chapter 29 Jess Flashcards
Measurement of vital signs to determine a patients what?
Baseline
Vital signs are used to:
Monitor patients condition
Identify problems
Evaluate response to intervention
Assessment of vital signs provide data for what?
- to identify nursing diagnosis
- implement planned interventions
- evaluate outcomes of care
Guidelines for measuring vital signs
6
- equipment is functional and right size
- know when ok and not ok to delegate
- understand and interpret values
- know patients usual range of vital signs
- get medical history, medication history , current meds
- control or minimize environmental factors that affect vital signs
Who is responsible for vitals?
The nurse is
Temp sights (8)
Oral, tympanic, temporal, esophageal, pulmonary artery, bladder
Normal adult temp
98.6-100.4f
36-38 c
Most common, or preferred temp sights in regular practice
Oral, axillary, temporal, tympanic
Define tachycardia
Elevated heart rate above 100 bpm
Define bradycardia
Slow heart rate below 60 bpm
What is a full assessment of the radial pulse
Measuring the rate rhythm strength and equality
What is a full assessment of an apical pulse
Rate and rhythm only
What are the two types of dysrhythmia?
Regularly irregular and irregularly irregular
What is Pulse strength and what is considered normal pulse strength?
0, 1+, 2 +, 3+, 4+,
2+ normal
When a person changes from a lying to sitting or standing position what can happen to the heart rate?
It can temporarily increase
What should you do if you detect abnormal heart rate when taking a radial pulse?
Assess the
apical pulse
What do the sounds lub and dub consist of?
Lub is S1 and is low pitched and dull
Dub is s2, is higher pitched and shorter
How do you calculate a pulse deficit?
Find the rate difference between the apical and the radial pulse
How do you assess a pulse deficit
Simultaneously one person taking radial pulse is another person takes apical pulse
What is the common order to document a dysrhythmia?
Electrocardiogram a Holter monitor or telemetry monitor
What is a common dysrhythmia of children?
A sinus dysrhythmia the heart rate speeds up with inspiration and slows down with expiration
What happens if a child with a sinus dysrhythmia holds her breath?
The heart rate becomes regular
What does the strength of a pulse measure?
The volume of blood ejected against the artery wall with each heart contraction
How is pulse strength chart defined?
4+ is bounding 3+ it’s full or strong 2+ is normal and expected 1+ is diminished or barely palpable 0 is absent
What pulses should you never assess simultaneously?
The carotid pulses because it will occlude blood supply to the brain
What three processes are included in respiration?
Ventilation, diffusion, and perfusion
Breathing is what kind of process
Passive
What does the body measure to regulate ventilation?
CO2 and O2 Ion concentrations in arterial blood
What happens o2 falls below acceptable parameters?
Respiratory rate and depth of ventilation will increase
What is hypoxia
Low blood level of oxygen
Define ventilation
Movement of gases into and out of the lung
Define diffusion
Movement of oxygen and carbon monoxide between alveoli and red blood cells
Define perfusion
Distribution of red blood cells to and from the pulmonary capillaries
Define Eupnea
Ventilation of normal rate and depth
What are the three things to assess when taking respiration?
Great depth and rhythm
Respirations are tied to what functions of body systems
All functions of bodies
What can influence respiratory rate?
Age illness injury or disease
What are the three movements of ventilation
Deep normal or shallow
How do you evaluate diffusion and perfusion
By measuring O2 saturation of blood the percentage of hemoglobin is down with auction in the arteries is percent of saturation of hemoglobin or SA O2 they should be between 95 and hundred percent
What is SaO2
This is a laboratory value it is the percentage of hemoglobin that is bound with oxygen in the arteries it is the percent saturation of hemoglobin it should be between 95 and 100%
What factors influence the characteristic of respiration
Exercise, anxiety, smoking neurologic injury, hemoglobin function , body position medication and acute pain
How does exercise affect respiration rate
Increases the rate and depth of respiration to meet bodies need for additional auction into rid the body of CO2
How does pain alter respiration
Makes respiration shallow
How does anxiety affect respiration rate
Increases respiration rate and depth as a result of sympathetic stimulation
How does smoking change respiration rate
Smoking changes pulmonary airways which results in increased rate of respiration at rest when not smokeing
What posture promotes full chest expansion and what posture impairs ventilation movement
A straight posture promotes full chest expansion. A stooped or slumped posture impairs ventilation movement
lying flat prevents full chest expansion
What medication classes depress rate and depth of respiration
Opioid, analgesic, general anesthetic, and sedative hypnotic
What types of drugs increase rate and depth of respiration
Amphetamine and cocaine
How do bronchodilators affect respiration
Slows rate by causing airway dilation
How could a brainstem injury affect respiration
Impairs respiratory center and inhibits respiratory rate and rhythm
How does anemia affect respiratory rate
Decreased hemoglobin levels equals anemia , reduces oxygen-carrying capacity of the blood which increases respiratory rate
How does increased altitude affect respiration.
Lowers the amount of saturated hemoglobin, which increases respiratory rate and depth
How can sickle-cell disease disease affect respiration?
Abnormal blood cell function reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth
Cheyne- stokes respiration
Respiratory rate and depth or irregular, characterized by alternating periods of apnea and hyperventilation seen in dying patients
Kussmauls respiration
Respirations are abnormally deep regular , increased in rate this is seen in ketoacidosis
Biots respiration
Respirations are abnormally shallow for 2 to 3 breaths followed by an irregular Period of apnea
What is SV 02
The hemoglobin saturation of venous blood, this is lower than the SaO2
What is the normal value for SV 02
70%
What is used for simple measurement of oxygen saturation
A pulse oximeter
What does the pulse ox meter measure
The pulse saturation SPO2
What is SPO2 a reliable estimate of?
SaO2 arterial oxygen saturation
What can affect the accurate reading of a pulse oximeter
Any factor that affects late transmission
What does the systolic blood-pressure measure?
Maxim peak pressure during ventricular contraction
What is the diastolic blood pressure measure
Minimal pressure during ventricular relaxation
What is pulse pressure
The difference between systolic and diastolic pressures
Define blood pressure
What pressure is the force exerted on the arterial wall by pulsing blood under pressure from the heart
What is blood-pressure a good indicator of
Cardiovascular health
What is the standard unit for measuring blood pressure
Millimeters of mercury this measurement indicates the height to which the blood pressure races a column of mercury
What is the pulse pressure for a blood pressure of 120/80
40
What five factors affect arterial blood pressure
Cardiac output, peripheral resistance, blood volume, viscosity, elasticity
What does blood-pressure depend on
Cardiac output
What is cardiac out put
The volume of blood ejected by the ventricles of the heart multiplied by the heart rate, other words stroke volume multiplied by the heart rate
What is Peripheral resistance
As the blood flows through arteries arterials capillaries and veins the size changes to meet the needs of surrounding structures and tissues
What is the normal blood circulating volume amount
5000 ML’s
How does the volume of circulating blood affect blood pressure
Rapid infusion of volume elevates blood pressure decreased volume such as hemorrhage or dehydration causes blood pressure to fall
How does blood viscosity affect blood pressure
The thickness or viscosity of blood affects the Ease of blood flow through small vessels
What laboratory test measures viscosity of blood
Hematocrit
As blood pressure increases what happens to the diameter of blood vessels
They increased to accommodate the pressure
What are four factors that influence blood pressure
Age, stress, Ethnicity, gender
Where the four classifications of blood pressure
Normal, prehypertensive, stage one hypertension, stage two hypertension
How does stress affect blood pressure
Increases heart rate increases cardiac output and vascular resistance
Do African-Americans have a higher or lower rate of hypertension then European Americans
Higher rate
At what lifestage do men tend to have a higher blood pressure than woman
Puberty
Out what lifestage do women tend to have a higher blood pressure than men
After Menopause
What are four more influences of blood pressure
Daily variation, medication, activity, wait, smoking
What does daily variation of blood pressure mean
Blood-pressure will vary during the day around sleep intervals and activities blood-pressure is highest during waking hours and lowest during hours asleep
What medications can increase blood pressure
Vasoconstrictors
What medications can lower blood pressure
Antihypertensives, and opioid analgesics
How does weight affect blood pressure
Raises it
How does activity affect blood pressure
Immediately after will reduce it for several hours. Overtime will lower it
How does smoking affect blood
Smoking affects vessels, producing vasoconstriction. This causes blood pressure to rise
How do you reduce risk of skin breakdown for multiple blood pressure readings
Rotate measurement site
What is a normal pulse pressure range
60 - 70
What are alternative methods of measuring blood pressures
Lower extremity blood pressure cuff position above Popliteal
artery at mid thigh with knee flexed
When is it not appropriate to use electronic blood pressure machine
Irregular heart rate, peripheral vascular obstruction,( clots) shivering, seizures, excessive tremors, inability to cooperate, blood pressure less than 90 systolic
What are the advantages and disadvantages of patients measuring blood pressure at home
Advantages; detection of new problems. Patients can provide information about patterns of blood pressure. Self-monitoring helps adherence to therapy.
Disadvantages improper use and in accurate readings. Patients me inappropriately adjust medication
What is more, hypertension or hypotension
Hypertension
What are symptoms of hypotension
Pale skin, skin molting, clamminess, confusion, increased heart rate, decreased urine output
What are risk factors of hypertension
Obesity smoking alcohol consumption and High salt diet
family history diabetics African-American descent
What is postural hypotension
When he person develops symptoms and low blood pressure when raising to an upright position
How do you assess for postural orthostatic hypotension
Take vital signs and pulse while patient is supine sitting and standing
