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Basics Ch 21
| Question | Answer |
|---|---|
| 5 vital signs | temperature, pulse, respirations, blood pressure, pain |
| give an indication of the state o health of an individual; represent interrelated physiologic systems of the body | vital signs |
| Vital signs are included in a _________________, or obtained individually to assess a patient's condition. | complete assessment |
| It is important that you are able to measure vital signs ______________, understand and interpret the ______________, communicate findings appropriately, and begin ____________ as needed. | correctly; values; interventions |
| When to measure vital signs: | on admission to a health care facility; when assessing the pt during home health visits; in a hopital on a routine schedule according to dr's orders or hospital standards of practice; before and after surgical procedures or invasive dianostic procedures |
| Vital signs should also be taken ____________________ the administration of medications that affect cardiovascular, respiratory, or temperature-control functions. | before and after |
| Do not interpret vital signs without knowing: | your patient's other physical signs or symptoms and ongoing health status. |
| When vital signs appear abnormal, double check with __________________. | another nurse |
| Normal body temperature: | 97.5° - 99.5°F (36.4° - 37.5°C) |
| Body temperature can vary within the normal range as the body: | adjusts to changes in the amount of heat produced or lost. |
| Individuals may run a low-normal or a _____________ body temperature. | high-normal |
| It is important to know the patient's normal ____________ and compare changes to that. | temperature |
| Heat production (body heat) is a by-product of: | metabolism |
| When metabolism increases, more ________ is produced, causing __________. | heat; fever |
| When ________ invade the body and the body attempts to destroy them,the increased activity (or metabolism) causes __________. | pathogens; fever |
| They hypothalamus controls: | body temperature |
| If the body heat rises above normal, the hypothalamus sends messages for: | vasodilation and sweating |
| If the body temperature drops below normal range, the hypothalamus sends messages for: | vasoconstriction of blood vessels to conserve heat and induces shivering to increase heat production. |
| Heat loss occurs through: | radiation; conduction; convection; evaporation |
| Blood flow from the internal organs carries heat to skin - heat is then: | radiated to cooler objects |
| When surrounding objects are warmer than the body, heat is: | radiated to the body and absorbed. |
| When warm skin touches a cool object, heat is lost to the object by: | conduction (example - ice bags) |
| Air movement causes heat to be transferred from the skin to the air molecules by: | convection |
| Heat loss increases when the skin is moistened and: | evaporation occurs |
| When water evaporates from the skin, heat is: | transferred to the air |
| Occurs when normal mechanisms of the body cannot keep up with the excessive heat production and the body temperature rises | pyrexia (fever) |
| temperature of fever: | above 100.4°F |
| febrile | with fever |
| afebrile | no fever |
| When pyrogens (bacteria) enter the body they cause an ___________________ and the hypothalamus is stimulated to ______________. This allows the body to become more hostile to the bacteria, and the immune system can more effectively destroy them. | immune; raise the temperature |
| Is a low grade temperature of 100.0 acceptable? | yes |
| Places where fever is measured: | mouth, rectum, axilla, ear, skin |
| Types of thermometers: | glass, electric/digital, tympanic, skin/temporal, rectal, disposable |
| Tip of thermometer or probe placed in sublingual pocket; be certain pt hasn't eater, drank, or smoked within 15 minutes of taking; never done on unconscious or uncooperative pt or if pt may have seizure | oral temperature |
| electronic thermometer is switched to rectal setting and different probe is attached; insert probe 0.5 to 1.5 inches into rectum; should not be used for cardiac pts or pts who have had rectal surgery | rectal temperature |
| thermometer placed in center of pt's dry axilla; ask pt to hold arm tightly against the chest | axillary temperature |
| Rectal temperatures are usually 1 degree __________ than oral temperature. | higher |
| Axillary temperaturs are usually 1 degree _________ than oral temperature. | lower |
| Probe is gently placed in the ear canal until it seals the opening; tympanic temperature is a good indicator of core body temperature (temp in deep tissues of the body) | tympanic temperature |
| Placed on skin of the forehead over the temporal artery; least invasive method of obtaining a temp and more reliable when used correctly | skin/temporal artery measurement |
| condition in which the pt's temperature is above the normal range | hyperthermia |
| Fever is not considered significant until the temp reaches: | 101.3° |
| Temp greater than ________ cause damage to body cells, particularly to the central nervous system. | 105.8 |
| the lowering of the temperature of the entire body | hypothermia |
| The thermal regulating center in the hypothalamus is greatly impaired when the temp of the body falls below: | 94° |
| Factors that affect body temperature: | time of day; environmental temperature; age of pt; physical exercise; menstrual cycle and pregnancy; emotional stress; disease conditions; drugs; thyroid hormone |
| Cardiac contractions produce a: | pulse |
| The pulse is the palpable bounding of the blood flow in a: | peripheral artery |
| number of pulsing snesations occurring in 1 minute: | pulse rate |
| normal pulse rate: | 60-100 bpm |
| When the heart contracts, blood is propelled into the: | aorta |
| volume of blood pushed into the aorta per heartbeat; affects the character of the pulse | stroke volume |
| A weak pulse may indicate a fall in: | stroke volume |
| Pulse points: | temporal, carotid, apical, brachial, radial, femoral, popliteal, dorsalis pedis (pic on pg. 339) |
| To obtain pulse: | place pads of 2-3 fingers lightly over the radial artery with the pt's palm down; count pulsations for 30 seconds and multiply by 2 to obtain the rpm (if irregular, count for a full minute) |
| Do not use __________ when obtaining pulse. | thumb |
| _____________ is the most common place for obtaining a pulse rate. | Radial pulse |
| To obtain apical pulse: | place stethoscope over the left chest wall (5th intercostal space - mid-clavicular line); listen to heart sounds and count for 1 full minute |
| Apical pulses are routinely obtained prior to administering: | digitalis (When giving Digoxin, hold med if pulse is <60 because it slows the heart and makes the heart beat stronger) |
| refers to a pulse greater than 100 bpm | tachycardia |
| refers to a pulse less than 60 bpm | bradycardia |
| an irregular pulse, has periods of normal rhythm and irregularity | arrythmia |
| If arrythmia is found, find out if that is normal for the pt or not. If not, _______. | report to RN or physician |
| The volume, or strength, of the pulse is just as ____________ as the rate. It measures stroke volume. | important |
| Pulse should be ___________ on both sides. | equal |
| Terms used to describe strength of pulse: | weak and regular (1+); strong and regular (2+); full and bounding (3+); thready; absent |
| Factors that affect pulse rate: | age; body build and size; blood pressure; drugs; emotions; blood loss; exercise; increased body temperature; pain |
| the exchange of oxygen and carbon dioxide in the lungs and tissues; it is initiated by the act of breathing | respiration |
| Respiration is a combination of two processes. They are: | external respiration and internal respiration |
| External respiration occurs in four ways: | ventilation; dispersion; diffusion; perfusion |
| mechanical movement of air in and out | ventilation |
| movement of air within (into) lungs (getting to the lungs) | dispersion |
| exchange of gases in aveoli (oxygen in and carbon dioxide out) | diffusion |
| movement of blood through the lungs | perfusion |
| Internal respiration happens on the: | cellular level |
| With internal respiration, oxygen is released from hemoblogin to the cell and the cell in turn: | releases carbon dioxide to the blood |
| Organs of respiration: | nose, pharynx, larynx, trachea, bronchi, lungs |
| right lung consists of: | 3 lobes |
| left lung consists of: | 2 lobes |
| The bronchial tree carries oxygen to verious parts of the lungs. It consists of: | bronchi and bronchioles |
| Movement of the _________ controls inhalation and exhalation. Gas exchange with the blood occurs in the __________. | diaphragm; alveoli |
| Breathing is an _______________, automatic function controlled by teh respiratory center located in the _______________ of the brainstem. | involuntary; pons and medulla oblongata |
| Normal respirations: | 12-20 breaths per minute |
| Unless irregular, respirations are counted for ____________ and multiplied by _____. Assess for full _____________ when counting ventilations. | 30; 2; inspiration and expiration |
| In a very ill patient or someone with respiratory illness, count for: | a full minute |
| If an adult does n ot breathe at a minimal rate of ____ respirations per minute and in sufficient depth, _________ may be noted as a result of low oxygen supply in the blood. | 12; hypoxia |
| S/S of hypoxia: | apprehension, restlessness, confusion, dizziness, change in the level of consciousness, cyanosis (bluish discoloration of skin) usually around the mouth and in the nail beds |
| machine that measures oxygen in the blood: | pulse oximeter |
| Oxygen saturation should be: | 95-100% |
| Oxygen saturation is measured by determining the percentage of ________ that is bound with oxygen. Many agencies check this during routine _________. | hemoblobin; vital signs |
| If your patient is cold, or has a low body temperature, will an oxygen saturation measurement be accurate? | no (it works off of heat) |
| respiratory patterns: | eupnea; dyspnea; apnea; tachypnea; bradypnea |
| normal, relaxed breathing pattern: | eupnea |
| difficult and labored breathing: | dyspnea |
| absence of breathing | apnea |
| increased or rapid breathing | tachypnea |
| slow and shallow breathing | bradypnea |
| Respiratory pattern is increased in the rate and depth of breaths and carbon dioxide expelled: | hyperventilation |
| Respiratory pattern has increased rate and depth with panting and long grunting exhalation | Kussmaul's Respirations |
| Respiratory pattern of dyspnea followed by apnea: | Cheyne-Stokes respirations |
| The pressure exerted on the arterial wall | blood pressure |
| maximum pressure exerted on the artery during left ventricular contraction; pushes blood out to body | systolic blood pressure |
| lower pressure exerted on the artery when the heart is at rest between contractions | diastolic blood pressure |
| Blood pressure is measured with the use of: | sphygmomanometer, cuff, and a stethoscope |
| When checking BP, this occludes the artery and then slowly allows blood flow through it | sphygmomanometer |
| When checking BP, this is used to hear the sounds made in the artery (Korotkoff sounds) | stethoscope |
| standard unit for measuring BP: | millimeters of mercury (mm HG) |
| Normal BP is considered to be: | 120/80 or less |
| Using the ____________ can cause a BP to be inaccurate. A _________ can cause a false high reading, and a __________ can cause a false low reading. | wrong cuff size; small (too tight); large (too loose) |
| To measure BP: | place cuff 1-2" above antecubital space; palpate the brachial artery, pump cuff until artery is occluded; inflate cuff 30 points higher; place stethoscope over artery and slowly release cuff; listen for Korotkoff sounds |
| Phase 1 Korotkoff sounds: | tapping - systolic pressure indicated by faint, clear tapping sounds that gradually grow louder |
| Auscultory gap | no sound - silence as cuff deflates for 30-40 mmHG |
| Phase 2 Korotkoff sounds: | swishing - murmur, or swishing sounds that increase as the cuff is deflated |
| Phase 3 Korotkoff sounds: | knocking - louder knocking sounds that increase as the cuff is deflated |
| Phase 4 Korotkoff sounds: | muffling - sudden change or muffling of the sound |
| Phase 5 Korotkoff sounds: | silence - dissapearance of sould (daistolic) |
| blood pressuer consistently elevated above normal range | hypertnesion |
| BP greater than _________ is considered hypertension. | 140/90 |
| Prehypertension | 120-139/80-89 |
| Stage 1 hypertension | 140-159/90-99 |
| Stage 2 hypertension | >160/>100 (greater than or equal to 160/100) |
| Prolonged hypertension can cause permanent damage to the: | brain, kidneys, heart, retina of eyes |
| Prolonged hypertension is the cause of: | many cerebrovascular accidents (strokes) |
| BP that is less than 90/60 | hypotension |
| When a pt is experiencing fatigue, light-headedness, falls, visual blurring, or syncope, use _____________. | orthostatic blood pressure |
| To obtain orthostatic BP: | 1st - obtain supine BP and heart rate 2nd - obtain a sitting BP and heart reat 3rd - obtain a standing BP and heart rate |
| drop in BP occurring with change from supine to sitting to standing position | orthostatic BP |
| If there is a ________ decrease from the pt's normal baseline BP, it signifies there is a positive orthostatic hypotension. | 20 mmHG |
| Factors that influence BP: | age, stress and emotions, medication, diurnal variation, reduced blood volume, increased blood volume, body position, vasodilation, vasoconstriction, head injury, sex (males are usually higher), environment, exercise, right vs left arm |
| If a pt has a high temp, will his BP be high or low? | low - hot environment causes vasodilation (the body tries to cool itself) |
| Vital signs should be _______ as soon as the measurements are obtained. Anything abnormal should be reported to charge nurse or physician. | charted |
| The fifth vital sign: | pain |
| To chart pain, the nurse must include: | pain location, intensity, character, frequency, duration |
| A ___________ is used for pain assessment. | pain scale |
| All pts have the right to: | pain relief and to be free of pain |
| If a pt is in severe pain, will it alter any of his other vital signs? If so, which ones? | yes; pulse, respiration, blood pressure |
| Which should be treated first? | pain (if the reason for the problem) |
Created by:
akgalyean
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