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30 Cards in this Set
- Front
- Back
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when to measure vitals |
admission home care hospital routine schedule/physician's order before and after surgical procedure before after during blood transfussion before after during drug therapies (expessially cardiovas. resp.and temp altering therapies) condition change before and after nursing interventions that alter vitals nonspecific symptoms (funny different etc)
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Thermoregulation of the hypothalamus |
Anterior: heat loss- vasodilation, perspiration, inhibition of heat production
Posterior: heat gain mechanism: vasoconstriction, shivering, muscle contraction |
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Behavioral factors affecting body temp. |
The temp environ. extremes ability to sense temp. ability to add remove cloths impaired thought process |
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why are newborns unable to thermoregulate? |
In womb temp. doesn't vary. Out side fluctuates. has not developed thermoregulation yet. |
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Why do older adults have narrower range of body temp? |
poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, reduced metabolism. |
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Hormonal factors affecting body temp. Women and Progesterone Men and Testosterone Thyroid hormone |
during menstrual cycle low progesterone decrease body temp just below base line. During ovulation progesterone increase and body temp returns to baseline or higher (indications ovulation). Menstruation results in heat flashes bc lack of vasomotor control. Testosterone can increase BMR Thyroid hormone increases BMR |
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Circadian rhythm affects on body temp |
Temp fluctuates .5-1ºC during day. Lowest between 1-4am. Max @ 4pm |
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pyrexia stages |
Fever 1. chills, shiver, feels cold 2. plateau: chills subside feels warm/dry 3. heat-loss: vasodilation warm to touch, diaphoresis |
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Physiology changes during pyrexia? |
Increased: Heart rate respiratory rate body metabolism (10%increase / 1ºC) oxygen consumption cellular metabolism |
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What are nursing intervention with fever? |
obtain blood cultures minimize heat production : decrease activity to reduce metabolic and oxygen demand maximize heat loss: reduce external coverings, keeping cloths dry and avoiding shivering satisfy higher metabolic requirements: oxy. therapy, stimulate appetite, and thirst. promote patient comfort: hygiene, enviroment temp. identify febrile episodes for trends. initiate teaching control enviroment temp. 21-27ºC (70-80ºF)
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Hyperthermia |
inability of body to promote heat loss: Disease to hypothalamus + malignant hypertension: hereditary, reaction to general anesthetic |
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Heat stroke |
Body temp over 40ºC/ 104ºF S/S hot dry skin+ confusion, delirium, nausea, muscle cramps at Risk: vary young/old, hypothyroidism, alcoholism, diabetes, cardiovascular disease |
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heat exhaustion |
dehydration result of fluid loss via diaphoresis RX: restoring fluid+electrolytes and moving to cooler enviroment |
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hypothermia |
Mild: 34-36ºC moderate: 30-34ºC severe <30ºC |
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What medication requires apical pulse |
Digoxin |
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When use stethoscope bell? |
heart /valve sounds |
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when to use stethoscope diaphram |
heart, bowl and lung sounds |
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how to rate strength of pulse |
+4 Bounding +3 strong +2 normal +1 weak 0 absent |
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What are factors influencing pulse rate? |
Increase: short term exercise, fever and heat, sympathetic stimulation bc acute pain and anxiety, positive chronotropic drugs, sympathetic stimulation increased by loss of blood, standing or sitting, disease that cause poor oxygenation.
Decrease: longterm exercise that condition heart, hypothermia, parasympathetic stimulation caused by unrelieved severe pain , relaxation, negative chronotropic drugs, lying down |
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what is the most important factor of ventilation/respiratory rate? |
Arterial C02 levels. normally drive to breath C02 levels but in some patients with hypercarbia low 02 levels( hypoxemia) drive respirations thus giving this person 02 would stop their respirations. |
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Respiration involves? |
Ventilation: movement of gases in and out of lungs diffusion: movement of C02 and 02 between the alveoli and capillaries perfusion: blood supply to the pulmonary capillaries |
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sigh |
sigh that interrupts normal breathing to fill small airways that were other wise not in use. |
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COPD |
Chronic obstructive pulmonary disease: asthma, bronchitis, emphysema
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Common alterations in breathing patterns |
eupnea: normal breathing Tachypnea: higher RR Bradypnea: lower RR Apnea: Respiratory arrest Hyper/hypoventilation: leads to hyper/hypocarbia Cheyne-stokes: irregular , usually ominous sign |
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Explain Sp02, Sa02, and Sv02 |
Sp02 is pulse saturation which gives an accurate indication of Sa02 (arterial saturation) as long as sat. >70%. Sv02 is venous sat. usually about 70%. |
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YHypertension values |
normal <120/80 recheck 2years prehypertension 120-139/80-89 check 1year hypertension i 140-159/90-99 2month follow up hypertension ii >150/100 1month-1week depending on severity |
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Vascular tone? Hyper/hypovolemia? atherosclerosis |
vascular peripheral resistance Change in blood volume decreased vessel elasticity
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Factors influencing BP |
Age: goes up with age. Stress: sympathetic stimulation ethnicity: AA have hypertension + 2X risk of MI and stroke. Gender: goes up after male puberty+ female menopause smoking: vasoconstriction Medication: antihypertension, or breathing treatment increases BP Daily variation: high while awake Activity and weight: long term exercise=low obesity=high |
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what are the modifiable risk factors of hypertension? |
smoking/drinking stress obesity/sedentary lifestyle high Na diet
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causes of hypotension |
dilation of arteries in vascular bed. loss of blood MI
S/S: pallor, skin mottling, clamminess, confusion. Increase HR/ decreased UO |
