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507 assessment - vit

vital signs

QuestionAnswer
6 measurements considered vital signs temp---bp---hr---resp---Pa02----pain
surface vs. core temps *** surface = oral, axillary, skin, tympanic ****core = rectal, bladder, hemodynamic probe
4 ways to gain/lose heat *conduction - direct contact *convection - air currents *radiation - ambient air temp *evaporation - loss through skin AND LUNGS
a nursing diagnosis describing a concern with abn vital sign nursing diagnosis = ineffective thermoregulation
pyrexia defn to have a fever
normal---average pulse rates 60-100 bpm-----70-80bpm
temperature conversion C to F °C x 9/5 + 32 = °F
common pulse points (6) apical---carotid---brachial---radial---femoral---popliteal
apical pulse procedure palpate 5th intercostal midclavicular line, place stethescope, always 1 full minute
pulse wave covers wave begins with left ventricle contract and ends when it relaxes
bradycardia <60 bpm
tachycardia >100 bpm
pulse intensity or quality measured by 0, 1+, 2+, 3+ pulse quality indicated by thready, bounding, irregular, etc
what do we observe in respiration assessement rate, rhythm, depth of respirations
deep depth of respiration reflects hyperventilation
shallow depth of respiration reflects hypoventilation
what does pulse oximetry measure Sa02 - % of Hg carrying 02. normal 95-100%
pulse oximetry documentation should always reflect room air/oxygen flow rates---terms of abn findings such as hypoxia---nursing diagnosis (impaired gas exchange)
3 factors that influence bp regulation *cardiac function *peripheral vascular resisitance *blood volume
the direct method of obtaining bp is ABP, only done in-pt bwo threading catheter into radial/brachial/femoral artery and measuring as waveform on monitor
most common method of measuring bp is indirect/non-invasive where bp is obtained by external measuring devices
cuff s/b 40% of upper arm circumfrence - if too narrow or too wide? too narrow --> false high too wide --> false low
stethescope bell sounds vs. diaphragm sounds bell = light pressure, low sounds diaphragm = firm pressure, high sounds
why do we do 2 step bp process don't want to miss auscultatory gap which may incicate high systolic pressure-----use bell if having trouble hearing sounds
Korotokoff's sounds 1st sound=systole----2nd sound, soft swishoing sound caused by blood turbulence---3rd sound= midway through, sharp, tapping---4th sound as 3rd but fading-----5th sound = SILENCE=DIASTOLE
hypoTN SBP < 100
recall normal, preHTN, Stage 1 & Stage 2 values ***normal <120----<80 ***preHTN 120-139----80-89 ***Stage 1 140-159----90-99 ***Stage 3 >160 --->100
to assess pain, use PQRSTU which is p=precipitation/palliation r=region/radiates q=quality/quantity s= severity t= timing (how long)
Created by: lorrelaws