Nurs200

• *When emitted somewhere new
• *Change in health status
• *odd symptoms-pain, weak, hot
• *Before and After surgery
• *Before and After medications

• *Temperature
• *Pulse
• *Respirations
• *Blood Pressure
• *Oxygen saturation -(Pulse ox)
• *Pain

• 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)

• *Neural and vascular control
• *Heat production
• *Heat loss
• *Behavioral control

• *Hypothalamus controls body's SET POINT
• *Vasodilation & Sweating
• *Shivering & Vasoconstriction (tighter body has to work harder

• Heat is produced as a by-product of metabolism
• *Muscular activity
• *Shivering
• *Non-shivering Thermogenesis (neonates-brown fat)

Heat produced by body at rest

• 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.

• *Radiation
• *Conduction
• *Convention
• *Evaporation

Heat transferred from one service to another on its own (standing to fetal position)

Transfer of heat with direct contact

Heat loss by circulation

Liquid loss 600-900 mL a day

visual perspiration on forehead and upper thorax reduces body temperature (fever, dehydration)

• *Age
• *Exercise
• *Hormone Level
• *Circadian Rhythms
• *Stress Environment

• 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.

• Malignant Hyperthermia
• Heat stroke
• *Body's too Hot

Bodys reaction to anasethic reaction (high fever, seizer, then death)

93.2-96.8 F

86-93.2 F

• Less than 86 F
• *shivering, loss of memory, depression and poor judgement (below 34 C heart/respiratory rate &BP drop)

Skin is wet, sweating, woozy, dry mouth

skin is warm and dry, patient gets giddy(confused, weak, muscle cramp, visual change)

shiver, feverish

body plays catch up, body warm and dry, things that go w/fever, chills go away

• having a fever, diaphretic (heavy sweating)
• *Intervention: fever breaks

• *Tympanic Membrane
• *Rectal
• *Oral
• *Axilla
• *Skin

Ear, thermometers vary in use, same thermometer on same patient

Should not take temp who is bleeding, rectal surgery, instead you can use regular thermometer

Bucal mucosa- all the way in the back, capable of keeping mouth closed, least invasive, use sheath

Under arm, cant be extremely skinny, runs 2 degrees below normal

• *Skin damage prior to taking temp
• *Temporal location
• * 2 degrees below normal

• 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

• 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)

provides a more accurate assessment of heart rate (on the chest)

• *Exercise
• *Temperature
• *Emotions
• *Drugs
• *Hemorrhage
• *Postural changes
• *Pulmonary Changes

• *Note Rhythm
• *Pulse volume
• full bounding
• Weak febrile thready

• *Dyspnea
• *Fatigue
• *Pallor
• *Cyanosis
• *Palpitations
• *Syncope

The force exerted on the walls of an artery created by the pulsing blood under pressure from the heart

The peak of max. pressure when ejection occurs (SKY)

When the hear relaxes, the blood remaining in the arteries exerts a min. (Down)

BP reflects the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity.

• 120/80
• Systolic range : 120-139
• Diastolic range: 80-89

• Systolic range: 140-159
• Diastolic range: 90-99

• Systolic: greater than 160
• Diastolic: greater than 100

• *Age
• *Stress
• *Ethnicity
• *Gender
• *Daily variation
• *Medications
• *Activity and Weight
• *Smoking

considered present when they systolic BP falls to 90 mmHg or below

• symptomatic drop in BP with change in postion
• *due to decreased systemic resistamce, low blood volume, anemia, dehydration etc.

• 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

• *Cuff too wide
• *Cuff too narrow
• *Cuff wrapped improperly
• *Repeating assessments too quickly

the mechanism the body uses to exchange gases between the atmosphere and the blood and the cells

• Ventilation
• Diffusion
• Perfusion

the mechanical movement of gases in and out of the lungs

The movement of oxygen and carbon dioxide between the alveoli and the red blood cells

the distribution of RBC and from the pulmonary capillaries

• *rate and depth of breathing
• *and the rhythm of ventilatory

observe a full inspiration and expiration when counting ventilations or respiratory rate

slow rate

fast rate of breathing

Faster and deeper breathing

• *sleep apnea
• *swallowing
• *chocking
• *Medicaiton

• Fast and shallow
• *Anxiety, body blows out
• *too much CO2

sleepy, damage to medula build up

• Respiratory rate/patter of death
• *deep ventilation

• increase rate, fruity breath
• *confuession
• *change in mental status
• *look drunk

• *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

• *Exercise: increase
• *Acute pain: Shallow
• *Anxiety:increase
• *Smoking:increase
• *Body position
• *Medications: increase and decrease
• *Neurologic Injury: increase and decrease
• *Hemoglobin Function: increase

• *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

• a person's ability to move around free in his or her envrornment
• * serves many purposes

an intervention in which the client is restricted to bed for therapeutic reasons

• 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

• *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

• Bones, joints, ligaments, tendons, cartilage
• *what is the function of the skeletal system
• *what changes occur in bones as a person ages

• *facilitates movement
• *determines body form and contour

• *regulation of movement and posture
• *Requires neurotransmitter production, transmission of impulses from nerve to muscle and activation of muscle activity

• *Congenital defects
• *Disorders of bones, joints, and muscles
• *CNS damage
• *Musculoskeletal trauma

Osteogenesis imperfecta, scollosis

Osteoporosis, arthritis, non-imflammatory joint disease

Damage to component that regulates voluntary movement

Bruises, contusions, sprains, and fractures

• *Physiological effects
• *Respiratory changes
• *Changes in metabolic rate
• *Changes in metabolism of carbohydrates, fats, and proteins
• *Fluid and electrolyte balances
• *Gastrointestinal changes

• *Cardiovascular changes
• *Musculoskeletal changes
• *Integument changes
• *Urinary elimination changes
• *Psychosocial effects
• *Developmental effects

• *Range of joint motion
• *Gait
• *Activity tolerance
• *Body alignment
• *Pain associated with activity

Nursing interventions for the completely or partially immobilized client focus on health promotion and prevention of the hazards of immobility

• *Musculoskeletal system
• *Skin integrity
• *Elimination system
• *Psychosocial problems
• *Developmental changes

Structured exercise programs for immobile clients can enhance their feelings of wellbeing, as well as their endurance, strength, and health

• *Respiratory system
• *Maintaining a patent airway
• *Cardiovascular system

• *Respiratory system
• *Promoting expansion of the chest and lungs
• *Preventing stasis of pulmonary secretions
• *Metabolic system
• *Cardiovascular system

• 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

HOB elevated, support and align hips and spine

Back lying, support with pillows, trochanter rolls, splints

Face down

Semiprone on right or left side with weight placed on ilium, humerus, and clavicle

Side lying with proper spine alignment

• *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

• *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

• *protection
• *secretion
• *excretion
• *temperature regulation
• *sensation

• Epidermis: shields underlying tissue
• Dermis: contains nerves, vessels, and glands
• Subcutaneous tissue: insulates and cushions skin

• *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

• *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

More thorough than bed bath

for clients who are dependent and require total hygienic care

involves bathing only those parts that would cause discomfort odor if left unbathed

• *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

• *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

infection and inflammation

4 hours min

within deep tissues

*** Rectal

"Set Point"

¨Vasodilation & Sweating

¨Shivering & Vasoconstriction

decreases body’s ability to control body temperature

metabolism

heat produced by body at rest

Non-shivering Thermogenesis (neonates- brown fat)

Newborns can not shiver they have a layer of brown fat

with age and they have a hard time maintaining heat

measurement of Circulation through the pts body

the Left ventricle and right ventricle are squezing

blood is circulating in you body

-point of maximal intensity (apical pulse) pointy part of the heart lies closest to the skin. 5th intercostal midclavicular

• Rate(speed)
• Force(strength)
• Rhythm (regularity) if irregular auscultate or palpate for one min

because they are easily palpated

accurate assessment of heart rate.

volume & pressure of blood ejected against arterial wall with each contraction & condition of vasculature leading to pulse site

• 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

60-100

we don’t want it to be like that all the time, body is working a lot harder more fluid in body

Normal

you can feel it but its hard to find

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

exerted on the walls of an artery created by the pulsing blood under pressure from the heart.

interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity.

around 1- 4:00 am

6:00 pm, and then declines to early morning levels

afebrile

conducted to the thermometer probe

radiation of body heat to an infrared sensor.

False low reading

False high reading

false high reading

False high

False low