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health assessment

fundamentals ati unit 2 ch 23

the ___ and ___ systems work together to keep body temperature within normal range neurological and cardiovascular
Core temperature measurement sites rectum and tympanic membranes
surface temperature measurement sites skin, mouth and axillae
normal temperature range 96.8 to 100.4 average is 98.6
Difference between oral and rectal temperature .5 degree higher than oral
difference between oral and axillary temperatures .5 degrees lower than oral
heat production results from inc in basal metabolic rate, muscle activity, thyroxine output and sympathetic stimulation
heat loss from body occurs through... conduction, convection, evaporation, radiation.
conduction transfer of heat from body to another surface.
convection dispersion of heat by air currents
evaporation dispersion of heat through water vapor
radiation transfer of heat from one object to another object w/o contact b/w them
newborns and temperature large surface to mass ration, lose heat rapidly to environment. Should be maintained at 95.9 to 99.5 degrees.
older adult and temperature lower body temperatures and feel cold, less subcutaneous fat. Average is 96.8 degrees. More likely to be affected by extremes in environmental temp. takes longer to register on thermometer
hormone and temperature slight rise w/ ovulation and menses. menopause, intermittent body temperature may inc. up to 7.2 degrees.
exercise, activity and dehydration may contribute to _ hyperthermia
illness and injury are often associated w/ ____ in temperature elevation. Fever is body's response to infection and inflammatory process.
recent ____ or ___ intake and ____ can interfere with accurate measurement of body temperature food, fluid, smoking
inaccuracy in tympanic technique for temperature if under 3 months of age. if excessive ear wax is present
Harmful fever temperature if the temperature exceeds 102.2 degrees
hyperthermia abnormally elevated body temperature
interventions for high fever obtain blood cultures if ordered, assess wbc counts, sedimentation rates and electrolytes if ordered, admin. antibiotics, up fluids/rest, antipyretics (tylenol). cooling blanket/tepid bath(85-90 degrees), blanket for chill, oral hygiene/dry clothes/linens
hypothermia body temperature < 95 degrees an abnormally low body temp.
interventions for hypothermia provide warm environment temp, heated humidified oxygen, warming blanket, friction to extremities/warmed oral or IV fluids. continuous cardiac monitoring, emergency resuscitation equipment on standby.
Cardiac output how much blood is pumped from the heart (left vent) to arterial circulation in 1 minute. CO=HR x SV (stroke volume)
The ____ system controls heart rate autonomic nervous system
The ____ system lower the heart rate parasympathetic
The ___ system raises the heart rate sympathetic
pulse as a vital sign is the... measurement of heart rate and rhythem. It is the wave-like sensations/impulses felt in a peripheral arterial vessel or over the apex of the heart.
rate of a pulse number of times per minute the pulse is felt or heard
rhythm of a pulse regularity at which each impulse is felt. Premature or late heart beat can result in an irregular interval and can indicate abnormal electrical activity of heart.
strength (amplitude) of a pulse strength of impulse should be same from beat to beat and graded on scale of 0-4. 0 absent, 1+ diminished, weaker than expected, 2+ brisk, expected, 3+ increased, 4+ full volume bounding
equality - peripheral pulse impulses should be symmetrical in quality and quantity on each side of body. evaluate adequacy of vascular system
normal pulse range for adults 60 - 100/ min at rest
tachycardia pulse rate > 100/min
bradycardia pulse rate < 60/min
dysrhythmia irregular rhythm of heart that frequently is noted as an irregular radial pulse
pulse deficit occurs when apical rate is greater than radial rate.
age impact on pulse infant pulse rate is 120-160/min. Gradually decreases as child ages. 12-14 yr old 80-90/min. older adult weaker pulse due to poor circulation or cardiac dysfunction, harder to palpate pulse.
Factors leading to tachycardia exercise, fever, medications (epinephrine, levothyroixine), changing positions (lay to sit to stand) acute pain, hyperthyroidism, anemia, hypoxemia, stress, anxiety, fear, hypovolemia, shock and heart failure lead to dec. CO w/ compensatory inc. HR
Factors leading to bradycardia long term physical fitness, hypothermia, meds (digoxin, beta-blockers, ca channel blockers), changing position (stand to sit to lay), chronic pain, hypothyroidism
how long should you count a regular pulse for? 30 seconds times it by 2
how long should you count an irregular pulse for? full minute and compared to apical pulse rate
location of apical pulse 5th intercostal space at left midclavicular line. Use for infant HR, rapid rates (>100/min), irregular rhythms or rates prior to administration of cardiac meds. 1 full minute.
what should you also assess for in a client with tachycardia? pain, anxiety, restlessness, fatigue, low bp, oxygen saturation
what should you also assess for in a client with bradycardia? hypotension, chest pain, diaphoresis, dyspnea, altered mental status
Chemoreceptors in the carotid arteries and aorta primarily monitor _ CO2 levels of the blood. If CO2 rises, RR inc. to rid body of excess.
Ventilation exchange of o2 and co2 in lungs. Measured with RR, rhythm and depth
Diffusion passage of oxygen and co2 b/2 alveoli and rbc. measure w/ pulse oximetry.
Perfusion flow of blood to and from pulmonary capillaries. measure w/ pulse oximetry
Respiration vital sign evaluates effectiveness of ventilatory process of oxygen and co2 exchange.
Respiration Rate number of full inspirations and expirations in 1 min. Determine by observing number of times chest rises and falls. Normal in adults is 12-20 RR/Min
Respiration depth amount of chest wall expansion occurs w/ each breath. abnormal depths are deep or shallow.
respiration rhythm observe breathing intervals. reg rhythm w/ occasional sigh is normal in adults
Pulse oximetry measure O2 saturation of blood by infrared light that measures SaO2 (arterial oxygen saturation) by light absorption by oxygenated and deoxygenated hemoglobin in arterial blood.
normal pulse ox 95-100% Acceptable levels may go from 91-100, some ilness states may allow for an SaO2 of 85-89
pulse ox values may be slightly lower in what type of client older or dark skinned client, hypothermia, poor peripheral blood flow, too much light, low hemoglobin levels, client movement, edema and nail polish
intervention required for pulse ox of _ <91%. <86% emergency <80% life threatening. The lower the value the less accurate the measurement
Age related issues to respiration decreases with age. newborns have rate of 30-60/min. School age children 20-30/min. adults 12-20/min
gender related issues to respiration men are diaphragmatic breathers and abdominal movements are more noticeable. Women use more thoracic muscles and chest movements are more pronounced when they breath.
pains effect on respiration decrease depth of respirations. Onset of acute pain, RR will increase but will return to normal over time.
anxiety effect on respiration inc rate and depth of respiration
smoking effect on respiration causes resting rate of respiration to increase
body position effect on respiration upright allow chest wall to expand fully
medications effect on respiration opioids, sedatives, bronchodilator and general anesthetics will dec. the RR and depth. can be serious adverse effect. Amphetamines/cocaine may inc rate and depth.
Neurological injury and respiration injury to brain stem dec. RR and rhythm
illness that impacts shape of chest wall and patency of passages or those impairing muscle function will __ RR and what sign/symptom may be seen dec, use of accessory muscles
anemia or high altitudes will __ in regards to oxygen, which in turn __ RR and __ impair oxygen carrying capacity of the blood, increases, change rhythm to compensate
Hypoxemia SaO2 <90%, interventions - confirm probe placement, oxygen delivery functioning and client receiving ordered levels, semi-Fowler's or fowler's position to maximize ventilation, deep breathing, assess signs such as tachypnea, tachycardia, restlessness
Blood pressure force exerted by blood in arteries during heart contraction (systole) and relaxation (diastole)
systolic bp occurs during ventricular systole of heart and represents max amt of pressure exerted on arteries.
diastolic bp occurs during ventricular diastole of heart and represents min amt of pressure exerted on arteries.
principle determinants of bp are CO and systemic vascular resistance. BP= CO x SVR. CO determined by HR, Contractility, blood volume, venous return (up any > up CO > up BP) SVR determined by amt of constriction/dilation of arteries. up in SVR > up BP
Normal BP systolic bp < 120 mmHg, diastolic bp < 80 mm Hg
prehypertension bp 120-139/80-89
stage 1 hypertension 140-159/90-99
stage 2 hypertension > or equal 160/greater or equal 100
client w/ blood pressure of 124/92 mm Hg is classified as having what? stage 1 hypertension bc diastolic places them in that category. determined by higher reading.
client with blood pressure of 146/82 mm Hg is classified as having what? stage 1 hypertension
Hypotension BP below normal systlic <90 and can be result of fluid depletion, heart failure or vasodilation
pulse pressure difference bw systolic and diastolic pressure readings
postural (orthostatic) hypotension BP falls when client changes position from lying to sitting or standing, may result from various causes. take client bp and hr lying down, then have sit or stand, wait 1-5 mins. reassess. if sbp dec > 20 mm Hg and dbp dec >10 with a 10-20% inc in HR
Age and blood pressure infants have low bp that gradually inc with age, older children/adolescents varying bp based on body size, older adult, slightly elevated systolic due to dec. elasticity of blood vessels.
circadian (diurnal) rhythms and BP bp usually lowest in early morning hours and peaking during later part of afternoon/evening
stress and bp in in bp assoc. w/ fear, emotional strain and acute pain
ethnicity and bp african american have higher incidence of hypertension in general and at earlier ages
gender and bp adolescent to middle age men have higher bp than female. postmenopausal women have higher bp's than male
medications and bp opiates, antihypertensives and cardiac meds can lower bp. cocaine, cold meds, oral contraceptives and antidepressants raise bp
exercise effect on bp dec bp for several hours after
a shpygmomanomter cuff width should be _ 40% of the arm circumference at the point where cuff will be wrapped.
BP should not be taken on an arm that __ has an iv - side of a mastectomy
where should the bp cuff be applied 2 cm above antecubital space w/ brachial artery in line w/ marking on cuff.
systolic pressure is measured at the _ first clear sound
diastlic pressure is measured at the __ point where sound is muffled then disappears
Lifestyle modification for hypertension stop smoking, DASH diet (restrict sodum, consume K+, Ca+ and Mg, low cholesterol/sat fat), wgt ctrl, mod alcohol, inc. activity, dec. stress.
Created by: FSclafani