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 |