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135 Cards in this Set
- Front
- Back
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the most frequently used form of assesment that is indications of health are called
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vital signs
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examples of vital signs are
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Temperatuire
Pulse Respiration Pain assessment Oxygen saturation |
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what identifies the usual state of health and reveals the patterns of minor fluctuations that are normal for that client.
it is also the basis for determining future date and used to monitor changes in a patients conditon |
baseline data
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vital signs are taken when ....
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a) agency facility policy/procedure
b)admission to facility c) routine office visit d) on medical order e) before and after surgical procedure or invasive procedures f)before and after medication that may affect cardio or respiratory functions g) on condition changes h)during patient report of distress |
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nursing responsibilities related to vital sign assessment
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-recognize NORMAL ranges and patients baseline
-know med history, medications and therapies -minimize environmental factors -decide frequency -use appropriate equiptment -use appropriate and accurate technique -ensure accuracy of data -communicate any changes |
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heat of the body measured in degrees.
measures difference between production and loss of heat |
temperature
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temperature is generated in __________ - ex) muscles, organs and distrubuted to the rest of body by circulation, transferred to skin and released into environment.
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core tissues
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surface temperature fluctuates between ____ and ____ degreees fahrenheit
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97 and 99.5 deg f (36.5-37.5d C)
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what is relatively constant and higher than surface temperatuer
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core temperature
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what is controlled by many mechanisms to keep temp constant
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body temperature
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body temperature is regulated by the
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hypothalamus
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how is heat transferred to the external environment?
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through the skin , inspired air and urine and feces
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name the 4 ways to lose heat via the skin
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regulation
conduction convection evaporation |
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heat lost by vaporization of a liquid is called
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evaporation
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the flow of heat from the body to an object is called
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conduction
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the release of heat waves by the body is called
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radiation
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heat conducted to air then carried away by currents is called
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convection
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name factors affecting body temperature
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age
excercise hormone influences circadian rhythms stress environment eating |
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a low body temperature or below 97F orally is called
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HYPOthermia
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muscle activity such as shivering and chattering of teeth is involuntary or voluntary?
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involuntary
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an increase above normal in body temperature WITHOUT change of thermoregularatory set point (Above 100.4F orally) is known as
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HYPERthermia
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prolonged exposure to increased temperature which will overwhelm hypothalmus is known as H
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Heat stroke
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symptoms:
decreased urinary output shivering chills pale cool skin decreased musucular coordination disorientation, drowsiness progressing to coma |
HYPOthermia
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an increase above normal in body temperature DUE TO a change of thermoregulatory set point
caused by bodys reaction to pyrogens is called |
Pyrexia (FEVER)
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bacteria products or chemicals which stimulates body to have fever is known as
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pyrogens
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how do you treat HYPOthermia?
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blankets, warm dry clothes, hot drinks, warm IVs
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T/F
Many microbial agents that cause infection are inhibited by temperatures in the fever range |
TRUE
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your body reacting to something is called a _______ and there are 4 types of them
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fever
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persistant fever elevation over 24 hours is called
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sustained/constant fever
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varies but always remains above a normal temp is called
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Remmitant
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temp elevated each day but returns to normal at least once a day is called
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Intermittent
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one or more episodes of fever, each as long as several days, with one or more days of normal temp between episodes is known as
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Relapsing/recurrent
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who is the most proned to symptoms of a fever
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elderly
(and infants) |
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how do you manage a fever?
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increase fluids
dry clothing , linens rest well balanced meals oxygen if needed. ANTIPYRETICS. |
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a fever reducing agent such as acetaminophen/tylenol, aspirin(asa) or ibuprofin/advil that temporarily resets hypothalamus is called an
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antipyretic
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are antipyretics given when children and young adults have a fever?
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NO
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The thermostat of your body is known as the
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hypothalamus
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what kind of fever is caused by disease or trauma to hypothalamus?
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Neurogenic fever
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what is it called when a Patient has prolonged fever without a cause?
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Fever of Uknown Origin (FUO)
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symptoms:
malaise aches,pains,fatigue chills shivering hot dry flushed skin increased pulse and resp sweating, decreased urine dehydration, thirst headache drowsiness, confusion loss of appetitie, nausea |
FEVER
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name some of the equiptment to assess a temperature
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Thermometers:
glass tympanic electronic, digital disposable single use patch or tape strips temporal artery pacifier |
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techniques for assessing body temperature are
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inspection and palpation
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TEMPERATURE NORMS
ORAL NORM most common |
98.6
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RECTAL NORM
also the MOST ACCURATE |
99.5
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AXILLARY NORM
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97.6
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TYMPANIC NORM
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99.5
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FORHEAD NORM
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94
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*name that site!*
Core temperature, most accurate Do Not Use in newborns, small children, patients with rectal prostate, perineal surgery or diseases, certain heart diseases and cardiac surgery, neurologic disorders and low white blood counts. Uncomfortable for PT |
RECTAL
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Patient must be able to hold mouth closed, wait 15-30 minutes after drinking, eating smoking or chewing gum***
Do Not Use when Pt with oral cavity diseases and surgery of the nose or mouth, unconscious, confused and seizure proned patients, infants and young children |
ORAL
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core temperature, do not use in PT with head and neck surgery, drainage from ear or scars on tympanic membrane
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TYMPANIC
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The nurse is caring for a pt who has a oral temperature of 99.6 F (SLIGHTLY ELEVATED) at the start of her shift. the patients medical orders indiciate that vital signs betaken once a shift.
what is the best way to plan for care of PT? |
Take Temp AS NECESSARY.
an independant nursing judgement. |
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what is the throbbing sensation that can be palpated over a peripheal artery or asculated over the APEX of the heart?
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pulse
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Physiology of THE PULSE
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Regulated by the NERVOUS SYSTEM
Nervous system control is NOT VOLUNTARY, UNCONSCIOUS Stimulation by different parts of the nervous system to slow down heart rate, increase heart rate, increase force of contraction. Inadvertant stimulation as a result of severe pain, taking rectal temperature, bearing down when moving bowels. intended manipulation as part of treatment. |
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Name some factors affecting pulse
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age
excercise heat stress,pain medication hemmorage postural changes diseases causing poor oxygenation valsalva maneuver |
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a newborn pulse is 2x that of an adult
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true
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physiology of PULSE
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Results from a wave of blood being pumped in the arterial circulation by the contraction of the left ventricle.
each time the left verntricle contracts to eject blood - the arterial walls expand to compensate for the increase of pressure of the blood. |
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Does the pulse normally correspond with the number of contractions by the heart?
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YES
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name the two CENTRAL PULSE SITES
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Caratoid
Femoral |
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Name the SIX PERIPHEAL PULSE SITES
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Temporal
Brachial Radial Popliteal Posterial Tibial Dorsalis Pedis |
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what is it called when you take a pulse at the apex of the heart area - between the 5th and 6th ribs or the 5th intercoastal space at the midclavicular line
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Apical Heart Rate (pulse)
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What are the four characteristics of a PULSE?
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RATE
QUALITY RHYHM STROKE VOLUME |
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What is the frequency of the pulse, normally 60-100bpm in adolescents and adults?
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RATE
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what pulse do you use if your having a hard time getting a radial pulse or you hear an irregular heartbeat or medication
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Apical Pulse Rate
Lubb-Dubb = 1 BEAT. |
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when a pulse is over 100bpm it is called
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Tachycardia
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when a pulse is under 60bpm it is called
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Bradycardia
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the strength of the pulse circulation is called the
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QUALITY
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where do you take the Apical Heart Rate and for how long?
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At the apex area of the heart between the 5th and 6th ribs or the 5th intercoastal space at the midclavicular line...
Take APR for 30 seconds unless irregular than 60 seconds. |
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The grading scale of QUALITY is
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0-absent
1-thready 2-weak 3-normal 4-bounding |
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pattern of pulsations and pauses between pulsations is called
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RHYTHM
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Any irregularity of pulsation or pauses is known as
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Dysrhythmia
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when you count the apical and radial pulse at the same time - requires two nurses
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Apical-Radial Pulse
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difference between the apical and radial pulse rate
which indicates that all of the heartbeats are not reaching the peripheal arteries or are too weak to be palpated is called |
Pulse Deficit
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A nurse describes the radial pulse as thready and irregular after taking morning vital signs - the most appropriate follow up nursing action is to
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take the apical pulse
- this will relay the most accurate information about the patients vitals. |
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what system performs its functions through Ventilation, Diffusion and Perfusion
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Respiratory System
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breathing or the movement of air in and out of lungs is called
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Pulmonary Ventilation
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inspiration is known as :
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inhalation, breathing in
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expiration is known as
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exhalation, breathing out
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a gas exchange, the movement of oxygen and co2 between air in the alveoli (small air sacs) and the blood in the capilarries of the lungs is called
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Diffusion (EXTERNAL respiration)
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oxygenated blood passing through the tissues of the body
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Perfusion
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changes in response to body demands that inhibit or stimulate respiratiory muscles is known as the control of
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Respirations
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what is the most powerful respiratory stimulant?
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CO2 CARBON DIOXIDE
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Name the 3 things chemorecptors are stimulated by :
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C02
Hydrogen Levels (PH) 02 |
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increased amount of CO2 in blood - normal stimulus to breath is called
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Hypercapnia
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Low decreased levels of 02 available to cells, inadequate amounts of O2 in inspired air is called
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Hypoxia
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what are the 3 characteristics of respiration?
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RATE
DEPTH RHYTHM |
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you assess respiration by
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inspection
ausculation with stethescope |
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what is the normal rate for respiration (Eupnea)
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12-20 rpm adults
30-60 rpm infant |
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shallow deep or normal breathing is called
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Depth
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regular or irregular is called
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Rhythm
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addition assessmenats of respiration
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pulse oxymetry
consciousness, confusion accessory muscles skin color, cyanosis, mucous memb |
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slow breathing, a regular rate that is less than 10 RPM is called
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Bradypnea
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rapid breathing, a regular rate is more than 24 RPM is called
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Tachypnea
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a period without breathing is called
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APNEA
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difficult or labored breathing is called
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Dyspnea
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an increased rate and depth of air movement in the lungs is called
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Hyperventilation
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a decreased rate and depth of air movement into the lungs is called
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Hypoventilation
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difficulty breathing is any position except upright sitting or standing is called
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Cheyne Stokes
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irregular rhythm varying depth and rate with Apnea is called
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Biots
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a patient is experience Dyspnea or difficult/labored breathing - what does a nurse do?
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Elevate the head of the bead to allow abdominal organs to descend givng the diaphram greater room for expansion and facilitation lung expansion.
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an average temperature for a rectal and a tympanic body temp is
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99.5 degrees F
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what is reflected in indicators of body functions regulated through homeostatic mechanisms and falling within certain normal ranges?
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Health Status
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normal ranges are found on --->
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table 24-1 taylor
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the __________ of a healthy person is maintained within a fairly constant range by the thermoregulatory center in the hypothalmus
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core body temp
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the primary source of heat in the body is _______
here heat is a byproduct of activties that generate energy for cellular functions |
metabolism
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the primary site of heat loss is
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the skin
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what is transferred to the external environment through the physical processes of radiation, convection, evaporation and conduction
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heat
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center that recieves messages from cold and warm thermal receptors located throughout the body - which compares info with its temperature set point and initiates response to prodcute or conserve body heat is called the
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hypothalmus
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who are most sensitive to changes in environemntal temperatue
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very young and very old
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who has more changes in body temp, women or men? this is due to change in hormones
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women
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nursing interventions for patients with a fever are outolined in the
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Examples of Nursing Interventions Classification
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death may occur when a temperature falls below
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34 C or 93.2 F
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unusual temperature measurement? try two sites ex)
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orally + anally
tympanically + axilaary |
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when both oral and rectal sites are contraindicted or inaccessible, you should take a PT temperature via
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axillary (armpit)
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what is regulated by the autonomic nervous system through the cardiac sinoatrial SA node
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the pulse
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the number of pulsations felt over a peripheal artery or heard over apex of the heart in1 minute
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pulse rate
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pulse not easily felt and slight pressure causes it to disapepar
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thready pulse 1+
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pulsation easily felt, takes modreate pressure to make disappear
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normal pulse 3+
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pulse stronger than thready - light pressure causes it to disappear
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weak pulse 2+
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pulsation strong and does not disappear with pressure
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bounding pulse 4+
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no pulse is felt despite pressure
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absent pulse 0
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what part of the brain allows voluntary control of breathing such as singing or playing instrument
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cerebral cortex
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under normal conditions healthy adults breathe about how many times per minute
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12-20 rpm
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when cardiac output or the amount of blood pumped per minute DECREASES ... the blood pressure
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FALLS
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what is the msot important risk factor associated with Stroke and a major risk factor for heart disease?
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Hypertension (BP above normal for a long period of time)
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patients that have been prolonged to bed rest, older patients, dehydrated or have blood loss ... who go from a supine to sitting condition, are likely to have
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postural hypotension or orthostatic hypotension
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the series of sounds a nurse listens when assessing bp is called
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Korotkoff sounds
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what is used to assess blood pressure consisting of a cuff and manometer
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sphygmomanometer
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an elevation of body temp above normal is known as a
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fever
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a rectal thermomenter insertion may cause a harmful condition ..what is it?
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a decrease in heart rate due to stimulating the vagus nerve
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what equiptment do you use to take an apical pulse
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stethescope
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a pt having dyspnea - or difficulty breathing - what would the nurse do first?
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elevate the head of the bed
allows abdominal organs to descend and greater room for expansion of diaphram and lungs |
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the measurement of force of blood against artieral walls is known as
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blood pressure
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blood pressure is higher with aging due to
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elasticity decreasing in arterial walls
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normal resp rate for adults is
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12-20 breaths per minute
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difference between the apical and radial pulse is known as
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pulse deficit
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