NURSING 1I02 Lecture Notes - Lecture 6: Vital Signs, Pulse Pressure, Accessory Muscle
27 Oct 2016
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Vital signs nursing and practice 1 oct 21. Patient relationship: explain procedure, consent, privacy, confidentiality, safety, body mechanics, preparations. Always take vital signs (baseline, before and after surgery, procedures, administration of medications, changes in status) Normal values 35. 8-37. 3 degrees c (96. 4-99. 1 degrees f) Oral or axilla (have a degree lower then normal) under tongue. We check the rate, rhythm, force, and elasticity. If you can"t feel a radial pulse, listen to the apical pulse (heart). Rhythm -2+ regular, irregular (pattern), irregularly irregular (most concerning) Force- 3+ (full, bounding) sepsis, 2+ (normal), 1+ (weak) low bp, fluid decease, 0 (absent) When patient takes a deep breath in and holds it (heart rate increases) , holds breath and exhales (decrease) Effort of breathing (relaxed, use of accessory muscles- rib cage muscles) Bradypnea= < less than 12 bpm; hypoventilation. Cheyne-stroke= rate and depth are irregular (waves of regular to larger deeps then back to regular) Kussmauls= abnormally deep, regular and fast, very laboured.
