INP 100 Final Exam Graded A+

Green Dishcharge purulent exudate Nose Bleed Epistaxis Bradycardia S&S (HR less than 60BPM) -fainting, dizzy, fatigue, confusion, disorientation, decreased BP, cyanosis, pale palour Bradycardia Treatment -diet, exercise, increase electrolytes, fowlers position, adjust temperature Tachycardia Causes (100+BPM) -anxiety, stress, smoking, high cholesterol, high LDL fat diet, kidney failure, hyperthyroidism, obesity, heat stroke Tachycardia S&S -flushed, sweating shakes, nervous, high heart palpations, delusional, tremors, dizzy, red face/skin, headache Tachycardia Treatment -Antiarrhythmics: slow HR to normal (quinidine, diltiazem, amiodrone) -Beta blockers: decrease BP + HR by blocking adrenergic receptors (metoprolol, atenolol) -CA Channel blockers: decrease BP (felodopine, nifedipine) -Digitalis: decrease edema, pulse, respirations, crackles -inhibit sodium potassium ATPhase (Digoxin) Dysrythmia/Arrythmia abnormal or irregular heart rhythm Fibrilation -heart quivers -use Afib. to get HR back to normal Causes: athersclerosis, anemia, surgery, shock, hemmorhage Pulse Deficit -when two people simultaneously check pulse rate on radial and apical sites What to note when taking a Pulse -rhythm (steady, abnormal or irregular) -rate -BPM -Strength -changes from last time checked What pulse do you check in an emergency? Carotid Blood Pressure Force of blood exerted on arterial walls as the heart pumps and relaxes (systolic/diastolic) BP Range Infant: 65/115 mmHg Children: 105/65 mmHg Adults: 120/80 mmHg Orthostatic Hypotension -when a person stands up or sits down resulting in dizzyness and possible loss of consciousness -lightheaded Interventions include rest at corner of bed before moving, positioning client and dangling legs over berd Contraindications to BP -after eating, exercising, sleeping, smoking, position of head, size of cuff/positions/too tight or loose Temperature Normal Range oral tympanic: 37 degrees Celsius rectal: 37.5 degrees Celsius axillary: 36.5 degrees Celsius Febrile/Pyrexia/Hyperpyrexia -increase in body temperature i.e. a fever Hypothermia range mild: 34-36 degrees Celsius moderate: 30-34 degrees Celsius severe: below 30 degrees Celsius Factors that effect temperature -exercise, age, hormone level, stress, environment, temp. alterations, drinking a hot beverage -radiation, evaporation, conduction Vital Signs-how measured -respiration's per minute -O2 saturation -temperature (degrees celcius) -BP -HR Respirations Normal Range infant: 30-60 toddler: 25-32 child: 20-30 adult: 12-20 breaths per minute older adult: Tachypnea an abnormally rapid rate of respiration, usually 20 breaths per minute Bradypnea abnormally slow rate of respiration usually of less than 10 breaths per minute Stridor High-pitched sound heard on inspiration; upper-airway sound indicating partial obstruction of the trachea or larynx Stertorous breathing Noisy Breathing ( Noisy Ventilation) -snoring Eupnea normal, good, unlabored ventilation Hypoxia -body is deprived of adequate oxygen supply Hypoxemia -deficiency of oxygen in arterial blood Most accurate way of checking core temp. rectal -though is it invasive and can have contraindications for hemorroids, decubitus etc Least accurate way to check temp. axillary Hypoxia/Hypoxemia S&S -headaches, fatigue, shortness of breath, a feeling of euphoria and nausea -changes in levels of consciousness, seizures, coma, death Core temperature vs. surface temp Core: rectum, tympanic, temporal artery, urinary bladder Surface: skin, mouth, axillae Cheyne-Stokes respiration pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea Systolic measurement of blood pressure taken when the heart is contracting and forcing blood into the arteries (left side of heart) Diastolic the blood pressure during that part of the heartbeat when the hearts venticles are relaxing When to take vitals -before or after surgery -before and after nursing interventions -patient shows signs of malaise of unusual fatigue -home care visits -clients administered into hospital (get a baseline line) How often do you take Vitals? after surgery: 15 minute rule...30 minute and then every hour for 4 hours Factors that Influence Urination -disease (prostate cancer) -fluid balance (intake vs. output) -medications (diuretics) pelvic muscle tone (diff. for male and female) -surgery -anxiety or culture -age -pregnant Transient Urinary Incontinence -comes and goes (pregnant or ill) Urge Urinary Incontinence sudden need to urinate Stress Urinary Incontinence sneeze or laugh Reflex Urinary Incontinence neurological condition Overflow Urinary Incontinence stretched bladder (holding urine or blockage) Mixed Urinary Incontinence combo of all urination types Functional Urinary Incontinence blockage of urine (cancer) Total Urinary Incontinence no control (muscle issue: do kegels to fix, sphincter issue or disease) Normal Urinary Elimination Morning, noon and night Intake: 8 glasses of water a day Output: Color: pale to amber Clarity: trasnparent unless pathology present Odour: ammonia-like in nature Urinary Retention an accumulation of urine due to the inability to empty the bladder Urinary Incontinenence involuntary leakage of urine UTI urinary tract infection -hygiene, catheters as the main cause for elderly Urinary Diversions Diversion of urine to external source when bladder is removed or bypassed -urethers implanted in abdominal wall(urostomy) or bowel(ilostomy) Urinalysis test urine for blood, ph etc -clean catch Nursing Diagnosis for urinary issues -incontinence: prmotoe kegel exercise, bladder training, or cathertor care -risk of infection: pormote hygiene -toilet-self care deficit -impaired urinary elimination -urinary retention Condom Catheter a catheter that has an attachment on the end that fits onto the penis -non invasive, can be changed by client at home -change every