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Maslow/vitals
test 2
| Question | Answer |
|---|---|
| What does Maslow believe drive's human potential? | humans strive for the highest level of consciousness |
| List five levels to Maslow's hierarchy | Bottom-top=Physiological needs, safety/security, love/belonging, self-esteem, self-actualization. |
| normal range for body temperature | 97-99.6 |
| When should you always check vitals? | upon admitting, morning assessment, upon return to floor from other department, after surgery, before certain meds and after certain meds, upon any significant change. |
| What part of the brain controls body temperature? | Hypothalamus |
| two types of body temperature | surface and core |
| factors that effect body temperature | age, exercise, hormones, time of day(lowest is early a.m. and highest late afternoon), emotions, environment, disease, drugs, ingestion of hot/cold liquids and smoking |
| procedure for taking rectal temperature | left SIMS position, lubricate probe, 1.5 in. adult/1 in child/.5 in infant insertion, for at least 3 minutes |
| how long to take temp in mouth | 1-3 minutes. |
| most reliable temperature site | rectal |
| normal temp rectal | 99.6 |
| normal temp axillary | 97.6 |
| normal tympanic | 98.6 |
| Afebrile | without fever |
| hyperthermia/pyrexia/febrile | elevated body temp above normal--fever |
| what temp usually gets treated for fever? | anything 101 or above in adults |
| some things nurses can do for fever | cover when shivering, remove when not, increase fluids, promote ventilation, cool cloth, fresh sheets, assess temp for accuracy, limit activity and give sponge bath |
| Hypothermia | (usually below 93.2 orally do not survive)prolonged exposure to cold, puffy skin, pallor, slow pulse/resp., irregular pulse, confusion, inability to feel pain |
| some things a nurse can do for hypothermia | warm blankets, remove wet clothing, warm fluids, eliminate drafts |
| pulse point is | the point at which the artery crosses over a solid surface and can be palpated. |
| pulse rate normals | adult 60-100/min, child 80-110/min, infant 100-160/min, newborn 120-160/min |
| ways to assess pulse | palpation, auscultation, doppler |
| areas to assess pulse | carotid, brachial, radial, apical, popliteal, femoral, pedal (posterior tibial/ dorsalis pedis) |
| only non-peripheral site for pulse assessment | apical |
| three things to note when cheking pulse | rate, rhythm and volume |
| how do you document pulse rhythm? | regular or irregular |
| how do you document pulse volume? | 0-absent, 1+ thready, 2+ Weak, 3+ normal, 4+ bounding |
| tachycardia | fast or increased heart rate (over 100 bpm) |
| bradycardia | slow or below 60 bpm |
| dysrhythmia | irregular pulse |
| pulse deficit | difference between apical and radial pulse. Need two people to check and must be done for one minute. |
| normal respiration ranges | infant 30-80, child 20-40, adult 12-20 |
| part of brain responsible for respirations | medula oblongota |
| eupnea | normal respirations; even, regular, quiet and unlabored |
| procedure to assess resp. rate | count inspiration/expiration (breaths) for 30 seconds and multiply by 2. count 1 minute if irregular |
| normal depth of respiration | about 500mL/breath |
| Cheyne-Stokes rhythm | increase, decrease and periods of apnea. |
| Kussmaul rhythm | fast and deep with out power (kin do like hyperventilation but usually associated with a disease) |
| unit of measure for blood pressure | mm Hg (milimeters of mercury) |
| smoking and blood pressure | nicotine causes vasoconstriction and thus higher bp...wait 30 minutes afte smoking to get bp |
| Avg. Bp | 120/80 |
| Blood Pressure normal ranges for systolic and diastolic | sys- 100-140 dias- 60-90 |
| Hypertension | increased bp; greater than 140/90; at least two reading taken at different times must be obtained to prove hypertension |
| Hypotension | decreased bp; systolic usually less than 90 |
| orthostatic hypotension | decrease in bp when changing from a lying to standing position. usually decrease of 25 systolic and 10 diastolic |
| syncope | loss of consciousness |
| pulse pressure | difference between the systolic and diastolic; normal is between 30-50 |
| bp assessment sites | brachial and popliteal arteries |
| korotkoff sounds | pulsating sounds you hear when listening to pulse |
| ausculatory gap | temporary disappearance in sound in bp; usually in hypertension patients; may record 3 numbers |
| common causes of errors in taking bp | noise, extremity in strain, extremity above heart level, improper cuff size, cuff too loose, improper working equipment, rapid cuff deflation |
Created by:
laceynickie
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