TPRO

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Author:
athors766ns
ID:
282251
Filename:
TPRO
Updated:
2014-09-06 17:02:59
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Skills test
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Description:
temp, pulse, respiration, oxygen saturation
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  1. VS purpose
    indicate body's ability to regulate temp, maintain blood flow, and oxygenate body tissues in response to physical, environmental, and psychological stressors
  2. vital signs monitor
    changes in the pt over time
  3. Nurses take VS when
    • pt is admitted into the hospital
    • on a routine schedule per dr order
    • before and after surgical procedure or invasive diagnostic procedure
    • before during and after transfusion of blood, getting meds, or therapies that affect cardiovascular, respiratory, and temp control functions
    • when pain increases or loss of consciousness
    • before and after nursing interventions
    • pt reports physical distress "feeling funny"
  4. normal Oral temp/tympanic
    • mouth and ear
    • 36-38 C or 96.8-100.4 F
  5. normal axillary
    • 36.5 C or 97.7F
    • slightly lower
  6. normal rectal
    • 37.5 C or 99.5
    • Slightly higher and most accurate.
  7. temperature depends on
    • age: decrease with increasing age
    • physical activity: increase with activity
    • status of hydration: increase with dehydration
    • state of health (presence of infection)
    • cardiac rhythms (24 hour cycle): increase temp is most accurate between (5pm-7pm)
  8. Euthermia
    • temp with normal (EU) range.
    • Body cells function within a small rage of normal temps
    • cells benefit from short term change in temp (fever to kill bacteria, hypothermia in drowndings)
    • long time heat/cold temps can lead to tissue damage and death
  9. Hypothermia
    low temp <36 C or 96.8 F
  10. Pyrexia .
    same as fever. abnormal elevation of temp above 37 C or 98.6 because of disease
  11. hyperthermia
    dangerously high temperature.
  12. febrile
    is to have a fever
  13. afebrile
    is when the fever breaks, or there is no more fever
  14. Oral temp considerations and tips
    • pt must be able to close lips (no mouth trauma or epilepsy)
    • temp is altered by ingestion of cold and warm liquids, smoking, and chewing gum (15 min)
    • -use automatic ejector to dispose of probe cover, do not touch with hand.
  15. tympanic considerations and tips
    • ear wax (cerumen) decreases accuracy
    • Blue Thermometer
    • -get temp in pt right ear if right handed
    • -adult pull pinna back and up child back and down
    • -hold snug or in figure 8.
  16. rectal considerations and tips
    • stool decreases accuracy
    • pt embarrassment and anxiety
    • RED thermometer
    • -lubricate 1-1.5 inches of probe
    • -insert probe 1-1.5 in aiming towers¬†umbilicus,¬†NEVER force
  17. temporal (skin) considerations
    sweating (diaphoresis) decreases accuracy
  18. Pulse definition
    pressure wave in the peripheral arteries generated by the left ventricle as it contracts.
  19. Pulse provides
    • indication of heart function and tissue perfusion
    • reflects clients metabolic rate, physiologic responses to stress, exercise, blood loss, pain
  20. Normal HR
    • 60-100 beats per min
    • easily palpable
    • regular
  21. bradycardia
    • less than 60 beats.
    • Brady:slow
  22. tachycardia
    • more than 100
    • tachy: fast
  23. HR rhythm
    • regular or irregular
    • arrhythmia and dysrthmia
  24. HR strength
    • 0: absent, non-palpable (no pulse)
    • 1+: weak feeble thread (barley palpable)
    • 2+: normal (expected)
    • 3+: full/strong
    • 4+: bounding (very strong)
  25. most common site to asses pulse
    • adults: radial (wrist)
    • infants: brachial or apical (elbow and heart)
  26. Carotid
    pulse felt in the neck
  27. apical
    apex of the heart or PMI
  28. Brachial
    elbow area
  29. radial
    wrist thumb side
  30. femoral
    where leg and hip meet
  31. popliteal
    flex knee, deep within behind knee area
  32. dorsalis pedis
    top of foot between big toe and the next
  33. posterior tibial
    side of foot under ankle knob
  34. factors affecting pulse
    • age: infant 180, preschool 160, school age 120, older children 110, adult 100
    • sex: females under 12 have higher HR
    • exercise: high so wait 5-10 min before assessing
    • fever: faster pulse
    • medications, hemorrhaging, and stress
  35. asses the apical pulse when
    radial pulse is irregular and prior to digoxin(medication)
  36. count pulse for
    30 sec if reg and 60 if irregular
  37. factors affecting RR
    exercise, anxiety, pain, smoking, meds
  38. Respiratory rate is
    • number of breaths per min
    • one inhale and one exhale is ONE respiratory cycle
    • Normal: 12-20 breaths per min
  39. RR depth/effort
    • depth: shallow, normal, deep
    • effort: labored or unlabored
    • labored: use of accessory muscles, flared nostrils, pursed lips.
    • Men, kids, athletes: belly breathers, diaphragmatic
    • women: chest breathers
  40. RR Rhythm and pattern
    • Rhythm: Regular or irregular
    • Patterns-
    • Eupnea: normal
    • Tachypnea: more than 20 breaths per min
    • bradypnea: less than 12 breaths per min
    • hyperventilation: deep and rapid
    • apnea: no breaths
    • cheyne-strokes: periods of rapid breathing followed by no breathing. irregular
  41. kussmal breathing
    abnormally deep but regular
  42. Pulse OX measures
    • % of hemoglobin that is bound with oxygen.
    • correlates with arterial oxgen saturation: level of oxygen in the blood available to the body tissues
  43. normal pulse ox
    more than 90% we want it to be 95-100
  44. asses the pulse OX
    • when the doctor orders
    • adventitious breath sounds
    • signs of altered oxygen saturation: cyanotic(blue) nails lips and skin, restlessness, and dyspnea (difficulty breathing SOB)
  45. sites to avoid for Pulse OX
    • finger on same side as electronic BP cuff
    • edema, altered skin integrity, hypothermia
    • nail polish, bad capillary refill
  46. best order for VS
    • BP baseline wait 30 seconds do below
    • temperature
    • radial pulse
    • respirations
    • check BP

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