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54 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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Stages of Fever
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Febrile episode, course, defervescence or febrile crisis)
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Types of Fever
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Intermittent, Remittent, Constant, Relapsing (recurrent)
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Symptoms of heat exhaustion
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Elevated core temp (98.6 to 103 deg F) weakness, nausea, vomitting, syncope, tachycardia, tachypnea, muscle aches, headache, diaphoresis (heavy), flushed skin.
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symptoms of heat stroke
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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
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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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early signs of Hypothermia
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shivering, cyanosis of lips and fingers, poor coordination, mental impairment, confusion, disorientation, slowing of the HR and Resp
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Symptoms of severe Hypothermia
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loss of consciousness, cessation of shivering thermogenesis, irregular and difficult to detect pulse and respirations, death usually occurs when BT falls below 70degF
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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 depth
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deep, normal, shallow
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Tidal Volume
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typically 300 to 500 mL
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Respiratory rhythm
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regular, irregular
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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
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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
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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 depth
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deep, normal, shallow
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Tidal Volume
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typically 300 to 500 mL
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Respiratory rhythm
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regular, irregular
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Prehypertension
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Systolic: 120-139, Diastolic: 80-89
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Hypertension
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systolic: >140, diastolic >90
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Primary Hypertension
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no known cause, accounts for 90% of known cases
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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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secondary Hypertension
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clearly identified cause (medications, drugs, alcohol use)
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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 asses lab data as ordered, administer antihypertensive meds as prescribed, teach self monitoring of BP and stress management, relaxation techniques.
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