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- List/recognize the admission protocol
- 1.Advance directives
2.Bill of rights
3.Admission assessment-RN only in specified time.
4.Legible ID band
5.Consent formed by mentally complete adult/gaurdian
- Who is responsible for admission assessment and why?
- The RN is responsible per the requirement of JCAHO.
- 3 ways to ensure accuracy of Wt.
- 1.Same scale each time
2.void before weighing
3.wearing same type of clothing
- 3 ways to ensure accuracy of ht.
- 1.Stand erect
2.Lshaped bar on top of head
3.Stand so back is facing balance bar
- Role of Nurse if client wants to leave AMA.
- -notify MD asap
-ask client why leaving
-Explain MD reasons to stay
-Explain risks of leaving
-offer AMA form and get sig, RN to cosign
-for refusal sig, note on form and witness, form in client chart,escort client,notify relatives if safety issues.
- APEX
- pointed end of a come shaped part or organ.
- APNEA
- ABSENCE OF BREATHING
- BRADYCARDIA
- PULSE RATE BELOW 60 BPM
- CARDIO
- PERTAINING TO THE HEART
- DIASTOLE
- PERIOD WHEN HEART DILATES AND FILLS WITH BLOOD; PERIOD OF RELAXATION
- HEART RYTHM
- TIME INTERVAL BETWEEN HEARTBEAT
- HYPERPNEA
- ABNORMAL INCREASE IN DEPTH/RATE OF BREATHING.
- HYPERTENSION
- BP CONSIDERED HIGHER THAN NORMAL RANGE
- HYPERTHERMIA
- UNUSUALLY HIGH BODY TEMP
- HYPOTHERMIA
- BODY TEMP BELOW AVERAGE NORMAL RANGE.
- NORMAL PULSE RATE
- -SMOOTH ROUNDED SHARP INCREASE STROKE TO DECREASE STROKE.
-PROVIDE INFO ON CARDIAC STATUS/BLOOD VOL.
-CORRELATES WITH CARIAC CONTRACTION.
- PALPATE
- TO EXAMINE BY TOUCH,FEEL
- PERIPHERAL
- PERIPHERY, AWAY FROM CENTRAL STRUCTURE
- PULSE DEFICIT
- HEART RATE COUNTED AT APEX BY AUSCULTATION GREATER THAN RATE BY PALPATION OF RADIAL PULSE. PULSE WAVE NOT TRANSMITTED TO PERIPHERY TO PRODUCE PALPABLE RADIAL PULSE.
- PULSE PRESSURE
- DIFF BTWEN SYSTOLIC/DIASTOLIC PRESSURE.
- PYROGEN
- ANY SUBSTANCE THAT PRODUCES FEVER.
- SET POINT
- BODY'S NORMAL CORE TEMP
- SHOCK
- INADEQUATE TISSUE PERFUSION RESULTING FROM CIRC FAILURE B/C OF MANY FACTORS.
-IDENTIFIED BY VARIOUS S&S.
- SPHYGMOMANOMETER
- DETERMINES ARTERIAL BP.
- TACHYCARDIA
- HR GREATER THAN 100 BPM
- TACHYPNEA
- RESP RATE ABOVE 24 BPM. RATE REMAINS REG BUT SHALLOW IN PATTERN.
- VALSALVA'S MANEUVER
- FORCIBLY EXHALE WTIH GLOTTIS,NOSE,MOUTH CLOSED.
INCREASED INTRATHORACIC PRESSURE
- INFO TEMP PROVIDES
- BALANCE BTWEEN HEAT GAIN/LOSS
- INFO PULSE PROVIDES
- OVERALL IMPRESSION OF HEARTS ACTION.
- INFO RESP PROVIDES
- DATA ON CLIENTS ENTIRE BREATHING PROCESS
- INFO BP PROVIDES
- COND OF HEART,ARTERIES,VESSEL RESISTENCE,ARTERIOLES,CARDIAC OUTPUT,CV STATUS
- INFO PAIN LEVEL PROVIDES
- HOMEOSTASIS,QUALITY OF LIFE. PAIN LOCATION, INTESITY,OUTCOMES OF RELIEVE MEASURES.
- FACTORS THAT INFLUENCE VS
- AGE,GENDER,RACE,HEREDITY,LIFESTYLE,ENVIRON,PAIN,EXERCISE,
ANXIETY,STRESS,METABOLISM,
CIRCADIAN RYTHMN,HORMONES
- S&S OF FEVER
- PERSPIRATION OVER BODY,BODY WARM TO TOUCH,CHILLS/SHIVERS,
FLUSHED FACE,HOT/COLD FLASHES,
INCREASEDPULSE/RESP,MALAISE/FATIGUE,PARCHED LIPS/DRY SKIN,CONVULSIONS
- CONDITIONS ALTERING FEVER
- DISEASE,INFLAMMATION,BRAIN LESIONS,PYROGENS,DEGENERATING TISSUE
- NORM ORAL TEMP
- 97-99.5F
36-37.5C
- NORMAL RECTAL TEMP
- 1 DEGREE HIGHER THAN ORAL: 98-100.5F
- NORMAL AXILLARY TEMP
- 96-98.5F 1 DEGREE LOWER THAN ORAL
- NORMAL EAR TEMP
- 98.5-99.5F 0.5 DEGREES HIGHER THAN ORAL
- FACTORS THAT ALTER CORE TEMP
- EATING,DRINKING,GUM,SMOKING,
EXERCISING
- WAIT TIME AFTER ALTERING FACTORS OF CORE TEMP
- 20-30 MINUTES ORALLY
- HOW DO TEMPS VARY THROUGHOUT THE DAY
- CIRCADIAN THERMAL RYTHMN
- WHEN TO AVOID ORAL TEMP
- UNCONSCIOUS,MOUTH BREATHER,FACIAL,NUERO,PROBLEMSOPENING MOUTH,LOW ORAL TEMP NO CAUSE
- PLACEMENT OF ELEC. THERMOMETER,ORAL
- UNDER TONGUE,ALONG GUMLINE IN SUBLINGUAL POCKET
- PLACEMENT OF ELEC. THERMOMETER,ORAL
- UNDER TONGUE,ALONG GUMLINE IN SUBLINGUAL POCKET