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Fundamentals of Nursing, 11 Ed., Potter, Perry, Stockert & Hall, 2022/
29 - Vital SignsAce Your Fundamentals of Nursing, 11 Ed., Potter, Perry, Stockert & Hall, 2022 Classes and Exams with Picmonic: #1 Visual Mnemonic Study Tool for Registered Nurse (RN) Students
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Fundamentals of Nursing, 11 Ed., Potter, Perry, Stockert & Hall, 2022 | Registered Nurse (RN) School Study Aid
Vital Signs - Adult
- Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
- Rectal
- Tympanic
- Oral
- Axillary
- Temporal
- Respiration (12-20)
- Oxygen Saturation (94%-100%)
- Pulse (60-100)
- Blood Pressure (<120/80)
- Pain
2 mins
Fever
- Flushed skin, warm to touch
- Chills
- Sweating
- Change in LOC
- Provide adequate fluids
- Monitor Electrolytes and Fluid
- Monitor vital signs, esp temperature
- Remove excess clothing and blankets
- Sponge bath with tepid water
2 mins
Stages of Hypothermia
- Mild
- 32 to 35°C (90 to 95°F)
- Shivering
- Moderate
- 28 to 32°C (82 to 90°F)
- Obvious Motor Impairment
- Slowed Thinking
- Severe
- < 28°C (< 82°F)
- Shivering Stops
- Paradoxical Undressing
- Arrhythmias
3 mins
Hypothermia Interventions
- Remove From Environment
- Remove Wet Clothing
- Passive Rewarming
- Warm Clothing
- Active Rewarming
- Heated Blankets
- Warm IV Solutions
- Heated Oxygen
- Warm Gastric Lavage
- Considerations
- Warm Trunk BEFORE Extremities
2 mins
Malignant Hyperthermia vs. Neuroleptic Malignant Syndrome vs. Serotonin Syndrome
- Autonomic Instability
- Muscle Rigidity
- Malignant Hyperthermia
- Ryanodine Receptor 1 Mutation
- Inhaled Anesthetics
- Succinylcholine
- Dantrolene
- Neuroleptic Malignant Syndrome
- Antidopaminergic Medications
- Hyporeflexia
- Myoglobinuria
- Dantrolene
- Serotonin Syndrome
- Serotonergic Medications
- Hyperreflexia
- Clonus
- Cyproheptadine
3 mins
ECG: Sinus Tachycardia
- Rate
- > 100 bpm
- Rhythm
- Regular
- P Wave
- Present, Upright, Every QRS
- PR Interval
- < 0.20 seconds
- QRS Interval
- < 0.12 seconds
- Treatment
- Treat Underlying Cause
2 mins
ECG: Sinus Bradycardia
- Rate
- < 60 bpm
- Rhythm
- Regular
- P Wave
- Present, Upright, Every QRS
- PR Interval
- < 0.20 seconds
- QRS Interval
- < 0.12 seconds
- Treatment
- Atropine
1 min
Hypoxia (Early Symptoms)
- Diaphoresis
- Restlessness
- Tachypnea
- Dyspnea on Exertion
- Tachycardia
- Hypertension
- Arrhythmias
- Decreased Urine Output
- Unexplained Fatigue
1 min
Hypoxia (Late Symptoms)
- Cyanosis
- Cool, Clammy Skin
- Use of Accessory Muscles
- Retractions
- Hypotension
- Arrhythmias
2 mins
Low Blood Pressure Response
- Characteristics
- Posterior Pituitary Releases Vasopressin
- Vasoconstriction
- Adrenal Cortex Releases Aldosterone
- Increased Na+ and H2O Reabsorption
1 min
High Blood Pressure Response
- Characteristics
- Atria Release Atrial Natriuretic Peptide
- Vasodilation
- Antagonizes Aldosterone
- Na+ and Water Excreted
1 min
Cardiac Cycle - Systole
- Characteristics
- AV Node
- AV Node Conducts Signal to Bundle of His
- Bundle of His Signals Purkinje Fibers to Contract Ventricles
- Tricuspid Valve Closes
- Pulmonary Valve Opens
- Mitral Valve Closes
- Aortic Valve Opens
2 mins
Cardiac Cycle - Diastole
- Characteristics
- Aortic Valve Closes
- Pulmonary Valve Closes
- Ventricles Relax
- Mitral Valve Opens
- Tricuspid Valve Opens
- Ventricles Fill
- Sinoatrial (SA) Node Fires
- Atrial Contraction
3 mins
Hematocrit (Hct) Lab Values
- Women: 36% - 46%
- Men: 41% - 53%
1 min
Hypertension Assessment
- Mechanism
- Essential Hypertension
- Secondary Hypertension
- Assessment
- Headache
- Vision Changes
- Nosebleed (Epistaxis)
- Chest Pain
- Syncope (Fainting)
- Diagnosis
- Average 2 Sets, 2 Minutes Apart
- After 2 or More Visits (within 1-4 weeks)
- Nursing Considerations
- Take BP Both Arms
- Common in African Americans
2 mins
Hypertension Intervention
- Lifestyle Modifications
- Weight Reduction and Exercise
- Diet Changes
- Relaxation Techniques
- Smoking Cessation
- Medications
- Encourage Self Monitoring
1 min
Hypertension Medications
- Diuretics
- ACE Inhibitors
- Angiotensin Receptor Blockers (ARBs)
- Beta Blockers
- Dihydropyridine Calcium Channel Blockers
2 mins
Supine Hypotension (Vena Cava Syndrome)
- Mechanism
- Compression of the Vena Cava and Descending Aorta
- Signs and Symptoms
- Hypotension
- Dizziness
- Tachycardia
- Decreased Renal Perfusion
- Decreased Uteroplacental Perfusion
- Intervention
- Side-lying Position
2 mins
