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Vital Signs
| Question | Answer |
|---|---|
| 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
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