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Patient Care > Chapter 6 > Flashcards

Chapter 6 Flashcards

1
Q

What is another name for Vital Signs

A

Cardinal Signs

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2
Q

Objective noninvasive evaluation

Temperature, pulse, respiration & blood pressure

A

Vital signs

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3
Q

Heat produced and heat loss
Degree of heat of the deep tissues
Hypothalamus/Respiratory system

A

Body Temperature

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4
Q

Body temperature is controlled by a small structure in the basal region of the diencephalon of the brain called

A

Hypothalamus

or Body’s thermostat

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5
Q

What happened when the body’s metabolism increases?

A

More heat is produced

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6
Q

When a whose body temperature is elevated above normal limits is said

A

Fever

or Pyrexia

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7
Q

As body temperature increases

A

the body’s demand for oxygen increases

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8
Q

What range of body temperature w/t normal limits?

A

0.5-1 degree

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9
Q

What is an Average oral temperature?

A

98.6 F

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10
Q

Average temperature in children 3 months-3 years

A

99 F (37.2 C)-99.7 F (37.7 C)

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11
Q

Average temperature in children 5 yrs-13 yrs

A

97.8 F-98.6 F

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12
Q

Symptoms of fever

A 
Increased pulse & respiratory rate
Discomfort
Aching
Flushed dry skin
Chill
Loss of appetite
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13
Q

Average temperature in children 5 yrs-13 yrs

A

97.8 F-98.6 F

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14
Q

A person with a body temperature below normal limits

A

Hypothermia

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15
Q

It is rare for a person to survive with a body temperature b/t

A

105.8 F (41 C) & 111.2 F (44 C)

or below 93.2 F (34 C)

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16
Q

What are 4 areas of body in which temperature is usually measured?

A

Oral
Tympanic
Rectal
Axillary

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17
Q

Hyperthermia

A

Fever

Febrile

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18
Q

Temporal artery (TA) thermometers

A

Most popular today on kids

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19
Q

Most common route
Taken by mouth under the tongue
98.6 F

A

Oral

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20
Q

Equivalent to rectal & tympanic

A

Tympanic membrane thermometer

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21
Q

Most accurate area to measure is?

99.6 F

A

Rectal

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22
Q

Most safest are to measure is?

97.6 F

A

Axillary

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23
Q

Most safest are to measure is?

A

Axillary

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24
Q

Area is measuring temperature with a tympanic thermometer
Is placed inside the external auditory canal
97.6

A

Tympanic

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25
Q

As the heart beats, blood is pumped in a pulsating fashion into arteries
Results in a throb ot pulsation of the arteries

A

Pulse

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26
Q

Which location requires the use of a stethoscope?

A

Apical pulse

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27
Q

Which location provides the most accurate pulse rate?

Over the apex of the heart

A

Apical pulse

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28
Q

Which pulse can be done over the carotid artery @ the front of the neck?
Most common

A

Carotid pulse

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29
Q

Which pulse can be done over the carotid artery @ the front of the neck?

A

Carotid pulse

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30
Q

Which pulse can be done over the femoral artery in the groin?

A

Femoral pulse

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31
Q

Which pulse can be done over the carotid artery @ the front of the neck?

A

Carotid pulse

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32
Q

Which pulse can be done over the femoral artery in the groin?

A

Femoral pulse

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33
Q

Which pulse can be done @ the posterior surface of the knee?

A

Popliteal pulse

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34
Q

Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?

A

Brachial pulse

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35
Q

Which pulse can be done @ the top of the feet in line with the groove b/t the extensor tendons of the great & 2nd toe
(May be congenitally absent)

A

Dorsalis pedis pulse (pedal)

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36
Q

Which pulse can be done on the inner side of the ankles?

A

Posterior tibial pulse

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37
Q

Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?

A

Brachial pulse

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38
Q

What is child 4-10 years pulse rate?

A

90-100 BPM

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39
Q

What does BPM stand for?

A

of beats per minute

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40
Q

What is an adult pulse rate?

A

60-90 BPM

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41
Q

Tarchycardia

A

Rapid heart rate over 100 BPM

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42
Q

Bradycardia

A

Slow heart rate below 60 BPM

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43
Q

What is an athlete pulse rate?

A

45-60 BPM

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44
Q

Abnormally rapid heart rate over 100 BPM called?

A

Tarchycardia

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45
Q

Abnormally slow heart rate below 60 BPM called?

A

Bradycardia

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46
Q

Can you use your thumb to assess the pulse?

A

NO

B/c Thumb has its own pulse

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47
Q

How to count pulse rate?

A

Count for one (1) full minute or
Count for 15 seconds then multiple by 4
Count for 30 seconds X 2

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48
Q

If pulse count is irregular?

A

Take for one full minute

Take apical pulse

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49
Q

Can you use your thumb to assess the pulse?

A

NO

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50
Q

What happens if you press too hard on the artery?

A

ARTERY IS COMPRESSED or DISAPPEARRED

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51
Q

What does an odd # mean when assessing the pulse rate?

A

1 full minute

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52
Q

What is a function of the respiratory system?

A

Exchange of oxygen & carbon dioxide
Between environment & blood
Assess depth and pattern of ventilation

53
Q

Diaphragm moves downward, chest expands

A

Inspiration

54
Q

Relaxation of diaphragm, returns to normal position

A

Expiration

55
Q

Adult Respiration Rates

A

15 to 20 breaths per minute (@ book 12-20)

56
Q

Respiration rates for Child (under 10)

A

20 to 30 breaths per minute

57
Q

Respiration for Infant (newborns)

A

30 to 60 breaths per minute

58
Q

Inability to breathe

A

Apnea

59
Q

Difficult to label breathing

A

Dyspnea

60
Q

Cannot breathe when lying down

A

Orthopnea

61
Q

More 20 Breath PM

A

Tachypnea

62
Q

Below 12 Breath PM

A

Bradypnea

63
Q

Dyspnea followed by apnea

Stroke or coma patients

A

Cheyne-Stokes

64
Q

Fewer than 10 breaths per minute

Results in cyanosis, apprehension, restlessness, blue color, change in LOC

A

Head trauma

65
Q

What is LOC?

A

level of consciousness

66
Q

Head trauma patients

A

May or may not response

67
Q

What makes one respiration?

A 
Breathe in and out for 1 min)
Count for 30 seconds X 2
Even rise and fall of chest
Abdomen breather
Alter breathing pattern (not pattern b/c pt look @ you)
68
Q

The rate of respiration to heartbeat is

A

1:4

69
Q

What is Blood Pressure?

A

Measure of force exerted by blood on the arterial walls during contraction & relaxation of the heart
Flow times resistance

70
Q

Sphygmomanometer includes

A 
Blood pressure cuff (Mercury/Aneroid)
Inflatable bladder within cuff
Pressure manometer
Thumbscrew valve (Maintain or release pressure)
Pressure bulb (Inflates bladder)
Rubber tubing
71
Q

Did you know….

A

Usually lower in am
Increases after large meal
Emotions/strenuous activity – systolic increases
Men higher than women/infants higher than adults/adolescents is lowest

72
Q

What equipment used to measure blood pressure?

A

Sphygmomanometer

73
Q

Sphygmomanometer includes

A 
Blood pressure cuff
Mercury/Aneroid
Inflatable bladder within cuff
Pressure manometer
Thumbscrew valve
Maintain or release pressure
Pressure bulb
Inflates bladder
Rubber tubing
74
Q

Which equipment is More accurate

Less convenient to use

A

Mercury manometer

75
Q

Which equipment is Needle should point to zero prior to inflating?

A

Aneroid manometer

76
Q

BP cuff should be

A

Selected according to patient size

77
Q

Too large or small BP cuff can result in

A

Incorrect reading

78
Q

What is 1st # is 120 mm Hg (highest #)

Peak pressure during contraction of the left ventricle as it pumps blood into the aorta

A

Systolic pressure

79
Q

What is 2nd # is 80 mm Hg (lowest #)

Pressure inside the artery during relaxation of the ventricles – minimal pressure exerted against arterial wall

A

Diastolic pressure

80
Q

Saints over Devils

A

Systolic over Diastolic

81
Q

Normal ranges of systolic pressure

A

90 to 120 mm Hg

Less than 120 mm Hg

82
Q

Normal ranges for diastolic pressure

A

50 to 70 mm Hg

Less than 80 mmHg

83
Q

higher: BP 140 over 90

A

Hypertensive

84
Q

lower: BP 90 over 65

A

Hypotensive

85
Q

How to Measure Blood pressure

A

Taken @ the brachial artery
Cuff is positioned around the arm @ 1” above anticubital space
Steadily inflate cuff with dominate hand until pulsations can no longer be palpated @ radial artery (approximate systolic pressure)
Release cuff and place earpieces into ears
Tighten thumbscrew and reinflate until gauge reaches 30 mmHg above appropriate systolic pressure
Slowly loosen gauge to drop 2 to 4 mmHg/sec
Note systolic and diastolic pressure reading

86
Q

Extraneous sounds
Tapping, knocking or swishing
Turbulent sound of blood flow through arteries

A

Korotkoff sounds

87
Q

Brain cannot function for

A

Not longer than 4- 6 minutes without oxygen

88
Q

What is an oxygen?

A

Toxic & supports combustion

oxygen is Drug

89
Q

Oxygen Prescribed by

A

physician

Determines amount and type of delivery device

90
Q

How to measure Oxygen?

A

Measured in LPM (liters per minute)

Ordered in LPM or concentration

91
Q

Oxygen Precautions

A

Never completely remove oxygen device from patient while in your care
Transfer patient using a portable oxygen tank
Transfer to wall unit once in room
Turn off portable unit
Keep same amount of oxygen level – do not adjust

92
Q

Decreased oxygen concentration in the blood

A

Hypoxemia

93
Q

Reduction of oxygen supply to tissue

A

Hypoxia

94
Q

Which Tissue is Most sensitive

A

Brain, heart, lungs & liver

95
Q

Carbon dioxide is retained in the arterial blood

A

Hypercapnia

96
Q

Brain cannot function for

A

Not longer than 4- 6 minutes without oxygen

97
Q

What is an oxygen?

A

Toxic & supports combustion

oxygen is Drug

98
Q

Oxygen Prescribed by

A

physician

Determines amount and type of delivery device

99
Q

How to measure Oxygen?

A

Measured in LPM (liters per minute)

Ordered in LPM or concentration

100
Q

Oxygen Precautions

A

Never completely remove oxygen device from patient while in your care
Transfer patient using a portable oxygen tank
Transfer to wall unit once in room
Turn off portable unit
Keep same amount of oxygen level – do not adjust

101
Q

Decreased oxygen concentration in the blood

A

Hypoxemia

102
Q

Reduction of oxygen supply to tissue

A

Hypoxia

103
Q

Which Tissue is Most sensitive

A

Brain, heart, lungs & liver

104
Q

Carbon dioxide is retained in the arterial blood

A

Hypercapnia

105
Q

Storage tank

A

In an upright crate or lay tank down for storage & transport – never leave upright without securing

106
Q

2 Regular valves

A

Pressure manometer & Flowmeter

107
Q

pressure or volume of oxygen (how much oxygen or BP)

A

Pressure manometer

108
Q

Rate of flow (LPM)

green color

A

Flowmeter

109
Q

A device used to monitor the oxygen saturation of hemoglobin

A

Pulse Oximetry

110
Q

Pulse Oximetry

A

Fast, noninvasive method of monitoring sudden changes

Sensor is attached to a fingertip or earlobe

111
Q

Advantages of Non-rebreathing mask

A

Keeps exhaled air from bag & prevents rebreathing

Bag fills with oxygen to supply constant oxygen

112
Q

8 Types of Oxygen Devices

A
  1. Nasal cannula
  2. Face Masks
  3. Simple Mask
  4. Non-rebreathing mask
  5. Partial rebreathing mask
  6. Venturi or air-entrainment mask
  7. Aerosol mask
  8. Oxygen Tent
113
Q

Most common seen
Disposable plastic device with 2 hollow prongs that deliver oxygen into the nostrils
Receives oxygen & room air
1 – 4 LPM
Higher levels tend to dry the nasal mucosa
Oxygen flowing through tube prior to placing on patient

A

Nasal Cannula

114
Q

Simple
Non-rebreathing (1 way valve)/Partial rebreathing (not have )
Aerosol
Venturi (aerosol mask)

A

Face masks

115
Q

Covers nose & mouth

Low flow device

A

Simple masks

116
Q

Simple mask is used for

A

Short term therapy

117
Q

Disadvantages of Simple Face Mask

A

Uncomfortable
Unable to eat, drink or talk with it in place
(pt don’t like it/likeNasal cannula better)

118
Q

Flow rates of Simple Masks

A

Flow rates greater than 5LPM to flush CO2 from mask

Concentration of 30 -50% (depends on pt/how much air they taking in)

119
Q

May supply 100% concentration of Oxygen

Reservoir bag attach to it/(opening bag has valve)One-way valve (make sure bag stay and place it)

A

Non-rebreathing mask

120
Q

Advantages of Non-rebreathing mask

A

Keeps exhaled air from bag & prevents rebreathing

Bag fills with oxygen to supply constant oxygen

121
Q

No valve

Delivers 60 -90% oxygen

A

Partial rebreathing mask

122
Q

Provides consistent concentration of oxygen regardless of patient’s respiratory pattern
Oxygen & entrained room air
Oxygen concentration at 24 – 50%

A

Venturi or air-entrainment mask

123
Q

Mask attached to nebulizer (generates a mist) filled saline or sterile water

A

Aerosol mask

124
Q

Functions of Aerosol mask

A

Provide medication (fine mist that is inhaled)
Provides precise oxygen concentration
60-80% oxygen mixed with water
Flow rate of a minimum of 6 – 8 LPM

125
Q

Pediatric or NICU patients
Oxygen therapy & additional humidity
Fire hazard

A

Oxygen Tent

126
Q

Artificial airway into trachea

Delivers a set respiratory rate, preset inspiratory volume & Fi02 (concentration)

A

Ventilators

127
Q

Purpose of Ventilators

A

CXR – proper placement of tube

Observe rise & fall of chest

128
Q

Inform nurse

A

Inform nurse before positioning patient
Use caution when moving patient & tubing
Alarms – do not silence or alter (in any way)

Patient Care (19 decks)

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