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FONDATION OF NURSING
EXAM 3 CHAPTER 25
| Question | Answer |
|---|---|
| VITALS SIGNS? | indicators of physiologic functioning and reflect the health status of a person. Include a person’s temperature, pulse, respiration, and blood pressure (abbreviated as T, P, R, BP) INCLUDING PAIN-BLOOD SUGAR TEST |
| PRE-ASSESSMENT ADMINISTRATION | Patients should refrain from vigorous exercise, caffeine, or tobacco prior to assessing, HX +DRUGS LIST ASSESS FOR PAIN-MEET NEEDS PT=BP, HR, RR GO UP |
| FACTORS AFFECTING FREQUENCY OF VITAL SIGNS ASSESSMENT AND CHANGES | Patient’s medical diagnosis/state of health Co-morbidities Types of treatments received Patient’s level of acuity/weight/body position Age and gender Environmental temperature Physical activity Emotional state Medications and treatments |
| NORMAL RANGES FOR VITAL SIGNS FOR HEALTHY ADULTS | Oral temperature: 37.0°C, 98.6°F Pulse rate: 60 to 100 (80 average) Respirations: 12 to 20 breaths/min Blood pressure: 120/80 IF PT IN DISTRESS, BUT VITALS LOOKS GOOD, DO IT MANUALLY. TREAT PATIENT, NOT MACHINE |
| TEMPERATURE | oral (98.6/37C) axillary (97.7/36.5C)** one degree lower rectal (core- 99.5/37.5C) Aural/tympanic (99.5/37.5C). TA: (98.6/37C)Rectal is most accurate and axillary is least. Proper technique is imperative to assessing and accurate temperature. |
| TYPES OF THERMOMETERS USED TO ASSESS BODY TEMPERATURE | SHAKE IT DOWN-PUT UNDER TONGUE- RED PROBE-RECTAL 99.5 BLUE-AUXILLARY97.7, TYMPANIC 99.5, ORAL98.6, TA 98.6 |
| HEAT PRODUCTION & LOSS | Primary source is metabolism (hormone, exercise increase Epi & norepin 4 MORE heat Thyroid horm. +shiverng increa heat productN. Energy productN decrea and heat productN increa LossSkinSweat (evaporation) Warm/humidifd inspird airEliminatN |
| ALTERATIONS IN BODY TEMP | •Increased body temp = fever/pyrexia)/febrile vs. afebrile •Multiple causes •Beneficial effects •Danger zone •> 104F(41C) = hyperpyrexia•< 95F (35C) = hypothermia |
| TYPES OF FEVER (PYREXIA)-FEVERHEAT BODY UP-KILL INFECTION Relapsing or recurrent: temperature returns to normal for one or more days with one or more episodes of fever, each | Intermittent: temperature returns to normal at least once every 24 hours• Remittent: temperature does not return to normal and fluctuates a few degrees up and down• Sustained or continuous: temperature remains above normal with minimal variations• |
| PHYSIOLOGICAL ASPECTS OF FEVER- KNOW BASELINE Onset can vary—gradual to sudden (febrile seizures) •FUO = fever of unknown origin | Hot, flushed skin, thirst, aches , fatigue, increase in pulse/respirations, seizures, confusion, and death •Treatment •Antipyretics (acetaminophen or ibuprofen, ASA (not for children-= Reyes syndrome) •Cool sponge baths•Cooling blankets |
| DECREASED BODY TEMP: HYPOTHERMIA Treatment: rewarming with blankets, warm fluids PO or IV | Unable to retain proper heat needed •Exposure to cold (actual or impaired perception, alcoholism, malnutrition (decreased body weight) and hypothyroid •Extreme cases of survival due to decreased metabolic demands and low O2 |
| What a pulse? Amplitude (force) 3+/4+ - full/bounding 2+ - normal1+ - weak, thready 0 - absent-VERIFY WITH A DOPPLER | A normal pulse should be regular, strong, and have a continuous normal amplitude & rhythm. Asses for full minute •Bradycardia (<60) •Tachycardia (>120) •Dysrhythmia (irregular) |
| FYI | Stroke heat , put ice pack on auxiliary, behand neck and groin |
| PULSE PLACE | CENTRAL PERIPHERAL SIDE(PALPITATION) APICAL (AUSCULATE) =TEMPORAL-COROTID-BRACHIAL-RADIAL- FEMORAL-POPLITEAL -POSTERIAL TIBIA-DORSAL PEDIS |
| DIAPHRAM-HIGHPITCH SOUND BELL-LOW PITCH SOUND LISTEN TO APICAL=CENTRAL COROTID | SYMPHATETIC-INCREASE HEART RATE PARASYNPATHETIC-DECREASE HEART RATE |
| RESPIRATORY RATE | Often the rate is most easily counted while actually listening to chest. LISTEN IN PEDS Ventilation: Inhalation/ExhalationDiffusion: exchange of O2 and CO2—ALVEOLI Perfusion: exchange O2 and CO2—CAPILLARY |
| RATE AND DEPTH OF BREATHING OUR DRIVE IS THE INCREASE IN CO2-STIMULANT OF O1 | CONTROL BY MEDULLA AND PONS Activated by impulses from chemoreceptors Changes in response to tissue demands |
| RESPIRATIONS | Eupnea (NORMAL BREATHING)=12-24 •Tachypnea = > 24•Bradypnea = < 10 •Apnea NONE•Dyspnea = difficult •Orthopnea = sitting up |
| BLOOD PRESSURE | MEASURE OF BLOOD AS IT FLOWS systolic pressure (contraction of ventricles) the diastolic pressure (ventricles at rest or filling). Normal = 120/80 mm /hg MILLIMIEER OF MERCURY |
| DISEASES ORTHOSTATIC-GET VITALS-FROM LAYING -SITTING AND STANDING=PRESURE TO FALL | •HypertENSION:greater 120/80 •Hypo: lower normal kids, athletes, pathology (failure of heart, blood loss, dehydration, shock) •Orthostatic hypo: systolic decrease of 20 mm HG or diastolic decrease of 10 mm Hg—moving from lying, sitting, standing |
| GOOD SIZE, ARTERY ARROW ON BRACHIAL PULSE- WHILE PUMPING, USE ANOTHER FINGER TO FEEL RADIAL PULSE. IF RADIAL PULSE IS GONE. GO 20 MORE ON THE PRESSSURE GAUGE-OR ASK PT WHAT THE BP IS-document in even number | BRACHIAL OR POPLITEAL IS MORE ACCURATE LISTEN TO KOROFF SOUND common errors: inflating cuff too quickly, slowly, too little or too much•Wrong size cuff•Incorrect use of equipment |
| children- | varies according to age but generally runs lower anywhere from 100’s – 40’s |
| check offs-answer neeeds to be withing 4mm of mercury was 120/80=118/78 -122/182 dont o | |
| hypertension | get you to MD to figure out which category u fall in primary(essential) disease secondary=caused by other disease-symptoms of a disease |
| CATEGORIES OF ANTIHYPERTENSIVE MEDICATIONS | diuretic-vasodilator-decrease fluid volume beta-adrenergic blocker-block sympathetic stimulation and decrease cardiac output Vasodilators and calcium channel blockers relax smooth muscles of arterioles , decrea peripheral vascular resistance)•ACE inhibi |
| ACCUCHECK-nursing consideration | Gather supplies, make sure you know how to use glucometer, & that its been updated•Know timing and note meal times on the unit—Most BG checks are AC•Understand Policy using scanner for machine and Pt ID band (this is how results are recorded and charged) |
| ACCUCHECK CONT. | use new test strip-stick it in glucometer before and activate machine. Make sure test strips doesnt touch finger dont squeeze too much document ASAP |
| When auscultating a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the: | The second heart sound, S2, is generated by the closure of the aortic and pulmonic valves, or semilunar valves, and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound. |
| To auscultating a patient's apical pulse accurately, you position the bell of the diaphragm of your stethoscope over the point of maximal impulse, which is located: | at the fifth intercostal space at the left midclavicular line. |
| You have assessed a 45 yr old patient's vital signs. Which of the following assessment values requires immediate attention? | Respirations of 30/min is above the expected reference range of 12 to 20/min and indicates the need for immediate attention. shortness of breath, or dyspnea. Without intervention, this can become a life-threatening situation. |
| You are assessing a patient's vital signs. The patient has a temperature of 102F (39C). Which of the following do you expect to find? | A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate. |
| Getting a rectal temperature? | An insertion depth of 2.5 to 3.5 cm (1 to 1.5 in) for an adult ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Positioning the probe against the blood vessels enables it to measure heat maximally and accurately. |
| AFTER LISTENING TO A FOURTH KOROKTOFF ? | You might not hear a fifth korotkoff sound |
| ASSESS RESPIRATION AT 45-60 DEGREE ? | This is a comfortable position for most clients and it allows full ventilatory movement. Discomfort can increase a client's respiratory rate. |
| GETTING ORAL TEMPERATURE? in the posterior lingual pocket lateral to the midline | The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket=accurate oral temp. probe “sideways” into the back of the area under the tongue on the left or the right will access this area. |
| The best way to determine the depth of a patient's respiration is to: | observe the degree of chest-wall movement during inspiration and expiration |
| You are preparing to use a tympanic thermometer. accurate use of the piece of equipment for measuring body temperature? | Gently pulling the pinna back and upward |
| You are assessing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient's respiration, you: | observe the patient's chest movements while appearing to assess his pulse |
| FACTORS AFFECTING VITAL SIGNS? | BMI of 35 stuffy" nose. The client who has nasal congestion might resort to "mouth breathing," = alter an oral temper. digoxin for an irregular heart rate .cardio condition that warrants pharmacological digoxin A respiration assessment for a full 60 s |
| DRUG INTERACTION | digoxin for an irregular heart rate .The presence of a cardiovascular condition that warrants pharmacological digoxin therapy would require an assessment of the client's apical pulse for a full 60 seconds. |
| POLYDISPIA POLYURIA POLYPHASIA | EXCESSIVE THIRST EXCESSIVE URINE EXCESSIVE HUNGER |
| GESTATIONAL DIABETES | HIGH IN OBESITY PRIOR TO PREGNANCY |
| DIABETIC KETOSIS | BLLOD GLUCOSE GREATER THAN 300DL HYPERLYEMIA, KETONE IS URINE, FRUITY BREATH, INCREASE RESPIRATION RATE |
| SULFONYLUREAS- USED ALONE OR COMBINED GLINIDES-INCREASE INSULIN SECRETION BY BETA CELLS-NATEGLINITE- ALPHA-GLUCOSADE INHIBITORS-DELAYS CARBS DIGESTION GLIPTINS-AUGMENT INCRETIN , INCREASE INSULIN AND DECREASE GLUCAGON | BIGUANIDES-REDUCE HEPATIC GLUCOSE PRODUCTION AND INCREASE INSULIN ACTION ON MUSCLE GLCOSE UPTAKE-TREAT METABOLIC SYNDROME-METFORMIN GLITAZONE-INCREASE CELLULAR RESPONSE BY DECREASING RESISTANCE |
| RAPID-ACTING INSULIN | MANAGE POSTPRADIAL INCREASE INSULIN ASPART(NOVOLOG) LISPRO(HUMALOG) GLUSILINE(APIDRA) ONSET=15MINS PEAK=30MINS-2.5HOUR DURATION 3-6HOURS |
| SHORT-ACTNG INSULIN | REGULAR INSULIN (NOVOLIN R) GIVEN RIGHT BEFORE MEALS ONSET 30 MINS PEAK 1-5 HOURS DURATION=3-7HOURS |
| INTERMIDIATE-ACTING INSULIN | DELYED ACTION TAKEN Q-BID NEUTRAL PROTAMINE HAGEDORN ONSET-60-120 MINUTES PEAK=6-14 HOURS DURATION=16-24HOURS |
| LONG-ACTING INSULIN | PROVIDE BASALE GLUCOSE INSULIN GLARGINE*TOUJEO ONSET =70 MINS-STEADY EFFECT PEAKLESS-RISK OF HYPOGLYCEMIA DURATION=18-24HOURS DETEMIR-LEVEMIR ONSET=SLOW PEAK=12 AND 24HOURS DURATION-VARIES WITH DOSAGE |
| COMBINATION | INTERMIDIATE_SHORT ACTING INSULIN HUMULIN 70/30 |
| FASTIN BLOOD GLUCOSE | 74-106MG/DL |
| oxygen therapy? | treat pneumonia, COPD, EMPHESYMA=cause impaired gas exchange ADR-CRACK IN ORL MUCOSA |
| whats hypoxia? | low o2 patient feels anxious, restless and confused develop hypotension, bradycardia and metabolic acidosis |
| O2 toxicity? | pallor, hallucination, vomiting, shortness of breath, dry cough and edema/ fibrosis |
| Cannula FIO2= 24-28, 32-36, 40-44 OXYGEN TENT- APPROXIMATELY 50 FIO2 RATE FLOW 10-15L FLOW RATE-1-2, 3-4, 5-6 L SIMPLE FACE MASK-40-60, 5-8L | NONBREATHER-60-95, MAINTAIN RESERVOIR 2/3 FULL Offers the highest oxygen concentration of the low-flow systems VENTRI MASK 24-50% FIO2 FOW RATE=,4-10L -PRECISE AMOUNT OF O2 FACE TENT= 24-100 FIO2 FLOW RATE= AT LEAST 10L |
| WHAT HAPPENS DURING THE EARLY STAGE OF HYPOXIA? | blood pressure is usually elevated (unless shock is the cause of the client's hypoxia). In the late stages of hypoxia, clients are likely to develop hypotension. |
| A PATIENT WEARING A SIMPLE MASK: | Tubing and elastic bands that are part of oxygen-delivery devices can cause pressure on the skin that can lead to breakdown. Padding them and frequently changing their position can help prevent this complication. |
Created by:
Seka_nurse