N260-Chapter 7

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N260-Chapter 7
2012-10-11 02:56:37
260 chap7 nurs260

Chapter 7 General Survey and Vital Signs
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  1. Explain how to prepare the client for a survey of general health status.
    Systematic examination and recording of general characteristics and impressions of the client. Observe any significant abnormalities, explain what you will be doing. Then go into Vitals: Temperature, Pulse, Respiration, Blood Pressure & Pain
  2. Identify and explain how to use the equipment needed to obtain vital signs and temperature.
    Temp- use an electronic thermometer with a disposable protective probe cover. Then place the thermometer under the client's tongue, Ask the client to close his or her lips around the probe. Hold the probe until you hear a beep. Remove the probe and dispose of its cover by pressing the release button.

    • Oral temperature is 96.0F to 99.9F
    • The axillary temperature is (1F) lower than the oral temperature.

    The rectal temperature is between (0.7F and 1F) higher than the normal oral temperature.

    The tympanic membrane temperature is about (1.4F) higher than the normal oral temperature.
  3. Discuss how to obtain accurate measurement of the radial and apical pulses.
    • radial pulse- Use the pads of your two middle fingers and lightly palpate the radial artery on the lateral aspect of the client's wrist and count for 30 seconds, them multiply by 2
    • apical-  is your heart rate when counted with a stethoscope  placed over your heart. A watch with a second hand will be needed to take your apical pulse. 

    • WNL is 10-20 breaths per minute
    • Check for regular beats or irregular beats
    • < 60 is called bradycardia
    • > 100 is called tachycardia
    • Heart rate slowly decreases with age, due to changes in the heart muscle as it ages. Therefore, the resting heart rate of the elderly will usually be slower than that of a younger adult.
  4. Obtain an accurate respiratory rate, and describe expected changes that may be apparent in the assessment of an older client's pulse, respiratory rate, and blood pressure.
    • After taking pulse, count respirations without saying what you are doing, Observe the client's chest rise and fall with each
    • breath. Count respirations for 30 seconds and multiply by 2the WNL is 10-20 breaths per minute
    • Fewer than 12 breaths/min or more than 20 breaths/min are abnormal.

    In the older adult, the respiratory rate may range from 15 to 22. The rate may increase with a shallower phase because vital capacity and inspiratory reserve volume decrease with aging.
  5. Obtain an accurate measurement of blood pressure, and discuss the parameters for blood pressure
    • Measure on dominant arm first.
    • Normal <120/80
    • Prehypertension 120-139 /80-89
    • Stage 1 hypertension 140-159 /90-99
    • Stage 2 hypertension >160/ >100

    More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults (top number).