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Explain the advantages and disadvantages of taking a patients temperature using the oral, rectal, axillary, and tympanic sites.
- -Easily accessible
- -accurate surface temperature
- -comfortable for clients
- -reflects rapid change in core temp
- -reliable route for intubated pt
- -not to be used on infants or small children also the confused
- -most reliable when oral cannot be obtained
- -lags behind core temp
- -safe and inexpensive
- -used with newborns and unconscious
- -long measurement time
- -effected by exposure to environment
- -easily accessible site
- -rapid result
- -use on newborns to decrease handling
- -most variability with core temp
- -affected by ambient temperature
Identify factors to assess in determining potential alterations in body temperature.
- Hormone level
- Circadian rhythm: temp changes 0.5-1 degree C during 24 h; lowest between 1-4 am; max around 4pm. Takes 1-3 weeks for cycle to reverse for those who work at night
- Temp alterations
- -Malignant Hyperthermia: hereditary condition uncontrolled heat production with anesthetic drugs
- -Heat exhaustion
- -Hypothermia: heat loss during prolonged exposure to cold
Identify factors to assess in determining potential alterations in pulse character.
- -posture changes
- -pulmonary condition
Identify factors to assess in determining potential alterations in respirations.
- -Exercise: +
- -pain: -
- -anxiety: +
- -smoking: +
- -body positions: straight upright promotes chest expansion; stooped or slumped impairs ventilator movement; lying flat prevents chest expansion
- -medications: opioid, anesthetics, sedatives lower rate and depth; amphetamines and cocaine increase rate and depth; bronchodilators slow rate by causing airway dilation
- -neurological injury: injury t brainstem impairs respiratory center and inhibits respiratory rate & rhythm
- -hemoglobin function: decreased hemoglobin reduce oxygen-carrying capacity so increase resp rate; increased altitude lowers amount of saturated hemoglobin so increase resp rate & depth; abnormal blood cll function (sickle cell) reduces ability to carry o2 so increases rep rate and depth
Identify factors to assess in determining potential alterations in blood pressure.
- -daily variation
- -activity and weight
Explain the advantages and disadvantages of using an automatic BP machine.
- -when multiple pressures are necessary like in unstable pt
- -easy and efficient
- -no stethoscope
- -more sensitive to outside interference
- -unable to process sounds and vibrations of low BP
Identify factors to assess in determining potential alterations in oxygen saturation.
- -outside light
- -CO poisoning
- -IVP dyes
- -nail polish
- -cold hands
- -dark skin
List and explain the rationale for the guidelines to measuring vital signs.
- Establishing a database of vital signs during routine physical examinations serves as a baseline for future evaluation. Need to understand and interpret values.
- -indicators of health status, circulatory function, respiratory, endocrine, and neural.
Explain what can be different when taking vital signs on an older adult. What intervention will you as a nurse take as a result?
- -lower temperature range 35C
- -sensitive to temperature extremes
- -rise in systolic BP
- Factors Affecting Vital Signs of Older Adults (Box 29-15)
- The temperature of older adults is at the lower end of the normal temperature range, 36° to 36.8° C (96.8° to 98.3° F) orally and 36.6° to 37.2° C (98° to 99° F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult. In an older adult fever is present when a single oral temperature is over 37.8° C (100° F); repeated oral temperatures are over 37.2° C (99° F); rectal temperatures are over 37.5° C (99.5° F); or temperature has increased more than 1° C (2° F) over baseline ( High et al., 2009 ).
- Older adults are very sensitive to slight changes in environmental temperature because their thermoregulatory systems are not as efficient.
- A decrease in sweat gland reactivity in the older adult results in a higher threshold for sweating at high temperatures, which leads to hyperthermia and heatstroke.
- Be especially attentive to subtle temperature changes and other manifestations of fever in this population such as tachypnea, anorexia, falls, delirium, and overall functional decline.
- With aging loss of subcutaneous fat reduces the insulating capacity of the skin; older men are especially high risk for hypothermia.
- Pulse Rate
- If it is difficult to palpate the pulse of an obese older adult, a Doppler device provides a more accurate reading.
- The older adult has a decreased heart rate at rest.
- It takes longer for the heart rate to rise in the older adult to meet sudden increased demands that result from stress, illness, or excitement. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate.
- When assessing the apical rate of an older woman, the breast tissue is gently lifted, and the stethoscope placed at the fifth intercostal space (ICS) or the lower edge of the breast. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs.
- Blood Pressure
- Older adults often have decreased upper arm mass, which requires special attention to selection of blood pressure cuff size.
- Older adults sometimes have an increase in systolic pressure related to decreased vessel elasticity while the diastolic pressure remains the same, resulting in a wider pulse pressure.
- Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries.
- Aging causes ossification of costal cartilage and downward slant of ribs, resulting in a more rigid rib cage, which reduces chest wall expansion. Kyphosis and scoliosis that occur in older adults also restrict chest expansion and decrease tidal volume.
- Older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles.
- The respiratory system matures by the time a person reaches 20 years of age and begins to decline in healthy people after the age of 25. Despite this decline older adults are able to breathe effortlessly as long as they are healthy. However, sudden events that require an increased demand for oxygen (e.g., exercise, stress, illness) create shortness of breath in the older adult.
- Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia.
List the normal range of values for adult vital signs. Include temperature, pulse, respirations, blood pressure, and oxygen saturation.
- BP SYS- <120 DYS<80
- Pulse- 60-100
- Temp-36C-38C or 98.6F-100.4F
What does PERRLA stand for? Describe how to measure it.
- Pupils Equal Round and reactive to light and accommodation
- Test pupillary reflexes (to light and accommodation) in a dimly lit room. Instruct the patient to avoid looking directly at the light. While the patient looks straight ahead, bring a penlight from the side of his or her face, directing the light onto the pupil ( Fig. 30-14 ). A directly illuminated pupil constricts, and the opposite pupil constricts consensually. Observe the quickness and equality of the reflex. Repeat the examination for the opposite eye.
What are the skills used for assessment? In what order are they performed?
What is the body mass index (BMI) for Angela Farley? Eric Thompson?
Describe normal heart sounds at the anatomical sites where you listen for them.
Explain what a bruit is and what it means.
- As blood passes through a narrowed section this creates turbulence, causing a blowing or swishing sound. The blowing sound is called bruit.
- -Occlusion or narrowing of the carotid artery
Explain what a pulse deficit is and what it means.
- When radial pulse is slower than apical pulse because ineffective contractions fail to send pulse waves peripherally.
- An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit you and a colleague assess radial and apical rates simultaneously and then compare rates. The difference between the apical and radial pulse rates is the pulse deficit. For example, an apical rate of 92 with a radial rate of 78 leaves a pulse deficit of 14 beats. Pulse deficits are often associated with abnormal rhythms.
Describe the use of a Doppler.
Ultra sound stethoscope amplifies pulse wave. Use gel and put Doppler directly on site.
Explain how to test for muscle strength in the extremities.
Assess muscle strength and tone during ROM measurement. Have the client flex and then resist pressure applied.
Describe how to test a patient for temperature sensation.
- 2 test tubes one filled with hot water and one with cold
- -touch client with one tube and have them identify hot or cold
Your patient had a mild stroke yesterday. Today she is opening her eyes and looking around, but when she tries to speak you cannot understand what she is saying. She can obey commands to move her limbs. Using Table 33-37, rate her on the Glasgow Coma Scale and explain what her score means.
- I. Motor Response
- 6 - Obeys commands fully
- 5 - Localizes to noxious stimuli
- 4 - Withdraws from noxious stimuli
- 3 - Abnormal flexion, i.e. decorticate posturing
- 2 - Extensor response, i.e. decerebrate posturing
- 1 - No response
- II. Verbal Response
- 5 - Alert and Oriented
- 4 - Confused, yet coherent, speech
- 3 - Inappropriate words and jumbled phrases consisting of words
- 2 - Incomprehensible sounds
- 1 - No sounds
- III. Eye Opening
- 4 - Spontaneous eye opening
- 3 - Eyes open to speech
- 2 - Eyes open to pain
- 1 - No eye opening
- GCS= 6+2+4=12
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