Vital Signs and I/O Flashcards
Temperature
T, temp
Pulse
P, HR
Respirations
Resp, R
Blood Pressure
BP, B/P
Oxygen saturation
O2 Sat, Pulse Ox
Body temp controlled by _____ of brain?
hypothalamus
Body temp sites of measurement:
oral, rectal, axillary, tympanic
Temperature can range depending on where you measure. This can also affect the temperature.
AGE
Body temps for axillary, oral, and rectal
97.6 - axillary
98.6 - oral
99.6 - rectal
can fluctuate one degree higher or lower and still be ok
A body temp below 95 degrees is considered
hypothermia
the clinical term for a fever is
pyrexia
rule of thumb for a fever, these are the body temps…
98 degrees axillary
99 degrees oral
100 degrees rectal
*if higher than that, may be fever
If respirations, or R>22 than the patients has
tachypnea
If respirations, or R<10 , the patient has
bradypnea
Blood oxygen saturation must be greater than ____ or patient will exhibit signs and symptoms (S&S) of hypoxemia.
90
How does a pulse ox device work?
uses infrared sensors that measure the saturation of oxygen in the hemoglobin molecules pulsating through underlying tissues… poor circulation can interfere with the reading
Blood pressure is dependent upon a few things:
blood volume, strength of the heart, conditions of the arteries
blood pressure, top number is _____ and bottom number is _____.
systolic (short term)
diastolic (long term)
guidelines for blood pressure: what is normal, prehypertension, hypertension stage 1, hypertension stage 2
normal
<120 and <80
prehypertension
120-139 or 80-89
hypertension stage 1
140-159 or 90-99
hypertension stage 2
160+ or 100+
Korotkoffs sounds
phase 1
faint tapping sounds
phase 2
murmur swishing sounds during cuff deflation
phase 3
sounds are crisper increase in intensity
phase 4
distinct muffling sound
phase 5
pressure level when last sound is heard
to avoid inaccurate bp readings… do these things
patient should be seated and rest 5 mins
arms must be supported at heart level
wait 1-2 mins before repeating on same arm
choose appropriate cuff size
to determine diet for patient who works together?
physician and dietician
considerations of patient in regards to I/o
likes/dislikes, patient religion/culture, patient diagnosis (diabetes mellitus, heart disease, dysphagia)
dysphagia is what
difficult swallowing
symptoms of dysphagia
taking a long time to begin to swallow, multiple swallows with each bite of food
lack of gag reflex, weak cough
difficulty controlling secretions and fluids in the outhitting
wet, gurgling voice
pocketing food, refusing to eat, spitting
feel as if food is sticking in esophagus
barium swallow would be a good therapeutic approach for a patient with
dysphagia
for someone with dysphagia, liquids should be
thickened
types of diets
house/regular diet
mechanical soft diet
pureed diet
diabetic diet
renal diet
sodium restricted cardiac diet
post op diet progression
clear liquids, full liquids, low residue, D.A.T. (or diet as tolerated - normal diet)
what are full liquids
INCLUDES all clear liquids ANNND
soups, ice cream, milk, all juices
intake and output, what are some output measurements
urinary, emesis (vomit), diarrhea, drainage from wounds
NPO
nothing by mouth
what’s total parenteral nutrition or TPN
intravenous infusion
npo patients, patients on bowel rest
alternative way for patients to receive nutrition like a nasogastric tube feeding, or gastronomy tube feeding
patients receiving tube feeds are at high risk for what
aspiration, keep them at semi-fowlers position or fowlers
fecal impaction aka
constipation
is catheterization a sterile procedure?
yes…
high risk of nosocomial infections
requires a doctors order
alternative methods to a catheter
bladder scan, condom catheter
