Chapter 10: Basic Nursing Skills Flashcards
what to check for when rounding
bathroom needs
pain levels
comfort/potential reposition
if pt needs help reaching something
properly functioning medical equipment
how often do you measure vitals
q4h
what are included in vitals
HR
RR
BP
O2 Sat
temp
pain
baseline oral temp range
97.6 - 99.6
baseline rectal temp range
98.6 - 100.6
baseline axillary temp range
96.6 - 98.6
baseline tympanic temp range
96.6 - 99.7
baseline temporal temp range
97.2 - 100.1
Adult baseline RR
12-20 rpm
adult baseline HR
60-100 bpm
normal BP
90-119
60-79
hypotensive BP
less than 90
less than 60
elevated BP
120-129
less than 80
stage 1 hypertension BP
130-139
80-89
stage 2 hypertension BP
higher than 140
higher than 90
hypertensive crisis BP
higher than 180
higher than 120
either need to occur
what color are rectal thermometers
red
what is the most accurate temp location
rectal
what is the least accurate temp location
axillary
diaphoresis
excessive sweating
sign of fear, pain, heart attack
cyanosis
blue/gray color of the skin
sign of decreased O2
pallor
pale skin
sign of poor circulation
flushing
skin appears red/darker than normal
sign of fever, pain, or environment too hot
what ages do you use the brachial pulse site for
under 6 y/o
