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chapter 17
concepts
| Question | Answer |
|---|---|
| THE SIX VITAL SIGNS | OBJECTIVE MEASUREMENTS – 1) Temperature (T) 2) Pulse (P) 3) Respirations (RR) 4) Blood pressure (BP) 5) Oxygen saturation (SpO2) SUBJECTIVE MEASUREMENT – 6) Pain |
| SUPERVISION/DELEGATION CONNECTION | There are times when you should assess a patient’s vital signs or reassess them after someone |
| BODY TEMPERATURE | 97 degrees Fahrenheit to 99.6 degrees 36.1 degrees Celsius to 37.5 degrees |
| THERMOGENESIS | production of heat |
| THERMOREGULATION | regulation of body temperature |
| Hypothalamus | When hypothalamus functions correctly, it maintains a comfortable core temperature known as the set point. |
| FACTORS AFFECTING BODY TEMPERATURE | Environment, Time of Day, Sex, Physical Activity and Exercise, Medications, Food Intake, Stress, illness |
| ORAL ROUTE | the best noninvasive method to obtain accurate reading. (98.6 degrees Fahrenheit or 37 degrees Celsius |
| RECTAL ROUTE | the most accurate method to obtain accurate reading. (99.6 degrees Fahrenheit or 37.5 degrees Celsius |
| FEVER | is the body’s natural defense against infection. |
| FEBRILE | is used to indicate the state of having a fever |
| AFEBRILE | is used to indicate the state of being without fever |
| HYPERTHERMIA | elevations above 105 degrees Fahrenheit |
| HYPOTHERMIA | a core temperature below 95 degrees Fahrenheit (35 degrees Celsius) |
| NURSING CARE FOR PATIENTS WITH FEVER | - Assess all vital signs at least every 2 hours or more often depending on the degree of abnormality. - Administer antipyretic, or fever-reducing, medications as ordered. |
| STROKE VOLUME | the amount of blood discharged from the left ventricle with each contraction. |
| PULSE | the arterial fluid wave can be palpated as a gentle pulsing, tapping, or throbbing sensation at various points over the body |
| CARDIAC OUTPUT | the volume of blood pumped from the heart in 1 minute |
| APICAL PULSE | is the central or primary pulse site located over the apex of the heart where the contraction is the strongest (and most accurate). |
| AUSCULTATION | listening to the apical pulse with the stethoscope. Listening to “lubb- dupp”. Refers to S1 and S2 of the rhythm |
| PULSE DEFICIT | when the radial pulse is slower than the apical pulse |
| TEMPORAL | can be used when the radial pulse is not accessible (head) |
| CAROTID | used in cardiac arrest and cardiopulmonary resuscitation (CPR) (neck) |
| BRACHIAL | used to measure BP; can be used to assess pulse rate in small children (crease of arm) |
| RADIAL | routinely used for pulse rate assessment (below thumb) |
| FEMORAL | used to determine circulation to the leg, cardiac arrest ( pelvis) |
| POPLITEAL | used to determine circulation to the lower leg (behind knee) |
| POSTERIOR TIBIALIS | used to determine circulation to the foot (ankle) |
| DORSALIS PEDIS | used to determine circulation to the foot ( top of foot) |
| AUSCULTATE | to listen attentively |
| PULSE ASSESSMENT | 1) Rate 2) Rhythm 3) Volume (strength) |
| NORMAL RANGE OF PULSE RATE | ADULTS – 60 to 100 bpm |
| BRADYCARDIA | a pulse less than 60 bpm |
| TACHYCARDIA | a pulse greater than 100 bpm |
| PERIPHERAL PULSE VOLUME 3+ OR BOUNDING | Pulse feels very strong and full and is easily counted; does not obliterate even with moderate pressure. |
| PERIPHERAL PULSE VOLUME 2+ OR STRONG | Pulse is easily detected, feels strong, and is easily counted; can be obliterated with moderate pressure. This is considered the normal finding. |
| PERIPHERAL PULSE VOLUME 1+ OR WEAK | Pulse feels weak and can be obliterated with slight pressure. |
| THREADY | If the pulse is so faint and weak that it is difficult to feel it long enough to count the rate, an additional descriptor may be used. |
| 0 OR ABSENT | Pulse is not detectable |
| DOPPLER ULTRASOUND | device that uses sound waves to determine whether blood flow is present. |
| RESPIRATION | the interchange of oxygen and carbon dioxide between the atmosphere and the body. |
| EXTERNAL RESPIRATION | is the exchange of these gases between the lungs’, alveoli, and the blood found in the capillaries that surround the alveoli. |
| INTERNAL RESPIRATION | process of exchanging gases between the circulating blood and tissue cells that make up the body. |
| INHALATION | involve the act of breathing in; diaphragm goes down |
| EXHALATION | involve the act of breathing out; diaphragm does up |
| medulla oblongata and the pons | regulate the respiratory system. |
| INSPIRATION | To effect inspiration, the medulla sends an impulse via the phrenic nerves to the diaphragm muscle and along the intercostal nerves to the intercostal muscles, telling the muscles to contract. |
| INSPIRATION | The contraction of the diaphragm causes it to flatten and move downward. |
| INSPIRATION | The contraction of the intercostal muscles results in pulling the ribs upward and outward, enlarging the chest cavity. |
| EXPIRATION | - Once the medulla stops sending the motor impulses to inhale, the intercostal and diaphragm muscles being to relax - Shrinks the thoracic or chest cavity to the smaller, preinhalation state and compressing the lungs. |
| ASESSING RESPIRATION | - Depth - Rhythm - Pattern - Respiratory effort |
| NORMAL RATE OF RESPIRATION | ADULTS – 12 to 20 bpm |
| EUPNEA | when rate, depth, rhythm, pattern, and respiratory effort fall within normal range. |
| BRADYPNEA | respiratory rate below 12 bpm |
| TACHYPNEA | respiratory rate above 20 bpm |
| APNEA | when respiration cease or are absent. Brief window of 3 to 5 minutes in which to restore respirations before brain damage and death occur. |
| TIDAL VOLUME | the average amount of air inhaled in one breath is between 300 and 500 mL. |
| DYSPNEA | labored or difficult breathing |
| HYPOXEMIA | decreased oxygen level in the blood |
| HYPOXIA | decreased delivery of oxygen to the tissues and cells |
| ORTHOPNEA | difficult to breathe unless positioned in an upright position such as sitting or standing. |
| STERTOROUS | breathing refers to noisy, snoring, labored respirations that are audible without a stethoscope. |
| ADVENTITIOUS | sounds are abnormal sounds that may be heard when auscultating the lungs with a stethoscope and include wheezes, rales or crackles, rhonchi, and stridor. |
| WHEEZES | are musical, whistling sounds that may be audible without a stethoscope or heard only during auscultation |
| CRACKLES or RALES | adventitious sounds that may be auscultated with a stethoscope and are the result of air moving over secretions in the lungs. |
| COARSE or RHONCHI | are continuous, low-pitched, rattling or bubbling, snoring, or sonorous wheezing sounds that can be auscultated when there is partial obstruction of the larger airways caused by secretions or tumor. |
| STRIDOR | an audible, high-pitched crowing sound that results from partial obstruction of the airways |
| ABNORMAL RESPIATORY PATTERNS Cheyne-Stokes respirations | - Respirations begin shallow, gradually increase in depth and frequency to a peak, and then begin to decrease in depth and frequency until slow and shallow. This is followed by a period of apnea lasting from 10 to 60 seconds. Pattern is repetitious. |
| ABNORMAL RESPIATORY PATTERNS Kussmaul respirations | Respirations are increased in rate and depth, with long, strong, blowing, or grunting exhalations |
| ABNORMAL RESPIATORY PATTERNS Biot respirations | Respirations are grouped as several shallow breaths followed by variable-length periods of apnea |
| BLOOD PRESSURE | the measurement of the pressure or tension of the blood pushing against the walls of the arteries in the vascular system. |
| Four Circulatory Qualities: | 1) Strength of the heart contraction, or pumping action of the heart 2) Blood viscosity, or thickness 3) Blood volume 4) Peripheral vascular resistance, or elastic recoil ability of the blood vessel walls |
| SYSTOLIC PRESSURE | which is the measurement of the force exerted by the blood against the walls of arteries during contraction of the heart ventricles. |
| DIASTOLIC PRESSURE | which is the measurement of the pressure exerted by the blood on the artery walls while the heart ventricles are not contracting |
| PULSE PRESSURE | is the measurement of the difference between the systolic and diastolic pressures (subtract the smaller number, the diastolic, from the larger number, the systolic) and normally is between 30 and 50 points. |
| Normal blood pressure range | ADULT BETWEEN 100/60 AND 120/80 MM HG |
| HYPERTENSION | A systolic reading consistently above 130 or a diastolic reading consistently over 80 |
| KOROTKOFF SOUND | 5 sounds |
| ARTHERIOSCLEROSIS | The thickening and hardening of the wall of the arteries |
| Primary hypertension | Rise of blood pressure or essential hypertension |
| Secondary hypertension | There is a renal or endocrine disease that results in elevation of blood pressure |
| Hypotension | Blood pressure below the patient normal pressure |
| SYNCOPE | Fainting resulted from blood pressure dropping and dizziness |
| Orthostatic hypotension/ postural hypotension | Sudden drop in blood pressure |
| Oxygen saturation | When oxygen enters the blood and it binds to the hemoglobin in the red blood cells |
| Normal saturation | 96%-100% |
| Acute pain | Pain that has sudden onset |
| Chronic pain | Ongoing with little change or progress |
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