ray andrew s. del rosario, rn college of nursing and health sciences aquinas university of legazpi
TRANSCRIPT
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Ray Andrew S. del Rosario, RNCollege of Nursing and Health SciencesAquinas University of Legazpi
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reflects changes in body functions that otherwise might not be observed
TemperaturePulseRespirationBlood pressurePain
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When to Assess Vital SignsUpon admission to any healthcare agencyBased on agency institutional policy and proceduresAny time there is a change in the patient’s conditionBefore and after surgical or invasive diagnostic
proceduresBefore and after activity that may increase riskBefore administering medications that affect
cardiovascular or respiratory functioning
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Special Nursing Interventions:Wash hands before and after a
procedure to maintain asepsisGather equipment needed including
watch with a second hand to maximize time and reduce effort
Greet client and introduce oneself to promote client’s sense of well-being
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Special Nursing Interventions:Inform client what you will do to elicit
cooperation and allay anxietyCheck for proper lighting and diminish noise
when necessary to obtain accurate baseline dataAssist to a comfortable resting position, for a
child, have the parent remain close by and position the child comfortably in the parent’s arm to ensure comfort
Record/document appropriately and transfer readings to TPR sheet
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Ray Andrew S. del Rosario, RNCollege of Nursing and Health SciencesAquinas University of Legazpi
BODY TEMPERATURE
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Body Temperaturethe balance between the heat produced by the
body and the heat lost from the bodyTypes:
Core Temperature – temperature of the deep tissues of the body measured by taking oral and rectal temperature
Surface Temperature – temperature of the skin, subcutaneous tissue and fat measured by taking axillary temperature
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Maintenance of Body TemperatureThermoregulatory center in the hypothalamus regulates temperature
Center receives messages from cold and warm thermal receptors in the body
Center initiates responses to produce or conserve body heat or increase heat loss
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Heat ProductionPrimary source is metabolismHormones, muscle movements, and
exercise increase metabolismEpinephrine and norepinephrine are
released and alter metabolismEnergy production decreases and
heat production increases
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Factors affecting Heat ProductionBasal metabolic rate (BMR)Muscle activityThyroxine outputEpinephrine, norepinephrine and sympathetic stimulation
Increased temperature of the body cells (fever)
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Sources of Heat LossSkin (primary source)Evaporation of sweatWarming and humidifying inspired air
Eliminating urine and feces
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Processes involved in Heat LossRadiation
transfer of heat loss from the surface of one object to the surface of another without contact between two objects
Convectiondissipation of heat by air currents
Evaporation continuous vaporization of moisture from the skin, oral
mucous, respiratory tract; insensible heat lossConduction
Transfer of heat from one surface to another transfer of heat from one surface to another, which requires
temperature difference between two surfaces
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Factors affecting TEMPERATUREAgeDiurnal variationsExerciseHormonesStress
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TYPES of FEVER (pyrexia):Intermittent
temperature fluctuates between periods of fever and periods of normal/subnormal temperature
Remittenttemperature fluctuates within a wide range over the 24
hour period but remains above normal rangeRelapsing
temperature is elevated for few days, alternated with 1 or 2 days of normal temperature
Constantbody temperature is consistently high
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Decline of FEVER (pyrexia):Crisis/flush/defervescent stage
sudden decline of fever which indicates impairment of function of the hypothalamus
Lysis gradual decline of fever which indicates that the body is able to maintain homeostasis
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Clinical Signs of FEVER (pyrexia):Onset (cold or chill stage) of fever
Course of feverDefervescence (fever abatement)
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TEMPERATURE CONVERSIONTo change from Fahrenheit to Celsius:
subtract 32 degrees from the Fahrenheit reading
Multiply by 5/9 or divide by 9/5 (1.8)oC = (oF – 32) x 5/9
To change from Celsius to FahrenheitMultiply the Celsius reading by 9/5 or 1.8Add 32oF = (9/5 x oC) + 32 or (oC x 1.8) + 32
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Special Nursing Interventions:Remove thermometer from its container and
check the temperature reading. Shake down the mercury as necessary (until mercury is below 35 C) by holding the thermometer between the thumb and forefinger at the end farthest from the bulb. Snap the wrist downward.
Wash/wipe the thermometer in a rotating manner before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.
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Special Nursing Interventions:Hold the thermometer
at eye level, and rotate it until the mercury column is visible
Rinse the thermometer in tap water, dry it, shake it down and return to its container
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METHODS of Temperature Taking:ORAL: most accessible and convenient
methodNursing Considerations:
Allow 15 minutes to elapse between client’s intake of hot or cold food or smoking and the measurement of oral temperature
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METHODS of Temperature Taking:ORAL: most accessible and convenient
methodNursing Consideration:
Place the thermometer under the tongue, directed towards the side and instruct client to gently close the lips not the teeth around the thermometer
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METHODS of Temperature Taking:ORAL: most accessible and convenient
methodNursing Consideration:
Wash the thermometer before use, from the bulb to the stem, after use, from the stem to the bulb. This practice ensures medical asepsis.
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METHODS of Temperature Taking:ORAL: most accessible and convenient
methodNursing Consideration:
Take oral temperature for 2 – 3 minutes. This ensures adequate time for recording of the temperature
Normal value:97.6 o – 99.6 oF (36.5 o – 37. 5 oC)
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METHODS of Temperature Taking:Contraindications to Oral Temperature
Taking:oral lesions or oral surgerydyspneacoughnausea and vomitingpresence of oro-nasal pack, nasogastric tube seizure pronevery young childrenunconsciousrestless, disoriented, confused
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METHODS of Temperature Taking:Oral Thermometers
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METHODS of Temperature Taking:RECTAL: most accurate measurement of
temperatureIndications:
When there is respiratory obstruction which prevents closure of the mouth
When the mouth is dry, parched and inflamedWhen there is oral/nasal surgery or diseaseFor very young, restless and irrational childrenFor mentally disturbed, unconscious, dyspneic, irrational,
restless and convulsive patientsWhen a patient is mouth breather and with oxygen
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METHODS of Temperature Taking:RECTAL: most accurate measurement of
temperatureNursing Considerations:
Assist client to assume lateral position/sims position. To expose anal area
Lubricate thermometer about 1 inch above the bulb with water soluble jelly before insertion. To reduce friction and prevent trauma to the mucous membrane in the anus
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METHODS of Temperature Taking:RECTAL: most accurate measurement of
temperatureNursing Considerations:
Insert thermometer by 0.5 – 1.5 inches (1.5 – 4 cm) for adults, 0.9 inch (2.5 cm) for a child and 0.5 inch (1.5 cm) for an infant or insert beyond the internal anal sphincter
Instruct the client to take a deep breath during the insertion of the thermometer. To relax the internal anal sphincter
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METHODS of Temperature Taking:RECTAL: most accurate measurement of
temperatureNursing Considerations:
Hold the thermometer in place for 2 minutes (for neonates, 5 minutes). To ensure recording of temperature
Do not force the insertion of thermometer. To prevent trauma in the area
Normal value:98.6 o – 100.6 oF (37.0 o – 38.1 oC)
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METHODS of Temperature Taking:Contraindications to Rectal
Temperature TakingAnal/rectal conditions or surgeries, e.g.
anal fissure, hemorrhoids, hemorrhoidectomy
DiarrheaQuadriplegic clients. Vagal stimulation
may occur, causing bradycardia and syncope
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METHODS of Temperature Taking:Rectal Thermometers
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METHODS of Temperature Taking:AXILLARY: safest and most non-invasive
methodNursing Considerations:
Pat dry the axilla. Rubbing causes friction and will increase temperature in the area
Place the thermometer in the client’s axillaPlace the arm tightly across the chest to keep the
thermometer in place for 9 minutes (for infants and children, 5 minutes
Normal value:96.6 o – 98.6 oF (35.8 o – 37.0 oC)
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METHODS of Temperature Taking:Axillary Thermometers
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METHODS of Temperature Taking:Tympanic: readily accessible, reflects the
core temperature, very fastNursing Considerations:
Can be very uncomfortable and involve risks of injuring the membrane if the probe is inserted too far
Repeated measurements may vary (right and left ears may differ)
Presence of cerumen can affect the readingNormal value:
98.2 o – 100.2 oF (36.8 o – 37.9 oC)
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METHODS of Temperature Taking:Tympanic Thermometers
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METHODS of Temperature Taking:Other Thermometers
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Ray Andrew S. del Rosario, RNCollege of Nursing and Health SciencesAquinas University of Legazpi
PULSE
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PULSEwave of blood created by contraction of left
ventricle of the heartRegulated by the autonomic nervous system
through cardiac sinoatrial nodeParasympathetic stimulation — decrease heart
rateSympathetic stimulation — increases heart ratePulse rate = number of contractions over a
peripheral artery in 1 minute
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Factors affecting the PULSE rateAgeSex/GenderExerciseFeverMedicationHemorrhageStressPosition changes
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PULSE sites: TemporalCarotidApicalBrachialRadialFemoralPoplitealDorsalis
PedisPedal
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PULSE site: TEMPORAL
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PULSE site: CAROTID
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PULSE site: APICAL
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PULSE site: RADIAL/BRACHIAL
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PULSE site: RADIAL
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PULSE site: FEMORAL
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PULSE site: POPLITEAL
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PULSE site: POSTERIOR TIBIAL
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PULSE sites: PEDAL/DORSALIS PEDIS
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ASSESSMENT of the Pulse:If pulse is regular, count for 30
seconds and multiply by 2. If irregular, count for 1 minute. When obtaining baseline date, count for the pulse for a full minute
Assess pulse rhythm by noting the pattern and intervals of beat. Dysrhytmia is irregular rhythm
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ASSESSMENT of the Pulse:Asses the pulse volume (amplitude) – strength of the pulseNormal pulse ca be felt with moderate pressure
Full or bounding pulse can be obliterated only by great pressure
Thready pulse can easily be obliterated (weak or feeble)
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ASSESSMENT of the Pulse:Arterial wall elasticity: the artery
feels straight, smooth, soft and pliable
Presence/absence of bilateral equality: absence of bilateral equality indicates cardiovascular disorder
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ASSESSMENT of the Pulse:Pulse pressure:
Systolic pressure MINUS diastolic pressurePulse deficit
Apical pulse MINUS peripheral pulsePulsus paradoxus
Systolic pressure falls by more than 15 mmHg during inhalation
Pulsus alternansAlternating strong and weak pulses
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ASSESSMENT of the Pulse:Age Normal Pulse Rate
Newborn to 1 month 80 – 180 beats/min1 year 80 – 140 beats/min2 years 80 – 130 beats/min6 years 75 – 120 beats/min10 years 60 – 90 beats/minAdult 60 – 100 beats/minTachycardia – pulse rate above 100 beats/minBradycardia – pulse rate below 60 beats/min
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Ray Andrew S. del Rosario, RNCollege of Nursing and Health SciencesAquinas University of Legazpi
RESPIRATION
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Respirationthe act of breathingcarbon dioxide is the primary chemical
stimulus of breathing; when carbon dioxide level in the blood is high, there is stimulation for breathing
Pulmonary ventilation — movement of air in and out of lungsInhalation: breathing inExhalation: breathing out
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RespirationThree processes
Ventilation: movement of gases in and out of the lungs
Diffusion: exchange of gases from an area of higher pressure to an area of lower pressure and occurs in the alveolo-capillary membrane
Perfusion: the availability and movement of blood for transport of gases, nutrients and metabolic waste products
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RespirationTwo Types of Breathing:Costal (thoracic)Diagphragmatic (abdominal)
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Respiratory Centers:Medulla Oblongata – primary center for respirationPons – (1) Pneumotaxic center; responsible for
rhythmic quality of breathing (2) Apneustic center; responsible for deep, prolonged inspiration
Carotid and aortic bodies – contain peripheral chemoreceptors, which take up the work of breathing when central chemoreceptors in the medulla are damaged, oxygen level concentration is low and respond to pressure.
Muscle and joints contain proprioreceptors, e.g. exercise
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Factors Affecting Respiratory Rate:
ExercisePain/Stress/AnxietyEnvironmentIncreased altitudeMedicationRespiratory and cardiovascular disease Alterations in fluid, electrolyte, and acid
balancesTraumaInfection
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Assessment of Respiration:With fingers still in place, after taking
pulse rate, note the rise and fall of patient’s chest with respiration. You may place the client’s arm across the chest and observe chest movement and for infants, observe the movement of the abdomen, these observes for depth of respiration
Observe rate. Count for 30 seconds if respirations are regular and multiply by 2. If irregular, count for 60 seconds.
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Assessment of Respiration:Observe the respiration (inhalations
and exhalations) for regular or irregular rhythm
Observe the character or quality of respiration – the sound of breathing and respiratory effort
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Assessment of Respiration:Normal rate in adult
12 – 20 breaths/minuteNormal rate in infant
20 – 40 breaths/minuteNormal rate in preschool
20 – 30 breaths/minute
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Assessment of Respiration:Types of
BreathingDescription
EupneaTachypneaBradypnea
HyperventilationHypoventilation
DyspneaOrthopnea
ApneaBiot’s respiration
Kussmaul respirationApneustic
respiration
Normal respiration that is quiet, rhythmic and effortlessRapid respiration, above 20 breaths/min in an adultSlow breathing, less than 12 breaths/minute in an adultDeep rapid respiration, carbon dioxide is excessively exhaled (resp. alkalosis)Slow, shallow respiration, carbon dioxide is excessively retained (resp. acidosis)Difficult and labored breathingAbility to breathe only in an upright positionAbsence/cessation of breathingQuick, shallow inspiration followed by regular or irregular periods of apneaVery deep and labored breathing; acetone breath (metabolic acidosis)
Deep, gasping inspiration with a pause at full inspiration followed by insufficient release
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Ray Andrew S. del Rosario, RNCollege of Nursing and Health SciencesAquinas University of Legazpi
BLOOD PRESSURE
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Physiology of Blood PressureForce of the blood against arterial wallsControlled by a variety of mechanism to
maintain adequate tissue perfusionSound of KorotkoffPressure rises as ventricle contracts and
falls as heart relaxesHighest pressure is systolicLowest pressure is diastolic
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Physiology of Blood Pressure: ..\Pictures\3DScience_Human_Heart.jpg
systolic pressure – pressure of blood as a result of contractions of the ventricles (100 – 140 mmHg); systole (contraction of the heart); numerator in BP reading
diastolic pressure – pressure exerted when the ventricles are at rest (60 – 90 mmHg); diastole (relaxation of the heart); denominator in BP reading
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Physiology of Blood Pressurepulse pressure – difference between
the systolic and diastolic pressures, normal is 30 – 40 mmHg
hypertension is an abnormally high blood pressure for at least two consecutive readings
hypotension is an abnormally low blood pressure, systolic pressure below 100/60 mmHg
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Determinants of Blood PressureBlood volumePeripheral resistanceCardiac outputElasticity or compliance of blood vesselsBlood viscosity
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Factors Affecting Blood Pressure:Age, gender, raceCircadian rhythmFood intakeExerciseWeightEmotional stateBody positionDrugs/medicationsDisease process
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Sphygmomanometers
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Sphygmomanometers
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Parts of the Stethoscope: stethoscopebasics.pdf
30 – 35 cm (12-14 inches) long0.3 cm (1/8 inch) internal diameter
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Stethoscope
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ASSESSING Blood Pressure:Ensure that the client is restedAllow 30 minutes to pass if the
client had engaged in exercise or had smoked or ingested caffeine before taking the BP (might tend to increase BP)
Use appropriate size of the BP cuff. Too narrow cuff causes high false reading and too wide cuff causes false low reading.
Position the client in sitting or supine position
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ASSESSING Blood Pressure:Position the arm at the level of
the heart, with the palm of the hand facing up. The left arm is preferably used because it is nearer the heart
Apply/warp the deflated cuff snugly in upper arm, the center of the bladder directly over the medial aspect or 1 inch above the antecubital space or at least 2 – 3 fingers above the elbow
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ASSESSING Blood Pressure:Determine palpatory BP
before auscultatory BP to prevent auscultatory gapUse the bell of the
stethoscope since the BP is a low frequency sound
Inflate and deflate BP cuff slowly, 2 -3 mmHg at a time
Wait 1 -2 minutes before making further determinations
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ASSESSING Blood Pressure:Palpate the brachial
artery with your fingertipsClose the valve on hand
pump by turning the knob clockwise
Insert the ear attachment of the stethoscope in your ears so they tilt slightly forward an ensure it hangs freely from the ear to the diaphragm
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ASSESSING Blood Pressure:Place the diaphragm of stethoscope
over brachial pulse and hold with the thumb and index finger
Pump out the cuff until the sphygmomanometer registers about 30 mmHg above the point where the brachial pulse disappeared
Release the valve on the cuff carefully so that the pressure decreases at the rate of 2 – 3 mmHg per second
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ASSESSING Blood Pressure:
As the pressure falls, note the first sound, muffling, and last sound heard
Deflate the cuff rapidly and completely after noting the last sound
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ASSESSING Blood Pressure:Read lower meniscus of the
mercury level of the sphygmomanometer at eye level to prevent error of parallaxError of parallax happens if
the eye level is higher than the lever of the lower meniscus of the mercury, this causes false low reading, if the eye level is lower, this causes false high reading
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Ray Andrew S. del Rosario, RNCollege of Nursing and Health SciencesAquinas University of Legazpi
END
References:Fundamentals of Nursing, Kozier, Erb et alLippincott William and WilkinsFundamental of Nursing, UdanWorld wide web