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74 Cards in this Set
- Front
- Back
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Vital Signs include:
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Temperature, pulse, respiration, blood pressure, and oxygen saturation
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Physical signs that are vital to the normal functioning of an individual
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Vital Signs
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Medications can affect...
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respiratory rate, the pulse rate, or the blood presssure
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If a patient has been on extended bedrest and is going to ambulate for the first time, the nurse should check....
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blood pressures both lying and sitting
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A recording of the balance of heat production and heat release by the body.
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Body Temperature
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Factors that result in heat production include:
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person's basic metabolic rate, the amount and rate of muscle activity, the level of thyroid hormones, and sympathethic stimulation
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A person's temperature tends to be lowest between _ and _. The temperature will rise steadily until about _ and then decline again until early morning.
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1:00 and 4:00 am
6:00 pm |
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A newborn's ability to regulate temperature is ___ and can vary greatly based on enviromental conditions. Children may have slightly ___ temp. ranges until they reach adulthood. Older aduls have a ___ tolerance to temperature changes.
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immature
higher decreased |
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Exercise will cause increase in
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temporary body temperature
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___ rhythms result in the variation in temperatures seen during a 24- hour period.
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Circadian
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Stress can cause an increase in ___ ___ due to the hormonal or neural stimulation.
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body temperature
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During time of menopause, the woman may experience changes in body temperature due to
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hormones
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the transfer of heat from one object to another with direct contact
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Conduction
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the loss of heat due to the movement of air across the person. Modern air-conditioning vents that direct cool air into a room may result in this event.
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Convection
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transfer of heat from the surface of one object to the surface of another. People lose a large amount of heat to surrounding structures in this manner.
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Radiation
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transfer of heat when a liquid on the body is changed to a gas. Ex: a person not being fully dried after a bedbath
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Evaporation
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The presence of this can signal important changes in th body or attempts to fight infection. It occurs when the heat losing mechanisms of the body are outpaced by the mechanisms of heat production.
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Hyperpyrexia or Fever
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The significant characteristic in this pattern is that the fever is a persistent elevation that lasts over 24 hours.
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Continuous or Sustained Fever
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will have normal readings with spikes of fever interspersed between normal readings
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Intermittent Fever
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will have rises and falls as the intermittent fever, but the lower readings will not return to normal ranges.
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remittent fever
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will be exhibited when the person has periods of normal and abnormal temperatures. Theses periods may lasts longer than 24 hours
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Relapsing Fever
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The body attempts to fights infection by increasing the activity of the immune system
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Fever that is caused by increased heat production
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A heat stroke where the heat-regulating mechanisms shut down is an example of this condition
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Fever that is caused by body trying to prevent heat loss
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A head injury is an example of the third group of conditions that result in elevated body temperatures.
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Fever that is caused by the central nervous system that control the heat-regulating function of the body are compromised and do not function properly.
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the palpation of the wave of blood flow as it is ejected from the heart as it contracts. As the heart contracts the blood leaves the heart and enters a continuous circuit
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The Pulse
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The number of times in one minute the heart pumps out the blood.
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Rate
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The ___ refers to the interval between each beat.
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rhythm
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The strength of the pulse is also important to assess. This measurement reflects...
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the force of the wave of blood ejected from the heart
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If there are differences noted in the strength of a pulse it could indicate...
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a blockage of blood flow to the area
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If a pulse rate lacks the normal regular rhythm, an ___ is present and further investigation may be needed.
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arrhythmia
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What are some factors that can affect the pulse rate?
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Exercise
Fever Heat Need for Oxygen Meds Blood Loss |
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Acute blood loss will result in an ___ in the pulse rate.
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Increase
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allows the body to bring in needed oxygen and give off the waste product carbon dioxide.
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Respiration
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Normal Range of Respirations
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12-20 breaths per minute
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The respiratory rate should be assessed for...
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Rate
Depth Rhythm |
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Increase in the depth of respirations often seen with exercise
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Hyperpnea
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If both the rate and depth of respirations have increased, the person is...
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Hyperventilating
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When the rate and depth of respirations have decreased the person is...
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Hypoventilating
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An increasingly common activity to evaluate the diffusion and perfusion of oxygen in tissue is by using an ... a.k.a someone's "sat level"
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Oxygen Saturation Monitor
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The machine used to test "sat level" is called
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pulse oximeter
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Normal arterial saturations are between __ and __.
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90% and 100%
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Normal venous saturations are approx.
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70%
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The sound of the highest force of the wave of blood as it is pushed from the heart.
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Systolic Pressure
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The measure of the lowest pressure.
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Diastolic Pressure
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The difference between the two (systolic and diastolic) pressures is called the ___ __ and represents the ______.
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pulse pressure
stroke volume of the heart |
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When the nurse evaluates the blood pressure, they can assess several points of infomation. These include:
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the efficiency of the heart as a pump
the elasticity of vascular walls the blood volume the resistance to blood flow found in the peripheral vasculature |
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If the walls of the arteries are not flexible, the pressure is __ because the walls of the vessels do not "give" with the pulse.
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higher
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If a person has lost a great amount of blood, there is less...
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volume of blood in the vessels to exert pressure
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If there is resistance to the flow of blood in the periphery, the pressure...
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increases
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reflection of blood flow as the heart contracts and blood is ejected from the ventricles
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Pulse
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Normal pulse rate
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60-100 bpm
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Pulse <60 bpm
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bradycardia
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Pulse >100 bpm
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tachycardia
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force of the wave of how strongly the blood is being ejected
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strength
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Pulse Grades
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0-no pulse
+1-weak pulse +2-normal pulse +3-bounding, full pulse |
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What can affect the pulse?
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-exercise
-medical conditions (hypothyroidism slows pulse) -meds -acute blood loss (pulse will increase) -anxiety -age (infants have higher pulse 120-160 bpm) |
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As we age, our pulse...
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decreases
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Measures saturation of 02 in the blood and arterial saturation
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Pulse Oxsymmetry
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Normal 02 sat. ranges for arterial and venous?
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arterial= 90-100%
venous= 70% |
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Factors that affect o2 saturation...
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-Chronic Lung Disease
-Chronic Pulmonary Disease -Pneumonia |
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amount of heat the body produces
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Temperature
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Temperature is controlled by the...
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hypothalamus
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Temperature can be affected by...
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age, health status, range of physical activity, gender
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Normal temperature ranges
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96.8-100.4 F
36-38 C |
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Most reliable temperature esp. in children
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Recal Temp.
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When taking rectal temp....
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subtract a degree
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When taking axillary temp...
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add a degree
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When taking tympanic temp...
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add a degree
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What can throw off tympanic temp?
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-ear wax
-exercise |
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When taking the oral temperature, where should you place the themometer?
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posterior sublingual pocket
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the way monitor adequate 02 intake into lungs
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Respirations
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when assessing respirations look at these 3 things:
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Rate
Depth Rhythm |
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Normal respirations
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12-20 breaths per min.
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Depth of respirations:
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shallow-hyperventilating
deep- snoring normal |
