MDC Exam 1

MDC Exam 1 basic physiological needs type of needs that are essential for the maintenance of life Air Food Water Temperature regulation Elimination Rest Sex Physical Activity Blood flow (perfusion) is necessary to meet other basic needs Basic physiological needs include Protection from physical harm Adequate shelter Freedom from fear and anxiety Safety and security needs would include what type of necessities? Vital signs One of the most critical nursing interventions the nurse has is the ability to monitor and interpret the client? Temperature Regulation or thermoregulation is determined using the client's? 96.4 - 99.5 degrees fahrenheit What is normal temperature range? Temporal Oral Tympanic Axillary Rectal different methods a temperature can be taken. Temporal What is the non invasive way to take a temperature? Rectal What is the most invasive way to take a temperature? hypothermia abnormally low body temperature, LESS than 95 Hyperthermia Abnormally high body temperature, ABOVE 99.5 Hypothermia interventions Provide warm environment Keep head covered Continuous cardiac monitoring Emergency resuscitation equipment on standy Hyperthermia interventions Obtain specimens Monitor WBC/ESR/Electrolytes Antibiotics Fluid & Rest Antipyretics PREVENT shivering Offer Blankets Oral Hygiene Dry Clothing/linens Keep env temp between 70-80 Perfusion The supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of the flow of blood through the capillaries. Normal pulse rate 60-100 beats per minute Bradycardia slow heart rate, below 60 bpm Tachycardia fast heart rate, above 100 bpm Pulse rhythm the pattern of the beats and intervals between the beats pulse quality the rhythm (regular or irregular) and force (strong or weak) of the pulse regular rhythm You should check pulse for 30 seconds x 2, or 15 seconds x 4 for ____________ irregular rhythm You should check pulse for one full minute in the apical region for a ___________ Amplitude Height of a wave, what is measured. blood pressure Pressure exerted by the blood upon the walls of the blood vessels, especially arteries, usually measured by means of a sphygmomanometer and expressed in millimeters of mercury. normal blood pressure 120/80 mmHg systolic pressure (90-120) occurs when the ventricles are contract. Maximum pressure on the arteries. diastolic pressure (60-80) occurs when the ventricles are relaxed; the minimum pressure against the arteries. hypotension ______________ is related to dehydration from inadequate fluid intake, from diarrhea, elevated temp Vital signs Initially Identify high-risk populations I & O, daily weights Describe s/s of associated with fluid loss Nursing interventions for hypotension S/s of fluid loss oliguria, increased HR,RR, HTC and temp. Change in LOC/Dizzy, activation RAAS, pallor, 1+ pulse strength, dark urine (odor), decreased GI motility Normal respiration rate 12-20 breaths per minute nasal flaring use of accessory muscles body positioning (tripod) How to determine the client's respiratory effort? Pulse Oximetry (SpO2) An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds. Hypoxia Low oxygen saturation of the body, not enough oxygen in the blood