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54 Cards in this Set

  • Front
  • Back
Vital Signs
BP, Pulse, Temp, Respiration, Pain, O2Sat
Normal BP Range
Systolic: 110-119mmHg, Diastolic: 60-80mmHg
Normal Pulse
Adults: 60-100
Normal Temp
Traditionally: 98.6degF, Current research: oral norm 97.3degF
Normal Respiration
12-20 breaths per min
Factors that influence BT
Developmental level,environment, sex, exercise, emotions, stress, circadian rhythm
Stages of Fever
Febrile episode, course, defervescence or febrile crisis)
Types of Fever
Intermittent, Remittent, Constant, Relapsing (recurrent)
Symptoms of heat exhaustion
Elevated core temp (98.6 to 103 deg F) weakness, nausea, vomitting, syncope, tachycardia, tachypnea, muscle aches, headache, diaphoresis (heavy), flushed skin.
symptoms of heat stroke
core temp above 103degF, rapid, strong pulse, throbbing headache, delirium, confusion, impaired judgement, red hot dry skin, dizzineess, seizure, eventually coma and without treatment: death
Interventions for Hyperthermia
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.
Hypothermia
core temp below 95 deg F
early signs of Hypothermia
shivering, cyanosis of lips and fingers, poor coordination, mental impairment, confusion, disorientation, slowing of the HR and Resp
Symptoms of severe Hypothermia
loss of consciousness, cessation of shivering thermogenesis, irregular and difficult to detect pulse and respirations, death usually occurs when BT falls below 70degF
Severe Hypothermia
core temp below 82.4 deg F
Interventions for Hypothermia
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).
Factors that influence pulse rate
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)
pulse rates
normal, tachycardia (>100BPM), bradycardia (<60BPM)
pulse rhythm
dysrhythmia (regularly irregular, irregularly irregular)
pulse quality
0 (absent), 1 (weak), 2 (Normal), 3 (bounding); Bilateral equality.
Factors of Respiration
developmental level, exercise, pain, stress, smoking, fever, hemoglobin, disease, medications, position
Respiratory depth
deep, normal, shallow
Tidal Volume
typically 300 to 500 mL
Respiratory rhythm
regular, irregular
Vital Signs
BP, Pulse, Temp, Respiration, Pain, O2Sat
Normal BP Range
Systolic: 110-119mmHg, Diastolic: 60-80mmHg
Normal Pulse
Adults: 60-100
Normal Temp
Traditionally: 98.6degF, Current research: oral norm 97.3degF
Normal Respiration
12-20 breaths per min
Factors that influence BT
Developmental level,environment, sex, exercise, emotions, stress, circadian rhythm
Stages of Fever
Febrile episode, course, defervescence or febrile crisis)
Types of Fever
Intermittent, Remittent, Constant, Relapsing (recurrent)
Symptoms of heat exhaustion
Elevated core temp (98.6 to 103 deg F) weakness, nausea, vomitting, syncope, tachycardia, tachypnea, muscle aches, headache, diaphoresis (heavy), flushed skin.
symptoms of heat stroke
core temp above 103degF, rapid, strong pulse, throbbing headache, delirium, confusion, impaired judgement, red hot dry skin, dizzineess, seizure, eventually coma and without treatment: death
Interventions for Hyperthermia
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.
Hypothermia
core temp below 95 deg F
early signs of Hypothermia
shivering, cyanosis of lips and fingers, poor coordination, mental impairment, confusion, disorientation, slowing of the HR and Resp
Symptoms of severe Hypothermia
loss of consciousness, cessation of shivering thermogenesis, irregular and difficult to detect pulse and respirations, death usually occurs when BT falls below 70degF
Severe Hypothermia
core temp below 82.4 deg F
Interventions for Hypothermia
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).
Factors that influence pulse rate
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)
pulse rates
normal, tachycardia (>100BPM), bradycardia (<60BPM)
pulse rhythm
dysrhythmia (regularly irregular, irregularly irregular)
pulse quality
0 (absent), 1 (weak), 2 (Normal), 3 (bounding); Bilateral equality.
Factors of Respiration
developmental level, exercise, pain, stress, smoking, fever, hemoglobin, disease, medications, position
Respiratory depth
deep, normal, shallow
Tidal Volume
typically 300 to 500 mL
Respiratory rhythm
regular, irregular
Prehypertension
Systolic: 120-139, Diastolic: 80-89
Hypertension
systolic: >140, diastolic >90
Primary Hypertension
no known cause, accounts for 90% of known cases
factors that influence BP
family history, age, race, obesity, diet, alcohol consumption, smoking, hight cholesterol, stress
secondary Hypertension
clearly identified cause (medications, drugs, alcohol use)
Interventions for Hypertension
monitor VS, Patient's activity tolerance, accurately measure intake and output, Weight the client regularly, collect and asses lab data as ordered, administer antihypertensive meds as prescribed, teach self monitoring of BP and stress management, relaxation techniques.