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171 Cards in this Set

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Vital signs
th measures indicate the effectiveness of circulatory, respiratory, neural and endocrine body functions
Who is responsible for vital signs
RN and the RN should know the Pts usual range of vital signs
Normal Temperature Range
36C-38C (96.8F-100.4F)
Oral temperature/Tympanic
37C (98.6F)
Rectal temperature
37.5 (99.5F)
Axillary temperature
36.5C (97.7F)
Tympanic
ear drum
Average Pulse
60-100 beats per min
REspirations
12 to 16 breaths per min
BP
average 120/80 mm Hg
Pulse pressure
30 -50 mm Hg
What must the RN do to make sure vital signs are accurate?
the RN must control or minimize environmental factors that may affect vital signs
If a PT vial signs are poor or deteriorating how often should vital signs be monitored?
They may need to be monitored every 5 to 15 min
What drugs are given to reduce fever
Antipyretics
Under which medication should the vital signs be re-cheeked?
before, during and after the administration of medication that affect cardiovascular, respiratory and temperature control functions
Body temperature =
Heat produced and Heat lost
Where are the sites to take temperature on a person
oral, rectal, axillary, tympanic membrane, esophageal, pulmonary artery, urinary bladder
Thermoregulation
the balance between heat lost and heat produced which is regulated by physiological and behavioral mechanisms
What two functions of the body help with thermoregulation
Neurological and cardiovascular mechanism
What control center in the brain regulates temperature
Hypothalamus which is located between the cerebral hemisphers
What area of the brain controls heat loss
anterior hypothalamus
What area of the brain controls heat production
posterior hypothalamus
vasodilation
widening of the blood vessels
casoconstriction
narrowing of blood vessels
Heat is produced in the body as a result of what function
Metabolism
What is basal metabolic rate (BRM)
the average heat produced by the body at absolute rest
What effects basal metabolic rate
larege amounts of thyroid hormones can increase the BMR by as much as 100%, in males sex hormone testosterone can increases the BRM,
Metabolic rate can increase by how much during exercise
2000 times heat production is increases up to 50 times
Where on the body can you take surface temperature
Skin, Oral, Axillae
Where on the body can you take core temperatures
Rectum, tympanic membrane, esophagus, pulmonary artery, urinary bladder
Shivering is what type of response
Involuntary involves skeletal muscles, can increase heat production 4 to 5 times greater than normal
How do neonates produce heat when cold?
Neonates cannot shiver so they have a small amount of vascular brown tissue, present at birth which is metabolized for heat producation
What are the 4 ways of heat loss the body can use
Radiation, conduction,, convection, and evaporation
What % of the body's surface area can transfer heat without direct contact
85% of body loss is thru radiation
How can an RN increase the radiation loss of heat of a Pt
By removing clothing or blankets
What is conduction
The transfer of heat from one object ot another with direct contact
What is convection
Transfer of heat away by air movement
How much evaporation dose the body continuously loses in a day, and from what areas of the body
600 to 900 ml, skin and lungs
In what lair of the skin are sweat glands found
Dermis
What physiological structure of the body triggers the the sweat glands to release sweat?
The anterior hypothalamus
What is diaphoresis
The visible perspiration primarily occurring on the forehead and upper thorax though it can also be seen elsewhere on the body
Skin blood flow can vary from a minimal amount to how much and what does this help with?
Increases up to 30% of the blood ejected from the heart to promote heat loss.
How much heat loss does an infant loss through he head
30%
What is important to keep in mind with an infant and a elderly person
Temperature may espond drastically to changes in teh environment
In a child temperature regulation is unstable until what age
Until the child reaches puberty
How high can the body's temperature reach in prolonged strenuous exercise
41C (105.8F)
When progesterone levels are low what does this do to temperature
Drops temperature by a few 10ths of a degree and temperature returns to normal after ovulation occurs
What are hot flashes
intermittent increase in skin temperature up to 4C (7.2F) during menopause which can last from 30 sec to 5 min
What is pyrexia
Fever
when dose pyrexia can become harmful
when the fever get above 39C (102.2F)
What are pyrogens
bacteria and viruses that cause a rise in body temperature, A pyrogen can either be an endotoxin or an exotoxin, although most pyrogens are endogenous.
What can happen when a person temperature is rising and a new set point has not been reached
chills, shivers, and can feel cold until set point is reached
What happen is a set point in temperature is overshot by the body?
drop in temp, diaphoresis can occur
What is afebrile
then a fever breaks, pt has no fever
what is a febrile episode
three phases of a fever,
raising pt has cillis,shivers, feels cold,
plateau - hits set point
afebrile
what is good about a pyrexia
enhance the body's immune sytem. reduces the concentration of iron in the blood plasma suprressing the growth of bactera, in viral infections helps by stimulating interferons
Patterns of pyrexia
sustained - temp above 38C (100.4F)

intermittent - ferver spikes interspersed with unsual temps goes to normal once every 24 hr

remittent - fever spikes and falls without a return to normal temp level
relapsing
periods of febrile episodes interspresed iwth accepatble temps, febrile episodes and periods of normothermia may be longer than 24 hr
Fever of unknown orgiin (FUO)
refers to a fever whose etiology (cause) cannot be determined
how high does the temperature of the body change during metabolism
13% increass for every degree C
cellular hypoxia
inadequate oxygen
what type of pain does myocardial hypoxia produced
Angina (chest pain)
what does cerebral hypoxia cause
confusion
hyperthermia
elevated body temperature related to the body's inability to promote heat loss or reduce heart production
malignant hyperthermia
is a hereditary condition of uncontrolled heat production occurring when susceptible persons receive certain anesthetic drugs
Heatstroke signs and symptoms
heat emergency with a high mortality rate - giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence - victuims of heatstroke do not sweat because of severe electrolyte loss body temp can be as high as 45C (113F) with an increase heart rate and low BP - pt can become unconscious w/ fixed unreactive pupils
Classification of hypothermia
Mild - 34C-36C (93.2F-96.8F)
Moderate - 30C-34C (86F-93.2F)
Severe <30C (86F)
Heat Exhaustion signs and symptoms
Occurs when profuse diaphoresis results in excess water and electrolyte loss.
Hypothermia signs and sysmptoms
drop in body core temp - uncontrolled shivering, loss of memory, depression , and poor judgment, as it progresses, cardiac dysrhythmias, loss of consciousness, unresponsiveness to painful stimuli, can show signs of clinical death
Frostbite signs and symptoms
body is exposed to subnormal temp - ice crystals froms
Convert Celsius to Fahrenheit
C = (F-32) X 5/9

F = (9/5 X C) + 32
Red tip thermometer is for
Rectal temp
In children most pyrexia are caused by
viral origin
When are febrile seizures most common in children?
when a child has a temp above 38.8C (101.9F) is dehydrated, and between the ages of 6 mo and 3 yrs
what do antipyretics do
Drugs that reduce pyrexia
What do corticosteroids do?
They are steroids that reduce heat production by interfering with the immune system and can mask signs of infection and should not be used to treat a fever
What are the benefits of nonpharmacological therapy for pyrexia
They should be avoided because they lead to shivering and have NOT demonstrated an advantage over antipyretic medications
What is something a RN should be keep in mind when cooling a person with a fever
Avoid the Pt from shivering, shivering can increase the energy expenditure up to 400% creating heat production
What should be done with a person with hypothermia
Prevent further decrease in body temp, if conscious give hot liquids while avoiding alcohol and caffeinated fluids
What is the educational responsibility of the RN to client in a febrile case
Stress the importance of taking and continuing any Abx as directed until the course of treatment is completed. In children and older adults are at risk for fluid volume deficit because they can quickly lose large amounts of fluids in proportion to their body weight
How do you determine cardiac output
Pulse rate X Stroke volume = Cardiac output in L/min
What is cardiac output
the volume of blood pumped by the heart during 1 min
What stimulates the cardiac contraction
Sinoatral node (SA)
How much blood enters the aorta with each ventricular contraction
60ml to 70 ml of blood enters the aorta
What us the normal amount of blood that is pumped thru the heart every min
5000 ml of blood per min
where are the best locations for take the pulse on an infant or young child
brachial or apical pulse sites
What are the locations where you can take a pulse on a person? (p. 638)
Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Femoral
Popliteal
Posterior tibial
Doralis pedis
What can factors can change a Pts pulse rate
Exercise
Temperature
Emotions
Drugs
Hemorrhage
Postural changes
Pulmonary conditions
What part of the heart sound makes a lub sound
S1
What part of the heart sounds makes the dub sound
S2
Tachycardia is
an abnormally elevated heart rate above 100 beats per minute in an adult
Bradycardia is
a slow rate below 60 beats per minute in adults
What is a pulse deficit
an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse sites
What is dysrhythmia
An interval interrupted by an early or late beat or missed beat
What is true about children and dysrhythmia?
It is common for a child to have irregular heartbeat that speeds up with inspiration and slow down with expiration
What are some of the diagnoses from tachycardia, bradycardia, and dysrhythmias
activity intolerance, anxiety, decreased cardiac output, fear, deficient/excess fluid volume, impaired gas exchange, hyperthermia, hypothermia, acute pain, ineffective tissue perfusion
What is the definition of ventilation
The movement of gases in and out of the lungs
What is diffusion in relation to respiration
the movement of oxygen and carbon dioxide between the alveoli and the read blood cells
What is perfusion in relation to respiration
The distribution of red blood cells t to and from the pulmonary capillaries
Respiration in adults is usually a what type of physiological control
Respiration is a passive process
Acceptable rage for respiration rate by age are?
Newborn 30 - 60 breaths per min
Infant (6 mo) 30 - 50
Toddler (2 yr) 25 - 32
Child 20 - 30
Adolescent 16 - 19
Adult 12 -20
What regulates ventilations
The levels of CO2, O2, and hydrogen ion concentration (pH) in the arterial blood
What is hypercarbia
excess CO2
what is Hypoxemia
Low levels or arterial O2
what is a normal tidal volume of an adult and the amount of movement of the body during inhales
500 ml of air, diaphragm moves approximately 1 cm (4/10 in) and the ribs retract upward from the body's midline approximately 1.2 - 2.5 cm (1/2 in - 1 in)
What is eupnea?
normal, unlaboured ventilation, sometimes known as quiet breathing or resting respiration
What device aids RN in assessment of respiratory
Apena monitor
What is the difference between Men/children vs women breathing
Men and children tend to demonstrate diaphragmatic breathing where as women ten to use thoracic muscles to breathe
What are normal Arterial blood gases level (ABGs?
pH 7.35 - 7.45
PaCO2 35 - 45
PaO2 80 - 100
SaO2 95% - 100% (Saturation of hemoglobin)
What are normal Complete blood count (CBC)
Hemoglobin 14 - 18 g/100 male
12 - 16 females
Heatocrit 40% - 54% males
38% - 47%
Red blood cell count
4.7 -6.1 million/ ml males
4.2 - 5.4 females
How do you determine respiratory rate?
if rhythm is regular count number of respirations in 30 sec and multiply by 2, if rhythm is irregular less than 12 or grater than 20 count for one full min
What is a normal Saturation of venouse blood (SvO2)
is 70% becuase tissues have removed some of the oxygen from the hemoglobin
What are the different types of alterations in breathing patterns? (p. 650)
bradypnea
Tachypnea
Hyperpnea
Apena
Hyperventilation
Hypoventilation
Cheyne-Stokes respiration
Kussmaul's respiration
Biot's respiration
What are some of the signs of Tachypnea
changes in depth of respiration, use of accessory mucles, cyanosis, and decline in SpO2
Blood pressure is defined as
the force exerted on the walls of an artery by the pulsing blood under pressure from the heart
that does BP a good indicator for?
Cardiovascular health
What is systolic pressure
the peak of maximum pressure when ejection occurs
What is diastolic pressure
When the ventricles relax and teh blood remaining int eh arteries exerts a minimum pressure
How do you record BP
Systolic over diastolic
What is the difference between systolic and diastolic pressure
pulse pressure
What is Cardiac output (CO)
volume of blood pumped by the heart (SV) during 1 minute (HR)

CO = HR X SV

BP depends on cardiac output and peripheral vascular resistance (R)
BP = CO X R
What can increase cardiac output
increase in hart rate, greater heart muscle contractility, or increase in blood volume
What must be watched in administrating IV fluids to a patient
the rapid uncontrolled infusion of IV fluids can elevate BP
what is Viscosity
the thickness of a fluid
What is hematocrit
the percentage of red blood cells in the blood
What happens if a patient has a high hematocrit?
Blood flows slower, and arterial blood pressure increases
What happens with reduced arterial elasticity
Vessels walls lose their elasticity and are replaced by fibrous tissue that cannot stretch, sytemic pressure rises, systolic pressure is more significantly elevated than diastolic prssure
Average BP by age
Newborn (3000g {6.6 lbs}) 40 mean
1 mo 85 / 54
1 yr 95 / 54
6 yr 105 / 65
10 - 13 yr 110 / 65
14 - 17 yr 120 /75
> 18 yrs <120 / 80
What are the factors to take into consideration when taking BP
Age, Stress, ethinity, Gender, Diuranl variation, Medications, Exercise
What is true about BP and males
after puberty males tend to have higher BO readings, Females tend to have high BP after menopause of men the same age
What is hypertension?
asymptomatic disorder characterized by persistently elevated BP ( one elevated BP is not enough diagnosis)
What are some life styles choices that increase the risk of hypertension?
obesity, cigarette smoking, heavy alcohol consumption, high sodium intake, sedentary lifesytlye, continued exposure to stress
Classification of BP for adults
Normal <120 / <80
Pre-hypertension
120-139 (OR)/ 80-89
stage 1 hypertension
140-159 (OR)/ 90-99
Stage 2 hypertension
>160 (OR)/ >100
What are some Antihypertension Rx (p. 656)
Diuretics
Beta-adrenegic blockers
Vsodilators
Calcium Channel blockers
Angiotensin - converting enzyme (ACE) inhibitors
what is a myocardial infraction
heart attack
Hypotension
present when the systolic blood pressure falls to 90 mm Hg or blow
When does hypotension occur
from hemorrhage, or myocardail infarction
othostatic hypotesnion or postural hypotension
occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position
when is invasive blood pressure monitoring used
In the ICU it is used to monitor BP
what is used to measure BP
Sphygomoanometer
what is the ideal size of BP cuff
should be 40% of teh circumference the midepoint of the limb on which the cuff is to be used, on an adult encircle at least 80% of the arm and the entire arm of a child
What is the difference between arms in BP
5 to 10 mm Hg
What are Korotkoff sounds
clear rhythmical tapping corresponding to the pulse rate that gradually increases in intenisty
the first Korotkoff sound is
the systolic pressure
In Adolescents and adults the fifth Korotkoff sound is the
Diastolic pressure
what is the auscultatory gap
The period during which Korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point; responsible for errors made in recording falsely low systolic blood pressure, especially in hypertensive patients, of up to 25 mm hg, and avoided by pumping the cuff 30 mm hg beyond palpable systolic pressure.
Under what conditions are not appropriate for electronic BP measurements
Irregular heart rate, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, BP less than 90 mm Hg systolic
Vital signs include all of the flowing
Temperature, pulse, blood pressure, respiration , and oxygen saturation
which two temperature sites will provide a core temperature measurement?
Typanic
Recal
A mother brings her infant son to the pediatric clinic and states she has been obtaining his temperature using a chemical strip attached to his leg. She is concerned that his temperature is 97.8 deg C. What is your priority nursing action?
Obtain a temperature using a tympanic thermometer on the infant.
a postoperative client complains of fatigue, dizziness, and feeling warm. You delegate vital signs to the nursing assistant, who reports a temperature of 102.3 deg F. and a heart rate of 124. What is (are) your priority nursing action(s)?
remove extra clothing and bed covers, and evaluate the client's complaints.
In delegating a pulse rate you inform the nursing assistant that a 60 sec count is required. what condition would cause you to make this request?
irregular rate
a young football player is admitted to your unit with an IV in the right hand and teh left arm splinted to his chest following surgery for a broken left collar bone. You assess the left radial pulse and note it is weak and thready. What is you priority nursing intervention?
Assess right radial pulse for symmetry
An older adult will be discharged soon after a myocardial infraction. You will be teaching him to take his own pulse rate. Which artery will he be palpating?
carotid
In which situation can the assessment of the apical pulse be delegated to a nursing assistant?
during routine vital sign measurments
Which of the following activities will decrease heart rate?
sleeping
why is the point of maximal impulse (PMI) used during apical heart rate assessment?
it reflects the cardiac apex
vital signs are obtained by the nursing assistant from a known hypertensive client. BP is 145/84 mm Hg redial pulse is 88 beats per min, apical pulse is 80 beats per min, tympanic temp is 97.8 deg F, and respiratory rate is 16 breaths per min. What is your priority nursing action?
ask the nursing assistant for help in obtaining apical-radial pulse
One cause of decreased respiratory rate is?
narcotic analgesics
What effect does increased age have on respiratory assessment?
decreased in chest expansion
A hypertensive client has a blood pressure of 164/92mm Hg. what is the pulse pressure?
72
What is the effect of a blood pressure cuff that is too small for a client's arm?
produces false high systolic pressure
When completing an assessment, the client is nervously talking while the blood pressure is the nursing action?
repeat the blood pressure measurement again at the end of the assessment after the client has been resting quietly.
what are the 5 vital signs
Temperature
Pulse
Respiration
blood pressure
pain
Where are core temp taken
rectum
tempanic
esophagus
pulmonary artery
urinary bladder
Surface tem
oral
skin
aunder axilla
Body temperature is what
Heat produced - heat loss
what are the 5 ethics
autonomy
beneficence
nonmaleficence
justic
fidelity
what are bioethics
deontology
actions are right or wrong


utilitarianism
valuse of something is determined by its usefulness - emphasis on outcome
What is assault vs battery
assault - treat to touch
battery - violance is acted out
Nurse practice act
regulatory law
describe and define the legal boundaries of RN practe with in a stae