Vital Signs
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| Normal Oral Temp Healthy Adult | 98.6/37
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| Normal Rectal Temp Healthy Adult | 99.5/37.5
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| Normal Axillary Temp Healthy Adult | 97.6/36.5
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| Normal Tympanic Temp Healthy Adult | 99.5/37.5
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| Normal Forehead Temp Healthy Adult | 94.0/34.4
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| 4 factors affecting body temp | -stress
-Circadian rhythms
-age & gender
-environmental temp
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| 5 sites to assess temp | oral
rectal
axillary
forehead
tympanic
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| definition of pulse rate | The number of contractions over a peripheral artery in 1 minute
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| factors affecting pulse rate (9) | -age
-blood volume
-cardiac output
-altered body temp
-hormonal changes
-physiological conditions
-medications
-activity level
-vagal stimulation (parasympathetic)
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| 3 pulse variations to assess & document | -rate
-quality
-rhythm
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| definition of pulse deficit | difference between apical and radial pulses
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| definition of apical pulse | pulse taken over apex of heart
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| where is apical pulse asssessed? | 5th intercostal space, midclavicular line
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| 8 pulse sites | radial
carotid
apical
brachial
femoral
popliteal
posterior tibial
dorsalis pedal
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| pyrexia | fever/febrile condition
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| sympathetic innervation | increases pulse rate
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| parasympathetic innervation | decreases pulse rate
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| most powerful respiratory stimulant | increase in CO2
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| what do you look for when assessing respirations | effort
depth
rate
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| 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
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| 4 ways to assess respirations | inspection
auscultate with stethescope
monitor arterial blood gas results
pulse oximetry
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| 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
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| pulse oximetry | noninvasive method of indicating the arterial oxygen saturation of functional hemoglobin, using a pulse oximeter
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| eupnea | normal respiration
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| tachypnea | very rapid respiration (also called polypnea)
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| bradypnea | abnormal slowness of breath
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| dyspnea | labored or difficulty breathing
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| apnea | cessation of breathing
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| orthopnea | dyspnea that is relieved in the upright position
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| 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
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| 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.
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| blood pressure | force of blood against arterial walls
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| pressure rises as: | ventricles contract and falls as heart relaxes
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| systolic | highest pressure
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| diastolic | lowest pressure
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| pulse pressure | difference between systolic and diastolic
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| 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
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| factors affecting blood pressure (8) | age/gender/race
Circadian rhythms
drugs/medications
exercise
food intake
weight
emotional state
body position
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| pain is described in terms of (4) | location
intensity
duration
etiology
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| 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.
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| cyanosis | bluish discoloration of skin/mucous membranes
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| syncope | fainting
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| costal (thoracic) breathing | movement of chest upward & outward
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| diaphragmatic (abdominal) breating | movement of abdomen due to diaphragm contracting and moving down
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| newborn pulse & resp average and ranges | pulse 130 (80-180)
resp 35 (30-60)
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| 1 yr pulse & resp average/ranges | pulse 120 (80-140)
resp 30 (20-40)
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| 5-8 yrs pulse & resp average/ranges | pulse 100 (75-120)
20 (15-25)
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| 10 yrs pulse & resp average/ranges | pulse 70 (50-90)
resp 19 (15-25)
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| teen pulse & resp average/ranges | pulse 75 (50-90)
18 (15-20)
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| adult pulse & resp average/ranges | pulse 80 (60-100)
resp 16 (12-20)
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| older adult pulse & resp average/ranges | pulse 70 (60-100)
resp 16 (15-20)
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| heat balance | when the amount of heat produced by the body equals the amount of heat lost
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| core temperature | temp of the deep tissues of the body, stays constant.
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| surface temperature | temp of the skin, subcutaneous tissue, and fat. rises & falls in response to environment
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| Basal metabolic rate | rate of energy utilization in the body required to maintain essential activities such as breathing. younger person = higher BMR
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| factors affecting body's heat production (5) | BMR, muscle activity, thyroxine output, epinephrine/norepinephrine & sympathetic stimulation/stress response, fever
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| causes of heat loss | radiation, conduction, convection, evaporation
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| epinephrine/norepinephrine & sympathetic stimulation/stress response | hormones that increase the rate of cellular metabolism
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| intermittent fever | body temp alternates at regular intervals between periods of fever & periods of normal temps (ex. malaria)
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| remittent fever | wide range of temp fluctuations over 24 period, all above normal. (ex cold/flu)
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| relapsing fever | short febrile periods of a few days interspersed with periods of 1-2 days of normal temps
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| constant fever | body temp fluctuates minimally but always above normal (ex typhoid fever)
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| fever spike | rises rapidly & returns to normal in a few hours, (ex bacterial blood infections)
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| parenchyma (ex "parenchyma of cells) | The tissue characteristic of an organ, as distinguished from associated connective or supporting tissues.
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| three phases of fever | onset (cold/chill phase)
course (plateau phase)
defervescence (fever abatement/flush phase)
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| 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
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| compliance of arteries | their ability to contract/expand
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| cardiac output | volume of blood pumped into arteries by the heart. equals result of stroke volume (SV) x heart rate (HR) per min.
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| point of maximal impulse (PMI) | apical pulse
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| what happens when you press both carotids simultaneously? | reflex drop in blood pressure/pulse rate
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| tachycardia | excessively fast HR, greater than 100 BPM in adult
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| bradycardia | slow HR, less than 60 BPM in adult
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| arrhythmia/dysrhythmia | pulse with irregular rhythm
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| perfusion | blood flow to a particular area
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| purpose for assessing apical pulse | HR of adult w/ irregular peripheral pulse, gather baseline data, determine if cardiac rate is WNL & rhythm regular
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| S1 heart sound (lub) occurs when... | AV valves close after ventricles have been sufficiently filled
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| S2 heart sound (dub) occurs when... | semi-lunar valves close after ventricles empty
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| volume of N adult inspiration/expiration | 500 mL
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| tidal volume | vol. of N inspiration/expiration
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| cheyne-stokes breathing | rhythmic waxing/waning of respirations, from v deep/shallow & temp. apnea
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| stridor | harsh/shrill sound during inspiration w/ laryngeal obstruction
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| stertor | snoring/sonorous respiration, usually due to partial obstruction of upper airway
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| intercostal retraction | indrawing btwn ribs
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| substernal retraction | indrawing beneath breastbone
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| suprasternal retraction | indrawing above clavices
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| hemoptysis | presence of blood in sputum
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| 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.
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| hematocrit | proportion of RBC -> blood plasma. BP is higher when blood is highly viscous.
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| orthostatic hypotension | BP that falls when client sits/stands
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| signs/symptoms of hypertension | headache, ringing in ears, flushed face, nosebleeds, fatigue
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| signs/symptoms of hypotension | tachycardia, dizziness, mental confusion, restlessness, cool & clammy skin, pale or cyanotic skin
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