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NURS105 > Chapter 31 > Flashcards

Chapter 31 Flashcards

Measurements

1
Q

afebrile

A

without a fever

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2
Q

blood pressure (BP)

A

amount of force exerted against artery walls

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3
Q

body temperature

A

amount of heat in body; balanced between heat produced and amount lost

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4
Q

bradycardia

A

slow heart rate; less than 60bpm

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5
Q

diastolic pressure

A

pressure in arteries when hearts at rest

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6
Q

febrile

A

with fever

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7
Q

fever

A

elevated body temperature; over 100°

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8
Q

hypertension

A

high BP

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9
Q

hypotension

A

low BP

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10
Q

pulse

A

beat of heart felt as blood passes through artery

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11
Q

pulse rate

A

number of heartbeats per min (BPM)

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12
Q

respiration

A

inhaling and exhaling

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13
Q

stethoscope

A

instrument used to listen to sounds produced by heart, lungs, etc.

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14
Q

systolic pressure

A

pressure in arteries when heart contracts

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15
Q

tachycardia

A

fast heart rate; more than 100bpm

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16
Q

thermometer

A

deice used to measure temperature

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17
Q

vital signs

A

temp, pulse, respiration, BP (pulse oximeter / pain in SOME agencies)

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18
Q

TPR

A

temperature, pulse, respiration

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19
Q

report vital signs to nurse when ?

A
  • changes from prior measurement
  • abnormal vital signs; out of normal range
20
Q

how to take vital signs from person with dementia ?

A

2 staff; one to take vitals, other to distract

21
Q

temperature sites

A
  • oral
  • tympanic (ear)
  • axillary (armpit)
  • temporal
  • rectal
22
Q

temperature sites for persons who are confused / resist care ?

A

tympanic / temporal

23
Q

rectal sites are dangerous for what kind of persons ?

A

those with heart disease; thermometer stimulates the vagus nerve, slowing heart to low levels

24
Q

least reliable temperature site ?

A

axillary

25
Q

baseline oral temp

A

98.6°F

26
Q

baseline rectal temp

A

99.6°F

27
Q

baseline axillary temp

A

97.6°F

28
Q

baseline tympanic temp

A

98.6°F

29
Q

baseline temporal temp

A

99.6°F

30
Q

nurse and care plan tell you what about taking a persons temp ?

A
  • when to take temp
  • what site to use
  • what thermometer to use
31
Q

proper use of a glass thermometer

A
  • hold by stem
  • shake down by snapping thermometer down, until mercury line is below lowest number
  • after use, read at eye level
32
Q

properly taking rectal temp

A
  • side-lying person
  • lift up upper butt-cheek
  • insert thermometer 1/2in
33
Q

pulse sites (9)

A
  • apical (2-3in left of heart)
  • temporal
  • carotid (neck)
  • brachial
  • radial
  • femoral
  • popliteal (back knee)
  • posterior tibial (ankle)
  • pedal (top foot)
34
Q

apical pulse taken when person has ?

A
  • heart disease
  • irregular heart rhythms
  • taking drugs affecting the heart
35
Q

count respiration when ?

A

do NOT tell person; will change respiration rate
- after taking pulse
- person is at rest

36
Q

regular respiration measurements ?

A
  • 12-20 respirations per min
  • quiet, effortless, regular on both sides
37
Q

systole

A

heart contraction

38
Q

diastole

A

heart rest

39
Q

normal BP

A

90-120 / 60-80 mm HG (systolic / diastolic)
report anything outside this range

40
Q

what arms do you not take BP on ?

A
  • IVs
  • cast
  • dialysis access site
  • side of breast surgery
  • injured
41
Q

how to take BP ?

A
  • let person rest 10-20 min before
  • person sitting / lying down
  • arm at heart position, resting
  • hands up
42
Q

what do you do if unable to take BP ?

A

wait 30-60 sec; if not, ask nurse

43
Q

pulse oximetry

A

blood oxygen level; taken with other vitals

44
Q

pain

A

warning sign from the body; signals tissue damage

45
Q

measuring weight / height

A
  • measured upon admission
  • measured daily (daily, weekly, monthly, depends)
  • in sleepwear / gown only
  • voided (after going to bathroom)
  • at same time of day before eating
  • same scale

NURS105 (43 decks)

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