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84 Cards in this Set
- Front
- Back
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When should vital signs be assessed?
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On admission
Change in client's health status Client reports symptoms Pre and post surgery/invasive procedure Pre and post medication administration that could affect CV system Pre and post nursing intervention that could affect vital signs |
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Factors affecting pulse rate
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Age, sex, exercise, fever, medication, hypovolemia/dehydration, stress, position
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Age
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As age increases, the pulse rate gradually decreases
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Sex
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After puberty, the average male's pulse rate is slightly than the females
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Exercise
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The pulse rate normally increases with activity. Both resting and exercising pulse in atheletes may be less than those of the average person
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Fever
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The pulse rate increases in response to the lowered blood pressure that results from peripheral vasdilation associated with elevated body temperature
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Medications
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Some medications decrease the pulse rate and others increase it
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Hypovolemia/Dehydration
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Loss of fluid from the vascular system increases the pulse rate
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Stress
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In response to stress, sympathetic nervous system stimulation increases the overall activity of the heart
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Position
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When a person is sitting or standing, blood pools in dependent vessels of the venous system and the pulse rate and stroke volume increases accordingly
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Pulse assessment sites
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Temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal
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Temporal
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Where the temporal artery passes over the temporal bone of the head
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Carotid
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At the side of the neck below the lobe of the ear where the carotid artery runs between the trachea and the sternocleidomastoid muscle
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Apical
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At the apex of the heart. Left side of the chest, about 8 cm left of the sternum, at the fifth intercostal space
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Brachial
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At the inner aspect of the biceps muscle of the arm or medially in the antecubital space
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Radial
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Where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist.
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Femoral
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Where the femoral artery passes alongside the inguinal ligament
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Popliteal
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Where the popliteal artery passes behind the knee
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Posterior tibial
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On the medial surface of the ankle where the posterial artery passes behind the medial malleolus
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Pedal (dorsalis pedis)
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Where the dorsalis pedis artery passes over the bones of the foot.
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Peripheral pulses may be assessed as:
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An indicator either of cardiac function or of vascular integrity
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The peripheral pulse is used to indicate cardiac function by:
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Providing baseline data
Indentifying whether the pulse rate is within normal rnage Determining whether the pulse rhythm is regular Monitoring and assess changes in status Monitoring clients at risk for pulse alterations |
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The peripheral pulse is used as an indicator of vascular integrity by:
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Determining whether the pulse volume is normal
Comparing the equality of corresponding peripheral pulses on each side of the body Determining the adequaqcy of blood flow to a particular part of the body |
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Average pulse for adults
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60-100
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Pulse lifespan considerations
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Newborns may have heart murmers that are not pathological
Children 1-6 heart apex located in 4th intercostal space. 7+ in 5th space Elders often have decreased peripheral circulation |
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Average respirations for adults
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12-20
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Costal breathing
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Movement of the chest upward and outward
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Diaphragmatic breathing
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Movement of the abdomen
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Factors affecting respirations:
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Age, exercise, fever, medications, stress
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Age
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As age increases, the respiratory rate gradually decreases
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Exercise
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Respirations increase in rate and depth with excercise
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Fever
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The respiratory rate will be faster in clients with an elevated temperature
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Medications
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Narcotics and other CNS depressants often slow the respiratory rate
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Stress
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Anxiety and pain are likely to increase respiratory rate and depth
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Respiratory rate is generally described as:
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Shallow
Normal or Deep |
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Respiratory rhythm can be described as:
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Regular
Irregular |
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Respiratory quality
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Those aspects of breathing that are different from normal, effortless breathing
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Tachypnea
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Quick, shallow breathing
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Bradypnea
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Abnormally slow breathing
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Apnea
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Cessation of breathing
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Hyperventilation
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Overexpansion of the lungs characterized by rapid and deep breaths
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Hypoventilation
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Underexpansion of the lungs, characterized by shallow respirations
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Cheyne-Stokes breathing
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Rhythmic, waxing and waining of respirations, from very deep to very shallow breathing and temporary apnea
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Dyspnea
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Difficult and labored breathing during which the individual has a persistant, unsatisfied need for air and feels distressed
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Orthopnea
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Ability to breathe only in upright sitting or standing positions
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Respiration lifespan considerations
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Infants sometimes display periodic-irregular breathing
Children are diaphragmatic breathers Elders anatomic and physioligical changes cause decreased respiratory efficiency |
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Respiratory conrol centers are located in the:
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Medula oblongada
Pons |
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Respiratory control chemoreceptors are located in the:
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Medula oblongada
Caroted and aortic bodies |
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Systolic blood pressure
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Represents the pressure of the blood as a result of contraction of the ventricles
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Diastolic blood pressure
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Represents the pressure of the blood when the ventricles are at rest
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Chemoreceptors respond to:
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O2, CO2, and H+ in arterial blood
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Pulse pressure
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The difference between the systolic and diastolic blood pressures
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Respiratory effectiveness is measured by:
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Uptake and transport of O2
and Transport and elimination of CO2 |
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Hypertension
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Blood pressure above the normal range
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Hypotension
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Blood pressure below the normal range
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Factors affecting blood pressure
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Age, sex, exercise, medications, stress, race, obesity, medical conditions, diurnal variations, fever/heat/cold
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Age
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systolic and diastolic pressures gradually rise with age.
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Sex
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Women usually have lower blood pressures than men due to hormonal variations
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Exercies
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Physical activity increases blood pressure
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Medications
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Many medications may increase or decrease blood pressure
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Stress
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Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles
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Race
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African American males over 35 tend to have higher blood pressure than European American males
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Obesity
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Both childhood and adult obesity predispose persons to hypertension
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Medical conditions
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Type 1 and type 2 diabetes can result in arterial disease and hypertension
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Diurnal variations
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Blood pressure is usually lowest early in the morning and peaks in the late afternoon (8pm to midnight)
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Fever
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Because of increased metabolic rate, fever can increase blood pressure
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Heat
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External heat causes vasodilation and decreases blood pressure
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Cold
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Cold causes vasoconstriction and elevates blood pressure
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Korotkoff"s Sounds
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The five phases of blood flow sounds heard while assessing blood pressure
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Auscultatory gap
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Occurrs in hypertensive clients and is the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is high followed by reappearance at a lower level
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Normal blood pressure in an adult
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<120 systolic and <80 diastolic
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Blood pressure lifespan considerations
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Infant arm and thigh pressures are equivalent under 1 year of age
Children thigh pressure is 10 mm Hg higher than arm Elders medications may affect how pressure is taken |
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Pulse oximetry
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Noninvasive device used to estimate arterial blood oxygen saturation
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Factors affecting oxygen saturation readings
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Hemoglobin
Circulation Activity Carbon monoxide poisioning |
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Hemoglobin
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If the hemoglobin is fully saturated with O2, the SpO2 will appear normal even if the total hemoglobin level is low. Thus, the client could be severly anemic and have inadequate O2 to supply the tissues.
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Circulation
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The oximeter will return an inaccurate reading if the area under the sensor has impaired circulation
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Activity
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Shivering or excessive movement may return inaccurate readings
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Carbon monoxide poisioning
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Hemoglobin saturated with CO returns the same reading as hemoglobin saturated with O2
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Normal blood pressure
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<120 and <80
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Prehypertension
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120-139 or 80-89
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Hypertension stage 1
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140-159 or 90-99
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Hypertension stage 2
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>160 or >100
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Nursing care for fever
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Monitor vital signs
Assess skin color and temperature Monitor lab results for dehydration or infection Remove excess covers when client feels warm Provide adequate nutrition and fluid Measure intake and output Reduce physical activity Administer antipyretics as ordered Provide oral hygene Provide tempid sponge bath Provide dry clothing and bed linens |
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Nursing care for hypothermia
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Provide warm environment
Provide dry clothing Apply warm blankets Keep limbs close to the body Cover the client's scalp Supply warm oral or intravenous fluids Apply warming pads |
