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what are the 5 vital signs
- temperature
- pulse
- blood pressure
- respirations
- pain
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baseline =
ususal state of health
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UAP =
unlicensed assistive personnel
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nurse cannot delegate what?
the first set of anything
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temperature =
heat produced - the heat lost
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normal range for temp =
97.0-99.5
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what regulates temp
hypothalamus
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mechanisms for heat production =
- metabolism
- shivering
- piloerection
- exercise
- hormones
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what are some development considerations for temperature
- neonates cannot shiver (have brown fat)
- elderly have lower baseline temp
- kids sensitive to changes in environmental temp
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pyrexia
fever 100.4 or greater
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what does the hypothalamus do in regards to temp
reset the set point for body temp
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FUO
fever of unknown origin
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neurogenic fever
caused from damage to hypothalamus
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antipyretics
ibuprofen, acetaminophen, aspirin
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what hapens to pulse and resp with fever
they go up
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oral temp avg
98.6 or 37c
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oral temp advantages and disadvantages
- advantages
- comfortable, easily accessible, accurate surface temp
- disadvantages
- must wait 30 min after food, drink , smoke etc
- must hold in mouth in posterior sublingual pocket
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rectal temp avg
99.5 or 37.5
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rectal advantage and disadvantage
- advantages = reliable core temp
- dis = can't use when diarrhea, rectal surgery, bleeding, impaction, low wbc,
- can stimulate vagus nerve not on newborns
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axillary avg temp
97.7 or 36.5c
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axillary advantages
safe, inexpensive, used with newborns and unconcious
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axillary disadvantages
positional, long time with glass, 5-10min,
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tympanic avg temp
99.5 or 37.5 c
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tympanic advantages
accessible, minimal positioning, unaffected by eating and drinking, provides core temp
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tympanic disadvantages
- inaccurate with position
- need to remove hearing aids
- dificult in children < 3months
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pulse locations
- temporal
- carotid
- brachial
- radial
- femoral
- popliteal
- posterior tibial
- dorsalis pedis
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parasympathetic NS does what to HR compared to symathetic
- para slows
- sympathetic speeds up
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apical auscultate how long
one minute
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pulse amplitudes =
- 0 = absent
- 1+ = weak, thready
- 2+ = normal
- 3+ = increased
- 4+ = bounding
- doppler
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which is an active process in respirations
inspiration
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Dyspnea
difficult or labored breathing
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BP =
CO x peripheral resistance
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stroke volume =
volume of blood pumped by LV one time
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BP determined by
- CO
- peripheral resistance
- volume
- viscosity
- elasticity of vessel walls
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normal BP for adult
100-120/60-80
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othostatic hypotension =
systolic drops 20mmHg diastolic drops 10mmHg after 3 minutes
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orthostatic hypotension is caused by what
peripheral vasodilation w/o compensatory rise in CO
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BP cuff size standards =
- length of bladder 80% arm circumference
- width of bladder 40% arm circumference
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