Patient Care, week 6: Evaluating And Meeting The Patients Neds Flashcards
What is I and O?
Input and output
Measured
What do you do when patient says they are thirsty?
Check with the nurse. May be on I an O or NPO (nihil pro ora- nothing by mouth)
When helping a patient with a bedpan…
- wash hands– use gloves
- use clean bedpan
- toilet tissue
- is bed pan cold?
- privacy!
- position bedpan under patient
- remove pan, discard contents, and put pan into appropriate place
- remove gloves and wash hands
- give patient wet wash cloth and clean towel to wash and dry hands
When assisting a patient with a urinal…
- wash hands–wear gloves
- use clean urinal
- privacy!
- check for stones? How?
- discard contents, and place urinal in the location provided for soiled items
- remove gloves–wash hands
- give the patient a wash cloth and towel to dry their hands
What is a symptom?
Symptoms are subjective signals and cannot be measured
Examples: Pain Coughing Vertigo Loss of appetite Weakened condition Nausea
What are signs?
Objective signals
By examination, observation and tests
Examples: Visual inspection Lab tests Palpation Tapping Auscultation
Vital signs include
Temperature Pulse Oxygen level Respiration Blood pressure
Vital signs indicate
- General health status
- Physiologically constant within normal range
- relative to sex, age, physical size, occupation, activity
- deviations can indicate a threat to patients safety
Vital signs include…
- temperature
- pulse
- oxygen level
- respiration
- blood pressure
What is temperature?
• balance of heat maintained between that which is produced from metabolism and that which is lost
Body heat is normally lost through
Perspiration
Respiration
Elimination
Deviations in temperature happen due to…
- time of day
- age
- menstrual cycle and pregnancy
- weight
- physical exercise
- injury
- disease
What is fever?
Abnormal increase of body temperature; usually a sign of an infectious process
Known as pyrexia
Signs and symptoms of fever
- increase of body temperature
- increased pulse rate
- increased respirations
- aching
- flushed, hot skin
- chills
- anorexia
What is the normal temperature for the oral method of taking temperature?
98.6 F
37 C
What is the normal temperature for the rectal method of temperature taking?
99.6 F
38 C
What is the normal temperature for auxiliary method of temperature taking?
- 6 F
36. 7 C
What is the pulse?
Alternate contraction and expansion of the wall of an artery corresponding to heart beat
What is the pulse affected by?
- sex
- age
- physical size
- weight
- activity
- disease process
- fever
- emotion
What are the normal parameters when reading pulse?
• adult male: 60-70 BPM
• adult female: 65-80
* children: 110-130
• elderly: 50-60
What are the characteristics or qualities of the pulse?
• amplitude: “force of pulse(volume)
- full(bounding)
- normal
- weak
- thready (feeble and rapid)
- rhythm: relative equality of the interval between beats
- regular vs irregular
- count irregular pulse for one full minute
Pulse sites
- radial (most accessible)
- temporal
- carotid
- femoral
- apical
- pedal(arch of foot)
- popliteal
- brachial
What is tachycardia?
> 100 BPM
What is bradycardia?
<60 BPM
What is arrhythmia?
Irregular pulse
What is respiration
Exchange of gases (o2 and co2) between organism and environment
Purpose is to maintain adequate oxygenation of body cells
Terms; hypoxia, anoxia
Characteristics of respiration
• normal: rhythmic and effortless • respiration rate: -adult male/female 12-16/min -child 30-50/min • note: each inspiration and expiration counts as one respiration
Influencing factors in respiration
- slow: CNS depression secondary to drugs, anesthesia, brain disease
- fast: pain, anxiety, fear, hypoxia, diabetic coma, brain tumors, activity
What is blood pressure?
Force of pressure within arterial walls during each phase of cardiac action (represented as a fraction)
• purpose: aids in evaluation of circulatory status and fluid balance
First phase of blood pressure
- systole (systolic)
- contraction of left ventricle
- greatest force on arterial walls
Second phase of blood pressure
- diastole (diastolic)
- relaxation of the left ventricle
- least pressure on arterial walls
Factors influencing BP
- time of day
- body position
- pathology
- gender
- age
- physical development
Readings for BP
Normal adult range: 100-140/60-90
Children 90mm hg indicates hypertension; <50 may indicate shock
Pulse oximetry normal values
Normal values: 95-100%
<95% means inadequate oxygen perfusion
