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Questions and Answers
Questions and Answers
Which of the following factors can influence vital signs?
Which of the following factors can influence vital signs?
- Environmental heat
- Different times of day
- Dressing type
- All of the above (correct)
A nurse is preparing to assess a patient's vital signs. Which guideline is most important to follow?
A nurse is preparing to assess a patient's vital signs. Which guideline is most important to follow?
- Using disposable equipment regardless of condition.
- Assuming all equipment is reliable regardless of source.
- Knowing how to evaluate vital sign findings and inform team members. (correct)
- Ignoring environmental factors to maintain a sterile environment.
A patient is scheduled for surgery and reports feeling unwell. When should vital signs be assessed?
A patient is scheduled for surgery and reports feeling unwell. When should vital signs be assessed?
- Only if the surgery is considered high-risk.
- Only after the patient explicitly requests it.
- Before and after the surgery. (correct)
- When the patient is being discharged.
Where is the frontal temperature value considered equivalent to?
Where is the frontal temperature value considered equivalent to?
The principle of body temperature regulation primarily involves a balance between which two elements?
The principle of body temperature regulation primarily involves a balance between which two elements?
Which physiological process contributes to heat loss from the body?
Which physiological process contributes to heat loss from the body?
Which of the following factors can influence body temperature?
Which of the following factors can influence body temperature?
What is the main function of the hypothalamus in body temperature regulation?
What is the main function of the hypothalamus in body temperature regulation?
What physiological response occurs when vasodilation is triggered, regarding body temperature?
What physiological response occurs when vasodilation is triggered, regarding body temperature?
A patient has a body temperature of 34°C. What condition is the patient experiencing?
A patient has a body temperature of 34°C. What condition is the patient experiencing?
What is the accepted average oral temperature?
What is the accepted average oral temperature?
Why are glass thermometers containing mercury no longer used?
Why are glass thermometers containing mercury no longer used?
What essential step should a healthcare provider take before measuring a patient’s body temperature, regardless of the method used?
What essential step should a healthcare provider take before measuring a patient’s body temperature, regardless of the method used?
For which conditions should oral temperatures NOT be taken?
For which conditions should oral temperatures NOT be taken?
What is a key instruction when taking temperature orally?
What is a key instruction when taking temperature orally?
How far should the receiver of a tympanic thermometer be placed into the ear canal?
How far should the receiver of a tympanic thermometer be placed into the ear canal?
When is rectal temperature measurement typically indicated?
When is rectal temperature measurement typically indicated?
Which of the following conditions is a contraindication for taking rectal temperatures?
Which of the following conditions is a contraindication for taking rectal temperatures?
When should you breathe slowly and deeply during rectal temperature measurement?
When should you breathe slowly and deeply during rectal temperature measurement?
Why is the axillary region commonly used for temperature measurement?
Why is the axillary region commonly used for temperature measurement?
During axillary temperature measurement, which precaution is important to observe?
During axillary temperature measurement, which precaution is important to observe?
What does the term 'pulse' refer to in the context of vital signs?
What does the term 'pulse' refer to in the context of vital signs?
When assessing a patient’s pulse, which three characteristics should absolutely be evaluated?
When assessing a patient’s pulse, which three characteristics should absolutely be evaluated?
Why is assessing the pulse important?
Why is assessing the pulse important?
A newborn has a pulse rate of 150 beats per minute. What does this indicate?
A newborn has a pulse rate of 150 beats per minute. What does this indicate?
An adult patient has a pulse rate of 50 beats per minute. How would you describe this?
An adult patient has a pulse rate of 50 beats per minute. How would you describe this?
How is pulse deficit defined?
How is pulse deficit defined?
A nurse notes that a patient's radial pulse is difficult to palpate, and the pulse disappears with slight pressure. What type of pulse is this?
A nurse notes that a patient's radial pulse is difficult to palpate, and the pulse disappears with slight pressure. What type of pulse is this?
Where are emergencies pulse points?
Where are emergencies pulse points?
Which action is most important when preparing to take a peripheral pulse?
Which action is most important when preparing to take a peripheral pulse?
Which fingers should be used when counting pulse?
Which fingers should be used when counting pulse?
How should you process If the pulse is measured for the first time and is irregular?
How should you process If the pulse is measured for the first time and is irregular?
Which body organs are included in respiration?
Which body organs are included in respiration?
What is the primary function of the alveoli in the respiratory system?
What is the primary function of the alveoli in the respiratory system?
What specifically occurs during external respiration?
What specifically occurs during external respiration?
Which physiological process is directly associated with 'ventilation' in respiration?
Which physiological process is directly associated with 'ventilation' in respiration?
What component of respiratory measurement gives information about diffusion and perfusion?
What component of respiratory measurement gives information about diffusion and perfusion?
Which part of the brain regulates respiration?
Which part of the brain regulates respiration?
What are the key components evaluated during respiratory measurement?
What are the key components evaluated during respiratory measurement?
What is normal respiratory rate of adult?
What is normal respiratory rate of adult?
What is the term for normal breathing?
What is the term for normal breathing?
What is the difference between hyperventilation and hypoventilation?
What is the difference between hyperventilation and hypoventilation?
What’s the term of "Difficult breathing"?
What’s the term of "Difficult breathing"?
Why is it important to monitor the respiratory rate silently?
Why is it important to monitor the respiratory rate silently?
When assessing respiration, which step is essential before counting the respiratory rate?
When assessing respiration, which step is essential before counting the respiratory rate?
Is the statement "Each expiration and inspiration value is considered as one breath" true?
Is the statement "Each expiration and inspiration value is considered as one breath" true?
Pulse oximetry is a procedure used to measure what?
Pulse oximetry is a procedure used to measure what?
What describes a lower than normal level of oxygen in your blood?
What describes a lower than normal level of oxygen in your blood?
What is the primary function that the blood pressure performs?
What is the primary function that the blood pressure performs?
How is systolic pressure determined?
How is systolic pressure determined?
An individual has a blood pressure reading of 150/95 mmHg. How is this classified?
An individual has a blood pressure reading of 150/95 mmHg. How is this classified?
What is the significance of vital signs in healthcare?
What is the significance of vital signs in healthcare?
Which scenario requires that vital signs be measured?
Which scenario requires that vital signs be measured?
According to the material, which statement is true regarding the frequency of vital sign measurements?
According to the material, which statement is true regarding the frequency of vital sign measurements?
Before documenting a patient's body temperature, what initial action should the healthcare provider perform?
Before documenting a patient's body temperature, what initial action should the healthcare provider perform?
When performing oral temperature assessments, where should the thermometer be placed?
When performing oral temperature assessments, where should the thermometer be placed?
A patient's chart indicates that a tympanic temperature needs to be taken. How should the healthcare provider proceed?
A patient's chart indicates that a tympanic temperature needs to be taken. How should the healthcare provider proceed?
A nurse is about to measure a patient's temperature rectally. What is an important step to take?
A nurse is about to measure a patient's temperature rectally. What is an important step to take?
What important step should be taken when taking an axillary temperature on a patient?
What important step should be taken when taking an axillary temperature on a patient?
What is the recommended method for counting respirations on a patient?
What is the recommended method for counting respirations on a patient?
During assessment of respiration, which of the following is considered very important?
During assessment of respiration, which of the following is considered very important?
What occurs during external respiration?
What occurs during external respiration?
In the alveoli, what process takes place?
In the alveoli, what process takes place?
A patient is experiencing difficult breathing. Which term would the healthcare provider use to document this condition?
A patient is experiencing difficult breathing. Which term would the healthcare provider use to document this condition?
What is a key characteristic of Kussmaul's respirations?
What is a key characteristic of Kussmaul's respirations?
Which statement correctly describes the relationship between inspiration and expiration in respiration?
Which statement correctly describes the relationship between inspiration and expiration in respiration?
What is the primary measurement obtained through pulse oximetry?
What is the primary measurement obtained through pulse oximetry?
When using a pulse oximeter, where should the finger probe be placed?
When using a pulse oximeter, where should the finger probe be placed?
Which term describes the condition when blood oxygen levels are lower than normal?
Which term describes the condition when blood oxygen levels are lower than normal?
Which definition properly define "pulse" assessment?
Which definition properly define "pulse" assessment?
What does it mean if a patient has 'bounding' pulse?
What does it mean if a patient has 'bounding' pulse?
What term do you use to describe if a patient's pulse rate is more than 100?
What term do you use to describe if a patient's pulse rate is more than 100?
A patient's pulse feels very thready. What is the best term to describe the condition?
A patient's pulse feels very thready. What is the best term to describe the condition?
A nurse assess one number for apical pulse and another number for radial pulse. What does she need to do?
A nurse assess one number for apical pulse and another number for radial pulse. What does she need to do?
In a newborn which pulse point is most accessible with emergency?
In a newborn which pulse point is most accessible with emergency?
A nurse will assess a patients radial pulse. What will she do or consider first?
A nurse will assess a patients radial pulse. What will she do or consider first?
A nurse assessing initial pulse has a responsibility if she finds some irregularity. What action is best?
A nurse assessing initial pulse has a responsibility if she finds some irregularity. What action is best?
Body temperature between 36-37 degree C is labeled how?
Body temperature between 36-37 degree C is labeled how?
Which factor is related to temperature regulation?
Which factor is related to temperature regulation?
There is a case of hypothermia. What is the temperature?
There is a case of hypothermia. What is the temperature?
Normal ranges of human temperature goes between which values?
Normal ranges of human temperature goes between which values?
For body temperature, heat production and consumptions must be?
For body temperature, heat production and consumptions must be?
There is a need measure rectal temperature. What do you do to protect dignity?
There is a need measure rectal temperature. What do you do to protect dignity?
There are several places for measuring the temperature. Which place do you consider often is often used.
There are several places for measuring the temperature. Which place do you consider often is often used.
Which is the right way to measure patient's temperature through oral method?
Which is the right way to measure patient's temperature through oral method?
For what condition, you should not messure a person's measurement through oral method?
For what condition, you should not messure a person's measurement through oral method?
If there is a bleeding at the rectum, what do you know what to do.
If there is a bleeding at the rectum, what do you know what to do.
You are measuring blood pressure what value of the arm it is considered Hypotension?
You are measuring blood pressure what value of the arm it is considered Hypotension?
If the value of blood pressure for is like this 150/90 what does it mean to be classified as
If the value of blood pressure for is like this 150/90 what does it mean to be classified as
If the patient has anxiety related to blood pressure.
If the patient has anxiety related to blood pressure.
What is the primary aim of healthcare professionals regarding vital signs?
What is the primary aim of healthcare professionals regarding vital signs?
What are the key indicators used to assess an individual's health status?
What are the key indicators used to assess an individual's health status?
When choosing equipment for measuring vital signs, which consideration is most important?
When choosing equipment for measuring vital signs, which consideration is most important?
Why should environmental factors be considered during vital sign assessments?
Why should environmental factors be considered during vital sign assessments?
After measuring a patient's vital signs, what is the necessary next step?
After measuring a patient's vital signs, what is the necessary next step?
Apart from admission and medical intervention, when else do health professionals consider taking vital signs?
Apart from admission and medical intervention, when else do health professionals consider taking vital signs?
What determines the balance pertaining to body temperature.
What determines the balance pertaining to body temperature.
The body temperature must be consistent and balanced and equal. Which body part contributes to temperature regulation?
The body temperature must be consistent and balanced and equal. Which body part contributes to temperature regulation?
How does the sympathetic nervous system affect the body temperature?
How does the sympathetic nervous system affect the body temperature?
What is the thermoregulation center?
What is the thermoregulation center?
If the value of the body temperature under 35 degree C which is labeled how?
If the value of the body temperature under 35 degree C which is labeled how?
Under what conditions is the usage of oral thermometers not allowed?
Under what conditions is the usage of oral thermometers not allowed?
What do you consider while placing a tympanic thermometer?
What do you consider while placing a tympanic thermometer?
Water soluble lubricant is used for rectal measurement. What is the next step?
Water soluble lubricant is used for rectal measurement. What is the next step?
Why we should not consider measuring recta temperature?
Why we should not consider measuring recta temperature?
The nurse is about the perform the axillary temperature. What she do to perform this act?
The nurse is about the perform the axillary temperature. What she do to perform this act?
What are 3 things to consider when assessing pulse?
What are 3 things to consider when assessing pulse?
What does pulse deficit mean?
What does pulse deficit mean?
Where could we check an emergency pulse beat for an infant?
Where could we check an emergency pulse beat for an infant?
Before assessing a patient's radial pulse, what action should the nurse take?
Before assessing a patient's radial pulse, what action should the nurse take?
Questions and Answers
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Flashcards
Flashcards
What are vital signs?
What are vital signs?
Basic indicators of an individual's health status.
What determines body temperature?
What determines body temperature?
Body temperature reflects the balance between heat production and consumption.
What is a normal body temperature?
What is a normal body temperature?
Normal range: 36-37°C. Body temperature should be consistent and balanced.
What affects temperature?
What affects temperature?
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What is the hypothalamus?
What is the hypothalamus?
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What is hypothermia?
What is hypothermia?
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What is hyperthermia?
What is hyperthermia?
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What are measurement sites for body temperature?
What are measurement sites for body temperature?
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Oral measurement
Oral measurement
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Rectal temperature
Rectal temperature
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Axillary temperature
Axillary temperature
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What is the pulse?
What is the pulse?
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Normal adult pulse rate
Normal adult pulse rate
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When assessing pulse, consider...
When assessing pulse, consider...
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What is bradycardia?
What is bradycardia?
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What is tachycardia?
What is tachycardia?
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What is Pulse deficit?
What is Pulse deficit?
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List pulse points
List pulse points
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What is respiration rate?
What is respiration rate?
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Normal respiration rates
Normal respiration rates
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In respiratory measurement...
In respiratory measurement...
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Where is the respiratory center?
Where is the respiratory center?
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Respiratory types
Respiratory types
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What is anoxia?
What is anoxia?
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What is hypoxia?
What is hypoxia?
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What is dyspnea?
What is dyspnea?
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What is cyanosis?
What is cyanosis?
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What is pulse oximetry?
What is pulse oximetry?
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Normal pulse oximeter reading
Normal pulse oximeter reading
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What is hypoxemia?
What is hypoxemia?
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What is blood pressure?
What is blood pressure?
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What is systolic pressure?
What is systolic pressure?
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What is diastolic pressure?
What is diastolic pressure?
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Normal blood pressure?
Normal blood pressure?
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What is hypertension?
What is hypertension?
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What is hypotension?
What is hypotension?
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Pulse pressure
Pulse pressure
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Flashcards
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Study Notes
Study Notes
- Vital signs are essential indicators of an individual's health status.
- Necessary nursing practices related to vital signs include identifying them, knowing their normal values, and evaluating them.
Factors Causing Changes in Vital Signs
- Different times of day can impact vital signs.
- Age can lead to changes in vital signs.
- The ovulation state can affect vital signs.
- Seasons can be a factor in vital sign changes.
- Physical activity can lead to changes in vital signs.
- Dressing type can impact vital signs.
- Environmental heat can cause changes in vital signs.
- Stress can lead to changes in vital signs.
- Disease can be a factor in vital sign change.
Guidelines on Assessing Vital Signs
- Nurses must know how to obtain and evaluate vital signs, and how to inform other team members.
- Equipment used should be reliable.
- Equipment should be chosen based on the patient's characteristics and condition.
- Normal vital sign values should be known.
- The patient's medical history, treatments, and medications should be taken into account.
- Environmental factors should be considered during assessment.
- Vital signs should be measured systematically at regular intervals.
- Effective communication with the patient when measuring vital signs is necessary.
- Nurses must cooperate with physicians.
- When measured, vital signs should be analyzed absolutely.
Frequency of Assessing Vital Signs
- Measurements should be taken when preparing a patient for admission.
- Measurements should be taken Before and after surgery. (frequency increases)
- Before and after diagnostic procedures.
- Before and after the administration of drugs that affect the heart and respiratory system.
- Measurements should be taken if there is sudden deterioration of the patient's condition.
- Before and after medical interventions that may affect life signs.
- When the patient feels a difference.
Body Temperature
- Body temperature is the balance between heat produced and consumed
- Heat production minus heat loss equals body temperature
- Consistent and balanced body temperature is crucial.
- Heat production and consumption in the body should be equal.
- Heat occurs through food consumption.
- Heat loss happens through breathing, sweating, and waste elimination.
Factors That Influence Body Temperature
- Age is a factor that influences body temperature.
- Exercise can affect body temperature.
- Hormone levels can influence body temperature.
- Stress can affect body temperature.
- The environment.
- Emotional states can affect body temperature.
- The basal metabolic rate can affect body temperature.
- The digestion of food can affect body temperatures
- Nutrition and sleep are factors that affect body temperature.
- Diseases are factors that affect body temperature.
- Induction of the sympathetic nervous system (adrenaline and noradrenaline)
Regulation of Body Temperature
- The thermoregulation center is the hypothalamus.
- The hypothalamus acts as a thermostat.
- Vasodilation decreases heat.
- Sweating decreases heat.
- Muscle tremor increases heat.
- Piloerection (steepening of feathers) increases heat.
Temperature Changes
- Hypothermy is a body temperature of 35 °C and below.
- Hyperthermia is a body temperature above 38 °C.
Normal Body Temperature Values by Site
- Oral: 36.5°C - 37.5°C; Average 37°C
- Ear: 36.5°C - 37.5°C; Average 37°C
- Axillary/Forehead: 36°C - 37°C, 36.5°C average
- Rectal: 37°C - 38°C; Average 37.5°C
Oral Measurement
- Degrees are placed right or left under the tongue with an average temperature of 36.5°C - 367.5 °C
Contraindications for Oral Temperature Measurement
- Do not take oral temperatures for patients that have dyspnea
- Do not take oral temperatures for children
- Do not take oral temperatures for elderly patients
- Avoid for patients with psychiatric diseases.
- Do not take oral temperatures for non-conscious patients
- Avoid after the surgery
- Do not take oral temperatures for mouth operations
- Avoid in case of infection
- Do not take oral temperatures for patients on continuous oxygen
Key Points for Oral Temperature Measurement
- The patient must have a personal thermometer
- Very hot or cold food affects measurement, advise patient to avoid before and after measurement.
- The thermometer should be placed under the tongue
- The mouth should be closed with teeth unsqueezed
Tympanic Measurement
- Measurement is made in 1-2 seconds.
- The receiver is placed in the 1/3 of the outer ear
- Before measurement, a disposable plastic cover must be placed over the receiver.
Rectal Measurement
- Rectal measurements should only be performed if heat cannot be taken by oral or axillary route.
- To preform a rectal measurement: close the room door and curtains, Put the patient in sim's position and flex the upper leg Wear gloves, Apply water-soluble lubricant to the probe, Separate the patient's hips with your hand and ask the patient to breathe slowly and deeply, insert the degree into the anus. Remove the probe if there is a signal.
- The degree must be advanced 2.5-3.5 cm in an adult , 2-2.5 cm in children and 1.2 cm in newborn
When not to take temperatures rectally
- Do not take rectal temperatures for rectal bleeding
- Don't take temperatures after Rectum surgeries.
- Do not take temperatures after birth.
- Avoid in the period of maternity
- Do not take temperatures for Continously as a routine
- Avoid the usage with way in children or in diarrhea cases.
Axillary Measurement
- The axillary region is the most commonly used region.
- Infection is very unlikely to be transmitted.
- The patient must have a personal thermometer.
- The armpit should not be sweaty.
Forehead measurement
- Measure using a special digital thermometer.
- The device is placed on the forehead.
Pulse
- Pulse is the number of heartbeats per minute.
- While assessing the pulse measure the 1-Pulse Rate (How Many Pulses Per Minute), Pulse Rhythm (Regular Pulse-arrhythmia), 3-Pulse Volume (Full Pulse) - Weak Pulse (Threaded Pulse)
- Pulse is counted to decide rate, rhythm and contraction of the heart and to identify peripheral vascular diseases
Pulse Rate
- Normal range in newborns is 120-160/min, children is 80-120/min and adults is 60-100/min.
- Bradycardia: Pulse rate is a rate below 60 beats per minute.
- Tachycardia: Pulse rate is above 100 beats per minute.
Factors Affecting Rate
- Affecting factors include exercise, hyperthermia, hypothermia, acute or chronic pain, drugs, age, gender, metabolism, bleeding, and posture change.
Pulse Rhythm
- If the heart beat is not regular, it is called irregular rhythm
- If there is arrhythmia, the difference between apical pulse and radial pulse should be checked; In arrhythmia, a deficit (Pulse deficit) develops.
- Pulse deficit is the difference between the apical and peripheral pulse rates; it can signal an arrhythmia and Occurs even as the heart is contracting, the pulse is not reaching the periphery, The radial pulse is lower than the apical pulse, and these two pulse rates is called Pulse deficit.
Pulse Volume
- Pulse volume is measure of the fullness of the pulse and it reflects power.
- In a normal pulse, it is easily found and every beat is felt in similar fullness.
- When the pulse is 'weak,' it is difficult to palpate and it easily disappears with finger pressure; it can also be called «filiform pulse» or «thready pulse
- Weak pulse is palpated very difficult and develops in bleeding, shock, or heart failure.
Procedure for Peripheral Pulse Taking
- First, the hands must be washed and identify is authentic. Inform the patient about the procedure and Evaluate the factors that will affect the patients condition and pulse, then allow Patient to rest.
- The the index, middle, and ring finger are placed on the artery; If irregular, count for 1 minute . record the the findings.
Emergency pulse points
Emergency pulse points include the apical / brachial/femoral artery, for 0-1 age and carotid artery for 1+ age
Respiration
- Respiration is the process that begins and involves the organism Taking in and using O2 and releasing CO2 There are two stages, it occurs between the atmosphere to the lungs(EXTERNAL), O2 and CO2 within cells and blood within the circulatory system.(Internal)
- There the Ventilation where Inspiration and Expiration, Diffusion where O2 passes fromthe alveoli to the lung circulation and CO2 from lung to alveoli,and Perfusion where O2 enters circulation.
Measure of Respiration
- Saturation measures diffusion and perfusion, and Respiratory rate, depth and rhythm of breathing Ventilation.
- Respiratory Normal rate in newborn is 30-60/min and in Adult is 12-20/min. Factors that influence the depth of Breathing and increase, superficial and normal. body position, some medications, exercise, fear, anxiety
Respiratory Types
- Dyspnea, Apnea, Cyanosis, and other different types and measure based on rate, depth, normal, etc...
How to measure breathign
- After the pulse is counted, Count respirations by chest movement for one minute without saying and one cycle is One Respiration.
- Never let know patients knowing this.
- Then, position the patient record your findings.
O2 levels and measurements
- Pulse Oximetry uses a non-invasive process Oxygen in the blood.
- Measure Pulse: Place probe on finger, earlobe, nose (etc) to measure O2.
- Normal pulse oximeter readings range from 95 to 100 percent and Readings under 90 percent signals a low level of Hypoxemia (oxygen in blood)
Procedure to Measure Oxygen Saturation
When measuring, place finger to where light source is emitted.
Blood Pressure
- Blood pressure is a measure of the force that heart uses to pump blood around your body.
Definitions
- Systolic pressure: pressure when heart pushes blood out .
- Diastolic pressure: pressure when heart rests beetween beats
- Ideal blood pressure: Beetween 90/60mmHg and 120/80mmHg
- High blood pressure: Higher than 140/90mmHg
- Low blood pressure: Lower thant 90/60mmHg
Pulse pressure
- Pulse Pressure is the numeric difference beetwen Systolic and distolic: For example (In millimetters of mercury Hg) 120/80 Pulse pressure is 40 The average pulse pressure is beetwen 30/50mmHg
Factors That Affect Bloos Pressure
Affectinf Factors: Age, Race, excersice,
How to measure blood pressure?
Use: Blood pressure monitor(spygmamometer) Stethoscope suitable desynfecant, pen and registration form and waste container.
- Semi flowler. or other Flex arm level with subjects body. if they have anxious , give them a few minutes
Steps to Measurement :
-
Position, Fowler Place a blood pressure cuff, 2-3 cm ahove the antenutibol
-
palpate the brachial artery Feel your brachial pulse with your passive hand and place the diaphragm on the brachial artery and hold it fixed Rapydly imflate the cuff (200/25000mg) . Then slowly inflate air and listen, also watch the dial, record systolic/ diastolic if we record for the first time, the Repeat on opposite am. If there isn't another am, Wait 2min
Mistakes and Erros to Avoid
Common mistakes to avoid while measuring blood pressure not have you feet planted firmly, Patient hasn't rested 5 mior , Patient did not sit upright , Patient talking Arm is level, not elevated nor face up Cuff not on direct skinn. too tide and so on. Also make sure. That not too quicly reoeated assessment. That arm it's below, or avobe heart level.
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