Chapter 6 Flashcards
1
Q
What is another name for Vital Signs
A
Cardinal Signs
2
Q
Objective noninvasive evaluation
Temperature, pulse, respiration & blood pressure
A
Vital signs
3
Q
Heat produced and heat loss
Degree of heat of the deep tissues
Hypothalamus/Respiratory system
A
Body Temperature
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
5
Q
What happened when the body’s metabolism increases?
A
More heat is produced
6
Q
When a whose body temperature is elevated above normal limits is said
A
Fever
or Pyrexia
7
Q
As body temperature increases
A
the body’s demand for oxygen increases
8
Q
What range of body temperature w/t normal limits?
A
0.5-1 degree
9
Q
What is an Average oral temperature?
A
98.6 F
10
Q
Average temperature in children 3 months-3 years
A
99 F (37.2 C)-99.7 F (37.7 C)
11
Q
Average temperature in children 5 yrs-13 yrs
A
97.8 F-98.6 F
12
Q
Symptoms of fever
A
Increased pulse & respiratory rate Discomfort Aching Flushed dry skin Chill Loss of appetite
13
Q
Average temperature in children 5 yrs-13 yrs
A
97.8 F-98.6 F
14
Q
A person with a body temperature below normal limits
A
Hypothermia
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)
16
Q
What are 4 areas of body in which temperature is usually measured?
A
Oral
Tympanic
Rectal
Axillary
17
Q
Hyperthermia
A
Fever
Febrile
18
Q
Temporal artery (TA) thermometers
A
Most popular today on kids
19
Q
Most common route
Taken by mouth under the tongue
98.6 F
A
Oral
20
Q
Equivalent to rectal & tympanic
A
Tympanic membrane thermometer
21
Q
Most accurate area to measure is?
99.6 F
A
Rectal
22
Q
Most safest are to measure is?
97.6 F
A
Axillary
23
Q
Most safest are to measure is?
A
Axillary
24
Q
Area is measuring temperature with a tympanic thermometer
Is placed inside the external auditory canal
97.6
A
Tympanic
25
As the heart beats, blood is pumped in a pulsating fashion into arteries
Results in a throb ot pulsation of the arteries
Pulse
26
Which location requires the use of a stethoscope?
Apical pulse
27
Which location provides the most accurate pulse rate?
| Over the apex of the heart
Apical pulse
28
Which pulse can be done over the carotid artery @ the front of the neck?
Most common
Carotid pulse
29
Which pulse can be done over the carotid artery @ the front of the neck?
Carotid pulse
30
Which pulse can be done over the femoral artery in the groin?
Femoral pulse
31
Which pulse can be done over the carotid artery @ the front of the neck?
Carotid pulse
32
Which pulse can be done over the femoral artery in the groin?
Femoral pulse
33
Which pulse can be done @ the posterior surface of the knee?
Popliteal pulse
34
Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?
Brachial pulse
35
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)
Dorsalis pedis pulse (pedal)
36
Which pulse can be done on the inner side of the ankles?
Posterior tibial pulse
37
Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?
Brachial pulse
38
What is child 4-10 years pulse rate?
90-100 BPM
39
What does BPM stand for?
of beats per minute
40
What is an adult pulse rate?
60-90 BPM
41
Tarchycardia
Rapid heart rate over 100 BPM
42
Bradycardia
Slow heart rate below 60 BPM
43
What is an athlete pulse rate?
45-60 BPM
44
Abnormally rapid heart rate over 100 BPM called?
Tarchycardia
45
Abnormally slow heart rate below 60 BPM called?
Bradycardia
46
Can you use your thumb to assess the pulse?
NO
| B/c Thumb has its own pulse
47
How to count pulse rate?
Count for one (1) full minute or
Count for 15 seconds then multiple by 4
Count for 30 seconds X 2
48
If pulse count is irregular?
Take for one full minute
| Take apical pulse
49
Can you use your thumb to assess the pulse?
NO
50
What happens if you press too hard on the artery?
ARTERY IS COMPRESSED or DISAPPEARRED
51
What does an odd # mean when assessing the pulse rate?
1 full minute
52
What is a function of the respiratory system?
Exchange of oxygen & carbon dioxide
Between environment & blood
Assess depth and pattern of ventilation
53
Diaphragm moves downward, chest expands
Inspiration
54
Relaxation of diaphragm, returns to normal position
Expiration
55
Adult Respiration Rates
15 to 20 breaths per minute (@ book 12-20)
56
Respiration rates for Child (under 10)
20 to 30 breaths per minute
57
Respiration for Infant (newborns)
30 to 60 breaths per minute
58
Inability to breathe
Apnea
59
Difficult to label breathing
Dyspnea
60
Cannot breathe when lying down
Orthopnea
61
More 20 Breath PM
Tachypnea
62
Below 12 Breath PM
Bradypnea
63
Dyspnea followed by apnea
| Stroke or coma patients
Cheyne-Stokes
64
Fewer than 10 breaths per minute
| Results in cyanosis, apprehension, restlessness, blue color, change in LOC
Head trauma
65
What is LOC?
level of consciousness
66
Head trauma patients
May or may not response
67
What makes one respiration?
```
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
The rate of respiration to heartbeat is
1:4
69
What is Blood Pressure?
Measure of force exerted by blood on the arterial walls during contraction & relaxation of the heart
Flow times resistance
70
Sphygmomanometer includes
```
Blood pressure cuff (Mercury/Aneroid)
Inflatable bladder within cuff
Pressure manometer
Thumbscrew valve (Maintain or release pressure)
Pressure bulb (Inflates bladder)
Rubber tubing
```
71
Did you know….
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
What equipment used to measure blood pressure?
Sphygmomanometer
73
Sphygmomanometer includes
```
Blood pressure cuff
Mercury/Aneroid
Inflatable bladder within cuff
Pressure manometer
Thumbscrew valve
Maintain or release pressure
Pressure bulb
Inflates bladder
Rubber tubing
```
74
Which equipment is More accurate
| Less convenient to use
Mercury manometer
75
Which equipment is Needle should point to zero prior to inflating?
Aneroid manometer
76
BP cuff should be
Selected according to patient size
77
Too large or small BP cuff can result in
Incorrect reading
78
What is 1st # is 120 mm Hg (highest #)
| Peak pressure during contraction of the left ventricle as it pumps blood into the aorta
Systolic pressure
79
What is 2nd # is 80 mm Hg (lowest #)
| Pressure inside the artery during relaxation of the ventricles – minimal pressure exerted against arterial wall
Diastolic pressure
80
Saints over Devils
Systolic over Diastolic
81
Normal ranges of systolic pressure
90 to 120 mm Hg
| Less than 120 mm Hg
82
Normal ranges for diastolic pressure
50 to 70 mm Hg
| Less than 80 mmHg
83
higher: BP 140 over 90
Hypertensive
84
lower: BP 90 over 65
Hypotensive
85
How to Measure Blood pressure
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
Extraneous sounds
Tapping, knocking or swishing
Turbulent sound of blood flow through arteries
Korotkoff sounds
87
Brain cannot function for
Not longer than 4- 6 minutes without oxygen
88
What is an oxygen?
Toxic & supports combustion
| oxygen is Drug
89
Oxygen Prescribed by
physician
| Determines amount and type of delivery device
90
How to measure Oxygen?
Measured in LPM (liters per minute)
| Ordered in LPM or concentration
91
Oxygen Precautions
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
Decreased oxygen concentration in the blood
Hypoxemia
93
Reduction of oxygen supply to tissue
Hypoxia
94
Which Tissue is Most sensitive
Brain, heart, lungs & liver
95
Carbon dioxide is retained in the arterial blood
Hypercapnia
96
Brain cannot function for
Not longer than 4- 6 minutes without oxygen
97
What is an oxygen?
Toxic & supports combustion
| oxygen is Drug
98
Oxygen Prescribed by
physician
| Determines amount and type of delivery device
99
How to measure Oxygen?
Measured in LPM (liters per minute)
| Ordered in LPM or concentration
100
Oxygen Precautions
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
Decreased oxygen concentration in the blood
Hypoxemia
102
Reduction of oxygen supply to tissue
Hypoxia
103
Which Tissue is Most sensitive
Brain, heart, lungs & liver
104
Carbon dioxide is retained in the arterial blood
Hypercapnia
105
Storage tank
In an upright crate or lay tank down for storage & transport – never leave upright without securing
106
2 Regular valves
Pressure manometer & Flowmeter
107
pressure or volume of oxygen (how much oxygen or BP)
Pressure manometer
108
Rate of flow (LPM)
| green color
Flowmeter
109
A device used to monitor the oxygen saturation of hemoglobin
Pulse Oximetry
110
Pulse Oximetry
Fast, noninvasive method of monitoring sudden changes
| Sensor is attached to a fingertip or earlobe
111
Advantages of Non-rebreathing mask
Keeps exhaled air from bag & prevents rebreathing
| Bag fills with oxygen to supply constant oxygen
112
8 Types of Oxygen Devices
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
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
Nasal Cannula
114
Simple
Non-rebreathing (1 way valve)/Partial rebreathing (not have )
Aerosol
Venturi (aerosol mask)
Face masks
115
Covers nose & mouth
| Low flow device
Simple masks
116
Simple mask is used for
Short term therapy
117
Disadvantages of Simple Face Mask
Uncomfortable
Unable to eat, drink or talk with it in place
(pt don’t like it/likeNasal cannula better)
118
Flow rates of Simple Masks
Flow rates greater than 5LPM to flush CO2 from mask
| Concentration of 30 -50% (depends on pt/how much air they taking in)
119
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)
Non-rebreathing mask
120
Advantages of Non-rebreathing mask
Keeps exhaled air from bag & prevents rebreathing
| Bag fills with oxygen to supply constant oxygen
121
No valve
| Delivers 60 -90% oxygen
Partial rebreathing mask
122
Provides consistent concentration of oxygen regardless of patient’s respiratory pattern
Oxygen & entrained room air
Oxygen concentration at 24 – 50%
Venturi or air-entrainment mask
123
Mask attached to nebulizer (generates a mist) filled saline or sterile water
Aerosol mask
124
Functions of Aerosol mask
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
Pediatric or NICU patients
Oxygen therapy & additional humidity
Fire hazard
Oxygen Tent
126
Artificial airway into trachea
| Delivers a set respiratory rate, preset inspiratory volume & Fi02 (concentration)
Ventilators
127
Purpose of Ventilators
CXR – proper placement of tube
| Observe rise & fall of chest
128
Inform nurse
Inform nurse before positioning patient
Use caution when moving patient & tubing
Alarms – do not silence or alter (in any way)
