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Vital Signs

QuestionAnswer
Normal Oral Temp Healthy Adult 98.6/37
Normal Rectal Temp Healthy Adult 99.5/37.5
Normal Axillary Temp Healthy Adult 97.6/36.5
Normal Tympanic Temp Healthy Adult 99.5/37.5
Normal Forehead Temp Healthy Adult 94.0/34.4
4 factors affecting body temp -stress -Circadian rhythms -age & gender -environmental temp
5 sites to assess temp oral rectal axillary forehead tympanic
definition of pulse rate The number of contractions over a peripheral artery in 1 minute
factors affecting pulse rate (9) -age -blood volume -cardiac output -altered body temp -hormonal changes -physiological conditions -medications -activity level -vagal stimulation (parasympathetic)
3 pulse variations to assess & document -rate -quality -rhythm
definition of pulse deficit difference between apical and radial pulses
definition of apical pulse pulse taken over apex of heart
where is apical pulse asssessed? 5th intercostal space, midclavicular line
8 pulse sites radial carotid apical brachial femoral popliteal posterior tibial dorsalis pedal
pyrexia fever/febrile condition
sympathetic innervation increases pulse rate
parasympathetic innervation decreases pulse rate
most powerful respiratory stimulant increase in CO2
what do you look for when assessing respirations effort depth rate
factors affecting respirations (8) exercise respiratory/cardiovascular disease medications trauma, neuro. dysfunction, brain lesions alterations in fluid, electrolyte, and acid-base balance infections pain anxiety
4 ways to assess respirations inspection auscultate with stethescope monitor arterial blood gas results pulse oximetry
arterial blood gases the oxygen and carbon dioxide content of arterial blood, assesses adequacy of ventilation and oxygenation and the acid-base status of the body
pulse oximetry noninvasive method of indicating the arterial oxygen saturation of functional hemoglobin, using a pulse oximeter
eupnea normal respiration
tachypnea very rapid respiration (also called polypnea)
bradypnea abnormal slowness of breath
dyspnea labored or difficulty breathing
apnea cessation of breathing
orthopnea dyspnea that is relieved in the upright position
hyperventilation Abnormally fast or deep respiration resulting in the loss of carbon dioxide from the blood, thereby causing a decrease in blood pressure and sometimes fainting
hypoventilation Reduced or deficient ventilation of the lungs, resulting in reduced aeration of blood in the lungs and an increased level of carbon dioxide in the blood.
blood pressure force of blood against arterial walls
pressure rises as: ventricles contract and falls as heart relaxes
systolic highest pressure
diastolic lowest pressure
pulse pressure difference between systolic and diastolic
ausculatory gap temporary disappearance of sounds normally heard over brachial artery when cuff pressure is high followed by the reappearance of sounds at a lower level
factors affecting blood pressure (8) age/gender/race Circadian rhythms drugs/medications exercise food intake weight emotional state body position
pain is described in terms of (4) location intensity duration etiology
etiology 1. The science and study of the causes or origins of disease. 2. The cause or origin of a disease or disorder as determined by medical diagnosis.
cyanosis bluish discoloration of skin/mucous membranes
syncope fainting
costal (thoracic) breathing movement of chest upward & outward
diaphragmatic (abdominal) breating movement of abdomen due to diaphragm contracting and moving down
newborn pulse & resp average and ranges pulse 130 (80-180) resp 35 (30-60)
1 yr pulse & resp average/ranges pulse 120 (80-140) resp 30 (20-40)
5-8 yrs pulse & resp average/ranges pulse 100 (75-120) 20 (15-25)
10 yrs pulse & resp average/ranges pulse 70 (50-90) resp 19 (15-25)
teen pulse & resp average/ranges pulse 75 (50-90) 18 (15-20)
adult pulse & resp average/ranges pulse 80 (60-100) resp 16 (12-20)
older adult pulse & resp average/ranges pulse 70 (60-100) resp 16 (15-20)
heat balance when the amount of heat produced by the body equals the amount of heat lost
core temperature temp of the deep tissues of the body, stays constant.
surface temperature temp of the skin, subcutaneous tissue, and fat. rises & falls in response to environment
Basal metabolic rate rate of energy utilization in the body required to maintain essential activities such as breathing. younger person = higher BMR
factors affecting body's heat production (5) BMR, muscle activity, thyroxine output, epinephrine/norepinephrine & sympathetic stimulation/stress response, fever
causes of heat loss radiation, conduction, convection, evaporation
epinephrine/norepinephrine & sympathetic stimulation/stress response hormones that increase the rate of cellular metabolism
intermittent fever body temp alternates at regular intervals between periods of fever & periods of normal temps (ex. malaria)
remittent fever wide range of temp fluctuations over 24 period, all above normal. (ex cold/flu)
relapsing fever short febrile periods of a few days interspersed with periods of 1-2 days of normal temps
constant fever body temp fluctuates minimally but always above normal (ex typhoid fever)
fever spike rises rapidly & returns to normal in a few hours, (ex bacterial blood infections)
parenchyma (ex "parenchyma of cells) The tissue characteristic of an organ, as distinguished from associated connective or supporting tissues.
three phases of fever onset (cold/chill phase) course (plateau phase) defervescence (fever abatement/flush phase)
name some nursing interventions for clients with fever monitor vitals, monitor lab reports like wbc/hematocrit, provide adequate nutrition/fluids, make client comfortable, measure intake/output, reduce physical activity, administer antipyretics as ordered
compliance of arteries their ability to contract/expand
cardiac output volume of blood pumped into arteries by the heart. equals result of stroke volume (SV) x heart rate (HR) per min.
point of maximal impulse (PMI) apical pulse
what happens when you press both carotids simultaneously? reflex drop in blood pressure/pulse rate
tachycardia excessively fast HR, greater than 100 BPM in adult
bradycardia slow HR, less than 60 BPM in adult
arrhythmia/dysrhythmia pulse with irregular rhythm
perfusion blood flow to a particular area
purpose for assessing apical pulse HR of adult w/ irregular peripheral pulse, gather baseline data, determine if cardiac rate is WNL & rhythm regular
S1 heart sound (lub) occurs when... AV valves close after ventricles have been sufficiently filled
S2 heart sound (dub) occurs when... semi-lunar valves close after ventricles empty
volume of N adult inspiration/expiration 500 mL
tidal volume vol. of N inspiration/expiration
cheyne-stokes breathing rhythmic waxing/waning of respirations, from v deep/shallow & temp. apnea
stridor harsh/shrill sound during inspiration w/ laryngeal obstruction
stertor snoring/sonorous respiration, usually due to partial obstruction of upper airway
intercostal retraction indrawing btwn ribs
substernal retraction indrawing beneath breastbone
suprasternal retraction indrawing above clavices
hemoptysis presence of blood in sputum
arteriosclerosis elastic/muscular tissues of arteries are replaced w/ fibrous tissue, they lose their ability to constrict/dilate. most common in middle-aged - older adults.
hematocrit proportion of RBC -> blood plasma. BP is higher when blood is highly viscous.
orthostatic hypotension BP that falls when client sits/stands
signs/symptoms of hypertension headache, ringing in ears, flushed face, nosebleeds, fatigue
signs/symptoms of hypotension tachycardia, dizziness, mental confusion, restlessness, cool & clammy skin, pale or cyanotic skin
Created by: poodley