Fund 1 Exam

1. Temp (T) 36.5C-37.5C (97.6F-99.6F)

2. Respiration rate (RR) 12-20

3. Pulse/HR - 60-100

4. Blood Pressure (BP) - 90-120 / 60-80

5. Oxygen Saturation (O2) - 90+

6. Pain

35 and below - recheck too cold get help

36 cool

37 perfect

38 getting hot

39 recheck get help

35/39 bad

1. Humans maintain consistent 36.5-37.5 C

2. When exceeds 37.5 termed hyperthermia, fever, febrile, or pyrexia.

3. Heat is lost through four processes: radiation conduction, convection, and evaporation.

4. death may occur drops to 25c/77f or 45c/113f

5. normal temp is afebrile

1. most closely approximates the core temp

2. most accurate peripheral route

3. this method is used when an accurate temp cannot be obtained orally or via other methods

4. lubricate

5. is 1 degree higher than oral temp

1. age

2. environment

3. time of day

4. exercise

5. stress

6. hormones

1. ventricle contractions eject blood into arteries

2. blood entering the aorta from the left ventricle causes aortic wall distension

3. as the aorta expands and contracts, a pulse wave travels along the blood vessels.

4. the pulse wave or pulsation can be felt where the arteries lie close to the skin surface.

1. temporal

2. carotid

3. brachial

4. apical

5. radial

6. femoral

7. popliteal

8. posterior tibial

9. dorsal pedis

1. Characteristics of pulse: rate (frequency), rythm, quality (strength), symmetry, pulsations can be bilaterally equal or unequal.

2. Palpation and auscultation are methods used to assess hr.

3. 0 = absent

1+ = palpable, but thready and weak, easily obliterated

2+ = normal, easily identified, not easily obliterated

3 + = increased pulse, moderate pressure for obliteration

4 + = full, bounding, cannot obliterate

age, ANS, medications

1. rate: 12-20 normal

2. should be assessed without patient awareness

3. tachypnea: abnormally fast >20

4. bradypnea: abnormally slow <12

5. rhythm = pattern of inspiration/expiration

6. depth = assessing excursing of chest and accessory muscles

7. eupnea = normal rhythm and depth

8. quality = resps are usually automatic, quiet and effortless

age, medications, stress, exercise, altitude, gender

1. the force that blood exerts against the walls of blood vessels

2. a function of the flow of blood produced by contraction of the heart and the resistance to blood flow through the vessels.

3. pressure in the systemic arteries is the most commonly measured

4. recorded in millimeters of mercury (mm Hg) as systolic pressure and diastolic pressure.

1. sphygmomanometer

2. stethoscope

3. doppler ultrasound

1. sites: upper and lower extremities

2. assessment may include auscultation and and palpation. (Korotkoff sounds)

3. patient should be in a resting state in a warm, quiet environment with feet flat on floor.

4. the appropriate cuff size should be used and applied properly.

1. hypertension: persistently elevated bp, sys > 140, dys > 90, need antihypertensive meds.

2. hypotension: low bp <90/<60

1. drop in sys pressure of atleast 25 or drop in dia of atleast 10, accompanied by an inc in hr of atleast 10 bpm, when moving from lying to sitting or standing.

2. may indicate hypovolemia or failure of ANS protective reflexes.

3. symptoms include dizziness, weakness, blurred vision, syncope, and marked changes in BP and HR.

1. condition should be assessed in pts exhibiting symptoms of dizziness, blurred vision, or weakness when changing position; pt taking diuretic meds, pt with hx of blood volume loss.

2. best data obtained when bp and hr measurements are taken before/after position change.

1. arterial blood gases (ABGs): directly measures the partial pressures of oxygen, carbon dioxide, and blood pH.

2. Pulse oximetry: noninvasive method of monitoring respiratory status, uses and external device

hypoxia, cyanosis, cough

1. on admission

2. beginning of shift

3. at visit to clininc/md

4. before/after surgery

5. to monitor effects of certain meds

6. whenever pt condition changes

8. q4/q8 in hospital

1. nurses can delegate the activity of taking vital signs, but the nurse is responsible for interpretation of vital signs, vital sign trends, and decisions based on abnormal vital sign findings.

2. as a student nurse, you are responsible for functioning within your scope of knowledge.

1. know pts baseline

2. trending is important

3. assess

4. make sure your equipment/technique is accurate

5. have general plan of action for vs that are abnormal.

1. first line - normal flora/skin/eyes/mouth/tears/salvia/urine/

2. second line - WBCs (phagocytosis), complement cascade, inflammation/edema/fever

3. third line - acquired defensives, vaccinations/monoclonal antibodies

1. adult/older adult have chronic illness, skin starts to thin and dry, urinary retention can lead to uti, incontinence leads to excoriation of skin, weakened immune system defenses, HAI (healthcare associated infections)

1. infections agents that can become opportunistic: bacteria, viruses, fungi, parasites.

2. compromised host - breaks in skin, invasive devices, stasis of body fluids, inadequate nutrition, stress/hyperglycemia, immune system dysfunction, co-existing medical problems, drug therapy.

1. local vs systemic

2. acute vs. chronic

3. HAI (healthcare associated infection)

4. sepsis

1. incubation - time of infection until manifestation of symptoms, can infect others

2. prodromal: appearance of vague symptoms; not all diseases have this stage.

3. acute phase of illness: signs and symptoms present

4. decline: number of pathogens decline

5. convalescence: tissue repair, return to health

1. causative agent is transmissible

2. latent period-agent is hiding without s/sx but inside the host cell

3. communicable s/sx prsent and host is shedding ex: resp secretions, feces, blood, urine.

1. fever, increased hr/rr, pain, purulent drainage, enlarged lymph nodes, rash, gi symptoms

1. immu history/ hx of exposure

2. chronic diseases

3. meds/immunosuppression drugs/ chemo/radiaiton therapy

4. diet/nutrional adequacy

5. pt sleep/exercise/recreation

6. history of nausea, vomiting, diarrhea, anorexia, etc

1. exogenous - involve a pathogen entering a patient's body from their environment. These pathogens can be introduced through a contaminated device, healthcare worker, surface, or other vector.

2. endogenous - An infection caused by an infectious agent that is present on or in the host prior to the start of the infection

1. related cause of death

2. 4.5 billy a year $$$

3. preventable with aseptic principles and techniques

1. before touching pt

2. before clean/aseptic procedure

3. after body fluid exposure risk

4. after touching procedure

5. after touching patient surroundings

caused by micro-organisms such as viruses, bacteria and parasites that cause intestinal illness. These diseases most frequently result from consuming contaminated food or water and some can spread from person to person.

1. spread through mouth, contact with animals or their environments, by contact with feces

1. wash needle sticks and cuts with soap and water

2. flush splashes to nose, mouth, or skin with water

3. irrigate eyes with clean water, saline or sterile wash

4. report all exposures promptly to ensure that you receive the proper follow-up care

5.