CHAPTER 4 GEN INSPECTION/MEASUREMENT OF VITAL SIGNS Flashcards
When does general inspection begin?
the moment nurse meets patient
True or false? Assessing presence of pain is considered standard
baseline data collected for all patients and
included with assessment of vital signs.
true
body temp is regulated by the ___
hypothalamus
how does the body generate heat?
heat is gained through the processes of metabolism and exercise
how is heat lost?
radiation, convection, evaporation, conduction
What are expected temperature ranges in celsius?
35.8-37.3
True or false? 35.8-37.3 C is the body temperature at which cellular metabolism is most efficient
true
True or false? emperature during menstrual cycle increases
from 0.5° F to 1.0° F (0.3° C to 0.6° C) at
ovulation and remains elevated until menses
cease because of progesterone secretion
true
Diurnal variations of _ F to _ F occur, with the
lowest temperature in the _____ and highest in the
late _____.
1, 1.5, morning, afternoon
a patient has just ingested hot or cold liquids or was smoking. how long should we wait to take their temperature orally?
10 minutes
how is oral temperature taken?
Electronic thermometer (sheathed): under
tongue in sublingual pocket for 15 to 30
seconds
true or false? the sublingual pocket receives blood supply from carotid artery, indirectly reflecting core temperature.
true.
in which populations are oral temps most often taken?
school-aged children, confused adults
how are tympanic temperatures taken?
Probe covered with protective sheath, placed in
external ear canal in contact with all sides of canal
for 2 to 3 seconds
true or false? axillary temperature measurement is very accurate.
false. axiallary temperatures have questionable accuracy.
heart rate vs rhythm
heart rate = number of times per minute a pulsation is felt
rhythm = regularity of pulsations
If pulse rhythm is irregular, note any odd rhythm, and
count pulsations for how long?
a full minute. basically do it again
Radial artery is most frequently used to measure
heart rate because
accessible and easily
palpated
where is the radial pulse found?
radial side of forearm at wrist
where is the brachial pulse found?
groove between biceps and triceps, in bend of elbow
where is the carotid pulse found?
the medial edge of sternocleidomastoid muscle in lower third of neck
heart rate is sometimes assessed by auscultating heart, which is known as ___
apical pulse
where is the apical pulse found
located over the 5th intercostal space at the midclavicular line
true or false? men usually breathe diaphragmatically, whereas women are usually thoracic breathers
true.
why should we count respirations when patients are unaware?
to prevent them from getting nervous and changing their breathing patterns
factors that increase respiratory rate
fever, anxiety, exercise, high altitude
should breathing be loud and labored at rest?
no.
small volume of air movement in and out of lungs
shallow breathing
force of blood agaisnt arterial walls
blood pressure
reflects relationship between cardiac output and peripheral resisistance
blood pressure
____ is the force that opposes flow of blood through vessels
peripheral resistance
When arteries are narrow = peripheral resistance to blood flow
is high =
elevated blood pressure
blood pressure is dependent on ___ of blood, ___ blood ____, and ____ of vessel walls
velocity, intravascular, volume, elasticity
how is blood pressure measured?
mm Hg millimeters of mercury
maximum pressure exerted on arteries when ventricles eject blood from heart
systolic blood pressure
represents minimum amount of pressure exerted on vessels when ventricles of heart relax
diastolic blood pressure
blood pressure top and bottom numbers
top=systolic
bottom=diastolic
pulse pressure
difference between systolic and diastolic pressures. normally ranges from 30 mm Hg to 40 mm Hg
orthostatic blood pressure
series obtained when the patient is lying, sitting, and then standing
direct (invasive) blood pressure method
insertion of a small catheter into an artery that provides continuous blood pressure measurements and arterial waveforms
when is direct blood pressure used?
critical care settings where continuous monitoring is required
indirect measurement of blood pressure
most commonly used/ auscultation with sphygomomanometer and stethoscope or w/ noninvasive blood pressure monitoring
when auscultating blood pressure, listen for
korotkoff sounds
mechanism of blood pressure measurement
blood flows freely through artery until inflated cuff interrupts the flow. as it slowly deflates, nurse listens for sounds of blood pulsating through artery again.
initial sound and point at which systolic pressure is detected
first korotkoff sound.
swishing sound heard as cuff continues to deflate
second korotkoff sound
korotkoff sound w/ softer thump than the first
3rd
muffled, low pitched sound as cuff is further deflated
4th korotkoff sound
sound which determines diastolic pressure
5th korokoff sound. last beat
electronic device attached to a cuff
NIBP
incidence of hypertension is twice as high in black americans than whites. true or false?
true
men have higher blood pressures than women until when?
menopause, when women’s may become higher
blood pressure diurnal variations
pressure lower in early morning, peaks in late afternoon or early evening
device that estimates oxygen saturation of
hemoglobin in blood
pulse oximeter
where can pulse oximeters be placed?
finger, toe, earlobe, nose
by what age is adult height attained?
18-20 years old
True or false? using too small of a blood pressure cuff can cause a patient’s systolic blood pressure to increase 10 to 40 mmHg
true
How far should a rectal thermometer go?
1.25 to 2.5 centimeters
pulse strengths
0= absent +1 diminished +2 normal +3 full volume +4 full volume and bounding
why should we check carotid pulses at the base of the neck?
taking them too high up can result in pushing on the sinuses and causing patients to faint
how long should we count apical pulses?
always the full minute
how are intercostal spaces named?
for the rib directly above it
