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Name the 5 Vital signs
- Temp
- Pulse
- Respiration
- Blood Pressure
- Pain
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What do vital sign provide
A good baseline of a patients overall condition and clues to changes in conditions
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What should be known as part of the assessment process
Age variable normal values and physiologic regulators
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When should vital signs be assessed
- Admission
- Change in Symptoms, AMS, and LOC
- Surgery, Procedures, Therapy and Treatment
- Certain Medications
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Why are vital signs assessed
To establish a baseline
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This is a by product of normal body metabolism
Heat
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What happens if a body is invaded by pathogens
The body raises the temperature to elevate the basal metabolic rate in a effort to destroy pathogens
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When is body temperature the lowest/highest
- Lowest in the morning bc the body has been at rest
- Highest in afternoon/evening bc activity increases temperature
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What hormone affects body heat production
Thyroid
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Cause of increased thyroid hormone
Causes a increase in metabolic rate and increased temp.
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Causes of decreased levels of thyroid hormone
Decrease in metabolic rate and decreases body temp
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Name other hormones that affect body heat production
- Epinephrine
- Norepinephrine
- Testosterone
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Name ways to increase heat production
- Shivering
- Huddled body position
- Piloerection (goosebumps)
- Placing something on head holds heat in
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What percentage of body heat is lost through the head
70%
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What does the hypothalamus do
Acts as a thermostat to control body temp
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What happens when you have a decrease in body temp
Peripheral vasoconstriction and shivering
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What happens in an increase in body temp
Vasodilatation and diaphoresis (sweating)
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Name the way heat loss occurs with exposure to the enviroment
- Radiation
- Conduction
- Convection
- Evaporation
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Temp is above the normal range, called a fever or pyrexia
Hyperthermia
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Lowering of the temp of the entire body
Hypothermia
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Name the problems of temp regulation
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97.5 to 99.5
Normal body temp
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Temp measurements vary depending on
Site used
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Differences in rectal and axillary temp than oral
- Rectal 1 degree higher
- Axillary 1 degree lower
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This measurement approximates core body temps
Tympanic
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Steps for taking oral temps
- Nothing to eat or drink 20 mins prior
- Place cover over tip (remove cover before reading a glass thermometer
- Place tip of thermometer in sublingual pocket (under tongue)
- Tongue down, mouth and lips closed
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Steps for rectal temp
- Provide privacy
- Use gloves
- Cover thermometer
- Lubricate tip
- Insert 1 to 2 inches, do not force
- Hold in place 3-5 min
- Wipe thermometer from stem to bulb
- Wipe off buttocks
- Correctly dispose of hazard materials
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Contraindications of use of rectal temp
- Combative patients
- Hemorrhage
- Diseases or surgery of rectum or colon
- (Cancer, diarrhea, cardiac disease)
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Steps for axillary temp
- Place thermometer w/sleeve in center of armpit
- Patient holds arm tightly against chest
- Hold for 3-8 mins or until signals complete
- Remove and dispose of sleeve, wipe clean
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Name the types of thermometers
- Glass
- Electronic
- Disposable
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Rarely used anymore, and cannot be used in inconscious, confused, or agitated patients
Glass Themometer
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Name the types of electronic thermometers
- Tympanic- ear
- Temporal- non invasive, good for kids and combative patients
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What substance is used in glass thermometers now
Galinstan
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How to read a glass thermometer
- Hold horizontally
- Rotate towards you until you can see alloy
- End of the alloy on lined scale is the temp
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Long lines on glass thermometer represent and short lines represent
- Each degree
- Two tenths of a degree
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These register body temp in 5 seconds to 1 min
Electronic thermometer
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What makes a tympanic thermometer less accurate
- User error
- Because it must be placed correctly in the ear canal to get a accurate reading
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How to use a tympanic thermometer in a child under 3
In an child older than 3/adult
When do you not use a tympanic
- Under 3- pull ear up and back
- 3 and up- pull ear down and back
- Ear infection, drainage, wax buildup
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Provide the least accurate readings of temps
Disposable Thermometer
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Factors that affect temp measurements
- Time of day (circadian rhythm)
- Environmental temp
- Age of patient- temp decreases with age
- Physical exercise
- Menstrual cycle/pregnancy
- Emotional stress
- Disease conditions
- Drugs
- Eating, drinking, breathing
- Mental status
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Fever is also called
pyrexia
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Pyrexia occurs
when normal regulation mechanisms cannot keep up with heat produced by the body
Temp is higher than 100.2
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Diaphoresis
Excessive sweating produced to cool the body
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Name the alterations in temps
- Afebrile-Normal
- Sustained-Stays above 100.2
- Remittent-Fluctuates above normal
- Intermittent-Fluctuates btween normal/above
- Relapsing-times w/out temp, then returns
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Alterations in body temp
- Heat Exhaustion
- Heat Stroke
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Describe Heat Exhaustion
Signs and Symptoms
Excessive heat exposure & dehydration
- pale, dizzy, weak, low grade temp (<102)
- dehydration, fainting, some sweating
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Signs and Symptoms of Heat Stroke
- Medical ER- call 911
- Flushed warm skin, no sweat, high temp of 106, seizures, signs of stroke (weakness in one side)
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Clinical signs of fever
- Prodromal
- Onset
- Stationary
- Resolution
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The phase of fever that has aches and lethargy
Prodromal
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The phase of fever that has shivers, pale, vital sign changes
Onset
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The phase of fever that feels hot, flushed skin, glassy eyed, thirst, loss of appetite
Stationary
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The phase of fever where sweating occurs and risk of dehydration
Resolution
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Signs of dehydration
sticky, dry mucous membranes, no sweating, decrease urine output, tenting of skin
Check the elderly for dehydration on the sterum
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Nursing interventions to reduce fever
- increase fluid intake
- lower room temps
- increase air circulation
- remove extra clothes or covers
- decrease activity
- antipyretics (acetaminophen)
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Body temps lower than 94 F
hypothermia
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At risk for hypothermia
- infants
- patients in OR
- Elderly exposed to cold for long periods
- People exposed to extreme cold (hikers)
- Exposure to cold water immersion
- Confused Patient
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Causes of hypothermia
- Excessive heat loss
- Inadequate heat production
- Impaired control mechanism
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Signs of hypothermia
- Slow vitals
- Irregular heart rate
- Pale, cool, puffy skin
- Decreased muscle strength, sensation
- Decreased urine output
- Frostbite
- Confusion
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Nursing interventions for hypothermia
- Warm environment
- Dry, layered clothing
- Cover head
- Limbs close to body
- Warming pads/blankets
- Warm fluids/IV if needed
- Monitor vitals for increase in temp
- Monitor skin for changes
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How is a pulse produced
Cardiac contractions causing a pressure wave against the walls of arteries
Each contraction propels 60-70 mL of blood into aorta (stroke volume)
5 liters/min cardiac output average adult
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What initiates cardiac contractions
Sinoatrial Node
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How are pulses normally found
by Palpation or Auscultation
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What determines the strength of a pulse
Force of cardiac contraction and circulating volume
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What affects the rate of a pulse
- fever
- pain
- hypoxia
- anxiety
- exercise
- cardiac disease
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Average pulse rate in an adult
72 bpm
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Pulse greater than 100 bpm
Tachycardia
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Pulse less than 60 bpm
Bradycardia
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How do you determine the difference between the apical and radial pulse
apical - radial = deficit
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How do you note pulse characteristics
Rate, Rhythm and Volume
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Dysrhythmia
A period of normal rhythms broken by periods of irregular or skipped beats
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Strengths of a Pulse
- Weak and Reg (even beats/poor force)
- Strong and Reg (even beats/moderate force)
- Full and Bounding (even beats/strong force)
- Feeble (barely palpable)
- Irregular (strong/weak beats within 1 min)
- Thready (weak/irregular)
- Absent (no palpable or heard)
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Pulse point
- Temporal-front of ear
- Carotid-side of neck
- Brachial-bend of arm
- Femoral-groin
- Apical-apex of heart
- Popliteal-behind knee
- Pedal-back/inside of ankle
- Dorsalis Pedis-top of foot
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Factors that affect pulse rate
- Age
- Body build and Size
- Blood Pressure
- Drugs
- Emotions
- Blood Loss
- Exercise
- Increased body temp
- Pain
- Hypoxia
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Factors affecting a pulse
- Condition of Heart and Vessels
- Age
- Gender
- Exercise/Activity
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Plaque buildup in arteries
Atherosclerosis
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Hardening of arteries
Arteriosclerosis
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Too much volume
Hypervolemia
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Too little volume
Hypovolemia
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Symptoms of Shock
- Rapid/weak pulse
- Rapid respirations
- Falling blood pressure
- Shortness of breath
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What medications will affect pulse
- Antiarrythmics (Digoxin, Lanoxin)
- If pulse < 60 do not give medication
- Thyroid & Respiratory meds
- Caffeine, Nicotine
- Street drugs
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Assessing Circulation if unable to find a pulse
- Go to distal pulse site
- Capillary refill
- Skin temp
- Color of skin
- Doppler Ultrasound
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Pulse located a 5th intercostal space, left mid-clavicular line
Makes Lub-Dub sound
Most reliable indicator of heart rate
Always use for children under 3
Apical Pulse
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Pulse deficit
Difference in Apical and Radial rates
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Controlled by the pons and medulla in the brainstem
Involuntary autonomic function
Respirations
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How are respirations triggered
By increased/decreased levels of CO2 or by serum hydrogen ion concentration
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Organs of respiration
- Nose
- Pharynx
- Larynx
- Trachea
- Bronchi
- Lungs
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How are oxygen, carbon dioxide, and hydrogen levels maintained
Oxygen and Carbon dioxide are diffused across capillaries in the lungs
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Movement of air in and out of lungs
Ventilation
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Inspiration
Expiration
Lungs fill with air
Pushes air out of lungs
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Normal resp. rates in adult
In infants
- 14-20/min
- Sleeping may drop to 10/min
40-60/min
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Cause of increased respiratory rate
increased levels of carbon dioxide/lower levels of oxygen in blood
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Respiratory Patterns
- Eupnea-normal
- Dyspnea-difficult and labored
- Tachypnea-rapid breathing
- Bradypnea-slow breathing
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Breathing/Respiratory Patterns
- Hypoventilation-shallow/diminished, ineffective
- Apnea-Absence or periods of absence
- Orthopnea-difficult breathing lying down (CHF)
- Hyperventilation-increase in rate and depth
- Cheyne-Stokes-difficult/labored followed by apnea
- Kussmaul's-Increase rate/depth with panting/grunting exhales
- Biot's-Shallow for 2-3 breaths variable apnea
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Signs/Symptoms of Ineffective Respirations
- Movement chest
- Flaring of nostrils
- Retractions (chest)
- Position
- Pain
- Cyanosis
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Factors affecting respirations
- Exercise
- Stress
- Environment/Temp
- Body Position
- Meds
- Pathology/Disease/Injury
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Breath Sounds
- Normal-breezy
- Rubs-sand paper sound
- Cough-productive/nonproductive
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Respiratory Patterns (Noisy)
- Crackles-abnormal nonmusical sound during inspiration
- Rhonchi-dry, rattling caused by partial obstruction
- Stertor-Snoring when unable to cough up secretions from trachea or bronchi
- Stridor-Crowing sound caused by obstruction of upper air passages (croup, laryngitis)
- Wheeze- sound of air forced past a partial obstruction
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How to assess respirations
Observe chest, abdomen, shoulders
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How to document respirations
- Rate per minute(30 x 2)
- Rhythm-(Reg/Irregular)
- Depth/location-(Labored/Shallow, Abdominal/Chest)
- Character- (unlabored/difficulty)
- Associated S/S- (AMS, pain)
- Normal/Abnormal sounds
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Where to measure oxygen saturation in blood
- Toe,
- Earlobe
- Fingers
- Bridge of nose
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Machine that measures oxygen in blood
Pulse Oximeter
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Normal Pulse Oxygen Saturation Levels
95-100%
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Factors that affect Oxygen Sat levels
- Hemoglobin
- Impaired Circulation
- Activity/Movement- (shivering)
- Edema
- Broken Skin
- Artificial Nail/Nail Polish
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In this poisoning, a pulse Ox cannot differentiate btween hemoglobin saturated with oxygen or carbon monoxide
Reading will be high and inaccurate
Carbon Monoxide Poisoning
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The pressure exerted on arterial walls by pumping action of the heart
Blood Pressure
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Affected by condition of vascular bed, circulating blood volume, and cardiac output
Blood Pressure
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In blood pressure, this pressure is exerted on the arterial wall during cardiac contraction
(working)
Systolic Pressure
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In blood pressure, this pressure is exerted on the arterial wall between contractions. (Resting)
Diastolic Pressure
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Blood Pressure is affected by
cardiac output
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Blood pressure rises with increases and decreases in
circulating blood volume
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What happens to blood pressure is blood volume decreases beyond the vascular beds ability to compensate
Causes:
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What alters blood pressure to compensate for changes in circulating volume
Vasoconstriction & Vasodilatation
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Average adult blood pressure
100/70 to 130/85
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Pulse Pressure
Difference between Systolic & Diastolic
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Non-Modifiable factors affecting blood pressure
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Modifiable factors affecting blood pressure
- Good lifestyle changes
- Circadian Rhythms (night shift workers)
- Exercise
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Other factors affecting blood pressure
- Pathology/Disease/Pain
- Cardiac Output/Stroke Volume
- Heart/Vessel Condition
- Stress
- Smoking
- Meds
- Alcohol/Street drugs
- Caffeine
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Volume of blood that fills the heart
Preload
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Peripheral resistance, force against which heart pushes in vessels
Afterload
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Increases BP
Hypervolemia
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Elevated cholesterol
Atherosclerosis
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Blood pressure consistently above normal range
- Hypertension
- Systolic above 140
- Diastolic above 90
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Prolonged hypertension can cause damage to
brain, kidneys, heart, and retinas
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Stage 1 Hypertension range
Stage 2 Hypertension range
Prehypertension range
- greater than 140/90
- greater than 160/100
- greater than 120/80 consistent
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Low blood pressure
Ranges
Safety Issue
Hypotension
Less than 90/60
Synscope (passing out)
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Ways to Assess Blood Pressure
BP Cuff- Syhygmomanometer
- Aneroid-gauge with needle on dial (used with stethoscope)
- Electronic
- Invasive/Direct
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Sites for blood pressure
- Arms - most common over Brachial pulse
- Leg/Thigh (systolic usually higher)
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When should you not take a blood pressure in arm
- Flowing IV
- Fractures/Cast
- Dialysis Shunt
- Burns
- Mastectomy
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Recognized by the Joint Commission as the 5th vital sign
Pain
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Assessment of pain includes
- Location
- Intensity
- Character
- Frequency
- Duration
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Vital Sign changes that occur in elderly
- Temp- heat loss leads to hypothermia
- Lower metabolic rate- hypothermia
- Respiratory rates- could vary
- BP- rises with hardening of arteries
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Recording Temperature Measurements
Record in even numbers (2)
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ACE Inhibitors
Angiotension Converting Enzyme Inhibitor
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Common ACE Inhibitor drugs
Main Side Effect...
- Capoten (captopril)
- Lotensin (benazepril)
- Vasotec (enalapril)
- Zestril (lisinopril)
- Monopril (fosinopril)
- Accupril (quinapril)
Chronic dry cough
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ACE drug interactions
Antacids, NSAIDS interfere with effectiveness of drug, Digoxin increase of dix toxicity, OTC cold remedies/antihistamines
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ACE food interactions
Avoid large amounts of caffeine and salt
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Nursing Considerations for ACE Inhibitors
Report cough, shortness of breath, swelling of face & mouth, chest pain, need hydration with water
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Anti Arrhythmics
Control cardiac irregularities, CHF, angina, MI, cardiomyopathy
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Hold anti arrhythmics when
- pulse less than 60 or greater than 100-120
- Certain abnormal rhythms- Vent Fibrilation
- Heart Block
- Sick Sinus Syndrome
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Side effects of Anti-arrhythmics
- Hypotension
- Headache
- Weakness
- Syncope
- Confusion
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Drug and Food Interaction of Anti-arrhythmics
- Herbs and supplements
- Thyroid meds
- alcohol
- ephedrin
- Licorice with Digoxin
- Grapefruit Juice with Verapamil
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Nursing Considerations with Anti-arrhythmics
- Check Apical pulse before administering
- Must be on cardiac monitor for IV use
- Hold for pulse less than 60/greater than120
- Do not double up if dose is missed
- Lab monitoring for toxicity
- Wear Medic ID
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