Exam 1 Topics Notes Flashcards
MAR
Where data are charted
Assess this pulse site prior to giving a cardiac medication
Apical pulse: check for rhythm (irregular or regular), rate (60-100 bpm), strength (no pulse, weak, moderate, bounding/strong), equality-(distal pulses), count and assess for full 60 seconds
Name of the chest/endpiece of the stethoscope used to auscultate high pitch sounds.
Diaphragm: high pitch sound. Ex: bowel (GI) sounds, respiratory sounds, PMI (point of maximal impulse- where the apex of the heart is)
Bell: Low pitch sound. Ex: bruits, korotkoff
Older age, stress, ethnicity, post menopausal, elevated BMI, cigarette smoking and time of day are factors affecting this VS.
Blood pressure: amount of blood exerted on walls of capillaries
Used to obtain an oxygen saturation.
Pulse oximeter: device that can be used to clip on fingers, toes, earlobes to know the oxygen saturation level (current O2 bind to hemoglobin compared to unbounded hemoglobin)
Used when counting a RR or HR.
Lapel watch
Used to auscultate Korotkoff’s sounds?
Stethoscope (bell side, but can use diaphragm as well)
This is the name for the waveform on the pulse oximeter indicating reliability.
Plethysmograph
Used to assess a pulse that is not palpable.
Doppler ultrasound
Normal BPM
60-100 beats per minute (normal resting HR adult)
> 95% on room air
Normal oxygen saturation level (lower for CO2 retainer patients and patients have problems with respiratory disorder - 92%)
12-20 breaths/min
Normal adult respiratory rate
96.8-99.5 (36C-37.5)
Normal adult body temp (for younger patients- more than 104 (40C) considers fever, or 101 (38.3)
SBP + 2(DBP)/3
Mean arterial pressure
Administer acetaminophen/Tylenol and use cooling measures.
Treatment of fever (febrile)
Keep skin clean and linens dry, give warm fluids and blanket from warmer, cover head.
Treating hypothermia (Uncontrolled shivering temp less than 96F [35.5C], HR and RR also decrease. Vasodilation occurs with warming – monitor for hypotension)
What to do for decrease resp rate or increase oxygen saturation pts?
Verbally calm, breathe with the patient, position for maximal lung expansion, decrease lights, use a fan.
How to treat tachycardia (fast heart beat)?
Administer a beta blocker i.e. metoprolol/Lopressor, treat pain and anxiety and give IV fluids.
When to give IV fluids?
Heart rate:Healthcare providers should consider fluid administration when the heart rate exceeds 90 bpm. Tachycardia may indicate a compensatory physiological response to preserve perfusion in hypovolemia and can manifest as an early sign of compensated hypovolemic shock. Nonetheless, tachycardia can have various other causes, including pain, fever, and anxiety.
Blood pressure:Healthcare providers should contemplate fluid administration when the systolic blood pressure falls below 100 mm Hg. A declining blood pressure is an ominous finding often linked with tachycardia. Hypotension and tachycardia indicate that the cardiovascular system can no longer compensate for hypovolemia effectively. Conversely, elevated blood pressure is typically associated with hypervolemia.
Orthostatic vital signs:These signs involve a reduction of at least 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure within 2 to 5 minutes of standing quietly after 5 minutes of supine rest, which signifies the presence of orthostatic hypotension.[6]These findings may be evident in dehydrated or older patients who have experienced reduced sensitivity in the baroreceptors of their blood vessels.
Respiratory rate:Healthcare providers should contemplate fluid administration when the patient’s respiratory rate exceeds 20 breaths per minute. An elevated respiratory rate suggests a compensatory response to metabolic acidosis resulting from lactic acidosis due to inadequate tissue perfusion.
Urine output:In clinical practice, healthcare providers should anticipate a minimum urine output of 1.5 mL/kg/h in children and more than 1 mL/kg/h in adults. Specific clinical scenarios may necessitate higher urine output thresholds to minimize the risk of renal toxicity, especially when administering nephrotoxic medicationssuch asacyclovir.