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Define blood pressure (BP)
force exerted by the blood against the aterial vessel walls
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What factors makeup BP?
- -Systolic (contraction)
- -Diastolic (ventricles relaxed & heart rested)
- -Pulse pressure
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1st sound heard when taking BP is called?
Systolic
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Last sound (Karortkoff)heard when taking BP?
Diastolic
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What factors affect BP?
- -Cardiac Output
- -Peripheral vascular resistance (BP=CO x R)
- -Elasticity and distensibility
- -Blood Volume
- -Blood Viscosity
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Where is BP taken?
Upper arm closest to heart 1 inch above brachial
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What type of equipment is needed to take accurate BP?
sphygmomanometer and stethoscope
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What factors can cause an inaccurate BP reading?
- -Bladder or cuff too wide, narrow, or short
- -Cuff wrapped loosely or unevenly
- -Deflatting cuff too slowly or quickly
- -Arm below or above heart level
- -Arm not supported
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Normal BP reading?
- < 120 and < 80
- (129/88 considered normal above that is pre hypertensive)
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Define hypertension?
>140/90 and symptomatic
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Define hypotension?
< 90/60 and symptomatic (light headed, pale, decreased level of consciousness)
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Define pulse oximetry?
non invasive measurement of arterial blood oxygen saturation (percent which hemoglobin is filled with O2)
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Normal Pulse oximetry value?
> 90% (normal SpO2 is > 90%)
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What equipment needed to obtain pulse oximetry reading?
Pulse oximeter
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Factors that give you a false pulse oximetry reading?
- -direct sunlight
- -carbon monoxide poisoning
- -IV dyes
- -conditions that decrease blood flow (hypothermia, edema, hypotension)
- -artificial nails & certain nail colors
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Purpose of monitoring blood glucose levels?
- check to see if hyper or hypoglycemic
- check parameters for treating blood glucose
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Normal BS range?
70-110 mg/dl
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Where do you obtain a BS sample from?
capillary sample (in adults the lateral side of finger)
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Define glycemia?
presence or level of glucose in one's blood
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Define hypoglycemia?
abnormal low levels of blood sugar (glucose)
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Define hyperglycemia?
high blood sugar
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Define intake?
measurment of liquids ingested or infused into body (including liquids, semi liquids, liquid meds, enteral tube feedings, IV therapy, blood components, and parenteral nutrition)
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Examples of intake?
- oral fluids (@ rm temp)
- ice chips (measured at 50% of measured volume)
- IV fluids & TPN
- Blood products
- Tube feedings
- Fluid Meds (oral or IV)
- Irrigation fluids
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Define output?
all liquids exerted from body
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Output examples?
- Urinary (urinals, bed pans, caths)
- NG drainage
- Drainage tubes (wounds, CT)
- diarrhea/stools
- stomies
- osmosis
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How do you measure intake and output?
chest tube, amt in oral/IV fluid, urine output, emesis/puking, diarrhea, wound drainage. When indicated you total the value and evaluate the I & O at the end of each shift at specified time,s usually 8 hrs.
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What is importance in taking input & output?
physical assessment d/t changes w/n pt (ie:if they are putting out more then in)
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Define components of fluid balance?
- Fluid Volume Deficit: output greater then intake, < BP, > pulse, fever, flat neck veins when supine, slow venous filling of hands, rapid wt loss, dry skin, and tenting.
- Fluid Volume Excess: intake greater then output, crackle (pulmonary edema), bound pulse, irregular venous distention (IVD)
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If pt has fluid volume overload, how would this effect fluid volume deficit/excess?
- Deficit: wt gain
- Excess: in > out, crackles, bounding pulse, IVD
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If pt had fluid volume deficit/dehydration, how would this effect deficit/excess?
- Deficit: dehydration
- Excess: out > in, decreased BP, increased pulse, fever
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What makes up Vitals?
- Temp
- Pulse
- BP
- Oxygen Saturation
- Respiration
- Pain
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Define body temp?
- difference between heat produced and heat lost
- regulated in hypothalmus of brain
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Normal body temp?
36-38 C or 96.8-100.4 F
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Body temp regulated by?
- Heat Production: metabolism, skeletal muscles (shiver), sympathetic stimulation(vasoconstriction)
- Heat loss: periperal vasodialation, evaporation
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4 places a temp can be taken?
- oral
- rectal
- tympanic
- axillary
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Define pulse?
palpable bounding of blood flow
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Normal Pulse rate?
60-100 bpm
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Pulse > 100 bpm is called?
tachycardia
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Pulse <60 bpm called?
bradycardia
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Define rhythm?
regularity of beats
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Characteristics of pulse?
- rate
- rhythm
- quality
- symmetry
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Where do you find apical pulse?
4th to 5th intercostal space at left midclavicular line
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Normal RR?
- Adult: 12-20
- Tachypnea: >20
- Bradypnea: <12
- Apnea: absence
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3 factors that make up respiration characteristics?
- rate: # breaths we take
- depth: degree of chest expansion
- pattern: regularity of effort
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What does suffix pnea mean?
breathing
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What can cause apnea?
- death
- heart attack
- trauma
- chocking
- sleep apnea
- COPD
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What can cause tachypnea?
- hyperventillation
- exercise
- smoking
- caffeine
- amphetamines
- fever
- pain
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What can cause bradypnea?
- decreased hemoglobin
- breathing disorder (COPD)
- barbituates
- beat blockers
- narcotics
- general anesthesias
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What is importance of taking a vital?
- Can show signs of sudden change in pt condition
- Indicates normal functioning of circulatory, pulmonary, neurological, and endocrinological systems
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When do you take vitals?
- pt admit to facility
- per MD order
- home care visits
- before/ after surgery, invasive procedures, admin of certain meds, or nursing interventions
- change in pt condition or pt reports distress
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S & S on increase body temp?
- tachycardia
- hypotension
- flushed skin
- shiver/chills
- dry/diaphoretic skin
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S & S of low temp?
- feel cold/cold to touch
- pale
- shivery
- decreased pulse
- shallow respiration
- decreased level of consciousness
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RN intervention for elevated temp?
- keep linens dry
- cool enviro
- administer antipyretics
- increase fluids
- good nutrition
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RN interventions for low body temp?
- heat enviro
- cover with warm blankets
- drink warm fluids
- remove wet clothes
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