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chapter 29 Jess Flashcards

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0
Q

Measurement of vital signs to determine a patients what?

A

Baseline

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1
Q

Vital signs are used to:

A

Monitor patients condition
Identify problems
Evaluate response to intervention

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2
Q

Assessment of vital signs provide data for what?

A
  • to identify nursing diagnosis
  • implement planned interventions
  • evaluate outcomes of care
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3
Q

Guidelines for measuring vital signs

6

A
  • 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
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4
Q

Who is responsible for vitals?

A

The nurse is

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5
Q

Temp sights (8)

A

Oral, tympanic, temporal, esophageal, pulmonary artery, bladder

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6
Q

Normal adult temp

A

98.6-100.4f

36-38 c

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7
Q

Most common, or preferred temp sights in regular practice

A

Oral, axillary, temporal, tympanic

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8
Q

Define tachycardia

A

Elevated heart rate above 100 bpm

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9
Q

Define bradycardia

A

Slow heart rate below 60 bpm

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10
Q

What is a full assessment of the radial pulse

A

Measuring the rate rhythm strength and equality

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11
Q

What is a full assessment of an apical pulse

A

Rate and rhythm only

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12
Q

What are the two types of dysrhythmia?

A

Regularly irregular and irregularly irregular

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13
Q

What is Pulse strength and what is considered normal pulse strength?

A

0, 1+, 2 +, 3+, 4+,

2+ normal

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14
Q

When a person changes from a lying to sitting or standing position what can happen to the heart rate?

A

It can temporarily increase

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15
Q

What should you do if you detect abnormal heart rate when taking a radial pulse?

A

Assess the

apical pulse

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16
Q

What do the sounds lub and dub consist of?

A

Lub is S1 and is low pitched and dull

Dub is s2, is higher pitched and shorter

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17
Q

How do you calculate a pulse deficit?

A

Find the rate difference between the apical and the radial pulse

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18
Q

How do you assess a pulse deficit

A

Simultaneously one person taking radial pulse is another person takes apical pulse

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19
Q

What is the common order to document a dysrhythmia?

A

Electrocardiogram a Holter monitor or telemetry monitor

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20
Q

What is a common dysrhythmia of children?

A

A sinus dysrhythmia the heart rate speeds up with inspiration and slows down with expiration

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21
Q

What happens if a child with a sinus dysrhythmia holds her breath?

A

The heart rate becomes regular

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22
Q

What does the strength of a pulse measure?

A

The volume of blood ejected against the artery wall with each heart contraction

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23
Q

How is pulse strength chart defined?

A

4+ is bounding 3+ it’s full or strong 2+ is normal and expected 1+ is diminished or barely palpable 0 is absent

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24
Q

What pulses should you never assess simultaneously?

A

The carotid pulses because it will occlude blood supply to the brain

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25
Q

What three processes are included in respiration?

A

Ventilation, diffusion, and perfusion

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26
Q

Breathing is what kind of process

A

Passive

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27
Q

What does the body measure to regulate ventilation?

A

CO2 and O2 Ion concentrations in arterial blood

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28
Q

What happens o2 falls below acceptable parameters?

A

Respiratory rate and depth of ventilation will increase

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29
Q

What is hypoxia

A

Low blood level of oxygen

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30
Q

Define ventilation

A

Movement of gases into and out of the lung

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31
Q

Define diffusion

A

Movement of oxygen and carbon monoxide between alveoli and red blood cells

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32
Q

Define perfusion

A

Distribution of red blood cells to and from the pulmonary capillaries

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33
Q

Define Eupnea

A

Ventilation of normal rate and depth

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34
Q

What are the three things to assess when taking respiration?

A

Great depth and rhythm

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35
Q

Respirations are tied to what functions of body systems

A

All functions of bodies

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36
Q

What can influence respiratory rate?

A

Age illness injury or disease

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37
Q

What are the three movements of ventilation

A

Deep normal or shallow

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38
Q

How do you evaluate diffusion and perfusion

A

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

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39
Q

What is SaO2

A

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%

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40
Q

What factors influence the characteristic of respiration

A

Exercise, anxiety, smoking neurologic injury, hemoglobin function , body position medication and acute pain

41
Q

How does exercise affect respiration rate

A

Increases the rate and depth of respiration to meet bodies need for additional auction into rid the body of CO2

42
Q

How does pain alter respiration

A

Makes respiration shallow

43
Q

How does anxiety affect respiration rate

A

Increases respiration rate and depth as a result of sympathetic stimulation

44
Q

How does smoking change respiration rate

A

Smoking changes pulmonary airways which results in increased rate of respiration at rest when not smokeing

45
Q

What posture promotes full chest expansion and what posture impairs ventilation movement

A

A straight posture promotes full chest expansion. A stooped or slumped posture impairs ventilation movement
lying flat prevents full chest expansion

46
Q

What medication classes depress rate and depth of respiration

A

Opioid, analgesic, general anesthetic, and sedative hypnotic

47
Q

What types of drugs increase rate and depth of respiration

A

Amphetamine and cocaine

48
Q

How do bronchodilators affect respiration

A

Slows rate by causing airway dilation

49
Q

How could a brainstem injury affect respiration

A

Impairs respiratory center and inhibits respiratory rate and rhythm

50
Q

How does anemia affect respiratory rate

A

Decreased hemoglobin levels equals anemia , reduces oxygen-carrying capacity of the blood which increases respiratory rate

51
Q

How does increased altitude affect respiration.

A

Lowers the amount of saturated hemoglobin, which increases respiratory rate and depth

52
Q

How can sickle-cell disease disease affect respiration?

A

Abnormal blood cell function reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth

53
Q

Cheyne- stokes respiration

A

Respiratory rate and depth or irregular, characterized by alternating periods of apnea and hyperventilation seen in dying patients

54
Q

Kussmauls respiration

A

Respirations are abnormally deep regular , increased in rate this is seen in ketoacidosis

55
Q

Biots respiration

A

Respirations are abnormally shallow for 2 to 3 breaths followed by an irregular Period of apnea

56
Q

What is SV 02

A

The hemoglobin saturation of venous blood, this is lower than the SaO2

57
Q

What is the normal value for SV 02

A

70%

58
Q

What is used for simple measurement of oxygen saturation

A

A pulse oximeter

59
Q

What does the pulse ox meter measure

A

The pulse saturation SPO2

60
Q

What is SPO2 a reliable estimate of?

A

SaO2 arterial oxygen saturation

61
Q

What can affect the accurate reading of a pulse oximeter

A

Any factor that affects late transmission

62
Q

What does the systolic blood-pressure measure?

A

Maxim peak pressure during ventricular contraction

63
Q

What is the diastolic blood pressure measure

A

Minimal pressure during ventricular relaxation

64
Q

What is pulse pressure

A

The difference between systolic and diastolic pressures

65
Q

Define blood pressure

A

What pressure is the force exerted on the arterial wall by pulsing blood under pressure from the heart

66
Q

What is blood-pressure a good indicator of

A

Cardiovascular health

67
Q

What is the standard unit for measuring blood pressure

A

Millimeters of mercury this measurement indicates the height to which the blood pressure races a column of mercury

68
Q

What is the pulse pressure for a blood pressure of 120/80

A

40

69
Q

What five factors affect arterial blood pressure

A

Cardiac output, peripheral resistance, blood volume, viscosity, elasticity

70
Q

What does blood-pressure depend on

A

Cardiac output

71
Q

What is cardiac out put

A

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

72
Q

What is Peripheral resistance

A

As the blood flows through arteries arterials capillaries and veins the size changes to meet the needs of surrounding structures and tissues

73
Q

What is the normal blood circulating volume amount

A

5000 ML’s

74
Q

How does the volume of circulating blood affect blood pressure

A

Rapid infusion of volume elevates blood pressure decreased volume such as hemorrhage or dehydration causes blood pressure to fall

75
Q

How does blood viscosity affect blood pressure

A

The thickness or viscosity of blood affects the Ease of blood flow through small vessels

76
Q

What laboratory test measures viscosity of blood

A

Hematocrit

77
Q

As blood pressure increases what happens to the diameter of blood vessels

A

They increased to accommodate the pressure

78
Q

What are four factors that influence blood pressure

A

Age, stress, Ethnicity, gender

79
Q

Where the four classifications of blood pressure

A

Normal, prehypertensive, stage one hypertension, stage two hypertension

80
Q

How does stress affect blood pressure

A

Increases heart rate increases cardiac output and vascular resistance

81
Q

Do African-Americans have a higher or lower rate of hypertension then European Americans

A

Higher rate

82
Q

At what lifestage do men tend to have a higher blood pressure than woman

A

Puberty

83
Q

Out what lifestage do women tend to have a higher blood pressure than men

A

After Menopause

84
Q

What are four more influences of blood pressure

A

Daily variation, medication, activity, wait, smoking

85
Q

What does daily variation of blood pressure mean

A

Blood-pressure will vary during the day around sleep intervals and activities blood-pressure is highest during waking hours and lowest during hours asleep

86
Q

What medications can increase blood pressure

A

Vasoconstrictors

87
Q

What medications can lower blood pressure

A

Antihypertensives, and opioid analgesics

88
Q

How does weight affect blood pressure

A

Raises it

89
Q

How does activity affect blood pressure

A

Immediately after will reduce it for several hours. Overtime will lower it

90
Q

How does smoking affect blood

A

Smoking affects vessels, producing vasoconstriction. This causes blood pressure to rise

91
Q

How do you reduce risk of skin breakdown for multiple blood pressure readings

A

Rotate measurement site

92
Q

What is a normal pulse pressure range

A

60 - 70

93
Q

What are alternative methods of measuring blood pressures

A

Lower extremity blood pressure cuff position above Popliteal
artery at mid thigh with knee flexed

94
Q

When is it not appropriate to use electronic blood pressure machine

A

Irregular heart rate, peripheral vascular obstruction,( clots) shivering, seizures, excessive tremors, inability to cooperate, blood pressure less than 90 systolic

95
Q

What are the advantages and disadvantages of patients measuring blood pressure at home

A

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

96
Q

What is more, hypertension or hypotension

A

Hypertension

97
Q

What are symptoms of hypotension

A

Pale skin, skin molting, clamminess, confusion, increased heart rate, decreased urine output

98
Q

What are risk factors of hypertension

A

Obesity smoking alcohol consumption and High salt diet

family history diabetics African-American descent

99
Q

What is postural hypotension

A

When he person develops symptoms and low blood pressure when raising to an upright position

100
Q

How do you assess for postural orthostatic hypotension

A

Take vital signs and pulse while patient is supine sitting and standing

Q1 nursing (27 decks)

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