Exam (elaborations) NURS 101

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings?️️False High Rationale: If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading. The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?️️Nosocomial Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection. When to measure vital signs️️-On admission to a healthcare facility -When assessing pts during home care visit -In hospital during routine schedule according to health care provider order or standard of practice -Before, during, & after surgical procedure/invasive diagnostic procedure -Before/during/after blood transfusion products -Before/during/after admin of med or therapies that affect cardiovascular, respiratory, or temp control function -When pt condition changes (ex. loss of consciousness) -Before/during/after interventions influencing VS (ex. ambulation, before/after ROM exercises -When pt reports nonspecific symptoms of physical distress (ex. feeling 'funny' or 'different') Normal Temperature Ranges️️36C- 38C (96.8F - 100.4F) -Average oral temp = 37C (98.6F) -Temp controlled by hypothalamus Patterns of Fever️️Sustained- constant body temp continuously above 100.4F- little fluctuation Intermittent- Fever spikes mixed with reg temp levels-returns to acceptable value at least once in 24 hrs Remittent- Spikes and falls w/o return to acceptable level Relapsing- Periods of febrile episodes mixed with acceptable values sometimes longer than 24 hrs Classifications of Hypothermia️️Mild- 34-36C // 93.2 - 96.8F Moderate- 30-40C // 86-93.2F Severe- >30C // >86F Heatstroke️️a dangerous condition in which the body loses its ability to cool itself through perspiration (40.2C // 104.4f) Na+ and K+ depletion, elevated pulse, low BP --mgmt = fluid/electrolyte support, cooling, rest Oral Temp Site Advantages & Limitation️️Advantages: easy access/no position change req, comfortable for pt, provides accurate surface reading, reflects rapid change in core temp, reliable for intubated patients Limitations- delay in measurement if pt ingests hot/cold fluid/food/smoked/chewed gum, not used if pt had oral surgery, trauma, shaking/chills, hist of seizure, not used in infants, small children, confused/uncooperative pt, risk of bodily fluid exposure Tympanic Temp Site Advantages & Limitations️️Advantages- easy access, obtained w/o disturbing, used for pt with tachypnea w.o affecting breathing, quick measure, unaffected by oral intake of food/drink, shown to have high precision, sensitivity, & specificity Limitations: Susceptible to user error, low sensitivity for detecting fever in comparison to rectal, requires removal of hearing aid, disposable cover, only 1 size, otitis/cerumen impaction can distort reading, doesn't accurately measure core temp changes during/post exercise, affected by ambient temp changes (ex. warmer, incubator, facial fans), anatomy of ear canal makes it