NUR 245 EXAM 2
What is significance of skin inspection and palpation?
- assess quality of scale or keratosis, texture changes, and skin temperature or
sweating differences.
- for localized lesions, palpation identifies tenderness, consistency, induration,
depth and fixation
- treatment and prevention
Normal ranges for vital signs
temp: 35.8-37.3C
older adult temp: 36.2C
heart rate: 50-95 beats/min
infant: 80-150
children: 70-100
respiration: 10-20 breaths/min
infant: 22-30
children: 18-24
BP: 120/80
What should you do if vital signs values are not as expected?
, temp: hyperthermia --> monitor WBCs, provide fluids and rest, cooling blanket, get
cultures, provide antipyretics
- hypothermia: warm environmental temp, keep head covered, continuous cardiac
monitoring
pulse: tachycardia: monitor for pain, anxiety, restlessness, fatigue, dizziness,
hypotension, chest pain, low O2
- bradycardia: monitor dizziness, hypotension, chest pain
BP: use auscultatory method w/ properly calibrated instrument; dont measure arm
with IV, avg 2 or more readings, after initial readings measure BP and pulse with client
standing
- orthostatic hypotension: assess for dizziness, weakness, and fainting, have client
sit at edge of bed for at least 1 min before standing up
Nutrition
eat healthy. stop eating McDonalds
xerosis
dry skin
Epistaxis
nosebleed
What is significance of skin inspection and palpation?
- assess quality of scale or keratosis, texture changes, and skin temperature or
sweating differences.
- for localized lesions, palpation identifies tenderness, consistency, induration,
depth and fixation
- treatment and prevention
Normal ranges for vital signs
temp: 35.8-37.3C
older adult temp: 36.2C
heart rate: 50-95 beats/min
infant: 80-150
children: 70-100
respiration: 10-20 breaths/min
infant: 22-30
children: 18-24
BP: 120/80
What should you do if vital signs values are not as expected?
, temp: hyperthermia --> monitor WBCs, provide fluids and rest, cooling blanket, get
cultures, provide antipyretics
- hypothermia: warm environmental temp, keep head covered, continuous cardiac
monitoring
pulse: tachycardia: monitor for pain, anxiety, restlessness, fatigue, dizziness,
hypotension, chest pain, low O2
- bradycardia: monitor dizziness, hypotension, chest pain
BP: use auscultatory method w/ properly calibrated instrument; dont measure arm
with IV, avg 2 or more readings, after initial readings measure BP and pulse with client
standing
- orthostatic hypotension: assess for dizziness, weakness, and fainting, have client
sit at edge of bed for at least 1 min before standing up
Nutrition
eat healthy. stop eating McDonalds
xerosis
dry skin
Epistaxis
nosebleed
