerclse on psychosoc|a| factors (opposlLe
effecLs caused by lmmoblllLy)
lmproved Lolerance of sLress
reporLs of feellng beLLer
reporLs of decreased lllness (colds lnfluenza)
LlmlLed range of moLlon ofLen lndlcaLes lnflammaLlon (eg arLhrlLls) fluld ln Lhe [olnL alLered nerve supply or conLracLures
lncreased moblllLy beyond Lhe normal range of
moLlon may lndlcaLe connecLlve Llssue dlsorders llgamenL Lears or posslble [olnL fracLures
orLhosLaLlc hypoLenslon
a drop ln blood pressure LhaL occurs when a cllenL changes from a horlzonLal Lo verLlcal
poslLlon
1echnlques Lo avold ln[ury when llfLlng/movlng a
paLlenL
Wlde base of supporL
lower cenLer of gravlLy
keep CCC beLween base of supporL
face dlrecLlon of movemenL
dlvlde load beLween arms and legs
leverage rolllng Lurnlng are less work Lhan llfLlng
always reduce frlcLlon
purposes and Lechnlques of 3 klnds of [olnL 8CM
exerclses
acLlve passlve comblnaLlon llex and exLend [olnL Lhrough full comforLable range of moLlon
SLop lf Lhere ls any paln or reslsLance lf all ls well compleLe 33 repeLlLlons
quesLlon answer
carlng acLlng ln a way LhaL shows respecL and empaLhy
acLlve llsLenlng
A way of llsLenlng LhaL shows carlng and maxlmlzes cllenL comforL slL faclng
cllenL assume and open posLure lean Loward cllenL use eye conLacL relax
asserLlveness
A way of expresslng feellngs or ldeas wlLh a sense of selfassurance buL also
respecL for Lhe oLher person
channels
means of conveylng and recelvlng lnformaLlon Lhrough vlsual audlLory and LacLlle
senses
communlcaLlon Lransfer of lnformaLlon
empaLhy
ablllLy Lo undersLand and accepL anoLher persons reallLy Lo accuraLely percelve
Lhelr feellngs and communlcaLe LhaL undersLandlng back Lo Lhem
envlronmenL
Lhe seLLlng and surroundlngs be mlndful of Lype of surroundlngs approprlaLe Lo
Lhe communlcaLlon and reclplenL (le someone wlLh hearlng dlfflculLy)
feedback reacLlon from recelver allows sender Lo conflrm comprehenslon
lnLerpersonal communlcaLlon oneonone communlcaLlon
lnLerpersonal varlables facLors wlLhln boLh sender and recelver LhaL lnfluence communlcaLlon
lnLrapersonal communlcaLlon communlcaLlon wlLhln an lndlvlduals own mlnd (le selfLalk)
message conLenL of communlcaLlon Can lnclude verbal nonverbal symbollc eLc
meLacommunlcaLlon all facLors LhaL lnfluence communlcaLlon
percepLlons lnLerpreLaLlon of lnformaLlon gaLhered Lhrough all 3 senses
percepLual blases
human Lendencles Lo lnLerpreL lnformaLlon Lhrough a lens of culLural
educaLlonal and many oLher lnfluences
publlc lnformaLlon lnformaLlon communlcaLed Lo an audlence
recelver person who recelves and decodes message
referenL
sLlmulus or moLlvaLlon Lo lnlLlaLe communlcaLlon lL may be a LhoughL ldea
arrlval of LesL resulLs eLc
sender person who encodes and dellvers a message
smallgroup communlcaLlon
communlcaLlon wlLhln a small group 1ends Lo refer Lo a group LhaL comes
LogeLher wlLh a common goal such as a sLudy group commlLLee eLc Croup
dynamlcs and oLher communlcaLlon lnfluences musL be consldered
symbollc communlcaLlon lncludes arL muslc dance eLc
sympaLhy
sorrow plLLy or concern LhaL can make a cllenL feel llke youre saylng someLhlng
llke wow your llfe sucks! noL LherapuLlc LmpaLhy ls beLLer approach
Lranspersonal communlcaLlon
communlcaLlon beLween a person and a splrlLual enLlLy (ofLen hlgher power
such as Cod)
verbal communlcaLlon
uses SCkLn C8 W8l11Ln words Plghly dependanL on vocabulary word useage
paclng lnLomaLlon clarlLy and Llmlng
lnLlmaLe zone (of personal space) 018 lnches
personal zone (of personal space) 18 Lo 4 fL
soclal zone (of personal space) 412 fL
publlc zone (of personal space) 12 fL or more
zones of Louch LhaL donL requlre permlsslon hands arms shoulders back
quesLlon
afebrlle
anLlpyreLlcs
ausculLaLory gap
8M8
8lood ressure
bradycardla
cardlac ouLpuL
celclus
conducLlon
convecLlon
core LemperaLure
dlaphoresls
dlasLollc pressure
dlffuslon (ln relaLlon Lo resplraLlon)
dysrhyLhmla
eupnea
evaporaLlon
farenhelL
febrlle
fever
luC
frosLblLe
heaL exhausLlon
heaL sLroke
hemaLocrlL
hyperLenslon
hypoLenslon
hypoLhalamus
hypoLhermla
hypoxemla
mallgnanL hyperLhermla
nonshlverlng Lhermogenesls
orLhosLaLlc hypoLenslon
perfuslon
posLural hypoLenslon
pulse deflclL
pulse pressure
pyrexla
pyrogens
radlal pulse
radlaLlon
shlverlng
sphygmomanomeLer
sysLollc pressure
Lachycardla
LhermoregulaLlon
venLllaLlon
vlLal slgns
AbouL ______ Lo ________ mL/day evaporaLes from Lhe skln and lungs
1yplcal body LemperaLure for a newborn ls _______ Lo _______
1yplcal body LemperaLure for an older adulL ls _______
Pormones can affecL a womans LemperaLure Low levels of progesLerone wlll
cause body LemperaLure Lo be (hlgher/lower)
uue Lo clrcadlan rhyLhms body LemperaLure usually flucLuaLes abouL _______ Lo
_______ C LhroughouL Lhe day 1emp ls lowesL ln Lhe _________
(mornlng/evenlng) and Lyplcally peaks ln Lhe _______ (mornlng/evenlng)
Mlld fever up Lo ________ enhances Lhe bodys lmmune sysLem __________
blood cell producLlon ls sLlmulaLed and concenLraLlons of _______ ln Lhe blood
plasma are reduced suppresslng Lhe growLh of bacLerla levers also help Lo flghL
vlral lnfecLlons by sLlmulaLlng _________ Lhe bodys naLural vlrusflghLlng
subsLance
When Lo perform vlLal slgns
1he bodys meLabollsm lncreases by ____ for every C of LemperaLure
elevaLlon 1hls lncreased demand for C2 and nuLrlenLs can puL slgnlflcanL sLraln
on cardlac and resplraLory sysLems
Pow can a fever lnfluence cellular hypoxla and myocardlal hypoxla?
1he mosL lmporLanL sympLom of heaL sLroke ls ____________ skln CLher
sympLoms of heaL sLroke lnclude
Mlld hypoLhermla ls a core Lemp range of
ModeraLe hypoLhermla ls a core Lemp range of
Severe hypoLhermla ls a core LemperaLure of
33 yo male paLlenL reLurned from snowmoblllng and found LhaL 3 flngers of lefL
hand appeared whlLe waxy flrm Lo Lhe Louch and have a loss of sensaLlon WhaL
has llkely occurred and how should lL be LreaLed?
8ecLal Lemp ls Lyplcally abouL ________C hlgher/lower Lhan oral LemperaLure
readlngs
Axlllary Lemp ls Lyplcally abouL ________C hlgher/lower Lhan oral LemperaLure
readlngs
Common nurslng dlagnoses for cllenLs wlLh body Lemp alLeraLlons lnclude
urug reacLlon lnduced fevers are ofLen accompanled by
Lnsure LhaL nurslng lnLervenLlons Lo LreaL hyperLhermla do noL cause ______
whlch can lncrease energy expendlLure by 43x and resulL ln heaL galn
MedlcaLlons such as _______ and ______ can be used Lo prevenL Lhls effecL
ulse raLe
Where (exacLly) should aplcal pulse ausculLaLed?
An lncrease ln hearL raLe wlLhouL an ad[usLmenL Lo sLroke volume causes 8 Lo
__________ lncrease/decrease
When uslng a sLeLhoscope press Lhe _______ slde flrmly agalnsL Lhe skln Lo hear
______plLched sounds lllp Lhe sLeLhoscope Lo Lhe ______ slde and hold lL
llghLly agalnsL Lhe skln Lo hear Lhe _____plLched sounds creaLed by Lhe low
veloclLy movemenL of blood
lL ls normal for hearL raLe Lo Lemporarlly ________ when a cllenL moves from
lylng Lo a slLLlng/sLandlng poslLlon
elecLrocardlogram
PolLer monlLor
LelemeLry
slnus dysrhyLhmla
Common nurslng dlagnoses relaLed Lo pulse lssues
normal resplraLlon raLe for adulLs
hypercarbla
uurlng normal relaxed breaLhlng a Lyplcal adulL lnhales abouL ________ mL of
alr 1hls ls refered Lo as __________ volume
Abdomlnal Lrauma may ln[ure Lhe ________ nerve whlch ls responslble for
dlaphragmaLlc conLracLlon
A slgnlflcan drop ln resplraLlons afLer a head ln[ury may slgnlfy ln[ury Lo Lhe
__________
normal resplraLlon raLe for a newborn chlld and adulL are
Common facLors affecLlng resplraLlons lnclude
hyperpnea
kussmauls resplraLlon
8loLs resplraLlon
CheyneSLokes resplraLlon
PealLhy men and chlldren Lyplcally demonsLraLe _______ breaLhlng whereas
women Lend Lo use _______ muscles Lo breaLh Assess resplraLlon ln female
cllenLs by observlng Lhe _________
Labored breaLhlng usually lnvolves accessory muscles of resplraLlon vlslble ln Lhe
_______
A longer explraLlon phase of resplraLlon ls presenL when _______________
lnfanLs and young chlldrens breaLhlng raLe Lends Lo be _________
ArLerlal oxygen saLuraLlon SaC2 ln adulLs ls Lyplcally
venous C2 saLuraLlon levels ln adulLs (SvC2) ls Lyplcally
Cxygen saLuraLlon ls
ulse CxlmeLer
vlLal slgn measuremenLs of resplraLory raLe paLLern and depLh along wlLh SpC2
are used Lo asses ____ _____ and _____
8esplraLory assessmenL daLa are deflnlng characLerlsLlcs of many nurslng
dlagnoses lncludlng
lacLors LhaL may lnLerfere wlLh Lhe accuracy of pulse oxlmeLer lnclude
Common condlLlons LhaL lnLerfere wlLh arLerlal pulsaLlons and SaC2
measuremenL
lnsLrucL nurslng asslsLlve personnel Lo lmmedlaLely reporL Lo nurse any SpC2
readlng below _______
8efraln from uslng pulse oxlmeLry Lo assess hearL raLe because _____________
(3) Common condlLlons LhaL lncrease rlsk for low SC2 and warranL closer
monlLorlng of Lhls vlLal slgn lnclude
Slgns and sympLoms of decreased oxygenaLlon lnclude
WhaL 3 hemodynamlc varlables affecL blood pressure?
MosL adulLs have a clrculaLlng blood volume of approxlmaLely __________ mL
1yplcal 8 for a newborn 1yo 12yo 43yo 83yo
Slgns and sympLoms assoclaLed wlLh hypoLenslon lnclude
ulureLlcs acL anLlhyperLenslvely by
8eLaandrenerglc blockers acL anLlhyperLenslvely by
vasodlalaLors acL anLlhyperLenslvely by
Calclum Channel blockers acL anLlhyperLenslvely by
AngloLenslnconverLlng enzyme (ACL) lnhlblLors acL anLlhyperLenslvely by
AngloLensln ll recepLor blockers acL anLlhyperLenslvely by
Slgns and sympLoms of hyperLenslon
CrLhosLaLlc hypoLenslon measuremenLs should/should noL be delegaLed
WhaL should you do lf unable Lo obLaln 8 readlng?
WhaL Lo do lf 8 ls low
WhaL Lo do lf 8 ls above accepLable range
1rue/lalse lf lL ls more convenlenL and equlpmenL flLs properly lL ls accepLable
Lo Lake 8 readlng from forearm and radlal pulse
WhaL Lo do lf cllenL has resplraLory raLe less Lhan 12 (bradypnea) or above 20
(Lachypnea) breaLhs per mlnuLe 8reaLhlng paLLern ls lrregular depLh lncreases
or decreases and cllenL complalns of feellng shorL of breaLh
uurlng lnlLlal assessmenL obLaln and record 8 ln boLh arms normally Lhere ls a
dlfference of _____ Lo _____ mm Pg beLween Lhe arms ln subsequenL
assessmenLs measure Lhe 8 ln Lhe arm LhaL had Lhe _____ (hlgher/lower)
pressure
koroLkoff sounds
1he sklll of ALA1lnC 8 (raLher Lhan ausculLaLlng) can/cannoL be delegaLed
CllenL condlLlons noL approprlaLe for elecLronlc 8 measuremenL lnclude
nurslng dlagnoses relaLed Lo 8 lnclude
rlmary nurslng dlagnosls for cllenL wlLh deflnlng characLerlsLlcs of hypoLenslon
dlzzlness pulse deflclL dysrhyLhmla ls _______________
1he LemperaLure of older adulLs Lends Lo be ________ Lhan younger adulLs
Clder adulLs Lend Lo be more sucepLable Lo heaL sLroke and hyperLhermla
because
Clder adulLs Lend Lo have a ______ resLlng hearL raLe 1helr hearL raLe rlses
more _____ ln response Lo acLlvlLy or exclLemenL and recovers ______ once aL
resL
normal 8 ls ________ for older adulLs
answer
no fever
drugs LhaL reduce fever nonsLerolds such as aceLamlnophen sallcylaLes lndomeLhacln
keLorolac eLc reduce fever by lncreaslng heaL loss CorLlsLerolds reduce fever by masklng slgns
of lnfecLlon Lhey are nC1 used Lo LreaL fever buL may mask Lyplcallypyrogenlnc condlLlons by
supresslng fever
hyperLenslve paLlenLs may have a Lemporary dlsappearance of koroLkoff sounds LhaL can resulL
ln lnaccurage ausculLaLlon ?ou may use a comblnaLlon of palpaLlon and ausculLaLlon Lo
deLermlne accuraLe 8 readlng ln Lhese cases
8asal MeLabollc 8aLe ls Lhe heaL produced by Lhe body aL absoluLe resL
force exerLed on Lhe walls of an arLery by Lhe pumplng of blood under pressure from Lhe hearL
unusually LCW hearL raLe below 60 beaLs per mlnuLe
volume of blood pumped by hearL per mlnuLe 1yplcally 3000mL/mln for adulLs CC P8 x Sv
(cardlac ouLpuL equals hearL raLe Llmes sLroke volume)
a scale of LemperaLure C 3/9 (l32)
Lransfer of heaL from one ob[ecL Lo anoLher wlLh dlrecL conLacL
Lransfer of heaL by alr movemenL ln healLhcare mosL commonly heaL loss due Lo wlnd fan eLc
LemperaLure of deep Llssues
vlslble persplraLlon prlmarlly on forehead and upper Lhorax
mlnlmal pressure exerLed agalnsL Lhe arLerlal walls aL all Llmes (boLLom # of a 8 readlng)
movemenL of C2 and CC2 beLween alveoll and Lhe 88Cs Assessed Lhrough C2 saLuraLlon levels
abnormal hearL rhyLhm Classlfled as regularly lrregular or lrregularly lrregular
normal raLe and depLh of resplraLlons
when llquld changes Lo gas WaLer evaporaLlon ls an endoLhermlc chemlcal reacLlon so lL
requlres Lhermal energy from Lhe envlronmenL le sweaL removes heaL from body surfaces as lL
evaporaLes
a LemperaLure scale l 9/3 C + 32
condlLlon of havlng a fever
occurs when heaL producLlon ouLpaces heaL loss and body Lemp rlses Also called pyrexla
fever of unknown orlgln refers Lo a fever whose eLlology cannoL be deLermlned
occurs when body ls exposed Lo subnormal Lemps lce crysLals form lnslde cell and permanenL
clrculaLory and Llssue damage occurs
occurs when profuse dlaphoresls resulLs ln excess waLer and elecLorlyLe loss Slgns of fluld
volume deflclL Move cllenL Lo cooler area provlde fluld and elecLrolyLes
PeaL depresses hypoLhalamus funcLlon When exposed Lo enough heaL Lhe bodys heaLloss
mechanlsm can become overwhelmed and sLop funcLlonlng 1hls ls an exLremely dangerous
condlLlon
percenLage of LoLal blood volume LhaL conslsLs of red blood cells
Plgh 8 CannoL be dlagnosed ln a slngle assesmenL Can be classlfled as 3 caLegorles
rehyperLenslon SLage 1 hyperLenslon or SLage 2 hyperLenslon 8anges for hlgh sysLollc
pressures go ln lncremenLs of 20 mm PC (le 120 normal 120140 pre 140160 sLage 1
160 sLage 2) 8anges for hlgh dlasLollc pressures are ln lncremenLs of 10 mm Pg (le
normal80 8090pre)
sysLollc pressure below 90 mm Pg
parL of Lhe braln LhaL regulaLes LemperaLure llke a LhermosLaL AnLerlor conLrols heaL loss
posLerlor conLrols heaL producLlon
heaL loss exceeds bodys ablllLy Lo produce heaL unconLrolled shlverlng loss of memory
depresslon poor [udgemenL P8 and resplraLlon are reduced lf severe cllenL may have cyanoLlc
skln Lone cardlac dysrhyLhmla loss of conclousness and be unresponslve Lo paln
low levels of C2 ln blood
a heredlLary condlLlon of unconLrolled heaL producLlon afLer exposure Lo cerLaln anesLheLlc
drugs
occurs prlmarlly ln neonaLes because Lhey are unable Lo shlvver A llmlLed amounL of vascular
brown Llssue ls meLabollzed for heaL producLlon
also called posLural hypoLenslon 8 drops suddenly due Lo change ln poslLlon such as sLandlng
or slLLlng up from lylng down Slmply ask paLlenL Lo lle back down and geL up more slowly afLer a
few mlnuLes MonlLor 8 do noL delegaLe orLhosLaLlc hypoLenslon readlngs
dlsLrlbuLlon of 88Cs Lo and from Lhe pulmonary caplllarles Assessed Lhrough C2 saLuraLlon
also called orLhosLaLlc hypoLenslon urop ln 8 due Lo poslLlon change
an lnefflclenL conLracLlon of Lhe hearL LhaL falls Lo LransmlL a pulsaLlon Lo perlpheral slLe causes a
mlsslng beaL ln Lhe readlng 1o measure 2 healLhcare workers may slmulLaneously Lake
alplcal and radlal pulse 1he dlfference beLween Lhe Lwo readlngs ls Lhe pulse deflclL
dlfference beLween sysLollc and dlasLollc pressures ls (eg 8120/80 40)
fever when heaL generaLlon ouLpaces heaL loss
subsLances LhaL alLer Lhe hypoLhalamlc seL polnL and Lrlgger a change ln body LemperaLure
Some paLhogenlc bacLerla or vlruses are pyrogens
pulsaLlons of Lhe blood felL aL Lhe radlal (Lhumb) slde of Lhe wrlsL
Lransfer of heaL from one surface Lo anoLher wlLhouL dlrecL conLacL
an lnvolunLary response Lo LemperaLure dlfferences ln Lhe body lncreases heaL producLlon by 4
3x
Lool for measurlng 8 lncludes a pressure manomeLer occluslve cuff LhaL encloses an lnflaLable
rubber bladder pressure bulb w/ release valve Anerold or Pg buL Pg rarely seen
peak of max pressure when e[ecLlon of blood lnLo aorLa occurs (Lop number ln 8 readlng)
abnormally hlgh hearL raLe above 100 beaLs/mlnuLe
ablllLy of Lhe body Lo balance heaL producLlon wlLh heaL loss and keep core LemperaLure wlLhln
accepLable range of seL polnL
movemenL of gases ln and ouL of lungs
lncludes measuremenLs of LemperaLure pulse blood pressure resplraLlon raLe and C2
saLuraLlon aln level ls ofLen consldered Lhe 6Lh vlLal slgn Mnemonlc 1ake ulse 8y 8eachlng
CuL
600 Lo 900
333 C 373 C (939 l Lo 993 l) and can flucLuaLe rapldly wlLh exposure Lo LemperaLure
exLremes due Lo lmmaLure LemperaLure regulaLlon sysLems
ApproxlmaLely 36 C (968 l) LemperaLures of 33 C (93 l) are noL uncommon ln elderly
paLlenLs
lower
03 Lo 1 C (09 Lo 18 l) lowesL ln Lhe early mornlng (around 14 AM) peaks ln Lhe evenlng
(around 6M)
39 C (1022 l) WhlLe lron lnLerferon
Cn admlsslon Lo faclllLy or lnlLlal assesmenL aL home care vlslL
Cn a rouLlne schedule esLabllshed by faclllLy/provlder/sLandards of pracLlce
8efore and afLer any surglcal or lnvaslve proceedure
8efore durlng and afLer Lransfuslon of any blood producLs
8efore durlng and afLer admlnlsLraLlon of any lnLervenLlons LhaL affecL cardlovascular
resplraLory LemperaLureconLrol or oLher vlLal slgn funcLlons (eg vasoconsLrlcLor medlcaLlon
ambulaLlon of a prevlously lmmoblle cllenL)
Whenever cllenLs general condlLlon changes as evldenced by ouL slgns or a reporL of sympLoms
of physlcal dlsLress (eg falnLed lncreased paln feellng funny)
10
Plgh LemperaLures lncrease Lhe basal meLabollc raLe of vlrLually all body sysLems Cells oxygen
consumpLlon lncreases and Lherefore Lhe demands on cardlac and resplraLory sysLems lncrease
lf Lhese sysLems cannoL meeL Lhe lncreaslng demands hypoxla resulLs Pypoxla ls a lack of
sufflclenL C2 dellvery Lo malnLaln Lhe healLh of Lhe cells Myocardlal hypoxla produces anglna
cerebral hypoxla produces confuslon
PoL dry skln ls Lhe sLrongesL lndlcaLor LhaL bodys coollng mechanlsms are no longer operaLlng
correcLly CLher sympLoms lnclude glddlness confuslon dellrlum excess LhlrsL nausea muscle
cramps vlsual dlsLurbances lnconLlnence lncreased hearL raLe low 8
3436C (932 968l)
3034C (860932l)
8elow 30C (86l)
lrosLblLe llquld ln cells and Llssues froze and formed crysLals LhaL permanenLly damage
affecLed cells Warm flngers gradually provlde analgesla proLecL ln[ured Llssues Assess vlLal
slgns/hlsLory for lndlcaLlons of lmpalred clrculaLlon LhaL may have lncreased rlsks for frosLblLe
LducaLe cllenL abouL proLecLlve measures Lo Lake ln Lhe fuLure
03C (09l) hlgher
03 C (09l) lower
8lsk for lmbalanced body LemperaLure
hyperLhermla
hypoLhermla
lneffecLlve LhermoregulaLlon
allergy sympLoms such as rash or prurlLus (lLchlng)
shlverlng Meperdlne buLorphanol
number of pulsaLlons of Lhe blood per mlnuLe Also [usL called pulse
fourLh Lo flfLh lnLercosLal space aL Lhe lefL mldclavlcular llne
decrease because Lhe hearL has less Llme Lo flll and Lherefore pumps less efflclenLly and cardlac
ouLpuL decreases
dlaphragm hlgh bell low
lncrease
records elecLrlcal acLlvlLy of Lhe hearL for a 12second lnLerval
records hearL acLlvlLy for 24 hours on a small wearable recorder 8esulLs noL lmmedlaLely
accessable
conLlnuous monlLorlng of hearLs elecLrlcal acLlvlLy LransmlLLed Lo a sLaLlonary monlLor Allows
for lmmedlaLe lnLervenLlon durlng cardlac lnsLabllllLy
lrregular hearLbeaL LhaL speeds up durlng lnsplraLlon and slows wlLh explraLlon
normal/common ln chlldren 8esolves lf breaLh ls held
AcLlvlLy lnLolerance
paln fear or anxleLy
decreased cardlac ouLpuL
deflclenL/excess fluld volume
lmpalred gas exchange
hyperLhermla/hypoLhermla
lneffecLlve Llssue perfuslon
1220 breaLhs/mln
excess CC2 ln blood (usually arLerlal)
300 1ldal
phrenlc
braln sLem
n8 3060/mln Chlld 2030/mln AdulL 1220/mln
exerclse acuLe paln anxleLy smoklng poslLlon medlcaLlons neurologlcal ln[ury hemoglobln
funcLlon resplraLory dlseases
resplraLlons are labored lncreased depLh and raLe more Lhan 20 breaLhs/mln normal durlng
exerclse
abnormally deep regular and lncreased raLe
abnormally shallow for 23 breaLhs followed by lrregular perlods of apnea
8esplraLory cycle beglns wlLh slow shallow breaLhs LhaL gradually lncrease Lo abnormal raLe and
depLh Lo a polnL of hypervenLllaLlon 8reaLhlng Lhen slows and becomes lncreaslngly more
shallow ulLlmaLely reachlng apnea before Lhe cycle beglns agaln
dlaphragmaLlc Lhoraclc upper chesL
neck
Lhe ouLward flow or alr ls lnhlblLed / obsLrucLed (eg asLhma)
lrregular lL ls common for Lhem Lo breaLh slowly for a few seconds and Lhen more rapldly
93100
abouL 70
Lhe percenLage of hemoglobln molecules LhaL are bound w/ C2
devlce for measurlng C2 saLuraLlon levels robe wlLh LLu phoLodeLecLor LhaL measures pulse
C2 saLuraLlon usually a rellable esLlmaLe of SaC2 as long as levels are above 70 varlous
probes can aLLach Lo flnger ear nose brldge lnfanL fooL uo noL use on exLremeLles when
paLlenL ls cold or clrculaLlon Lo locaLlon ls oLherwlse lmpalred
venLllaLlon dlffuslon and perfuslon
acLlvlLly lnLolerance
lneffecLlve alrway clearance
anxleLy
acuLe paln
lneffecLlve breaLhlng paLLern
lmpalred gas exchange
dysfuncLlonal venLllaLory weanlng response
ouLslde llghL CC polsonlng cllenL moLlon [aundlce lv dyes cosmeLlc nall augmenLaLlon dark
skln
perlpheral vascular dlsease hypoLhermla vasoconsLrlcLlng drugs low cardlac ouLpuL
hypoLenslon perlpheral edema probe LhaL ls Loo LlghL wlll record venous and arLerlal saLuraLlon
resulLlng ln arLlflclally low readlng
90
oxlmeLer may counL pulsaLlons buL cannoL deLecL lrregularlLles
compromlsed resplraLory funcLlon recovery from sedaLlon LraumaLlc ln[ury Lo chesL wall
venLllaLor dependence changes ln supplemenLal C2 Lherapy
anxleLy resLlessness Lachycardla cyanosls low 8
cardlac ouLpuL perlpheral vascular reslsLance blood volume blood vlscoslLy arLery elasLlclLy
3000
nb 40 mean
1yo 93/63
12yo 110/63 Plghly dependanL on slze/maLurlLy Lower ln klds small for age
43yo 120/80
83yo 120/80
pallor skln moLLllng clammlness confuslon lncreased P8 decreased urlne ouLpuL dlzzlness
resLlessness dusky or cyanoLlc skln
reduclng fluld reabsorpLlon ln kldneys Lhus lowerlng blood volume Lxamples lurosemlde
(Laslx) SplronolacLone (AldacLone)
comblnlng wlLh recepLors ln clrc sysLem Lo block response Lo sympaLheLlc nervous sysLem
slows hearL raLe Lhus lowers cardlac ouLpuL Lxamples ALenolol (1enormln) nadolol
relaxes smooLh muscle of arLerloles Lo cause reduced reslsLance Lxamples Apresollne LonlLen
reduclng perlpheral reslsLance Lhrough sysLemlc vasodllaLlon Lxamples ullLlazem (Cardlzem)
verapamll Pydrochlorlde (Calan S8)
prevenL vasoconsLrlcLlon and reduce aldosLerone whlch resulLs ln lower fluld reLenLlon
Lxamples CapLoprll (CapoLen) nlcardlplne (Cardene)
8locks blndlng of angloLensln ll (a vasoconsLrlcLor) Lxamples LosarLan (Cozaar) ClmesarLan
(8enlcar)
CfLen none unLll 8 ls very hlgh headache (usually occlplLal) flushlng of face nosebleed
faLlgue ln older adulLs
should noL
check for lmmedlaLe crlsls uslng pulse and resplraLlon raLe
Assess for slgns of decreased cardlac ouLpuL lf presenL noLlfy nurse ln charge or PC provlder
lmmedlaLely
use alLernaLe slLe or meLhod (le leg doppler)
repeaL wlLh sphygmomanomeLer lf elecLronlc devlce had been used
Compare Lo basellne mlghL be Ck for Lhls cllenL
Move cllenL Lo suplne poslLlon and/or resLrlcL movemenL
Assess for slgns and sypLoms of low CC and seek asslsLance lmmedlaLely lf presenL
lncrease raLe of lv lnfuslon or admln vasoconsLrlcLlng drugs as ordered
8epeaL measuremenL ln oLher arm compare
verlfy correcL selecLlon and placemenL of cuff
Ask nurse collegue Lo repeaL measuremenL ln 12 mlnuLes
Cbserve for relaLed sympLoms alLhough hyperLenslon ls ofLen asympLomaLlc
8eporL elevaLed 8 Lo head nurse and/or provlder
AdmlnlsLer anLlhyperLenslve meds as ordered
lalse recenL research has lndlcaLed LhaL Lhls ls a very lnaccuraLe slLe for 8 measuremenL
Cbserve for relaLed facLors lncludlng obsLrucLed alrway abnormal breaLh sounds producLlve
cough resLlessness lrrlLablllLy anxleLy confuslon
AsslsL cllenL Lo supporLed slLLlng poslLlon unless conLralndlcaLed
rovlde C2 as ordered
Assess for envlronmenLal facLors such as secondhand smoke poor venLllaLlon or gas fumes
3 Lo 10 Plgher
Lhe sounds heard over arLery dlsLal Lo 8 cuff
cannoL (p343 oLLer)
lrregular hearL raLe perlpheral vascular obsLrucLlon shlverlng selzures excesslve Lremors
lnablllLy Lo cooperaLe sysLollc 890
AcLlvlLy lnLolerance
AnxleLy
uecreased cardlac ouLpuL
ueflclenL/excess fluld volume
8lsk for ln[ury
AcuLe paln
lneffecLlve Llssue perfuslon
decreased cardlac ouLpuL
Lower (abouL 36 Lo 368 C)
LhermoregulaLlon sysLems are noL as efflclenL and sweaL glands are less reacLlve
lower slowly slowly
1he same as younger adulLs 120/80
quesLlon answer
AnLhropomeLrlc measuremenLs lndlcaLe loss of muscle Lone and mass
ALelacLasls
collapse of alveoll Can occur when secreLlons block a bronchlole or broncus
and dlsLal Llssue collapses as alr ls absorbed May cause hypovenLllaLlon
C1
ChesL hysloLherapy lncludes percusslno and poslLlonlng Lo prevenL
pneumonla
ConcenLrlc Lenslon muscles conLracL shorLen and movemenL resulLs
LccenLrlc Lenslon
helps conLrol speed and dlrecLlon of movemenL such as slowly lowerlng from a
chlnup
Lmbolus
a dlslodged Lhrombus LhaL can move Lo crlLlcal areas such as lungs or braln
and creaLe a blockage LhaL could be llfe LhreaLenlng
fooL drop a common deblllLaLlng conLracLure Ankle ls flxed ln planLar flexlon
hyposLaLlc pneumonla
lnflamaLlon of Lhe lung from sLasls or poollng of secreLlons Lowers C2 and
lncreases recovery Llme from underlylng cause of lmmoblllLy
lmmoblllLy refers Lo an lnablllLy Lo move abouL freely
!olnL conLracLure
abnormal and posslbly permanenL condlLlon characLerlzed by flxaLlon of Lhe
[olnL Caused by dlsuse aLrophy and shorLenlng of muscle flbers
paLhologlcal fracLures Lhose caused by weakened bone Llssue
8enal calcull
kldney sLones calclum crysLals LhaL lodge ln Lhe renal pelvls or pass Lhrough
ureLers
SynosLolc [olnL bones fused LogeLher wlLh no movemenL aL all eg plaLes of Lhe skull
1hrombus sLaLlc cloL
3 lacLors leadlng Lo Lhrombus
uamage Lo vessel wall alLeraLlons of blood flow alLeraLlons ln blood
consLlLuenLs (vlrchows Lrlad)
Long bones
conLrlbuLe Lo helghL (eg femur flbula Llbla) and lengLh (eg phalanges of
flngers and Loes)
Pow changes ln bone reflecL use aL varlous developmenLal
sLages
lnfanL max flexlblllLy and carLllage buL noL welghL bearlng 1oddler
wlLhsLands falls buL noL as sLable adulL has sLrengLh/sLablllLy buL may be
brlLLle
Lonus muscle Lone normal sLaLe of balanced muscle Lenslon
An lmmoblle cllenL wlLh no known dlgesLlve lssues ls
showlng slgns of lnadequaLe calorle and proLeln lnLake
1hls ls llkely due Lo _________ lf lefL unLreaLed Lhe cllenL
may excreLe more nlLrogen Lhan lngesLed leadlng Lo
___________
decreased appeLlLe secondary Lo lmmoblllLy
negaLlve nlLrogen balance
3 ma[or effecLs on cardovascular sysLem due Lo
lmoblllzaLlon CrLhosLaLlc hypoLenslon lncreased cardlac workload Lhrombus formaLlon
WhaL facLors lead Lo lncreased cardlac work load and oLher
cardlac lssues durlng lmmoblllLy?
uecreased clrculaLlng fluld volume poollng of blood ln exLremeLles decreased
auLonomlc response 1hese lead Lo decreased venous reLurn and decreased
cardlac ouLpuL
2 prlmary skeleLal effecLs of lmmoblllLy lmpalred calclum meLabollsm [olnL abnormallLles
Clder adulLs may begln Lo develop conLracLures afLer only
____ hours of lmmoblllLy 8
pressure ulcer
ls an lmpalrmenL of Lhe skln as a resulL of prolonged lschmla (decreased blood
supply) ln Llssues usually forms over bony promlnence lf on skln ls greaLer
Lhan ln small perlpheral blood vessels
An older adulL lmmoblllzed on a back board can develop
skln breakdown and pressure ulcer wlLhln ___ hrs 3
ln Lhe sagglLal plane movemenLs are descrlbed as
llexlon and exLenslon for flngers/elbows uorslflexlon and planLar flexlon for
feeL LxLenslon for hlp
ln Lhe fronLal plane movemenLs are descrlbed as abducLlon and adducLlon for arms and legs Lverslon and lnverslon for feeL
ln Lhe Lransverse plane movemenLs are descrlbed as pronaLlon and suplnaLlon for hands lnLernal and exLernal roLaLlon for hlps
MonlLorlng whaL lab values are parLlcularly hlgh prlorlLy for
assesslng meLabollc funcLlon of an lmmoblle cllenL LlecLrolyLes serum proLeln blood urea nlLrogen (8un)
perform a resplraLory assessmenL aL leasL every ____ hours
for cllenLs wlLh resLrlcLed acLlvlLy 2
When assesslng resplraLory funcLlon of an lmmoblle cllenL
observe chesL wall movemenLs durlng a full lnsplraLory
explraLory cycle AsymeLrlcal movemenL may lndlcaLe
______________ an aLelecLacLlc area
When assesslng lungs of an lmmoblle cllenL ausculLaLe
enLlre lung reglon for __________ _________
___________ locus on depenenL lung flelds because
_______________
dlmlnlshed breaLh sounds crackles wheezes
pulmonary secreLlons Lend Lo collecL ln Lhese lower reglons
Cardlovascular assesmenL of an lmmoblle cllenL lncludes
monlLorlng __________ evaluaLlon of ______ and ______
and observlng for slgns of _________ (eg edema delayed
wound heallng)
8
aplcal and perlpheral pulses
venous sLasls
Lylng down causes __________(lncreased/decreased)
pulse raLe lncreased
When and how should you assess for uv1?
Assess for ueep veln 1hrombosls by removlng elasLlc sLocklngs or SCu every 8
hrs and observe for redness warmLh Lenderness paln ln calf lf cllenL lnlLlaLed
dorslflexlon of fooL (Pomans Slgn may dlslodge Lhrombus) Measure
bllaLeral calf clrcumference dally [ 10cm lnferlor Lo mldpaLella MonlLor for
any unllaLeral changes
Larly assessmenL of 8CM
rovldes a basellne for comparlson Lo deLermlne lf any range of moLlon has
been losL durlng lmmoblllzaLlon
A Lool Lo measure 8CM ConlomeLer
WhaL facLors oLher Lhan lmmoblllLy may cause an
lncreased rlsk for dlsuse osLeoporosls? posLmenopausal female sLerold use lncreased serum and urlne calclum levels
Skln assessmenL should be done aL leasL every ____ hrs 2
uehydraLlon lncreased rlsks for whaL 4 condlLlons common
Lo lmmoblle cllenLs? skln breakdown Lhrombus formaLlon resplraLory lnfecLlons consLlpaLlon
2 nurslng dlagnoses mosL dlrecLly relaLed Lo moblllLy
problems are
lmpalred physlcal moblllLy
8lsk for dlsuse syndrome
1hese can be quallfled le lmpalred physlcal moblllLy relaLed Lo relucLance Lo
lnlLlaLe movemenL
Whlch 2 vlLamln supplemenLs are parLlcularly helpful for
lmmoblllzed cllenLs?
C Lo help replace proLeln sLores
8 promoLes skln lnLegrlLy and wound heallng
arenLeral nuLrlLlon ls dellvered _____ Lhrough a cenLral or perlpheral lv caLheLer
LnLeral nuLrlLlon ls dellvered __________ Lhrough nasogasLrlc gasLrosLomy or [e[unosLomy Lube
Lncourage lmmoblllzed cllenLs Lo deep breaLhe and cough
every _____ Lo ____ hrs 1each alerL cllenLs Lo deep
breaLh _______ cough and/or use an lncenLlve _____
every hour
1 Lo 2 hours
yawn
splromeLer
unless conLralndlcaLed ensure lmmoblle cllenLs Lake ln aL
leasL _______ mL of fluld per day 2000
SLeps when reposlLlonlng a cllenL
1 Assess cllenLs comforL ablllLy llmlLaLlons resLrlcLlons eLc Lo deLermlne
besL approach/goal
2 lf paLlenL can provlde some asslsLance and ls less Lhan 200lbs use a frlcLlon
reduclng devlce and 23 careglvers (use 3+ careglvers for cllenL over 200lbs)
lf unable Lo asslsL use full body llfL and 2+ careglvers
3 evaluaLe ouLcome paLlenL comforL check devlces eLc
quesLlon answer
AccounLablllLy Lo answer for ones own acLlons
advocacy
supporL of a cause AdvocaLe for Lhe healLh and safeLy of a cllenL Also as a
healLh advocaLe you musL reporL lncompeLenL lmpalred uneLhlcal or lllegal
nurslng care
auLonomy
refers Lo a comlLmenL Lo lnclude cllenLs ln declslons abouL all aspecLs of Lhelr
care
beneflcence refers Lo Laklng poslLlve acLlons Lo help oLhers
code of eLhlcs
a seL of guldlng prlnclples LhaL all members of a professlon accepL AnA code
of eLhlcs ls 8esponslblllLy AcconLablllLy Advocacy ConfldenLlallLy
ConfldenLlallLy
proLecLlon of Lhe personal lnformaLlon LhaL Lhe healLhcare Leam has abouL a
cllenL
consequenLlallsm
a uLlllLarlan sysLem of eLhlcs LhaL values Lhlngs by Lhelr usefulness Maln
emphasls ls on consequences (seems Lo lnclude Lhe ends [usLlfy Lhe means
Lype acLlons)
deonLology
a LradlLlonal eLhlcal Lheory LhaL focuses on Lhe lnLrlnslc rlghLness or
wrongness of acLlons regardless of ouLcomes
eLhlc of care
a phllosophy LhaL focuses on undersLandlng relaLlonshlps especlally personal
narraLlves
eLhlcs
a sLudy of conducL and characLer lL ls concerned wlLh deLermlnglng whaL ls
good of valuable for lndlvlduals groups and socleLy
fldellLy Lo keep promlses
[usLlce
falrness healLhcare workers sLrlve Lo provlde falr and equlLable LreaLmenL Lo
all
nonmaleflcence a commlLmenL Lo do no harm
responslblllLy Lo malnLaln respecL for obllgaLlons and follow Lhrough on promlses
Leleology sLudy of Lhe ends or flnal causes 8elaLed Lo uLlllLarlan sysLem of eLhlcs
value a personal bellef abouL Lhe worLh of an ldea
values clarlflcaLlon
ldenLlfylng and deflnlng values 1hls may be useful when resolvlng eLhlcal
dllemas and helps Lo separaLe facLs from oplnlons
8loeLhlcs
ls Lhe sLudy of conLroverslal eLhlcs broughL abouL by advances ln blology and
medlclne
veraclLy conformlLy Lo facLs hablLual LruLhfulness
SLeps Lo resolve eLhlcal dllema
1 ldenLlfy problem as an eLhlcal dllema
2 gaLher lnformaLlon
3 clarlfy values dlsLlngulsh facL oplnlon value
4 verballze problem
3 lndenLlfy posslble courses of acLlon
6 negoLlaLe a plan
7 conLlnuously reevaluaLe plan over Llme
quesLlon answer
admlnlsLraLlve law
also called regulaLory law reflecLs Lhe rules and regulaLlons made by
admlnlsLraLlons such as sLaLe boards of nurslng
assaulL any lnLenLlonal LhreaL Lo brlng abouL harmful or offenslve conLacL
baLLery any lnLenLlonal Louchlng wlLhouL consenL Always lncludes assaulL
clvll laws
proLecL Lhe rlghLs of lndlvldual persons wlLhln our socleLy and encourage falr
and equlLable LreaLmenL uamages are Lyplcally moneLary
common law precedenLs esLabllshed by [udlclal declslons made ln courLs
crlmlnal laws prevenL harm Lo socleLy and provlde punlshmenL for crlmes
defamaLlon of characLer publlcaLlon of any false sLaLemenLs LhaL resulL ln damage Lo repuLaLlon
felony
a classlflcaLlon of crlme LhaL descrlbes crlmlnal acLlon of a serlous naLure LhaL
cane be penallzed by 1 or more years ln prlson or deaLh
lnformed consenL
a persons agreemenL Lo allow someLhlng Lo happen based on full dlsclosure
of rlsks beneflLs alLernaLlves and consequences of refusal
lnLenLlonal LorLs
wlllful acLs LhaL vlolaLe anoLhers rlghLs such as assaulL baLLery false
lmprlsonmenL
llbel ls Lhe wrlLLen defamaLlon of characLer
llvlng wllls
represenL wrlLLen documenLs LhaL dlrecL LreaLmenL ln accordance wlLh a
cllenLs wlshes
mallce
when a person publlshlng damaglng lnformaLlon knows lL Lo be false or has
reckless dlsregard for Lhe LruLh
malpracLlce
ofLen referred Lo as professlonal negllgence ln nurslng malpracLlce 3 Lhlngs
musL be Lrue
1 nurse had a duLy Lo Lhls cllenL
2 nurse dld noL carry ouL LhaL duLy
3 CllenL was ln[ured as a resulL of nurses fallure Lo carry ouL LhaL duLy
mlsdemeanor
less serlous crlme LhaL has a penalLy of a flne or lmprlsonmenL for less Lhan 1
yr
negllgence ls conducL LhaL falls below a sLandard of care
nurse racLlce AcLs descrlbe and deflne Lhe legal boundarles of nurslng pracLlce wlLhln each sLaLe
Cccurrence 8eporL
(also called lncldenL reporL) uocumenLs anyLlme any person paLlenL guesL
employee eLc ls hurL or oLher unusual negaLlve evenL LhaL may have been
due Lo devlaLlons from sLandards of care
regulaLory law
also called admlnlsLraLlve law reflecLs rules and regulaLlons puL ln place by
admlnlsLraLlve bodles such as sLaLe boards of nurslng
rlsk managemenL
a sysLem of ensurlng approprlaLe nurslng care LhaL aLLempLs Lo ldenLlfy
poLenLlal hazards and ellmlnaLe Lhem before harm occurs
slander
occurs when one verballzes a false sLaLemenL LhaL causes damage Lo a cllenLs
repuLaLlon
SLandards of care legal guldellnes LhaL esLabllsh Lhe MlnlMuM ACCL1A8LL nurslng care
sLaLuLory law
laws creaLed by elecLed leglslaLlve bodles such as sLaLe leglslaLure and uS
congress
1orL a clvll wrongdolng
AuA
Amerlcans wlLh ulsablllLles AcL a federal sLaLuLe LhaL proLecLs rlghLs of
lndlvlduals wlLh dlsablllLles (lncludlng Plv) LhroughouL uS socleLy
prlvacy
Lhe rlghL of a cllenL Lo keep lnformaLlon abouL Lhemselves from belng
dlsclosed
ln a nurslng malpracLlce sulL
Lhe nurse would be Lhe _____
and Lhe paLlenL Lhe _______
(plalnLlff or defendanL) nurse defendanL aLlenL plalnLlff
lf a nurse ls asked Lo care for
more cllenLs Lhan has been
esLabllshed by Lhe sLafflng
sLandards s/he should flle a
formal proLesL wlLh ________ nurslng admlnlsLraLlon
quesLlon answer
normal LemperaLure range for a healLhy adulL 968l 1004l (3638C)
normal LemperaLure range for a healLhy chlld/lnfanL 939l 993l (333C 373C)
normal LemperaLure for healLhy elder (70+) 968l 991l (36C 377C)
normal 24hr LemperaLure varlaLlon due Lo clrcadlan rhyLhm 09l 18l (03C Lo 1C)
8ody LemperaLure ls usually lowesL around 01000400
8ecLal Lemp ls Lyplcally ________(compared Lo oral) 09l hlgher (03C hlgher)
Axlllary Lemp ls Lyplcally _______ (compared Lo oral) 09l lower (03C lower)
1ympanlc Lemp ls Lyplcally ______ (compared Lo oral) Lhe same (986)
Low grade fever ls ______ Lo ______ 988l Lo 1006l oral (371C Lo 381C)
Pyperpyrexla hlgh fever 1038l (41C)
AuuL1 normal pulse raLe 60100 beaLs/mln
AuuL1 mosL common pulse raLe range 7280 beaLs/mln
ln addlLlon Lo pulse raLe oLher aspecLs of pulse LhaL are assesed lnclude 8hyLhm (regular/lrregular) volume/AmpllLude (descrlbed as weak Lhready no
1wo dlfferenL Lypes of pulses (relaLed Lo locaLlon) aplcal (over Lhe Ml apex of Lhe hearL) erlpheral (on llmbs)
lnlAn1 normal pulse raLe 120160 beaLs per mlnuLe
1CuuLL8 normal pulse raLe 90140 beaLs per mlnuLe
8LSCPCCLL8 normal pulse raLe 80110 beaLs per mlnuLe
LLLMLn1A8? SCPCCLACL normal pulse raLe 73100 beaLs per mlnuLe
AuCLLSCLn1 normal pulse raLe 6090 beaLs per mlnuLe
MosL common resplraLlon raLe for healLhy adulLs abouL 16
AuuL1 8esplraLory raLe 1220 breaLhs per mlnuLe (abouL 16)
newborn (06 monLhs) resplraLory raLe 3060 breaLhs per mlnuLe (abouL 43)
lnfanL (6 monLhs) resplraLory raLe 3030 breaLhs per mlnuLe (abouL 40)
1oddler (2 yrs) resplraLory raLe 2332 breaLhs per mlnuLe (abouL 29)
Chlld resplraLory raLe 2030 breaLhs per mlnuLe (abouL 23)
AdolescenL (abouL 13) resplraLory raLe 1619 breaLhs per mlnuLe (abouL 18)
Llder resplraLory raLe 1620 breaLhs per mlnuLe (abouL 18)
8efore Laklng basellne blood pressure check Lo see lf paLlenL has recenLly________eaLen smoked exerclsed lf so walL 2030 mlnuLes
8efore dolng An?1PlnC Check Lhe fucklng lu braceleL ALWA?S check Lhe braceleL (or oLher means of