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
normal HR range for small children
100-120 bpm
normal Hr range for newborns
120-180 bpm
causes of tachycardia
fever, dehydration, heart failure
causes of bradycardia
infection
apical pulse
pulse in the heart; below the nipple
auscultation
listening to the body
normal RR for infants
30-40 rpm
apnea
absense of breathing
dyspnea
difficulty breathing
eupnea
normal respirations
orthopnea
SOB when lying down that’s relieved by sitting up
tachypnea
rapid respirations
bradypnea
slow respirations
cheyne-stokes
alternating periods of slow, irregular respirations and rapid, shallow respirations, along w/ short periods of apnea
normal O2 stat
95-100%
convert lbs to kg
2.2 lbs = 1 kg
convert in to cm
2.54 in = 1 cm
hydrocephalus
abnormal accumulation of fluid in the head
how to measure head circumference
measure from above eyebrow and around the widest part of the back of the head
calculate BMI
weight
height^2
NPO how long before surgery
2-8 hr
goal of postoperative care
prevent infections, promote healing, return pt to a State of health
immediate concerns postoperative
breathing problems, mental status, pain, and wound healing
potential complications of surgery
urinary retention, infections, constipation, BP variances, blood clots
rights of med administration
right pt
med
time
route
dose
documentation
