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2017 PNLE REVIEW MATERIALS FOR SALE

Thursday, January 8, 2015

Nursing Review: Vital Signs



Vital Signs

 Ø  Temperature (NV 36 – 37.5 C)
ü  Elderly people are at risk of hypothermia
ü  Hard work or strenuous exercise can increase body temperature
ü  Oral: most accessible 2-3 mins. * 15 minutes interval after ingestion of hot or cold drinks
ü  Rectal: most accurate 2-3 mins.
ü  Axillary: most safest 6-9 mins.

Ø  Pulse (NV 60-100 bpm)
   ü  Wave of blood created by contraction of the left ventricle of the heart
   ü  Radial: best site for adult
   ü  Brachial: best site for children
   ü  Apical: best site for 3 years old below

Ø  Respiration (NV 12/16-20)

Normal Breath Sound

Vesicular
Soft, low pitch
Lung periphery
Broncho-vesicular
Medium pitch
Larger airway blowing
Bronchial
Loud, high pitch
Trachea

Abnormal Breath Sound
Crackles
Dependent lobes
Random, sudden reinflation of alveoli fluids
Rhonchi
Trachea, bronchi
Fluids, mucus
Wheezes
All lung fields
Severely narrowed bronchus
Pleural Friction Rub
Lateral lung field
Inflamed Pleura


Ø  Blood Pressure (NV 120/80 mm/hg)
  ü  This is the force exerted by the blood against a vessel wall
  ü  The pressure rises with age.
  ü  A rest of 30 minutes is indicated before the blood pressure can be readily assessed 
             after stressful activity.
  ü  Interval of 30 minutes is needed after smoking or drinking caffeine.
  ü  After menopause, women generally have higher blood pressures than before.
  ü  Pressure is usually lowest early in the morning, when the metabolic rate is lowest, 
             then rises throughout the day and peaks in the late afternoon or early evening


Common Errors in Blood Pressure Assessment

Errors
Effect
Bladder cuff too narrow
Erroneously high
Bladder cuff too wide
Erroneously low
Arm unsupported 
Erroneously high
Insufficient rest before the assessment
Erroneously high
Repeating assessment too quickly
Erroneously high
Cuff wrapped too loosely or unevenly   
Erroneously low
Deflating cuff too quickly
Erroneously low systolic and high diastolic reading
Deflating cuff too slowly
Erroneously high diastolic reading
Failure to use the same arm consistently
Inconsistent measurements

Arm above level of the heart
Erroneously low
Assessing immediately after a meal or while client smokes
Erroneously high

Failure to identify auscultatory gap pressure
Erroneously low systolic pressure and erroneously low diastolic
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