Ch 30: Vital Signs - SG PT2 Flashcards
Define Tachycardia
Tachycardia is an abnormal elevated heart rate
(>100 beats/min in adults)
Define Bradycardia
Bradycardia is a slow rate
(<60 beats/min in adults)
Define Pulse Deficit
Pulse deficit is an inefficient contraction of the heart
that fails to transmit a pulse wave to the peripheral site; it is the difference between the apical and the radial pulse rate.
Define Dysrhythmia
A dysrhythmia is an abnormal rhythm, including early, late, or missed beats.
Define Respiratory Ventilation
Ventilation is the movement of gases in and out of the lungs.
Define Respiratory Diffusion
Diffusion is the movement of oxygen and carbon dioxide between the alveoli and the red blood cells.
Define Respiratory Perfusion
Perfusion is the distribution of red blood cells to and from the pulmonary capillaries.
Define Hypoxemia
Hypoxemia is low levels of arterial O2
Identify which phase of respirations is active and which is passive.
- Inspiration
- Expiration
- Inspiration = Active
- Expiration = Passive
Identify factors that influence the character of respirations and the mechanism of each factor
- Exercise: increases rate and depth
- Acute Pain: alters rate and rhythm of respirations; breathing becomes shallow.
- Anxiety: increases respiration rate and depth as a result of sympathetic stimulation
- Smoking: changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking
What is the acceptable respiratory rate for adults?
12-20
Briefly explain the alterations in breathing patterns for:
Bradypnea
Rate of breathing is regular but slow; <12 breaths/ min.
Briefly explain the alterations in breathing patterns for:
Tachypnea
Rate of breathing is regular but rapid; >20 breaths/ min.
Briefly explain the alterations in breathing patterns for:
Hyperpnea
Respirations are labored and increased in depth, and the rate is >20 breaths/min.
Briefly explain the alterations in breathing patterns for:
Apnea
Respirations cease for several seconds.
Briefly explain the alterations in breathing patterns for:
Hyperventilation
Rate and depth of respirations increase
Briefly explain the alterations in breathing patterns for:
Hypoventilation
Respiratory rate is abnormally low, and depth of ventilation is depressed
Briefly explain the alterations in breathing patterns for:
Cheyne–Stokes:
Respiratory rate and depth are irregular; alternating periods of apnea and hyperventilation
Briefly explain the alterations in breathing patterns for:
Kussmaul
Kussmaul respirations are abnormally deep, regular, and increased in rate
Briefly explain the alterations in breathing patterns for:
Biot
Biot respirations are abnormally shallow for two or three breaths followed by an irregular period of apnea
Briefly explain the alterations in breathing patterns for:
SaO2
SaO2 is the percentage of hemoglobin that is bound with oxygen in the arteries and is the percent of saturation of hemoglobin; normal range is usually
between 95% and 100%
Define Blood Pressure
Blood pressure is the force exerted on the walls of an artery by the pulsing blood under pressure from the heart.
Define Systolic Pressure
Systolic pressure is the peak of maximum pressure
when ejection occurs
Define Diastolic Pressure
Diastolic pressure occurs when the ventricles relax; the blood remaining in the arteries exerts a minimum pressure
Define Pulse Pressure
Pulse pressure is the difference between systolic and diastolic pressure
How is blood pressure effected by cadiac output?
Cardiac output increases as a result of an increase in heart rate, greater heart muscle contractility, or an increase in blood volume; thus raising blood pressure
How does peripheral resistance relate to blood pressure?
Peripheral resistance is the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels.
How does blood volume affect blood pressure?
The volume of blood circulating within the vascular system affects blood pressure, which normally remains constant. Higher blood volume = higher BP
How does blood viscosity affect blood pressure?
Viscosity is the thickness that affects the ease with which blood flows through blood vessels, determined by the hematocrit.
Thicker = higher bp, thinner = lower
How does blood vessel elasticity affect blood pressure?
With reduced elasticity, there is greater resistance to blood flow, and the systemic pressure rises (systolic pressure).
List eight factors that influence blood pressure.
- Age
- Stress
- Ethnicity
- Gender
- Daily variations
- Medications
- Activity and weight
- Smoking
Optimal blood pressure in adults is…
<120 / <80
List some of the risk factors that are linked to hypertension
- Family history,
- obesity,
- smoking,
- heavy alcohol consumption,
- high sodium,
- sedentary life- style,
- continuous stress,
- diabetics,
- older, African Americans
Identify some of the risk factors for orthostatic hypotension
- Dehydrated,
- anemic,
- experienced
- prolonged bed rest,
- recent blood loss,
- medications
Define Orthostatic Hypotension
A decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within three minutes of standing when compared with blood pressure from the sitting or supine position.
Identify the first through fifth Korotkoff sounds.
- First: Clear, rhythmic tapping corresponding to the pulse rate that gradually increases in intensity (systolic pressure)
- Second: Blowing or swishing sound as the cuff deflates
- Third: A crisper and more intense tapping
- Fourth: Muffled and low-pitched as the cuff is further deflated (diastolic pressure in infants and children)
- Fifth: The disappearance of sound (diastolic pressure in adolescents and adults)
Identify at least two variations in temperature that are unique to older adults.
- The temperature of older adults is at the lower end of the normal temperature range, (96.8° to 98.3° F). Therefore temperatures considered within normal range sometimes reflect a fever in an older adult.
- Older adults are very sensitive to slight changes in environmental temperature because their thermoregulatory systems are not as efficient.
- A decrease in sweat gland reactivity in the older adult results in a higher threshold for sweating at high temperatures, which leads to hyperthermia and heatstroke.
- Be especially attentive to subtle temperature changes and other manifestations of fever in this population such as tachypnea, anorexia, falls, delirium, and overall functional decline.
• Older adults without teeth or with poor muscle control may be unable to close their mouths tightly to obtain accurate oral temperature readings.
Identify at least two variations in pulse that are unique to older adults.
- Pedal pulses are often difficult to palpate in older adults.
- The older adult has a decreased heart rate at rest.
- It takes longer for the heart rate to rise in the older adult to meet sudden increased demands that result from stress, illness, or excitement. Once elevated, the pulse rate takes longer to return to normal resting rate.
- Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs.
Identify at least two variations in blood pressure that are unique to older adults.
- Older adults who have lost upper arm mass, require special attention to selection of a smaller size blood pressure cuff.
- Older adults sometimes have an increase in systolic pressure related to decreased vessel elasticity, whereas the diastolic pressure remains the same, resulting in a wider pulse pressure.
- Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries.
- Skin of older adults is more fragile and susceptible to cuff pressure during frequent measurements. More frequent assessment of skin under the cuff or rotating blood pressure sites is recommended.
Identify at least two variations in respirations that are unique to older adults.
- Aging causes ossification of costal cartilage and downward slant of ribs, resulting in a more rigid rib cage, which reduces chest wall expansion. Kyphosis and scoliosis that occur in older adults also restrict chest expansion and decrease tidal volume.
- Older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles.
- The respiratory system matures by the time a person reaches 20 years of age and begins to decline in healthy people after the age of 25. Despite this decline older adults are able to breathe effortlessly as long as they are healthy. However, sudden events that require an increased demand for oxygen create shortness of breath in the older adult.
- Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia.
The skin plays a role in temperature regulation by:
- Insulating the body
- Constricting blood vessels
- Sensing external temperature variations
- All of the above
- The skin regulates the temperature through insula-
tion of the body, vasoconstriction, and temperature
sensation
The nurse bathes the patient who has a fever with cool water. The nurse does this to increase heat loss by means of:
- Radiation
- Convection
- Conduction
- Condensation
- The transfer of heat from one object to another
with direct contact (solids, liquids, and gases
The nurse is assessing a patient who she suspects has the nursing diagnosis hyperthermia related to vigorous exercise in hot weather. In reviewing the data, the nurse knows that the most important sign of heatstroke is:
- Confusion
- Excess thirst
- Hot, dry skin
- Muscle cramps
- Victims of heat stroke do not sweat
The nurse is auscultating Mrs. McKinnon’s blood pressure. The nurse inflates the cuff to 180 mm Hg. At 156mmHg, the nurse hears the onset of a tapping sound. At 130mmHg, the sound changes to a murmur or swishing. At 100mmHg, the sound momentarily becomes sharper, and at 92mmHg, it becomes muffled. At 88mmHg, the sound disappears. Mrs. McKinnon’s blood pressure is:
- 130/88mmHg
- 156/88mmHg
- 180/92mmHg
- 180/130mmHg
- 156 is the onset of the first Korotkoff sound (sys-
tolic pressure), and 88 is the fifth sound that corre- sponds with the diastolic pressure.
