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Define blood pressure (BP)
force exerted by the blood against the aterial vessel walls
What factors makeup BP?
- -Systolic (contraction)
- -Diastolic (ventricles relaxed & heart rested)
- -Pulse pressure
1st sound heard when taking BP is called?
Last sound (Karortkoff)heard when taking BP?
What factors affect BP?
- -Cardiac Output
- -Peripheral vascular resistance (BP=CO x R)
- -Elasticity and distensibility
- -Blood Volume
- -Blood Viscosity
Where is BP taken?
Upper arm closest to heart 1 inch above brachial
What type of equipment is needed to take accurate BP?
sphygmomanometer and stethoscope
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
Normal BP reading?
- < 120 and < 80
- (129/88 considered normal above that is pre hypertensive)
>140/90 and symptomatic
< 90/60 and symptomatic (light headed, pale, decreased level of consciousness)
Define pulse oximetry?
non invasive measurement of arterial blood oxygen saturation (percent which hemoglobin is filled with O2)
Normal Pulse oximetry value?
> 90% (normal SpO2 is > 90%)
What equipment needed to obtain pulse oximetry reading?
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
Purpose of monitoring blood glucose levels?
- check to see if hyper or hypoglycemic
- check parameters for treating blood glucose
Normal BS range?
Where do you obtain a BS sample from?
capillary sample (in adults the lateral side of finger)
presence or level of glucose in one's blood
abnormal low levels of blood sugar (glucose)
high blood sugar
measurment of liquids ingested or infused into body (including liquids, semi liquids, liquid meds, enteral tube feedings, IV therapy, blood components, and parenteral nutrition)
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
all liquids exerted from body
- Urinary (urinals, bed pans, caths)
- NG drainage
- Drainage tubes (wounds, CT)
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.
What is importance in taking input & output?
physical assessment d/t changes w/n pt (ie:if they are putting out more then in)
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)
If pt has fluid volume overload, how would this effect fluid volume deficit/excess?
- Deficit: wt gain
- Excess: in > out, crackles, bounding pulse, IVD
If pt had fluid volume deficit/dehydration, how would this effect deficit/excess?
- Deficit: dehydration
- Excess: out > in, decreased BP, increased pulse, fever
What makes up Vitals?
- Oxygen Saturation
Define body temp?
- difference between heat produced and heat lost
- regulated in hypothalmus of brain
Normal body temp?
36-38 C or 96.8-100.4 F
Body temp regulated by?
- Heat Production: metabolism, skeletal muscles (shiver), sympathetic stimulation(vasoconstriction)
- Heat loss: periperal vasodialation, evaporation
4 places a temp can be taken?
palpable bounding of blood flow
Normal Pulse rate?
Pulse > 100 bpm is called?
Pulse <60 bpm called?
regularity of beats
Characteristics of pulse?
Where do you find apical pulse?
4th to 5th intercostal space at left midclavicular line
- Adult: 12-20
- Tachypnea: >20
- Bradypnea: <12
- Apnea: absence
3 factors that make up respiration characteristics?
- rate: # breaths we take
- depth: degree of chest expansion
- pattern: regularity of effort
What does suffix pnea mean?
What can cause apnea?
- heart attack
- sleep apnea
What can cause tachypnea?
What can cause bradypnea?
- decreased hemoglobin
- breathing disorder (COPD)
- beat blockers
- general anesthesias
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
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
S & S on increase body temp?
- flushed skin
- dry/diaphoretic skin
S & S of low temp?
- feel cold/cold to touch
- decreased pulse
- shallow respiration
- decreased level of consciousness
RN intervention for elevated temp?
- keep linens dry
- cool enviro
- administer antipyretics
- increase fluids
- good nutrition
RN interventions for low body temp?
- heat enviro
- cover with warm blankets
- drink warm fluids
- remove wet clothes