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When do you do Vital signs
- *When emitted somewhere new
- *Change in health status
- *odd symptoms-pain, weak, hot
- *Before and After surgery
- *Before and After medications
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Vital signs consist of ?
- *Temperature
- *Pulse
- *Respirations
- *Blood Pressure
- *Oxygen saturation -(Pulse ox)
- *Pain
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Temperature
- Control mechanisms of human beings keep the body's core temperature or temperature of deep tissues relatively constant.
- *Acceptable Temp ranges ( 96.4-100.4)
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Body Temperature Regulation
- *Neural and vascular control
- *Heat production
- *Heat loss
- *Behavioral control
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Neural and Vascular Control
- *Hypothalamus controls body's SET POINT
- *Vasodilation & Sweating
- *Shivering & Vasoconstriction (tighter body has to work harder
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Heat Production
- Heat is produced as a by-product of metabolism
- *Muscular activity
- *Shivering
- *Non-shivering Thermogenesis (neonates-brown fat)
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Basal Metabolic Rate
Heat produced by body at rest
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Frostbite
- more externam, icy covering (nose, earlobes) but tissue break down
- *White waxy skin color
- *Graduate loss of sensation
- *Warm extremities slowly
- * Can not pronounce dead until warmed up b/c easier to bring a cold temp to high and come back to life.
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Heat Loss
- *Radiation
- *Conduction
- *Convention
- *Evaporation
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Radiation
Heat transferred from one service to another on its own (standing to fetal position)
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Conduction
Transfer of heat with direct contact
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Convention
Heat loss by circulation
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Evaporation
Liquid loss 600-900 mL a day
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Diaphoresis
visual perspiration on forehead and upper thorax reduces body temperature (fever, dehydration)
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Factors that affect body temperature
- *Age
- *Exercise
- *Hormone Level
- *Circadian Rhythms
- *Stress Environment
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Fever
- Heat loss unable to keep pace with excess heat production
- *results from alteration of hypothalamic set point caused by pyrogens that stimulate the immune system
- *Stimulates WBC production, suppresses growth of bacteria, and fights viral substances through production of interferon.
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Hyperthermia
- Malignant Hyperthermia
- Heat stroke
- *Body's too Hot
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Malignant Hyperthermia
Bodys reaction to anasethic reaction (high fever, seizer, then death)
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Mild Hypothermia
93.2-96.8 F
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Moderate Hypothermia
86-93.2 F
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Severe Hypothermia
- Less than 86 F
- *shivering, loss of memory, depression and poor judgement (below 34 C heart/respiratory rate &BP drop)
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Heat exaustion
Skin is wet, sweating, woozy, dry mouth
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Heat Stroke
skin is warm and dry, patient gets giddy(confused, weak, muscle cramp, visual change)
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Chill Phase
shiver, feverish
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Plateu Phase
body plays catch up, body warm and dry, things that go w/fever, chills go away
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Febrial Phase
- having a fever, diaphretic (heavy sweating)
- *Intervention: fever breaks
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Temperature Measurement
- *Tympanic Membrane
- *Rectal
- *Oral
- *Axilla
- *Skin
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Tympanic Membrane
Ear, thermometers vary in use, same thermometer on same patient
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Rectal
Should not take temp who is bleeding, rectal surgery, instead you can use regular thermometer
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Oral
Bucal mucosa- all the way in the back, capable of keeping mouth closed, least invasive, use sheath
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Axilla
Under arm, cant be extremely skinny, runs 2 degrees below normal
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Skin Temperature
- *Skin damage prior to taking temp
- *Temporal location
- * 2 degrees below normal
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Pulse
- Measures the pressure in the arteries (the left ventricle pumping out to body)
- *the # of pulsing sensations occurring in 1 min. is the pulse rate
- *Adult: 60-100
- *children have a higher, faster metabolism and are growing
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The Different Pulses
- Radial(underneath thumb) and carotid (neck) are commonly used because they are easily palpated
- *Temporal- Head
- *Brachial- Mid arm (elbow)
- *Ulnar
- *Femoral-half way through the leg
- *Popliteal-Knee
- *Posterior tibial-inside of ankle
- *Dorsalis Pedis- Top of foot (farthest away from heart)
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Apical Pulse
provides a more accurate assessment of heart rate (on the chest)
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Factors influencing Pulse Rates
- *Exercise
- *Temperature
- *Emotions
- *Drugs
- *Hemorrhage
- *Postural changes
- *Pulmonary Changes
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Pulse Assessment
- *Note Rhythm
- *Pulse volume
- full bounding
- Weak febrile thready
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Signs and Symptoms of Pulse Rate
- *Dyspnea
- *Fatigue
- *Pallor
- *Cyanosis
- *Palpitations
- *Syncope
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Blood Pressure
The force exerted on the walls of an artery created by the pulsing blood under pressure from the heart
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Systolic
The peak of max. pressure when ejection occurs (SKY)
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Diastolic
When the hear relaxes, the blood remaining in the arteries exerts a min. (Down)
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Physiology of Arterial BP
BP reflects the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity.
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Prehypertension
- 120/80
- Systolic range : 120-139
- Diastolic range: 80-89
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Stage 1 hypertension
- Systolic range: 140-159
- Diastolic range: 90-99
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Stage 2 hypertension
- Systolic: greater than 160
- Diastolic: greater than 100
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Influences on BP
- *Age
- *Stress
- *Ethnicity
- *Gender
- *Daily variation
- *Medications
- *Activity and Weight
- *Smoking
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Hypotension
considered present when they systolic BP falls to 90 mmHg or below
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Orthostatc hypotension (postural)
- symptomatic drop in BP with change in postion
- *due to decreased systemic resistamce, low blood volume, anemia, dehydration etc.
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Auscultation of BP
- indirect measurement based on basic principles or pressure
- *blood flows freely through arteris until inflated cuff exerts pressure and causes artery to collapse
- *When cuff pressure is released and blood flow returns=systolic BP
- *When sound disappears=diastolic BP
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Common Mistakes in BP Assessment by Auscultation
- *Cuff too wide
- *Cuff too narrow
- *Cuff wrapped improperly
- *Repeating assessments too quickly
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Respiration
the mechanism the body uses to exchange gases between the atmosphere and the blood and the cells
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Respiration involves 3 processes
- Ventilation
- Diffusion
- Perfusion
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Ventilation
the mechanical movement of gases in and out of the lungs
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Diffusion
The movement of oxygen and carbon dioxide between the alveoli and the red blood cells
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Perfusion
the distribution of RBC and from the pulmonary capillaries
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Measurement of Respiration
- *rate and depth of breathing
- *and the rhythm of ventilatory
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Respiratory Rate
observe a full inspiration and expiration when counting ventilations or respiratory rate
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Tachypnea
fast rate of breathing
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Hyperpnea
Faster and deeper breathing
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Apnea
- *sleep apnea
- *swallowing
- *chocking
- *Medicaiton
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Hyperventilation
- Fast and shallow
- *Anxiety, body blows out
- *too much CO2
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Hypoventilation
sleepy, damage to medula build up
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Cheyne-Stokes
- Respiratory rate/patter of death
- *deep ventilation
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Kussmauls respirations
- increase rate, fruity breath
- *confuession
- *change in mental status
- *look drunk
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Respiratory Assessments
- *depth of respirations is assessed by observing the degree of excursion or movement in the chest wall & regularity respiratory rhythm
- *May also see associated diaphragmatic movement (babies not adults)
- *Ventilatory movements may be described as deep, normal, or shallow
- *Use of intercostal or accessory muscles and retractions
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Factors influencing Character of Respirations
- *Exercise: increase
- *Acute pain: Shallow
- *Anxiety:increase
- *Smoking:increase
- *Body position
- *Medications: increase and decrease
- *Neurologic Injury: increase and decrease
- *Hemoglobin Function: increase
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Measurement of Arterial Oxygen Satuation
- *A pulse oximeter permits the indirect measurement of oxygen saturation
- *Light sensor that distinguishes between oxygenated and deoxygenated hemoglobin molecules
- *Accuracy dependent upon light transmission and adequate arterial pulsations
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Mobility
- a person's ability to move around free in his or her envrornment
- * serves many purposes
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Bed Rest
an intervention in which the client is restricted to bed for therapeutic reasons
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Body Mechanics
- coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment
- *used during lifting, bending, moving, and performing activities of daily living
- *balance is achieved when a relatively low center of gravity is balanced over a wide base of support
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Principles of Body Mechanics
- *Equilibrium maintained as long as center of gravity aligns with base of support
- *Facing different of movement prevents abnormal twisting of the spine
- *Balanced use of arms and legs reduced risk of back injury
- *Leverage, rolling, turning and pivoting requires less work than lifting
- *Less friction= less force needed to move object
- *Alternating period of rest and activity helps to reduce fatigue and injury
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Musculoskeletal System (regulation of movement)
- Bones, joints, ligaments, tendons, cartilage
- *what is the function of the skeletal system
- *what changes occur in bones as a person ages
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Skeletal Muscle (regulations of movement)
- *facilitates movement
- *determines body form and contour
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Nervous System (regulation of movement)
- *regulation of movement and posture
- *Requires neurotransmitter production, transmission of impulses from nerve to muscle and activation of muscle activity
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Pathological Influences on Mobility
- *Congenital defects
- *Disorders of bones, joints, and muscles
- *CNS damage
- *Musculoskeletal trauma
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Congenital defects
Osteogenesis imperfecta, scollosis
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Disorders of bones, joints, and muscles
Osteoporosis, arthritis, non-imflammatory joint disease
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CNS damage
Damage to component that regulates voluntary movement
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Musculoskeletal trauma
Bruises, contusions, sprains, and fractures
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Effects of Immobility
- *Physiological effects
- *Respiratory changes
- *Changes in metabolic rate
- *Changes in metabolism of carbohydrates, fats, and proteins
- *Fluid and electrolyte balances
- *Gastrointestinal changes
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Effects of Immobility (systems)
- *Cardiovascular changes
- *Musculoskeletal changes
- *Integument changes
- *Urinary elimination changes
- *Psychosocial effects
- *Developmental effects
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Assessment of Mobility
- *Range of joint motion
- *Gait
- *Activity tolerance
- *Body alignment
- *Pain associated with activity
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Implementation
Nursing interventions for the completely or partially immobilized client focus on health promotion and prevention of the hazards of immobility
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Nursing Interventions and Health Promotion
- *Musculoskeletal system
- *Skin integrity
- *Elimination system
- *Psychosocial problems
- *Developmental changes
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Health Promotion
Structured exercise programs for immobile clients can enhance their feelings of wellbeing, as well as their endurance, strength, and health
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Nursing Interventions in Acute Care
- *Respiratory system
- *Maintaining a patent airway
- *Cardiovascular system
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Nursing Interventions
- *Respiratory system
- *Promoting expansion of the chest and lungs
- *Preventing stasis of pulmonary secretions
- *Metabolic system
- *Cardiovascular system
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Therapeutic Positioning
- Clients with impaired nervous or musculoskeletal system functioning; increased weakness, or restricted to bed rest benefit from therapeutic positioning
- *Repositioning
- -clients should be repositioned as needed
- -at lease every 2 hours if they are in bed
- - every 20 to 30 min. if they are sitting in a chair
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Fowler's
HOB elevated, support and align hips and spine
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Supine
Back lying, support with pillows, trochanter rolls, splints
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Sim's
Semiprone on right or left side with weight placed on ilium, humerus, and clavicle
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Lateral
Side lying with proper spine alignment
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Range-of-Motion Exercises
- *the easiest intervention to maintain or improve joint mobility for clients is the use of range of motion exercies
- *active range of motion exercises
- -the client is able to move his or her joints
- *passive range of motion exercises
- - the nurse moves the client's joints
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Assisting with Ambulation
- *Clients with hemiplegia/hemiparesis
- -use of gait belt
- -support affected side
- *Clients feeling dizziness or faint during ambulation
- -return to closest bed or chair
- -gently lower client to floor to prevent injury if necessary
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The Skin's Function
- *protection
- *secretion
- *excretion
- *temperature regulation
- *sensation
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Skin's 3 Layers
- Epidermis: shields underlying tissue
- Dermis: contains nerves, vessels, and glands
- Subcutaneous tissue: insulates and cushions skin
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Feet and Nails
- *Require special attention
- *Discomfort causes stress and pain
- *The normal nail is transparent, smooth, and convex, with a pink nail bed and white tip
- *Changes in shape, thickness, and curvature can occur
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Nursing Knowledge Base
- *Personal preferences for hygiene
- *Hygiene care is never routine
- *During hygiene
- -assess physical status and limitations
- - assess client's readiness to learn
- -provide privacy
- -foster physical well being
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Tub or shower
More thorough than bed bath
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Complete Bed Bath
for clients who are dependent and require total hygienic care
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Partial bed bath
involves bathing only those parts that would cause discomfort odor if left unbathed
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Perineal Care
- *part of bed bath
- *clients most in need are those with secretions or Foley catheters and following rectal surgery or childbirth
- *be alert to discharge, skin irritation, and odors
- *good perineal care prevents skin irritation and breakdown
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Foot and Nail Care
- *soak and soften cuticles
- *cleanse and dry the feet thoroughly
- *trim nails straight across (check agency policy regarding trimming of nails)
- *inspect for lesions, dryness, and signs of infection
- *clients with DM or PVD are at risk for impaired circulation
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Temperature tells us
infection and inflammation
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What is the minimum time length for checking pain level??
4 hours min
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Core temperature
within deep tissues
*** Rectal
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Hypothalamus controls the body's ???
"Set Point"
¨Vasodilation & Sweating
¨Shivering & Vasoconstriction
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Disease or trauma to the hypothalamus or spinal cord (which carries hypothamic messages) does what????
decreases body’s ability to control body temperature
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Heat is produced as a by-product of
metabolism
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Basal Metabolic Rate
heat produced by body at rest
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Why cant newborns shiver??
Non-shivering Thermogenesis (neonates- brown fat)
Newborns can not shiver they have a layer of brown fat
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BMR decreases with???
with age and they have a hard time maintaining heat
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Pulse is the ...???
measurement of Circulation through the pts body
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Apical pulse is where the
the Left ventricle and right ventricle are squezing
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5L a minute of what???
blood is circulating in you body
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PMI
-point of maximal intensity (apical pulse) pointy part of the heart lies closest to the skin. 5th intercostal midclavicular
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The Pulse measures..???
- Rate(speed)
- Force(strength)
- Rhythm (regularity) if irregular auscultate or palpate for one min
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Radial and carotid arteries are commonly used
because they are easily palpated
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Apical pulse provides a more
accurate assessment of heart rate.
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Strength and amplitude of a pulse reflects
volume & pressure of blood ejected against arterial wall with each contraction & condition of vasculature leading to pulse site
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Normal Pulse for newborns
- 120-160 infants because they are growing and their basal metabolic is faster and Lower blood pressure. Not normal for an infant to have a pulse rate lower
- than 100
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Normal Adult Pulse
60-100
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Bounding Pulse
we don’t want it to be like that all the time, body is working a lot harder more fluid in body
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Weak Pulse
you can feel it but its hard to find
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Thready Pulse
don’t feel every beat could feel irregular, adjust fingers sometimes to feel it
- *is the pulse the same on each side
- -if unequal than there is some kind of problem
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Blood pressure is the force
exerted on the walls of an artery created by the pulsing blood under pressure from the heart.
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Blood pressure reflects the
interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity.
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your temperature is lowest
around 1- 4:00 am
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you temperature is at its Maximum at
6:00 pm, and then declines to early morning levels
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When the fever “breaks,” the client becomes
afebrile
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The heat of the blood is what to the thermometer??
conducted to the thermometer probe
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Tympanic temperature relies on the
radiation of body heat to an infrared sensor.
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Bladder or cuff too wide
False low reading
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Bladder or cuff too narrow or too short
False high reading
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Cuff wrapped too loosely or unevenly
false high reading
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Arm below heart level
False high
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Arm above heart level
False low
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