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test 2

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