Exam (elaborations)
NUR 103- Exam 3 (Answered) 183 Questions and Correct Answers, 100% Correct, Latest 2024/2025.
- Course
- Institution
NUR 103- Exam 3 (Answered) 183 Questions and Correct Answers, 100% Correct, Latest 2024/2025.
[Show more]
Content preview
NUR 103- Exam 3 (Answered) 183Questions and Correct Answers, 100%
Correct, Latest 2024/2025.
Vital signs
indicators of physiologic functioning; body temperature, pulse, respiratory rates, and blood pressure
Pulse (P)
-pulse (peripheral): a throbbing sensation that can be palpated over a peripheral artery, such as the
radial or carotid artery
-pulse pressure: the difference between systolic and diastolic pressure
Respirations (R)
-act of breathing and using oxygen in body cells
-inspiration: act of breathing in; inhalation
-expiration: act of breathing out; exhalation
Apnea
absence of breathing
Orthopnea
a condition in which people with dyspnea can often breathe more easily in an upright position
Conversions for temperature
Celcius to Fahrenheit: x 9/5 + 32
Fahrenheit to Celcius: - 32 x 5/9
Normal Temperature by Age
Newborn (0-28 days): Axillary: 35.9-36.9 or 96.7-98.5
Infants (1-12 months): Temporal: 37.1-38.1 or 98.7-100.5
Toddler (1-3 years): Temporal: 37.1-38.1 or 98.7-100.5
Child (4-10 years): Tympanic: 36.8-37.8 or 98.2-100
Preteen (11-12 years): Oral: 35.8-37.5 or 96.4-99.5
Teen (13-19 years): Oral: 35.8-37.5 or 96.4-99.5
Adult (20-64 years): Oral: 35.8-37.5 or 96.4-99.5
Aged Adult (65+): Oral: 35.8-36.8 or 96.4-98.3
Normal Pulse by Age
Newborn (0-28 days): 70-190
Infants (1-12 months): 80-160
Toddler (1-3 years): 80-130
Child (4-10 years): 70-115
Preteen (11-12 years): 65-110
,Teen (13-19 years): 55-105
Adult (20-64 years): 60-100
Aged Adult (65+): 40-100
Normal Respirations by Age
Newborn (0-28 days): 30-40
Infants (1-12 months): 20-40
Toddler (1-3 years): 25-32
Child (4-10 years): 20-26
Preteen (11-12 years): 18-26
Teen (13-19 years): 12-22
Adult (20-64 years): 12-20
Aged Adult (65+): 16-24
Normal Blood Pressure by Age
Newborn (0-28 days): 73/55
Infants (1-12 months): 85/37
Toddler (1-3 years): 89/46
Child (4-10 years): 95/57
Preteen (11-12 years): 102/61
Teen (13-19 years): 112/64
Adult (20-64 years): 120/80
Aged Adult (65+): 120/80
Health Assessment
-includes a health history, vital signs, and physical assessment
-questions: about patient subjective and objective data
-includes 4 types: comprehensive, ongoing, focused, emergency
Comprehensive health assessment
-detailed history and physical examination at onset of care in primary care setting or on admission to
hospital or long-term care facility; encompasses health problems, health promotion, disease
prevention, and assessment for problems associated with known risk factors
-goal is to find the baseline data
Ongoing health assessment
monitor changes after receiving interventions
Focused health assessment
Assessment based on the patient's problems; components include performing a general survey,
taking vital signs, and assessing specific areas that relate to the problem
Emergency health assessment
conducted to determine life-threatening or unstable conditions
What is the purpose of the physical assessment?
,-to gather objective data to identify physical changes in the patient
-this information, along with subjective data, is used to formulate diagnoses
Equipment needed for a physical assessment
-thermometer
-sphygmomanometer
-scale
-penlight
-stethoscope
-metric tape measure and ruler
-eye chart
-tuning fork
Order of techniques for a physical assessment
1. inspection
2. palpation
3. percussion
4. auscultation
Inspection
-seeing; deliberate and methodical
Palpation
-feeling; using finger pads and dorsum of hand
Percussion
-sound- tapping fingers
Auscultation
-hearing; utilizing stethoscope
-pitch, loudness, duration, quality
-ex: abdominal sound is gurgling, loud, and high pitched for 2 seconds
When is it appropriate to measure vital signs?
-in the home
-screenings at health care facilities and clinics
-upon admission and before discharge
-when medications are given that can affect cardiac rhythms
-before and after any invasive or surgical procedure
-in emergency situations
-when patient condition changes
Temperature (T)
-controlled in the hypothalamus: which is a thermoregulatory center that sends messages to gain or
lose heat
-heat is a byproduct of metabolic activity on the cellular level
-normal oral temp for an adult is 37 C (98.6 f)
, What are factors that affect body temperature?
-circadian rhythms (more in infants and children)
-age & gender (women due to hormone cycles, infants and older adults due to environmental
changes)
-physical activity (more activity=more body heat; increased metabolism)
-state of health- disease
-environmental temperature- (hypothermia/hyperthermia)
Increased body temperature
-cause: pyrogens, chemicals, environment
-> 41 C = hyperpyrexia (can cause brain damage)
-effects: first shivering, piloerection, & vasoconstriction (increased metabolism) then sweating,
vasodilation, increased RR
-Increased RR & P, loss of appetite, headache, hot/dry skin, flushed face, thirst, muscle aches fatigue
-treatment: cool environment, cooling blanket, ice packs, cool bath, increase oral fluids, simple
carbs, antipyretic medications, antibiotics
Decreased body temperature
-cause: exposure, chronic conditions
-older adults: impaired perception, accidental
-temperature below 35 C can result in death
-effects: poor coordination, slurred speech, poor judgement, amnesia, hallucinations, stupor,
decrease RR, pulse weak and irregular, low BP
-treatment: rewarm with blankets, clothing, heating pads, radiant warmer, warm fluid intake
Assessing temperature
-action of taking a temperature can be delegated
nurse responsibilities
-assessing: findings, effect of changes in body temp
-implementing interventions
-teaching patient about: methods of temperature measurement, normal values, and abnormal
values
Equipment for Temperature
Electronic and digital- oral, axillary, rectal
Tympanic membrane
Disposable single use- no cross contamination, forehead/ abdomen
Temporal artery- as accurate as oral and more than axillary and tympanic
Automated monitoring device- measures all 4 vitals without time investment
Oral Temperature
-35.8-37.5
-under the tongue
-wait 15 minutes after eating, chewing gum, or smoking
Contraindications:
-oral or nasal surgery
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller StudyHubSolutions. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
82388 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now