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81 Cards in this Set
- Front
- Back
DEF: The heat of the body determined by the balance of heat produced and heat lost; stated in Fahrenheit or Celsius
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DEF: Temperature
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DEF: Reflects temperature of body tissues such as muscles or viscera
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DEF: Core Temperature
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DEF: Temperature that varies according to site used
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DEF: Surface Temperature
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DEF: A subnormal body temperature. State the value- F and C!
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DEF: Hypothermia; <96.8F or 36C
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DEF: Body temperature greater than normal; State the value- F and C!
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DEF: Fever; >100.4F or 38C
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DEF: A high body temperature. State 3 terms
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DEF: Hyperthermia; pyrexia; fever
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DEF: A substance that induces fever. These can be either internal (endogenous) or external (exogenous) to the body
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DEF: Pyrogens
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Describe processes of heat production. What is the primary source of body heat?
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BMR - heat production at rest;
Muscle Activity/Exercise - increases body metabolism; Shivering - increases body metabolism; Primary source of heat is metabolism. |
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Describe 4 processes of heat loss.
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Radiation - heat diffusion by electromagnetic waves;
Conduction - transfer thru direct contact; Convection - cooling by air currents; Evaporation - conversion of liquid to vapor |
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List factors (6) affecting body temperature.
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Age;
Diurnal Variations; Exercise; Hormones; Stress;- and Environment. |
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List contraindications to taking oral temperature.
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mouth breathing;
uncooperative; seizures; unconscious; younger than 6 years; nasal or oral surgery or trauma |
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List contraindications to taking rectal temperature.
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rectal or prostate surgery or disorders;
diarrhea or impacted stool; serious heart disease (vagal stimulation may slow heart rate); newborns (may perforate rectal wall) |
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DEF: The wave of blood within an artery that is created by contraction of the left ventricle.
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DEF: Pulse
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DEF: Volume of blood pumped by the heart in one minute. State formula to calculate.
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DEF: Cardiac Output;
CO = SV * HR |
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DEF: The amount of blood ejected with EACH cardiac contraction
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DEF: Stroke Volume
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List peripheral sites (7) to take a pulse.
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Carotid;
radial; brachial; femoral; popliteal; posterior tibial; dorsalis pedis |
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List 5 characteristics of a pulse.
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Rhythm;
Amplitude (volume); Rate; Elasticity of arteries; Equality |
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DEF: Occurs when the APICAL PULSE is greater than (OR rarely less than) a PERIPHERAL PULSE.
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DEF: Pulse Deficit
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What is the method to determine a pulse deficit? When are they reported?
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TWO nurses measure an APICAL-RADIAL pulse at the same time for 60 SECONDS.
Pulse deficits are reported immediately. |
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What is the significance of a pulse deficit?
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Indicates that the thrust of blood from heart is too weak to be felt at the peripheral pulse site OR indicates vascular disease.
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List factors affecting the pulse rate (9).
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Age
Gender Exercis Fever Medications- Hypovolemia Stress Position Changes Pathology |
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DEF: The act of breathing for ONE MINUTE.
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DEF: Respiration.
1 inspiration + 1 respiration = 1 breath. |
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Describe respiratory assessment of RATE. How to report? Normal range?
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Count for 30 seconds and multiply by 2. Report as breaths per minute. Normal is 12 to 20 per minute.
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Describe respiratory assessment of RHYTHM.
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Regular or irregular respiration.
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Describe respiratory assessment (4 terms) of EFFORT.
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Eupnea; dyspnea; labored; orthopnea
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Describe respiratory assessment of DEPTH. How is a SIGH assessed?
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Full;
hypoventilation; hyperventilation. A SIGH is considered a normal breath. |
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What factors (8) affect the character of respiration?
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Exercise; Acute Pain; Anxiety; Smoking; Body Position; Medications; Neurological Injury; Hemoglobin Function.
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DEF: A measure of the arterial wall pressure created as blood flows through the arteries throughout the cardiac cycle. How is it written?
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DEF: Blood Pressure.
Written Systolic pressure/Diastolic pressure |
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DEF: The phase when the left ventricle ejects blood. What is considered normal?
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DEF: Systole. 90 - 139
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DEF: The phase when the heart relaxes. What is considered normal?
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DEF: Diastole. 60 - 89
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DEF: Difference in systolic and diastolic BP.
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DEF: Pulse Pressure.
Average range is 30-50 mm Hg. |
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Where may the blood pressure be measured?
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Radial - systolic; Brachial - systolic and radial; Femoral - ?
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What instruments are used to measure the blood pressure?
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Blood pressure cuff w/manometer and stethoscope
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What factors affect the blood pressure (8)?
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Age- Stress- Gender- Race- Diurnal Variations- Medications- Activity- Disease Process
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When are Vital Signs taken?
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1. On admission;
2. Per hospital or physician; 3. before & after surgery- procedures- medication- or interventions; 4. before- during- after transfusions; 5. when there is a change in client's condition or distress |
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DEF: It is the thermoregulatory center; receives messages from thermal receptors to produce body heat or increase heat loss
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DEF: Hypothalamus
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Normal values for Oral- Rectal- Axillary- and Tympanic temp.
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O = 97.6 - 99.6F; 36.5 - 37.5C;
R = Oral + 1F or 0.5C; Ax = Oral -1F or 0.5C; Tympanic = Oral + 0.5F |
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List 6 types of thermometers.
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Glass; Electronic; Chemical; Temp;sensitive Tape; Infrared; Temporal Artery
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Beneficial Aspects of Fever (3)
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1. Stimulate WBC production;
2. Decrease iron in blood (anti-bacterial); 3. Increase interferon production (anti-viral). |
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Harmful Aspects of Fever (3)
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1. Increase BMR- P & R rates (use of protein stores);
2. excessive sweating/dehydration; 3. Above 41C may lead to seizures or neuro complications |
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DEF: A patient who has a fever is said to be ___?
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DEF: Febrile
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List phases of febrile episode (3).
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1. Chill phase - heat is conserved- shivering occurs- setpoint rises;
2. Plateau phase - chills subside; 3. Fever break - heat is lost- vasodilation- sweating |
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How is pulse rate regulated?
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Pulse rate is regulated by the ANS via the VAGUS nerve. The vagus nerve slows the pulse rate.
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List 2 methods for assessing the pulse.
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1. Palpation using the fingertips of the middle 3 fingers- and
2. Auscultation using a stethoscope or doppler sound |
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List 3 sites where the pulse should be assessed on each client.
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1. Carotid
2. Radial and 3. Pedal pulses |
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What is an apical pulse? Where is it taken?
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The most accurate pulse- must be assessed if peripheral pulse is abnormal- ascultated with stethoscope over apex of heart.
Heard loudest at 5 LICS- MCL. |
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List 3 muscle(s) of respiration.
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1. Diaphragm; 2. Intercostal; and 3. Accessory
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List the 3 processes of respiration
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1. Ventilation; 2. Diffusion; and 3. Perfusion
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List 3 abnormal respiration patterns.
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1. Kussmal; 2. Cheyne-Stokes; 3. Agonal
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DEF: Kussmaul Respiration
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DEF: Deep- rapid breathing that accompanies metabolic acidosis to blow off CO2
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DEF: Cheyne-Stokes Respiration
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DEF: Rhythmic waxing and waning of repirations from very deep breathing to very shallow with periods of apnea. Often associated with cardiac failure- intercranial pressure- or brain damage.
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DEF: Agonal Respiration
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DEF: Totally eratic breathing patterns; typically dying patients.
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List 3 normal respiratory changes in elderly clients.
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1. Decrease in elasticity; 2. Shallow; 3. Slightly faster.
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What is the range for normotensive BP?
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90/60 - 139/89
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What is the range for pre-hypertensive BP?
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120/80 - 139/89
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What is the range for hypertensive- stage 1 BP?
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greater than 140/90
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List 3 methods to assess BP.
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1. Direct - arterial line.
2. Indirect - palpatory (systolic only). 3. Indirect - auscultatory. |
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What are the Korotkoff's sounds for an adult? For children?
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Adult: K1 & K5; Children: K1 & K4
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DEF: The temporary disappearance of sounds normaly heard over the brachial artery when the cuff pressure is high and the sounds reappear at a lower pressure.
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DEF: Auscultatory gap
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DEF: Abnormally fast- rapid respirations
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DEF: Tachypnea
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DEF: Abnormally slow respirations
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DEF: Bradypnea
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DEF: Ability to breath only when in an upright position (standing or sitting)
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DEF: Orthopnea
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VS variations in older adults: Temperature Range
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Older adults: 95 - 97F
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VS variations in infants: Heart Rate
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"Newborns: Do not palpate
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What is a fever's effect on HR? Medication? Hemorrhage?
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Increase; Either up or down; Initially increases to maintain pressure but eventually decreases
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What is the effect of stimulation of the Vagus Nerve on HR and where is it located?
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The vagus nerve reduces HR. It is travels from the mouth to the anus.
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Where is the proper location to palpate the carotid artery and way?
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Palpate in lower half of neck to avoid the vagal sinus in the upper 1/3 of neck.
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How do we describe rhythm of the pulse?
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Regular (good) or arhythmic (bad)
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How do we describe amplitude of the pulse?
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"normal +2
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How do we assess/describe the elasticity of the veins?
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"Normal is soft & pliable; abnormal is hard
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What is the norm for equality of pulse?
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Equal from side to side during simultaneous measurement.
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What is the word for fast pulse and when is it used?
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Tachycardia; greater than 100
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What is the word for slow pulse and when is it used?
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"Bradycardia
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What is the time length of inspiration vs expiration in an adult?
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1 - 1.5 sec in; 2 - 3 sec exp
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How are the intercostal spaces name?
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Each space are named for the rib above it.
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DEF: The respiratory process for moving O2 throughout the body
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DEF: Perfussion
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DEF: The respiratory process for exchanging gas between the alveoli and RBCs in the pulmonary capillaries.
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DEF: Diffusion
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DEF: The act of inhalation
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DEF: Ventilation
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What are the 2 types of regulation of Respiration and where are the control centers?
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Neural (cerebral cortex and medulla oblongata) and Chemical (chemoreceptors in aorta and carotid arteries)
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DEF: Pulse Pressure
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DEF: Systolic - Diastolic Pressure
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What effect do vasoconstrictor drugs have on blood pressure? Vasodilators?
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Raises BP by constricting vessels;
Lowers BP by relaxing vessels. |