Vitals (basics) Flashcards
Normal temperature
36.5°-37.5°C or 97.6°-99.6°F
Adult pulse
60 to 100 beats/min
Newborn pulse
130-160 bpm
Adult respirations
12-20 breaths/min
Newborn respirations
40-60 breaths/min
Adult blood pressure
120/80
O2 saturation normal level
Above 94
Blood pressure (BP) measured during ventricular contraction is known as
Systolic pressure
Blood pressure measured during ventricular relaxation is known as
Diastolic pressure
Formula for Pulse Pressure
Pulse Pressure = Systolic BP – Diastolic BP
What is the Auscultatory gap
Period of silence/reduced intensity of Korotkoff sounds during BP measurement
Maximum inflation
What are Body mechanics?
Coordinated efforts of M/A and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing ADL’s
What are the 2 Nursing Interventions
Positioning and Turning
Purpose of footboard/splints
To prevent irreversible foot drop
Purpose of abduction pillow
Keeps patients spread while laying down or on their side
Purpose of a trapeze
Allows paraplegic patient to assist you.
Can hold onto the bar and pull themselves up in bed, encourages upper body strength and independence
What is a pulse?
A wave created by expansion and contraction of blood in aorta that travels along blood vessels
What are the characteristics of a pulse?
Pulsation can be felt as a throb or a tap in a peripheral artery
Orthostatic hypotension
BP drop with change in position drop in systolic BP >20 mmHg or diastolic BP >10 mmHg when getting up from lying down.
What is Eupnea
Normal breathing
Your patient had surgery 1 week ago and has been on bedrest. They decide that they want to get up and walk around the unit today, but when they do, they get dizzy and stumble. What are your priorities?
a) Take their blood pressure
b) Help them continue to walk around the unit
c) Take their temperature
d) Help the patient return to bed
a) Take their blood pressure
d) Help the patient return to bed
What is a HERO?
Hopkins Event Reporting Online
Report adverse event, like a medical error or a fall.
When is SBAR used?
When there is a change in the pt’s state.
Sentinel Event
An event that’s life threatening or life-changing
What are some NON-pharmacological things nurses can do to treat pain?
Heat/cold, Massage, Positioning, Hygiene: wash their face/hair, Ensure comfortable environment: lighting, music, cleanliness of room, Distraction, guided imagery, meditation etc.
What other reasons would you take an apical pulse on a patient?
If the pulse is difficult to palpate
If the pulse is weak.
If the patient was an infant
Effects of Immobility on Musculoskeletal System
Osteoporosis, Atrophy, Contractures/spasticity, Decubitus Ulcer
Effects of Immobility on Nutrition and Metabolism
Decreased BMR
Negative nitrogen balance (Protein breakdown → Body eating itself)
Calcium loss from bone
Effects of Immobility on Elimination
Urinary stasis
UTI
Renal calculi (From calcium loss from bones)
Constipation
List some methods to prevent thrombus formation
Anticoagulants (Heparin, Lovenox)
Pt must continue these until completely d/ced
TED (Thrombo-Embolic-Deterrent) stockings
Calf pumping exercises
Sequential Compression Device
Sleeves that are pumped with air to help push blood
Effects of Immobility on Cardiovascular System
Orthostatic hypotension
Increased workload of heart due to decrease in venous return to heart
Risk for thrombus (blood clot)
Part of it can break off and become an embolus
Necrosis or DVT (Deep vein thrombosis) can occur from poor circulation
Effects of Immobility on the Respiratory System
Decreased activity → Decreased BMR → Decreased CO2 production → Decreased stimulation to breathe → Slower, more shallow respirations
___% of cardiopulmonary arrest potentially avoidable
84% of cardiopulmonary arrest potentially avoidable
Evisceration
Organs pop back out
Korotkoff sounds
sounds heard when a blood pressure cuff is deflated, which indicate blood pressure
Dehiscence
The separation or opening of a previously closed structure, such as a wound, incision, or fruit capsule.
Pressure ulcer prevention/interventions
Turning patients Q2 (laying), turn a sitting patient every 15 minute
How often do you have to check on patients with restraints
Once the order is done, check pt an hour after and then after 2 hours
What makes an elderly person a fall risk (aside from age and fragility)
Confused patients, patients who can use the bathroom or on diuretic medication
Pannis
Skin folds for obese pts
