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81 Cards in this Set

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DEF: The heat of the body determined by the balance of heat produced and heat lost; stated in Fahrenheit or Celsius
DEF: Temperature
DEF: Reflects temperature of body tissues such as muscles or viscera
DEF: Core Temperature
DEF: Temperature that varies according to site used
DEF: Surface Temperature
DEF: A subnormal body temperature. State the value- F and C!
DEF: Hypothermia; <96.8F or 36C
DEF: Body temperature greater than normal; State the value- F and C!
DEF: Fever; >100.4F or 38C
DEF: A high body temperature. State 3 terms
DEF: Hyperthermia; pyrexia; fever
DEF: A substance that induces fever. These can be either internal (endogenous) or external (exogenous) to the body
DEF: Pyrogens
Describe processes of heat production. What is the primary source of body heat?
BMR - heat production at rest;
Muscle Activity/Exercise - increases body metabolism;
Shivering - increases body metabolism;

Primary source of heat is metabolism.
Describe 4 processes of heat loss.
Radiation - heat diffusion by electromagnetic waves;
Conduction - transfer thru direct contact;
Convection - cooling by air currents;
Evaporation - conversion of liquid to vapor
List factors (6) affecting body temperature.
Age;
Diurnal Variations;
Exercise;
Hormones;
Stress;- and
Environment.
List contraindications to taking oral temperature.
mouth breathing;
uncooperative;
seizures;
unconscious;
younger than 6 years;
nasal or oral surgery or
trauma
List contraindications to taking rectal temperature.
rectal or prostate surgery or disorders;
diarrhea or impacted stool;
serious heart disease (vagal stimulation may slow heart rate);
newborns (may perforate rectal wall)
DEF: The wave of blood within an artery that is created by contraction of the left ventricle.
DEF: Pulse
DEF: Volume of blood pumped by the heart in one minute. State formula to calculate.
DEF: Cardiac Output;

CO = SV * HR
DEF: The amount of blood ejected with EACH cardiac contraction
DEF: Stroke Volume
List peripheral sites (7) to take a pulse.
Carotid;
radial;
brachial;
femoral;
popliteal;
posterior tibial;
dorsalis pedis
List 5 characteristics of a pulse.
Rhythm;
Amplitude (volume);
Rate;
Elasticity of arteries;
Equality
DEF: Occurs when the APICAL PULSE is greater than (OR rarely less than) a PERIPHERAL PULSE.
DEF: Pulse Deficit
What is the method to determine a pulse deficit? When are they reported?
TWO nurses measure an APICAL-RADIAL pulse at the same time for 60 SECONDS.

Pulse deficits are reported immediately.
What is the significance of a pulse deficit?
Indicates that the thrust of blood from heart is too weak to be felt at the peripheral pulse site OR indicates vascular disease.
List factors affecting the pulse rate (9).
Age
Gender
Exercis
Fever
Medications-
Hypovolemia
Stress
Position Changes
Pathology
DEF: The act of breathing for ONE MINUTE.
DEF: Respiration.
1 inspiration + 1 respiration = 1 breath.
Describe respiratory assessment of RATE. How to report? Normal range?
Count for 30 seconds and multiply by 2. Report as breaths per minute. Normal is 12 to 20 per minute.
Describe respiratory assessment of RHYTHM.
Regular or irregular respiration.
Describe respiratory assessment (4 terms) of EFFORT.
Eupnea; dyspnea; labored; orthopnea
Describe respiratory assessment of DEPTH. How is a SIGH assessed?
Full;
hypoventilation;
hyperventilation.

A SIGH is considered a normal breath.
What factors (8) affect the character of respiration?
Exercise; Acute Pain; Anxiety; Smoking; Body Position; Medications; Neurological Injury; Hemoglobin Function.
DEF: A measure of the arterial wall pressure created as blood flows through the arteries throughout the cardiac cycle. How is it written?
DEF: Blood Pressure.

Written Systolic pressure/Diastolic pressure
DEF: The phase when the left ventricle ejects blood. What is considered normal?
DEF: Systole. 90 - 139
DEF: The phase when the heart relaxes. What is considered normal?
DEF: Diastole. 60 - 89
DEF: Difference in systolic and diastolic BP.
DEF: Pulse Pressure.

Average range is 30-50 mm Hg.
Where may the blood pressure be measured?
Radial - systolic; Brachial - systolic and radial; Femoral - ?
What instruments are used to measure the blood pressure?
Blood pressure cuff w/manometer and stethoscope
What factors affect the blood pressure (8)?
Age- Stress- Gender- Race- Diurnal Variations- Medications- Activity- Disease Process
When are Vital Signs taken?
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
DEF: It is the thermoregulatory center; receives messages from thermal receptors to produce body heat or increase heat loss
DEF: Hypothalamus
Normal values for Oral- Rectal- Axillary- and Tympanic temp.
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
List 6 types of thermometers.
Glass; Electronic; Chemical; Temp;sensitive Tape; Infrared; Temporal Artery
Beneficial Aspects of Fever (3)
1. Stimulate WBC production;
2. Decrease iron in blood (anti-bacterial);
3. Increase interferon production (anti-viral).
Harmful Aspects of Fever (3)
1. Increase BMR- P & R rates (use of protein stores);
2. excessive sweating/dehydration;
3. Above 41C may lead to seizures or neuro complications
DEF: A patient who has a fever is said to be ___?
DEF: Febrile
List phases of febrile episode (3).
1. Chill phase - heat is conserved- shivering occurs- setpoint rises;
2. Plateau phase - chills subside;
3. Fever break - heat is lost- vasodilation- sweating
How is pulse rate regulated?
Pulse rate is regulated by the ANS via the VAGUS nerve. The vagus nerve slows the pulse rate.
List 2 methods for assessing the pulse.
1. Palpation using the fingertips of the middle 3 fingers- and
2. Auscultation using a stethoscope or doppler sound
List 3 sites where the pulse should be assessed on each client.
1. Carotid
2. Radial and
3. Pedal pulses
What is an apical pulse? Where is it taken?
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.
List 3 muscle(s) of respiration.
1. Diaphragm; 2. Intercostal; and 3. Accessory
List the 3 processes of respiration
1. Ventilation; 2. Diffusion; and 3. Perfusion
List 3 abnormal respiration patterns.
1. Kussmal; 2. Cheyne-Stokes; 3. Agonal
DEF: Kussmaul Respiration
DEF: Deep- rapid breathing that accompanies metabolic acidosis to blow off CO2
DEF: Cheyne-Stokes Respiration
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.
DEF: Agonal Respiration
DEF: Totally eratic breathing patterns; typically dying patients.
List 3 normal respiratory changes in elderly clients.
1. Decrease in elasticity; 2. Shallow; 3. Slightly faster.
What is the range for normotensive BP?
90/60 - 139/89
What is the range for pre-hypertensive BP?
120/80 - 139/89
What is the range for hypertensive- stage 1 BP?
greater than 140/90
List 3 methods to assess BP.
1. Direct - arterial line.
2. Indirect - palpatory (systolic only).
3. Indirect - auscultatory.
What are the Korotkoff's sounds for an adult? For children?
Adult: K1 & K5; Children: K1 & K4
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.
DEF: Auscultatory gap
DEF: Abnormally fast- rapid respirations
DEF: Tachypnea
DEF: Abnormally slow respirations
DEF: Bradypnea
DEF: Ability to breath only when in an upright position (standing or sitting)
DEF: Orthopnea
VS variations in older adults: Temperature Range
Older adults: 95 - 97F
VS variations in infants: Heart Rate
"Newborns: Do not palpate
What is a fever's effect on HR? Medication? Hemorrhage?
Increase; Either up or down; Initially increases to maintain pressure but eventually decreases
What is the effect of stimulation of the Vagus Nerve on HR and where is it located?
The vagus nerve reduces HR. It is travels from the mouth to the anus.
Where is the proper location to palpate the carotid artery and way?
Palpate in lower half of neck to avoid the vagal sinus in the upper 1/3 of neck.
How do we describe rhythm of the pulse?
Regular (good) or arhythmic (bad)
How do we describe amplitude of the pulse?
"normal +2
How do we assess/describe the elasticity of the veins?
"Normal is soft & pliable; abnormal is hard
What is the norm for equality of pulse?
Equal from side to side during simultaneous measurement.
What is the word for fast pulse and when is it used?
Tachycardia; greater than 100
What is the word for slow pulse and when is it used?
"Bradycardia
What is the time length of inspiration vs expiration in an adult?
1 - 1.5 sec in; 2 - 3 sec exp
How are the intercostal spaces name?
Each space are named for the rib above it.
DEF: The respiratory process for moving O2 throughout the body
DEF: Perfussion
DEF: The respiratory process for exchanging gas between the alveoli and RBCs in the pulmonary capillaries.
DEF: Diffusion
DEF: The act of inhalation
DEF: Ventilation
What are the 2 types of regulation of Respiration and where are the control centers?
Neural (cerebral cortex and medulla oblongata) and Chemical (chemoreceptors in aorta and carotid arteries)
DEF: Pulse Pressure
DEF: Systolic - Diastolic Pressure
What effect do vasoconstrictor drugs have on blood pressure? Vasodilators?
Raises BP by constricting vessels;
Lowers BP by relaxing vessels.