Chapter 7 * Flashcards
what are the pulse location on the body cephalocaudal order
temporal artery, common carotid artery, apical, brachial artery, radial artery, femoral artery, popliteal artery, posterior tibial artery, dorsalis pedis
What is tachycardia
heart rate of 100 or more.
Is tachycardia an indicator for respirations?
No, it is an indicator for pulse
What is bradycardia
heart rate below 60
Is bradycardia an indicator for pulse or heart function
Yes, pulse is a indicator of heart function.
Dyspnea
difficulty breathing
Tachypnea
rapid rate of respirations more than 20 breaths per minute
bradypnea
less than 12 breathes per minute
Hypoventilation
shallow, slow breathing, which can be related to sedation
Hyperventilation
deep, rapid breathing usually from hypoxia, anxiety, or exercise
Orthopnea:
difficulty breathing unless sitting or standing
Cheyne-stokes:
rhythmic waxing and waning of respirations
Apnea:
cessation of breathing
Biot’s respirations:
shallow breathing with periods of apnea
Kussmaul’s breathing:
deep and rapid breaths
normal range for pulse ox is
95-100%
anemia is (in regarding pulse ox) ?
A lack of oxygen circulating in the blood with a pulse ox reading of 90% or below
Oral tempature
The oral temperature is the most accessible, convenient, and accurate method. Oral temperatures are obtained by using an electronic or digital probe device in a hospital setting. Glass mercury thermometers are no longer used in the clinical setting.
Rectal tempature
A rectal temperature is obtained if the client is comatose, confused, having seizures, or is unable to close his or her mouth.
Axillary tempature
This is the safest method as it is less invasive compared to the oral or rectal route. This route is also considered the least accurate due to the variety of possible probe positions.
Tympanic tempature
The tympanic temperature is taken with an electronic thermometer using an infrared probe. Placing the probe in the client’s ear gives a core temperature quickly and accurately.
Temporal Artery tempature
The temporal thermometer is noninvasive and scans over the forehead across the temporal artery. This convenient method displays the temperature within seconds.
Hypothermia
most common body response to prolonged exposure to cold.
Blood pressure sounds (also called Korotkoff sounds) change over the duration of the blood pressure monitoring procedure. The five phases are described as follows
- Initial sounds are faint with a clear tapping quality.
- Distinctive swishing sounds are heard.
- Similar tapping sounds as Phase 1 yet with greater intensity.
- Muffled sounds ensue.
- The sounds disappear.
hyperthermia
Fever corresponding to viral or bacterial infection. usually from tissue breakdown following myocardial infarction, malignancy, surgery or trauma.
what are the factors that influence body temperature?
age, diurnal variations, exercise, hormones, stress, illness.
vital signs
temperature, pulse, respiratory rate, blood pressure, and pain.
how is oxygen saturation measured?
pulse oximeter
what are the 4 factors that considered when assessing the pulse?
rate, rhythm, force, elasticity.
what are the circulatory factors that influence Blood Pressure?
Cardiac output-amount of blood ejected by the heart
Blood Volume-total amount of blood circulating within the entire vascular system
Peripheral vascular resistance- resistance the blood encounters as it flows within the vessels.
Blood viscosity-the ratio between the blood cells and the blood plasma
Vessel Compliance-the elasticity of the smooth muscle in the arterial walls.
O L D C A R T & I C E
O- Onset L-Location D-Duration C-Characteristics A-Aggravating factors R-Relieving Factors T-Treatment & I-Impact on ADL's C-Coping strategies E-Emotional Response
Functional Assessment
is an observation to gather data while the client is performing common or routine activities.
what are the four major categories observed during General survey?
physical appearance-provides immediate cues to the level of individual wellness. (undernourished, skin color, gestures)
mental status- orientated to time place and person.
mobility- range of motion posture and gait.
behavior- dress and grooming, body odors, facial expression, mood and ability to make eye contact as well as level of anxiety.
Systolic pressure
the pressure of blood at the height of the wave when the left ventricle contracts. (first number in blood pressure)
Diastolic pressure
the pressure between the ventricular contractions when the heart is at rest. (second number in blood pressure)
what behaviors indicate a client is in pain?
facial grimacing, moaning, crying or screaming, guarding, or immobilization of body part, tossing or turning and rhythmic movements.
pain’s physiologic response
Sympathetic response is demonstrated in elevation of blood pressure, pulse and respiratory rates, pallor, and diaphoresis.
Parasympathetic stimulation often accompanies visceral pain. resulting in lowered blood pressure and pulse rate and warm dry skin.
Regulates temperature in the body
Hypothalamus
Stroke volume
the amount of blood pumped from the heart with each heartbeat
Compliance
the ability of the arteries to contract and expand
How does position changes affect the pulse rate?
when sitting or standing for long periods, blood may pool in the veins, resulting in a temporary decrease in venous blood return to the heart and consequently, reduce blood pressure and lowered pulse rate.
how would a fever affect pulse rate?
pulse rate increases. ( the peripheral vasodilation that accompanies an elevated body temperature lowers systemic blood pressure)
Age related considerations while assessing height and weight
infants- should be placed on an examining table on a supine position. with a ruler, headboard and adjustable footboard. infants are weighed on a modified platform scale with curved sides to prevent injury.
children 2 or 3- may be weighed on the upright scale or seated on the infant scale. to assess height the nurse uses the platform scales or a measuring stick attached to the wall.
Adult- weight platform scale. height measuring stick.
older adults-height declines with age, because the thinning or compression of the intervertebral disks and a general flexion of the hips and knees. weight may decrease because of muscle shrinkage.
