HCA 162 Final Exam
How do you convert pounds to get Kilograms?
I.E. 140 pounds divide by 2.2 = 63.63 Kilograms
When is the clients body weight and heigh measured and recorded?
- upon admission
- required set intervals: ie. LTC: monthly usually at bath time.
- for specific health issues
What does vital signs include?
- temperature - Temp or T
- pulse or heart rate - HR or P
respiration rate - Resps or RR
- blood pressure - BP
- oxygen saturation - SP02, Sats
When are vitals taken?
- client's condition changes
- nurse has requested
- upon admission
- monthly * more frequently in acute care
When reporting or recording vitals you must be:
Accurate
When to report to nurse when taking client's vital signs:
- if there is a change from the client's baseline
- it they are higher than normal
- if they are lower than normal
What routes can you take a client's temperature?
- Oral
- Axilla * least accurate
- Tympanic
- Rectal
,- Temporal artery
- InfraRed
What different types of thermometers are there?
- Electronic
- Digital
- Dot Matrix
- Tape
- Disposable oral
When taking an adult's tympanic temperature how do you insert into the ear?
you pull the ear up and back before inserting.
What is a pulse?
beats of the heart felt through the walls of the arteries.
What is the average heart rate for adults?
60-100 BPM
Tachycardia:
fast heart rate
100+ BPM
Bradycardia:
slow heart rate
under 60 BPM
How do you take some ones pulse(HR)?
either have the client lay down in supine w/arm across the chest palm down.
OR
sitting down with elbow at 90 degree and support on arm rest. wrist with palm down.
You: Place 3 fingers along radial artery at base of thumb. count pulse for 60 seconds.
* note strength(strong and full vs weak and thready) and rhythm( normal or
abnormal(dysrhythmia/irregular).
What are respirations?
The breathing rate of the patient.
What are some signs of problems when applying heat/cold application?
, heat: redness at site, facial redness, blisters, complaints of discomfort/pain, changes in client's
behaviour, and signs of skin irritation.
cold: pale/white/or grey skin, cyanosis, shivering, complaints of discomfort/pain, changes in
client's behaviour.
How do you count respirations?
count one inspiration and one expiration as one respiration. Count these for a full 60 seconds.
What is a normal rate of respiration?
12-20 breaths per minute
What is Dypsnea?
difficult or labored breathing
What is Apnea?
Respirations pause
What does noisy or gurgled respirations normally mean?
fluid in the lungs
When you take respirations what do you need to make note of?
- rate
- uniformity or depth of respirations
- rhythm (regular or not)
- dyspnea or pain
- noises
- any abnormalities
When recording Vitals unsure you include:
- client's full name
- date vitals were taken
- time vitals were taken
- vital signs measurements
- ACCURACY-
When do you apply hot or cold to a client
Only when on the care plan or/and delegated by a nurse.
When applying heat or cold to a client what is important to know?
How do you convert pounds to get Kilograms?
I.E. 140 pounds divide by 2.2 = 63.63 Kilograms
When is the clients body weight and heigh measured and recorded?
- upon admission
- required set intervals: ie. LTC: monthly usually at bath time.
- for specific health issues
What does vital signs include?
- temperature - Temp or T
- pulse or heart rate - HR or P
respiration rate - Resps or RR
- blood pressure - BP
- oxygen saturation - SP02, Sats
When are vitals taken?
- client's condition changes
- nurse has requested
- upon admission
- monthly * more frequently in acute care
When reporting or recording vitals you must be:
Accurate
When to report to nurse when taking client's vital signs:
- if there is a change from the client's baseline
- it they are higher than normal
- if they are lower than normal
What routes can you take a client's temperature?
- Oral
- Axilla * least accurate
- Tympanic
- Rectal
,- Temporal artery
- InfraRed
What different types of thermometers are there?
- Electronic
- Digital
- Dot Matrix
- Tape
- Disposable oral
When taking an adult's tympanic temperature how do you insert into the ear?
you pull the ear up and back before inserting.
What is a pulse?
beats of the heart felt through the walls of the arteries.
What is the average heart rate for adults?
60-100 BPM
Tachycardia:
fast heart rate
100+ BPM
Bradycardia:
slow heart rate
under 60 BPM
How do you take some ones pulse(HR)?
either have the client lay down in supine w/arm across the chest palm down.
OR
sitting down with elbow at 90 degree and support on arm rest. wrist with palm down.
You: Place 3 fingers along radial artery at base of thumb. count pulse for 60 seconds.
* note strength(strong and full vs weak and thready) and rhythm( normal or
abnormal(dysrhythmia/irregular).
What are respirations?
The breathing rate of the patient.
What are some signs of problems when applying heat/cold application?
, heat: redness at site, facial redness, blisters, complaints of discomfort/pain, changes in client's
behaviour, and signs of skin irritation.
cold: pale/white/or grey skin, cyanosis, shivering, complaints of discomfort/pain, changes in
client's behaviour.
How do you count respirations?
count one inspiration and one expiration as one respiration. Count these for a full 60 seconds.
What is a normal rate of respiration?
12-20 breaths per minute
What is Dypsnea?
difficult or labored breathing
What is Apnea?
Respirations pause
What does noisy or gurgled respirations normally mean?
fluid in the lungs
When you take respirations what do you need to make note of?
- rate
- uniformity or depth of respirations
- rhythm (regular or not)
- dyspnea or pain
- noises
- any abnormalities
When recording Vitals unsure you include:
- client's full name
- date vitals were taken
- time vitals were taken
- vital signs measurements
- ACCURACY-
When do you apply hot or cold to a client
Only when on the care plan or/and delegated by a nurse.
When applying heat or cold to a client what is important to know?
