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83 Cards in this Set
- Front
- Back
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When should you assess a pt's vitals?
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admission
physician's orders established protocols change in pt condition or pt complaint loss of consciousness before/after meds that affect cardiovascular or respiratory function before/after interventions surgery invasive procedure ambulation (walking) |
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What is the normal adult temperature?
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97-99.5 F
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What is the normal adult respiratory rate?
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12-20 resp/min.
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What is the normal adult pulse?
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60-100 beats/min
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What is the normal adult blood pressure?
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<120/<80 mmHg
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What are the 4 types of ways to lose/transfer heat?
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radiation- transfer of heat from body w.o contact (take coat on or off)
conduction- transfer of heat from body w/ contact (ice on a injury) convection- transfer of heat from body by air currents (fanning yourself) evaporation- transfer of heat from body by liquid becoming a vapor (sweating) |
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How does the body regulate temperature?
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thermoreceptors (nerves sensitive to changes in body temp)
hypothalamus- acts like a thermostat and maintains set point which normally remains relatively stable w. in a narrow range stimulates an increase or decrease in head production or loss effectors respond to messages from the hypothalamus blood vessels dilate if too hot, constrict if too cold sweat glands activate/inhibit evaporation skeletal muscle shivers to produce heat epinephrine is released |
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What can affect body temp?
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circadian rhythms- natural body rhythm
age- infants and children have undeveloped thermoregulatory systems, elderly have loss of subcutaneous tissue, less basal constriction/dilation hormonal influences- increase in progesterone during ovulation exercise- temp is normal up to 102 F stress- releases epinephrine, NE |
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What are core body temperatures?
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tympanic and rectal temps
usually 1 degree higher than oral and 2 degrees higher than axillary |
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What are surface body temperatures?
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oral and axillary temps
lower than tympanic and rectal temps |
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What is pyrexia?
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an increase in body temp that results from an increase in set point
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What is febrile?
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fever, > 100.4 in oral, 99.4 axillary, 101.4 rectal or tympanic
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What is hyperpyrexia?
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oral temp greater than 105.8
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What is hyperthermia?
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increase in body temp w/o a change in the set point usually due to environment
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What is hypothermia?
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decrease in core body temp, < 96.8 usually from environment or burn pts
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What is neurogenic fever?
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caused by injured hypothalamus, any injury in the brain
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What are some causes of fever?
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bacterial infection or viral infection
cancer myocardial infarction pulmonary embolism trauma or surgery neurogenic |
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What is the chill phase of fever?
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change in set point in hypothalamus
body needs to gain heat to reach the new set point, shivering, vasoconstriction |
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What is the fever phase of fever?
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when the core body temp reaches the new set point
pt doesn't feel hot or cold, skin is warm to touch, flushed, weak, general malaise, achy muscle |
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What is the flush phase of fever?
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when the set point falls back to normal
body needs to lose heat, vasodilation causes hot flushed skin, diaphoresis |
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What are the types of fevers?
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sustained/constant- temp. remains elevated but doesn't fluctuate > 2 F
remittent- temp. remains elevated but has wide fluctuations intermittent- temp. changes from febrile to afebrile relapsing- afebrile for > 24 hrs then the fever returns fever spike- afebrile and w/in several hrs fever |
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What to do for a pt w/ a fever?
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apply/remove blankets
provide food/fluids as ordered maintain prescribed IVs (antipyretics, antibiotics) administer prescribed anti-infectives &/or antipyretics provide oral hygiene as needed change clothing bed linens as needed tepid bath/cooling blanket as ordered ice pack/cool washcloths to neck, axilla, groin as ordered |
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Who is at risk for hyperthermia?
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children and athletes
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What are the signs and symptoms of hyperthermia?
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heat cramps from fluid and electrolyte imbalance
heat syncope (fainting) heat exhaustion (dry skin, not sweating so body can't cool down) heat stroke (body starts to shut down) |
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When is a temp life threatening? damaging to the brain?
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> 104
> 106 |
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Who is at risk for hypothermia?
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children, elderly, homeless
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What are signs and symptoms of hypothermia?
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shivering, muscle stiffness, decreased heart rate, decreased blood pressure, poor coordination, slurred speech, blue lips, nail beds, or skin, unconsciousness
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How to treat hypothermia?
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re-warm slowly to prevent massive vasodilation and a drop in blood pressure, warm environment, warm blankets, hot water bottles, heating pad
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Oral temperature
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in the sublingual pocket
pt must be able to close the mouth around probe contraindicated: oral disease, surgery of the nose or mouth, seizures, comatose or confused, pt receiving O2 by mask wait 15-30 mins if pt has had hot/cold food/fluids, smoked or chewed gum |
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Tympanic temperature
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used commonly w/ children, confused, disoriented, or comatose pts
should not be used for: infants or pts that have drainage from the ear or scarring of tympanic membrane must seal the opening of the ear for accurate reading angle the thermometer toward the pts jawline child- pull ear lobe back and down adults- pull ear lobe back and up |
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Axillary temperature
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used for infants, children, disoriented, or comatose pts
generally 1 degree lower than oral temps use only when other sites are contraindicated in an adult pt |
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Rectal temperature
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do not take for infants or small children, pt w/ rectal/prostate surgery or diarrhea/disease of rectum, pt w/ low WBCs, low platelet count or spinal cord injury, pts w/ cardiac diseases
can cause vagal response or injury to rectal mucosa vagal response causes bradycardia which drops blood pressure generally 1 degree higher than oral temps most accurate core body temperature |
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How to assess rectal temperature?
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use gloves
lubricate probe w/ water soluble lubricant insert probe 1.5 in into anus |
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What are respirations?
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pulmonary ventilation- act of breathing, the mechanical movement of air in and out of the lungs
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What is external respiration?
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exchange of O2 and CO2 between alveoli and pulmonary capillaries
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What is internal respiration?
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exchange of O2 and CO2 between capillaries and cells
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How are respirations controlled?
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controlled by chemoreceptors in the medulla and pons and in the carotid and aortic bodies
stretch and irritant receptors in the lungs |
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What is the main stimulus to breath?
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is a high level of CO2 in the body
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What factors affect respirations?
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age
body position- proper position, sitting up meds- inhalers, narcotics, epinepherine (increases) brain injury- respiratory centers are in the brain (strokes, tumors) respiratory diseases- asthma acid/base imbalance |
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What can increase respirations?
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acute pain
anxiety smoking fever elevated environmental temp exercise |
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How to assess respirations?
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pt at rest and unaware of assessment
depth- shallow or deep rhythm- regular, irregular |
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What is tachypnea?
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> 24 bpm
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What is bradypnea (respiratory depression)?
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< 10 bpm
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What is apnea?
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periods of no respirations
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What is hyperventilation?
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rapid respirations and deep breaths
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What is hypoventilation?
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slow rate w/ shallow breaths
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What is dyspnea?
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difficult, labored, shortness of breath
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What is orthopnea?
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must be in upright position to breathe easily
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What is stridor?
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upper airway obstruction (high pitched)
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What is wheezing?
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musical sounds common in pts w/ asthma
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What is the pulse?
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wave of blood generated by left ventricular contraction
assesses mechanical contractility (how hard does the left ventricle pump blood) electrical condition (rhythm, SA node has regular rhythm) |
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What is the stroke volume?
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amount of blood ejected per heartbeat (60-70 ml)
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What is the cardiac output?
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heart rate x stroke volume
5-6 L/min |
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What factors affect the pulse?
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age, exercise
hypotension, hypertension fever pain, emotion, stress meds (cardiovascular meds, degoxine, beta blockers) physical condition (athletes have lower pulse vagal stimulation is a direct connection to the heart (constipation, weight lifting) |
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Where to assess the pulse?
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carotid for CPR
apical brachial (BP, children pulse) radial pedal pulses posterior tibial dorsalis pedis |
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What is tachycardia?
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> 100 beat/min
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What is bradycardia?
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< 60 beats/min
chest pains, shortness of breath, drop in BP, change in level of consciousness, EKG changes |
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Apical pulse
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assess apical pulse if:
peripheral pulse is irregular 5th intercostal space at left midclavicular line cannot palpate peripheral pulse administering certain meds S1 and S2 listen for one minute |
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Radial pulse
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use first 2-3 fingertips
hyper extend wrist if difficult to find count for 30 sec and X by 2 assess radial pulse for one minute when: baseline data, initial assessment, irregular pulse document rate, rhythm, strenght, equality evaluate right and left |
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What is blood pressure?
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force exerted by the blood against the arterial wall
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What is the systolic pressure?
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pressure against the arterial wall during cardiac contraction
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What is the diastolic pressure?
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pressure against the arterial wall during cardiac relexation which is usually constant
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What is the pulse pressure?
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the difference between the SBP & DBP
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What is the goal of the cardiovascular system?
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to maintain adequate tissue perfusion because cells need continuous suppoy of O2 and nutrients and waste removed
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How does peripheral vascular resistance control BP?
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vasodilation, vasoconstriction
compliance (ateries can stretch/recoil which allows for distention when blood is ejected w/ againg arteries lose elasticity and have decreased compliance which makes BP higher |
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How does blood volume effect BP?
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when fluids are lost then BP goes down
when fluids are retained the BP goes up |
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What regulates BP?
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baroreceptors/chemoreceptors- located in the aorta and internal carotid arteries, send info about BP and blood leves of O2 and CO2 and pH to the vasomotor center
vasomoter center- cluster of neurons in the medulla oblongata that regulate BP, nerves travel from the vasomotor venter to arteries SNS- short term control vasoconstrict w/ epi/ne increased HR- beta1 receptor stimulation |
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How does the renin-angiotension-aldosterone system regulate BP?
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increases sodium and water retention by the kidneys to increase BP
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What is angiotension II?
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potent vasoconstrictor
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What is aldosterone?
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causes kidneys to conserve sodium which leads to water retention to higher BP
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What is ADH?
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anti-diuretic hormone
causes kidneys to retain water |
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What factors affect BP?
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age- elderly tend to have higher BP b/c of a decrease in compliance and increase in peripheral vascular resistance
circadian rhythm- lowest in am and during sleep, peak in late afternoon eating- bp increases after eating exercise- BP increases weight- BP usually higher in obese pts emotions/stress- increase BP due to SNS stimulation smoking- potent vasoconstrictor which increases BP pain- increases BP due to SNS stimulation, severe pain can decrease BP body position- BP= supine lower than sitting is lower than standing eds |
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A rise or fall of in BP is significant even if it is within the normal range
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20-30 mmHg
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What is hypotension?
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a consistently low systolic blood pressure < 90-115
SBP < 90 shouldn't be a concern if pt is asymptomatic |
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What are the signs and symptoms of hypotension?
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low BP
increased HR pallor diaphoresis confusion/unresponsive |
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What is orthostatic hypotension?
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a low BP associated w/ weakness, dizziness, or fainting when rising to an erect position
caused b/c peripheral vasodilation occurs without a compensation for rise in cardiac output |
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Who is at risk for orthostatic hypotension?
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older adults
pts on prolonged bed rest post op pts dehydration blood loss meds (antihypertensives, diuretics, narcotic analgesics) |
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How to prevent falls in pts w/ orthostatic hypotension.
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raise head of bed
sit on side of bed for several mins. assist pt to stand asess for dizziness, light headedness if pt complains of dizziness or feeling faint return pt to bed |
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What is hypertension?
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consistent elevation of BP
primary HTN can't be cured secondary HTN is caused by identifiable diseases like kidney tumor, renal vascular diseases, thyroid tumors/disease, alcoholism "silent killer" complications of HTN kidney failure heart failure and coronary artery disease stroke retionpathy (loss of vision) |
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What will happen if the sphygmomanometer is too small or too large?
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too small= high BP
too large= low BP |
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How to assess BP?
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pt should be at rest for 5 min and no caffeine or tobacco for 30 min.
check for ausculatory gap (temporary disappearance of sounds, mostly in HTN pts take pressure in both arms should be no more than 10mmHg difference b/w arms record the higher BP |
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How to assess the popliteal pressure?
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prone position preferred
same procedure as brachial pressure evaluation SBP is normally 10-40mmHg > brachial DBP same as brachial |
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What are some errors is assessing BP?
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false high:
releasing valve too slowly cuff width too small false low: releasing valve too quickly arma above hear level not identifying ausculatory gap |
