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Cheat Sheet 2

This document provides information on assessing various vital signs including: - Respiration rates for different age groups and characteristics to note - Pulses sites and rates for different age groups and what defines abnormalities - Blood pressure readings for different age groups and what defines abnormalities - Blood sugar levels for kids and adults and what defines low and high levels - Wound healing process, types of wounds and drainage, and the steps for a wet to dry dressing change"

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Katelyn Hill
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114 views5 pages

Cheat Sheet 2

This document provides information on assessing various vital signs including: - Respiration rates for different age groups and characteristics to note - Pulses sites and rates for different age groups and what defines abnormalities - Blood pressure readings for different age groups and what defines abnormalities - Blood sugar levels for kids and adults and what defines low and high levels - Wound healing process, types of wounds and drainage, and the steps for a wet to dry dressing change"

Uploaded by

Katelyn Hill
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Respiration

Adult: 12-20
Newborn: 30-60
Young Child: 22-24
Older Adult: 12-20

Deep/Shallow
Regular/Irregular
Labored/unlabored
Chest symmetry:1:2
Even/uneven

Diaphragmatic: abdominal breather


Adventitious: abnormal sound
Eupnea: normal
Excursion: movement/depth of chest
Bronchial: loud high pitched w/hollow quality heard best over trachea.
Bronchovesicular: blowing sound, med. pitch and intensity heard over upper
thorax
Vesicular: soft, breezy, low pitched heard over the lower thorax
Note depth, rate, and rhythm
Pitch: high/low
Intensity: tone
Quality: clear/muffled
Duration

Pulse Rates
Bradycardia- less than 60 beats
Tachycardia- more than 100 beats

Adult: 60 -100 Average 72


Pregnant- Slight Increase
Post-Partum- Transient Bradycardia
Newborn- 120-140
FHR- 120-160
Young Child-average 90
Older Adult- less than 80

Sites: Temporal, carotid, brachial, radial, ulner- pinky side, apical over apex of
heart, 4th & 5th ICS-midclavicular, used for infants up to 3, used to determine
probs w/ radial pulse, popiliteal, posterior tibial-inner below and behind ankle
bone, dorsalis pedis

Rhythm: regular, irregular, missed beat or abnormal rhythm:dysrythmia

Strength: Strong, weak/thready, or bounding,


4+ - strong bounding
3+ - full easy to palpate
2+ - normal easy to palpate
1+ - difficult to palpate, weak/thready
0+ - absent

If pulse irregular do an apical/radial pulse rate to detect pulse deficit. More than
2.

Equality: Assess both radials simultaneously: not together could be thrombus


formation

Blood Pressure

Adult:120/80 average
Pregnancy: within normal limits
Labor/delivery: Slight Increase
Post-partum:WNL
Newborn: 63-70/40-50
Young Child: 95/58 average
Older Adult: 140-160/80-90

Systolic: below 90= hypotension


When pulse increases 15-20 and BP drops 15mmHg = Orthostatic hypotension
BP- is the lateral force on the artery walls from the pressure of the blood.
Systolic- when ventricles contract ejecting blood in the aorta
Diastolic- blood remaining in arteries

Pulse pressure- diff. between systolic and diastolic. Norm=30 – 50

Norms: 120/80
Prehype: 120-139/80-89
Hype 1: 140-159/90-99
Hype 2: 160-179/100-109
BAD: > 180/110

Blood Sugar

Normal Blood Sugar Levels Chart for Kids and Adults

Blood Sugar Level Kids Adults


Normal 70 - 100 mg/dL 70 - 140 mg/dL
Low Below 70 mg/dL Below 70 mg/dL
High Over 140 mg/dL Over 180 mg/dL
Low Blood Sugar Levels

Blood Sugar Levels Readings (mg/dL)


Normal 70 - 140

Hypoglycemia (Initial Stage) Below 70


Hypoglycemia (Fasting) 50
Insulin Shock Less than 50

High Blood Sugar Levels

Blood Sugar Fasting Post Meal Value: 2 hrs after the Meal
Levels Values(mg/dL) (mg/dL)
Normal 70 - 100 Less than 140
Early Diabetes 101 - 126 140 - 200
Established
More than 126 More than 200
Diabetes

Wounds

Acute- proceeds through an orderly and timely reparative process, results in


sustained restoration of anatomical and functional integrity.
Chronic- Wound that fails to proceed through orderly or timely process to
produce integrity.
Healing Process:
Primary Intention- wound that is closed, surgical incisions (sutured or stapled),
heals by epitheliallization, quickly with minimal scarring.
Secondary Intention- wound edges are not approximated, pressure ulcers,
surgical wounds that have lost tissue, heals by granulation formation, wound
contraction and epithelialization.
Tertiary Intention- wound left open for several days and later the edges are
approximated, usually contaminated and require observation- inflammation.
Partial Thickness-shallow wounds involving loss of the epidermis and possibly
partial loss of the dermis: components of healing: inflammatory response,
epithelial proliferatioin/migration, and renewed epidermal layers
Full Thickness- Full thickness skin loss with extensive destruction,
tissue necrosis or damage to underlying structures such as muscle, tendon or
bone. It may look like a deep crater and may even tunnel into surrounding
subcutaneous tissue, components of healing: inflammatory, proliferation, and
remodeling.
Types of Wound Drainage: Serous- clear, watery plasma. Purulent- thick, yellow,
green, tan, or brown. Seroussanguineous- pale, red, watery;mixture of clear and
red fluid. Sanguineous- bright red, indicates active bleeding.

Wet to Dry Dressing Change


Equipment for dressing change:

• Sterile gloves

• Variety of gauze dressings and pads

• Irrigation kit

• Cleansing solution

• Sterile solution

• Clean, disposable gloves

• Tape, ties, or bandage as needed

• Waterproof pad and bag

• Extra gauze dressings, or topper dressing (ABD pads)

• Montgomery ties; elastic net

Moist dressing:

1. Apply sterile gloves.

2. Allows handling of sterile supplies without contamination.

3. Assess appearance of surrounding skin (see illustration).

4. Surrounding skin assessment provides an evaluation of wound management.

5. Cleanse wound base with normal saline or commercially prepared wound


cleanser. Assess wound base.

6. Cleansing removes wound debris for adequate assessment.

7. Moisten gauze with prescribed solution. Gently wring out excess solution.
Unfold.

8. Gauze needs to be moist to allow for absorption of wound debris.


9. Apply gauze as a single layer directly onto the Iwound surface. If wound is
deep, gently pack dressing into wound base by hand or forceps until all wound
surfaces are in contact with the gauze. If tunneling is present, use a cotton-tipped
applicator to place gauze into tunneled area. Be sure gauze does not touch the
surrounding skin.

Inner gauze needs to be moist, not dripping wet, to absorb drainage and adhere
to debris. Excessively moist dressings result in moisture-associated skin damage
(maceration) in the periwound skin. The wound needs to be loosely packed to
facilitate wicking of drainage into absorbent outer layer of dressing.

10. Cover with sterile dry gauze and topper dressing.

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