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60 Cards in this Set
- Front
- Back
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What are vital signs?
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- measurement of temperature, pulse, respiration and blood pressure while the client is at rest
- wait at least 15 minutes after any activity before taking VS - May also include the measurement of oxygen saturation and pain |
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When should VS be taken?
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- on admission
- per hospital routine or doctor's orders - before and after surgery or procedure - before, during, and after blood/blood product transfusion - when there is a change in client's condition or a report of physical distress |
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What is the definition of body temperature?
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- The heat of the body determined by the balance of heat produced and heat lost
- stated in F or C |
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What is core temperature?
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- reflects temperature of core body tissues (muscles, viscera)
- ex.) tympanic and rectal temps |
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What is surface temperature?
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- temperature varies according to site used
- lower than core temp - ex.) oral and axillary |
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How does neurovascular control affect body temperature?
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- hypothalamus (thermoregulatory center - maintains setpoint) receives messages from thermal receptors to produce body heat or increase heat loss
- feedback system: when nerve cells in hypothalamus become heated, setpoint increases. |
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What are compensatory mechanisms for regulating body heat?
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- sweating and vasodilation to promote heat loss (and cool down)
- muscle shivering and vasoconstriction to conserve heat (and warm up) |
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What is the primary source of heat production?
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- Metabolism
- BMR (basal metabolic rate): heat production at rest - Muscle activity (exercise) increases body metabolism - Shivering increases body metabolism |
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What are the mechanisms of heat transfer/loss?
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- radiation: sitting in a cold room (diffusion of heat by electromagnetic waves)
- conduction: taking a cool bath (transfer thru direct conduct) - convection: using an electric fan to cool off (thru air currents) - evaporation: sweating and respiration (conversion of liquid to vapor) |
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What are fever/pyrexia and hypothermia?
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- Fever: temp is above 100.4 F or 38 C
- Hypothermia: temp is below 96.8 F or 36 C |
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What are the normal values for temperature?
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Axillary: 96.6 F - 97.6 - 98.6
Oral: 97.6 - 98.6 - 99.6 Rectal: 98.6 - 99.6 - 100.6 |
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What are key characteristics of the oral method of assessment for temperature?
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- easily accessible, most commonly used
- wait at least 15 minutes before - Takes 3-5 min for gallium thermometer - Contraindications: mouth breathing, uncooperative, seizures, unconscious, younger than 6 years, nasal or oral surgery or trauma |
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What are key characteristics of the rectal method of assessment for temperature?
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- more accurate than oral, but inconvenient and invasive
- must insert 1.5 in for adults, 1 in for children, 0.5 in for infant - Takes 2-4 min - Contraindications: rectal or prostate surgery or disorders, diarrhea or impacted stool, serious heart disease (don't want to stimulate vagus nerve) |
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What are key characteristics of the axillary method of assessment for temperature?
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- safest, noninvasive
- axilla must be dry - use gallium or electronic thermometer - takes 8-10 min for gallium thermometer |
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What are key characteristics of the tympanic method of assessment for temperature?
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- easily accessible
- reliable non-invasive core temp, quick - best to use in children older than 2 - Complication: injury to tympanic membrane |
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What are key characteristics of using the temporal artery for assessment of temperature?
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- easily accessible
- fast - reliable - non-invasive core temp |
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What indicates fever in an adult and what are the causes?
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- greater than 100.4 F or 38 C
- Infection, inflammatory, or immunologic processes - Endogenous pyrogens trigger fever response and act on hypothalamus to raise body's setpoint above normal |
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What are beneficial consequences of fever?
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- stimulates the immune system to produce disease-fighting WBCs
- decreases iron in blood plasma which suppresses bacterial growth - In viral infections, increases production of interferon, a virus-fighting substance |
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What are harmful consequences of fever?
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- increases BMR, Pulse, and Respiratory rates
- excessive sweating may lead to dehydration - prolonged fever may result in tissue catabolism, muscle wasting, aching, negative nitrogen balance, weight loss, apathy, delirium, and withdrawal - fever above 41 C or 105.8 F may lead to seizures or neurological complications |
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What are the 3 phases of the febrile episode?
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1. Chill phase (heat conserved): setpoint rises, chills and shivering
2. Plateau Phase: chills subside, warm and dry feeling b/c new temp setpoint is reached 3. Fever Break (heat is lost): vasodilation, diaphoresis b/c setpoint decreases and body is trying to lose heat and return to normal setpoint |
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What is done in the Assessment phase of caring for clients with fever?
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- assess for causality (dehydration, infection, environment, etc.)
- monitor VS - Assess skin color and temp - determine phase of febrile episode |
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What nursing Interventions are used to care for clients with fever?
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- decrease heat production
- increase heat loss - Meet increased BMR needs (administer O2 as ordered ) - Promote client comfort (frequent oral hygiene, prevent shivering) - blood cultures and specimens should be obtained at the time of the temp spike when the causative organism is most prevalent - teach client as indicated |
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What is cardiac output?
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- Volume of blood pumped by the heart during ONE MINUTE
CO = HR x SV (stroke volume) |
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What is stroke volume?
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- total volume of blood into the aorta with each contraction
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What is the definition of pulse/heart rate (P/HR)?
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- During systolic phase of cardiac cycle, the left ventricle (LV) ejects ~60-70 ml of blood volume into the aorta. As the blood travels thru peripheral arteries, can be felt as pulse
- Adult normal range is 60-100 BPM |
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What is neural regulation?
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- Pulse rate is regulated by the ANS via the parasympathetic Vagus nerve - SLOWS the pulse rate
- Sympathetic nervous system INCREASES pulse rate by releasing epinephrine and norepinephrine -> more forceful contraction of left ventricle |
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What are some factors that affect HR/P?
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- Age (infants have higher HR)
- Sex (males are lower) - Activity - Fever - Medications - Hemorrhage increases HR - Stress increases HR - Position changes - Vagal stimulation decreases HR - Fear/anxiety/pain increases HR |
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What are the methods of assessing the pulse?
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- palpation
- auscultation |
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What are the sites for assessment of the pulse?
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- Carotid (most accurate, only one at a time to not interfere with blood flow to brain)
- Radial (most common) - Brachial (used in infant CPR) - Femoral - Popliteal - Pedal Pulses (Dorsalis pedis and Posterior tibial) |
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What is the apical pulse and how is it taken?
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- Central, auscultate over precordium (5th intercostal space, midclavicular line) and count for full 60 seconds
- most accurate pulse, must be assessed if abnormal pulse and if client has CV disease - 2 sounds correlate with systole (S1) and diastole (S2) and are counted as 1 heartbeat |
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When is the apical-radial pulse measured?
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- simultaneous measurement of both pulses to assess if there is a pule deficit - should be identical
- pulse deficit occurs when the APICAL pulse is greater than a peripheral pulse - indicates poor peripheral circulation/perfusion - measurement of apical-radial pulse by 2 nurses at the same time for 60 seconds will confirm if there is a pulse deficit |
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What should the pulse be assessed for?
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- Rhythm: regular or irregular
- Amplitude (volume): only measured by palpation 0 = absent 1 = difficult to feel 2 = normal 3 = strong, bounding - Rate: number of beats per min. If regular count for 30 seconds and double, if irregular count for 60 sec - Elasticity: compliance of arteries. Normal is soft, abnormal is hard - Equality: compare peripheral R and L |
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What are bradycardia and tachycardia?
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- Bradycardia: HR below 60 beats/min
- Tachycardia: HR above 100 beats/min |
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What should be reported immediately with regard to heart rate?
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- absent, weak, thready pulse; pulse deficit
- significant change in resting pulse - change in volume or rhythm - cool, pale skin |
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What should be documented with regard to heart rate/pulse?
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- Location, rate, rhythm, volume, elasticity
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What are respirations?
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- act of breathing for 1 minute
- cycle of inspiration and expiration counts as 1 breath |
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What are the muscles of respiration?
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- Diaphragm: inhale - goes out
- Intercostal: Muscles b/w ribs - Accessory: sometimes used, muscles in neck. Only used when person is having difficulty breathing |
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What are the 3 processes of respiration?
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- Ventilation: how often, deep, regular does person breathe in/out
- Diffusion: How does CO2 diffuse out of blood into alveoli - Perfusion: How does O2 get into the blood and throughout body |
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What contributes to neural and chemical regulation?
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- neural regulation
- cerebral cortex (automatic) - medulla oblongata - chemical regulation - chemoreceptors (short-acting, adaptive) |
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What is the normal respiration rate for an adult?
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- 12-20 breaths per minute - Eupnea
- 28-30 could indicate a catastrophic event is about to occur - count for a full minute if respirations are fast/slow/irregular - Bradypnea: less than 12 - Tachypnea: greater than 20 - Apnea: lack of resp. movement |
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What are the characteristics of effort/ease with respirations?
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- Eupnea: normal rate/depth
- Dyspnea: SOB, sensation of breathlessness - Labored: abnormal, use of accessory muscles in neck and intercostals - Orthopnea: person needs to be in certain position to breathe |
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What does TPR stand for?
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Temperature/Pulse/Respirations
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What are the characteristics of depth of respirations?
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- Full: normal
- Hypoventilation: shallow, mainly just shoulders moving - Hyperventilation: can see chest wall moving - Sigh |
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What are abnormal patterns of oxygen saturation in respirations?
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- Kussmaul: usually associated with ketoacidosis, form of hyperventilation
- Cheyne-Stokes: slow, deep, slow, fast - Agonal: occurs when person is dying |
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What factors influence the character of respirations?
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- exercise
- acute pain - anxiety - smoking - body position - medications - neurological injury - hemoglobin function |
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What are normal respiratory changes in elderly clients?
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- decrease in elasticity
- shallow (might need to feel or use stethoscope) - slightly faster (22-24 BPM) |
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What is pulse oximetry?
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- oxygen saturation of arterial blood
- measured by pulse oximetry monitor - normal level is 95-100, less than 70 is life-threatening |
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What is blood pressure?
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- arterial BP measures the arterial wall pressure created as blood flows thru the arteries throughout cardiac cycle
- Systolic BP: higher value, more pressure as the LV ejects blood - Diastolic BP: lower value, when the heart relaxes |
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What is pulse pressure?
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- the difference in systolic and diastolic BP
- Range: 30-50 mmHg - Abnormal pulse pressure may indicate neurological or cardiac dysfunction |
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What are abnormal/normal BP readings?
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- Normotensive: 90/60 - 119/79
- Pre-Hypertensive: 120/80 - 139/89 - Hypertensive: 140/90 or above * Important to know the baseline BP for individual patient * |
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The physiology of BP is the interrelationship of what?
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- Cardiac output: stroke volume pumped in one minute
- peripheral resistance: determined by tone of vascular musculature and diameter of blood vessels - Blood volume: volume of blood circulating within vascular system - viscosity: thickness of blood - Elasticity: ability of arteries to stretch, as we get older we lose elasticity |
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Which factors affect BP?
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- Age
- Stress - Gender - Race (blacks have hypertension) - Diurnal Variations (lower while sleeping and in the morning) - Medications (vasoconstrictors increase BP, vasodilators decrease) - Activity - Disease process |
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What is hypertension?
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- above 140/90 in an average of 2 or more readings taken at each of 2 or more visits
- Symptoms may be fatigue, headache, flushing of face, nosebleed - May be asymptomatic |
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What is hypotension?
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- Below 90/60 in a person who is normally higher than that
- Symptoms are pallor, skin mottling, clammy, confusion, dizziness, chest pain, increased heart rate, decreased urine output |
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What is orthostatic hypotension?
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- BP drops when person changes position
- AKA postural hypotension - Drop of 20 or more systolic, 10 or more diastolic |
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What are risk factors?
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causes
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What are complications?
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what is the result
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What are the methods to assess BP?
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- Direct - arterial line: invasive, used in hospitals
- Indirect: palpatory (only used for systolic) or auscultatory |
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What is the equipment used for indirect measurement of BP?
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- BP cuff with inflatable bladder, width should be 40% of the circumference of the midpoint of the limb on which the cuff is used.
- Sphygmomanometer: aneroid (dial) or mercury (Hg) - stethoscope |
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What are common mistakes in BP assessment?
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- wrong size cuff
- haste - "0" preference |
