Final Review- Combined Sets
Radial Pulse
Felt slightly after S1
Liters
L
Grams
g
Micro
One-millionth of base
Child Vital Sign Range
Temp: Oral, 98.2-100oF Blood Pressure: 95/57
Milligrams
mg
Fahrenheit
(0C x 1.8) + 32 Freezing = 32 oF Boiling = 212 0F
Pulse Volume Scale (Amplitude/Strength of pulse)
0 = Absent pulse 1+ = Weak and thready pulse 2+ = Normal pulse 3+ = Bounding pulse (Very strong, typically after exercise, increase in fluids, or anxious)
mL -> L L -> mL
1 L/ 1000 mL 1000 mL/1 L
fl oz -> c c -> fl oz
1 c/8 fl oz 8 fl oz/1 c
mm -> cm cm -> mm
1 cm/ 10 mm 10 mm/1 cm
tbsp -> fl oz fl oz -> tbsp
1 fl oz/2 tbsp 2 tbsp/ 1 fl oz
mL -> fl oz fl oz -> mL
1 fl oz/30 mL 30 mL/1 fl oz
in -> ft ft -> in
1 ft/12 in 12 in/ 1 ft
cm -> in in -> cm
1 in/2.5 cm 2.5 cm/ 1 in
kg -> g g -> kg
1 kg/ 1000 g 1000 g/ 1 kg
kg -> lbs lbs -> kg
1 kg/2.2 lbs 2.2 lbs/1 kg
mcg -> mg mg -> mcg
1 mg/1000 mcg 1000/1 mg
c -> pt pt -> c
1 pt/ 2 c 2 c/1 pt
mL -> pt pt -> mL
1 pt/500 mL 500 mL/1 pt
L -> qt qt -> L
1 qt/ 1 L (1000 mL) 1 L (1000 mL)/1 qt
fl oz -> qt qt -> fl oz
1 qt/ 32 fl oz 32 fl oz/1 qt
c -> qt qt -> c
1 qt/ 4 c 4 c/1 qt
pt -> qt qt -> pt
1 qt/2 pt 2 pt/1 qt
tsp -> tbsp tbsp -> tsp
1 tbsp/ 3 tsp 3 tsp/1 tbsp
mL -> tbsp tbsp -> mL
1 tbsp/15 mL 15 mL/1 tbsp
mL -> tsp tsp -> mL
1 tsp/ 5 mL 5 mL/1 tsp
ft -> yd yd -> ft
1 yd/ 3 ft 3 ft/ 1 yd
Factors Affecting Temperature
1) Age: Very young have a large surface area and mass ratio & lose heat rapidly to environment, the very old begins to lose ability to maintain this 2) Normal Hormonal Ranges: Female ovulation can raise this 3) Exercise, Activity & Dehydration 4) Injury/Illness: Fever as a response to infectious/inflammatory response 5) Food/Drink Consumption, Smoking: Have to take this 20-30 mins after eating, drinking, or smoking 6) Circadian Rhythms/Stress: Stress can raise the metabolic rate
Factors Affecting the Pulse
1) Exercise, Fever, Heat Exposure, & Medications 2) Changing Positions: Going from sitting to standing can raise this 3) Pain: Can cause tachycardia 4) Disease: Can cause tachycardia or bradycardia 5) Age 6) Stress, Anxiety & Fear: Can raise this 7) Gender/In shape: Men & athletes can have lower of this 8) Fluid loss/Heart failure
Hyperpyrexia
105-106+ oF fever Considered a medical emergency Can cause severe dehydration & changes in sodium (Puts client at risk for seizures)
lbs -> oz oz -> lbs
16 oz/ 1 lb 1 lb/ 16 oz
mg -> g g -> mg
1g/1000 mg 1000 mg/ 1g
Pulse Deficit
A condition in which the apical pulse rate is greater than the radial pulse rate indicates a perfusion deficit Assess: 2 clinicians should measure the apical & radial pulse simultaneously **W/o this, the apical & radial pulses should be the same rate If there is a big difference, need to figure out why apical is not getting enough blood flow out of the peripheral Need to assess skin for color, synosis (numbness/dizziness)
Irregular & abnormal pulse
Assessments required: Find out if irregularity is new, if client is symptomatic, and assess pulse for a full 60 sec. through auscultation/palpations Intervene: Document findings, determine if client is on meds for this and if they took them that day Teach: Refer them to a healthcare provider if it is abnormal, make client aware of signs & symptoms so they are able to report it to a healthcare provider, encourage them to take meds @ same times during the day (if necessary) & note response to medication
Ways to Determine Pulse:
Ausculation & Palpation
Respirations
Body's mechanisms of exchanging CO2 and O2 Measured in breaths per minute
How to Assess Peripheral Pulse Locations
Carotid: Only palpate 1 at a time, can occlude the blood flow to the brain (can cause dizziness & fainting) Radial: Press fingers right beneath bone on thumb side of the wrist Dorsalis pedis: Put 3 fingers b/t big toe & the 2nd toe and palpate up toward the bony prominents (Don't palpate too hard- can occlude the artery) Posterior tibilais: Take hand & wrap around the ankle, finger tips and palpate behind ankle
Cardiac Output
Determined by stroke volume Amount of volume of pressure coming out of the heart
Types of Thermometers
Digital: -Oral (blue): Probe is slim & straight -Rectal (red): Probe is rounded at bottom to prevent damage to rectal mucosa Temporal: Noninvasive, good for children & comatose, or those who cannot use an oral Tympanic: Used in ear, closely related to core temp. Reflects off tympanic/ear drum
Convection
Dispersion of heat by air currents ex)Fan (changes temp in room)
Evaporation
Dispersion of heat molecules through water vapor Insensible water loss: -Perspiration -Panting Client pants to lower temperature, can cause flu-like deficit in clients
Palpation
Examination by touch How we assess peripheral pulses
Peripheral Pulse
Felt via palpation/touch via temporal, carotid, brachial & radial, femoral, popliteal, dorsalis pedis, posterior tibialis Check and compare both sides: Make sure they are both regular Work your way distally Listen for bruits (swishing sound) if needed, particularly the carotid
Pyrexia
Fever over 101 oF orally
Nursing Interventions: Alterations in temperature (Fever)
Frequent vital signs: Monitor for client's response to interventions Adequate fluids: Helps maintain homeostasis & regulate temp., reduces risk for dehydration & flu-like deficit Decrease physical activity: Lowers metabolic needs Lightweight clothing: Allows temp to escape in environment Reduce the room temperature (Radiation) Acetaminophen or Ibuprofen ?Aspirin: Antipyretics that reduces fever **Do NOT administer Aspirin, especially to children, puts them at risk for Reye's Syndrome, GI bleeding/distress, impair blood clotting Hypothermia blanket Avoid chilling!
Apical Pulse
Heard on the chest using the diaphragm of the stethoscope For infants and children up to 3 years old *Can do this for children up to 5 y/o if pulse is fast & hard to palpate For clients with an irregular pulse Prior to giving medications that affect heart rate ***Assess for a full minute if pulse is irregular
Tachycardia
Heart rate above 100 bpm Can be caused by exercise, fear, overheated, certain meds, stress/anxiety, Sometimes when a client goes from sitting to standing and has a low blood pressure, their heart rate will increase to compensate to maintain perfusion Determine why they're like this & if they're symptomatic
Bradycardia
Heart rate below 60 bpm Can be seen in an athlete, from meds, a hypothermic client, anyone with hypovolemia bleeding can initially start out with a heart rate above 100 bpm and become this if they don't get more volume Determine why they're like this and if they are symptomiatic
Volume
Milliliters (mL) Liters (L) Teaspoon (tsp or t) Tablespoon(tbsp or T) Ounces (oz)
Nursing Diagnoses for Temperature
Hypothermia Hyperthermia Risk for Altered Body Temperature Ineffective Thermoregulation
Systolic Pressure
Initial sound reflecting the height of the blood wave when the ventricles contract 1st tapping sound of w/ Korotkoff's sound
Diastolic Pressure
Last Korotkoff's sound, last sound during time of "filling" Lower pressure when the ventricles relax
Auscultation
Listening to through stethoscope How we determine apical pulse
Auscultate
Listening with a stethoscope
Reading a bulb-type thermometer
Locate the silver color (formally mercury) by slowly rotating until visible The long lines represent the whole numbers Each small line is equal to 0.2 Important to shake down the silver color to the bottom before using & to wash it afterwards
Finding Apical Pulse
Located in 5th intercostal space 1) Left sternal border, mid-clavicular line 2) Also called pulse of maximal impulse (PMI) at the Mitral area Start at the 2nd intercostal space @ mid-clavicular line and palpate down to the 5th intercostal The PMI is at the 5th intercostal space: basically listening to the mitral valve closing Landmark to find is the Angle of Louis
Vital Signs
Measurement in body's most basic functions Establishes client's baseline, "the gateway to nursing process" Temperature, Pulse, Respirations, and Blood Pressure (Certain institutions will include pain & O2 saturation)
Pulse
Measurement of heart rate and rhythm that corresponds with the amount of blood flowing through the various points of the circulation system (mainly arteries)
Weight
Micrograms (mcg) Milligrams (mg) Grams (g) Kilograms (kg)
Rectal Assessment Methods
Most invasive & closest to the core temperature Do not use on someone with rectal bleeding, a cardiac condition, bleeding/hemorrhoids, have any bleeding disorder (can lower WBC), and newborns Position client on their left lateral sims (left side), clean buttocks/anus area & assess for bleeding before inserting, use lubrication & insert 1-1.5 in (adults) or 0.5 in (children)
Oral Assessment Methods
Non-invasive Appropriate for children, adults & elderly who can close their mouths, keep them their tongues & can follow directions Can't use on mouth-breathers, those who can't follow directions, had oral surgery, or can't keep the this under their tongues
Tympanic Assessment Methods
Non-invasive Can be used across lifespan Do not use on clients with ear infections or a ruptured tympanic membrane/ear drum For <3 y/o: Pull ear back & down Pull ear up & backwards for clients 3+ y/o
Axillary Assessment Methods
Non-invasive Taken under armpit/axillary Appropriate for children or adults/elderly, not young children or newborns (Takes too long for a child to sit there) Must keep arm close to chest with this under armpit Can be inaccurate if skin is very hot or cold, along with the environmental temp. making client sweat a lot
When are Vital Signs Taken
On admission Based on agency policy Change in Client Condition Change in Client Mental Status Before/After Procedure or Activity Before/After Medications
Milli
One-thousandth of base
Weight
Pounds (lbs)
Nursing Interventions for Hypothermia:
Put client in a war environment, can give hyperthermia blanket, warm fluids/IV fluids, cover their head and put on several layers of clothing Educate: Teach client to go inside after recognizing signs & symptoms of hypothermia, to wear layers and remain dry outside
Mechanism of Heat Transfer
Radiation, Convection, Conduction, & Evaporation
Pulse Assessment
Rate: If the pulse is regular, count for 30 sec. & multiply by 2 **If pulse is not regular, count for the full minute Rhythm: Determine if the pulse is regular or irregular Amplitude: How strong is their pulse? Are both the left and right side pulses equal? Compare both
Electrocardiogram
Records an electrical representation of the heart's activity Indicates heart rate and rhythm on a graph or a screen Normal Sinus Rhythm (NSR) (Conduction through the heart is regular)
Temperature
Reflects the balance between the heat the body produces and the heat loss
Blood Pressure
Reflects the force of the blood exerted against the walls of the arteries during systolic & diastolic Reflects our cardiac output (Force of the moving blood against walls) As ventricles contract, blood is forced out of the ventricle, goes through the body to the arteries carrying oxygenated blood Contains systolic & diastolic pressure
Korotkoff's Sound
Series of sounds that the nurse listens to while assessing blood pressure Only heard through stethoscope 5 phases
Dimensional Analysis or Factor Labeling for Dosage calculations
Simple Formula: ? = ordered x have Complex Formula: ? = ordered x have x conversion
Newborn Vital Sign Range
Temp: Axillary, 96.7 - 98.5oF Pulse: 120 - 160 Beats/Minute Respirations: 30 - 55 breaths/Minute (Highly Irregular) Blood Pressure: 73/55
Adult Vital Sign Range
Temp: Oral - 98.6o F (96.4 - 99.5) Rectal - 99.5oF Tympanic - 99.5oF Axillary - 97.6o F Pulse: 60 - 100 Beats/Minute Respirations: 12 - 20 breaths/Minute Blood Pressure: <120/80 but >100 Systolic *Teens: 102-112/62-64
Elderly Vital Sign Range
Temp: Oral -96.4-98.3o F Pulse:~60-100 beats/Minute Often become irregular at this age, make sure to ask them if this is new & assess for symptoms Respirations: 12 - 20 Breaths/Minute
Infant Vital Sign Range
Temp: Tympanic, 98.7 -100.5oF
Mitral
The apex Also S1 heart sound
Pulse Pressure
The difference between diastolic and systolic Should typically be ~40 (ex: 120-80=40)
Why do We Avoid Chilling a Client?
This can signal a client's body to reset their internal temperature and have it raise again Client can shiver Puts client at risk for pyrexia
Conduction
Transfer of heat from one molecule to a molecule of lower temperature ex) Tepid (lukewarm) bath, Hypothermia blanket **Never put client in cold bath/ice bath, it can make them shiver and raise temperature & do not put alc in bath Hypothermia blanket: filled w/ water, connected to an electric source, set it to temp desired & do not put directly on client's skin: it can damage & lower blood flow
Radiation
Transfer of heat from one object to another without contact of two objects ex) Temperature of the room, raising A/C or heat in room (affects environment)
Doppler Device
Used to hear hard to palpate peripheral pulses Sound transmitted is RBC's moving through the blood vessels Put transmitting fluid on area you want to feel pulse and then put transmitter on top of pulse Usually for palpating pedial pulses
Who is at Risk for Hypothermia (Alteration in Temp)
Very young, Very old, and those who work outside Children who play outside in the snow and do not come inside frequently or change out of damp clothing
Formula for Conversions using Dimensional Analysis
What is known x Conversion = the units wanted (memorize this formula) When writing the conversion the units wanted is written on top. ex) __5500 mg__ x __1 g__= ?? g 1000 mg
Pounds to kilograms
divide
Kilograms
kg
Pounds
lbs
Milliliters
mL
Micrograms
mcg
Kilograms to pounds
multiply
Centi
one-hundredth of base
Deci
one-tenth of base
Celsius (Centigrade)
oF-32/ 1.8 Freezing = 0C Boiling - 100 oC
Kilo
one thousand times the base unit
Ounces
oz
Tablespoon
tbsp or T
Teaspoon
tsp or t
