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175 Cards in this Set
- Front
- Back
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What is the formula to change Celsius to Fahrenheit?
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C=(F-32)x(5/9)
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What is the formula to change Fahrenheit to Celsius?
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F=[(9/5)xC]+32
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What is the normal range for temperature?
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36-38 C
96.8-100.4 F |
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What is the average oral temp?
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37 C
98.6 F |
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What is the average rectal temp?
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37.5 C
99.5 F |
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What is the average axillary temp?
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36.4 C
97.7 F |
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What is the range for pulse?
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60-100 beats per minute
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What is the range for respirations?
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12-20 breathes a minute
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What is the average for blood pressure?
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< 120/80
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What is the range for pulse pressure?
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30-50 mmHg
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When a client reports he/she is feeling "funny" or "different," what should you do?
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take vitals
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When a client's condition is worsening, the nurse should the vitals signs every...
A. shift B. two hours C. 10-15 minutes D. 5-10 minutes |
D. 5-10 minutes
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When a client's condition is worsening, the nurse should the vitals signs every...
A. two hours B. 5-10 minutes C. shift D. 10-15 minutes |
B. 5-10 minutes
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Core temperature
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temperature of the deep tissues
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What part of the brain controls temperature?
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hypothalamus
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To release heat do you VC or VD?
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VD
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To conserve heat do you VD or VC?
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VC
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If you have hypothyroidism are you cold or warm?
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cold
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If you have hyperthyroidism are you cold or warm?
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warm
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Radiation
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transfer of heat from the surface of one object to the surface of another without direct contact between the two
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Conduction
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transfer of heat from one object to another with direct contact
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Convection
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transfer of heat away by air movement
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Evaporation
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transfer of heat energy when a liquid is changed to a gas
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Diaphoresis
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visible perspiration
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The ability to control body temperature depends on what 4 factors?
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1. Degree of temperature extreme
2. Client's ability to sense discomfort 3. Thought process and emotions 4. Mobility or ability to add or remove clothes |
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When is temperature the lowest?
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1-4 am
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When is temperature the highest?
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6 pm
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Hyperpyrexia
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fever
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What is the temperature that enhances the immune system?
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102.2 F
39 C |
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Pyrogen
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toxins given off by bacteria that raise temperature
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Sustained fever
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a constant body temperature continuously above 100.4 that has little fluctuation
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Intermittent fever
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fever spikes interspersed with usual temperature levels. Temperature returns to acceptable value at least once in 24 hours
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Remittent fever
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fever spikes and falls without a return to normal temperature levels
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Relapsing fever
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periods of febrile episodes adn periods with acceptable temperature values. Febrile episodes and periods of normothermia are often longer than 24 hours
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With a FUO what should you expect to be done?
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CBC, urinalysis, culture, chest x-ray, antibiotics
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With a FUO what cultures will be done?
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blood, urine, sputum, throat, wound
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With a FUO when should the antibiotic be given?
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after the culture
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What three ways of taking temperature takes the surface temperature?
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skin, oral, axillae
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What is the range for pyrexia?
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anything above 101 F
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What is the range for hyperthermia?
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anything above 104.2 F
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What is the range of hypothermia?
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anything below 96.8
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Malignant hyperthermia?
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hereditary condition of uncontrolled heat production, occurring when susceptible person receive certain anesthetic drugs
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What is the difference between delirium and dementia?
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delirium is a quick onset
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During a heat stroke, how does the skin appear?
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hot and dry
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What is the temperature range for heat stroke?
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105-113 F
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What are signs and symptoms of heat stroke?
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giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence, tachycardia, hypotension,
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What are the classifications of hypothermia and the respective ranges?
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Mild: 96.8-93.2 F
Moderate: 93.2-86.0 F Severe: <86.0 F |
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What does frostbite look like?
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white, waxy, firm to the touch --> tissue necrosis
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What is the treatment for frostbite?
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gradual increase of water
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When would you be concerned with a pulmonary artery temperature?
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during a surgery concerned with volume
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When would you be concerned with an esophageal temperature?
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with a surgery that isn't concerned with fluid volume
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If someone is eating ice and you want to take their oral temperature, how long do you wait?
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20 minutes
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How much fluid should you give to a person with renal and cardiac function with a fever?
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3 l/day
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What temp should the room be for a person with a fever?
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70-80 F
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What do you do to treat a fever caused by a drug?
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withdraw the drug
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What is the stroke volume
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60-70 ml/stroke
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What is the amount for cardiac output?
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5,000 ml pumped in 1 min
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If a patient's condition is worsening do you take the radial or carotid pulse? Why?
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radial - you may miss the beat if it's premature if you take the carotid
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When do you use a temporal pulse?
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children
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When do you use a carotid pulse?
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physiological shock or cardiac arrest when other site are not palpable
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Why do you use a brachial pulse?
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to assess circulation to lower arm
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Why do you use a radial pulse?
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to assess character of pulse peripherally and assess circulation to hand.
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Why do ou use an ulnar pulse?
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assess circulation to hang and Allen's test
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Why do you use a femoral pulse?
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assess character of pulse during physiological shock or cardiac arrest when other aren't palpable, also to assess circulation to the leg
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Who shouldn't have an oral temp done?
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people with oral surgery, trauma, history or epilepsy, shaking chills, infants, small children, confused people, unconscious, and mouth breathers
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Who is typmanic temps done for?
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client with tachypnea and newborns
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Who is a tympanic temp not for?
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client's with surgery of ear
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What is the temp that reflect rapid core temp change?
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oral and temporal
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Who is a rectal temp not used for?
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client's with diarrhea, client with rectal surgery, rectal disorders, or bleeding tendencies not for routine vital signs in newborns
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Who is an axillary temp used for?
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newborns and unconscious people
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Who is a skin temp used for?
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neonates
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Who is a skin temp not used for?
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clients with allergies to adhesive and clients with diaphoresis
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who is a temporal temp used for?
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premature infants, newborns,and children
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Who is a temporal temp not used for?
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people with diaphoresis
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Do you give people with acute fevers ice/alcohol baths? why?
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no, promotes shivering and no more effective than meds
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When doing a blood culture for a fever when do you do it?
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during a fever
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When treating a fever, what do you do about covering?
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reduce coverings, keep dry, don't allow shivering
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Why do you use a popliteal pulse?
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assess status of circulation to lower leg
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Why do you use posterior tibial pulse?
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assess circulation to foot
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What do you use dorsalis pedis pulse?
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assess circulation to foot
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What is the difference between an echo and an ekg?
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EKG- looks at the electrical impulses of the heart
Echo - takes an ultrasound picture of the heart |
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concerning exercise, what increases and decreases pulse rate?
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increase - short term
decrease - long term/conditioning |
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Concerning temp, what increases and decreases pulse rate?
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increase - fever and heat
decreases - hypothermia |
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Concerning emotions, what increases/decreases pulse rate?
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increase - actute pain, anxiety
decrease - unrelieved sever pain |
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Does acute pain affect sympathetic or parasympathetic?
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sympathetic
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Does chronic pain affect sympathetic or parasympathetic?
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parasympathetic
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Concerning drugs, what increases/decreases pulse rate?
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increases - positive chronotropics (ephredrine)
decreases - negative chronotropics (digitalis, beta - adrenergic, Ca channel blockers) |
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Does hemmorage stimulate sympathetic or parasympathetic?
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sympathetic
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Does hemmorging increase of decrease pulse rate?
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increase
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Does standing, sitting, lying down increase/decrease pulse rate?
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increases - standing and sitting
decrease - lying down |
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Do pulmonary conditions increase or decrease pulse rate?
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increase - poor oxygenation ones (asthma, COPD)
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At the top of the heart, which is louder lub or dub?
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dub
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At the bottom of the heart, which is louder lub or dub?
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lub
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Tachycardia
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pulse > 100
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Bradycardia
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pulse < 60
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EKG
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test electrical conduction of heart
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What is the ejection fraction of an echo?
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55-75%
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Why can high levels of O2 be fatal in people with hypercarbia?
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Because the brain will be tricked into thinking that people don't need to breath because there is already sufficient oxygen
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What nerve controls the diaphragm?
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phrenic
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What is the amount of the tidal volume?
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500 ml
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Bradypnea
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rate of breathing is regular but abnormally slow <12 breathes/min
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Tachypnea
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rate of breathing is regular but abnormally rapid > 20 breathes/min
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Hyperpnea
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respirations are labored, increased in depth, and increased in rate > 20 breaths/min, happens normally during exercise
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Apnea
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respirations cease for several seconds. Persistent cessation results in respiratory arrest
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Hyperventilation
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rate and depth or respirations increase. Hypocarbia sometimes occurs
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Hypoventilation
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respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs
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Cheyne-Stoke respiration
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respiratory cycle begins with slow, shallow breaths taht gradually increased to abnormal rate and depth. The pattern revers, breathing slows and becomes shallow, climaxing in apnea before respiration resumes
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Kussmaul's respiration
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respirations are abnormally deep, regular, adn increased in rate
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Biot's respiration
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respirations are abnormally shallow for two to three breaths followed by irregular period of apnea
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If a patient has an outward flow obstruction, is inspiration or expiration longer?
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expiration
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Perfusion
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blood going to air sac from artery
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Diffusion
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air being exchanged
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What does exercise do to the character of respirations?
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exercise increases rate and depth
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What does acute pain do to the character of respirations?
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breathing becomes shallow, client splints chest wall movement when pain is in that area
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What does anxiety do to the character of respirations?
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increases respirations rate and depth (sympathetic stimulation)
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What does smoking do to the character of respirations?
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increased rate of respirations at rest when not smoking
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What does body position do to the character of respirations?
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erect promotes full chest expansion
stoop position impairs ventilatory movement lying flat prevents full chest expansion |
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Which medications increase rate and depth of respirations?
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Amphetamines and cocaine sometimes
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What effect does neurological injury have on the character of respirations?
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injury to the brain stem impairs the respiratory center and inhibits respiratory rate and rhythm
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What is the percentage of O2 that should be in the veins?
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70%
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Which medications decrease rate and depth of respirations?
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Opoid analgesics general anesthetics and sedative hypnotics, bronchodialators
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Does increased altitude increase or decrease respirations?
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increases
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How do you figure the pulse pressure?
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systolic - diastolic
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How do you figure the ranges for hypertensions?
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systolic is broken up into 20 mmHg increments
diastolic is broken up into 10 mmHg increments |
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How much blood do we have in our body at a time?
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5,000 ml
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What ethnicity is at higher risk for hypertension?
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African Americans
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What is the action of diuretics?
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lower bp by reducing reabsorption of Na and H2O
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What is the action of beta - adrenergic blockers?
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block response to sympathetic nerve impulses; reduce heart rate and cardiac output
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What is the action of vasodilators?
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act on arteriolar smooth muscle to cause relaxation and reduce peripheral vascular resistance
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What is the action of antiotensin-converging enzyme (ACE) inhibitors?
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lowers bp by reducing aldosterone production and fluid retention
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What is the action of angiotensin II receptor blockers?
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lowers bp and blocks binding of angiotensin II which prevents vasoconstriction
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What medications are names of diuretics?
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furosemid, spironolactone, metolazone, polythiazide, benzthiazide
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What medications are names of beta adrenergic blockers
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atenolol, nadolol, timolol maleate, propranolol
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What are names of vasodilators?
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hydralazine hydrocholride, minoxidil
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What are names of calcium channel blockers?
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DITIAZEM, VERAPAMIL HYDROCHOLIDE, NICARDIPINE,
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What are names of ACE inhibitors?
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captopril, enalapril, lisinopril
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What are names of angiotensin II receptor blockers?
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losartan, olmesartan
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When is bp the lowest?
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12-3 am
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When is bp the highest?
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10am-6pm
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When are men's bps higher?
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after puberty
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When are women's bps higher?
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after menopause
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When can someone be described as hypotensive?
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systolic <90
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When does bp get so low that you knock off kidneys?
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< 70 systolic
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Can you delegate an orthostatic bp?
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nope
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What are some signs and symptoms of hypotension?
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pallor, skin mottling, clamminess, confusion, increased heart rate, decreased urine output
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If the bladder of the cuff is too wide what is the effect on bp?
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false low reading
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If the bladder or cuff is too narrow or too short what is the effect on the bp?
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false high reading
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If the cuff is wrapped too loosely of unevenly what is the effect on the bp?
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false high reading
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If deflating cuff too slowly what is the effect on the bp?
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false high diastolic reading
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If deflating cuff too quickly what is the effect on the bp?
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false low systolic and false high diastolic reading
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If the arm is below the heart level what is the effect on bp?
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false high reading
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If the arm is above the heart level what is the effect on bp?
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false low reading
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If the arm is not supported what is the effect on bp?
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false high reading
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If the stethoscope that fits poorly of impairment of the examiner's hearing, causing sounds to be muffled
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false low systolic and false high diastolic reading
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If stethoscope applied too firmly against antecubital fossa, what is the effect on bp?
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false low diastolic reading
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If the examiner inflates the bp cuff too slowly what is the effect on bp?
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false high diastolic reading
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If the examiner is repeating assessments too quickly what is the effect on bp?
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false high systolic reading
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If there is an inadequate inflation level, what is the effect on bp?
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false low systolic reading
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If there are multiple examiners using different korotkoff sounds for diastolic readings, what is the effect on bp?
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false high systolic and false low diastolic reading
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What is the difference between bp in the lower extremities and upper extremities?
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lower has 10-40 mm Hg higher systolic
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If on fat people you use too small a cuff what will happen to the reading?
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too high
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What is nociceptive pain?
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normal - responsive to opiods
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Whatt is neuropathic pain?
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abnormal - treatment is adjuvant analgesics
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Substance P
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causes VD and edema - transmits pain impulses from periphery to higher brain centers
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Serotonin
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released from brain stem and inhibits pain transmission
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Prostaglandins
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increases sensitivity to pain
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Bradykinin
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released from plamsa, increases pain, makes prostaglandins
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What are the excitatory neurotransmitters?
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substance p, serotonin, prostaglandins, bradykinin
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What activates inhibitory neurotransmitters?
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stress and pain
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somatic pain
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comes from bone, join, muscle, skin, or connective tissue (achy or throbbing)
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visceral pain
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arises from visceral organs, such as the GI tract and pancreas
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What are the parts of nociceptive pain?
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somatic and visceral
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Is severe pain parasympathetic or sympathetic?
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parasympathetic
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Endogenous opiates
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what the body releases
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How long does acute pain last?
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less than 6 months
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