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199 Cards in this Set
- Front
- Back
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heat transfer
diffusion of heat by electromagnetic wave |
radiation
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sitting in a cold room transfers heat through
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radiation
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heat transfer through direct contact
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conduction
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taking a cool bath transfers heat?
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conduction
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heat transfer through air currents
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convection
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using an electric fan to cool of is ex. of ____heat transfer
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convection
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heat transfer by the conversion of liquid to vapor
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evaporation
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sweating and respiration are examples of heat transfer through
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evaporation
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Factors that affect body temperature
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age, diurnal variations, exercise, hormones, stress, environment
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contraindication of oral temp
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mouth breathing, uncooperative, seizures, unconsciousness,younger than 6, nasal/oral surgery/trauma
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contraindications of rectal temp
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rectal or prostate surgery/disorder, diarrhea or impacted stool, serious heart disease, newborns
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why is serious heart disease a contraindication of rectal temp
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vagal stimulation may slow heart rate
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why is rectal temp contraindicated in newborns
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could perforate rectal wall
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____ is a wave of blood created by contraction of the left ventricle of the heart
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pulse
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____is the amount of blood that enters the arteries with each ventricular contraction
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cardiac output
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___is the amount of blood ejected with each cardiac contraction ( pulse wave)
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stroke volume
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Pulse sites
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temporal, carotid, apical, brachial, radial,femoral, popliteal, dorsalis pedis, posterior tibial
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5 characteristics of a pulse
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rate, rhythm, volume, arterial wall elasticity, equality
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the difference between the apical and radial pulse
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pule deficit
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when & how to measure pulse deficit
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when apical is greater than peripheral. two nurses measure at same time for 60 seconds
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what is the significance of a pulse deficit
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indicates poor peripheral circulation/perfusion
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mechanism used by to body to exchange gases between atmosphere. blood, and cells. the act of breathing
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respiration
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3 processes of respiration
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ventilation, diffusion, perfusion
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movement of gas in and out of lungs
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ventilation
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movement of O2 and CO2 between alveoli and RBCs in pulmonary blood vessels
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diffusion
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distribution fo RBCs to and from pulmonary capillaries
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perfusion
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assessing ventilation assesses
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resp rate, depth, rhythm
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diffusion assesses
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O2 saturation
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Perfusion asseses
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O2 saturation
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how to assess rhythm?
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regular or irregular
sigh is regular |
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describe normal respiration rhythm
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evenly spaced and uninterrupted 12-20 count for one full minute
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to assess rate of respiration?
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count 30 sec. multiply by 2
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normal resp rate
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12-20 breaths per minute
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normal respiration, quiet rhythmic and effortless
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eupnea
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abnormal slow breathing, less than 12 breaths per minute
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bradypnea
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quick shallow breaths
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tachypnea
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cessation of breathing
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apnea
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Effort/ease of resp. are descibed as
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eupnea, dyspnea, labored, orthopnea
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difficult and labored breathing, evidence of unsatisfied need for air and distress
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dyspnea
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abnormal resp. with increased use of accessory muscles, stridor, grunting, nasal flaring
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labored
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shrill harsh sounds during inspiration with laryngeal obstruction
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stridor
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ability to breath only in upright sitting or standing
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orthopnea
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Depth of resp are described as
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full, hypoventilation, hyperventilation, sigh
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to assess depth of resp
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observe chest wall movement, palpate chest wall excursion, auscultate post/ant thorax
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measures the arterial wall pressure created as blood flows through the arteries throughout the cardiac cycle
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blood pressure
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systole?
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when LEFT ventricle ejects blood
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diastole?
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when the heart relaxes
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the difference in systolic and diastolic BP
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pulse pressure
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Normal range of pulse pressure
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30 - 50 mm Hg
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if pulse pressure is abnormal it may indicate
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neurological or cardiac dysfunction
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BP can be measured on the _ or __
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arm , thigh
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BP can be direct or indirectly measured
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true
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instruments to measure BP
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cuff & bladder, sphygmomanometer, stethoscope
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Factors that affect BP
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age, stress, gender, race, diurnal variations, medications, activity, disease process
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factors that affect pulse
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age, gender, exercise, fever, meds, hypovolemia, stress, position changes, pathology
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factors that affect respiration
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exercise, stress, environment temp, lowered oxygen increase rate///lowered environment temp, meds, intracranial pressure decrease rate
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assess resp when the client is
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relaxed
non active for 5-10 min |
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assess temp when?
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patient hasn't eaten, drank, smoked, chewed gum for 15 min
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if patient has been active wait___ bf taking pulse and if they have smoked wait___
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5-10 min
15 min |
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to asses bp make sure patient hasn't
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exercised, has caffeine, or smoked for 30 min
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Normal oral temp
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97.6 -99.6F
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Normal rectal temp
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1F higher than oral
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Normal axillary
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1F lower than oral
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Normal tympanic
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0.5F higher than oral
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normal pulse
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+2, easy to feel, obliterates with stronger force; 60-100BPM, soft & pliable elasticity; compare right and left for equality
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normal resp
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12- 20 breaths per min
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factors that affect respiration
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exercise, pain, anxiety, smoking, body position, meds, neurological injury, hemoglobin function
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bp norms
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90/60 - 139/89
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in the older adult, temp is ___
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lower
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pulse rate in elders
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decreases
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elders have __ resp
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lowered
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bp in elders in elevated bc
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elasticity of the arteries has decreased
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measurement of temp, pulse, resp, and blood pressure while patient is____ for vital signs
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at rest
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wait ____after activity bf taking vs
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15 min
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vital signs are taken to
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monitor essential physiologic functions of vital organs and to evaluate health status
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Observe TRENDS in VS to do________, make decisions about______,evaluate______, and evaluate______
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clinical problem solving
treatments/interventions meds/interventions response to illness |
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are VS taken on admission
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yes
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VS are taken per hospital routine and physician's orders
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true
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bf and after surgery or procedure or meds or nursing internventions what should be done
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VS
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when should VS be taken suring blood/blood product transfusion
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before, during, after
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if there is a change in client's condition or they report a physical distress, DO
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VS
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neurovascular controller of temp
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hypothalamus
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when nerve cells in hypoth. become heated, ______happens
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the setpoint increases and compensatory mechanisms kick in to promote heat loss
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mechanisms to promote heat loss
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sweating and vasodilation
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primary source of heat is
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metabolism
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5 factors that affect body heat production
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BMR
Muscle activity thyroxine output epi,norepi, symp. stim fever all increase met. rate |
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fever/pyrexia temp
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>100.4 or 38C
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hypothermia, subnormal temp
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<96.8 F or 36C
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types of thermometers
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shake down, elctronic, chemical, temp-sensi tape, infrared, tympanic
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most accurate temp
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rectal
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safest temp
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axillary, must be dry, 8-10min
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accurate core temp, quick
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tympanic..pull pinna back& up
or under 3 pull back & down |
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if a fever occurs, it may be caused by
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infection, inflammatory or immunologic process
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pyrogen
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substance that induces fever
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endogenous pyrogens trigger the fever response and act on_____to raise body's ____
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hypothalamus
setpoint |
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how long for oral temp
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3-5 min
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gloves are required for rectal temp
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true
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how to take rectal temp
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lubricate, insert towards umbilicus, adult: 1.5 in, child: 1 in, infant:0.5 in
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Beneficial consequences of fever
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stimulates immune system to produce disease fighting WBC
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Fever decreases___ in blood plasma, which_____
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iron
suppresses bacterial growth |
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In viral infections, fever ____
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increases production of interferon, a virus fighting substance
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Harmful effects of fever
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increased BMR, Pulse, Respiration; possible dehydration
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Prolonged fever may result in
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tissue catabolism, muscle wasting, aching, negative nitrogen balance, weight loss, apathy, delirium, withdrawal
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fever above ____may lead to seizures, or neurological complications
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41C
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3 phases of febrile episode
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chill
plateau break |
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in the chill phase of fever____ is conserved
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heat
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a patient with chills and shivering is in the ___phase of fever
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chill
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why does the body shiver during chill phase
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setpoint is rising and body is trying to conserve heat
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symptoms of chill phase
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increased heart rate, resp rate and depth; shivering; pallid cold skin; complaints of feeling cold; cyanotic nail beds; goosebumps; cessation of sweating
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Describe plateau phase of fever
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chills subside, client feels warm and dry because new setpoint has been reached
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signs of plateau phase
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no chills; warm skin; photosensitivity; glassy eyes; Increased pule & resp& thirst; mild to severe dehydration; drowsi, restless, delirium, convulsions; herpetic lesions on mouth; lapse of appetite;malaise; weakness; aching muscles
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During the fever break___is lost
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heat
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during fever break vasonconstriction occurs
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false
vasodilation |
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the client sweats suring ___phase of fever because
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break
setpoint decreases and body attemptsto lose heat and return to normal setpoint |
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fever break AKA
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defervescence, abatement, flush
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signs of fever break
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sweating, flushed & warm skin, decreases shivering, possible dehydration
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remove extra blankets when client feels warm but provide them extra
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when chilled
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reduce physical activity during fever to limit___, especially during
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heat production, fever break
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when assesing clients with fever
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assess for causality(dehydration, infection, environment)
monitor VS assess skin color and temp determine febrile episode assess comfort level |
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fever interventions
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decrease heat production
increase heat lossmeet administered BMR needs promote comfort teach client |
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to increase heat loss during fever
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remove external covers, keep linens and clothes dry
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to meet BMR needs during fever
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O2 therapy as ordered
adequate nutrition and fluids( 3 L day for normal cardiac/renal function |
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to promote client comfort during fever
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oral hygeine
control environment temp |
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the pulse is the heart rate
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true
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systole phase LV ejects
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60-70 mL blood into aorta
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regulates pulse rate
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ANS via parasympathetic VAGUS nerve
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Vagus nerve affect on pulse rate
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slows
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To increase pulse rate, symp. nervous syst?
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releases epi/norepi
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what does epi/norepi do
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faster contraction of left ventricle
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factors affecting pulse
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age, sex, activity, fever, meds, hemorrhage, stress, position change, vagal stimulation(GI-gag, vomit, deficate,strain)carotid artery sinus(
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asses pulse by
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palpate ( 3 mid fingers)
auscultate(steth or doppler) |
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which pulses should be assessed on each client
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carotid, radial, pedal
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most accurate pulse of peripheral
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carotid
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why do you use lower half carotid
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to avoid stimulating carotid sinus and vagus nerve
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why palpate only one carotid at a time
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so blood flow to brain is not compromised
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most common pulse site__
where? |
radial, thumb side
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pulse site used in infant cpr
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brachial
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circulation to leg is checked at
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femoral pulse
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Central pulse is auscultated over
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precordium
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most accurate pulse site
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apical
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apical--steth over___,__ventricle.PMI usually heard loudest at
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apex, LV
5 LICS, MCL |
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PMI
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point of maximum thrust/impulse
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one heartbeat +__sounds
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2
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apical and radial pulses should be
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identical
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amplitude/volume of pulse is
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strength or force, quality
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amp of pulse is measured by
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0--absent
+1--difficult to feel, ez obliterate +2--normal +3--strong, bounding, difficult to obliterate |
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bradycardia
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less than 60beats/min pulseq
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tachycardia
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more than 100 pulse beats per min
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when checking pulse, immediately report
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absent, weak,tready,deficit
significant change in resting pulse change in vol/rhythm cool, pale skin |
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to document pulse
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location, rate, rhythm, volume, elasticity
ex. radial 88/m regular, +2 smooth ex. apical 54/m, irregular |
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cycle of inspiration and expiration
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one breath
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act of breathing for 1 min
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respiration
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muscles of respiration
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diaphragm, intercostal, accessory
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controls rhythm, depth, balnce between inspiration and expiration, need more oxygen
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neural regulation
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voluntary control of resp
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cerebral cortex
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automatic control of resp
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medulla oblongata
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chemical regulation of respirations
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controls rate and depth based on changes in blood levels of CO2, O2, and H+
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chemoreceptors regulate resp
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short term adaptive responses from changes in concentration of O in arterial blood; centrally in medulla and peripherally in carotid and aortic bodies
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asses resp
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observe rate, rhythm,effor/ease,depth;
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depth of resp
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full, hypoventilation, hyperventilation, sigh
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normal volume of resp(depth)
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500 mL
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abnormal resp. Kussmaul
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deep rapid breathing seen in acidosis
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what is happening in Kussmaul
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body tries to give off excess body acids by blowing off CO2
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abnormal Cheyne-Stokes respiration
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alterating periods of very deep to very shallow breathing periods of apnea
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abnormal agonal resp
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irregular, erratic pattern seen in dying client
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normal changes in elderly resp
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decreased elasticity of tissue
shallow slightly faster 22-24 |
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prehypertensive BP
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120/80-139/89
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hypertensive stage 1
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greater than 140/90
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hypertensive stage 2
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greater than 160/100
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prehypertensive requires
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healthy lifestyle modifications
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Cardiac output =
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volume of blood pumped by heart in one minute
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CO=
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HR x SV
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BP=
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CO x resistance
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resistance to blood flow determined by tone of vascular musculature and diameter of blood vessels
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peripheral resistance
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volum of blood circulating within vascular system
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blood volume
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thickness of blood
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viscosity
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ability of arteries to stretch
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elasticity
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how does stress affect BP
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increased CO and vasoconstriction
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gender and Bp
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males-after puberty increases
females -after menopause |
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bp decreases in sleepand increases
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afternoon and early evening
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obesity increases bp
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true
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persistently elevated Bp
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hypertension
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symtoms of high BP
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headache
fatigue flushed face |
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risk factors of hypertension
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family history, obesity, smoking, alcohol, cholesterol, lipid levels, DM
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below normal BP
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hypotension
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signs of hypotension
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pallor, skin mottling, clamminess, confusion, dizziness, chest pain, increase heart rate, decrease urine output
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lowering of BP when client moves from sitting to standing
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orthostatic hypotension
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causes of orthostatic hypotension
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decreased blood volume, inadequate neurovascular, antihypertensive meds, immobility
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direct assessment of BP
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arterial line
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if cuff is too narrow, BP will
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false high
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if cuff is too wide, BP
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false low
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Korotkoff adult
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K1,5
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Korotchoff child
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K1,4
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occurs in hypertensive patients where there is temporary disappearance of sound over brachial artery when the cuff pressure is high followed by reappearance at lower pressure
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auscultatory gap
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K1
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sharp thump
systolic |
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K2
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murmur
swishing sound |
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K3
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crisper, not as strong as K1
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K4`
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softer blowing sound that fades
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K5
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silence( diastolic)
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