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Vitals,General Survey, IV therapy

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
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Question
Answer
The width of the bladder of a BP cuff should equal...?   40% of the circumference of patient's arm  
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What is the purpose of a palpable BP?   To determine target BP/unable to hear during routine BP check/low BP, unable to assess via stethoscope  
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What is a normal O2 range?   92%-100%  
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What factors may affect BP?   Age, sex, weight, exercise, emotions, stress  
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What are the 4 characteristics of pulse?   Rate, Rhythm, Symmetry & Strength (also called amplitude)  
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How can a pulse rhythm be classified?   Regular or irregular  
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Name two common causes of visceral pain.   pancreatic cancer, metastases in the abdomen (less severe; cramping,etc)  
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What is the most common form of pain?   Visceral pain  
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What causes visceral pain?   Activation of pain receptors d/t infiltration, compression, extension or stretching of the viscera  
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What causes somatic pain?   Activation of pain receptors in either the cutaneous or deep tissues  
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What is deep somatic pain?   Pain in the musculoskeletal tissues  
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What is PQRST?   Pain assessment: Point/location,Quality/Quantity,Radiation,Scale,Timing  
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What is the normal range of respirations for a neonate? A 1 year old?   30-40 breaths per minute/ 20-40 breaths per minute  
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What is the normal range of respirations for an adult?   12-20 breaths per minute  
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What is the normal range of respirations for a 2 year old?   25-32 breaths per minute  
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What is the normal range of respirations for a school age kid?What about a 12-14 year old?   20-26 breaths per minute/18-22 breaths per minute  
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What is tachypnea?   Rapid respirations  
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What is bradypnea?   slow rate of respirations  
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What is considered prehypertension?   120-139/80-89  
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What is a normal BP for an adult?   <120/<80  
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What is considered hypertension stage 1?   140-159/90-99  
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What is considered hypertension stage 2?   160 and up/100 and up  
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What is the average pulse rate for a newborn?   100 to 170  
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What is the average pulse rate for a 1 year?   80 to160  
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What is the average pulse rate for 3yr?   80 to 120  
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What is the average pulse rate for 6 year old? 10 year old?   70 to 115/ 70 to110  
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What is the average pulse rate for a 14 year old? An adult?   60 to 110/ 60 to 100  
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Cheyne-Stokes   Cycle in which respirations gradually wax and wane in a regular pattern with patterns apnea alternating the cycle. Seen in heart failure, renal failure, meningitis, OD, increased ICP. Normal in infants and eldery during sleep.  
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Diurnal rhythm   daily cycle of peak and trough-BP climbs to high late afternoon, declines to early morning low  
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How is the amplitude of a pulse graded?   0-absent 1+ - weak and thread 2+ - normal 3+ Full and bounding (abnormal)  
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What sort of solution is a LR?   Isotonic  
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How many drips per minute for micro tubing?   60 drips per minute  
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How many drips per minute for macro tubing?   10,15 OR 20 drips per minute  
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What are 3 examples of hypertonic solutions?   D5 1/2 NS, D5 1/3 NS, D5 LR  
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What solutions is isotonic on the shelf but hypotonic once administered? Why?   D5W because the sugar is metabolized right away, and then it's just water.  
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What is 1/2 NS- Hypotonic, Isotonic or Hypertonic?   Hypotonic  
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Hypertonic solutions shrinks cells and causes blood vessels to expand greatly, T or F   True  
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Hypotonic solutions shrink cells and cause blood vessels to expand greatly, T or F   False- they cause cells to expand and shrink vessels  
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What solution is used to treat dehydration?   LR- lactated ringers  
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Which patients should not be given hypertonic solutions?   DKA (dextrose), impaired heart or kidney function(fluid overload)  
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Which patients should not be given hypotonic solutions?   Nuero pts- at risk for increased ICP d/t CVA, head trauma, neurosurgery or pts w third spacing issues (burns, trauma, malnutrition, liver disease)  
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Which patients should not be given LR?   Liver disease- their liver can't metabolize the lactate  
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Which solution promotes diuresis, provides calories and sodium chloride, corrects excessive fluid loss and prevents alkalosis?   Hypertonic  
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What are hypotonic solutions used for?   preventing dehydration, preventing and treating ketosis, supply free water, promote sodium diuresis  
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What are signs of phlebitis?   IV site warm to touch, reddened/red streaks. Signs of infection.  
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What are signs of infiltration?   IV site cool to touch, pale  
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What are signs of dehydration?   Dry skin, sunken eyes, poor skin turgor, decreased output, confusion, dry mucous membranes  
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What are signs of fluid overload?   altered LOC, distended neck veins, crackles in lungs, periorbital edema  
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What do TPN, NTG, Insulin, cardiac titrated drugs and PCA have in common?   They CANNOT be run by gravity. MUST USE PUMP.  
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Which products require a second RN to double check?   Blood products, insulins, heparin, PCA  
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