Chapter 10: Vital Signs and Laboratory Reference Intervals (1)

Vital signs : temperature, pulse, respirationn, BP, osygen saturation, pain assessment

vital sign measurements may be delegated to assistive personnel ( AP ) but the nurse is responsible for interpreting the findings.

delegate : 위임

 

Peripheral artery : 말초동맥

- The average adult pulse rate is 60 - 100 beats per minute.

- pedal pulses are checked to determine whether the circulation is blocked in the artery up to that pulse point.

- when the BP is low, the heart rate is usually increased.

→ cardiac out put 보상위해,( stroke volume = 1회 박출량이 떨어짐)

- hemorrhage increases the heart rate.

 

pulse point and location

The apical pulse may be detected at the left midclavicular, fifth intercostal space.

심첨맥박 고령의 경우 LVH, diviation 등으로 인해 겨드랑이 밑쪽에서 들린다. 고혈압 등으로 좌심실 늘어나 점점 옆으로 이동.

LVH : Left Ventricle Hypertrophy 좌심방 비대

dilation ( dialation ) : 확장증

antecubital fossa : joint

shallow respiration : 얕은호흡