Fundamentals Questions Answered 100% correct

Fundamentals Questions Answered 100% correct ABCS Airway, Breathing, Circulation, Safety Airway Mechanical process of having an open airway with which to breath Breath actual act of inhaling and exhaling Circulate Movement of blood through the body Safety physical Maslow's Physiological oxygen, fluids, nutrition, body temperature, elimination, shelter, sex Maslow's Safety and Security physical and psycholoical safety Maslow's Third Row Love and Belonging Needs Maslow's Fourth Row Self-esteem Maslow's Top Self- actualization Nursing Process Assess, Diagnose, Plan, Implement, Evaluate Patient's Vitals know what clients normal is Who can delegate Vital Signs to techs and other unlicensed individuals *CANT delegate interpretation Changeable Factors influencing VS lifestyle, environment, meds, pain Unchangeable Factors influencing VS age, gender, heredity, race Temperature -controlled by balancing metabolic heat production and loss Systems involved in Temperature neurological and circulatory Core Temperature internal temperature *Best by rectal/tympanic ((but its rarely taken)) Surface Temperature oral or axillary Temperature Range 98.6 to 100.4 F (36-38 C) Temperature Sites 1) oral 2) rectal 3) axillary 4) tympanic membrane 5) temporal artery 6) esophageal 7) pulmonary artery Pediatric Patient Temperatures no difference in results obtained from various thermometers Heat Loss types Radiation, Conduction, Convection, Evaporation Radiation teh transfer of heat from the surface of one object to the surface of another without direct contact between the two ex:removing clothing or blankets Conduction heat transfered from one object to another WITH DIRECT CONTACT ex: using an ice pack Convection transfer of heat away from the body by air movement ex: fan Evaporation insensible water loss- transfer of heat energy when a liquid is changed to a gas ** accounts for greatest heat loss when body heat increases (10%) ex: breathing, sweating, stool Factors Affecting Temperature SHE ACE stress hormone level enviroment age circadian rhythm exersize emotions and stress, food or fluid intake Fever (pyrexia) Temperature rises in response to pyrogens and stimulates phagocytosis Pyrogens induce secretion of prostaglandins (reset the hypothalamus and temperature increase) Giving tylenol for a fever? No, because 100.1 F is the max you should give tylenol at Hyperthermia elevated BT related to inability to promote heat loss and reduce heat production Heatstroke occurs from prolonged exposure to the sun or high environmental temperatures Heatstroke/ Hyperthermia Signs and Symptoms MEN GET inc HR and lower BP V. DC giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual distrubances, elevated body temperature, increased HR, and lower BP Heat Exhaustion occurs when profuse diaphoresis results in water and electrolyte loss To Treat Hyperthermia move client to a cooler environment take off shoes/socks place cool wet towels oscillating fans elevate legs to have BF to major organs rub with alcohol pad Most likely to get heatstroke elderly/ small children most likely Hypothermia heat loss due to prolonged cold (less than 96.8) metabolic processes slow severe hypothermia less then 82.4 To Treat Hypothermia cover/warm body heat exchange change wet linens head covered A 68 year old client presents to the ED with an oral 7: 101 P 114/min RR 22/min. His skin is warm to touch and the client is restless. Which interventions are appropriate (Select all that apply) a) restrict fluids b) provide oral care c) obtain cultures then start antibiotics d) allow for adequate rest e) apply extra blanket if client is chilled f) change bed linens upon client request BCDE keep him comfortables... would only change bed linens if they were wet Stroke Volume measurement of blood that enters aorta with each verntricular contraction 60-70 mL Cardiac Output amout of blood pumped by heart in 1 minute the product of HR and teh SV Pulse expansion of artery produced when a bolus of blood is forced into it by contraction of heart (normal adult is 60-100bpm) Factors Affecting Pulse Rate age - (higher in infants, decreases with age) sex- (women) exercise (lower in those that exercise) Food/Stress/Fever (all increase) Disease/Drugs- some increase, others decrease Apical Pulse 4th-6th intercostal space at midclavicular line Peripheral Pulses radial brachial carotid femoral dorsalis pedis posterior tibial popliteal artery Thumb with Pulse NEVER have thumb on skin when measuring pulses What to Look for in Pulse rate, rhythm, quality, color issue (pallor) Rate of Pulse bradycardia/Tachycardia Rhythm of Pulse dysrhythmia Quality of Pulse aka strength remember to check bilaterally Inequality of Pulses tells you.. circulation is poor The nurse is checking VS on an 80 year old client. The radial pulse is irregular with a rate of 92bpm. The client is asymptomatic. What should be the nurses actions? a) place the client on telemetry b) Obtain an EKG c) Report the finding to the HCP immediately d) Take an apical pulse for 60 seconds and note pulse deficit D - because you need to reevalutae for 60 seconds