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These are the data that can be observed or measured on patient.
Data from the client's perspective
to measure blood pressure
also using hand to feel for signs
using stethoscope to hear any abnormal sound
The nursing diagnosis is focused on
problems that exist now. Nursing diagnosis identifies problem the client is at risk for if some preventive action is not taken.
- Blood pressure,
- pulse rate,
- respiratory rate.
Temprature Normal ranges
- Axillary: 96° to 98° F
- Oral: 97° to 99° F
- Rectal: 98° to 100° F
- Tympanic: 97° to 99° F
number of times the heat beat per minute
the frequency of heart beat
on Carotid artery (neck)
over the apex of the heart; listen with stethoscope; count one full minute
Normal Values of pulse rate-
- Infant-110-160 beat/min
- 2-6years 90-110 beat/min
- Adult-60-100 beat/min
refers to the force of contraction and relaxation of the heart as it is been applied to the wall of the arteries.
Unit of measurement blood pressure
Millimeters of Mercury
Systolic Blood pressure
is the force exerted against the arterial walls when the heart is contracting
is the force exerted against the arterial walls when the heart is relaxing.
the difference between systolic and diastolic pressures.
Infant- 75/50 mmHg
2-6 year old- Systolic- 85-100mmHg; diastolic 60-70mmHg
6-12years old – Systolic-95-108mmHg; diastolic- 56-68mmHg
Adult- Systolic-90-140mmHg; Diastolic- 60-90mmHg
basal metabolic rate
the rate at which heat is produced when the body is at rest
absence of breathing
noisy breathing or snoring
abnormal increase in the depth and rate of breathing;
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