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104 Cards in this Set

  • Front
  • Back
The Five vital Signs are:
temperature - T
pulse - P
respiration - R
blood pressure - BP
and pain.
Assessment of vital signs in these patients should be performed every:
hospitalized- every four hours.
critical care - continually via monitors.
long term care - monthly
Medicare A - daily(Medicare-payed skilled nursing care).
it is the nurse's responsibility to ensure accuracy of data and to report abnormal findings.
unexpected changes should be double-checked.
Body Temperature
the difference between the heat produced by the body and amount of heat lost to the environment.
Body Temperature:
surface measurement sites:
oral(sublingual)
axillary,
skin surface.
Body Temperature:
core measurement sites:
tympanic
rectal
& by invasive monitoring devices:
esophagus
pulmonary artery
bladder.
Core temperature variations by time of day:
circadian rhythm:
lowest in morning by about 0.6 C( 1 - 2 F).
highest in late afternoon, between 4 and 7 p.m.
Core temperature is normally:
higher than surface body temperature'
within a range of:
36.0 C(97.0 F) to 37.5 C(99.5 F).
Core temperature is maintained within a fairly constant range by:
the thermoregulatory center in the
Hypothalamus which receives messages from the cold and warm thermal receptors located throughout the body and either produces or conserves heat..
The primary source of heat in the body is:
metabolism of cellular functions and muscle movement.
Shivering
increases heat production,
muscle tremors are initiated by the hypothalumus along with contraction of pilomotor muscles in the skin- piloerection -goosebumps- reduce surface area of the skin and minimize heat loss.
Modes of heat loss:
sympathetic control of arteriovenous shunts in the skin in response to core temperature and external environment.
evaporation of sweat.
warming of inspired air.
elimination of urine and feces.
The physical processes that transfer heat to the external environment:
Radiation - diffusion of heat by electromagnetic waves from uncovered surfaces.
Convection - dissemination of heat between areas of unequal density-a fan blowing cool air on your body.
Evaporation - the conversion of perspiration into vapor.
Conduction - the transfer of heat to another object during direct contact- heat transferred to an ice pack on the skin.
Circadian rhythm
recurring every 24 hours.
Factors affecting body temperature:
circadian rhythms,
age,
gender,
stress,
environmental temperatures.
Body Temperature Range:
Normal
36 C(97.0 F) to 37 C(98.6 F)
Body Temperature Range:
Hypothermia
34 C(93.2 F) -death to 35 C(95.0 F)
Body Temperature Range:
Pyrexia
38 C(100.4 F) to 40 C(104.0 F)
Body Temperature Range:
Hyperpyrexia
41 C(105.8 F) to 44 C(111.2 F)-death.
Afebrile
without fever.
Febrile
with fever
Pyrexia
fever. above 37 C(98.6 F).
occurs in response to an upward displacement of the thermoregulatory set point from cytokines produced by pyrogens.
or:
tissue injury from myocardial infarction,
pulmonary emboli,
trauma
& surgery.
Pyrogens
microorganisms or substances that cause fever.
The onset and significance of fever from an illness differs by age:
onset can be sudden or gradual.
-more rapid in children.
-a mild elevation in infants <3 months ,which do not have a well-developed temperature control, may indicate a serious infection.
-older adults may have only a slight elevation even with a serious infection.
Hyperthermia
elevated body temperature.
not a fever.
thermoregulatory set point of the hypothalamus is not changed and mechanisms that control body temperature are ineffective.
ex: extreme heat exposure or excessive heat production during strenuous exercise.
Neurogenic fever
result of damage to the hypothalamus from pathologies such as:
intracranial trauma, bleeding or
increased pressure.
this does not respond to antipyretic medications.
FUO
Fever of Unknown Origin
a fever of 38.3 C(101 F) or higher that lasts for 3 weeks or more without an identified cause.
Intermittent Fever
when the temperature alternates regularly between a period of fever and a period of normal or subnormal temperature.
Remittent Fever
when the temperature fluctuates several degrees more than 2 C(3.6 F) above normal but does not reach normal between fluctuations.
Constant Fever
the temperature remains consistently elevated and fluctuates less than 2 C(3.6 F).
Relapsing Fever
the temperature returns to normal for at least a day, but then the fever recurs.
Crisis (Fever)
when the fever returns to normal suddenly.
Lysis (Fever)
when the fever returns to normal gradually.
Fever blisters
fever activated type 1 herpes simplex virus.
Fever control
antipyretics-aspirin and acetaminophen reset hypothalamic set point.
cool sponge baths
cool packs
hypothermia blankets
Aspirin should not be given to:
children under age of 2,
children and teenagers with chickenpox or influenza because of a possible association with Reye's Syndrome.
Electronic thermometers
measure oral, rectal or axillary body temperature within 1 to 60 seconds with a numerical display and disposable covers.
Tympanic Membrane thermometers
use infrared sensors to detect heat emitted by the tympanic membrane within 1 to 3 seconds.
not to be used if there is drainage or scars on the membrane.
Disposable thermometers
single-use & non-breakable
record temp.of skin within seconds.
used in isolation.
color changing patches are available, too., for young children.
Temporal thermometers
measure temperature from temporal artery.
Oral temperatures should not be taken with:
patients with oral surgery or disease of oral cavity, or those on on oxygen.
those who eat hot,cold food, smoke or chew gum must wait 15-30 minutes before temperature is taken.
Anal temperatures should not be taken with:
newborns,
children with diarrhea,
those having rectal surgery or disease.
insertion in rectum stimulates vagus nerve and should not be used in those with cardiac surgery or disease.
those who are neutropenic(low white blood cell counts such as leukemia) or neurologic disorders such as spinal cord injuries.
Peripheral Pulse
throbbing sensation palpated over a peripheral artery, radial or carotid.
left ventricle ejects blood into the already full aorta and the smooth muscle in the artery expands to compensate for the increased pressure.
Apical Pulse
auscultated(listened to) over the apex of the heart by the mitral valve..
found at the the fifth intercostal space, just inside the left midclavicular line.
Characteristics of a pulse:
rate
quality(strong or weak)
volume(stroke volume)
rhythm
Stroke volume- SV
quantity of blood forced out of left ventricle with each beat.
Cardiac Output- CO
the amount of blood pumped per minute.
CO=SV x HR
CO averages 3.5 to 8.0L/min.
Heart Rate
Beats/min.
Pulse is regulated by
autonomic control of the sinoatrial node(SA) the pacemaker.
Parasympathetic stimulation of the SA node via the vagus nerve decreases HR.
Sympathetic stimulation of the SA node increases HR and force of contraction.
Normal pulse rates at rest
60 to 100 beats/min.
Tachycardia
a rapid heart rate-100 to 180beats/min.
it decreases cardiac filling time,
which
decreases stroke volume and cardiac output.
Bradycardia
slow heart rate-below 60 beats/min.
HR normally slows during sleep, in men and thin people, older people.
Sinus bradycardia results from a slower firing of the SA node- this is seen during sleep, hypothermia and trained athletes, beta blockers and vagal stimulation,severe pain, increased intracranial pressure and MI.
emergency treatment consists of intravenous atropine to block vagal stimulation.
Pulse Amplitude and Quality
amplitude describes quality of pulse in terms of its fulness and reflects the strength of the left ventricular contraction.
0 =Absent pulse =No pulsation is felt despite extreme pressure.
1+ = Thready pulse =Pulsation is not easily felt, and slight pressure causes it to disappear.
2+ = Weak pulse = Stronger than a thready pulse; light pressure causes it to disappear.
3+ =Normal pulse = Pulsation is easily felt, takes moderate pressure to cause it to disappear.
4+ = Bounding pulse = The pulsation is strong and does not disappear with moderate pressure.
Pulse Rhythm
pattern of pulsations and the pauses between them.
described as normal, weak or bounding.
Dysrhythmia
an irregular pattern of heartbeats and pauses that occur with no pattern or predictability.
described as bisferiens, pulsus alterans or bigeminal.
Stethoscope
diaphram is the large flat disk that is useful for hearing high frequency sounds like respiratory sounds.
the bell has a hollowed appearance hears low frequency sounds commonly made by the heart and blood vessels.
Peripheral arterial pulse sites
--radial- used most often.
femoral, popliteal,posterior tibial and dorsal pedalis assess circulation to the feet and legs.
-brachial used most often for infants.
-carotid is used in emergency assessments.
Pulse deficit
a difference between the apical and radial pulses.
a large value >10 indicates that all the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.
Respiration
involves ventilation,diffusion, and perfusion.
Ventilation
breathing-the movement of gasses in and out of the lungs.
inhalation & expiration.
has both autonomic and voluntary control.
Diffusion
the exchange of oxygen and carbon dioxide between the alveoli and circulating blood.
Perfusion
the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells.
The rate and depth of breathing can change in response to tissue demands and are brought about by
inhibition or stimulation of the respiratory muscles by the respiratory centers in the medulla and pons.
Activation of the respiratory centers occurs via:
-carbon dioxide changes detected via chemoreceptors located in the aortic arch and carotid arteries.
-stretch and irritant receptors in the lungs.
-cerebral cortex allows voluntary control.
-receptors in muscles and joints.
Eupnea
normal breathing.
respiratory rate decreases with age
newborn = 30-60 breaths/min
adult = 12-20 breaths/min
Tachypnea
increased respiratory rate.
during fever, the rate increases as much as 4 breaths/min. per every 0.6 C(1 F).
Bradypnea
a decrease in respiratory rate.
seen in depression of the respiratory center,
brain damage.
Apnea
periods during which there is no breathing.
death or brain damage may occur if apnea lasts longer than 4 to 6 minutes.
Dyspnea
difficult or labored breathing.
Orthopnea
when dyspneic people can breathe more easily in an upright position.
Normal respiration rate
12-20 breaths/min.
Tachypnea respiration rate
more than 24 breaths/min.
Bradypnea respiration rate
less than 10 breaths/min.
Hyperventilation
increased respiration rate and depth.
Kussmaul's respirations seen in diabetic ketoacidosis
seen in an overdose of aspirin,
extreme exercise and fear.
Hypoventilation
decreased respiration and depth; irregular.
can occur when there has been an overdose of narcotics or anesthetics.
Cheyne-Stokes
alternating periods of deep, rapid breathing followed by periods of apnea;regular.
indicative of impending death.
seen in increased intercranial pressure and renal failure.
Biot's
varying depth and rate of breathing, followed by periods of apnea;irregular. seen with sever brain damage.
Blood Pressure
the force of the moving blood against arterial walls.
the pressure rises as the left ventricle contracts-SYSTOLE.
the pressure falls as the left ventricle relaxes-DIASTOLE.
the continuous cantraction and relaxation of the left ventricle creates a pressure wave that travels through the arterial system.
Systolic Pressure
the highest pressure on the arterial walls..
Dyastolic Pressure
the lowest pressure on the arterial walls...
Pulse Pressure
the difference between systolic and diastolic pressures.
a wide value indicates an increased intercranial pressure
a narrow value indicates poor cardiac output.
Systolic and Diastolic pressures are determiined by
Cardiac output and peripheral resistance.
Peripheral resistance reflects
blood viscosity and changes in the radius of the arterioles.
Blood pressure is measured in
mm Hg.- millimeters of mercury.
Compliance
the stretch and distention of the elastic tissue in arterial walls with each contraction.
Hypertension
sustained above normal blood pressure of 140/90mmHg.
Hypotension
below normal systolic blood pressure of 90-115mmHg.
Orthostatic Hypotension
aka postural hypotension.
a drop in systolic bp equal or greater than 20 mmHG. or 10mmHG diastolic within 3 minutes of supine to standing, sitting or sitting to standing.
it is a result of vasodilation without a compensatory rise in cardiac output.
Korotkoff Sounds
sounds heard when using a stethoscope to assess blood pressure.
the first sound heard is the onset of phase 1 and represents the systolic pressure.
phase 4 and 5 are the levels at which a change in or a cessation of sound takes place and this is the diastolic pressure.
The most common sites for assessing blood pressure are the
brachial artery and the popliteal artery.
Popliteal Artery blood pressure
systolic pressure is normally 10 to 40 mmHg higher at this site, and the diastolic is usually the same.
hypoxia
inadequate amount of oxygen available to the cells.
hemothorax
blood in the pleural space.
pleurae
membranes that cover the lungs.
pleural effusion
fluid in the pleural space.
pneumothorax
air in the pleural space.
spirometer
instrument used to measure lung capacity and volume.
pulse oximetry
a non-invasive technique that measures the arterial oxyhemoglobin saturation SaO2 or SpO2 of arterial blood.
they also measure pulse rate.
useful for monitoring patients receiving oxygen therapy,
titrating oxygen therapy,
monitoring postoperative patients and those at risk for hypoxia.
SpO2 values of 95-100% are normal.
pulse oximetry
hemoglobin level should be tested because pulse oximetry only measures % of oxygen carried by the available hemoglobin, not its level in the blood.
Erb's point refers to
the third intercostal space on the left sternal border where S2 is best auscultated.
avoiding an auscultatory gap
Determining systolic blood pressure by palpatory method before recording the blood pressure with auscultatory method.
Inflating the blood pressure cuff to 20-40 mmHg higher than the pressure required to occlude the brachial pulse.
auscultatory gap
An auscultatory gap also called as silent gap is the interval of pressure where korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point during the manual measurement of blood pressure by auscultatory method. The auscultory gap occurs when the first Korotkoff sound fades out for about 20-50 mmHg only to return. It can result in following erroneous blood pressure reading:

Underestimation of systolic blood pressure
Overestimation of diastolic blood presssure
An auscultatory gap is common in elderly hypertensive patients. It occurs in some hypertensive patients only. Auscultatory gaps are related to carotid atherosclerosis and to increased arterial stiffness in hypertensive patients
pulse for a newborn is
80-180 beats/min.
respiration for a newborn is
30-80 breaths/min.
blood pressure for a newborn is
73/55