Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
82 Cards in this Set
- Front
- Back
|
How often should you measure vital signs?
|
hospital- every 4-8 hrs
home health setting: each visit clinic: each visit Skilled Nursing Facility: weekly to monthly ICU: can be as much as every 15 minutes |
|
|
What are the vital signs?
|
-pulse
- respiration - blood pressure - temperature - pain |
|
|
Pulse
|
Number of times your heart beats reported in one minute and with attention to regularity
- the rhythmic expansion of an artery produced when a bolus of blood is forced into it by contraction of the heart |
|
|
Pulse
|
rate and rhythm, regular, irregular, thready, bounding
|
|
|
Where can I find the pulses in the body?
|
carotid artery, temporal artery, facial artery, brachial artery, radial artery, femoral artery, popliteal artery, apical pulse, posterior tibial artery, dorsalis pedis artery
|
|
|
What is a normal pulse?
|
60-100 beats per minute
-strongest in larger arteries |
|
|
What is tachycardia? Under What conditions would this occur?
|
-fast heart rate
pain, bleeding, scared, febrile, conduction, hypoxia, drug use, shock, hyperthyroidism, allergy, heat, anxiety/stress |
|
|
What is bradycardia? What conditions would this occur?
|
-slow heart rate (under 60)
- conduction/heart attack (MI), medications/narcotics, the dying process, vagus nerve stimulation (vasovagal), hypothermia, alochol, sleep, |
|
|
What is normal respirations?
|
- the exchange of oxygen and carbon dioxide in the body
- 12-20 per minute - measure by unknowing count for 30 seconds |
|
|
Hyperventilation
|
tachypnea- occurs when rapid and deep breathing result in excess loss of CO2 (hypocapnia)
- caused by low oxygen states, fear/anxiety, exertion, diseases (pulmonary emboli), acid bas imbalance, pulmonary edema (fluid in lungs), orthopnea, drugs (aspirin or amphetamines), diabetes mellitus |
|
|
What is orthopnea?
|
breathing becomes worse when lying flat
|
|
|
Carotid Artery & Pulse
|
Through carotid artery pressure we can speed up and slow down the heart
- the vagus nerve can slow down the heart rate |
|
|
How to stimulate the vagus nerve?
|
- vagus nerve is stimulated by carotid artery pressure, bearing down for bowel movement, rubbing your eyes when they are closed
|
|
|
What is the difference between feeling for the radial pulse and listening to the apical pulse?
|
Apical pulse shows that the heart is beating and radial pulse can show a blood flow issue
- apical pulse is very accurate |
|
|
Orthostatic State
|
BP changes from lying to sitting to standing
|
|
|
Stroke Volume
|
the quantity of blood forced out by each contraction of the left ventricle (70mL for healthy adults)
|
|
|
Cardiac output
|
total quantity of blood pumped per minute
=stroke volume x pulse rate (beats/min) |
|
|
What part of the CNS regulates heart rate?
|
Autonomic nervous system
- Sympathetic stimulation increases heart rate - Parasympathetic stimulation decreases heart rate |
|
|
What factors influence the pulse rate?
|
Developmental- infants have a faster pulse rate
Sex- adult women have a slightly more rapid pulse than men Exercise- the pulse for a fit person is usually lower and returns to normal after exercise faster than a non-fit person Food- ingestion of food raises pulse for serveral hours Stress- increases pulse and strength of heart contractions Fever- pulse increases 10 beats.min for each degree F of elevation because metabolic rate increases and trying to compensate for lower BP Disease- diseases such as heart disease, hyperthyroidism, respiratory diseases and infections increase pulse rate. Hypothyroidism decreases pulse rate. Position changes & Medications |
|
|
When should I take an apical pulse?
|
- the radial pulse is weak or irregular
- the rate is <60bpm or >100bpm -the patient is taking cardia medications -assessing infants and children up to age 3 (other pulses may be difficult to palpate) |
|
|
Respiration- Mechanical & Chemical
|
Mechanical- involve the active movement of air into and out of the respiratory system (pulmonary ventilation)
- Chemical- includes the exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply (external respiration), the transport of gases throughout the body (gas transport), and the exchange of these gases between the capillaries and body tissue cells (internal respiration) |
|
|
How does the body regulate respiration?
|
respiratory centers in the medulla oblongata and pons of the brain, along with nerve fibers of the autonomic nervous system, regulate breathing in response to minute changes in concentration of oxygen and carbon dioxide in the arterial blood
|
|
|
How do we breathe?
|
IN response to impulses sent from the respiratory center along the phrenic nerve, the thoracic muscles and the diaphragm contract.
|
|
|
Inspiration & Expiration
|
Inspiration- expansion causes the airway pressure to decrease below atmospheric pressure, air moves into and expands the lungs
Expiration- the diaphgram and thoracic muscles relax, the chest cavity decreases in size, the lungs recoil, forcing air from the lungs until the pressure within the lungs again reaches atmospheric pressure |
|
|
Factors that affect Respiration
|
Developmental- infants breathe a lot faster (40-90 breaths per minute)
Exercise- increases breathing rate to get more oxygen to the tissues Pain- increases respiratory rate but decrease in depth Stress- increase in rate- sympathetic nervous system Smoking- increases respiratory rate because of lack of compliance (elasticity) Fever- respiratory rate increases Hemoglobin- respiratory rate increases as a result of anemia, sickle cell anemia, and high altitude Disease- brain stem injuries and increased intracranial pressure may interfere with respiratory center inhibiting respiration or messing with the rythym Medication- CNS depressants, such as morphine and general anesthetics, cause slower deeper respirations. Caffeine and atropine can cause shallow, fast breathing Position- standing up is awesome |
|
|
Respiratory rate
|
number of times a person breathes within a full minute
- assess depth, rhythym, effort, rate |
|
|
Pulse Oximeter
|
shows saturation of the cells
- not necessarily oxygenation but that's what we use it for |
|
|
Tidal Volume
|
Amount of air taken in on inspiration- about 300-500mL for a healthy adult
|
|
|
Dyspnea
|
increased effort is required to breathe (labored breathing)
|
|
|
Respiratory rate
|
number of times a person breathes within a full minute
- assess depth, rhythym, effort, rate |
|
|
Pulse Oximeter
|
shows saturation of the cells
- not necessarily oxygenation but that's what we use it for |
|
|
Tidal Volume
|
Amount of air taken in on inspiration- about 300-500mL for a healthy adult
|
|
|
Dyspnea
|
increased effort is required to breathe (labored breathing)
|
|
|
Abnormal Breathing Sounds
|
Wheezes- high pitched, continuous musical sounds- usually hear on expiration
Rhonci- low pitched, continuous gurgling sounds caused by secretions in large airways Crackles- caused by fluid in alveoli- discontinuous sounds usually heard on inspiration, but they may be heard throught the respiratory cycle- may be high pitched popping sounds or low pitched bubbling sounds Stridor- piercing high pitched sound that is heard without a stethoscope, primarily during inspiration Stertor- labored breathing (snoring sound) |
|
|
What can I see when someone is having difficulty breathing?
|
Intercostal retraction- the visible sinking of tussues around and between the ribs
Substernal retraction- when tissues are drawn in beneath the sternum Suprasternal retraction- when tissues are drawn in above the clavicle |
|
|
Signs of Hypoxia?
|
pallor or cyanosis, restlessness, apprehension, confusion, dizziness, fatigue, decreased level of consciousness, tachycardia, tachyapnea, and changes in blood pressure
|
|
|
Type of breathing-
|
1) Eupnea- normal respirations
2) Bradypnea- slow respirations, less that 10 per minute 3) Tachypnea- fast respirations- more than 24 per minute 4) Kussmaul's Respirations- respirations that are regular but are abnormally deep and increased in rate Biot's Respirations- irregular respirations of variable depth, alternating with periods of apnea Cheyne-Stokes Respirations- gradual increase in depth of respirations followed by gradual decrease and then a period of apnea Apnea- absence of breathing |
|
|
What are two ways to measure the amounts of oxygen and carbon dioxide in the blood?
|
Arterial blood gas sampling (ABG) and pulse oximetry
|
|
|
Hypoventilation
|
occurs when the rate and depth of respirations are decreased and CO2 is retained or alveolar ventilation is compromised
- Can happen because of COPD, general anesthesia, impending respiratory failure, brain stem injuries/increased intracranial pressure, medication/narcotics, bradypnea |
|
|
Blood pressure
|
important indicator of overall cardiovascular health, is the pressure of the blood as it is forced against arterial walls during cardiac contraction
|
|
|
Systole
|
Systolic pressure is the peak pressure exerted against arterial walls as teh ventricles contract and eject blood
|
|
|
Diastole
|
Diastolic Pressure is the minimum pressure exerted against arterial walls, between cardiac contractions when the heart is at rest
|
|
|
Pulse Pressure
|
the difference between systole and diastole- should be no greater than 1/3 of the systolic pressure
|
|
|
What is normal BP?
|
Systolic BP below 120 and a diastolic BP of below 80
|
|
|
How does the body regulate BP?
|
- influenced by cardiac function, peripheral vascular resistance, and blood volume
|
|
|
Things that increase cardiac output/ BP?
|
increased blood volume, more forceful contraction of ventricles (exercise)
|
|
|
things that decrease cardiac output/BP
|
dehydration, active bleeding, damage to heart (MI), a very rapid heart rate
|
|
|
Peripheral resistance
|
refers to arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls-- it creates a temporary raise in BP
|
|
|
The amount of friction between blood and the vessel walls depends on?
|
blood viscosity- determined by hematocrit-- hematocrit has a direct affect on BP
Arterial size-indirect relationship Arterial Compliance- the elasticity and resistance in a vessel--- less elasticity increase BP--- arteriosclerosis |
|
|
What factors affect BP?
|
Developmental Stage- a newborn has a very low BP
Sex- men have slighter higher non statistically significant- womens BP increases after menopause perhaps because of a decrease in estrogen Family history Lifestyle- increased sodium, smoking, and consumption of three or more alcohol beverages a day raise BP Exercise- Physical fit reduces BP Body Position- BP is higher when standing Stress- fear, worry, excitement raises BP to rise because of sympathetic nervous system Pain- causes increased BP Race- African Americans have higher rate of hypertension Obesity- increases BP Diurnal variations- BP varies with peoples schedule Medication- Diseases- that affect circulatory system or any other major organ of the body |
|
|
How is BP assessed?
|
Direct- a catheter is threaded into an artery under sterile conditions and attached tot tubing that is connected to an electronic monitoring system
Indirect- the way we always do it |
|
|
Korotkoff sounds
|
1st sound- as you deflate the BP cuff, you will initially hear a sound that occurs during systole
2nd sound- a swishing sound caused by blood turbulence 3rd sound- is sharp, rhythmic tapping sound 4th sound- like the third but softer 5th sound- silence (diastolic BP) |
|
|
Orthostatic Hypertension
|
occurs when a person's BP drops suddenly on moving from a lying position to a sitting or standing position and feels dizzy or faint
|
|
|
Hypotension
|
- diagnosed when systolic blood pressure is less than 100 mm Hg
- causes may be hemmorrhage or heart failure |
|
|
Hypertension
|
Prehypertension is a BP reading of 120-139 mm Hg systolic and 80-89 mm Hg diastolic with the readings taken 2x 6 minutes apart
Hypertension is diagnosed when BP is above 140 mm Hg systolic or above 90 mm Hg diastolic - related to thickening of the walls of the arteries and loss of elasticity |
|
|
Primary and Secondary Hypertension
|
Primary- diagnosed when there is no known cause for the BP elevation
Secondary- clearly identified reason for raise in BP such as renal and endocrine disorders |
|
|
Stroke Volume
|
The quantity of blood pumped out by each contraction of the left ventricle
|
|
|
Body Temperature
|
the degree of heat maintained by the body
|
|
|
Core temperature
|
an adult's normal internal ranges from 97-100.8
-rectal and tympanic membrane measures core temperature - oral and axillary represent surface temperature |
|
|
Hypothalamus
|
- responsible for thermal regulation
- when the body is too warm the hypothalamus is stimulated and this activates compensatory mechanisms such as peripheral vasodilation, sweating, and inhibiting of heat production - when the body is cold the hypothalamus increases heat production and reduces heat loss by shivering and releasing epinephrine, to increase metabolism - to reduce heat loss the blood vasels constrict |
|
|
Vasodilation
|
diverts core warm blood to the body surface where heat can be transferred to the surrounding environment
|
|
|
Vasoconstriction
|
conserves heat by shunting blood away from the periphery to the core of thebody, where blood is warmed
|
|
|
HOw is heat produced in the body?
|
Metabolism- uses energy and generates heat- Hyperthyroidism increases BMR which means they feel warm even in a cool environment and vice versa
-Epinephrine and Norepinephine produced from the sympathetic nervous system also increase BMR and heat production - Skeletal Muscle Movement- the breakdown of fats and carbs in muscles produces heat-- when we exercise we get hot when we shiver we warm up the body Nonshivering thermogenesis- the metabolism of brown fat to produce heat (used in infants and dissapears after the first few months of life) |
|
|
BMR
|
teh Basal metabolic rate (BMR) is the amount of energy required to maintain the body at rest
|
|
|
Heat is exchanged between body and environment?
|
-Heat moves down a concentration gradient
- Radiation - Convection - Evaporation - Conduction |
|
|
Radiation
|
the loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air
- when there are a lot of people in the room it gets hot - a heat lamp will heat a room |
|
|
Convection
|
the transfer of heat through currents of air or water
- nurses use this via immersion ina warm bath may taise body temperature of a hypothermic client - a fan can help reduce a fever |
|
|
Evaporation
|
occurs when water is converted to a vapor and lost from the skin or mucous membranes
- causes cooling - water loss by evaporation is called insensible loss - it is affected by relative humidity - more humidity less cooling occurs |
|
|
Conduction
|
the process whereby heat is transferred from a warm to a cool surface by direct contact
- a patient on a cool metal table may have a lower temperature |
|
|
What factors affect temperature?
|
Developmental Level- infants and older adults are more susceptible to temp extremes in the environment
Environment- Sex- women's body temp varies with menstrual cycle Exercise Emotions and Stresss- can stimulate the sympathetic nervous system which can increase metablolic rate which can increase body temperature Circadian Rhythym- lowest in the early morning hours and highest in late afternoon or early evening |
|
|
Fever (Pyrexia)
|
Oral temperature greater than 100 and rectal temp greater than 101.
|
|
|
Hyperpyrexia
|
a fever above 105.8
|
|
|
Why does a fever happen?
|
it happens in response to pyrogens
- when bacteria or foriegn substances invade the body, they stimulate phagocytes which ingest invaders and secrete pyrogens - pyrogens induce secretion of prostaglandins (which reset the hypothalamic thermostat to a higher temperature) |
|
|
Fever occurs in three phases?
|
The initial phase- the body temperature is rising but has not reached a new set point
The second phase- the body temperature reaches its maximum and remains fairly constant - The third phase- the period when the temperature returns back to normal (fevver is breaking) |
|
|
Intermittent fever
|
temperature alternates regularly between periods of fever and period of normal or below normal temperature
|
|
|
Remittent fever
|
flunctuations in temperature, all above normal, during a 24 hour period
|
|
|
Constant fever
|
temperautre may flunctuate slightly but is always above normal
|
|
|
Relapsing fever
|
short periods of fever alternating with periods of normal temperatures, each lasting 1 to 2 days
|
|
|
Why should we not take an antipyretic sometimes?
|
Fever is beneficial!
- high temperatures enhance the immune repsonse because 1) they kill or inhibit the growth of many microorganisms, 2) enhance phagocytosis, 3( cause the breakdown of lysosomes and self desctuction of virall infected cells, and 4) cause the release of interferon, a substance that protects cells from viral infection |
|
|
Hyperthermia
|
body cannot promote heat loss fast enough to ballance heat production- heat exhaustion and heat stroke
|
|
|
Heat exhaustion
|
- weakness, nausea, vomitting, syncope, tachycardia, tachypnea, muscle aches, headache, diaphoreses, and flushed skin
|
|
|
Heat Stroke
|
rapid, strong pulse, throbbing headache, delirium, confusion, impaired judgement, red hot dry skin, dizziness, seizures, and coma
- can result in death! |
