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80 Cards in this Set

  • Front
  • Back
What are the 6 vital signs?
Temperature, Pulse, Respirations, Arterial Blood Pressure, Pain, Oxygen Saturation
When are vital signs measured?
Before and after meds, as withdrawl precautions, when condition is worsening, if patient seems "wrong", when patient reports distress,on discharge, admission, transfer, surgery, transfusion, during invasive diagnostics
Delegation- Nursing responsibilities
Nurse may delegate but he/she is ultimately responsible for:
Accuracy, interpretation, verification, communication, documentation
transfer of heat between two objects without contact
transfer of heat from one object to another through direct contact
transfer of heat away by air currents
transfer of heat energy when a liquid is turned to gas.
Surface temperature
equal to the heat produced minus the heat lost. acceptable range 36-38c or 96.8-100.4f
Core temperature
reflects temperature of deep tissues may range from 95 to 100.4f. Pulmonary artery temp is the gold standard
Hypothalamic set point
maintained by vasodilation in response to increased body temp and vasoconstriction in response to decreased body temp.
Farenheit to Centigrade
Centigrade to Farenheit
(C* 9/5)+32
Site selection of Temps
Dependent upon age, mental status and disease process
Oral Temps advantage
reflects rapid change in core
Oral temps disadvantage
placement, age, oral surgery, mental status
Rectal temp advantages
Reflects core
Rectal temp disadvantages
positioning, does not reflect as rapid a change in core, invasive
Skin Temp advantages
able to use for continuous monitoring, non-invasive
Skin Temp disadvatages
doesn't reflect core, affected by environment, can not be used if pt is diaphoretic
Axillary advantages
easily accessible site
axillary disadvantages
does not represent core temp, placement can be difficult, requires pt cooperation
Sustained fever
temp greater than 100.4f or 38c continuously
Intermittent Fever
spikes: normal at least once in 24 hours
Remittent Fever
spikes and falls but not to baseline.
Relapsing Fever
like intermittent but spikes and normal last for longer intervals
Nursing care for pt with fever
obtain frequent readings, assess for signs and symptoms of fever, assess for contributing factors,obtain blood cultures if ordered, administer ordered meds, keep pt dry
involuntary response to temperature differences in body. Shivering can increase body temp 4 degrees. Babies do not shiver.
the palpable bounding of the blood flow in a peripheral artery as a result of cardiac contraction
Stroke volume
amount of blood ejected into the aorta on each contraction
Heart rate
number of ejections per minute
cardiac output
Pulse sites
Temporal, carotid, apical, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibialis
Normal pulse rate
60-100 bpm
over 100 bpm
under 60 bpm
Regular Heart Rhythm
regular time intervals between beats
Irregular Rhythm
an interval is interrupted by an early or late beat
Pulse deficit
calculated by counting the apical and radial pulses simultaneously. The difference between the two is the pulse defecit.
Arterial Blood pressure
the force exerted on the walls of an artery created by the pulsing of blood under pressure from the heart.
Systolic Blood Pressure
Maximum pressure as blood is ejected into aorta. Heart at work
Diastolic Blood Pressure
the pressure on the arteries when the heart is at rest. Heart relaxed. High diastolic means the heart is not recovering enough
Pulse pressure
difference between systolic and diastolic pressure
Mean arterial pressure
the avg pressure during a given cardiac cycle
Pysiologic factors affecting BP
blood volume, viscosity (measured by hematocrit), peripheral resistance, elasticity of arterial wall
Additional Factors affecting BP
age, stress, gender (men typically higher than women before menopause), race (bp higher in blacks 2x higher complications),daily variation (peaks in late eve), meds, activity
asymptomatic disorder characterized by persistently elevated blood pressure. One elevated reading does not qualify as diagnosis
Optimal BP
<120 systolic <80 diastolic
Normal BP
<130 systolic <85 diastolic
High Normal BP
130-139 systolic 85-89 diastolic
Hypertension Stage I
Systolic 140-159 Diastolic 85-89
Hypertension Stage II
Systolic 160-179 Diastolic 100-110
Hypertension Stage III
180-209 Systolic 110-119 Diastolic
Hypertension Stage IV
>210 systolic >120 diastolic
Hypotension Problems
orthostatic hypertension, occurs when pt develops low bp and is associated with symptoms when rising to upright position.
Common in elderly, may indicate fluid volume deficit, may be caused by meds
Cuff Size
The width of the cuff should be 40% of the circumference of the midpoint of the limb used. I.E. arm=15" so cuff size is 15*.40=6
Improper cuff sizing
Too lose too slow
Too tight too high
Too big too low
Too little too high
Baseline BP
measure in both arms should not deviate more than 10mmhg
Korotkoff Sounds
sounds heard over an artery during cuff deflation
normal breathing 12-20 bpm
absence of respirations
slow respirations <12 breaths per minute
rapid respirations > 20 breaths per minute
Cheyne Stokes Breathing
apnea interspersed with regular respirations
Kusmals Breathing
deep and fast
Ventillation Measurement
rate, rhythm and depth
the movement of Oxygen and co2 between the alveoli and rbc's. assessed by determining oxygen saturation
distribution of rbc's to and from pulmonary capillaries. assessed by oxygen saturation
Factors affecting respirations
age, exercise, anxiety, altitude,disease, medications(especially opiates)
Factors influencing SpO2 monitoring-interference with light monitoring
motion, carbon monoxide poisoning will give false high O2, dyes from studies, jaundice, nail varnish
SPO2- factors interfering with arterial pulsations
pulse defecit, cold hands, meds, hypotension, edema, hypothermia,peripheral vascular disease, probe too tight.
Two areas where bp may be auscultated
popliteal space or antecubital space
Purposes for a patient bath
Cleanliness, comfort, assessment, therapy, prevention of skin breakdown
Methods of bathing
complete, partial,sitz, shower, tub
inflammation of the mouth
Medial and lateral margins of the eye
bluish discoloration of the skin
change in or lack of nerve sensation
Nursing Diagnosis
a clinical judgment about individual, family or community responses to actual or potential problems. Nursing diagnoses are formed from the data collected during assessment.
Responsibilities related to bathing of patients
Provide privacy, maintain safety, maintain warmth, promote independence, anticipate needs
Pearls of personal hygiene
siderails up, suction available for unconcious pt., dentures in properly labeled container, ask about contact lenses, call light placement, safety bars in baths and tubs, return foreskin to normal position, never cut toenails or fingernails, document and notify of abnormal findings, use gloves and wash hands.