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Dillon Ch 3

Approach to the Physical Assessment/Vital Signs

Identify the 6 measurements that can be considered vital signs BP, Pulse (HR), Resp, Temp, SaO2 (Pulse ox), Pain
State a nursing diagnosis to describe an abnormal temperature reading Nursing Diagnoses: Ineffective Thermoregulation (Hyperthermia / Hypothermia)
State a nursing diagnosis to describe an abnormal SaO2 reading Nursing Diagnosis: Impaired Gas Exchange
Identify 4 means of heat loss or gain Conduction, Convection, Radiation, Evaporation
Conduction is heat loss/gain by: Direct contact
Convection is heat loss/gain by: Air currents
Radiation is heat loss/gain by: Ambient air temperature
Evaporation is heat loss/gain by: Water loss through skin, lungs
Explain the difference in the Fahrenheit and Centigrade (Celsius) temperature scales Fahrenheit temp scale is based on 32 for the freezing point of water and 212 for the boiling point of water. Celsius tempe scale is the scale based on 0 for the freezing point of water and 100 for the boiling point of water. F to C value: C=5/9(F-32)
Normal Adult VS ranges Temp: 96.8F (36C) - 99.5F (37.5C) Pulse: 60-100 (Avg = 70-80) Resp: 12-20 BP: 120/80
Normal Newborn VS ranges Temp: 98.6F (37C) -99.8 (37.7C) Pulse: 120-160 Resp: 30-80 BP:50-52/25-30, Mean: 35-40
Normal Aging Adult VS ranges Temp: 96.5F (35.9C) - 97.5F (36.3C) Pulse: 60-100 Resp: 15-25 BP: 120/80
Normal 3 yr VS ranges Temp: 98.5F (36.9C) - 99.5F (37.5C) Pulse: 80-125 Resp: 20-30 BP: 78-114/46-78
Normal 10 yr VS ranges Temp: 97.5F (36.3C) - 98.6F (37C) Pulse: 70-110 Resp: 16-22 BP: 90-132/5-86
Normal 16 yr VS ranges Temp: 97.6F (36.4C) - 98.8F (37.1C) Pulse: 55-100 Resp: 15-20 BP: 104-108/60-92
Normal Sa)2 value 95-100%
Describe the skills needed in assessing respirations Count Unobtrusively (While Palpating Radial Pulse) Count for 60 Seconds Observe the Rate, Rhythm, and Depth of Respirations
Understand the use of a pulse oximeter -Noninvasive method of monitoring respiratory status -SaO2 reflects the percentage of hemoglobin molecules carrying oxygen
Korotkoff’s Sounds - 1st sound As you deflate the BP cuff, a sound that occurs during systole (systolic BP)
Korotkoff’s Sounds - 2nd sound As you further deflate the cuff, a soft swishing sound caused by blood turbulence
Korotkoff’s Sounds - 3rd sound Begins midway through the BP and is a sharp, rhythmic tapping sound
Korotkoff’s Sounds - 4th sound Similar to the third sound, but softer and fading
Korotkoff’s Sounds - 5th sound Silence, corresponding with diastole (diastolic BP)
Systolic Pressure Peak pressure exerted against arterial walls as the ventricles contract and eject blood Working pressure (SBP)
Diastolic Pressure Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest Resting pressure (DBP)
Explain the importance of identifying trends and/or evaluating differing patterns in vital signs The initial set of VS is the baseline, serial measurements are more reflective of health than one-time measurements. For example: a BP of 150/98 in a pt who was late to his appt may not be a reflection of his usual BP - it may be increased due to stress.
Terms for abnormal temperature Hypothermia, Hyperthermia, Pyrexia
Hypothermia Abnormally low body temp
Hyperthermia Abnormally high body temp
Pyrexia Fever
6 Common Pulse Points Apical: At the apex of the heart Carotid: Between midline and side of neck Brachial: Medially in the antecubital space Radial: Laterally on the anterior wrist Femoral: In the groin fold Popliteal: Behind the knee
Terms for abnormal pulse Bradycardia, Tachycardia, Irregular, Bounding, Thready
Bradycardia Abnormally low pulse/heart rate (<60 BPM in adults)
Tachycardia Abnormally high pulse/heart rate (>100 BPM in adults)
Terms for abnormal respirations Apnea, Bradypnea, Tachypnea, Dyspnea, hyperventilation, hypoventilation
Apnea Cessation of breathing
Bradypnea Abnormally slow respirations (<12 for adults)
Tachypnea Abnormally fast respirations (>20 in adults)
Hyperventilation Abnormally deep breathing
Hypoventilation Abnormally shallow breathing
Term for abnormal SaO2 value Hypoxia
Terms for abnormal BP values Hypotension, Hypertension (pre-hypertension, Stage I hypertension, Stage II hypertension)
Classification of Pre-hypertension (BP values), of an adult 120-139/80-89
Classification of Stage I hypertension (BP values), of an adult 140-159/90-99
Classification of Stage II hypertension (BP values), of an adult >160/>100
Describe the techniques of obtaining height and weight Height done routinely in clinics for adults – measure with pt’s back to the scale, shoes off, paper towel for infection control. Weight – routinely done on acutely ill patients! Balance scale, have void prior, same time of day, and with minimal clothing
Created by: MEPN 2013