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30 Cards in this Set

  • Front
  • Back
Site for Body Temp
Oral, Rectal, Tympanic, Axillary
Oral is most common but contraindicated in confused etc patients that cannot follow orders.
Rectal is highly accurate but AVOID PLACING IN STOOL!
Axillary is least accurate but sometimes necessary.
Tympanic is considered a core temp.
Normal Range of Adult Body Temp
When to take vital signs?
-before and after diagnostic procedure
-before and after surgical procedure
-routinely scheduled (MD's order or hospital policy)
-patient's condition changes (inc in pain or loss of consciousness)
-before and after nursing interventions that could influence a patient's vital signs (EX: initial ambulation after bedrest)
-patient reports nonspecific symptoms of distress (feeling funny or different)
Factors that affect Body TEMP?
-hot/cold liquids
-smoking (2 degree diff)
-time of day
Factors affecting newborn TEMP?
Newborns have unstable body temp bc of an immature thermo-regulatory system and this stabilizes in Adolescence
Convert F to C and vice versa
F = (9/5 * C) + 32

C = (F - 32) * 5/9
Factors affecting Pulse
-acute pain and anxiety
-unrelieved severe and chronic pain
-fever and heat
-postural changes
-"White coat syndrome"
Normal Range for Pulse in Adults
60-100 in adults
Use Apical pulse when?
Newborns and children bc radial is too weak.
If patient has cardiac dysrhythmias, apical pulse may be more accurate (pulse deficit difference btw apical pulse and radial pulse)
Pulse sites
Temporal, carotid, apical, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
Factors affecting respirations
-body position
Normal range for respirations in Adults
12- 20
-average tidal vol of 350-500mL in adults
-inspiration to expiration ratio is 1:2
Cheyne-Stokes Respiration
-variable rate
-apneic periods alternate with hyperventilation
-depth of each breath varies in a cyclical pattern: shallow before and after apnea, deep with hyperventilation
decrescendo pattern
-rapid rate
-shallow: small tidal volume with each breath
-may be associated with CO2 retention
-regular rhythm
-I:E appraches 1:1
-complete cessation of breathing
-may be of a temp nature
-aka Central Neurogenic Hyperventilation if secondary to lower midbrain or upper pons lesions, OR Kussmaul's breathing when secondary to diabetic coma.
-rapid rate
-deep to large tidal vols
-may be asso with CO2 loss
-usually regular
-I:E approaches 1:1
Biot's Breathing (Ataxia)
-variable breathing
-apnea alternates with breathing periods
-depth variable but predominantly shallow
-unpredictable irregularity
-slow rate
-tidal vols vary depending on the cause
-I:E ration 1:2
Obstructive Breathing
-noted with obstructive pulmonary disease
-rate inc as air trapping occurs
-becomes shallower with air trapping
-longer expiratory phase
Tidal Volume
Volume of air inhaled and exhaled with each breath
Blood Pressure is?
The force that the blood exerts against the walls of the BV.

A function of the flow of blood produced by contraction of the heart and the resistance to blood flow through the vessels.
Systolic BP
the blood pressure measured during ventricular contraction (aka cardiac systole)
Diastolic BP
the BP measured during ventricular relaxation (aka cardiac diastole) and due to the elastic recoil of the vessels
Factors affecting BP?
-Circulating volume
-Normal Fluctuations
Normal BP
120/80 and ranges btw 90-140/60-90
Mean Arterial Pressure MAP
(systolic BP + 2(diastolic BP))/3
-some NPs prefer to know this vs S/D
Orthostatic Hypotension
lie to sit to stand. wait 2 mins in btw. if patient feels dizzy do not get up
vaiable: 20mmHg in Systolic BP and 10 mmHg in Diastolic BP
Pulse Oximetry
Arterial Oxygen Saturation (SaO2)
-a noninvasive means to approximate oxygenation
-machine uses infrared light to determine the percentage of hemoglobin (Hgb) that has combined with O2.
-97% of O2 in blood binds with Hgb and serves as a reserve to replenish plasma
Normal Pulse Ox
below 93 = cause for concern
below 90 = panties in a twist!
Factors affecting Pulse Ox
-adequate peripheral blood flow
-patient motion
-edema at site
-dark fingernail polish/artificial nails
-CO poisoning
-Bilirubin lamps can skew numbers