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171 Cards in this Set
- Front
- Back
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Vital signs
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th measures indicate the effectiveness of circulatory, respiratory, neural and endocrine body functions
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Who is responsible for vital signs
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RN and the RN should know the Pts usual range of vital signs
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Normal Temperature Range
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36C-38C (96.8F-100.4F)
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Oral temperature/Tympanic
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37C (98.6F)
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Rectal temperature
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37.5 (99.5F)
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Axillary temperature
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36.5C (97.7F)
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Tympanic
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ear drum
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Average Pulse
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60-100 beats per min
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REspirations
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12 to 16 breaths per min
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BP
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average 120/80 mm Hg
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Pulse pressure
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30 -50 mm Hg
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What must the RN do to make sure vital signs are accurate?
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the RN must control or minimize environmental factors that may affect vital signs
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If a PT vial signs are poor or deteriorating how often should vital signs be monitored?
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They may need to be monitored every 5 to 15 min
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What drugs are given to reduce fever
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Antipyretics
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Under which medication should the vital signs be re-cheeked?
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before, during and after the administration of medication that affect cardiovascular, respiratory and temperature control functions
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Body temperature =
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Heat produced and Heat lost
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Where are the sites to take temperature on a person
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oral, rectal, axillary, tympanic membrane, esophageal, pulmonary artery, urinary bladder
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Thermoregulation
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the balance between heat lost and heat produced which is regulated by physiological and behavioral mechanisms
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What two functions of the body help with thermoregulation
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Neurological and cardiovascular mechanism
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What control center in the brain regulates temperature
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Hypothalamus which is located between the cerebral hemisphers
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What area of the brain controls heat loss
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anterior hypothalamus
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What area of the brain controls heat production
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posterior hypothalamus
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vasodilation
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widening of the blood vessels
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casoconstriction
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narrowing of blood vessels
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Heat is produced in the body as a result of what function
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Metabolism
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What is basal metabolic rate (BRM)
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the average heat produced by the body at absolute rest
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What effects basal metabolic rate
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larege amounts of thyroid hormones can increase the BMR by as much as 100%, in males sex hormone testosterone can increases the BRM,
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Metabolic rate can increase by how much during exercise
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2000 times heat production is increases up to 50 times
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Where on the body can you take surface temperature
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Skin, Oral, Axillae
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Where on the body can you take core temperatures
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Rectum, tympanic membrane, esophagus, pulmonary artery, urinary bladder
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Shivering is what type of response
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Involuntary involves skeletal muscles, can increase heat production 4 to 5 times greater than normal
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How do neonates produce heat when cold?
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Neonates cannot shiver so they have a small amount of vascular brown tissue, present at birth which is metabolized for heat producation
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What are the 4 ways of heat loss the body can use
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Radiation, conduction,, convection, and evaporation
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What % of the body's surface area can transfer heat without direct contact
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85% of body loss is thru radiation
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How can an RN increase the radiation loss of heat of a Pt
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By removing clothing or blankets
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What is conduction
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The transfer of heat from one object ot another with direct contact
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What is convection
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Transfer of heat away by air movement
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How much evaporation dose the body continuously loses in a day, and from what areas of the body
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600 to 900 ml, skin and lungs
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In what lair of the skin are sweat glands found
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Dermis
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What physiological structure of the body triggers the the sweat glands to release sweat?
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The anterior hypothalamus
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What is diaphoresis
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The visible perspiration primarily occurring on the forehead and upper thorax though it can also be seen elsewhere on the body
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Skin blood flow can vary from a minimal amount to how much and what does this help with?
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Increases up to 30% of the blood ejected from the heart to promote heat loss.
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How much heat loss does an infant loss through he head
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30%
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What is important to keep in mind with an infant and a elderly person
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Temperature may espond drastically to changes in teh environment
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In a child temperature regulation is unstable until what age
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Until the child reaches puberty
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How high can the body's temperature reach in prolonged strenuous exercise
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41C (105.8F)
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When progesterone levels are low what does this do to temperature
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Drops temperature by a few 10ths of a degree and temperature returns to normal after ovulation occurs
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What are hot flashes
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intermittent increase in skin temperature up to 4C (7.2F) during menopause which can last from 30 sec to 5 min
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What is pyrexia
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Fever
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when dose pyrexia can become harmful
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when the fever get above 39C (102.2F)
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What are pyrogens
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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.
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What can happen when a person temperature is rising and a new set point has not been reached
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chills, shivers, and can feel cold until set point is reached
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What happen is a set point in temperature is overshot by the body?
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drop in temp, diaphoresis can occur
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What is afebrile
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then a fever breaks, pt has no fever
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what is a febrile episode
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three phases of a fever,
raising pt has cillis,shivers, feels cold, plateau - hits set point afebrile |
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what is good about a pyrexia
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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
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Patterns of pyrexia
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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 |
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relapsing
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periods of febrile episodes interspresed iwth accepatble temps, febrile episodes and periods of normothermia may be longer than 24 hr
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Fever of unknown orgiin (FUO)
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refers to a fever whose etiology (cause) cannot be determined
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how high does the temperature of the body change during metabolism
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13% increass for every degree C
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cellular hypoxia
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inadequate oxygen
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what type of pain does myocardial hypoxia produced
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Angina (chest pain)
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what does cerebral hypoxia cause
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confusion
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hyperthermia
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elevated body temperature related to the body's inability to promote heat loss or reduce heart production
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malignant hyperthermia
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is a hereditary condition of uncontrolled heat production occurring when susceptible persons receive certain anesthetic drugs
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Heatstroke signs and symptoms
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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
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Classification of hypothermia
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Mild - 34C-36C (93.2F-96.8F)
Moderate - 30C-34C (86F-93.2F) Severe <30C (86F) |
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Heat Exhaustion signs and symptoms
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Occurs when profuse diaphoresis results in excess water and electrolyte loss.
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Hypothermia signs and sysmptoms
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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
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Frostbite signs and symptoms
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body is exposed to subnormal temp - ice crystals froms
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Convert Celsius to Fahrenheit
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C = (F-32) X 5/9
F = (9/5 X C) + 32 |
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Red tip thermometer is for
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Rectal temp
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In children most pyrexia are caused by
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viral origin
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When are febrile seizures most common in children?
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when a child has a temp above 38.8C (101.9F) is dehydrated, and between the ages of 6 mo and 3 yrs
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what do antipyretics do
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Drugs that reduce pyrexia
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What do corticosteroids do?
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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
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What are the benefits of nonpharmacological therapy for pyrexia
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They should be avoided because they lead to shivering and have NOT demonstrated an advantage over antipyretic medications
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What is something a RN should be keep in mind when cooling a person with a fever
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Avoid the Pt from shivering, shivering can increase the energy expenditure up to 400% creating heat production
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What should be done with a person with hypothermia
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Prevent further decrease in body temp, if conscious give hot liquids while avoiding alcohol and caffeinated fluids
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What is the educational responsibility of the RN to client in a febrile case
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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
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How do you determine cardiac output
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Pulse rate X Stroke volume = Cardiac output in L/min
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What is cardiac output
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the volume of blood pumped by the heart during 1 min
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What stimulates the cardiac contraction
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Sinoatral node (SA)
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How much blood enters the aorta with each ventricular contraction
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60ml to 70 ml of blood enters the aorta
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What us the normal amount of blood that is pumped thru the heart every min
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5000 ml of blood per min
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where are the best locations for take the pulse on an infant or young child
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brachial or apical pulse sites
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What are the locations where you can take a pulse on a person? (p. 638)
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Temporal
Carotid Apical Brachial Radial Ulnar Femoral Popliteal Posterior tibial Doralis pedis |
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What can factors can change a Pts pulse rate
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Exercise
Temperature Emotions Drugs Hemorrhage Postural changes Pulmonary conditions |
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What part of the heart sound makes a lub sound
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S1
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What part of the heart sounds makes the dub sound
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S2
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Tachycardia is
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an abnormally elevated heart rate above 100 beats per minute in an adult
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Bradycardia is
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a slow rate below 60 beats per minute in adults
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What is a pulse deficit
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an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse sites
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What is dysrhythmia
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An interval interrupted by an early or late beat or missed beat
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What is true about children and dysrhythmia?
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It is common for a child to have irregular heartbeat that speeds up with inspiration and slow down with expiration
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What are some of the diagnoses from tachycardia, bradycardia, and dysrhythmias
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activity intolerance, anxiety, decreased cardiac output, fear, deficient/excess fluid volume, impaired gas exchange, hyperthermia, hypothermia, acute pain, ineffective tissue perfusion
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What is the definition of ventilation
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The movement of gases in and out of the lungs
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What is diffusion in relation to respiration
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the movement of oxygen and carbon dioxide between the alveoli and the read blood cells
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What is perfusion in relation to respiration
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The distribution of red blood cells t to and from the pulmonary capillaries
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Respiration in adults is usually a what type of physiological control
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Respiration is a passive process
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Acceptable rage for respiration rate by age are?
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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 |
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What regulates ventilations
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The levels of CO2, O2, and hydrogen ion concentration (pH) in the arterial blood
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What is hypercarbia
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excess CO2
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what is Hypoxemia
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Low levels or arterial O2
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what is a normal tidal volume of an adult and the amount of movement of the body during inhales
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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)
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What is eupnea?
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normal, unlaboured ventilation, sometimes known as quiet breathing or resting respiration
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What device aids RN in assessment of respiratory
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Apena monitor
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What is the difference between Men/children vs women breathing
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Men and children tend to demonstrate diaphragmatic breathing where as women ten to use thoracic muscles to breathe
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What are normal Arterial blood gases level (ABGs?
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pH 7.35 - 7.45
PaCO2 35 - 45 PaO2 80 - 100 SaO2 95% - 100% (Saturation of hemoglobin) |
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What are normal Complete blood count (CBC)
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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 |
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How do you determine respiratory rate?
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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
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What is a normal Saturation of venouse blood (SvO2)
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is 70% becuase tissues have removed some of the oxygen from the hemoglobin
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What are the different types of alterations in breathing patterns? (p. 650)
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bradypnea
Tachypnea Hyperpnea Apena Hyperventilation Hypoventilation Cheyne-Stokes respiration Kussmaul's respiration Biot's respiration |
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What are some of the signs of Tachypnea
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changes in depth of respiration, use of accessory mucles, cyanosis, and decline in SpO2
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Blood pressure is defined as
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the force exerted on the walls of an artery by the pulsing blood under pressure from the heart
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that does BP a good indicator for?
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Cardiovascular health
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What is systolic pressure
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the peak of maximum pressure when ejection occurs
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What is diastolic pressure
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When the ventricles relax and teh blood remaining int eh arteries exerts a minimum pressure
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How do you record BP
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Systolic over diastolic
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What is the difference between systolic and diastolic pressure
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pulse pressure
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What is Cardiac output (CO)
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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 |
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What can increase cardiac output
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increase in hart rate, greater heart muscle contractility, or increase in blood volume
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What must be watched in administrating IV fluids to a patient
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the rapid uncontrolled infusion of IV fluids can elevate BP
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what is Viscosity
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the thickness of a fluid
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What is hematocrit
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the percentage of red blood cells in the blood
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What happens if a patient has a high hematocrit?
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Blood flows slower, and arterial blood pressure increases
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What happens with reduced arterial elasticity
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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
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Average BP by age
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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 |
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What are the factors to take into consideration when taking BP
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Age, Stress, ethinity, Gender, Diuranl variation, Medications, Exercise
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What is true about BP and males
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after puberty males tend to have higher BO readings, Females tend to have high BP after menopause of men the same age
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What is hypertension?
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asymptomatic disorder characterized by persistently elevated BP ( one elevated BP is not enough diagnosis)
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What are some life styles choices that increase the risk of hypertension?
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obesity, cigarette smoking, heavy alcohol consumption, high sodium intake, sedentary lifesytlye, continued exposure to stress
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Classification of BP for adults
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Normal <120 / <80
Pre-hypertension 120-139 (OR)/ 80-89 stage 1 hypertension 140-159 (OR)/ 90-99 Stage 2 hypertension >160 (OR)/ >100 |
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What are some Antihypertension Rx (p. 656)
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Diuretics
Beta-adrenegic blockers Vsodilators Calcium Channel blockers Angiotensin - converting enzyme (ACE) inhibitors |
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what is a myocardial infraction
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heart attack
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Hypotension
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present when the systolic blood pressure falls to 90 mm Hg or blow
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When does hypotension occur
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from hemorrhage, or myocardail infarction
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othostatic hypotesnion or postural hypotension
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occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position
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when is invasive blood pressure monitoring used
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In the ICU it is used to monitor BP
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what is used to measure BP
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Sphygomoanometer
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what is the ideal size of BP cuff
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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
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What is the difference between arms in BP
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5 to 10 mm Hg
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What are Korotkoff sounds
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clear rhythmical tapping corresponding to the pulse rate that gradually increases in intenisty
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the first Korotkoff sound is
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the systolic pressure
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In Adolescents and adults the fifth Korotkoff sound is the
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Diastolic pressure
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what is the auscultatory gap
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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.
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Under what conditions are not appropriate for electronic BP measurements
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Irregular heart rate, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, BP less than 90 mm Hg systolic
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Vital signs include all of the flowing
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Temperature, pulse, blood pressure, respiration , and oxygen saturation
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which two temperature sites will provide a core temperature measurement?
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Typanic
Recal |
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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?
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Obtain a temperature using a tympanic thermometer on the infant.
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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)?
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remove extra clothing and bed covers, and evaluate the client's complaints.
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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?
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irregular rate
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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?
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Assess right radial pulse for symmetry
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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?
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carotid
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In which situation can the assessment of the apical pulse be delegated to a nursing assistant?
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during routine vital sign measurments
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Which of the following activities will decrease heart rate?
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sleeping
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why is the point of maximal impulse (PMI) used during apical heart rate assessment?
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it reflects the cardiac apex
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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?
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ask the nursing assistant for help in obtaining apical-radial pulse
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One cause of decreased respiratory rate is?
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narcotic analgesics
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What effect does increased age have on respiratory assessment?
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decreased in chest expansion
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A hypertensive client has a blood pressure of 164/92mm Hg. what is the pulse pressure?
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72
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What is the effect of a blood pressure cuff that is too small for a client's arm?
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produces false high systolic pressure
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When completing an assessment, the client is nervously talking while the blood pressure is the nursing action?
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repeat the blood pressure measurement again at the end of the assessment after the client has been resting quietly.
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what are the 5 vital signs
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Temperature
Pulse Respiration blood pressure pain |
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Where are core temp taken
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rectum
tempanic esophagus pulmonary artery urinary bladder |
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Surface tem
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oral
skin aunder axilla |
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Body temperature is what
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Heat produced - heat loss
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what are the 5 ethics
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autonomy
beneficence nonmaleficence justic fidelity |
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what are bioethics
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deontology
actions are right or wrong utilitarianism valuse of something is determined by its usefulness - emphasis on outcome |
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What is assault vs battery
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assault - treat to touch
battery - violance is acted out |
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Nurse practice act
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regulatory law
describe and define the legal boundaries of RN practe with in a stae |
