Vital signs CH 29 Test 2 Flashcards

pulse
Terms Definitions
Vital signs
Body temp, pulse, respirations, blood pressure, and pain. Oxygen saturation is also usually taken with these.
Body Tempurature
Reflects the balance between heat produced and heat lost from the body, and is measured in heat units called degrees.
Core Teperature
The temperature of the deep tissues of the body, such as abdominal cavity and pelvic cavity. It remains relatively constant.
Surface Temperature
The temperature of the skin, the subcutaneous tissue, and fat. It, by contrast, rises and falls in response to the environment.
Heat balance
When the amount of heat produced by the body equals the amount of heat lost.
Basal metabolic rate (BMR) heat production
The rate of energy utilization in the body required to maintain essential activities such as breathing. This decreases with age.
Heat production
Basal metabolism, muscular activity (shivering)' thyroxine and epinephrine (stimulating effects on metabolic rate), temperature effect on cells.
Heat loss
Radiation, conduction/convection, evaporation.
Muscle activity heat production
Shivering, increases metabolic rate.
Thyroxine Output heat production
Increases rate of cellular metabolism throughout body.
Epinephrine, norepinephrine, and sympathetic stimulation/ stress response heat production
These hormones immediately increase the rate of cellular metabolism in many body tissues.
Fever
Increases the cellular metabolic rate and thus increases body temperature.
Radiation
The transfer of heat from the surface of one object to the surface of another without contact between two objects.
Regulation of body temperature
Sensors in the periphery and in the core, an integrator in the hypothalamus, and an effector system that adjust the production and loss of heat.
Factors affecting body temperature
Age, diurnal variations (circadian rhythms) , exercise, hormones, stress, environment.
Normal range of body temp
36-37.5C, 96.8-99.5F
Pyrexia
Temperature above normal range.
Hyperthermia
Fever
Hyperprexia
A very high fever 41C (105.8F)
Febrile
A client who has a fever.
Afebrile
A client who does not have a fever.
Times to asses vital signs
To obtain baseline data, client has a change in health status, or chest pain or feeling hot or faint, before and after surgery, before and after the administer of meds that could effect respiratory or cardiovascular systems, before and any nursing interventions that could affect vitals signs.
Onset fever
Increased heart rate, increased respiratory rate and depth, shivering, pallid or cold skin, complains of feeling cold, cyanotic nail beds, "goose flesh", cessation of sweating.
Course fever
Absence of chills, skin that feels warm, photosensitivity, glassy-eyed appearance, increase pulse and respiratory rates, increased thirst, mild to severe dehydration, drowsiness, restlessness, delirium, convulsions, herpetic lesions of the mouth, loss of appetite, malaise, weakness, and aching muscles.
Defervescence fever
Skin that appears flushed or feels warm, sweating, decreased shivering, possible dehydration.
Very high temperatures 106F to 108 F , 41C to 42 C
Damage the parenchyma of cells throughout the body particularly in the brain where destruction of neuronal cells is irreversible. Also damage to the kidneys, liver and other organs of the body an be great enough to cause death.
Hypothermia
Excessive heat loss, inadequate heat production to counteract heat loss, impaired hypothalamic thermo regulation. Decreased body temp, pulse, and respiration, severe shivering, feeling of cold and chills, pale, cool, and waxy skin, frostbite, hypotension, decreased urinary output, lack of muscle coordination, disorientation, drowsiness progressing to coma.
Nursing interventions for clients with fever..
Monitor vital signs, assess skin color and temperature, monitor WBC count, hematocrit value, and other pertinent lab reports for indications of infection or dehydration, remove excess blankets when client feels warm, but provide warmth when client is chilled, provide adequate nutrition of fluids to meet increase metabolic demands and prevent dehydration, measure intake and output, reduce physical activity, provide oral hygiene to keep mucous membranes moist, provide tepid sponge bath, provide dry clothing and bed linens.
Nursing interventions for clients with hypothermia
Provide warm environment, provide dry clothing, apply warm blankets, keep limbs close to body, cover the clients scalp with cap and turban, supply warm oral or or intravenous fluids, apply warming pads.
Oral temp
Advantages: accessible and convenient. Disadvantages: thermometers can break if bitten, inaccurate if client has just ingested hot or cold food or fluid or smoked. Could injure the mouth following oral surgery.
Rectal temp
Advantage: reliable measurement. Disadvantages: inconvenient and more unpleasant, difficult for client who cannot turn to the side, could injure rectum, presence of stool may interfere w thermometer placement.
Axillary temp
Advantages: safe and noninvasive. Disadvantages: thermometer may need to be left in place a long time to obtain an accurate measurement.
Tympanic membrane temp
Advantages: readily accessible, reflects the core temp, very fast. Disadvantages: can b uncomfortable and involves risk off injuring the membrane if the probe is inserted too far. Repeated measurements may vary. Right and left measurements can differ. Presence of cerumen can affect reading.
Temporal Artery temp
Advantages: safe and noninvasive, very fast. Disadvantages: requires electronic equipment that may be expensive or unavailable. Variation in technique needed if the client has perspiration on the forehead.
Calculating temperature
C= (Fahrenheit temperature - 32) x 5/9. F= (Celsius temperature x 9/5) + 32
Pulse
Is a wav of blood created by contraction of the left ventricle of the heart.
Compliance
The arteries ability to contract and expand.
Cardiac output
Is the volume of blood pumped into the arteries by the heart and equals he result of stroke volume (SV) times the heart rate (HR) per minute.
Peripheral pulse
Pulse located away from the heart EX: foot, wrist.
Apical pulse
Central pulse, that is located in the apex of the heart also know as the point of maximal impulse.
Factors affecting the pulse
Age gradually decreases, sex after puberty the average pulse rate is slightly lower than the females, exercise pulse rate normally increases w activity, fever, medications, hypovolemia/dehydration loss of blood from the vascular system increases pulse rate, stress increases pulse rate, position, pathology.
Adult pulse rate
Average 80 (60-100)
Adult respiration
16 (12-20)
Older adult pulse
70 (60-100)
Older adult respiration
16 (15-20)
Pulse sites
Temporal, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal.
Apical pulse
Used for assessment of cardiac conditions. Auscultate before administration of cardiac medications. Routinely used for infants and children up to 3 years of age. Taken full minute.
Pulse assessment
Palpate- feel, auscultate- listen, Doppler ultra sound, collect rate, rhythm, volume, arterial wall elasticity and presence or absence bilat.
Bradycardia
Slow heart rate
Tachycardia
Fast heart rate
Dysrythmia
Irregular heart rate.
Strong and regular
Even beats with a good force
Weak and regular
Even beats with poor force (hard to feel)
Irregular
Unevenly spaced, both strong and weak beats occur within a minute.
Thready
Indicates irregular and weak.
Pulse deficit
Means apical and radial pulses do not match up. Normally they are identical in a healthy individual.
Respiration
O2 and co2 are exchanged, on ventilation equals one inspiration and one expiration.
Costal breathing
Thoracic breathing involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles. Chest up and down.
Diaphragmatic breathing
Abdominal involves the contraction and relaxation of the diaphragm and is observed by the movement of the abdomen diaphragm downward movement.
Respirations assessment
Should b done resting, try to count with out being obvious, document rate, depth, rhythm, and character, count for 30 seconds if regular and 60 seconds if irregular.
Respirations affecting factors
Exercise, stress, change in environment temperature, low O2 at high altitude, medications, increased inter cranial pressure.
Hyperventilation
Refers to very deep, rapid respirations.
Hypoventilation
Refers to very shallow respirations.
Dyspnea
Labored and difficult breathing.
Tachypnea
Quick shallow breaths.
Bradypnea
Abnormally small slow breathing
Orthopnea
Need to sit up to breath.
Apnea
The absence of breathing.
Respiratory Rhyhm
Refers to the regularity of expirations and the inspiration.
Respiration Quality or Character
Refers to those aspect of breathing that are different from normal, effortless breathing .
Arterial blood pressure
Measure of pressure exerted by the blood as it flows through the arteries
Systolic Pressure
Is the pressure of the blood as a result of contraction of the ventricles , that is, the pressure of the height of the blood wave.
Diastolic Pressure
Is the pressure when the ventricles are at rest
Blood pressure is measured in
Millimeters of mercury mmHG
Pulse pressure
The difference between the diastolic and the systolic pressures. Average is about 40 mmHG
Blood pressure determinants
Pumping action of the heart, peripheral vascular resistance, blood volume, blood viscosity.
Pumping action of the heart
Weak- less blood is pumped to the arteries lower cardiac output bp decreases. Strong- volume blood pumped into circulation increases, higher cardiac output,increased bp.
Peripheral vascular resistance
Impedance or opposition to blood flow to the tissues, determined by viscosity, or thickness, of the blood, blood vessel length, blood vessel diameter.
Blood volume
When decreases hemorrhage or dehydration, bp decreases bc of decreased fluid in arteries. Increases rapid IV infusion bp increases bc of greater blood volume in circulatory system
Blood viscosity
Thickness
Artiosclerosis
A condition in which the elastic and muscular tissues of the arteries are replaced with fibrous tissue.
B/P normal
Systolic <120 and diastolic <80
Prehypertension
Systolic 120-139 or Diastolic 80-89
Hypertension stage 1
Systolic 140-159 or diastolic 90-99
Hypertension stage 2
Systolic >160 or Diastolic >100
Factors affecting blood pressure
Age, exercise, stress, race, sex, medications, diurnal variations, medical conditions, temperature.
Hypertension
Blood pressure persistently above normal.
Hypotension
Blood pressure that is below normal, that is a systolic reading consistently between 85 and 110 mmHg in an adult whose normal pressure is higher than this.
Orthostatic hypotension
Blood pressure that falls when a client sits or stands.
Blood pressure assessment
Position client sitting with feet on the floor is the best position. Locate the brachial and palpate while inflating the cuff until the pulse disappears then wait 1-2 minutes. Re-pump the sphygmomanometer 30 mmHg above the number that the brachial pulse disappeared. Deflate at rate of 2-3 mmHg. Variation: thigh b/p. Wipe off cuff afterword. Document like a fraction systolic/diastolic site: RA, LA, RL, LL.
Primary hypertension
Elevated blood pressure with an unknown cause.
Secondary hypertension
Elevated blood pressure with a known cause.
Supplies needed to take a blood pressure
Blood pressure cuff, sphygmomanometer, stethoscope.
Pulse oximeter
A noninvasive measurement of a patients arterial blood saturation (SaO2) by means of sensor.
Pulse oximetry
Normal 95-100% . Death <70%
Korotkoff's sounds
Five phases occur but may not always b audible. The systolic pressure is the first tapping sound is heard, in adults the diastolic pressure is the point where the sound become inaudible.
The clients temperature was taken at 8:00am using an oral thermometer is 36.1C (97.2F). If the respiration, pulse, and blood pressure were within normal range hat would the nurse do next?
Check what the clients temperature was last time it was taken.
Which client meets the criteria for selection of apical site for assessment of pulse rather than radial pulse?
A client with an arythmia
When a nurse enters the room to measure vital signs in preparing the client for a diagnostic test, the client is on he phone. What technique should the nurse use to determine the respitory rate.
Since there is no evidence of distress or urgency, defer the measurement.
For a client with a previous blood pressure of 138/74 and a pulse of 64, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?
30-45 seconds
It would be appropriate to delegate the taking of vital signs of which client to unlicensed assisting personnel?
A client being prepared for elective facial surgery with a history of stable hypertension.
An 85 year old has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are appropriate for taking temperature.
Axillary, tympanic, temporal artery.
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following?
Absent posterior tibial and pedal pulses.
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?
Shortness of breath
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