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44 Cards in this Set
- Front
- Back
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What are the vital signs? |
temp pulse respiratory rate blood pressure pulse oximetry pain |
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when to assess a patient's vital signs |
baseline upon admission change in status before/after/during invasive procedure before/after admin of med that affects cardiac or respiratory before/after interventions that could affect patient |
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temperature |
balance btw heat loss and heat production |
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more sensitive to hot or cold? |
cold |
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temperature regulated by? |
hypothalamus and skin shivering |
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what factors affect temperature
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basal metabolic rate circadian rhythms environment hormones exercise stress fever age |
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hyperpyrexia |
105.8 |
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pyrexia |
100.4-105.7 |
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average |
96.8-98.6 |
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hypothermia |
93.3-96.7 |
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death |
less than 93.2 |
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what temp is harmful to patient? |
over 101.2 |
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when do you notify physical of fever? |
over 105 |
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what interventions to help pt with fever? |
tylonel (not a cold bath) monitor vital signs assess skin color or temp monitor labs remove blankets provide nutrition and fluids measure intake and output reduce activity give antipyretics oral hygiene tempted sponge bath place on cooling blankets provide dry clothing and bed linens |
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feberal |
seizures with fever |
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interventions for hypothermia |
provide warm environment provide dry clothes apply warm blankets keep limbs close to body cover person's scalp supply warm IV or PO fluids apply warming pads |
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what is pulse |
wave of blood created by left ventricle of heart |
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cardiac output |
stroke volume X HR normal is 5L/min |
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normal pulse |
60-100 |
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pulse sites |
temporal carotid apical brachial radial femoral popliteal posterior tibial dorsalis pedis |
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what factors affect a person's pulse? |
age: older lower sex: males lower exercise: increase while exercising fever: increase HR, BP down, vasodilation medications hypvolemia/dehydration: increase stress position pathology |
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PMI |
point of maximum impact: apical pulse |
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how to monitor person's pulse? |
telemetry, pulse ox, EKG |
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what are the two types of breathing? |
coastal/thoracic (chest move up and down) diaphragmatic (diaphragm, stomach moving up and down) |
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normal respiratory rate? |
8-20 per min |
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how do you assess respiration rate? |
rhythm, depth, quality |
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factors affecting respirations? |
anxiety/stress exercise sleep environment medications body position: lying down lower respiratory rate |
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pulse ox normal reading |
between 95-100 |
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factors affecting pulse ox? |
hemoglobin circulation activity carbon monoxide poisoning |
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blood pressure |
measure of pressure exerted by blood as it flows through the arteries two readings systolic (contraction), diastolic (fill, relaxation) |
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normal blood pressure |
120/80 |
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pusle pressure? |
systolic - diastolic normal is 40 |
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factors affecting blood pressure |
age: younger lower exercise stress race sex medications obesity circadian rhythms medical conditions temp |
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three classifications of high blood pressure? |
pg. 501 normal: 120/80 prehypertension 120-139/80-89 hypertension, stage 1: 140-159/90-99 hypertension, stage 2: >160/ >100 |
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orthostatic hypotentison |
blood pressure falls when patient sits or stands happens bc of peripheral vasodilation where blood leads the central organs and moves to the periphery pt feels faint |
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how to asses orthostatic? |
supine 10 mins pulse and BP sit or stand recheck pulse and BP repeat after 3 mins record results drop in BP 20 systolic or 10 diastolic = orthostatic hyoptension |
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Can UAPs take vitals |
yes but nurse must interpret if normal or abnormal |
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common errors in blood pressure? |
cuff too large (reading too low) cuff to small (reading too high) pg. 504 29-5 |
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routes of temperature assessment |
oral rectal axillary tympanic temporal artery internal temp monitoring |
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finding correct fit for cuff size |
40% of arm circumference or 20% wider than the midpoint of the limb |
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what do you do with blood pressure reading? |
document manual or automatic, extremity used, related to previous readings notify patient of result notify clinical instructor if abnormal |
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when do you not use an extremity? |
IV PICC line history of mastectomy on that side dialysis catheter in place |
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capillary blood glucose |
have to have dr. orders consider oral intake of pt normal fasting: 70-100 mg/dl |
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obtain blood glucose specimen |
choose site cleanse the site put on gloves pierce skin wipe away first drop gently squeeze until drop of blood forms cover reagent strip with blood apply pressure to skin observe result |
