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Lab skills

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by

Angela Gagne

on 16 January 2013

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Transcript of Lab skills

PNR 125 And one more thing... is here Vital Signs p. 493-539 Temperature
Pulse
Respirations
Blood Pressure
Oxygen Saturation Pulse Respiration Blood Pressure Oxygen Saturation Temperature vital signs are part of the assessment database
included in a complete physical assessment
or as needed to assess patient status
baseline for future assessments
box 31-1 acceptable ranges
Use guidelines in Potter and Perry to ensure proper measuring of vital signs
nurse most responsible for patient interprets vital signs
use functional equipment for the proper age of patient
minimize environmental factors (hot room, loud etc)
calm caring manner, some deameanor can alter vital signs (esp BP)
use vital sign measurement to determine indications for medication
increase vital sign frequency if condition warrants
analyze according to treatment
if baseline abnormal and you are unsure, have another team member verify
teaching plan to instruct family or patient measurement of difference between amount of heat produced by body processes and the amount of heat lost to the external environment
despite extremes, body self regulates, called core temperature (temp. of deep tissues)
surface temp fluctuates according to external temp
range is 36C to 38C according to Potter and Perry (2010).
no single temp is N for all people
Thermoregulation is the balance between heat lost and heat produced.
for body temp to remain constant there must be a balance between the two
Neural and vascular control
the hypothalmus controls body temperature
like a thermostat
anterior hypothalmus controls heat loss and the posterior controls heat production
hypothermia < 36C
hyperthermia >38C
Heat Production - by-product of metabolism, food is fuel, increased need = increased heat (exercise)
shivering is an involuntary way to warm the body
Heat Loss - radiating heat (into environment), conduction (warm skin touches cooler environment), convection (transfer of heat away by air movement (fan), evaporation (constant loss of heat by evap., body can loose 600-900 ml per day in evaporation alone
when body temp rises the anterior hypothalmus signals the millions of sweat glands to release sweat, therefore lowering temp,
diaphoresis is visible persperation which occure on forehead and upper thorax
people who have congenital absence of sweat glands have a hard time thermoreguling Factors affecting body temperature age, exercise, hormone level, circadian rhythm, stress, environment. temperature alterations,
FEVER - occurs because heat-loss mechanisms are unable to keep pace with excess heat production: therefore temp rises
not harmful usually if below 39C
remember a single reading may not indicate a true fever, base infection of several readings
bacteria and viruses cause a rise in body temp
pyrogens act as antigens which trigger the immune system
hypothalmus responds
patients can have chills, shivers, and feels cold, as the temp is rising because the hypothalmus is trying to cool as the pyrogen continues to affect the body
also called febrile
when fever "breaks" the patient is afebrile
temp rising is a body defense mechanism
stimulates white cell production
reduces the concentration of iron decreases which suppresses the growth of bacteria
it also fights viruses by releasing interferon which naturally fights the virus
Term fever of unknown origin means a fever with unknown cause
Malignant Hyperthermia- hereditary condition of uncontrolled heat production, occuring when receiving anaesthetic drugs
Heatstroke - prolonged exposure to heat
temperature can reach 45C, severe electrolyte loss, no sweating, hypothalmic dysfunction
It is a heat emergency with a high mortality rate
Cooling measures as treatment
HYPOTHERMIA
opposite
<35C
decreased metobolic demand therefore heart rate and blood pressure drop and temp falls below 34.4C
if not corrected, cardiac dysrhythmia and unconciousness and death

Assessment, (sites, thermometers(types).
Nursing diagnoses p. 506
Planning, (goals and outcomes, prioritized, continuity of care).
Implementation (health promotion, acute care, restorative and continuing care).
Evaluation ( evaluate the expected outcomes the bounding of blood flow
palpable at various points on the body
flows in a continuous circuit
indicator of circulatory status

Physiology and Regulation

electrical impulses from heart (SA node)
the amount of pulsing sensations in one minute is called the pulse rate
blood pumped in one minute called cardiac output
heart pumps about 5000 ml (5L) per minute
mechanical, neural and chemical factors regulate the strength of contractions
many sites to assess pulse, radial most commonly used
if a sudden change in condition (unresponsive etc, carotid checked - the carotid artery delivers oxygen to the brain as long as possible
peripheral pulses weaken when cardiac output declines
apical pulse with stethoscope for medication delivery (eg digoxin)
we will discuss sites and a stethoscope during lab
stethoscope to determine apical pulse
pulse can be weak or thready
regular or irregular Rate
measure baseline
if you detect abnormal rhythm peripherally, check apical
ID first two heart sounds
S1 and S2 (lub-dub equal one heart beat) -- how many lub-dubs in one minute is the heartrate
normal rate 60-100 beats per minute
>100 is tachycardia
<60 is bradycardia
pulse deficit is the difference between the peripheral pulse and the apical pulse (usually associated with abnormal rhythms) Rhythm
normal interval usually happens between heartbeats
interrupted (early or late beat) is called dysrhythmia
they are described by irregularly irregular or regularly irregular
monitor heart rhythms on telemetry or holter Strength
strength of blood volume on artery wall with each contraction of the heart
described as bounding, strong, weak, thready or absent
will talk more about this is vascular assessment Equality
comparing both sides periphery
unequal pulses must be noted
never measure carotids at same time....blood flow to brain Nursing Process
pulse assessment helps you determine the general cardiovascular health and body's response to other system imbalances human survial depends on Oxygen exchange
O2 (oxygen) to body cells and tissues and CO2 (carbon monoxide) to be removed from the cells
respiration is ventilation
it is the mechanism to exchange gases
ventilation is the movement of gases in and out of lungs
diffusion is the movement of gases between the alveoli and the red blood cells
perfusion is the distribution of RBC's to and from pulmonary capillaries
all three must considered to have an accurate assessment Breathing is passive
we think little about it
brain stem regulates the involuntary control of respiration
N 12-20 resps per minute
ventilation regulated by oxygen and carbon dioxide and hydrogen
higher CO2 = increased rate and depth of breathing (trying to blow it off)
for chronic lung disease they have less effect of blowing off CO2 because of damage
hypoxemia is when low levels of O2 (arterially)
box 31-11 factors influence Mechanics
normally passive
muscular work is involved in moving the lungs and chest wall.
inspiration is an active process - the resp center sends impulses causing the diaphragm to contract
abdominal organs move downward and forward to allow air in
N inhalation is 500ml of air Assessment
no equipment
note sudden changes
count for a full minute
measure rate and depth Oxygen saturation
a pulse oximeter measures oxygen saturation (LED light)
the amount of oxygen bound to hemoglobin is measured (oxygen carrying capacity)
value should be between 95-100% for normal person.
some numbers are considered N for patients with existing lung conditions Nursing Process
assessment, diagnoses, planning implementation, and evaluation next week Vital Signs
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