Nurs 3100 Exam 2 Review 2021/2022

Nurs 3100 Exam 2 Review 2021/2022. Understand there are 5 vital signs that are done when assessing your patient and that oxygen saturations should be included also. (p. 275) o Vital signs are used to monitor the functioning of body systems o Assessment of vital signs allows the nurse to detect changes in the health status of the patient, identify early warning signs of life-threatening health conditions, and evaluate the effectiveness of interventions o Vital signs consist of body temperature (T), pulse (P), respirations (r), and blood pressure (BP). > T= refers to the measurable heat of the human body > P= detectable rhythmic expansion of an artery that occurs with the pumping action of the beating heart; thus, the pulse rate is measured as a number of heart beats per minute (BPM), with pulse intensity and pattern often specified as well. > R= the act of breathing, so respirations are assessed for frequency, or breaths per minute (BPM); abnormal quality and pattern of breathing also should be noted > BP= the measurable pressure of blood within the systemic arteries > Pulse oximetry= measures the amount of oxygen available to tissues, typically are included with reported vital signs. The pulse oximeter reading is the percentage of hemoglobin that combines with oxygen (SpO2). 2. Know the different pulse sites and how to assess these sites. (p. 283-285) o Temporal: Where temporal artery passes over temporal bone of head; above and lateral to the eye; used when radial pulse is not accessible o Carotid: At the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle; used in cases of cardiac arrest and for determining circulation to the brain o Apical or point of Maximal impulse (PMI): Apical, at the apex of the heart, and PMI, at the fifth intercostal pace, midclavicular line; used for infants and children up to 3 years of age, placed in the supine position, to determine discrepancies with radial pulse, and used in adults with conjunction with some diseases and medications and during a head to toe assessment o Brachial: At the inner aspect of the arm; used to assess pulse in pediatric emergencies and to measure blood pressure o Radial: On the thumb side of the inner aspect of the wrist where the radial artery runs along the radial bone o Femoral: where the femoral artery passes alongside the inguinal ligament; used in cases of cardiac arrest and for assessing circulation to the leg o Popliteal: behind the knee where the popliteal artery passes; used to determine circulation to the lower leg o Posterior tibial: Medial surface of the ankle; used to determine circulation to the foot o Pedal (Dorsalis Pedis): Where the dorsalis pedis artery passes across the top of the foot; used to determine circulation to the foot o Most definitive site used for pulse assessment is over the apex of the heart, where apical pulse can be auscultated o Most common site for assessing the quality, rate, and rhythm of the pulse is the radial artery o Dorsalis pedis and posterior tibial artery pulses are used to evaluate effectiveness of peripheral vascular system but NOT to asses heart rate or rhythm 3. Know the elderly age-related findings of each vital sign. (p. 278, 283, 286, 290, 295) o Temperature: it is common for the baseline temperature to drop as the person ages. Infants and elderly people are more susceptible to environmental temperature extremes. o Pulse: As age increases from infancy to adulthood, the pulse rate decreases o Respiratory Rate: RR decreases with age through late adolescence when it stabilizes o Blood Pressure: with age, elasticity in arteries decreases; this increases peripheral resistance, leading to higher BP 4. Know the procedure for assessing the pulse on a client. (p. 301-303) o Textbook 5. Know the location of each of the pulse sites. (p. 303) o Temporal: both sides of the head may be assessed simultaneously o Carotid: the pulse must be assessed on one side of the neck at a time o Brachial: the arm is held straight out and supported o Femoral: assessment involves deeper palpation in groin area o Popliteal: knee flexed slightly, and leg muscles relaxed o Dorsalis Pedis: If this pulse is not palpable, use of a portable Doppler ultrasound machine may be required o Posterior Tibial: located posterior to the medial malleolus, may feel both extremities simultaneously o View page 303 for more detail: but this is the basics of it 6. Know how to use and assess a site when using a pulse oximeter. (p. 307) Refer to textbook starting from interprofessional collaboration and delegation and special circumstances 7. Know when to use a rectal thermometer. (p. 280) o Rectal temperature readings are considered to be very accurate o rectal route is contraindicated in newborns in patients who are neutropenic (manifested as low white blood cell count), any patients with spinal cord injury o should not be used for patients with diarrhea or rectal disease, post rectal surgery patients or quadriplegic patients