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39 Cards in this Set
- Front
- Back
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Pulse
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wave of blood created by contraction of the left ventricle of the heart
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Procedure for taking a Pulse
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1) -Determine if the client has taken meds that affect the HR? if client has been physically active wait 15 minutes for HR to return to normal. does baseline data exist for the client? should the client assume a particular position (ex orthostatic BP)?
2. Pulse is normally palpated by applying moderate pressure w/ 3 middle fingers 3. collect the following data: rate, rhythm, volume, arterial wall elasticity, presence of bilateral equality. |
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normal BP for an adult
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120/80
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cut off for hypertension
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140/90
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Order to take vitals in adult
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T P R BP
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order to take vitals in child
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R P(apical) T BP
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Factors that affect BP (9)
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1. age (systolic incr newborn-puberty, decr slightly after puberty, older people have elevated systolic & diastolic pressure due to decr vein elesticity)
2. exercise (incr cardiac output) 3. stress 4. race (african american males have higher BP than white) 5. obesity (overweight generally have higher BP) 6. sex (hormonal changes) 7. medications 8. diurnal variations (lowest in am when metabolic rate is lowest, incr throughout day peaking late afternoon early evening) 9. Disease processes |
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Factors that affect Respiratory Rate (7)
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1. Exercise: Incr metabolism (Incr RR)
2. Stress: readies for fight or flight (Incr RR) 3. Environment: Incr Temp (Incr RR) 4. Environment: Decr Temp (Decr RR) 5. Incr Altitude: lower 02 conc. (Incr RR) 6. certain meds ex. narcotics, analgesics (Decr RR) 7. Incr Intracranial Pressure (Decr RR) |
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Factors that affect HR (8)
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1. Age (as age decr HR gradually Decr)
2. Sex (male slightly lower than female) 3. Exercise (HR incr w/ activity) 4. Fever (HR incr in response to lowered BP resulting from peripheral vasodialation associated w/ elevated temp & b/c of incr MBR) 5. Medications (some incr, some decr) 6. hemorrhage (loss of blood incr HR due to lack of blood volume) 7. Stress (incr) 8. Position changes |
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Factors that affect body temp (6)
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1. Age
2. Diurnal Variations 3. exercise 4. hormones 5. stress 6. environment |
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Scale for Measuring Pulse Volume
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0- absent, not discernable
1- thready or weak; difficult to feel 2- normal, detected readily, obliterated by strong pressure 3- Bounding, difficult to obliterate |
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Areas of the body that control respiration
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1) respiratory centers in the medulla oblongota and pons in the brain.
2) chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies |
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Symptoms of Hypothermia
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1. decr body temp, pulse, & respirations.
2. severe shivering (initially) 3. feelings of cold and chills 4. pale, cool, waxy skin. 5. hypotension 6. decr urinary output 7. lack of muscle coordination 8. disorientation 9. drowsiness progressing to coma |
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symptoms of hyperthermia (fever)
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Onset (cold or chill stage)
- incr HR - pallid, cold skin - shivering - incr resp rate and depth - complaints of feeling cold - cyanotic nail beds - "gooseflesh" appearance of skin - cessation of sweating Course - absence of chill - skin that feels warm - photosensitivity - glassy eyed appearance - incr pulse and resp rates - incr thirst Mild to severe dehydration - drowsiness, restlessness, delirium, or convulsions - herpetic lesions in mouth - loss of appetite (if fever is prolonged) - malaise, weakness, and aching muscles. Defervescence (fever abatement) - skin that appears flushed and feels warm - sweating - decr shivering - possible dehydration |
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when to avoid taking BP on arm
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b/c of trauma (ex. burns)
BP in one thigh is supposed to be compared to the other. |
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BP not measured in arm or thigh when:
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-the shoulder, arm, or hand (or hip, knee or ankle) is injured or deceased.
-A cast or bulky bandage is on any part of the limb. -the client has has removal of axillary (or hip) lymph nodes on that side -the client has an IV in that limb -client has an arteriovenous fistula (ex, for renal dialysis) in that limb. |
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Age group respiratory irregularity is most likely
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Infant
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Pulse pressure
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Difference between systolic and diastolic pressures.
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orthopenic position
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high fowlers with bedside table in front and client resting head on pillows above table.
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when is orthopenic position used?
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for clients with COPD (allows maximum chest expansion & eases breathing)
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orthostatic hypotension
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sudden decrease in central BP when position changes (BP that falls when the client sits or stands)
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how to take an orthostatic BP
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1. place client in supine position for 2-3 minutes
2. record clients pulse and BP 3. assist client to sit or stand slowly 4. after 1 minute in upright position, recheck BP and pulse in the same sites. |
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Systolic Pressure
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pressure of the blood as a result of the contraction of the ventricles. (pressure of the height of the blood wave.
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Diastolic Pressure
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Pressure when the ventricles are at rest, the lower pressure that is present at all times w/ in the arteries.
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phantom pain
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A painful sensation perceived in a body part that is missing
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acute pain
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pain that lasts only through the expected recovery period.
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chronic pain
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pain that lasts beyond the typical healing period
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referred pain
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pain felt in a part of the body that is considerably removed from the tissues causing the pain
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ausculatory gap
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temporary disappearance of sounds normally heard over the brachial artery when cuff pressure is high followed by the reappearance of sounds at a lower level.
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what to do about an ausculaltory gap when taking a BP
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palpate the pulsations, systolic pressure is when the first pulsation is felt. a single whip like vibration, felt in addition to the pulsations, determines the diastolic pressure.
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Common side affects of opiod pain meds (morphine and codeine)
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drowsiness when 1st administered
nausea, vomiting, constipation (most common) respiratory depression |
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effect of immobility on the musculoskeletal system
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DISUSE OSTEPOOROSIS
bones become spongy and deformed DISUSE ATROPHY muscles decr in size CONTRACTURES permanent shortening of muscle JOINT PAIN AND STIFFNESS connective tissues become permanently immobile & calcium may deposit in joints |
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effects of immobility on the cardiovascular system
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- diminished cardiac reserve
- orthostatic hypotension -venous vasodialatioon & stasis -dependent edema -thrombophlebitis and emboli |
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effects of immobility on teh respiratory system
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-decr respiratory movement
-pooling of respiratory secretions -atelectasis (collaspe of lobe or entire lung) -hypostatic pneumonia |
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Effects of immobility on the metabolic system
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-anorexia
-negative calcium balance |
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effects of immobility on the urinary system
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-urinary stasis
-renal calculi -urinary retention |
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effects of immobility on the gasterointestinal system
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-decreased peristalsis and colon motility
- decr strenght of abdominal and perineal muscles both cause constipation |
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effects of immobility on the integumentary system
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-reduced skin turger (elasticity_
-skin break down |
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pulse locations (9)
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temporal
carotid apical brachial radial femoral polpliteal posterior fibial dorsalis pedis |
