NRS 122

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Author:
marisol_martinez2
ID:
128645
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NRS 122
Updated:
2012-01-18 03:19:59
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RN Theory wk
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RN theory wk 1
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  1. Define blood pressure (BP)
    force exerted by the blood against the aterial vessel walls
  2. What factors makeup BP?
    • -Systolic (contraction)
    • -Diastolic (ventricles relaxed & heart rested)
    • -Pulse pressure
  3. 1st sound heard when taking BP is called?
    Systolic
  4. Last sound (Karortkoff)heard when taking BP?
    Diastolic
  5. What factors affect BP?
    • -Cardiac Output
    • -Peripheral vascular resistance (BP=CO x R)
    • -Elasticity and distensibility
    • -Blood Volume
    • -Blood Viscosity
  6. Where is BP taken?
    Upper arm closest to heart 1 inch above brachial
  7. What type of equipment is needed to take accurate BP?
    sphygmomanometer and stethoscope
  8. What factors can cause an inaccurate BP reading?
    • -Bladder or cuff too wide, narrow, or short
    • -Cuff wrapped loosely or unevenly
    • -Deflatting cuff too slowly or quickly
    • -Arm below or above heart level
    • -Arm not supported
  9. Normal BP reading?
    • < 120 and < 80
    • (129/88 considered normal above that is pre hypertensive)
  10. Define hypertension?
    >140/90 and symptomatic
  11. Define hypotension?
    < 90/60 and symptomatic (light headed, pale, decreased level of consciousness)
  12. Define pulse oximetry?
    non invasive measurement of arterial blood oxygen saturation (percent which hemoglobin is filled with O2)
  13. Normal Pulse oximetry value?
    > 90% (normal SpO2 is > 90%)
  14. What equipment needed to obtain pulse oximetry reading?
    Pulse oximeter
  15. Factors that give you a false pulse oximetry reading?
    • -direct sunlight
    • -carbon monoxide poisoning
    • -IV dyes
    • -conditions that decrease blood flow (hypothermia, edema, hypotension)
    • -artificial nails & certain nail colors
  16. Purpose of monitoring blood glucose levels?
    • check to see if hyper or hypoglycemic
    • check parameters for treating blood glucose
  17. Normal BS range?
    70-110 mg/dl
  18. Where do you obtain a BS sample from?
    capillary sample (in adults the lateral side of finger)
  19. Define glycemia?
    presence or level of glucose in one's blood
  20. Define hypoglycemia?
    abnormal low levels of blood sugar (glucose)
  21. Define hyperglycemia?
    high blood sugar
  22. Define intake?
    measurment of liquids ingested or infused into body (including liquids, semi liquids, liquid meds, enteral tube feedings, IV therapy, blood components, and parenteral nutrition)
  23. Examples of intake?
    • oral fluids (@ rm temp)
    • ice chips (measured at 50% of measured volume)
    • IV fluids & TPN
    • Blood products
    • Tube feedings
    • Fluid Meds (oral or IV)
    • Irrigation fluids
  24. Define output?
    all liquids exerted from body
  25. Output examples?
    • Urinary (urinals, bed pans, caths)
    • NG drainage
    • Drainage tubes (wounds, CT)
    • diarrhea/stools
    • stomies
    • osmosis
  26. How do you measure intake and output?
    chest tube, amt in oral/IV fluid, urine output, emesis/puking, diarrhea, wound drainage. When indicated you total the value and evaluate the I & O at the end of each shift at specified time,s usually 8 hrs.
  27. What is importance in taking input & output?
    physical assessment d/t changes w/n pt (ie:if they are putting out more then in)
  28. Define components of fluid balance?
    • Fluid Volume Deficit: output greater then intake, < BP, > pulse, fever, flat neck veins when supine, slow venous filling of hands, rapid wt loss, dry skin, and tenting.
    • Fluid Volume Excess: intake greater then output, crackle (pulmonary edema), bound pulse, irregular venous distention (IVD)
  29. If pt has fluid volume overload, how would this effect fluid volume deficit/excess?
    • Deficit: wt gain
    • Excess: in > out, crackles, bounding pulse, IVD
  30. If pt had fluid volume deficit/dehydration, how would this effect deficit/excess?
    • Deficit: dehydration
    • Excess: out > in, decreased BP, increased pulse, fever
  31. What makes up Vitals?
    • Temp
    • Pulse
    • BP
    • Oxygen Saturation
    • Respiration
    • Pain
  32. Define body temp?
    • difference between heat produced and heat lost
    • regulated in hypothalmus of brain
  33. Normal body temp?
    36-38 C or 96.8-100.4 F
  34. Body temp regulated by?
    • Heat Production: metabolism, skeletal muscles (shiver), sympathetic stimulation(vasoconstriction)
    • Heat loss: periperal vasodialation, evaporation
  35. 4 places a temp can be taken?
    • oral
    • rectal
    • tympanic
    • axillary
  36. Define pulse?
    palpable bounding of blood flow
  37. Normal Pulse rate?
    60-100 bpm
  38. Pulse > 100 bpm is called?
    tachycardia
  39. Pulse <60 bpm called?
    bradycardia
  40. Define rhythm?
    regularity of beats
  41. Characteristics of pulse?
    • rate
    • rhythm
    • quality
    • symmetry
  42. Where do you find apical pulse?
    4th to 5th intercostal space at left midclavicular line
  43. Normal RR?
    • Adult: 12-20
    • Tachypnea: >20
    • Bradypnea: <12
    • Apnea: absence
  44. 3 factors that make up respiration characteristics?
    • rate: # breaths we take
    • depth: degree of chest expansion
    • pattern: regularity of effort
  45. What does suffix pnea mean?
    breathing
  46. What can cause apnea?
    • death
    • heart attack
    • trauma
    • chocking
    • sleep apnea
    • COPD
  47. What can cause tachypnea?
    • hyperventillation
    • exercise
    • smoking
    • caffeine
    • amphetamines
    • fever
    • pain
  48. What can cause bradypnea?
    • decreased hemoglobin
    • breathing disorder (COPD)
    • barbituates
    • beat blockers
    • narcotics
    • general anesthesias
  49. What is importance of taking a vital?
    • Can show signs of sudden change in pt condition
    • Indicates normal functioning of circulatory, pulmonary, neurological, and endocrinological systems
  50. When do you take vitals?
    • pt admit to facility
    • per MD order
    • home care visits
    • before/ after surgery, invasive procedures, admin of certain meds, or nursing interventions
    • change in pt condition or pt reports distress
  51. S & S on increase body temp?
    • tachycardia
    • hypotension
    • flushed skin
    • shiver/chills
    • dry/diaphoretic skin
  52. S & S of low temp?
    • feel cold/cold to touch
    • pale
    • shivery
    • decreased pulse
    • shallow respiration
    • decreased level of consciousness
  53. RN intervention for elevated temp?
    • keep linens dry
    • cool enviro
    • administer antipyretics
    • increase fluids
    • good nutrition
  54. RN interventions for low body temp?
    • heat enviro
    • cover with warm blankets
    • drink warm fluids
    • remove wet clothes

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