NUR256 Exam 1 Prep: Core Concepts and A+ Study
Guide
week 1 material
-vital signs + pain
-clinical judgement and critical thinking
Average adult temperature range
36 C to 38 C (96.8 F to 100.4 F)
average older adult temperature range
35 C to 36.1 C (95 F to 97 F)
factors affecting body temperature
-Age
-exercise
-hormone level
-circadian rhythm
-stress
-environment
-temperature alterations
-time of day ( lowest at 0600, highest at 1600)
hyperthermia
An elevated body temperature related to the inability of the body to promote heat loss or reduce heat
production.
-any disease of hypothalamus impairs heat loss
malignant hyperthermia
A hereditary condition of uncontrolled heat production that occurs when susceptible people receive
certain anesthetic drugs.
heatstroke
a body temp of 104 or more accompanied by hot dry skin and CNS abnormalities such as delirium,
convulsions or coma
,heat exhaustion
caused by environmental heat exposure and presents with profuse diaphoresis that results in excess
electrolyte and water loss
hypothermia
heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat
-mild hypothermia = 90 -95 F
routes to take temp
-oral (most common, ask if they have eaten or drank in last 30 min)
-rectal (most accurate core temp)
-axillary (taken in armpit/ most accurate when rectal and oral aren't available)
-tympanic (in ear)
-temporal (forehead)
parts of stethoscope
ear pieces, binaurals, tubing, chest piece (diaphragm and bell)
-should be placed directly on skin
-do not hold chest piece with thumb
-clean between use
bell transmits
low pitched sounds (heart and vascular sounds)
diaphragm transmits
high pitched sounds (bowel, lungs, heart sounds)
pulse
Palpable bounding of the blood flow in a peripheral artery
-indirect indicator of circulatory status
average pulse range for adult
60-100
average pulse range for infant
120-160
average pulse range for toddler
90-140
average pulse range for preschooler
80-110
, average pulse range for school age child
75-100
average pulse range for adolescent
60-90
average pulse range for older adults is
decreased
Tachycardia
fast heart rate (higher than 100BPM)
Bradychardia
slow heart rate (less than 60BPM)
pule deficit
an inefficient contraction of the heart that fails tp transmit pulse wave to the peripheral pulse site
how to count pulse
-if rhythm is regular = 30 sec X 2
-if rhythm is irregular = 1 min
when taking pulse you need to look for
-rate (the number you get)
-rhythm ( regular/irregular)
-strength ( 4+, 3+, 2+, 1+, 0)
-equality ( are they equal in strength)
what factors increase pulse rate?
exercise (short term), temperature (fever and heat), acute pain, emotions, medications (epinephrine) ,
hemorrhage, postural changes ( standing or sitting) , pulmonary conditions
what factors decrease pulse rate?
exercise (long term exercise) , temp (hypothermia), chronic pain, medications ( digitalis, beta adrenergic,
calcium channel blockers), postural changes (lying down)
What are the 10 pulse sites?
Temporal, carotid, femoral, radial, ulnar, brachial, dorsalis pedis, posterior tibial , popliteal, apical
apical and radial pulse deficit
difference between apical and radial pulse
-two examiners needed to take pule in 2 locations at the same time
Guide
week 1 material
-vital signs + pain
-clinical judgement and critical thinking
Average adult temperature range
36 C to 38 C (96.8 F to 100.4 F)
average older adult temperature range
35 C to 36.1 C (95 F to 97 F)
factors affecting body temperature
-Age
-exercise
-hormone level
-circadian rhythm
-stress
-environment
-temperature alterations
-time of day ( lowest at 0600, highest at 1600)
hyperthermia
An elevated body temperature related to the inability of the body to promote heat loss or reduce heat
production.
-any disease of hypothalamus impairs heat loss
malignant hyperthermia
A hereditary condition of uncontrolled heat production that occurs when susceptible people receive
certain anesthetic drugs.
heatstroke
a body temp of 104 or more accompanied by hot dry skin and CNS abnormalities such as delirium,
convulsions or coma
,heat exhaustion
caused by environmental heat exposure and presents with profuse diaphoresis that results in excess
electrolyte and water loss
hypothermia
heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat
-mild hypothermia = 90 -95 F
routes to take temp
-oral (most common, ask if they have eaten or drank in last 30 min)
-rectal (most accurate core temp)
-axillary (taken in armpit/ most accurate when rectal and oral aren't available)
-tympanic (in ear)
-temporal (forehead)
parts of stethoscope
ear pieces, binaurals, tubing, chest piece (diaphragm and bell)
-should be placed directly on skin
-do not hold chest piece with thumb
-clean between use
bell transmits
low pitched sounds (heart and vascular sounds)
diaphragm transmits
high pitched sounds (bowel, lungs, heart sounds)
pulse
Palpable bounding of the blood flow in a peripheral artery
-indirect indicator of circulatory status
average pulse range for adult
60-100
average pulse range for infant
120-160
average pulse range for toddler
90-140
average pulse range for preschooler
80-110
, average pulse range for school age child
75-100
average pulse range for adolescent
60-90
average pulse range for older adults is
decreased
Tachycardia
fast heart rate (higher than 100BPM)
Bradychardia
slow heart rate (less than 60BPM)
pule deficit
an inefficient contraction of the heart that fails tp transmit pulse wave to the peripheral pulse site
how to count pulse
-if rhythm is regular = 30 sec X 2
-if rhythm is irregular = 1 min
when taking pulse you need to look for
-rate (the number you get)
-rhythm ( regular/irregular)
-strength ( 4+, 3+, 2+, 1+, 0)
-equality ( are they equal in strength)
what factors increase pulse rate?
exercise (short term), temperature (fever and heat), acute pain, emotions, medications (epinephrine) ,
hemorrhage, postural changes ( standing or sitting) , pulmonary conditions
what factors decrease pulse rate?
exercise (long term exercise) , temp (hypothermia), chronic pain, medications ( digitalis, beta adrenergic,
calcium channel blockers), postural changes (lying down)
What are the 10 pulse sites?
Temporal, carotid, femoral, radial, ulnar, brachial, dorsalis pedis, posterior tibial , popliteal, apical
apical and radial pulse deficit
difference between apical and radial pulse
-two examiners needed to take pule in 2 locations at the same time
