Fundamentals HESI Study Guide

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StuDocu is not sponsored or endorsed by any college or university Fundamentals HESI Study Guide Fundamentals of nursing (Duquesne University) StuDocu is not sponsored or endorsed by any college or university Fundamentals HESI Study Guide Fundamentals of nursing (Duquesne University) Downloaded by samuel kamunyu ([email protected]) lOMoARcPSD|13445102 Stuvia.com - The Marketplace to Buy and Sell your Study Material

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Stuvia.com - The Marketplace to Buy and Sell your Study MaterialFundamentals HESI Study Guide

Vital Signs:

August 22 Temperature, pulse, respiration, blood pressure, pulse ox

Temperature: lower in the morning, highest in the evening,

98.6 F-100.4 F, 36-38 C

Pulses: carotid, brachial, radial, ulnar, femoral, popliteal,

dorsalis pedis, posterior tibial Loudest heart sounds heard at apical pulse

Normal heart rate:

oInfants: 120-160

oToddler: 90-140

oAdolescent: 60-90

oAdult: 60-100

Tachycardia vs. bradycardia

oTachycardia: greater than 100

oBradycardia: less than 60

Strength of pulse: 0: absent, 1: weak, 2: normal, 3: full, 4: bounding

Amplitude: volume of blood pushed against the wall of an

artery during ventricular contraction

Ox saturation: usually 95% to 100%

Systolic: force exerted as left ventricle contracts and pumps

blood into aorta  MAX PRESSURE

Diastolic: force exerted during ventricular relaxation, when

heart is �lling  MINIMUM PRESSURE Blood pressure ranges

oNormal: <120, <80

oPrehypertension: 120-139, 80-89

oStage 1 Hypertension: 140-159, 90-99

oStage 2 Hypertension: >160, >100

Blood pressure cu�…

oToo wide: false low

oToo narrow: false high

Patient Safety and Quality:

August 22 Downloaded by samuel kamunyu ([email protected]) lOMoARcPSD|13445102 Stuvia.com - The Marketplace to Buy and Sell your Study Material

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Stuvia.com - The Marketplace to Buy and Sell your Study MaterialFall risk: age, medication, post op, confusion, previous history, repeated falls, bone fractures, etc.Make sure patient is aware of environment  items at reach, call light, phone, etc.

Restraint:

oLast resort – try all other options �rst ** all other possibilities have been tried and failed, bene�ts outweigh the risks

oBehaviors that result: wandering, restlessness,

violence, agitation, pulling out tubes, resisting care

oAlternatives: treat pain, rule out physical causes for

agitation, involve family, reduce stimulation, noise, light, environmental factors, use therapeutic touch, discontinue bothersome treatment oNEED ORDER WITHIN 1 HOUR AFTER APPLICATION oRENEWED EVERY 24 HOURS oOnly one restraint at a time (physical or chemical – no two at once) oREMOVE EVERY 2 HOURS FOR ASSESSMENT AND NEEDS (skin integrity, ROM, circulation) Fire Safety oRACE Rescue, alert, contain, extinguish oPASS Pull, aim, squeeze, sweep

Hygiene:

August 24 Wash legs from distal to proximal to promote venous return Observe skin for warmth, redness, swelling, rashes, tenderness, pain, etc. while bathing Do not massage reddened areas on client’s skin

Wear gloves when: washing perineum, anal areas, skin

infections, skin not intact, open wounds, draining, oozing skin, performing oral care

Female: front to back

Male: retract foreskin, wash from urethral meatus and

outward, return foreskin to natural position Apply lotion  skin barriers especially on pressure points Downloaded by samuel kamunyu ([email protected]) lOMoARcPSD|13445102 Stuvia.com - The Marketplace to Buy and Sell your Study Material

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