Fundamentals of Nursing PDF

Vidya Kishan online Nursing Academy) PULSE – Pulse is an alternate expansion and recoil of an artery as the wave of blood forced through it during the contraction of the left ventricle. Pulse can be felt by the finger. Not by the thumb because due to presence of vessels in thumb. Normal pulse rate...

Vidya Kishan online Nursing Academy) PULSE – Pulse is an alternate expansion and recoil of an artery as the wave of blood forced through it during the contraction of the left ventricle. Pulse can be felt by the finger. Not by the thumb because due to presence of vessels in thumb. Normal pulse rate in adult – 60-100b/min Tachycardia – more than 100 b/min Breadycardia – less than 60 b/min Common site for pulse assessment  Radial artery(most common)  Temporal artery  Carotid artery  Brachial artery  Femoral artery  Popliteal artery  Dorsalis pedis artery  Posterior tibial artery  Apical pulse (5th intercostals space left midclavicular line) Special point  Never press both carotid artery at the same time as this can cause reflex drop in BP/ Pulse  Cardiac artery used for victims of shock and cardiac arrest  Brachial and femoral artery used with cardiac arrest in infants 1  Vidya Kishan online Nursing Academy)  Count the pulse for full one minute specifically infant and young children  Pulse should not assess after exercise /mental stress or painful treatment  Do not apply to much pressure  Choose appropriate site Abnormal volume of pulse  Water hammer pulse - Watson's water hammer pulse, also known as Corrigan's pulse or collapsing pulse, is the medical sign (seen in aortic regurgitation)  Bounding pulse - A bounding pulse is a strong throbbing felt over one of the arteries in the body as seen in increased cardiac output.  Bigeminal pulse - Bigeminal pulse is a medical condition when alternate pulses are abnormally weaker and not at regular interval. It is mainly due to inadequate feeling of the ventricles  Weak wiry/ thread pulse - A weak thready pulse may reflect a decreased stroke volume and can be associated with conditions such as heart failure, heat exhaustion, or hemorrhagic shock.  Paradoxical pulse – in this pulse feels weaker when the client takes in a breath.  Pulses alternans – rhythm is normal regular but the volume has an alternative strong and weak character. Respiration  Normal respiration is termed as eupnea  Respiration is act of breathing process of taking in oxygen and giving out co2 2  Vidya Kishan online Nursing Academy) Internal respiration – The exchange of gases between blood and tissue External respiration – The exchange of gases between alveoli and blood Respiration controlled by respiratory center medula oblongata Normal rate – 12-20 b/min ABNORMAL RESPIRATION Tachypnea/ polypnea – More than 24 b/min Bradypnea – Less than 10 b /min Apnea – Cessation of breath Hyperpnea – Increase in the depth of breathing Orthopnea - Breath only in upright position Stertorous respiration – Noisy breathing due to secretion. Rale /Rhale - Abnormal ratting or bubbling sound caused by the mucous in the airway e.g. bronchitis, pneumonia Wheeze – High pitches, musical wistling sound e.g. Asthma Sigh – A very deep inspiration followed by a prolonged expiration. Air hunger – A form of dyspnea in which there are deep sighing respiration Cheyne stroke respiration – Hyperpnea with apnea 3  Vidya Kishan online Nursing Academy) Kussmaul breathing - is rapid, deep breathing. BLOOD PRESSURE BP is the force exerted by the blood against the walls of the blood vessel. Systolic BP – Highest pressure during ventricular contraction Diastolic pressure – lowest pressure during ventricular contraction Normal BP – 120/80 mmHg MAP (Mean arterial pressure) = systolic pressure + 2 diastolic pressure 3 Normal MAP is between 70 and 100 mmHg Pulse pressure = systolic blood pressure – diastolic blood pressure Normal pulse pressure is40 mmHg. Too narrow cuff – false high Too wide cuff – false low Width of the BP cuff should be 20% greater than the diameter of extremity on which it will be used. Bladder size width should be 40% of the circumference of the mid point of the limb and length is 80% of the limb circumference Do not take BP reading on a client arm with  Iv line  Injured arm  Fistula  On the side of patient had a mastectomy  If arm is paralyzed 4  Vidya Kishan online Nursing Academy) Size of BP cuff Newborn – width (3cm) length (6cm) Adult - width (13 cm) length (30cm)  The sounds detected by the stethoscope in the auscultatory blood pressure measurement, known as Korotkoff sounds.  The systolic blood pressure is taken to be the pressure at which the first Korotkoff sound is first heard and the diastolic blood pressure is the pressure at which the fourth Korotkoff sound is just barely audible. BLOOD TRANSFUSION A blood transfusion is a routine medical procedure in which donated blood is provided to patient through IV lines Packed red blood cells (PRBC) - PRBC are blood cell used to replace erythrocytes in case of anemia (less than 7 gm /dl hb transfused blood)  Infusion time for 1 unit is 2-4 hours  And 1unit = 300ml (RBC 180ml)  For fast infusion used blood warmer  Each unit of blood increase the 1 gm of Hb and 3% hematocrit  The change in laboratory values takes 4-6 hours after completion of the blood transfusion  Storage for 35-42 days at 1-6o C  Platelets - Used to treat thrombocytopenia and platelets dysfunction  Cross matching is not required but usually is done and administered over 15 -30 min  Each unit of platelets increase 5000 to 10000 mm3 amount of platelets  Storage – 7 days at room temperature(22 o C) 5  Vidya Kishan online Nursing Academy) Fresh frozen plasma (FFP) – May be used to provide clotting factor or volume expansion  It contain no platelets  Infused with in 15-30 min  RH compatibility and ABO compatibility required to transfused FFP  Stored for 1 year at -40o C Cryoprecipitate – Prepared from fresh frozen plasma  Stored for 1 year at -40o C  Administered within 15-30 min  Used to replace clotting factor Types of blood donation Autologous- A donation of client own blood before a schedule procedure.  And it is not option for patient with leukemia and bacteremia  Donation begins with in5 weeks of transfusion Blood salvage- is an autologous transfusion that involves suctioning blood from body cavities joint spaces or other closed surfaces blood may need be washed Designated donor – occurs when recipient select their own compatible donor Nursing responsibility  18 G cannula used to blood transfusion  No solution other than normal saline 0.9% should be added to blood content  Medication are never added  The blood transfusion set should be change after 1 unit of blood transfusion  It should be administered with in 30 minute after receiving from blood bank 6  Vidya Kishan online Nursing Academy)  Used blood warmer for large amount of blood transfusion  Vital sign monitored before and after administration first 15 minute for half an hour’s and after that every hourly  Check blood bag for expiration any clot  Cross matching done by 2 registered nurse if doctor is not available. COMPLICATION 1. Transfusion reaction (most dangerous) Sign of an immediate transfusion reaction are  Chills and diaphoresis or chest pain  Rashes itching and swelling  Rapid thready pulse pallor cyanosis  Stay with patient for first 15 min. to assess transfusion reaction  Stop the transfusion immediately if a transfusion reaction is suspected 2. Circulatory overloaded  Caused by rapid infusion of blood Sign of circulatory overloaded are  Cough dyspnea chest pain and wheezing , hypertension , tachycardia and bounding pulse  Slow the rate of infusion if circulatory overloaded occur 3. Septicemia Transfusion of blood that is contaminated with microorganism Sign are chills and a high fever vomiting diarrhea. 4. Iron overloaded – managed by giving defrexamine (iron chelating agent) reducing the amount of iron in patient body 5. Hypocalcaemia – citrate in transfused blood bind with calcium and is excreted so assess the blood calcium level before and after the transfusion 7  Vidya Kishan online Nursing Academy) 6. Hyperkalemia - Stored blood liberated potassium through hemolysis.The older blood have greater risk of Hyperkalemia assess the date on the blood bag and assess serum potassium after and before administration. 7. Disease transfusion- Most commonly transfused is hepatitis C, others like hepatitis B HIV. 8