Module D Lee- 102 Vital Signs -Calhoun
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show | Adult Temperature
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98.6 | show 🗑
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96.8 | show 🗑
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Labor-Delivery: T, P, R, B/P | show 🗑
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Pregnancy: T, P, R, B/P | show 🗑
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Post-Partum: T, P, R, B/P | show 🗑
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show | 95.9-99.5
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show | 120-160
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Newborns Respirations: | show 🗑
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Newborns B/P: | show 🗑
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F.H.R. Pulse: | show 🗑
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show | Average 90
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show | 20-30
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show | 95/65
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Older Adult/Pulse: | show 🗑
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Older Adult/Repirations: | show 🗑
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Older Adult B/P | show 🗑
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show | 30-50 mm Hg
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show | before, during, & after giving blood, ambulation, & change in mental status
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show | Monitor pulse or B/P & Teach patient how to take V/S & the importance
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show | Vital Signs
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show | Nurse
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Baseline measurement ... | show 🗑
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When would you have another nurse recheck V/S? | show 🗑
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show | MD or Charge Nurse
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show | Neonate
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Radiation | show 🗑
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Conduction | show 🗑
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show | Transfer of heat away by air movement.
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Evaporation | show 🗑
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Core Temperature | show 🗑
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show | Newborn's
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show | 94 degrees & below
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show | Hot flashes, vasoconstriction & vasodialation
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This can alter temperature set points... | show 🗑
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Temperature is lowest at... | show 🗑
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show | 10:00 AM To 6:00 PM
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Normally changes 0.9 to 1.8 degrees... | show 🗑
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Rectal Temperature lubercate... | show 🗑
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show | Axillae thermometer
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show | right ear or (left handed/left ear)Point speculum toward nose, small figure 8 in ear.
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Pull ear pinna backward, up, & out... | show 🗑
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show | Child 3 or older
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show | Child older than 3
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Don't use Oral Temperature on these patient's.. | show 🗑
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show | Ingestion of fluids/food, smoke, & oxygen delivery.
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show | Rectal, Axillae, Cutaneous Temperatures
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show | Axillae
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show | Axillae
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show | Rectal temperature
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show | Newborns & uncooperative patients
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show | Tympanic Membrane
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Not accurate core temp. after exercising... | show 🗑
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show | Tympanic Membrane
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Provides continuous readings & can be used on neonates... | show 🗑
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Sweating , environmental temp, chill phase of fever cause it to be unreliable... | show 🗑
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show | Controls body temperatures "Set Point"
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Anterior Hypothalamus controls.. | show 🗑
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show | heat production
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Hyperpyrexia | show 🗑
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show | Hereditary, Uncontrolled heat production when susceptible people receive certain anestetics.
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show | Environmental heat exposure, profuse diaphoresis excess loss of H20/Electrolytes, S/S:Increased heart rate, dry mucous membranes, thirst, lethargy, poor skin turgor, & confusion; Place in cooler environment, give fluids/elctrolytes.
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show | Emergency!!! Treat Immediately!! S/S: hot, dry skin, confusion, delirium, incoherent, may be unresponsive; Place them out of the sun, fan person, pour cool water on them & PO fluids Call 911
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Heat Stroke: | show 🗑
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Pulse | show 🗑
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Assess pulse for... | show 🗑
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Rate | show 🗑
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show | The pattern of the beats & the intervals between the beats (Regular or Irregular)
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Strength | show 🗑
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Equality | show 🗑
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show | Temporal pulse
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show | Carotid pulse & (Femoral Pulse if Carotid not palpable)
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Pulse site best for infants or young children up to age 3.... | show 🗑
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show | Apical Pulse
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If abnomal/intermittent, or inaccessible use this pulse site... | show 🗑
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Assessment of these two pulse sites reveal heart rate variations.... | show 🗑
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show | Apical Pulse
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show | Apical Pulse
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Pulse sites used to Assess circulation to hand ... | show 🗑
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Pulse site routinely used... | show 🗑
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show | Radial & Ulnar Pulse
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show | Radial Pulse
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How do you get a childs heart who has sinus dysrhythmia to become regular? | show 🗑
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show | Increase
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Some Drugs, Hypothermia, chronic pain & lying down causes the heart rate & pulse to... | show 🗑
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show | is when a regular interval occurs between each pulse or heart beat (count for 60 sec or 30 sec x 2)
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show | Abnomally elevated heart rate, >100 beats per minute in adults
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Bradycardia: | show 🗑
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show | is an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site.(Frequently associated with dysrhythmias)
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show | Compare apical & radial rates simultaneously to determine if a pulse deficit exists (two nurse assessing at same time)
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show | One examiner technique- Auscultate the apical pulse first & then the radial pulse immediately after. Report abnormal pulse rate to physician immediately!
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Apical rate 90 & Radial rate is 70 what is the pulse deficit? | show 🗑
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show | 0- absent,not discernible, 1+ Pulse diminished, barely palpable, 2+ Normal, easily palpable, 3+ Full pulse, increased, 4+ Strong, Bounding, Cannot be obliterated
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show | The exchange of Gases between the atmosphere & the blood, & the blood & the cells.
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show | Abdominal or normal pattern of exhalation & inhalation in which the ventilatory works done in the diaphragm.
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show | Breathing is difficult characterized by increased effort to inhale & exhale. (uses intercostal & accessory muscles)
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show | Increase in depth & rate >20/min
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Bradypnea | show 🗑
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show | Regular, > 20/min
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Hyperventilation | show 🗑
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show | rate is abnormally low & depth depressed
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show | Abnormally deep, but regular, increased rate
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show | Shallow breathing interrupted by irregular periods of apnea, condition of CNS, increased intracranial pressure followed by irregular period of apnea.
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show | Irregular rate, alternating periods of apnea & hyperventilation.
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show | Cheyne stokes
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Depth | show 🗑
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Systolic | show 🗑
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Diastolic | show 🗑
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Systolic pressure 120 minus diastolic pressure 80 what is the pulse pressure? | show 🗑
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show | The smaller the lumen the greater peripheral vascular resistance to blood flow. As resistances rises, arterial blood pressure rises. As vessels dilate & resistance falls, blood pressure drops.
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show | If blood volume increases, more pressure is exerted against arterial walls & B/P increases.
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Example of Blood Volume: | show 🗑
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show | thickness of blood affects the ease with which blood flows thru small vessels. The hematocrit (HCT), or % of RBC's in the blood, determines blood viscosity.
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Elasticity | show 🗑
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Cardiac Cycle Consist of two phases.. | show 🗑
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show | The ventricles contract & eject blood from the left ventricle into the aorta & from the right ventricle into the pulmonary artery.
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show | The ventricles relax & the atria contract to move blood into the ventricles & fill the coronary arteries.
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Events on the.... of the heart have the most dramatic effect on assessment findings. | show 🗑
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Body size & age would be considered with respect to... | show 🗑
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show | Increase
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Hypertension is higher, genetically & environmentally related in.. | show 🗑
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show | Antihypertensive & Narcotic analgesics
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show | B/P gradually rises & falls throughout the day & night. No two persons have the same pattern or degree of variation.
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show | Higher
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show | Hypertension 140/90 & above
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Prehypertension B/P... | show 🗑
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show | systolic 90 mm/Hg or below
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S/S of Hypotension: | show 🗑
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show | measure B/P between each position change & document each. (1 to 3 minutes between each)LYING, SITTING, & STANDING
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show | 60x72= 4320
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The amount of blood ejected from the left ventricle each minute at adult rest.. | show 🗑
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