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concepts 15&17
| Question | Answer |
|---|---|
| the six vital signs | temp, BP, pulse, SpO2, pain, and R |
| no smoking or drinking at least | 20-30 mins before temp is taken |
| thermogenesis | production of heat |
| basal metabolic rate | BMR, heat produced at rest |
| vital signs are assessed when | there is a change in patient status |
| thermoregulation | regulation of body temp |
| hypothalamus | maintains set point |
| set point | core temp |
| when to take vitals | every 5-15 if unstable |
| when to take vitals | suspected condition change |
| when to check vitals | before and after surgical procedures |
| core temperature | temperature of vital organs |
| factors that affect temperature | environment, illness, and exercise |
| normal oral temperature | 98.6 F and 37 C |
| most accurate temperature | oral and rectal |
| oral temperature | non invasive |
| rectal | invasive |
| normal axillary temperature | 97.6 F and 36.4 C |
| normal rectal temperature | 99.6 F and 37.5 |
| febrile | fever |
| afebrile | no fever |
| pyrexia | fever |
| hyperthermia | core temp above 100.4 F and 38 C |
| hypothermia | core temp below 95 F and 30 C |
| signs and symptoms of a fever | diaphoresis, flushed, increased pulse and respirations, lethargic |
| headache, muscle aches | myalgia |
| pulse sites | apical, radial, temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis |
| PMI | point of maximum impulse |
| apical pulse | is not a peripheral pulse point, left side of chest @ 5th intercoastal space along midclavicular line |
| stoke volume | amount of blood discharged from left ventricle with each contraction |
| antipyretic | fever reducing medication: Tylenol, ibuprophen |
| reye syndrome | from kids taking asprin, affects nervous system, and liver damage, after taking it while recovering from infection |
| cardiac output | amount of blood pumped from heart in one minute |
| bradypnea | less than 60 bpm |
| tachypnea | more than 100 bpm |
| hypoxia | increase in pulse rate |
| hypoxemia | drop in oxygen in blood |
| pulse deficit | a difference in apical and radial pulse |
| normal pulse rate | between 60-100 bpm |
| regular rhythm | 2+, weak |
| irregular rhythm | 1+, weak |
| volume strength | 0-3 scale |
| bounding | 3+, strong |
| thready | difficult to count, fast and weak |
| capillary refill | how long it takes for blood to return to the nail bed after applying pressure |
| inspiration | breathing in, chest goes down, lungs fill with air |
| expiration | breathing out, chest goes up, lungs release air |
| external respiration | alveoli to and from blood |
| internal respiration | blood to and from tissue |
| breaths per minute (slow) | bradypnea |
| breaths per minute (fast) | tachypnea |
| assessment components | depth, rhythm, pattern |
| eupnea | normal |
| apnea | absence of breathing |
| dyspnea | difficulty breathing |
| orthopnea | difficulty breathing when not sitting up |
| abnormal breath sounds | strenuous, wheezes, crackles, stridor, rhonchi |
| cheyne stokes | shallow breath, deeper, repeat, apnea, closer to death |
| biot | several shallow breaths followed by apnea (longer) |
| kussmaul | increased respirations, rapid snorting sound |
| 4 circulatory factors | heart strength, blood viscosity, blood volume, peripheral vascular resistance |
| factors that affect BP | age, dehydration, hemorrhage, obesity, pregnancy, nicotine |
| systolic | contraction phase of the heart |
| diastole | relaxation phase of the heart |
| pulse pressure | difference between systolic and diastolic, less than 30 and greater than 50 is abnormal |
| hypertension | elevated BP, consistently over 130/80 |
| tap sounds that represent blood flow from deflation of cuff and blood returning | korotkoff sounds |
| normal BP range | 100/60-120/80 |
| normal SpO2 | 95-100 |
| primary hypertension (essential) | develop over years due to genetics age and lifestyle |
| secondary hypertension | caused by underlying medical conditions |
| hypotension | sudden drop, BP lower than 100/60 |
| how to treat hypotension | Trendelenburg position |
| pain assessment type | acute vs chronic |
| maceration | softened skin due to consistent moisture |
| excoriation | scraps on skin due to scratching |
| benefits to bathing | cleanses skin and skin assessment |
| venous return | washing from distal to proximal to improve blood return from extremities to heart |
| mottling | purplish, blotching of skin from slow circulation |
| types of care | self, assisted and total care |
| patrial bath | washing hot spots, buttocks, face, hands, perineal, axillae |
| therapeutic bath | for specific medical purpose |
| tinea capitis | ring worm |
| seborrhea | thick oily scales from overproduction of sebrum |
| special mouth care | provided for patients: NPO, feeding tube, nasal canula or mask, unconsious |
| shave a patient again | 2-3 days later |
| repeat treatment for lice and nits | 1-2 weeks after initial treatment |
| open bed | top linens fan folded to foot of bed |
| surgical bed | top linens fan folded to side of bed |
| closed bed | discharged and cleaned |
| mitered | slanted corners |
| flat position | used for sleep and rest |
| fowlers position | head elevated knees slightly raised, used for visiting or watching TV |
| semi-fowlers position | partial head elevation, for tube feeders to prevent aspiration |
| Trendelenburg position | head flat and feet slightly elevated used for patients with low BP |
| reverse Trendelenburg position | head elevated legs flat, used for procedures that need to keep legs straight |
Created by:
muvamayi