Chapter 12 Flashcards
Vital signs included ?
-temperature,pulse,respiration, and blood pressure
Vital signs is important ?
-ability to obtain accurate measurement is critical
-often provide the basis for people-solving
-many facilities are using fifth vital sign -pain leave or comfort level
The nurse must be able to do the following ?
-measure vital signs correctly
-understand and interpret the values
-communicate the finding appropriately
The body’s regulation of temperature ?
-a relative measure of sensible heat or cold
-the body strives to maintain a temperature 98.9 F (37 C) which normal
Two types of body temperature ?
-core temperature (temperature of the internal organs, such as the liver, located deep within the body)
Rectum
-surface temperature
Temperature measurements are obtained by several methods ?
-Heat-sensitive patches
-Electronic thermometers
-Tympanic thermometer
-Temporal artery method
The body’s regulation of pulse?
The pulse is the regular recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the last ventricle of the heart as it contracts
Major pulses include ?
-temporal , facial, carotid , brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis
-the pulses provide both general and specific information
-Auscultating the apical rate (apex of the heart) is essential on all cardiac patients
Pulse Apical pulse is the actual beating of the heart?
When auscultating the apical rate, the “lub-dub” that heard represents one cardiac cycle, or heartbeat
Radial pulse?
is measured in groove along radial side of forearm , lateral to flexor tendon of wrist
Pulse deficit?
difference between the radial and apical rates
Respiration Assessment of respiration?
-when assessing respirations, note the rate, depth quality, and rhythm
-assessment of respirations is done by observing the movement of the diaphragm and the intercostal muscles
Dyspnea ?
breathing with difficulty
Blood Pressure?
Pressure exerted by the circulating volume of blood on the arterial walls , the veins, and the chambers of the heart
What the unit of blood pressure ?
Measured in millimeters of mercury ( mm Hg)
Systolic pressure/ diastolic pressure ?
-Pulse pressure
-Cardiac output
-Hypertension blood pressure elevated
- Hypotension blood pressure below normal
Normal Limits Temperature:
Pulse rate (adult):
Respiratory rate (adult):
Blood pressure (adult):
Normal Limits Temperature: 97to 98.8F (36.1to 37.5C)
Pulse rate (adult): 60 to 100 beats per minute
Respiratory rate (adult): 12 to 20 respirations per minute
Blood pressure (adult): 120/80 mm Hg
Factors that Affect Vital Signs?
-Environment
-Age -Stress -Smoking -Time of day -Patient’s state of health –Activity levels -Stage of monthly menstrual cycle
Height and Weight ?
-Helps assess normal growth and development
-Aids in proper drug dosage calculation
-May be used to assess the effectiveness of drug therapy, such as diuretics
-Significant loss of weight may be a sign of an underlying disease
Obtaining weight measurement ?
-Patients should be weighed the same time of day, on the same scale , and in the same type or amount of clothing
-1 liter of fluid =1 kilogram (kg) = 2.2 pounds ]
-A significant loss or gain of weight can point to an underlying disease
Obtaining height measurements?
-Patient should remove shoes and stand erect
-A measuring stick or tape may be attached vertically to the weight scales or wall
-Standing scales may have a metal rod which is attached to the back of the scale and swings out over the top of the patient’s head
When Vital Signs Are Assessed ?
-Temperature, pulse, respirations, and blood pressure are usually assessed at the same time at set intervals
-A set of vital signs is taken when the patient is admitted to the facility, and then as prescribed by the health care provider or as policy dictates
-Example: every 4 hours, once a shift, weekly
-The more ill the patient, the more frequently vital signs are taken
Accuracy?
Be sure equipment used to measure vital signs (e.g., thermometer, stethoscope, sphygmomanometer) is in proper working condition to ensure accuracy of findings
Self- Measurement of Blood Pressure?
-Portable home devices
-Stationary automated machines
-Patient education
Recording Vital Signs (Graphic flow sheet) ?
-Used for charting vital signs
-“R” indicates a rectal temperature
“Ax” indicates an axillary temperature
-Blood pressures are always written with the systolic first and the diastolic beneath Example: 120/80 mmHg
-Apical pulse is indicated with an apnext to the number Example : 78 ap
When to Assess Vital Signs?
- During admission and discharge to a health care facility
-On a routine schedule as determined by health care provider’s order or agency policy
-Before and after surgical procedures Before and after invasive diagnostic procedures
-Before and after administering certain medications especially those that affect cardiovascular , respiratory and temperature control function
-When the patient’s general condition changes (loss of consciousness , hemorrhage , cardiac dysrhythmias , or the onset of intense pain)
-Before and after certain nursing interventions ( when a patient ambulates for the first time or after tracheal suctioning )
-When the patient reports nonspecific symptoms of physical distress (reports of “feeling funny “ or “different “)
-Routinely as part of a procedure ( e.g. , blood transfusion , liver biopsy , paracentesis , thoracentesis )
-When assessing a patient during home health visit
-Pain is considered the fifth vital sign .
-Pain must be evaluated and documented each time other vital signs are taken
-depth discussion of pain and the interventions available for pain control .
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Body temperature falls into two categories ?
-core temperature, which is the temperature of the deep tissues of the body
-core temperature remains relatively constant unless the environment
-surface temperature, which is the temperature of the skin.
-often varies a great deal in response to the environment
The terms pyrexia , febrile , and hyperthermia are used ?
describe the condition of having above -normal body temperature
When the body temperature is abnormally low, the condition is called ?
hypothermia also (happened surgical procedure)
Factors the affect body temperature?
-age -exercise -hormone influences -diurnal daily variations -stress -environment -ingestion of food and hot cold liquids -smoking
Signs and Symptoms of Elevated Body Temperature?-
-Anorexia -Disorientation , progressing to convulsions in infants and children
-Elevated pulse and respiratory rates
-Flushed, warm skin
-Glassy eyes or photophobia (sensitivity to light)
-Headache Increased perspiration
-Irritability
-Restlessness or excessive sleepiness
-Thirst
electronic thermometers are used?
-to obtain the tympanic temperature by scanning the tympanic (eardrum ) membrane
-sustainable for patient all age expect infant less 6 month
Auscultate ?
(listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones ) bowel , lung , and heart sounds with the diaphragm .
A pulse ?
is a rhythmic beating or vibrating movement .
If the pulse is faster than 100 beats per minute, the adult patient has ?
tachycardia
if it is slower than 60 beats per minute, the patient has?
bradycardia
dysrhythmia ?
(any disturbance or abnormality in a normal rhythmic pattern , specifically , irregularity in the normal rhythm of the heart).
Factor the influence pulse rate ?
-acute pain, anxiety -age -exercise -fever,heat -hemorrhage(loss of blood) -medication -metabolism -postural change -pulmonary condition -unrelieved severe pain, chronic pain
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At times, a difference is found between the radial and the apical rates this is called ?
a pulse deficit when radial is less than the apical rate
are an abnormal pattern of respiration characterized by alternating periods of apnea and deep rapid breathing?
Cheyne-Stokes respirations
Where to find the apical ?
1.intercostal space 2.find the midclavicular line 3.Find 5th intercostal space
The systolic pressure?
is the higher number and represents the ventricles contracting , forcing blood into the aorta and the pulmonary arteries
diastolic ?
artery between beats, that is, between contractions of the atria or the ventricles , when blood enters the relax chamber from systemic circulation and the lungs
Orthostatic hypotension?
(a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from a lying to a sitting or from a sitting to a standing position ) occurs when a person rises too quickly, usually from a supine position
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Blood pressure readings are taken with ?
a sphygmomanometer and a stethoscope
Factors that influence blood pressure?
-alcohol and tobacco use -anxiety,fear,pain and emotion stress -diet -diurnal -gender -hormone -medication-obesity and being overweight-race
pulse pressure ?
The difference between the two readings of blood pressure
Blood pressure reflects cardiac output?
(the amount of blood discharged from the heart per minute), the quality of the arteries, the blood volume, and blood viscosity
Autonomic nervous system controls?
the heart rate.
Parasympathetic nervous system?
lowers the heart rate .
Sympathetic nervous system?
raises the heart rate .
The number of times per minute you feel or hear the pulse?
rate
Rhythm ?
The regularity of impulses
Dysrhythmia ? .
An irregular heart rhythm , generally with an irregular radial pulse
Pulse deficit?
The difference between the apical rate and the radial rate
Ventilation ?
The exchange of oxygen and carbon dioxide in the lungs through inspiration and expiration
Diffusion ?
The exchange of oxygen and carbon dioxide between the alveoli and the red blood cells
Perfusion ?
The flow of red blood cells to and from the pulmonary capillaries
Depth?
The amount of chest wall expansion that occurs with each breath.
Altered depths are deep or shallow
Bradypnea ?
Regular breathing pattern with a rate less than 12 / min
Hypoventilation?
Shallow breathing pattern with an abnormally low rat
Apnea?
periods where there is no breathing ongoing apneic spells can lead to respiratory arrest
regular breathing pattern with a rate greater than 20 / m * in?
Tachypnea
Hyperventilation Hyperpnea ?
Respiratory rate , depth , and work of breathing are increased common during exercise
Faster 20 breaths per minute deep breathing
Irregular rate and depth of respirations that follow a cyclical pattern . The client will experience shallow breaths that progress to a normal pattern , and increased rate , then the rate begins to slow again , ending with an apneic period ?
Cheyne -Stokes respirations
Increased respiratory rate , regular pattern , but abnormally deep?
Kussmaul respirations
Cardiac Output ?
the equality arteries -heart rate -contractility -blood volume -venous return book
Circadian ( diurnal) rhythms?
affect BP, with BP usually lowest in the early morning hours and peaking during the later part of the afternoon or evening .
Obesity ?
It is a contributing factor to hypertension.
