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BHC & Filipino > Basta BHC ni > Flashcards

Basta BHC ni Flashcards

1
Q
  • measures of various physiological status, in order to assess the most basic body function
  • indicates that the person is alive
  • can be observed, measured and monitored
  • changes with age and medical condition
  • useful in detecting or monitoring medical problems
A

Vital Signs

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2
Q

Measurements for the body’s basic function

A

a.Body temperature (Temp)
b.Pulse/heart Rate (PR/HR)
c.Respiration Rate (RR)
d.Blood Pressure (BP)

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3
Q
  • the balance between the heat production due to chemical activities by the body and heat lost from the body through radiation, conduction, convection and vaporization
A

Body Temperature

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4
Q

When to assess Vital Signs?

A

Upon admission to any healthcare agency
Based on agency institutional policy and procedures
Any time there is changes in the patient’s condition
Before and after surgical or invasive diagnostic procedure
Before and after activity that may increase risk
Before and after administering medications that affect cardiovascular ore respiratory functioning

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5
Q

-the temperature of deep tissues of the body (ex: cranium, thorax, abdominal cavity)
true core temperature can only be measured by invasive means

A

CORE TEMPERATURE

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6
Q

What is the normal body temperature?

A

normal body temp : 36.2 to 37.2c

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7
Q

the temperature of the skin, the subcutaneous tissue and fat
rises and falls in response to environmental changes
average oral temp: 36.7 – 37c

A

Surface Temperature

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8
Q

Factors affecting Body’s Heat Production

A

Basal Metabolic Rate (BMR)
Muscle Activity
Epinephrine and symphathetic stimulation
Age
Gender
Diurnal variation
Exercise

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9
Q

A body temperature above the usual range

A

Gender Alterations in Body temperature: PYREXIA

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10
Q

usually referred as fever

A

Hyperthermia

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11
Q

A very high temperature, e.g. 41c (105 f) is called

A

Hyperpyrexia

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12
Q

temperature alternates at regular intervals between periods of fever and periods of normal temperatures.


A

Intermittent Fever

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13
Q

a wide range of temperature fluctuations occurs over the 2 hour period, all of which are above normal

A

Remittent Fever

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14
Q

short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.

A

Relapsing Fever

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15
Q

body temperature fluctuates minimally but always remains elevated.

A

Constant Fever

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16
Q

increased heart rate and respiratory rate and depth.
Shivering due to increased skeletal muscle tension and contraction.
Cold skin due to vasoconstriction.
Cyanotic nail beds due to vasoconstriction.
Complain of feeling cold.
Gooseflesh appearance of the skin.
Rise in body temperature.

A

Clinical Signs of Fever: ONSET (Cold or Chill Stage)

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17
Q

Skin feels warm
increased pulse and respiratory rate.
increased thirst
mild to severe dehydration.

Cyanotic nail beds due to vasoconstriction.
Complain of feeling cold.
Gooseflesh appearance of the skin.
Rise in body temperature.

A

Clinical Signs of Fever: COURSE

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18
Q

Flushed and warm skin
Sweating
Decreased shivering
Possible dehydration

A

Clinical Signs of Fever: ABATEMENT

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19
Q

Treatment of Increasing Body temperature

A

Antypyretics (Paracetamol)
Cold sponge bath
Cold compress

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20
Q

Core body temperature below the lower limit of normal
The ability of hypothalamus to regulate temperature is greatly impaired when the body temperature falls below 34.5c ( 94 F), and death usually occurs when the temperature falls below 34c (93.2 F)

A

Alterations in Body temperature: HYPOTHERMIA

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21
Q

Physiologic Process of Hypothermia

A

excessive cold environment
inadequate heat production to counteract the heat loss

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22
Q

Clinical signs of Hypothermia

A

Decreased body temperature
Pale, cool, waxy skin
Hypotension
Lack of muscle coordination
Disorientation
Drowsiness may progress to coma

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23
Q
  • considered reliable when thermometer is place posteriorly into the sublingual pocket
  • tracks changes of core temp
  • the most common way in checking temp.
A

Orally (common way) n: 37c – taken 3- 5mins

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24
Q
  • measure by placing thermometer in the central position and adducting the arm close to the chest wall
  • considered unreliable for estimating body temperature because there are no main blood vessels around this area
  • most safest way in getting a patients body temp.
A

Axillary (safe way) n:36c +0.5c (10mins)

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25
Q
  • most accurate method for measuring the core temperature
  • should reduce 0,5c to actual reading
  • the most accurate way in getting the body temp.
A

Rectal (accurate reading) 37c – 0.5c (2-3 mins)

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26
Q

Contraindications of Oral thermometer

A

the child is under 6 years old
unconscious patient
psychiatric patients
patient who cannot breath from his nose
mouth surgery or infection
patient on oxygen mask

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27
Q

Contraindications of Rectal thermometer

A

rectal surgery
rectal disorder (hemorrhoids, rectal fissure)
diarrhea

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28
Q

Types of Thermometer

A

Electronic /Digital
Glass/mercury
Tympanic
infrared

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29
Q

Alterations in thermoregulation

A

Heat exhaustion
Heat stroke
Hypothermia
Frostbite

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30
Q
  • a wave of blood created by contraction of the left ventricle of the heart
  • a measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta
A

Pulse

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31
Q

refers to the feel of the pulse, its rhythm and forcefulness

A

Pulse Quality

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32
Q

indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waved over a pulse point

A

Pulse Rate

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33
Q

regularity of the heartbeat

A

Pulse Rhythm

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34
Q

the beats are evenly spread

A

Regular

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35
Q

the beats are not evenly spread

A

Irregular

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36
Q

 irregular rhythm caused by early or late or missed heartbeat

A

Dysrhythmia (arrhythmia)

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37
Q

measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction

A

Pulse Volume

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38
Q

less than normal rate

A

Bradycardia

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39
Q

more than normal rate

A

Tachycardia

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40
Q

Pulse Volume Scale

A

Scale Description
0 Absent Pulse
1 Weak and thread pulse
2 Normal Pulse
3 Bounding Pulse

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41
Q

Factors contributing to increase pulse rate

A

pain
fever
stress, exercise
bleeding
decrease in blood pressure
some medications (Adrenalin, aminophylline)

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42
Q

Factors contributing to slow pulse rate

A

rest
increasing age
people with thin body size
some medications
thyroid gland disturbances

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43
Q
  • Accessible, used routinely and when radial is inaccessible
A

Temporal

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44
Q

Accessible, used routinely for infants and during shock or cardiac arrest when peripheral pulses are too weak to palpate,
- Used to assess cranial circulation

A

Carotid

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45
Q

used to auscultate heart sounds and assess apical field

A

Apical

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46
Q
  • used in cardiac arrest for infants
  • to assess lower arm circulation
  • to auscultate the blood pressure
A

Brachial

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47
Q
  • accessible, used routinely in adults to assess character of peripheral pulse
A

Radial

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48
Q

used to assess circulation to ulnar side of hand and to perform allen’s test

A

Ulnar

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49
Q

used to assess circulation to legs and during cardiac arrest

A

Femoral

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50
Q

used to assess circulation to the legs and blood pressure

A

Popliteal

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51
Q

Use to assess circulation of the feet

A

Posterior Tibial & Dorsalis

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52
Q

is indicator for clients whose peripheral pulse is irregular as well as for clients with known cardiovascular, pulmonary, and renal diseases.
It is commonly assessed prior to administering medications that effect heart rate.
The apical side is also used to assess the pulse for newborns, infants, and children up to 2-3 years old.

A

Apical Pulse Assessment

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53
Q

difference in the apical pulse and the radial pulse.
These should be taken at the same time, which will require that 2 people take the pulse.
One with a stethoscope and one at the wrist.
Count for 1 full minute. Then subtract the radial from the apical.

A

Pulse Deficit

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54
Q

movement of air in and out of the lungs

A

Pulmonary Ventilation (breathing)

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55
Q

Factors affecting Respiration

A

Pain, anxiety, exercise
Medications
Trauma
Infection
Respiratory and cardiovascular disease
Alteration in fluids, electrolytes, acid base balance

56
Q

Assessing Respiration

A

inspection
listening with stethoscope
monitoring arterial blood gas result (ABG)
using pulse oximeter

57
Q

located centrally in the medulla in peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentration of oxygen ( O2), carbon dioxide ( Co 2), and hydrogen ( H+) levels in the arterial blood.

A

Chemoreceptors

58
Q

refers to easy respirations with normal rate of breaths per minute that is age specific

A

Eupnea

59
Q

characterized by rate of 10 or fewer breaths per minute

A

Bradypnea (less than normal)

60
Q

characterized at a rate of 10 or fewer breaths per minute

A

Bradypnea (less than normal)

61
Q

characterized by shallow respiration

A

Hypoventilation

62
Q

respiratory rate greater that 24 breaths per minute

A

Tachypnea (more that normal)

63
Q

characterized by deep, rapid respiration

A

Hyperventilation

64
Q

occurs when external intercostal muscles and the other accessory muscles are used to move the chest upward and outward.

A

Costal (thoracic) breathing

65
Q

occurs when the diaphragm contracts and relaxes as observed by movement of the abdomen.

A

Diaphragmatic(abdominal) breathing

66
Q

refers to difficulty in breathing as observed by labored or forced respirations through the use of accessory muscles in the chest and neck to breathe.

A

Dyspnea

67
Q

respirations cease for several seconds. Persistent cessation is called respiratory arrest.

A

Apnea (a- absence)

68
Q

respiratory rhythm is irregular, characterized by alternating periods of apnea and hyperventilation.

A

Cheyne–Stockes respiration

69
Q

respirations are abnormally deep but regular, similar to hyperventilation. Characteristic of clients with diabetic ketoacidosis.

A

Kussmaul respiration

70
Q

respiratory condition in which a person must sit or stand in order to breathe deeply or comfortably.

A

Orthopnea (ortho- bones/movement)

71
Q

RR: adults

A

16-20 cmp (cycles per minute)

72
Q

Patterns of Respiration

A

Respiration Desperation
Tachycardia >24 cpm, shallow
Bradypnea <10cpm, regular
Hyperventilation Increase rate and depth
Hypoventilation Decrease rate and depth, irregular

73
Q

is the force required by the heart to pump blood from the ventricles of the heart into the arteries. It is measured in systolic and diastolic pressure.

A

Blood pressure

74
Q

NORMAL BP

A

(systolic)120/80mmHg (diastolic)

75
Q

it is known as the force to pump blood out of the

A

Systolic pressure

76
Q

it is known as relaxation period of the heart pump (ventricles ).

A

Diastolic pressure

77
Q

The most common site for indirect blood pressure measurement

A

client’s arm over the brachial artery.

78
Q

refers to a systolic blood pressure more than 120 mm Hg or 20 to 30 mm Hg more the client’s normal systolic pressure

A

Hypertension

79
Q

a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110 mmHg in an adult whose normal pressure is higher than this

A

Hypotension

80
Q

Factors Increasing Blood Pressure

A

Factor Effect
Age Increase
Exercise Increase
Stress Increase
Sex (Gender) Females- lower
Males- Higher
Medications either

81
Q

Selected conditions affecting blood pressure

A

Condition Effect
Fever Increase
Stress Increase
Arteriosclerosis Increase
Obesity Increase
Hemorrhage decrease
Low hematocrit decrease
External heat decrease
Exposure to cold Increase

82
Q

The period initiated by the first faint clear taping sound. These sound gradually become more intense.

A

Phase 1: Korotkoff’s sounds

83
Q

The period during which the sounds have a swishing quality.

A

Phase 2: Korotkoff’s sounds

84
Q

The period during which the sounds are crisper and more intense.

A

Phase 3: Korotkoff’s sounds

85
Q

The period , during which the sounds become muffled and have a soft, blowing quality.

A

Phase 4: Korotkoff’s sounds

86
Q

The period where the muffled, blowing sound disappear.

A

Phase 5: Korotkoff’s sounds

87
Q

Pulse Pressure

A

the numeric difference between the systolic and diastolic blood pressure
For example, if the resting blood pressure is 120/80 millimeters of mercury (mm Hg), the pulse pressure is 40.
A pulse pressure within 40 is the normal and healthy pulse pressure .
A pulse pressure greater than 40 mm Hg is abnormal.
A high pulse pressure may be a strong predictor of heart problems (valve regurgitation), especially for older adults.
A pulse pressure lower than 40 may mean a patient have poor heart function.

88
Q

Equipment for assessing blood pressure

A

Stethoscope and sphygmomanometer.
Electronic or digital devices.
Alcohol cotton swap.

89
Q

Pain assessments consist of two major components

A

(a) a pain history to obtain facts from the client
(b) direct observation of behaviors, physical signs of tissue damage, and secondary physiological responses of the client.

90
Q

Pain History

A

Location
Duration: acute or chronic
Pain Intensity

91
Q

Mild Pain

A

1 to 3

92
Q

Moderate Pain

A

4 to 6

93
Q

Severe Pain

A

7 to 10

94
Q

elevated blood pressure with unknown cause.

A

Primary hypertension

95
Q

elevated blood pressure with known cause

A

Secondary hypertension

96
Q

located centrally in the medulla in peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentration of oxygen ( O2), carbon dioxide ( Co 2), and hydrogen ( H+) levels in the arterial blood

A

Chemoreceptors

97
Q

-Process of moving gases into and out of the lungs, This requires the coordination of the muscular and elastic properties of the lung and thorax
-Major Muscle for inspiration: Diaphragm stimulated by phrenic nerve (3rd cervical vertebrae)

A

Ventilation

98
Q

-The process that brings oxygen into the body and removes carbon dioxide waste
-The exchange occurs in the lungs

A

Respiration

99
Q

the process by which oxygen is taken from the bloodstream into the cell and carbon dioxide is removed from cell to the bloodstream

A

Internal Respiration

100
Q

refers to delivery of oxygen to the lungs so that it can be taken into the bloodstream

A

External Respiration

101
Q

-The passage of fluid through the circulatory and lymphatic system to an organ or tissue
-Usually referred as delivery of blood to a capillary bed in tissue

A

Perfusion

102
Q

1.Degree of Compliance
2.Airway Resistance
3.Presence of Active Respiration
4.Use of Accessory muscles of Inspiration

A

Factors Affecting respiration

103
Q

-state of ventilation in excess of that required to eliminate the normal venous CO2 produced by cell metabolism
Anxiety, infection, drugs or acid-base imbalance can produce hyperventilation

A

HYPERVENTILATION

104
Q

Signs and Symptoms of Hypoventilation

A
  • Lightheadedness - Chest pain
  • Disorientation - Shortness of Breath
  • Dizziness - Blurred Vision
  • Tachycardia - Extremity Numbness
105
Q

Intervention of Hyperventilation

A

Breathe through pursed lips
Breath slowly into a paper bag or cupped hands
Attempt to breathe into your belly rather than chest
Hold breath for 10 to 15 seconds
Brown bag

106
Q

-Alveolar ventilation is inadequate to meet body’s O2 demand
-PaCO2 elevates, PaO2 drops
-Severe atelectasis can cause hypoventilation
-COPD (Chronic Obstructive Pulmonary disease)

A

HYPOVENTILATION

107
Q

Signs and Symptoms of Hypoventilation

A

Disorientation - convulsion
- lethargy - coma
- dizziness - dysrythmias
- headache - cardiac death
- decrease ability to follow instructions

108
Q

Interventions of Hypoventilation

A

Oxygen therapy
Airway management: CPAP/BIPAP
Surgery
Weight loss
Inhaled medications

109
Q

-Inadequate tissue oxygenation at the cellular level
-Deficiency of O2 delivery or O2 utilization at cell level
-Causes: Decreased Hgb, diminished concentration of inspired O2, decreased diffusion poor tissue perfusion, impaired ventilation

A

HYPOXIA

110
Q

Other factors affecting Oxygenation

A

-Age
-Environment
-Lifestyle
-Medications
-Stress
-Infection

111
Q

Nursing History

A

-Contains respiratory component
-Before starting the interview make sure patient is not in respiratory distress
-If distress, postpone the interview and help patient
If no emergency intervention are needed, obtain comprehensive history

112
Q

Inspection

A

-Inspect chest contour and shape
-Observe respiratory rate and depth for 1 full minute

113
Q

Palpation

A

-Palpate trachea (Should be midline) and assess skin temp
-Ensure thoracic excursion is symmetrical
-Assess tactile fremitus (the capacity to feel sound on the chest wall)

114
Q

Auscultation

A

-Using diaphragm move from apex to base of lungs comparing one side other side
-Normal breath sounds includes vesicular, bronchial and broncho vesicular
If abnormal breath sounds is heard ask patient to cough then reassess

115
Q

popping sound heard on inspiration

A

Crackles

116
Q

continuous sound produced as air passes through constricted airways, narrowing, secretions and around obstruction

A

Wheezes

117
Q

-Group of test that evaluate respiratory status to detect abnormalities
-Evaluate lung dysfunction and respiratory interventions

A

Pulmonary Function

118
Q

measure the volume of air in liters exhaled or inhaled over time

A

Spirometry

119
Q

refers to point of highest flow during expiration

A

Peak flow Expiratory flow rate

120
Q

facilitate removal of respiratory tract secretion by reducing the viscosity of the secretion

A

Expectorant

121
Q

drugs that suppress cough, recommended if patient is unable to sleep

A

Cough suppressants

122
Q

use to relieve milk, nonproductive cough

A

Lozenges

123
Q

If patient is unable to clear the coughing, aspirate secretions
* Nursing Interventions in Suctioning

A

Suctioning Airway

124
Q

Appropriate size for suction catheter

A

Adult: Fr 12-18
Child :Fr 8-10
Infant: Fr 5-8

125
Q

Length of Catheter

A

measure from tip of the clients nose to the earlobe or about 13cm (5in) for adult

126
Q

Administered to dilate airways

A

Bronchodilators

127
Q

loosen thick secretions

A

Mucolytics

128
Q

reduce inflammation

A

Corticosteroid

129
Q

disperse fine particles of medication into the airway

A

Nebulizers

130
Q

CPAP

A

continuous positive airway pressure

131
Q

BPAP

A

bi-level positive airway pressure
Applies mild airway pressure on continuous basis to keep airways continuously open in people who are not able to breath spontaneously

132
Q

-Also called pleural tap
-Invasive procedure to remove fluid and air from the pleural space
-A cannula is introduced to the thorax
-Drains fluids from the lungs
-Used for patient with pleural effusion, hemothorax, pneumothorax

A

Thoracentesis

133
Q

forceful striking of the skin with cupped hands. Can mechanically dislodge tenacious secretion from bronchial walls

A

Percussion (Clapping)

134
Q

series of vigorrous quivering produced by hands that are place flat against the client’s chest wall. It is done to loosen mucous secretions

A

Vibration

135
Q

expulsion of secretion form various lung segment by gravity

A

Postural Drainage

BHC & Filipino (2 decks)

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