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507 assessment - vit
vital signs
| Question | Answer |
|---|---|
| 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
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