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Fund Nurs 3

Fundamentals of Nursing Test 3

4 Vital signs 1 Body Temperature 2 Pulse 3 Respirations 4 Blood Pressure
Body Temperature 2 definitios 1 Heat of Body in degrees 2 Difference between heat production and loss
Core temperature v Surface Core temperature is higher
Where is the thermoregulatory center? Hypothalamus
The primary source of heat production in the body Metabolism- the sum of the chemical reactions of the body
The primary source of heat loss in the body? The skin
Celcius to Fehrenheit conversion C = 5/9 (F - 32) or F = 9/5 C + 32
d Pulse A wave of blood from pumping of the left ventricle
3 characteristics of Pulse 1 Rate 2 Quality of Amplitude 3 Rhythm
How is the pulse Rate measured? bpm Beats per minute
How is the quality or amplitude of a pulse measured? 5 0 Absent 1+ Thready 2+ Weak 3+ Normal 4+ Bounding
How is the Rhythm measured? 4 Regular Weak Bounding Irregular
The pulse is regulated by ( ) through ( ) The autonomic nervous system through the cardiac sinoatrial node
Parasympathetic stimulation Decreases the heart rate
Sympathetic Stimulation Increases the heart rate
d pulmonary ventilation Moving air in and out of the lungs
inspiration breathing in
expiration breathing out
External respiration Exchange of Oxygen and carbon dioxide between the alveoli and circulating blood
Internal respiration Exchange of oxygen and carbon dioxide between the circulating blood and the tissues
Respiratory centers in the (2) do what (2) medulla and pons inhibit or stimulate respiratory muscles
The most powerful stimulant to breathe is ( ) Carbon Dioxide
Can breathing be controlled voluntarily? If so how? Yes, through the cerebral cortex
d. Blood Pressure Force of blood through arterial walls
How is blood pressure recorded? Measured as mm of Mercury (HG)
Systolic pressure The highest pressure- left ventricle contracts
Diastolic pressure The lowest pressure- heart rests between beats
Pulse pressure Systolic minus Diastolic
Korotkoff Sounds A series of sounds a nurse listens for when assessing blood pressure
KS Phase 1 The first faint tapping sounds; the systolic pressure
KS Phase 2 Swooshing sound called the ausculatory gap
KS Phase 3 Distinct loud sounds
KS phase 4 distinct abrupt muffling sound; first diastolic figure
KS phase 5 Last sound heart; second diastolic measurement
3 constant minor variations in blood pressure 1 Peripheral Resistance 2 Neural and Humoral mechanisms 3 Cardic Output
Peripheral Resisance and BP Contraction and Relaxation of Arterioles alters the BP
Neural and Humoral mechanisms and BP Kidneys and Posterior Pituitary alter BP
Cardiac Output and BP The amount of blood pumped per min varies and alters BP
Circadian Rhythm Predictable repeated 24 hour fluctuations in physiologic processes
Time of day when temp is highest and lowest Lowest in early morning, highest in late afternoon
2 age groups most sensitive to environmental changes to body temperature Old and young
Which gender has more body temp fluctuations? Women
Hyperthermia High body temperature
Hypothermia Low body temperature
Pyrexia Increased body temperature caused by upward tick in hypothalamic center set point
Febrile Person with an increased temperature
Afebrile Person with a normal temperature
TAchycardia Pulse over 100
Bradycardia Pulse under 60
Normal adult respirations 12-20
TAchypnea Over 24 respitations per minute
Bradypnea under 10 respirations per minute
Hyperventilation Increased rate/ depth breathing
Hypoventilation Decreased rate/ depth breathing
Cheyne-stokes altered deep/ rapid breathing followed by apnea
Biots Varying depth/ rate followed by period of apnea
4 sites for assessing body temperature Tympanic membrane Oral Rectal Axillary
8 sites for assessing pulse Radial (Wrist) Brachial (Arm) Coratid (neck) Temporal (Above ear) Femoral (Inner thigh) Popliteal (back of knee) Dorsalis pedis (instep of ankle) Posterior tibial (side of ankle)
2 actions for assessing respirations Inspection and Auscultation
2 areas to assess BP Brachial Artery and Popliteal Artery
Normal Temp C and F 37 C and 98.6 F
Axillary temp newborn 36.8 C
REctal temp age 1-3 37.7 C
Over age 70 C and F temp 36 C and 96.8 F
Normal pulse teen and older 60 - 100
Pulse newborn 80 - 180
Pulse age 1 -3 80 140
Pulse age 6-8 75 - 120
Pulse age 10 75 - 110
Respirations Newborn 30 - 80
Resp 1 - 3 20 - 40
Resp 6 - 8 15 - 25
REsp age 10 15 - 25
Respirations Teen 15 - 20
Respirations Adult 12 - 20
Respirations Over 70 15- 20
Blood Pressure Adult and Elderly 120 / 80
BP Teens 102 / 80
BP age 10 102 / 62
BP age 6-8 95 / 75
BP age 1 -3 90 / 55
BP newborn 73 / 55
Adult Prehypertension 120-139/ 80-89
Adult Stage I Hypertension 140- 159/ 90- 99
Adult Stage II Hyperstension Greater than 160/ Greater than 100
Patient teaching for temperature (4) 1) 30 min after eating or smoking 2) Under side of tounge with mouth closed 3) Leave in place 2-3 min 4) Wash thermometer
patient teaching for Pulse (3) 1) May need to take before medication 2) Need a watch with second hand 3) Teach how to find pulse and count for 1 min
Patient teaching for BP (2) 1) May need to check for medications 2) Teach about cuff size and placement
Normal pulse for a newborn 120- 160
Initial assessment when? Shortly after arrival
Initial assessment Why? 2 To establish a baseline and to identify problems
Focuses assessment looks at? A specific problem or body system
4 types of assessment 1) Initial 2) Focused 3) Emergency 4) Time-lapsed
Emergency assessment identifies Life-threatening problems
Time lapsed assessment Compares curent status with a baseline
Medical assessment Targets pathological conditions and their treatments
Nursing assessment Target responses to health problems and diseases impact on the person
Objective data is (2) observable and measureable
Objective data and others It can be validated by another
Subjective data Percieved only by the person affected
The 4 characteristics of Data 1) Purposeful 2) Complete 3) Factual and Accurate 4) Relavent
2 components of Nursing observation 1) Nursing history 2) Physical assessment
Observation uses ( ) The 5 senses
Interview skills are used in ? The nursing history
2 purposes of the nursing physical assessment 1) Appraisal of health status 2) Identification of patient problems
Type of data used in the nursing physical assessment Objective
What is the primary and best source of patient data? The patient
Other than the patient name 4 sources of patient data 1) Family and Significan others 2) the patient record 3) Other healthcare professionals 4) Nursing and other healthcare literature
The patient record provides information from ( ) Different members of the health care team
Data Validation The act of confirming and verifying data
The goal of data validation Keep data free of error, bias, or misinterpretation
Invalid data may lead to ( ) Inappropriate care
2 times when data needs to be validated? When there is a discrepancy between what the person is saying and what the nurse is observing and When data lacks objectivity
Significant patient data may lead to? 1) Alerting other healthcare professionals of assessment changes 2) Increased frequency of assessment 3) Initiate changes in treatment
Critical changes require (time) Immediate consultation
Created by: twininger1