Chapter 15 vital signs Flashcards
primary mechanism that adapt to response to maintain
homeostasis
physiological process by which the internal systems are maintained
homeostasis
mechanisms in homeostasis
body temp pulse rate respiratory rate blood pressure sensorium (mental alertness)
measurement of degree of heat in deep tissue
body temperature
term used to describe body’s maintenance of heat production and loss
Thermoregulation
gland responsible for thermoregulation
hypothalamus
regulation of heat loss
diaphoresis (sweating)
heat generation
removes excess heat by ventilation
respiratory system
five routes for body temperature measurement
Oral Axillary Tympanic Rectal Temporal
Oral temp
under tongue 20 sec to 3 min
Axillary temp
arm pit
inaccurate and time consuming 5-10 min
Tympanic temp
electronic in ear
stable in 3 seconds
rectal temp
ensure proper thermometer
2.5-5 min
temporal temp
TA meter
most accurate and fastest
sweep divice along forehead
most popular
normal body temps
- 7-99.5F
36. 5-37.5 C
temperature abnormalities
when body temp increases, metabolic rate increases and demands on cardiopulmonary system increase
temp above 99.5
hyperthermia
febrile
fever
temp below 97.7
hypothermic
hypothermic causes
exposure to cold
trauma to hypothalamus
medically induced
Respiratory system
delivery of O2 and elimination of CO2
major muscle of ventilation
diaphragm
inspiration
diaphragm moves downward expanding the chest cavity
expiration
diaphragm relaxes and chest cavity compresses
respiratory phase
inspiration and expiration
measuring respiration rate
without patients knowledge
normal adult respiration rate
12-20
normal child respiration rate
20-30
normal newborn respiration rate
30-60
respiration rate descriptions
rate
depth
pattern
tachypnea
rate above 20
child 30
bradypnea
rate below 12
child 20
dsypnea
difficult breathing
apnea
absence of breathing
sites for pulse measurment
wrist brachial artery carotid artery pedal artery apical pulse oximeter
Wrist measurement
base of thumb
use index finger
brachial artery
antecubital fossa (inside of elbow) upper arm of children
carotid artery
just below angle of the mandible
pedal artery
over instep of foot
can be significant with concerns for peripheral circulation
Apical
stethoscope at apex of heart
count for full min
done if pulse is slow or irregular
assculation
listening to internal sounds of body with stethoscope
pulse oximeter
non invasive device
measures pulse and O2 saturation of arterial blood
usually located on finger, maybe earlobe, foot or nose
can be inaccurate. poor peripheral perfusion, nail polish/acrylic nails hinder readings
Normal resting pulse adult
60-100
normal resting pulse child
70-120
tachycardia
heart rate above 100
bradycardia
heart rate below 60
tachycardia causes
exercise, fever, anemia, shock , fear, pain and anger
bradycardia causes
unrelieved severe pain, physically fit atheletes, hypothermia
blood pressure
systolic over diastolic
diastolic
constant pressure on arteries when heart is relaxed
systolic
peak pressure during heart contraction
measure systolic
first sound you hear when cuff pressure released
measure diastolic
when blood flow sound is no long heard
normal systolic
95-140
normal diastolic
60-90
BP abnormalities
hypertension
hypotension
hypertenstion
high BP above 140/90
hypotension
low BP
95/60
hypertension factors
increase workload on heart
heart, brain, kidney and lung damage
higher in men and African Americans
stress, medication, obesity and smoking
hypotension factors
dizziness, confusion, blurred vision
may have inadequate blood volume
shock
oxygen therapy
administration of additional O2
oxygen saturation
21% of atmospheric gas
absence of O2
brain damage in 6 min
hypoxia
low oxygen level to tissues
oxygen is defined as a
drug
must be prescribed by physician
as liters per min or concentration
oxygen tank identification
green tank labeled as oxygen
bad to give too much oxygen?
yes
dry out nasal mucosa
damage lungs
aveolar adema
oxygen therapy devices
low flow
high flow
low flow
less than 6 lpm
variable oxygen concentration
high flow
greater than 6 lpm
fixed or precise concentration
provides entire respiratory volume
oxygen therapy device types
nasal cannula
oxygen mask
nasal cannula
most prequently used never over 6 lpm prongs point downward inserted into nares rates of 1-4 lpm 24-36% low flow device
Oxygen mask
not tolerated as well as cannula simple mask non-rebreathing mask partial re breathing aerosol air entrainment
simple mask
low flow
non rebreathing mask
bags attached
1 way valve to prevent exhaled air from being re breathed
partial re breathing
does not have 1 way valve
aerosol
high flow
w/nebulizer
at least 8 LPM
watch for fluid in corrugated tubing
air entrainment
high flow
O2 forced through small tube in mask
constant O2 concentration regardless of changes to respiratory system
Pediatric Oxy patients
tent
oxy hood
pediatric tent
covers entire bed
difficult due to constant entering and exiting
pediatric hood
generally used on infants
plastic or disposable box fits over infants head
ventilator
artificial airway inserted into trachea connected to ventilator
controls rate, volume and content
intubation
insertion of tube into canal or hollow organ, cavity
tracheal intubation
trans laryngeal via nose or mouth
oro-throat
endo nose
tracheostomy
surgical opening through naterior of trachea
proper placement of trach tube
distal tip 1-2 inches superior to tracheal bifurcation
malposition of tube
right stem due to lesser angle
can cause atelectasis of left lung (collapsed lung)
chest tubes (thoracostomy)
used to drain intrapleural space and mediastinum
pleural effusion
fluid in the plerual cavity
pneumothorax
air/gas in pleural cavity bleb fractured rib cv line insertion error gas producing microorganisms (empyema)
bleb
rupture of lining of lung
CV lines
may be single double or triple lumen
types of cv lines
percutaneous
implanted
PICC lines
externally tunneled
percutaneous
subclavin
implanted
mediport
infusa port
PICC line
peripheral insterted central cathether
basilic or cephalic vein
less infection
externally tunneled
through layers of skin
preferred junction for CV line
SVC
2-3 cm above right arterial junction
preferred CV line insertion site
RT subclavian vein
