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NUR151 - VitalSigns
Vital Signs
| Question | Answer |
|---|---|
| Body temperature is the difference between __. | the amount of heat produced by body processes and the amount of heat lost to the external environment. |
| Body surface temperatures fluctuate usually within a range of __. | 36 °C to 38 °C (96.8 °F to 100.4 °F) |
| The balance between heat lost and heat produced. | Thermoregulation |
| The __ controls heat loss, while the ___ controls heat production. | anterior hypothalamus, posterior hypothalamus |
| Heat production can occur through? | Metabolism, Shivering, and Excessive muscle activity (as seen with exercise). |
| Heat loss can occur from? | Radiation, Conduction, Convection, or Diaphoresis and Evaporation. |
| Radiation | Transfer of heat from the surface of one object to the surface of another without direct contact between the two. |
| Conduction | Transfer of heat from one object to another with direct contact. |
| Convection | Transfer of heat away by air movement. |
| Diaphoresis and evaporation | Transfer of heat energy when a liquid is changed to a gas. |
| Celsius to Fahrenheit Formula | C=(F-32 degrees)X.55 |
| Name a major disadvantage of a rectal thermometer. | Risk of transferring nosocomial Clostridium infections rectally. |
| Name one disadvantage of a Tympanic Thermometer (ear). | More variability of measurement than other core temperature devices. |
| Which thermometer provides accurate body core temperature? | Tympanic Thermometer |
| Assess for signs and symptoms that may accompany temperature alterations such as __. | Fever, Hyperthermia, Heatstroke, and Hypothermia. |
| In what direction should the nurse pull the pinna of the adult when taking a tympanic temperature? | Up, then backward and out. |
| You remove Mary Helen’s blanket and turn a fan on in the room. By what mechanism will this help lower Mary Helen’s temperature? | Convection – the transfer of heat away by air movement. |
| Vital signs are import indicators of the body's ___. | physiologic status and response to physical, environmental, and psychological stressors. |
| You should always obtain a baseline measurement of vital signs on first contact with a client to provide a means for ___. | comparison with subsequent vital sign measurements. |
| Vital Signs are important indicators of the body’s____. | physiologic status |
| Vital signs consist of ___. | temperature, pulse, respiration, blood pressure, and oxygen saturation. |
| Vital signs reveal sudden changes in a client’s condition, as well as changes that occur ____. | progressively |
| Acceptable Range of Respiration for an adult. | 12-20 breaths per minute. |
| Acceptable Range of Heart Rate for an adult. | 60-100 beats per minute. |
| Normal SpO2 is ___. | 90% to 100%. Between 85% and 89% may be acceptable for certain chronic disease conditions. Less than 85% is considered abnormal. |
| Aortic distention creates a ___ that travels rapidly toward the extremities. | pulse wave |
| The ___ is the palpable bounding of the blood flow. | pulse |
| Pulse rate, rhythm, and strength indirectly evaluate the heart's ___. | cardiac output (CO) |
| The strength or amplitude of a pulse reflects the volume of blood ejected against the arterial wall with each heart contraction, also called ___. | stroke volume (SV) |
| The integrity of peripheral pulses indicates the status of ___ to the area distributed by the pulse. | blood perfusion |
| A decrease in fluid volume will result in an ___ heart rate as the body attempts to increase cardiac output. | increased |
| If the client has been active, wait ___ before assessing the pulse. | 5 to 10 minutes |
| Bradycardia is when a client's heart rate ___. | falls below 60 beats per minute. |
| Tachycardia is when a client's heart rate ___. | is above 100 beats per minute. |
| All excessively fast or slow pulses should be counted for ____ rather than 30 seconds multiplied by two. | 60 seconds/1 full minute |
| Whenever there is abnormality in rate, rhythm, or amplitude, it is best to take an ___. | apical pulse |
| The ___ of the stethoscope is best for transmitting an apical pulse, since the pulse is a high-pitched sound. | diaphragm |
| The ___ is best for transmitting low-pitched sounds, so it is used for other assessments such as detecting heart murmurs. | bell |
| An inefficient contraction of the heart that does not transmit a pulse wave to the peripheral pulse site creates a ___. | pulse deficit. |
| The pulse deficit reflects the number of ____ in 1 minute. | ineffective cardiac contractions |
| The mechanism of ___ exchanges oxygen (O2) and carbon dioxide (CO2) between cells of the body and the atmosphere. | respiration |
| Ventilation | Mechanical movement of gases into and out of the lungs. |
| Diffusion | Movement of O2 and CO2 between the alveoli and the red blood cells. |
| Perfusion | Distribution of red blood cells to and from the pulmonary capillaries. |
| You directly assess ventilation by observing the ___ of respiratory movements. | rate, depth, and rhythm. |
| Expiration is an active process only during __. | exercise, voluntary hyperventilation, and certain disease states. |
| Orthopnea | Labored breathing that occurs when lying flat and is classic symptom of left ventricular heart failure. Rapid resp. rate. |
| ______ (position) promotes full ventilation movement and lung expansion. | Standing or sitting erect |
| Decreased ___ levels lower the amount of oxygen carried in the blood, which results in increased respiratory rate to increase oxygen delivery. | hemoglobin |
| Pulse oxygen saturation (SpO2) less than ___ is often accompanied by changes in respiratory rate, depth, and rhythm. | 85% |
| CBC measures red blood cell count, volume of red blood cells, and concentration of hemoglobin, which reflects the client's capacity to carry __. | O2 |
| Hemoglobin values | Males: 14 to 18 g per 100 mL and Females: 12 to 16 g per 100 mL. |
| Hematocrit values | Males: 40% to 54% and Females: 38% to 47%. |
| Red blood cell count | Males: 4.6 to 6.2 million per mm3 and Females: 4.2 to 5.4 million per mm3. |
| Human pH values | 7.35 to 7.47 |
| Arterial carbon dioxide saturation | 35 – 45 mm Hg. |
| Cheyne-Stokes | Varying periods of increasing breathing depth interspersed with apnea. |
| Kussmaul's | Rapid, deep, labored breathing |
| Systolic | The force exerted against he wall of the artery when the ventricles contract. |
| Diastole is a ___ process. | passive |
| The five different sounds heard over an artery are called ___ phases. | Korotkoff |
| The difference between ____ pressure is called the pulse pressure. | systolic and diastolic. |
| Hypertension is defined as systolic BP (SBP) of ____, diastolic BP (DBP) of ___ or greater. | 40 mm Hg or greater, 90 mm Hg |
| Hypotension is generally considered present when the systolic BP falls to ___ or below. | 90 mm Hg. |
| Orthostatic hypotension, also referred to as postural hypotension, occurs when ___. | a normotensive person develops symptoms (e.g., light-headedness or dizziness) and low BP when rising to an upright position. |
| A noninvasive method of estimating arterial blood oxygen saturation by measuring oxyhemoglobin in arterial blood. | Pulse oximetry - a light-emitting diode (LED), two wavelengths of light determine oxygenated and deoxygenated hemoglobin. |
| When arterial oxygen tension falls below ___, oxygen saturation falls. | 50 mm Hg |
| To prevent ___, you should assess the skin integrity underneath the probe used for continuous monitoring every 2 hours. | tissue ischemia |
| Why is it necessary to take vital signs preoperatively? | To use for comparison during and after surgery and make sure client is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention. |
| Average body temperature approximately ___. | 36 °C (96.8 °F) |
| The apical pulse it taken at the __ | .5th Intercostal Space (ICS) at the left Mid-Clavicular line (MCL). |
| Bradypnea—rate is regular but less than __ breaths per minute. | 12 |
| Tachypnea—rate is regular but greater than __ breaths per minute. | 20 |
| Hyperpnea—respiration is __ than normal, usually during exercise. | deeper |
| Kussmaul's—deep regular respiration, common with ___. | diabetics |
| Respiratory rate may increase when the client is in pain, but breathing becomes ___. | shallow |
| Repeating a BP too quickly will result in a false ___ reading. Wait 1 to 2 minutes to repeat a measurement, or measure the pressure in the opposite arm. | high systolic |
| The ___ controls body temperature the same way a thermostat works in the home. | hypothalamus |
| When nerve cells in the __ hypothalamus become heated beyond the set point, impulses are sent out to reduce body temperature. | anterior |
| How does hypothalamus reduce body temperature? | Induces sweating, vasodilation , and inhibition of heat production. |
| How does posterior hypothalamus induce heat conservation? | Vasoconstriction, shivering. |
| BMR | Basal metabolic rate – depends on body surface area and accounts for the heat produced by body at absolute rest. |
| What hormone affects BMR? | Thyroid – promotes breakdown of glucose and fat and increases chemical rxn in body cells. |
| Shivering increases body heat production by __. | 4-5 times greater than normal. |
| Applying an ice pack to lower body temperature is what kind of heat loss? | Conductive heat loss. |
| Peripheral vasodilation increases blood flow from the internal organs to the skin to increase heat loss. What kind of heat loss is this? | Radiation/radiant heat loss. |
| Diaphoresis is what kind of heat loss? | Evaporation |
| Which population is at most risk of heat loss or gain due to behavioral control?Infants and older adults. | (blank) |
| What factors affect body temp? | Age, exercise, hormone level, circadian rhythm, environment, and temperature alteration (fever, hyperthermia, heatstroke, hypothermia). |
| Pyrexia | Fever |
| A fever is usually not harmful if it says below __. | 39 C (102.2 F) |
| Pyrogens | bacteria and viruses that act as antigens and trigger immune system responses. |
| When a fever breaks, a client becomes __. | afebrile |
| During a febrile episode, white blood cell production is __. | stimulated |
| Increased temp reduces concentration of ___ in the blood. | iron |
| The duration and degree of fever depends on what 2 factors? | Pyrogen’s strength and the ability of the individual to respond. |
| Myocardial hypoxia produces __. | angina (chest pain) |
| Cerebral hypoxia produces __. | confusion |
| Why is oxygen therapy important during a fever? | Because increased metabolism requires addition oxygen, leaving possibility open for hypoxia. |
| Heat exhaustion occurs when __. | profuse diaphoresis results in excess water and electrolyte loss. |
| At what temp does a client suffer uncontrolled shivering? | 35 C or 95 F. |
| At what temp does skin become cyanotic? | 34.4 C or 94F – heart rate, respiratory rate, and blood pressure fall. |
| ICU measures what temperature in clients? | Core – through continuous invasive devices placed in body cavities or organs. |
| Temporal artery measurements detect temp of? | Cutaneous blood flow. |
| How long must you wait for an oral temperature is someone has eaten? | 20-30 minutes |
| What are 2 internal temperature sites? | Pulmonary artery and bladder |
| Antipyretic | Drugs that reduce fever. |
| How do nonsteroidal drugs like acetaminophen reduce fever? | through increasing heat loss. |
| The pulse is a __. | palpatable place on the body in which to measure heart beat. |
| Electrical impulses for the pulse originate from where? | the Sinoatrial (SA) node. |
| What is cardiac output? | Volume pumped by the heart in 1 minute. |
| If CO is low, pulse will be? | weaker or more difficult to palpate |
| If CO is high, pulse will be stronger, “bounding”. | (blank) |
| What factors regulate ventricular contraction and stroke volume? | Mechanical, neural and chemical factors. |
| Where is the brachial pulse? | Grove between biceps and tricepts muscles at antecubital fossa. |
| Where is the carotid pulse? | Along medial edge of sternocleidomastoid mucle in neck. |
| Where is the Posterior tibial pulse? | Inner side of ankle, below medial malleolus. |
| Where is the Dorsalis pedis pulse? | ”Pedal Pulse” – Along top of foot, between extension tendons of great and first toe. |
| Which pulses are easiest to palpate? | radial or carotid arteries |
| Where is PMI (point of maximal Impulse) in an adult? | Apical impulse – at the apex of heart. |
| Pulse deficits are often associated with ___. | abnormal rhythms. |
| A __ threatens the heart’s ability to provide adequate cardiac output, particularly if it occurs respectively. | dysrhythmia |
| To document a dysrhythmia, a __ is needed. | electrocardiogram, Holter monitor, or telemetry. |
| Peripheral resistance | Determined by vasculature tone – how elastic. |
| Name factors that influence blood pressure. | Age, stress, ethnicity, gender, daily variation, medications, activity, weight, smoking. |
| Stage 2 hypertension occurs above __. | 160 systolic or 100 diastolic. |
| Assessment of BP and pulse evaluates __. | the general state of cardiovascular health. |
| What does a drop in respiration after a head injury indicate? | significant injury to the brain stem. |
| What can abdominal trauma due to affect respiration? | damage phrenic nerve which is responsible for diaphragmatic contraction. |
| The usual range of respiratory rate __ throughout life. | declines |
| Biot’s respiration | Abnormally shallow for 2-3 breaths, followed by apnea periods. |
| What affects Sa02? | Factors that interfere with ventilation, perfusion, or diffusion. |
| Why is SvO2 lower? | Because tissues have removed some of the oxygen from hemoglobin molecules. |
| What is typical value of Sv02? | 70%. |
| What determines hematocrit? | Percentage of RBCs in blood. |
| What is preferred position for blood pressure? | sitting |
| Client's temperature is 36.1° C (97° F) and remaining vital signs are in the normally acceptable range. What should the nurse do next? | If everything seems satisfactory, the nurse should chart the temperature and check the client for signs of hypothermia. |
| The ___ are usually used to assess a client in shock. | carotid or femoral pulses |
| The ___ pulse gives the nurse the most information and accuracy when assessing irregular cardiac rhythm. | apical |
| With a fever, therapies such as tepid water or alcohol sponge baths should be avoided because they lead to ___, which stimulates body heat. | shivering |
| ___ respiration is an irregular respiratory rate and depth w/alternating periods of apnea and hyperventilation; it begins with slow breaths and climaxes in apnea before respiration resumes. | Cheyne-Stokes |
Created by:
Ladystorm