Nurse 500

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Author:
Anonymous
ID:
261708
Filename:
Nurse 500
Updated:
2014-02-12 19:58:13
Tags:
Assessment
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Description:
Nursing Assessment
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  1. Height  (4)
    • - use measuring poleon balance scale    
    • - align headpiecewith top of head    
    • - shoeless, standingstraight, looking straight ahead    
    • - arm span (fingertipto fingertip) equals height
  2. Height Infant
    up to age 2; use horizontal measuring board
  3. Height Child
    - measuring pole on a balance scale; or flat ruler taped to wall
  4. Height Adult
    - measuring pole on a balance scale
  5. Weight- Adult 
    Types of scales used:
    • balance scale (balance to zero)
    • chair scale
    • bed scale
  6. Weight Infant
    • use platform-type balance scale
    • check calibration, set weight at zero
    • weigh to nearest 10 gor(1/2 oz)
  7. Weight Child
    • 2-3y/o 
    • use upright scale
    • medications given based on kg.
    • (1kg= 2.2 lbs.)
  8. Vital Signs
    • Temperature,
    • Pulse,
    • Blood Pressure
  9. Temperature: Methods
    • oral
    • tympanic membrane
    • axillary
    • rectal
    • other
  10. Pulse
    • Palpating the peripheral pulse gives rate & rhythm of heartbeat
    • Radial pulse usually palpated with V. S.
    • Use pads of 1st 3 fingers, palpate radial pulse at - flexor aspect of wrist laterally along radius bone
  11. Pulse Regular rhythm
    - count 30 seconds x by 2.
  12. PulseIrregular rhythm
    - count for full minute
  13. Pulse First pulse felt is
    0 - second pulse is one
  14. Stroke volume -
    every beat, heart pumps approx. 70 ml(adult) blood
  15. Pulse- Rate 
    Adult -
    • resting 60 - 100 beats per minute
    • (average - 74-76)
  16. Pulse- Rate Well-conditioned athlete
    • - 50-100 (bpm)
    • (average - 50-60)
  17. Pulse- Rate Newborn
    -70- 190 bpm(average - 120)
  18. Pulse Rate 1y/o -
    80-160 bpm(average 120)
  19. Pulse bradycardia -
    <60 bpm
  20. tachycrdia
    >100 bpm
  21. Pulse Rhythm
    • -even tempo
    • -regular or irregular(regularity of the pulsations)
  22. Pulse Force
    • -strength of heart’s stroke volume
    • -use scale on p. 182
    • 3+ - full, bounding
    • 2+ -normal
    • 1+ -weak, thready 
    • 0   -absent

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