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What type of lighting do you use for darkly pigmented person
natural or halogen light (prevents blue tones)
components of vital signs
T, P, R, BP and pulse oximeter
What is the normal adult range for temperature
- 36-38 C or 96.8-100.4 F
- ALWAYS CONSIDER BASELINE
Name 6 factors affecting temperature
Age, Hormonal levels, circadian rhythms, stress, exercise, environment
What time of the day do we normally have the lowest temp?
What time of the day do we normally have our highest temp?
Explain Pyrexia or Hyperpyrexia
An elevation of normal temperature, fever, common symptom of illness, helps fight disease
Explain Prodromal stage of a fever
First stage- pyrogens are secreted by toxic bacteria during infection or form tissue breakdown (heart attack, trauma, surgery, malignanc) and trigger an immune response (fatigue, aches, malaise)
Explain the chill stage of a fever
2nd stage- while the body is trying to reach a new set point, the person has chills, shivers and feels cold
Explain the flush stage of a fever
3rd stage- once the new set point is reached, the person feels warm and dry
Explain the defervescence stage of a fever
4th stage- when the set point is interfered with , person becomes warm, flushed, diaphoretic, and fever "breaks" and person is afebrile....stage when we give antipyretics
How often should a temperatue be evaluated
every 2-3 hours, and not more then 1 hour after treatment
??Increased body temp, body is unable to promote heat loss or decrease heat production due to overload of body's hypothalamus, can cause heat exhaustion (fluid loss with changes in fluid and electrolyte balances) and heat stroke
What are 8 signs of hyperthermia??
lowered skin turgor, skin cool and moist, increased pulse, decreased BP, Increased resp., decreased capillary refill, concentrated urine, Temp = 104
??Body temperature below lower limit of normal, 36 C or 96.8 F...
At what temp could death occur??
93.2 F or 34 C
When might Hypothermia be induced?
Open heart surgery
What are signs of hypothermia??
Decreased pulse, resps, BP, cyanosis, skin cool or cold, uncontrolled shivering, memory loss, poor judgement, apathy, slurred speech, confusion, increased BP and shallow resp.
What is the INITIAL trmt. of hypothermia
Keep in horizontal posititon to decrease cardiac workload, prevent further heat loss, remove wet or cold clothing, dry client, insulate with warm blankets including head and neck monitoring vital signs
What is the average pulse rate in an adult?
What is Stroke Volume??
Quantity of blood forced out of the left ventricle into aorta with each contraction
What is the average stroke volume in an adult?
60-70 ml per contraction
What is cardiac output??
Amount of blood pumped out by the heart per minute
What is normal cardiac output for an adult?
5000 ml per minute
How do you figure cardiac output??
pulse rate x stroke volume
What are 8 factors that influence pulse rate??
age, exercise, postition changes, gender, fluid balance, meds, temp and sympathetic stimulation
What is a normal pulse rate for a neonate?
What is a normal pulse rate for a toddler?
What is a normal pulse rate for a child??
How is bradycardia classified??
less then 60 BPM, can be an indication of too much or not enough medication, less common in illness than increased pulse
How is tachycardia classified??
greater then 100 BPM in an adult, greater then 180 BPM in an infant.
Rapid or unusual heart rate felt by client
Name stages of scale rating for pulse
- 0- absent pulse, no pulse felt despite extreme pressure
- +1- thready pulse, not easily felt; requires very light pressure to disappear
- +2- normal, easily felt; moderate pressure causes to disappear
- +3- Full pulse
- +4- strong, bounding, doesnt disappear with moderate pressure
What should you document about pulse??
Rate, indication of irregularity, amplitude for radial and apical, prescence for all others
What are normal resp. rate for an adult??
12-20 per minute
What are normal resp. for infant? toddler? children?
- infant- 40
- toddler- 30
- child- 20
What is eupnea
Relaxed, normal, regular, automatic and silent respirations
rapid, regular resp. greater then 20 RPM
SLOW, regular resperations less then 12 RPM
Difficult or labored breathing
easier breathing when sitting up
Abnormally prolonged deep breathing; due to fear, anxiety; causes DECREASED CO2 levels
Irregular shallow, slow breathing; narcotic overdose, anesthetics, resp. pain; causes INCREASED CO2 levels
Define Kussmaul's resp.
RAPID, abnormally deep regular "air hunger" breathing....DIABETICS can have
Define Cheyne-Stokes resp
irregualr, slow, shallow breaths increase to rapid rate and depth (30-45 sec) then reverse followed by abscence of breahting (20 sec); CHF, drug overdose, increased intacranial pressure, may be normal in infants and elderly during sleep
What should you document for Respirations??
Rate and regularity, depth if abnormal, SOB/dyspnea,
Define Blood Pressure
The force of the blood pushing against the sides of the arterial walls as the heart contracts and relaxes
IF BP = 120/80.....what is SV??
When is BP normally the highest??
In the late p.m.
Name the 3 stages of hypertension
- Pre- systolic 120-139, diastolic 80-90
- stage 1- systolic 140-159, diastolic 90-99
- stage 2- systolic 160 or greater, diastolic 100 or greater
blood pressure below normal
low blood pressure associated with weakness or fainting when rising to an erect position
What is the most common site for assessing BP?
If you cannot take Brachial BP, what is the next place to check for BP?
What are the 5 different phases of Korotkoff sounds in BP??
- 1- faint, first sound; tapping that increases in intensity...systolic
- 2- muffled, swishing that may temporarily disappear especially in hypertensive clients
- 3- distinct loud sounds, blood flows freely
- 4- muffled; soft blowing sounds; distinct change in quality; diastolic in children
- 5- last sound before silence; diastolic in adults
Define Ausculatory Gap
The temporary disappearance of sound
Between what "Korotkoff Phases" is ausculatory gap usually noticed?
Between first and second phase
What steps do you take for increased BP?
repeat, verify cuff size, assess in other arm, compare with previous readings, may need to give medications, notify RN/charge nurse
What steps do you take if BP is decreased??
Compare to previous readings, position in supine position, observe for related symptoms; administer meds, notify physician, notify RN/charge nurse
What is the 5th vital sign??
What does acronym "PQRST" stand for??
- P- Precipitated
- Q- quantitiy or quality
- R- region or radiation
- S- severity
- T- timing
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