140 data collection Flashcards
What type of temperature method is used when the normal is: 96.4 - 99.1
-Oral
-Tympanic
What type of temperature method is used when the normal is: 97.4- 100.1
-Rectal
What type of temperature method is used when the normal is: 95.4-98.1
-Axillary
What is the normal temperature for Oral and Tympanic
96.4-99.1
What is the normal temperature for Rectal
97.4-100.1
What is the normal temperature for Axillary
95.4-98.1
What is the normal pulse rate for an Adult
60-100 bpm
What is the normal pulse rate for an Infant (birth - 1 year)
100-160 bpm
What is the normal pulse rate for a Toddler (1-3 years)
90-150 bpm
What is the normal pulse rate for an Preschooler ( 3-6 years)
80-140 bpm
What is the normal pulse rate for an School- age child (6-12 years)
70-120 bpm
What is the normal pulse rate for an Adolescent (12-18 years)
60-100 bpm
What is the normal respiration rate for an Adult
12- 20 rpm
What is the normal respiration rate for an Infant (birth- 1 year)
30-60 rpm
What is the normal respiration rate for a Toddler (1-3 years)
24-40 rpm
What is the normal respiration rate for a Preschooler (3-6 years)
22-34 rpm
What is the normal respiration rate for a School-age (6-12 years)
18-30 rpm
What is the normal respiration rate for an Adolescent (12-18 years)
12-16 rpm
What are some clinical situations that would cause the use of the thigh as an alternate BP site
-Injury/disease bilaterally on the shoulder, arm or hand
-Dressings or cast on the arm
-IV therapy being administered in the arm
-History of axilla or lymph node surgery in the arm (mastectomy)
-Dialysis access in the arm (Fistula)
What is phase 1 Korotkoff sound
Systolic reading
(First, faint clear tapping or thumping
What is phase 2 Korotkoff sound
Sounds have muffled, whooshing, swishing quality
What is phase 3 Korotkoff sound
Sounds are crisper and more intense
What is phase 4 Korotkoff sound
Sounds become more muffled and have a soft, blowing quality
What is phase 5 Korotkoff sound
Diastolic reading
-Last sound is heard, followed by silence
What is:
-Associated with reduced peripheral blood flow caused by changes in the pulse wave
Oscillatory gap
What risk does a nurse take by not finding the Oscillatory gap before taking BP
-Inaccurate systolic assessment
-Unneeded compression of the arm which may cause injury
What is normal BP for an Adult
-Systolic: Less than 120 mmHg
-Diastolic: Less than 80mmHg
What is normal BP for a Pediatric
-80 + 2x child’s age
-Diastolic will be heard at phase 4 Korotkoff sound
What is the range for an Elevated BP
Systolic: 120-129
Diastolic: Less than 80mmHg
What is the range for Hypertension stage 1
Systolic: 130-139
Diastolic: 80-89 mmHg
What is the range for Hypertension stage 2
Systolic: 140 or higher
Diastolic: 90 or higher
What is the range for Hypertensive crisis
Systolic: Higher than or 180
Diastolic: Higher than 120
What is the first step of the nursing process
Assessment
What is the second step of the nursing process
Nursing diagnosis
What is the third step of the nursing process
Planning
What is the fourth step of the nursing process
Implementation
What is the fifth step of the nursing process
Evaluation
What concept is:
-Respiratory and cardiovascular systems work together
-Provides oxygen and nutrients to every cell in the body
The concept of perfusion
Where do you place the BP cuff on the radial artery
On the wrist
Where do you place the BP cuff on the brachial artery
On the upper arm
Where do you place the BP cuff on the Dorsalis pedis artery and posterior tibial artery
Midcalf
Where do you place the BP cuff on the popliteal artery
Above the knee
What is associated with:
Reduced peripheral blood flow caused by changes in the pulse wave
Oscillatory gap
