Chapter 6 Flashcards
What is another name for Vital Signs
Cardinal Signs
Objective noninvasive evaluation
Temperature, pulse, respiration & blood pressure
Vital signs
Heat produced and heat loss
Degree of heat of the deep tissues
Hypothalamus/Respiratory system
Body Temperature
Body temperature is controlled by a small structure in the basal region of the diencephalon of the brain called
Hypothalamus
or Body’s thermostat
What happened when the body’s metabolism increases?
More heat is produced
When a whose body temperature is elevated above normal limits is said
Fever
or Pyrexia
As body temperature increases
the body’s demand for oxygen increases
What range of body temperature w/t normal limits?
0.5-1 degree
What is an Average oral temperature?
98.6 F
Average temperature in children 3 months-3 years
99 F (37.2 C)-99.7 F (37.7 C)
Average temperature in children 5 yrs-13 yrs
97.8 F-98.6 F
Symptoms of fever
Increased pulse & respiratory rate Discomfort Aching Flushed dry skin Chill Loss of appetite
Average temperature in children 5 yrs-13 yrs
97.8 F-98.6 F
A person with a body temperature below normal limits
Hypothermia
It is rare for a person to survive with a body temperature b/t
105.8 F (41 C) & 111.2 F (44 C)
or below 93.2 F (34 C)
What are 4 areas of body in which temperature is usually measured?
Oral
Tympanic
Rectal
Axillary
Hyperthermia
Fever
Febrile
Temporal artery (TA) thermometers
Most popular today on kids
Most common route
Taken by mouth under the tongue
98.6 F
Oral
Equivalent to rectal & tympanic
Tympanic membrane thermometer
Most accurate area to measure is?
99.6 F
Rectal
Most safest are to measure is?
97.6 F
Axillary
Most safest are to measure is?
Axillary
Area is measuring temperature with a tympanic thermometer
Is placed inside the external auditory canal
97.6
Tympanic
As the heart beats, blood is pumped in a pulsating fashion into arteries
Results in a throb ot pulsation of the arteries
Pulse
Which location requires the use of a stethoscope?
Apical pulse
Which location provides the most accurate pulse rate?
Over the apex of the heart
Apical pulse
Which pulse can be done over the carotid artery @ the front of the neck?
Most common
Carotid pulse
Which pulse can be done over the carotid artery @ the front of the neck?
Carotid pulse
Which pulse can be done over the femoral artery in the groin?
Femoral pulse
Which pulse can be done over the carotid artery @ the front of the neck?
Carotid pulse
Which pulse can be done over the femoral artery in the groin?
Femoral pulse
Which pulse can be done @ the posterior surface of the knee?
Popliteal pulse
Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?
Brachial pulse
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)
Which pulse can be done on the inner side of the ankles?
Posterior tibial pulse
Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?
Brachial pulse
What is child 4-10 years pulse rate?
90-100 BPM
What does BPM stand for?
of beats per minute
What is an adult pulse rate?
60-90 BPM
Tarchycardia
Rapid heart rate over 100 BPM
Bradycardia
Slow heart rate below 60 BPM
What is an athlete pulse rate?
45-60 BPM
Abnormally rapid heart rate over 100 BPM called?
Tarchycardia
Abnormally slow heart rate below 60 BPM called?
Bradycardia
Can you use your thumb to assess the pulse?
NO
B/c Thumb has its own pulse
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
If pulse count is irregular?
Take for one full minute
Take apical pulse
Can you use your thumb to assess the pulse?
NO
What happens if you press too hard on the artery?
ARTERY IS COMPRESSED or DISAPPEARRED
What does an odd # mean when assessing the pulse rate?
1 full minute
What is a function of the respiratory system?
Exchange of oxygen & carbon dioxide
Between environment & blood
Assess depth and pattern of ventilation
Diaphragm moves downward, chest expands
Inspiration
Relaxation of diaphragm, returns to normal position
Expiration
Adult Respiration Rates
15 to 20 breaths per minute (@ book 12-20)
Respiration rates for Child (under 10)
20 to 30 breaths per minute
Respiration for Infant (newborns)
30 to 60 breaths per minute
Inability to breathe
Apnea
Difficult to label breathing
Dyspnea
Cannot breathe when lying down
Orthopnea
More 20 Breath PM
Tachypnea
Below 12 Breath PM
Bradypnea
Dyspnea followed by apnea
Stroke or coma patients
Cheyne-Stokes
Fewer than 10 breaths per minute
Results in cyanosis, apprehension, restlessness, blue color, change in LOC
Head trauma
What is LOC?
level of consciousness
Head trauma patients
May or may not response
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)
The rate of respiration to heartbeat is
1:4
What is Blood Pressure?
Measure of force exerted by blood on the arterial walls during contraction & relaxation of the heart
Flow times resistance
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
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
What equipment used to measure blood pressure?
Sphygmomanometer
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
Which equipment is More accurate
Less convenient to use
Mercury manometer
Which equipment is Needle should point to zero prior to inflating?
Aneroid manometer
BP cuff should be
Selected according to patient size
Too large or small BP cuff can result in
Incorrect reading
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
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
Saints over Devils
Systolic over Diastolic
Normal ranges of systolic pressure
90 to 120 mm Hg
Less than 120 mm Hg
Normal ranges for diastolic pressure
50 to 70 mm Hg
Less than 80 mmHg
higher: BP 140 over 90
Hypertensive
lower: BP 90 over 65
Hypotensive
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
Extraneous sounds
Tapping, knocking or swishing
Turbulent sound of blood flow through arteries
Korotkoff sounds
Brain cannot function for
Not longer than 4- 6 minutes without oxygen
What is an oxygen?
Toxic & supports combustion
oxygen is Drug
Oxygen Prescribed by
physician
Determines amount and type of delivery device
How to measure Oxygen?
Measured in LPM (liters per minute)
Ordered in LPM or concentration
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
Decreased oxygen concentration in the blood
Hypoxemia
Reduction of oxygen supply to tissue
Hypoxia
Which Tissue is Most sensitive
Brain, heart, lungs & liver
Carbon dioxide is retained in the arterial blood
Hypercapnia
Brain cannot function for
Not longer than 4- 6 minutes without oxygen
What is an oxygen?
Toxic & supports combustion
oxygen is Drug
Oxygen Prescribed by
physician
Determines amount and type of delivery device
How to measure Oxygen?
Measured in LPM (liters per minute)
Ordered in LPM or concentration
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
Decreased oxygen concentration in the blood
Hypoxemia
Reduction of oxygen supply to tissue
Hypoxia
Which Tissue is Most sensitive
Brain, heart, lungs & liver
Carbon dioxide is retained in the arterial blood
Hypercapnia
Storage tank
In an upright crate or lay tank down for storage & transport – never leave upright without securing
2 Regular valves
Pressure manometer & Flowmeter
pressure or volume of oxygen (how much oxygen or BP)
Pressure manometer
Rate of flow (LPM)
green color
Flowmeter
A device used to monitor the oxygen saturation of hemoglobin
Pulse Oximetry
Pulse Oximetry
Fast, noninvasive method of monitoring sudden changes
Sensor is attached to a fingertip or earlobe
Advantages of Non-rebreathing mask
Keeps exhaled air from bag & prevents rebreathing
Bag fills with oxygen to supply constant oxygen
8 Types of Oxygen Devices
- Nasal cannula
- Face Masks
- Simple Mask
- Non-rebreathing mask
- Partial rebreathing mask
- Venturi or air-entrainment mask
- Aerosol mask
- Oxygen Tent
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
Simple
Non-rebreathing (1 way valve)/Partial rebreathing (not have )
Aerosol
Venturi (aerosol mask)
Face masks
Covers nose & mouth
Low flow device
Simple masks
Simple mask is used for
Short term therapy
Disadvantages of Simple Face Mask
Uncomfortable
Unable to eat, drink or talk with it in place
(pt don’t like it/likeNasal cannula better)
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)
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
Advantages of Non-rebreathing mask
Keeps exhaled air from bag & prevents rebreathing
Bag fills with oxygen to supply constant oxygen
No valve
Delivers 60 -90% oxygen
Partial rebreathing mask
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
Mask attached to nebulizer (generates a mist) filled saline or sterile water
Aerosol mask
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
Pediatric or NICU patients
Oxygen therapy & additional humidity
Fire hazard
Oxygen Tent
Artificial airway into trachea
Delivers a set respiratory rate, preset inspiratory volume & Fi02 (concentration)
Ventilators
Purpose of Ventilators
CXR – proper placement of tube
Observe rise & fall of chest
Inform nurse
Inform nurse before positioning patient
Use caution when moving patient & tubing
Alarms – do not silence or alter (in any way)
