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13 Cards in this Set
- Front
- Back
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Temperature
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1. Axillary: 36.5 C (97.7 F)
2. Tympanic: 37 C (98.6 F) 3. Rectal: 37.5 C (99.5 F) Heat produced - heat lost = body temperature Heat produced by the body is a by-product of metabolism. Factors affecting body temerature - age (lower in older adults), exercise, hormone level, circadian rhythm. Controlled by hypothalamus. |
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Pulse
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60 to 100 beats per minute
Before measuring, review the cleint's baseline rate, rhythm, strenght and equality. When auscultating an apical pulse, assess rate and rhythm only. If you detect an abnormal rate while palpating a peripheral pulse, the next step is to assess the apical rate. |
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Bradycardia
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Apical pulse is < than 60 beats per minute.
Inadequate cardiac output, fatigue, chest pain, orthopnea, cyanosis, dizziness.Decreases with acute pain, broncodilators. Slow heart rate, below 60 beats per minute in adults. Creating a pulse deficit. To assess a pulse deficit you and a colleague assess radial and apical rates simultaneously and then compare rates. The difference between the apical and radial pulse rates is the pulse deficit. Negative chronotropic drugs sucs as digitalis, beta-adrenergic and calcium channel blockers. Hold digixin. |
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Tachycardia
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Apical pulse > than 100 beats per minute. Fever, anxiety, pain, hypotension, decreased oxygenation or dehydration, inadequate cardiac output, incuding fatigue, chest pain, orthopnea, cyanosis and dizziness. Increases with exercise, anxiety, smoking.
Positive chronotropic drugs such as epinephrine. |
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Respiration
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12 to 20 breaths per minute.
Sitting semi- or high Fowler's improves ventilation. Normal brathing is regular and uniterrupted. The objective measurements of respiratory status include the rate and depth (shallow, normal or deep) of breathing and the rhythm (regular, irregular) of ventilatory movements. The usual range of respiratory rate declines throughout life. Controlled by brain stem. Assess laboratory values 1. Arterial blood gases (measures arterial blood pH, partial pressure of O2, CO2, and arterial O2 saturation, which reflects client's oxygenation status. 2. Pulse oximetetry (SpO2) 3. Complete blood count (CBC) - measures red blood cell count, volume of red blood cells, and concentration of hemoglobin, which reflects client's capacity to carry O2. Position client preferably sitting or lying with the head of the bed elevated 45 to 60 degrees. |
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Tachycardia
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Abnormaly elevated heart rate, above 100 beats per minute.
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Blood pressure
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< 120/80
pulse pressure 30 to 50 mm Hg |
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High BP
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2
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disinterested
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unbiased
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Low blood pressure
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a
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Hyperthermia
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An elevated body temperature related to the body's inability to promote heat loss or reduce heat production.
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Hypothermia
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Heat loss during prolonged exposure to cold. Classified by core temperature measurements.
1. Mild - 34-36 C (93.2-96.8F) - uncontrolled shivering, loss of memory, depression, poor judgment. 2. Moderate - 30-34 C (86.0-93.2F) - heart. respiratory and BP fall, skin becomes cyanotic. 3. Severe - <30 C (<86.0 F) - cardiac dysrhythmias, loss of consciousness, unresponsiveness to painful stimuli. |
