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;
131 Cards in this Set
- Front
- Back
afebrile |
no fever
|
|
antipyretics
|
drugs that reduce fever. Non-steroids such as acetaminophen, salicylates, indomethacin, ketorolac, etc reduce fever by increasing heat loss. Cortisteroids reduce fever by masking signs of infection - they are NOT used to treat fever but may mask typically-pyrogeninc conditions by supressing fever.
|
|
auscultatory gap
|
hypertensive patients may have a temporary disappearance of Korotkoff sounds that can result in inaccurage auscultation. You may use a combination of palpation and auscultation to determine accurate BP reading in these cases.
|
|
BMR
|
Basal Metabolic Rate is the heat produced by the body at absolute rest
|
|
Blood Pressure
|
force exerted on the walls of an artery by the pumping of blood under pressure from the heart
|
|
bradycardia
|
unusually LOW heart rate - below 60 beats per minute
|
|
cardiac output
|
volume of blood pumped by heart per minute. Typically 5000mL/min for adults. CO = HR x SV (cardiac output equals heart rate times stroke volume)
|
|
celcius
|
a scale of temperature. C = 5/9 (F-32)
|
|
conduction
|
transfer of heat from one object to another with direct contact
|
|
convection
|
transfer of heat by air movement. In healthcare, most commonly heat loss due to wind, fan, etc
|
|
core temperature
|
temperature of deep tissues
|
|
diaphoresis
|
visible perspiration - primarily on forehead and upper thorax
|
|
diastolic pressure
|
minimal pressure exerted against the arterial walls at all times. ("bottom" # of a BP reading).
|
|
diffusion (in relation to respiration)
|
movement of O2 and CO2 between alveoli and the RBCs. Assessed through O2 saturation levels
|
|
dysrhythmia
|
abnormal heart rhythm. Classified as regularly irregular or irregularly irregular
|
|
eupnea
|
normal rate and depth of respirations
|
|
evaporation
|
when liquid changes to gas. Water evaporation is an endothermic chemical reaction so it requires thermal energy from the environment. ie - sweat removes heat from body surfaces as it evaporates.
|
|
farenheit
|
a temperature scale. F = 9/5 C + 32
|
|
febrile
|
condition of having a fever
|
|
fever
|
occurs when heat production out-paces heat loss and body temp rises. Also called pyrexia
|
|
FUO
|
fever of unknown origin - refers to a fever whose etiology cannot be determined
|
|
frostbite
|
occurs when body is exposed to subnormal temps. Ice crystals form inside cell and permanent circulatory and tissue damage occurs.
|
|
heat exhaustion
|
occurs when profuse diaphoresis results in excess water and electorlyte loss. Signs of fluid volume deficit. Move client to cooler area, provide fluid, and electrolytes
|
|
heat stroke
|
Heat depresses hypothalamus function. When exposed to enough heat, the body's heat-loss mechanism can become overwhelmed and stop functioning. This is an extremely dangerous condition.
|
|
hematocrit
|
percentage of total blood volume that consists of red blood cells
|
|
hypertension
|
High BP. Cannot be diagnosed in a single assesment. Can be classified as 3 categories: Prehypertension, Stage 1 hypertension, or Stage 2 hypertension. Ranges for high systolic pressures go in increments of 20 mm HG (i.e. <120: normal; 120-140 = pre; 140-160 = stage 1; >160 = stage 2). Ranges for high diastolic pressures are in increments of 10 mm Hg (i.e. normal=<80; 80-90=pre...)
|
|
hypotension
|
systolic pressure below 90 mm Hg
|
|
hypothalamus
|
part of the brain that regulates temperature like a thermostat. Anterior controls heat loss, posterior controls heat production.
|
|
hypothermia
|
heat loss exceeds body's ability to produce heat. Uncontrolled shivering, loss of memory, depression, poor judgement. HR and respiration are reduced. If severe, client may have cyanotic skin tone, cardiac dysrhythmia, loss of conciousness, and be unresponsive to pain.
|
|
hypoxemia
|
low levels of O2 in blood
|
|
malignant hyperthermia
|
a hereditary condition of uncontrolled heat production after exposure to certain anesthetic drugs.
|
|
nonshivering thermogenesis
|
occurs primarily in neonates because they are unable to shivver. A limited amount of vascular brown tissue is metabolized for heat production
|
|
orthostatic hypotension
|
also called "postural hypotension". BP drops suddenly due to change in position such as standing or sitting up from lying down. Simply ask patient to lie back down and get up more slowly after a few minutes. Monitor BP - do not delegate orthostatic hypotension readings
|
|
perfusion
|
distribution of RBCs to and from the pulmonary capillaries. Assessed through O2 saturation
|
|
postural hypotension
|
also called "orthostatic hypotension". Drop in BP due to position change.
|
|
pulse deficit
|
an inefficient contraction of the heart that fails to transmit a pulsation to peripheral site causes a "missing" beat in the reading. To measure, 2 healthcare workers may simultaneously take aipical and radial pulse. The difference between the two readings is the pulse deficit.
|
|
pulse pressure
|
difference between systolic and diastolic pressures is PP. (eg. BP=120/80, PP=40)
|
|
pyrexia
|
fever - when heat generation out-paces heat loss
|
|
pyrogens
|
substances that alter the hypothalamic set point and trigger a change in body temperature. Some pathogenic bacteria or viruses are pyrogens.
|
|
radial pulse
|
pulsations of the blood felt at the radial (thumb) side of the wrist
|
|
radiation
|
transfer of heat from one surface to another without direct contact
|
|
shivering
|
an involuntary response to temperature differences in the body. Increases heat production by 4-5X
|
|
sphygmomanometer
|
tool for measuring BP - includes a pressure manometer, occlusive cuff that encloses an inflatable rubber bladder, pressure bulb w/ release valve. Aneroid or Hg but Hg rarely seen
|
|
systolic pressure
|
peak of max pressure when ejection of blood into aorta occurs ("top" number in BP reading).
|
|
tachycardia
|
abnormally high heart rate - above 100 beats/minute
|
|
thermoregulation
|
ability of the body to balance heat production with heat loss and keep core temperature within acceptable range of set point
|
|
ventilation
|
movement of gases in and out of lungs
|
|
vital signs
|
includes measurements of temperature, pulse, blood pressure, respiration rate, and O2 saturation. Pain level is often considered the 6th vital sign. Mnemonic = Take Pulse By Reaching Out
|
|
About ______ to ________ mL/day evaporates from the skin and lungs
|
600 to 900
|
|
Typical body temperature for a newborn is _______ to _______
|
35.5 C - 37.5 C (95.9 F to 99.5 F) and can fluctuate rapidly with exposure to temperature extremes due to immature temperature regulation systems
|
|
Typical body temperature for an older adult is _______
|
Approximately 36 °C (96.8 °F) - temperatures of 35 °C (95 °F) are not uncommon in elderly patients
|
|
Hormones can affect a woman's temperature. Low levels of progesterone will cause body temperature to be (higher/lower)
|
lower
|
|
Due to circadian rhythms, body temperature usually fluctuates about _______ to _______ °C throughout the day. Temp is lowest in the _________ (morning/evening) and typically peaks in the _______ (morning/evening)
|
0.5 to 1 °C (0.9 to 1.8 °F), lowest in the early morning (around 1-4 AM), peaks in the evening (around 6PM)
|
|
Mild fever up to ________ enhances the body's immune system. __________ blood cell production is stimulated, and concentrations of _______ in the blood plasma are reduced suppressing the growth of bacteria. Fevers also help to fight viral infections by stimulating _________ the body's natural virus-fighting substance.
|
39 °C (102.2 °F), White, iron, interferon
|
|
When to perform vital signs -
|
On admission to facility or initial assesment at home care visit
On a routine schedule established by facility/provider/standards of practice Before and after any surgical or invasive proceedure Before, during and after transfusion of any blood products Before, during and after administration of any interventions that affect cardiovascular, respiratory, temperature-control, or other vital sign functions. (e.g. vasoconstrictor medication, ambulation of a previously immobile client) Whenever client's general condition changes as evidenced by out signs or a report of symptoms of physical distress (e.g. fainted, increased pain, feeling "funny") |
|
The body's metabolism increases by ____ % for every °C of temperature elevation. This increased demand for O2 and nutrients can put significant strain on cardiac and respiratory systems.
|
10
|
|
How can a fever influence cellular hypoxia and myocardial hypoxia?
|
High temperatures increase the basal metabolic rate of virtually all body systems. Cells' oxygen consumption increases and therefore the demands on cardiac and respiratory systems increase. If these systems cannot meet the increasing demands, hypoxia results. Hypoxia is a lack of sufficient O2 delivery to maintain the health of the cells. Myocardial hypoxia produces angina, cerebral hypoxia produces confusion.
|
|
The most important symptom of heat stroke is ____________ skin. Other symptoms of heat stroke include:
|
Hot dry skin is the strongest indicator that body's cooling mechanisms are no longer operating correctly. Other symptoms include - giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, incontinence, increased heart rate, low BP
|
|
Mild hypothermia is a core temp range of -
|
34-36°C (93.2- 96.8°F)
|
|
Moderate hypothermia is a core temp range of -
|
30-34°C (86.0-93.2°F)
|
|
Severe hypothermia is a core temperature of -
|
Below 30°C (86°F)
|
|
35 yo male patient returned from snowmobiling and found that 3 fingers of left hand appeared white, waxy, firm to the touch and have a loss of sensation. What has likely occurred and how should it be treated?
|
Frostbite - liquid in cells and tissues froze and formed crystals that permanently damage affected cells. Warm fingers gradually, provide analgesia, protect injured tissues. Assess vital signs/history for indications of impaired circulation that may have increased risks for frostbite. Educate client about protective measures to take in the future.
|
|
Rectal temp is typically about ________°C higher/lower than oral temperature readings.
|
0.5°C (0.9°F) higher
|
|
Axillary temp is typically about ________°C higher/lower than oral temperature readings.
|
0.5 °C (0.9°F) lower
|
|
Common nursing diagnoses for clients with body temp alterations include:
|
Risk for imbalanced body temperature
hyperthermia hypothermia ineffective thermoregulation |
|
Drug reaction induced fevers are often accompanied by
|
allergy symptoms such as rash or pruritus (itching)
|
|
Ensure that nursing interventions to treat hyperthermia do not cause ______ which can increase energy expenditure by 4-5X and result in heat gain. Medications such as _______ and ______ can be used to prevent this effect.
|
shivering Meperdine, butorphanol
|
|
Pulse rate
|
number of pulsations of the blood per minute. Also just called "pulse"
|
|
Where (exactly) should apical pulse auscultated?
|
fourth to fifth intercostal space at the left mid-clavicular line
|
|
An increase in heart rate without an adjustment to stroke volume causes BP to __________ increase/decrease.
|
decrease - because the heart has less time to fill and therefore pumps less efficiently and cardiac output decreases
|
|
When using a stethoscope, press the _______ side firmly against the skin to hear ______-pitched sounds. Flip the stethoscope to the ______ side and hold it lightly against the skin to hear the _____-pitched sounds created by the low-velocity movement of blood.
|
diaphragm, high bell, low
|
|
It is normal for heart rate to temporarily ________ when a client moves from lying to a sitting/standing position.
|
increase
|
|
electrocardiogram
|
records electrical activity of the heart for a 12-second interval
|
|
Holter monitor
|
records heart activity for 24 hours on a small wearable recorder. Results not immediately accessable
|
|
telemetry
|
continuous monitoring of heart's electrical activity transmitted to a stationary monitor. Allows for immediate intervention during cardiac instabillity
|
|
sinus dysrhythmia
|
irregular heartbeat that speeds up during inspiration and slows with expiration. Normal/common in children. Resolves if breath is held.
|
|
Common nursing diagnoses related to pulse issues:
|
Activity intolerance
pain, fear or anxiety decreased cardiac output deficient/excess fluid volume impaired gas exchange hyperthermia/hypothermia ineffective tissue perfusion |
|
Normal respiration rate for adults -
|
12-20 breaths/min
|
|
hypercarbia
|
excess CO2 in blood (usually arterial)
|
|
During normal relaxed breathing, a typical adult inhales about ________ mL of air. This is refered to as __________ volume
|
500 Tidal
|
|
Abdominal trauma may injure the ________ nerve which is responsible for diaphragmatic contraction
|
phrenic
|
|
A significan drop in respirations after a head injury may signify injury to the __________
|
brain stem
|
|
Normal respiration rate for a newborn, child, and adult are
|
NB = 30-60/min, Child = 20-30/min, Adult = 12-20/min
|
|
Common factors affecting respirations include:
|
exercise, acute pain, anxiety, smoking, position, medications, neurological injury, hemoglobin function, respiratory diseases
|
|
hyperpnea
|
respirations are labored, increased depth and rate, more than 20 breaths/min, normal during exercise
|
|
Kussmaul's respiration
|
abnormally deep, regular and increased rate
|
|
Biot's respiration
|
abnormally shallow for 2-3 breaths followed by irregular periods of apnea
|
|
Cheyne-Stokes respiration
|
Respiratory cycle begins with slow shallow breaths that gradually increase to abnormal rate and depth to a point of hyperventilation. Breathing then slows and becomes increasingly more shallow, ultimately reaching apnea before the cycle begins again.
|
|
Healthy men and children typically demonstrate _______ breathing whereas women tend to use _______ muscles to breath. Assess respiration in female clients by observing the _________
|
diaphragmatic, thoracic, upper chest
|
|
Labored breathing usually involves accessory muscles of respiration visible in the _______
|
neck
|
|
A longer expiration phase of respiration is present when _______________
|
the outward flow or air is inhibited / obstructed (eg - asthma)
|
|
Infants' and young children's breathing rate tends to be _________
|
irregular - it is common for them to breath slowly for a few seconds and then more rapidly
|
|
Arterial oxygen saturation SaO2 in adults is typically -
|
95-100%
|
|
Venous O2 saturation levels in adults (SvO2) is typically -
|
about 70%
|
|
Oxygen saturation is
|
the percentage of hemoglobin molecules that are bound w/ O2
|
|
Pulse Oximeter
|
device for measuring O2 saturation levels. Probe with LED photodetector that measures pulse O2 saturation - usually a reliable estimate of SaO2 as long as levels are above 70%. Various probes can attach to finger, ear, nose bridge, infant foot. Do not use on extremeties when patient is cold or circulation to location is otherwise impaired.
|
|
Vital sign measurements of respiratory rate, pattern and depth along with SpO2 are used to asses: ____, _____, and _____
|
ventilation, diffusion, and perfusion
|
|
Respiratory assessment data are defining characteristics of many nursing diagnoses including:
|
activitiy intolerance
ineffective airway clearance anxiety acute pain ineffective breathing pattern impaired gas exchange dysfunctional ventilatory weaning response |
|
Factors that may interfere with the accuracy of pulse oximeter include :
|
outside light, CO poisoning, client motion, jaundice, IV dyes, cosmetic nail augmentation, dark skin
|
|
Common conditions that interfere with arterial pulsations and SaO2 measurement:
|
peripheral vascular disease, hypothermia, vasoconstricting drugs, low cardiac output, hypotension, peripheral edema, probe that is too tight will record venous and arterial saturation resulting in artificially low reading.
|
|
Instruct nursing assistive personnel to immediately report to nurse any SpO2 reading below _______
|
90%
|
|
Refrain from using pulse oximetry to assess heart rate because _____________
|
oximeter may count pulsations but cannot detect irregularities
|
|
(5) Common conditions that increase risk for low SO2 and warrant closer monitoring of this vital sign include:
|
compromised respiratory function, recovery from sedation, traumatic injury to chest wall, ventilator dependence, changes in supplemental O2 therapy
|
|
Signs and symptoms of decreased oxygenation include:
|
anxiety, restlessness, tachycardia, cyanosis, low BP
|
|
What 5 hemodynamic variables affect blood pressure?
|
cardiac output, peripheral vascular resistance, blood volume, blood viscosity, artery elasticity
|
|
Most adults have a circulating blood volume of approximately __________ mL
|
5000
|
|
Typical BP for a newborn, 1yo, 12yo, 45yo, 85yo
|
nb= 40 mean
1yo = 95/65 12yo = 110/65 Highly dependant on size/maturity. Lower in kids small for age 45yo = 120/80 85yo = 120/80 |
|
Signs and symptoms associated with hypotension include:
|
pallor, skin mottling, clamminess, confusion, increased HR, decreased urine output, dizziness, restlessness, dusky or cyanotic skin
|
|
Diuretics act antihypertensively by
|
reducing fluid reabsorption in kidney's thus lowering blood volume. Examples - Furosemide (Lasix), Spironolactone (Aldactone)
|
|
Beta-andrenergic blockers act antihypertensively by
|
combining with receptors in circ. system to block response to sympathetic nervous system -> slows heart rate -> thus lowers cardiac output. Examples - Atenolol (Tenormin), Nadolol
|
|
Vasodialators act antihypertensively by
|
relaxes smooth muscle of arterioles to cause reduced resistance. Examples - Apresoline, Loniten
|
|
Calcium Channel blockers act antihypertensively by
|
reducing peripheral resistance through systemic vasodilation. Examples - Diltiazem (Cardizem), Verapamil Hydrochloride (Calan SR)
|
|
Angiotensin-converting enzyme (ACE) inhibitors act antihypertensively by
|
prevent vasoconstriction and reduce aldosterone which results in lower fluid retention. Examples - Captopril (Capoten), Nicardipine (Cardene).
|
|
Angiotensin II receptor blockers act antihypertensively by
|
Blocks binding of angiotensin II (a vasoconstrictor). Examples - Losartan (Cozaar), Olmesartan (Benicar).
|
|
Signs and symptoms of hypertension
|
Often none until BP is very high - headache (usually occipital), flushing of face, nosebleed, fatigue in older adults
|
|
Orthostatic hypotension measurements should/should not be delegated
|
should not
|
|
What should you do if unable to obtain BP reading?
|
check for immediate crisis using pulse and respiration rate
Assess for signs of decreased cardiac output. If present, notify nurse in charge or HC provider immediately Use alternate site or method (i.e. leg, doppler) repeat with sphygmomanometer if electronic device had been used |
|
What to do if BP is low
|
Compare to baseline - might be OK for this client
Move client to supine position and/or restrict movement Assess for signs and syptoms of low CO and seek assistance immediately if present increase rate of IV infusion or admin vasoconstricting drugs as ordered |
|
What to do if BP is above acceptable range
|
Repeat measurement in other arm, compare
Verify correct selection and placement of cuff Ask nurse collegue to repeat measurement in 1-2 minutes Observe for related symptoms although hypertension is often asymptomatic Report elevated BP to head nurse and/or provider Administer antihypertensive meds as ordered |
|
True/False - If it is more convenient and equipment fits properly, it is acceptable to take BP reading from forearm and radial pulse
|
False - recent research has indicated that this is a very inaccurate site for BP measurement
|
|
What to do if client has respiratory rate less than 12 (bradypnea) or above 20 (tachypnea) breaths per minute. Breathing pattern is irregular, depth increases or decreases and client complains of feeling short of breath -
|
Observe for related factors including obstructed airway, abnormal breath sounds, productive cough, restlessness, irritability, anxiety, confusion
Assist client to supported sitting position unless contraindicated Provide O2 as ordered Assess for environmental factors such as second-hand smoke, poor ventilation, or gas fumes |
|
During initial assessment, obtain and record BP in both arms. Normally there is a difference of _____ to _____ mm Hg between the arms. In subsequent assessments, measure the BP in the arm that had the _____ (higher/lower) pressure.
|
5 to 10 Higher
|
|
Korotkoff sounds
|
the sounds heard over artery distal to BP cuff.
|
|
The skill of PALPATING BP (rather than auscultating) can/cannot be delegated.
|
cannot (p545 Potter)
|
|
Client conditions not appropriate for electronic BP measurement include:
|
irregular heart rate, peripheral vascular obstruction, shivering, seizures, excessive tremors, inability to cooperate, systolic BP<90,
|
|
Nursing diagnoses related to BP include:
|
Activity intolerance
Anxiety Decreased cardiac output Deficient/excess fluid volume Risk for injury Acute pain Ineffective tissue perfusion |
|
Primary nursing diagnosis for client with defining characteristics of: hypotension, dizziness, pulse deficit, dysrhythmia is _______________
|
decreased cardiac output
|
|
The temperature of older adults tends to be ________ than younger adults.
|
Lower (about 36 to 36.8 C)
|
|
Older adults tend to be more suceptable to heat stroke and hyperthermia because -
|
thermoregulation systems are not as efficient and sweat glands are less reactive
|
|
Older adults tend to have a ______ resting heart rate. Their heart rate rises more _____ in response to activity or excitement and recovers ______ once at rest.
|
lower, slowly, slowly
|
|
Normal BP is ________ for older adults.
|
The same as younger adults 120/80
|