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29 Cards in this Set
- Front
- Back
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Two types of body temp (2) |
core temp- the temp of the deep tissues of the body surface temp- temp of skin, subcutaneous tissue, fat |
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Factors effecting body heat production(5) |
Basal metabolic rate- BMR, of energy utilization in body required to maintain essential activities muscle activity, including shivering thyroxine production- increased thyroxine output increases rate of cellular metabolism throughout body. epinephrine, norepinephrine, sympathetic stimulation/ stress response- these hormones immediately increase the rate of cellular metabolism in many body tissues fever- fever increases the cellular rate and thus increases the bodies temperature further. |
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mechanisms by which heat is lost from the body (4) |
radiation- transfer of heat from surface of one object to another, without contact between objects conduction- heat from one molecule to a molecule of lower temp convection- dispersion of heat by air currents evaporation- continuous vaporization of moisture from mouth and skin. water lost in this manner is called insensible water loss. heat lost in this way is insensible heat loss. accounts for 10% of heat loss. |
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regulation of body temp |
sensors for heat and cold all over skin. when skin becomes chilled: shivering increases to produce heat, sweating in inhibited to decrease heat loss, constriction decreases heat loss. the warmth/cold receptors stimulate the hypothalamic integrator in the hypothalamus (brain) which controls body temp. |
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factors effecting body temp (6) |
age- infants can't control body temp well, childrens temps vary more than adults, older adults at risk for hypothermia diurnal variations( circadian rhythms)- body temp varies during day exercise- hard work or exercise can increase body temp hormones- female hormones can raise body temp stress- stress causes the release of epinephrine which increases metabolic activity and heat production environment- environment temp effects people |
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alterations in body temp |
pyrexia(fever)- body temp above normal hyperpyrexia- fever above 105 febrile- has a fever afebrile- no fever |
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elevated temp but no fever |
heat exhaustion- a result of excessive heat and dehydration, signs include paleness, dizziness, nausia, fainting heat stroke- usually have been exercising in hot weather, temp over 106, deleterious, unconscious, or having seizures. |
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hypothermia |
is core body temp below lower limit of normal. 3 physiological mechanisms: excessive heat loss, inadequate heat production to counteract loss, impaired hypothalamic regulation 2 types- induced, to lower need for oxygen during surgery, accidental, managing hypothermia includes warming body, warm blankets, warm fluids, remove wet clothing. |
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assessing body temp |
orally- (accessible and convenient) client must not have been drinking liquid or smoking rectal- accurate, unpleasant axillia- safe and non-invasive, temp usually lower than rectal readings, could be inaccurate tympanic membrane- (ear)fast, reflects core temp, could be impracise temporal artery- forehead, fast, good for infants, requires special temporal thermometer. |
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types of thermometers(6) |
mercury in glass- unsafe, dispose of if seen electronic- fast chemical disposable- like a tape you put on forehead, tells temp like a mood ring does, forehead infrared- sense body heat given off without touching skin of inner ear temporal artery- uses a scanning infrared thermometer to approximate core body temp by scanning forehead. |
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temperature scales |
c=(f - 32) x 5/9 f= (c x 9/5) + 32 |
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assessing body temp |
put cover over thermometer is appropriate, wait appropriate amount of time, wash thermometer and return to container. newborns temp is fragile and they must be kept warm, children- ear is preferred older adults tend to have lower body temp, temp may not be an accurate reading of whether on not they have a problem. |
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pulse |
pulse- is a wave of blood created by contraction of the left ventricle of the heart. compliance- ability of arteries to contact and expand. cardiac output- is the volume of blood pumped into the arteries by the heart. = stroke volume x heart rate per minute ex: 65ml x 70 bpm = 4.55L peripheral pulse- a pulse located away from the heart, ex: foot or wrist Apical pulse- ( point of maximal impulse) a pulse at the apex of the heart, |
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Factors affecting the pulse |
pulse measured in beats per minute BPM age- as age increases pulse rate gradually decreases sex- after puberty females pulse slightly higher exercise- pulse increases with activity fever- pulse rate increases in response to lowered blood pressure that results from periphery vasodilation associated with elevated body temp, because of increased metabolic rate. medications- can lower or elevate pulse hypovolemia/ dehydration- loss of blood from vascular system increases pulse rate stress- increases activity of heart position- sitting or standing effects how blood pools, pooled blood results in decrease in venous blood return and increased heart rate pathology- certain diseases |
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a pulse may be measured in 9 sites |
temporal - beside eyes carotid- side of neck apical- over heart brachial- inner biceps above inner elbow. radial- wrist , most common in adults femoral- side of groin popliteal- back of calf under knee posterior tibial- inner side of ankle pedal- top of foot |
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assessing the pulse |
a pulse in commonly assessed by palpation ( feeling), auscultation ( hearing) or DUS doppler ultrasound stethoscope. use 3 middle fingers when assessing the pulse a nurse collects: rate, rhythm, volume, arterial wall elasticity, presence of absence of bilateral equality. tachycardia- a heart rate in an adult of over 100 bmp. bradycardia- a heart rate in an adult of less than 60 bpm pulse rhythm-regularity of the beats irregular beat is dysrhythmia or arrhythmia. pulse volume is called, pulse strength or amplitude, force of blood with each beat. a forceful pulse that can only be obliterated ( when using finger to take pulse) is called full or bounding weak / feeble readily obliterated when taking periphery pulse to see blood flow on that part of body take both sides. |
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taking a pulse |
peripheral pulse- relax client, arm at 90 degrees, palpate and count for 15 second then multiply by four. apical- two fingers over the heart lifespan- apical for newborns, peripheral for children, older adults may have tremors or weak pulse |
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respiration |
inhalation- intake of air into lungs exhalation- breathing out ventilation- movement of air in and out of the lungs costal breathing- chest up and down diaphragmatic- abdominal breathing Mechanics of inhalation- diaphragm contracts(flattens), ribs move upwards and outwards,lungs expand exhalation- diaphragm relaxes, ribs move down and in, lungs compressed respiration controlled by respiratory center in the medulla, and chemo receptors in the medulla, carotid and aortic bodies, measuring O2 in blood. |
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assessing respiration |
eupnea- breathing normal in rate and depth bradypnea- abnormally slow tachypnea- abnormally fast Apnea- absence of breathing respiratory depth-normal 500ml of air, deep or shallow, categorized by volume of air exchanged and lung tissue used, tidal volume- volume of air exchanged in a breath hyperventilation- deep rapid breaths hypoventilation- very shallow breaths respiratory rhythm- regularity of in and out breaths respiratory quality- any non normal, amount of effort used to breath, or sound produced, ect labored breathing- requires substantial effort to breath. pulse oximetry- measures pulse rate and O2 in blood |
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p 558 box 29-5 p 559 box 29-5 p 560 lifespan considerations p564 box 29-6 p 564 box 29-5 565-566 skill 567 both boxes 569-570 O2 saturation |
read this stuff |
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Blood pressure |
arterial blood pressure- pressure exerted by blood as it flows through the arteries systolic- pressure of blood as a result of contraction of ventricles diastolic- pressure when ventricles are at rest pulse pressure- difference between diastolic and systolic pressures. pulse pressure is recorded in mmhg ( millimeteres of mercury) and recorded as fractions systolic over diastolic 120/80 |
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Determinants of blood pressure |
pumping action of heart- weak pumping action = less blood pumped into arteries = low BP, strong is opposite peripheral vascular resistance- resistance of blood in arterial system, can be effected by blood viscosity, ect blood volume- blood volume down = blood pressure decreases, blood volume up = BP up ex; dehydrated, blood infusion blood viscosity- Bp is high when blood viscosity is high, viscosity high when blood plasma high hematocrit- proportion of red blood cells to plasma, viscosity high when more than 60-65% |
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Factors affecting blood pressure |
age- from birth to puberty BP increases, then declines among older adults exercise- physical activity increases cardiac output and thus BP stress- increases BP race- African Americans over 35 have higher BP sex- after puberty males have higher BP than females medications- can increase or decrease BP obesity- can cause high BP diurnal variations- BP lowest in morning along with metabolic rate then rises to peak in late afternoon medical conditions- any condition affecting cardiac system can affect BP temperature- fever can increase BP. heat causes vasodilation and decreased BP. cold causes vasoconstiction and increased BP |
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Hypertension |
Hypertension- BP persistently above normal primary hypertension- cause of high BP is unknown secondary hypertension- cause of high BP is known diastolic 80-89 systolic 120-139 are hypertensive and w/o medication could develop cardiac disease. factors include- smoking, drinking, obesity, lack of exercise follow up care- lifestyle changes and monitoring BP |
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Hypotension |
Hypotension- BP below normal orthostatic hypotension- (postural) BP falls when client sits or stands b/c blood leaves centeral organs and moves to limbs, causing client to feel feint. Hypotension can be caused by; medicine, bleeding, severe burns, and dehydration when assessing orthostatic hypotension have client- have client lay down, record pulse and BP, help client get up, record pulse and BP, a rise in pule of 15 to 30 bpm or a drop in BP 20 mmhg systolic or 10 mmgh diastolic indicates orthostatic hypotension |
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assessing blood pressure |
sphygmomanometer- a blood pressure cuff aneroid- old style BP measuring tool with cuff and dial digital- digital BP measuring tool doppler ultrasound stethoscopes- used when BP is hard to measure, like an infant blood pressure cuffs come in many sizes b/c it needs to fit arm of patient correctly or measurement will be off width of band should be 40% of arm circumfrence see pg- 563 top cuff too narrow- BP erroneously high cuff too wide- BP erroneously low length of bladder- long enough to cover 2/3 of limbs circumference usually assessed on arm but can also be assessed on thigh if arm injured |
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factors affecting O2 saturation readings |
Hemoglobin- If hemoglobin 02 is high spO2 will appear high even if total hemoglobin level is low, client would be anemic but reading normal circulation- if area has impaired circulation reading will be incorrect. activity- shivering or movement will mess up reading carbon monoxide poisoning- pulse oximeters cannot distinguish between O2 in blood and other gasses. |
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Blood pressure methods |
Direct- by inserting a catheter into an artery auscultatory- pressure is applied using a sphygmomanometer and nurse listens for korotkoff's sounds with a stethoscope palpatory- by touch |
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oxygen saturation- |
pulse oximeter measures oxygen saturation- SaO2 hypoxemia- low O2 saturation SpO2- measure of oxygenation of hemoglobin in peripheral arterial blood |
