HOSA CLINICAL NURSING: Clinical Care for Systems Diseases and Disorders: Signs and Symptoms

Locations to measure body temperature

Oral (O), Rectal ®, Axillary (Artmpit), tympanic/aural (ear), temporal artery (forehead)

Oral temperature

Under tongue-If they drank something hot/smoked wait 15 minDon't use oral for people with seizures, nose/mouth surgery, suicidal, young children

Rectal Temp.

Super accurateUsed for unconscious patients or after mouth surgery

Axilary

Least accurat Use frequently for newborns

Tympanic

great for core body temperature, Used by many pediatric and ICU

Temporal Artery

Quickest and least invasive, More accurate than tympanic but less than recturm

Glass thermometers have a scale of

93 to196 F

Pulse

every heartbeat produces a wave of blood

Pulse places

carotid, radial, mandibular, temporal, femoral

Pulse rate

how often a person's heart beats/min

Normal pulse rate

60to80 BPM

Who has higher pulse men or women

women

Newborn pulse rate

120to140 BPM

Pulse rate increases in proportion to body temp.

pulse increases 10 beats for every 1 degree F increase

Tachycardia

pulse rate consistently above normal (100 beats per minute), may signify hemorrhage, heart disease, heart failure

Bradycardia

pulse rate consistently slower than normal (55-60), common in athletes, can be signal of cerebral hemorrhage or heart block

Pulse volume

hemorrhage pulse is weak

PV full/bounding

pulse is strong and difficult to obliterate

Dysrhythmia

Pulse irregular in force and rhythm, sign of some form of heart disease/overcative thyroid gland

Auscultation

listening to sounds and counting apical pulse normally herd at heart's apex, point of maximal impulse

Doppler device

used to detect peripheral pulses, apply gel on skin and put doppler over artery being assessed

Radial pulse

radia artery in wrist most commonly used

Apical pulse

more accurate than radial and is always used for kids under 2

Apicalradius pulse

Of suspected patients heart is pumping properly

Pedal pulse

Foot pulse is over tibial artery indicated unrestricted blood flow to lower extremities (check in both feet), if not possible must write "pedal pulse not palpable"

Popliteal pulse

posterior to knee used to assess circulation to lower leg

Carotid pulse

neck pulse edge of stercocleidomastoid muscle

Apnea

cessation of breathing that occurs in sudden infant death (SIDS< sleep ones and other conditions

Average breathing rate

12/18 breaths amin and for nw borns ~40 breaths

Eupnea

normal breathing rate

Tachypnea

abnormally repaid 20/24

Bradypnea

abnormally slow breathing below 10

Cheyenna

Stokes respiration - alternating deep rapid breathing followed by periods of apnea

Biot's respiration

varying depth and rate of respiration followed by apnea associated with meningitis or brain damage

Kussmaul's respirations

accumulation of poisons in uremia and diabetic coma increase dearth of respirations, increase acid in body and body tried to compensate by removing excess acid through fast breathing

Stertorous breathing

air passes through secretions in air passage, bubbling noise before death; when air passage fills with mucus

Dyspnea

difficult/painful breathing

Orthopnea

can only breathe upright

Asthma

difficulty breathing due to bronchial spams and edema

Cheyenna

stokes respirations - slow and shallow at first but gradually get faster, tapering opp until they stop. Last few seconds and repeats.

How many times a day is BP measured

at least 2

What is blood pressure determined by

cardiac output and peripheral resistance (resistance of biodisses to flow)

Arterioscelerosis

harding of blood vessels

Atherosclerosis

build up of plaque in blood vesses

Hypertension

high BP (circulatory problem)

Hypotension

low Bp (hemorrhage of shock)

Mean arterial pressure (MAP)

mathematic approximation of diastolic pressure plus ⅓ of pulse pressure

Diastolic is ⅓ to ½ of systolic pressure

Average BP

120/80

Direct and indirect measurement of Bp

direct inserting a probe/acter into patient heart and indirect BP cuff

Syphometer

placed over branchial rather

Aneroid manometer

one we have with the handheld pump and clock

Korotstoff

Orthostatic/postural hypotension

severe drop in BP

Oximetry

noninvasive procedure using photoelectric impulses to measure amount of light transmitted/reflected by deoxygenated compared to oxygenated hemoglobin