Assessment
Terms
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- OLDCART
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-O: onset
-L: location
-D: duration
-C: characteristics
-A: aggrevations
-R: relieving factors
-T: treatments - Diagnostic Studies
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-Pulmonary Function Test (PFT)
-Arterial Blood Gases (ABG)
-Throat Culture
-Sputum Specimen
-Chest X-Ray
-Pulse Oximetry
-Bronchoscopy
-Thoracentesis - Seizure Precautions
-
-Provide safe environment
-Pad side rail (up x 4)
-Lower to floor if standing
-Record: Time, Type, VS, Incontinent,
Drolling, - Cold Application
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-Causes vasoconstriction
-Helps control bleeding
-Decreases swelling
-Uses: Trauma, Injury, Spasms
> 4L of air needs to be humidified - Aqua Pad
-
-Do not place over open wound, localized tumor, bleeding, or imflammed area
-Filled w/ distilled water
-Usually 110-115 F
-Wrap in towel
-Secure w/ tape or gauze
-Assess pts skin frequently for burns - Tests
-
-Allen's: aerterial circulation
-Holman's: venous circulation in the lower extremities for clots (DVT)
-Breugger's Sign: venous circulation in the upper extremities - Normal Ranges for Vital Signs
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Respiratory Rate: 12-20
Temperature: 98.6 F (>97 <99)
Heart Rate: 60-100 BPM
BP: 90-149/50-90 - Heat Application
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-Causes vasodilation (which increases blood flow)
-Increases phogocytes to area
-Promotes soft tissue healing
-Uses: musculo-skeletal problems, joint stiffness, muscle spasms - Neuro Assessment
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-Pupil Dilation
-Vitals
-Orientation to person, place & time
-Grip and foot strength
-Pupils: Accomidation and consentual - Location of Heart Sounds
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-Aortic: Right Sternal 2nd IC space
-Pulmonic: Left Sternal 2nd IC space
-Tricuspid: Left Sternal 5th IC space
-Mitral: Lft Midclavicular 5th IC space
-Erbs: Left Sternal 3rd IC space - Circulation of Heart
-
-S1 (lub): closing of AV valves
(tricuspid & mitral)
-S2 (dub): closing of semilunar valves
(pulmonic & aortic) - Normal Lab Values
-
-Hematoglobin: m(13.5-17.5 g/dl)
f(11.5-15.5 g/dl)
-Hematocrit: m(44-52%) f(39-47%)
-Albumin: (3.5-5.5 g/dl)
-Electrolytes:
*Sodium: 136-145
*Potassium: 3.5-5.2
*Chloride: 96-106
-Glucose: 70-110 mg/dl
-Total Cholesterol: <200 mg/dl
*HDL: 35-85 mg/dl
*LDL: <130 mg/dl
-BUN: 8-28 mg/dl
-Calcium: 8.5-10.5 mg.dl
-Creatine: 0.6-1.2 mg/dl
-Uric Acid: 2.5-8 mg/dl
-Magnesium: 1.8-3.0 mg/dl
-Phosphorus: 2.3-4.7 mg/dl - C to F Conversion
- C = (F - 32)5/9
- Tachycardia
- greater than 100 BPM
- Bradycardia
- Less than 60 BPM