Chapters 8-9 Flashcards
Observe a client for significant abnormalities in any of these 8 areas:
1) Skin color
2) Dress
3) Hygiene
4) Posture/ gait
5) Physical development
6) Body build
7) Age
8) Gender
Vital signs provide data that reflect status of what 4 body systems?
Cardiovascular, neurologic, peripheral vascular, respiratory
List the 4 vital signs
Temperature, pulse, respirations, blood pressure
What vital sign should you take first?
Temperature
What amplitude indicates a weak or diminished pulse?
1+
What amplitude indicates a normal pulse?
2+
What amplitude indicates a bounding pulse that can’t be obliterated?
3+
Define systolic blood pressure
Measurement of the pressure of the blood in the arteries when the ventricles are contracted
Define diastolic blood pressure
Measurement of the pressure of the blood in the arteries when the ventricles are relaxed
What is considered the “fifth vital sign”?
Pain
Normal temperature in older clients may range from ___-___
95.0 - 97.5
What 2 occurrences, second to bone loss, may result in kyphosis. in older adults?
Osteoporotic thinning, collapse of vertebrae.
Arteries of older clients may feel
Rigid, hard, bent
What qualifies for isolated systolic hypertension?
Systolic pressure over 140; diastolic pressure under 90
The respiratory rate of older patients may range from ___-___
15 - 22
T/F: Pulse pressure widens with age
True
List 4 causes of a rise in temperature
1) Strenuous exercise
2) Stress
3) Ovulation
4) Hyperthermia (resulting from viral/ bacterial infections, malignancies, trauma, various disorders)
List 5 factors affecting blood pressure
1) Cardiac output
2) Elasticity of arteries
3) Blood volume
4) Blood velocity (HR)
5) Blood viscosity (thickness)
What 4 characteristics should you consider when taking a patient’s pulse?
Rate, rhythm, amplitude/ contour, elasticity
Define acute pain
Usually associated with recent injury
Define chronic nonmalignant pain
Usually associated with specific cause or injury; described as constant and persistent (6+ months)
Define cancer pain
Often results from compression of peripheral nerves/ meninges, or from damage to these structures following surgery, chemotherapy, radiation, or tumor growth/ infiltration
What does cutaneous pain refer to?
Skin or subcutaneous
Where is visceral pain felt?
In the abdominal cavity thorax, cranium
Where is deep somatic pain found?
Ligaments, tendons, bones, blood vessels, nerves
Describe radiating pain
Perceived at both the pain source, and extending to other tissues
Describe referred pain
Perceived in body areas away from the pain source
Describe phantom pain
Perceived in nerves left by a missing, amputated, or paralyzed body part
Anxiety, sleeplessness, grimaces, decreases in cognitive function, confusion,, increased HR/ BP/ RR, decreased output/ urinary retention - these are all physiological responses to ___
Pain
List the 7 dimensions of pain
Physical, sensory, behavioral, sociocultural, cognitive, affective, spiritual (PSCABSS)
QUESTT Principles for Pain in Children - what does QUESTT stand for?
Question the child Use pain-rating scales Evaluate behavior, physiologic changes Secure parents' involvement Take cause of pain into account Take action and evaluate results
Pain source stimulates ___ which are peripheral nerve endings that transmit the sensations to the CNS
Nociceptors
List 3 types of nociceptors stimulated by different stimuli
Mechanosensitive (of A-delta fibers) Thermosensitive (of A-delta fibers) Polymodal nociceptors (of C fibers)
Mechanosensitive nociceptors are sensitive to what kind of stimulation?
Intense mechanical stimulation
Thermosensitive nociceptors are sensitive to -
Intense heat and cold
Polymodal nociceptors are sensitive to -
Noxious stimuli that is mechanical, thermal, or chemical in nature
Transduction of pain begins when?
When a mechanical, thermal, or chemical stimulus results in tissue injury or damage, stimulating nociceptors
A-delta primary afferent fibers transmit what kind of pain, where, and how fast?
A-delta fibers transmit fast pain to spinal cord within 0.1 second
What does pain stemming from A-delta fibers feel like?
Prickling, sharp, electric
What stimulates A-delta fibers?
Mechanical or thermal stimuli
C fibers transmit what kind of pain, and how fast?
C fibers transmit slow pain within 1.0 second
What does pain stemming from C-fibers feel like?
Burning, throbbing, aching; usually results in tissue damage
What stimulates C-fibers?
Mechanical, thermal, or chemical stimuli.
Define hypothermia and its causes
Definition: abnormally low body temperature
Causes: prolonged exposure to cold, hypoglycemia, hypothyroidism, starvation
Define hyperthermia and its causes
Definition: an abnormally high body temperature
Causes: viral or bacterial infections, malignancies, trauma, various disorders
Blood pressure reflects what pressure in the body?
The pressure exerted on the walls of the arteries
What does blood pressure measure?
The pressure of the blood in the arteries when the ventricles are contracted (systolic) and relaxed (diastolic)
What is the term for the difference between systolic and diastolic blood pressure?
Pulse pressure
Pulse pressure reflects the amount of blood ejected with each heartbeat - what is the term for this?
Stroke volume
