Exam 1 - Ch. 32 Vital Signs Fundamentals Of Nursing Potter Perry

Front 1

afebrile

Back 1

no fever

Front 2

antipyretics

Back 2

drugs that reduce fever. Non-steroids such as acetaminophen, salicylates, indomethacin, ketorolac, etc reduce fever by increasing heat loss. Cortisteroids reduce fever by masking signs of infection - they are NOT used to treat fever but may mask typically-pyrogeninc conditions by supressing fever.

Front 3

auscultatory gap

Back 3

hypertensive patients may have a temporary disappearance of Korotkoff sounds that can result in inaccurage auscultation. You may use a combination of palpation and auscultation to determine accurate BP reading in these cases.

Front 4

BMR

Back 4

Basal Metabolic Rate is the heat produced by the body at absolute rest

Front 5

Blood Pressure

Back 5

force exerted on the walls of an artery by the pumping of blood under pressure from the heart

Front 6

bradycardia

Back 6

unusually LOW heart rate - below 60 beats per minute

Front 7

cardiac output

Back 7

volume of blood pumped by heart per minute. Typically 5000mL/min for adults. CO = HR x SV (cardiac output equals heart rate times stroke volume)

Front 8

celcius

Back 8

a scale of temperature. C = 5/9 (F-32)

Front 9

conduction

Back 9

transfer of heat from one object to another with direct contact

Front 10

convection

Back 10

transfer of heat by air movement. In healthcare, most commonly heat loss due to wind, fan, etc

Front 11

core temperature

Back 11

temperature of deep tissues

Front 12

diaphoresis

Back 12

visible perspiration - primarily on forehead and upper thorax

Front 13

diastolic pressure

Back 13

minimal pressure exerted against the arterial walls at all times. ("bottom" # of a BP reading).

Front 14

diffusion (in relation to respiration)

Back 14

movement of O2 and CO2 between alveoli and the RBCs. Assessed through O2 saturation levels

Front 15

dysrhythmia

Back 15

abnormal heart rhythm. Classified as regularly irregular or irregularly irregular

Front 16

eupnea

Back 16

normal rate and depth of respirations

Front 17

evaporation

Back 17

when liquid changes to gas. Water evaporation is an endothermic chemical reaction so it requires thermal energy from the environment. ie - sweat removes heat from body surfaces as it evaporates.

Front 18

farenheit

Back 18

a temperature scale. F = 9/5 C + 32

Front 19

febrile

Back 19

condition of having a fever

Front 20

fever

Back 20

occurs when heat production out-paces heat loss and body temp rises. Also called pyrexia

Front 21

FUO

Back 21

fever of unknown origin - refers to a fever whose etiology cannot be determined

Front 22

frostbite

Back 22

occurs when body is exposed to subnormal temps. Ice crystals form inside cell and permanent circulatory and tissue damage occurs.

Front 23

heat exhaustion

Back 23

occurs when profuse diaphoresis results in excess water and electorlyte loss. Signs of fluid volume deficit. Move client to cooler area, provide fluid, and electrolytes

Front 24

heat stroke

Back 24

Heat depresses hypothalamus function. When exposed to enough heat, the body's heat-loss mechanism can become overwhelmed and stop functioning. This is an extremely dangerous condition.

Front 25

hematocrit

Back 25

percentage of total blood volume that consists of red blood cells

Front 26

hypertension

Back 26

High BP. Cannot be diagnosed in a single assesment. Can be classified as 3 categories: Prehypertension, Stage 1 hypertension, or Stage 2 hypertension. Ranges for high systolic pressures go in increments of 20 mm HG (i.e. <120: normal; 120-140 = pre; 140-160 = stage 1; >160 = stage 2). Ranges for high diastolic pressures are in increments of 10 mm Hg (i.e. normal=<80; 80-90=pre...)

Front 27

hypotension

Back 27

systolic pressure below 90 mm Hg

Front 28

hypothalamus

Back 28

part of the brain that regulates temperature like a thermostat. Anterior controls heat loss, posterior controls heat production.

Front 29

hypothermia

Back 29

heat loss exceeds body's ability to produce heat. Uncontrolled shivering, loss of memory, depression, poor judgement. HR and respiration are reduced. If severe, client may have cyanotic skin tone, cardiac dysrhythmia, loss of conciousness, and be unresponsive to pain.

Front 30

hypoxemia

Back 30

low levels of O2 in blood

Front 31

malignant hyperthermia

Back 31

a hereditary condition of uncontrolled heat production after exposure to certain anesthetic drugs.

Front 32

nonshivering thermogenesis

Back 32

occurs primarily in neonates because they are unable to shivver. A limited amount of vascular brown tissue is metabolized for heat production

Front 33

orthostatic hypotension

Back 33

also called "postural hypotension". BP drops suddenly due to change in position such as standing or sitting up from lying down. Simply ask patient to lie back down and get up more slowly after a few minutes. Monitor BP - do not delegate orthostatic hypotension readings

Front 34

perfusion

Back 34

distribution of RBCs to and from the pulmonary capillaries. Assessed through O2 saturation

Front 35

postural hypotension

Back 35

also called "orthostatic hypotension". Drop in BP due to position change.

Front 36

pulse deficit

Back 36

an inefficient contraction of the heart that fails to transmit a pulsation to peripheral site causes a "missing" beat in the reading. To measure, 2 healthcare workers may simultaneously take aipical and radial pulse. The difference between the two readings is the pulse deficit.

Front 37

pulse pressure

Back 37

difference between systolic and diastolic pressures is PP. (eg. BP=120/80, PP=40)

Front 38

pyrexia

Back 38

fever - when heat generation out-paces heat loss

Front 39

pyrogens

Back 39

substances that alter the hypothalamic set point and trigger a change in body temperature. Some pathogenic bacteria or viruses are pyrogens.

Front 40

radial pulse

Back 40

pulsations of the blood felt at the radial (thumb) side of the wrist

Front 41

radiation

Back 41

transfer of heat from one surface to another without direct contact

Front 42

shivering

Back 42

an involuntary response to temperature differences in the body. Increases heat production by 4-5X

Front 43

sphygmomanometer

Back 43

tool for measuring BP - includes a pressure manometer, occlusive cuff that encloses an inflatable rubber bladder, pressure bulb w/ release valve. Aneroid or Hg but Hg rarely seen

Front 44

systolic pressure

Back 44

peak of max pressure when ejection of blood into aorta occurs ("top" number in BP reading).

Front 45

tachycardia

Back 45

abnormally high heart rate - above 100 beats/minute

Front 46

thermoregulation

Back 46

ability of the body to balance heat production with heat loss and keep core temperature within acceptable range of set point

Front 47

ventilation

Back 47

movement of gases in and out of lungs

Front 48

vital signs

Back 48

includes measurements of temperature, pulse, blood pressure, respiration rate, and O2 saturation. Pain level is often considered the 6th vital sign. Mnemonic = Take Pulse By Reaching Out

Front 49

About ______ to ________ mL/day evaporates from the skin and lungs

Back 49

600 to 900

Front 50

Typical body temperature for a newborn is _______ to _______

Back 50

35.5 C - 37.5 C (95.9 F to 99.5 F) and can fluctuate rapidly with exposure to temperature extremes due to immature temperature regulation systems

Front 51

Typical body temperature for an older adult is _______

Back 51

Approximately 36 °C (96.8 °F) - temperatures of 35 °C (95 °F) are not uncommon in elderly patients

Front 52

Hormones can affect a woman's temperature. Low levels of progesterone will cause body temperature to be (higher/lower)

Back 52

lower

Front 53

Due to circadian rhythms, body temperature usually fluctuates about _______ to _______ °C throughout the day. Temp is lowest in the _________ (morning/evening) and typically peaks in the _______ (morning/evening)

Back 53

0.5 to 1 °C (0.9 to 1.8 °F), lowest in the early morning (around 1-4 AM), peaks in the evening (around 6PM)

Front 54

Mild fever up to ________ enhances the body's immune system. __________ blood cell production is stimulated, and concentrations of _______ in the blood plasma are reduced suppressing the growth of bacteria. Fevers also help to fight viral infections by stimulating _________ the body's natural virus-fighting substance.

Back 54

39 °C (102.2 °F), White, iron, interferon

Front 55

When to perform vital signs -

Back 55

On admission to facility or initial assesment at home care visit
On a routine schedule established by facility/provider/standards of practice
Before and after any surgical or invasive proceedure
Before, during and after transfusion of any blood products
Before, during and after administration of any interventions that affect cardiovascular, respiratory, temperature-control, or other vital sign functions. (e.g. vasoconstrictor medication, ambulation of a previously immobile client)
Whenever client's general condition changes as evidenced by out signs or a report of symptoms of physical distress (e.g. fainted, increased pain, feeling "funny")

Front 56

The body's metabolism increases by ____ % for every °C of temperature elevation. This increased demand for O2 and nutrients can put significant strain on cardiac and respiratory systems.

Back 56

10

Front 57

How can a fever influence cellular hypoxia and myocardial hypoxia?

Back 57

High temperatures increase the basal metabolic rate of virtually all body systems. Cells' oxygen consumption increases and therefore the demands on cardiac and respiratory systems increase. If these systems cannot meet the increasing demands, hypoxia results. Hypoxia is a lack of sufficient O2 delivery to maintain the health of the cells. Myocardial hypoxia produces angina, cerebral hypoxia produces confusion.

Front 58

The most important symptom of heat stroke is ____________ skin. Other symptoms of heat stroke include:

Back 58

Hot dry skin is the strongest indicator that body's cooling mechanisms are no longer operating correctly. Other symptoms include - giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence, increased heart rate, low BP

Front 59

Mild hypothermia is a core temp range of -

Back 59

34-36°C (93.2- 96.8°F)

Front 60

Moderate hypothermia is a core temp range of -

Back 60

30-34°C (86.0-93.2°F)

Front 61

Severe hypothermia is a core temperature of -

Back 61

Below 30°C (86°F)

Front 62

35 yo male patient returned from snowmobiling and found that 3 fingers of left hand appeared white, waxy, firm to the touch and have a loss of sensation. What has likely occurred and how should it be treated?

Back 62

Frostbite - liquid in cells and tissues froze and formed crystals that permanently damage affected cells. Warm fingers gradually, provide analgesia, protect injured tissues. Assess vital signs/history for indications of impaired circulation that may have increased risks for frostbite. Educate client about protective measures to take in the future.

Front 63

Rectal temp is typically about ________°C higher/lower than oral temperature readings.

Back 63

0.5°C (0.9°F) higher

Front 64

Axillary temp is typically about ________°C higher/lower than oral temperature readings.

Back 64

0.5 °C (0.9°F) lower

Front 65

Common nursing diagnoses for clients with body temp alterations include:

Back 65

Risk for imbalanced body temperature
hyperthermia
hypothermia
ineffective thermoregulation

Front 66

Drug reaction induced fevers are often accompanied by

Back 66

allergy symptoms such as rash or pruritus (itching)

Front 67

Ensure that nursing interventions to treat hyperthermia do not cause ______ which can increase energy expenditure by 4-5X and result in heat gain. Medications such as _______ and ______ can be used to prevent this effect.

Back 67

shivering Meperdine, butorphanol

Front 68

Pulse rate

Back 68

number of pulsations of the blood per minute. Also just called "pulse"

Front 69

Where (exactly) should apical pulse auscultated?

Back 69

fourth to fifth intercostal space at the left mid-clavicular line

Front 70

An increase in heart rate without an adjustment to stroke volume causes BP to __________ increase/decrease.

Back 70

decrease - because the heart has less time to fill and therefore pumps less efficiently and cardiac output decreases

Front 71

When using a stethoscope, press the _______ side firmly against the skin to hear ______-pitched sounds. Flip the stethoscope to the ______ side and hold it lightly against the skin to hear the _____-pitched sounds created by the low-velocity movement of blood.

Back 71

diaphragm, high bell, low

Front 72

It is normal for heart rate to temporarily ________ when a client moves from lying to a sitting/standing position.

Back 72

increase

Front 73

electrocardiogram

Back 73

records electrical activity of the heart for a 12-second interval

Front 74

Holter monitor

Back 74

records heart activity for 24 hours on a small wearable recorder. Results not immediately accessable

Front 75

telemetry

Back 75

continuous monitoring of heart's electrical activity transmitted to a stationary monitor. Allows for immediate intervention during cardiac instabillity

Front 76

sinus dysrhythmia

Back 76

irregular heartbeat that speeds up during inspiration and slows with expiration. Normal/common in children. Resolves if breath is held.

Front 77

Common nursing diagnoses related to pulse issues:

Back 77

Activity intolerance
pain, fear or anxiety
decreased cardiac output
deficient/excess fluid volume
impaired gas exchange
hyperthermia/hypothermia
ineffective tissue perfusion

Front 78

Normal respiration rate for adults -

Back 78

12-20 breaths/min

Front 79

hypercarbia

Back 79

excess CO2 in blood (usually arterial)

Front 80

During normal relaxed breathing, a typical adult inhales about ________ mL of air. This is refered to as __________ volume

Back 80

500 Tidal

Front 81

Abdominal trauma may injure the ________ nerve which is responsible for diaphragmatic contraction

Back 81

phrenic

Front 82

A significan drop in respirations after a head injury may signify injury to the __________

Back 82

brain stem

Front 83

Normal respiration rate for a newborn, child, and adult are

Back 83

NB = 30-60/min, Child = 20-30/min, Adult = 12-20/min

Front 84

Common factors affecting respirations include:

Back 84

exercise, acute pain, anxiety, smoking, position, medications, neurological injury, hemoglobin function, respiratory diseases

Front 85

hyperpnea

Back 85

respirations are labored, increased depth and rate, more than 20 breaths/min, normal during exercise

Front 86

Kussmaul's respiration

Back 86

abnormally deep, regular and increased rate

Front 87

Biot's respiration

Back 87

abnormally shallow for 2-3 breaths followed by irregular periods of apnea

Front 88

Cheyne-Stokes respiration

Back 88

Respiratory cycle begins with slow shallow breaths that gradually increase to abnormal rate and depth to a point of hyperventilation. Breathing then slows and becomes increasingly more shallow, ultimately reaching apnea before the cycle begins again.

Front 89

Healthy men and children typically demonstrate _______ breathing whereas women tend to use _______ muscles to breath. Assess respiration in female clients by observing the _________

Back 89

diaphragmatic, thoracic, upper chest

Front 90

Labored breathing usually involves accessory muscles of respiration visible in the _______

Back 90

neck

Front 91

A longer expiration phase of respiration is present when _______________

Back 91

the outward flow or air is inhibited / obstructed (eg - asthma)

Front 92

Infants' and young children's breathing rate tends to be _________

Back 92

irregular - it is common for them to breath slowly for a few seconds and then more rapidly

Front 93

Arterial oxygen saturation SaO2 in adults is typically -

Back 93

95-100%

Front 94

Venous O2 saturation levels in adults (SvO2) is typically -

Back 94

about 70%

Front 95

Oxygen saturation is

Back 95

the percentage of hemoglobin molecules that are bound w/ O2

Front 96

Pulse Oximeter

Back 96

device for measuring O2 saturation levels. Probe with LED photodetector that measures pulse O2 saturation - usually a reliable estimate of SaO2 as long as levels are above 70%. Various probes can attach to finger, ear, nose bridge, infant foot. Do not use on extremeties when patient is cold or circulation to location is otherwise impaired.

Front 97

Vital sign measurements of respiratory rate, pattern and depth along with SpO2 are used to *****: ____, _____, and _____

Back 97

ventilation, diffusion, and perfusion

Front 98

Respiratory assessment data are defining characteristics of many nursing diagnoses including:

Back 98

activitiy intolerance
ineffective airway clearance
anxiety
acute pain
ineffective breathing pattern
impaired gas exchange
dysfunctional ventilatory weaning response

Front 99

Factors that may interfere with the accuracy of pulse oximeter include :

Back 99

outside light, CO poisoning, client motion, jaundice, IV dyes, cosmetic nail augmentation, dark skin

Front 100

Common conditions that interfere with arterial pulsations and SaO2 measurement:

Back 100

peripheral vascular disease, hypothermia, vasoconstricting drugs, low cardiac output, hypotension, peripheral edema, probe that is too tight will record venous and arterial saturation resulting in artificially low reading.

Front 101

Instruct nursing assistive personnel to immediately report to nurse any SpO2 reading below _______

Back 101

90%

Front 102

Refrain from using pulse oximetry to assess heart rate because _____________

Back 102

oximeter may count pulsations but cannot detect irregularities

Front 103

(5) Common conditions that increase risk for low SO2 and warrant closer monitoring of this vital sign include:

Back 103

compromised respiratory function, recovery from sedation, traumatic injury to chest wall, ventilator dependence, changes in supplemental O2 therapy

Front 104

Signs and symptoms of decreased oxygenation include:

Back 104

anxiety, restlessness, tachycardia, cyanosis, low BP

Front 105

What 5 hemodynamic variables affect blood pressure?

Back 105

cardiac output, peripheral vascular resistance, blood volume, blood viscosity, artery elasticity

Front 106

Most adults have a circulating blood volume of approximately __________ mL

Back 106

5000

Front 107

Typical BP for a newborn, 1yo, 12yo, 45yo, 85yo

Back 107

nb= 40 mean
1yo = 95/65
12yo = 110/65 Highly dependant on size/maturity. Lower in kids small for age
45yo = 120/80
85yo = 120/80

Front 108

Signs and symptoms associated with hypotension include:

Back 108

pallor, skin mottling, clamminess, confusion, increased HR, decreased urine output, dizziness, restlessness, dusky or cyanotic skin

Front 109

Diuretics act antihypertensively by

Back 109

reducing fluid reabsorption in kidney's thus lowering blood volume. Examples - Furosemide (Lasix), Spironolactone (Aldactone)

Front 110

Beta-andrenergic blockers act antihypertensively by

Back 110

combining with receptors in circ. system to block response to sympathetic nervous system -> slows heart rate -> thus lowers cardiac output. Examples - Atenolol (Tenormin), Nadolol

Front 111

Vasodialators act antihypertensively by

Back 111

relaxes smooth muscle of arterioles to cause reduced resistance. Examples - Apresoline, Loniten

Front 112

Calcium Channel blockers act antihypertensively by

Back 112

reducing peripheral resistance through systemic vasodilation. Examples - Diltiazem (Cardizem), Verapamil Hydrochloride (Calan SR)

Front 113

Angiotensin-converting enzyme (ACE) inhibitors act antihypertensively by

Back 113

prevent vasoconstriction and reduce aldosterone which results in lower fluid retention. Examples - Captopril (Capoten), Nicardipine (Cardene).

Front 114

Angiotensin II receptor blockers act antihypertensively by

Back 114

Blocks binding of angiotensin II (a vasoconstrictor). Examples - Losartan (Cozaar), Olmesartan (Benicar).

Front 115

Signs and symptoms of hypertension

Back 115

Often none until BP is very high - headache (usually occipital), flushing of face, nosebleed, fatigue in older adults

Front 116

Orthostatic hypotension measurements should/should not be delegated

Back 116

should not

Front 117

What should you do if unable to obtain BP reading?

Back 117

check for immediate crisis using pulse and respiration rate
Assess for signs of decreased cardiac output. If present, notify nurse in charge or HC provider immediately
Use alternate site or method (i.e. leg, doppler)
repeat with sphygmomanometer if electronic device had been used

Front 118

What to do if BP is low

Back 118

Compare to baseline - might be OK for this client
Move client to supine position and/or restrict movement
Assess for signs and syptoms of low CO and seek assistance immediately if present
increase rate of IV infusion or admin vasoconstricting drugs as ordered

Front 119

What to do if BP is above acceptable range

Back 119

Repeat measurement in other arm, compare
Verify correct selection and placement of cuff
Ask nurse collegue to repeat measurement in 1-2 minutes
Observe for related symptoms although hypertension is often asymptomatic
Report elevated BP to head nurse and/or provider
Administer antihypertensive meds as ordered

Front 120

True/False - If it is more convenient and equipment fits properly, it is acceptable to take BP reading from forearm and radial pulse

Back 120

False - recent research has indicated that this is a very inaccurate site for BP measurement

Front 121

What to do if client has respiratory rate less than 12 (bradypnea) or above 20 (tachypnea) breaths per minute. Breathing pattern is irregular, depth increases or decreases and client complains of feeling short of breath -

Back 121

Observe for related factors including obstructed airway, abnormal breath sounds, productive cough, restlessness, irritability, anxiety, confusion
Assist client to supported sitting position unless contraindicated
Provide O2 as ordered
Assess for environmental factors such as second-hand smoke, poor ventilation, or gas fumes

Front 122

During initial assessment, obtain and record BP in both arms. Normally there is a difference of _____ to _____ mm Hg between the arms. In subsequent assessments, measure the BP in the arm that had the _____ (higher/lower) pressure.

Back 122

5 to 10 Higher

Front 123

Korotkoff sounds

Back 123

the sounds heard over artery distal to BP cuff.

Front 124

The skill of PALPATING BP (rather than auscultating) can/cannot be delegated.

Back 124

cannot (p545 Potter)

Front 125

Client conditions not appropriate for electronic BP measurement include:

Back 125

irregular heart rate, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, systolic BP<90,

Front 126

Nursing diagnoses related to BP include:

Back 126

Activity intolerance
Anxiety
Decreased cardiac output
Deficient/excess fluid volume
Risk for injury
Acute pain
Ineffective tissue perfusion

Front 127

Primary nursing diagnosis for client with defining characteristics of: hypotension, dizziness, pulse deficit, dysrhythmia is _______________

Back 127

decreased cardiac output

Front 128

The temperature of older adults tends to be ________ than younger adults.

Back 128

Lower (about 36 to 36.8 C)

Front 129

Older adults tend to be more suceptable to heat stroke and hyperthermia because -

Back 129

thermoregulation systems are not as efficient and sweat glands are less reactive

Front 130

Older adults tend to have a ______ resting heart rate. Their heart rate rises more _____ in response to activity or excitement and recovers ______ once at rest.

Back 130

lower, slowly, slowly

Front 131

Normal BP is ________ for older adults.

Back 131

The same as younger adults 120/80