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20 Cards in this Set
- Front
- Back
Vital Signs
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BP, Pulse, Temp, Respiration, Pain, O2Sat
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Normal BP Range
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Systolic: 110-119mmHg, Diastolic: 60-80mmHg
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Normal Pulse
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Adults: 60-100
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Normal Temp
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Traditionally: 98.6degF, Current research: oral norm 97.3degF
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Normal Respiration
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12-20 breaths per min
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Factors that influence BT
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Developmental level,environment, sex, exercise, emotions, stress, circadian rhythm
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Types of Fever
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Intermittent, Remittent, Constant, Relapsing (recurrent)
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Interventions for Hyperthermia
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focused assessments: determine cause, monitor, observe symptoms (decreased urine output, unusual thirst, nausea, etc), collaborative care, oral or intravenous fluids, cooling blankets, tepid baths, cloth covered ice packs, minimal bed covers, nutritional support, special oral care (lip lubricant), keep clothing dry, emergency treatment prn, advise to stay cool.
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Hypothermia
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core temp below 95 deg F
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Severe Hypothermia
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core temp below 82.4 deg F
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Interventions for Hypothermia
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provide warm, dry clothing, warm drinks, blankets, warm environment (for mild hypothermia), Severe cases (BT below 86 degF): warm IV fluids, heating pads, heating blankets, warm sweet drinks, don't use electric blankets on vasoconstricted skin (burns easy) or pulse ox to vasoconstricted finger (false readings).
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Factors that influence pulse rate
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developmental level (newborns rapid), sex (F higher), exercise, food (increase), stress, fever (increase), disease, blood loss, position change, medications (epinephrine increase, difitalis, opoids, sedatives, decrease)
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pulse rates
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normal, tachycardia (>100BPM), bradycardia (<60BPM)
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pulse rhythm
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dysrhythmia (regularly irregular, irregularly irregular)
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pulse quality
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0 (absent), 1 (weak), 2 (Normal), 3 (bounding); Bilateral equality.
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Factors of Respiration
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developmental level, exercise, pain, stress, smoking, fever, hemoglobin, disease, medications, position
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Respiratory rhythm
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regular, irregular
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Hypertension
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systolic: >140, diastolic >90
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factors that influence BP
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family history, age, race, obesity, diet, alcohol consumption, smoking, hight cholesterol, stress
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Interventions for Hypertension
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monitor VS, Patient's activity tolerance, accurately measure intake and output, Weight the client regularly, collect and ***** lab data as ordered, administer antihypertensive meds as prescribed, teach self monitoring of BP and stress management, relaxation techniques.
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