II - Taking Vital Signs Part 2 Flashcards
It is the act of breathing. This involves external and internal types.
Respiration
____ respiration refers to the interchange of oxygen and carbon dioxide between the alveoli of the lungs and pulmonary blood.
External
____ respiration takes place throughout the body; it is the interchange of these same gases between the circulating blood and the cells of the body tissues.
Internal
Factors that may increase the respiratory rate:
- Exercise
- Stress
- Fever or increased environmental temperature
- Lowered O2 concentration at increased altitude
At high altitudes, there is less oxygen in the air. Meaning there is a relative shortage of oxygen or ___.
hypoxic
Factors that may decrease the respiratory rate:
- Decreased environmental temperature
- Medications: Narcotics
- Increased intracranial pressure
– normal breathing
Eupnea
Normal breathing sounds
- Vesicular breath sounds
2. Bronchial breath sounds
3. Broncho-vesicular breath sounds
4. Tracheal breath sound
is a condition that refers to rapid breathing. The normal breathing rate for an average adult is 12 to 20 breaths per minute.
Tachypnea
is an abnormally slow breathing rate. The normal breathing rate for an adult is typically between 12 and 20 breaths per minute.
Bradypnea
is breathing repeatedly stops and starts again or cessation of breathing.
Apnea
is an overexpansion of the lungs characterized by rapid and deep breathing.
Hyperventilation
is an under-expansion of the lungs characterized by shallow respirations.
Hypoventilation
Gradual increases and decreases in respirations with periods of apnea
Cheyne-Stokes
Fine, short, interrupted.
Sound can be stimulated by rolling a lock of hair near the ear.
Crackles (rales)
Continuous, low-pitched, gurgling, harsh, louder sounds with moaning (complaining).
Gurgles (rhonchi)
Superficial grating (harsh) or creaking.
Friction rubs
High-pitched, squeaky (noisy) musical sounds.
Wheeze (expiration)
Rapid, deep respirations (gasps) with short pauses between sets.
Biot’s
Tachypnea and hyperpnea
Kussmaul’s
Prolonged inspiratory phase with shortened expiratory phases.
Apneustic
is difficult and labored breathing.
Dyspnea
is the ability to breathe only in an upright position.
Orthopnea
is the presence of blood in the sputum.
Hemoptysis
a cough accompanied by expectorated secretions.
Productive cough
a dry, harsh cough without secretions.
Nonproductive cough
is the force exerted by the blood against the vessel’s walls (arterial wall) which is measured in millimeters of mercury (mmHg).
BLOOD PRESSURE
is the pressure of the blood as a result of contraction of the ventricles, and is the pressure of the height of the blood wave.
Systolic pressure
is the pressure of the blood as a result of contraction of the ventricles, is the pressure of the height of the blood wave.
Systolic pressure
is the pressure when the ventricles are at rest. this pressure is the lower pressure, present at all times within the arteries.
Diastolic pressure
Are the “tapping” sounds heard with a stethoscope as the cuff is gradually deflated. These are classified into five different phases.
Korotkoff’s Sound:
Age: Newborns have a mean systolic pressure of about ___ mm Hg. The pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat.
75
Exercise: Physical activity increases the cardiac output and hence the blood pressure, thus ___ minutes of rest following exercise is indicated before the resting blood pressure can be reliably assessed.
20 to 30
Any condition affecting the cardiac output blood volume, blood viscosity and/or compliance of the arteries has a direct effect on the blood pressure.
Disease process:
: A blood pressure that is persistently above normal.
Hypertension
is an elevated blood pressure of unknown cause
Primary hypertension
is an elevated blood pressure of known cause.
Secondary hypertension
is a blood pressure that is below normal.
Hypotension
is a blood pressure that falls when the client sits or stands.
Orthostatic hypotension
is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Pain
– pain as a result of tissue or muscle injury
Examples include sprains, bone fractures, burns, bumps, bruises, inflammation (from an infection or arthritic disorder), obstructions, and myofascial pain (which may indicate abnormal muscle stresses).
Nociceptive pain
– an abnormal inflammation caused by an inappropriate response by the body’s immune system.
It is the spontaneous response to pain when there is tissue damage and inflammation (e.g., postoperative pain, trauma, arthritis).
Inflammatory pain
– pain caused by damage or disease affecting the somatosensory nervous system.
Examples include neuralgia (pain in the nerve pathway), cancer pain, phantom limb pain, carpal tunnel syndrome, and peripheral neuropathy (widespread nerve damage).
Neuropathic pain
– pain without obvious physiologic origin, but can cause pain
Functional pain
is defined as a chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain.
Addiction
happens when a person no longer responds to a drug in the way they did at first. So it takes a higher dose of the drug to achieve the same effect as when the person first used it.
Tolerance
___ on a drug can be demonstrated by the presence of withdrawal symptoms when the drug is not taken.
Physical dependence
are clinical manifestations like nausea and vomiting, abdominal cramps, muscle twitching, profuse perspiration, delirium, and convulsions.
Withdrawal or abstinence syndrome
PQRST Characteristics of Pain
P = Palliative, Provocative
Q = Quality
R = Radiation
S = Severity
T = Temporal
What makes the pain better or worse?
P = Palliative, Provocative
How is the pain described?
Q = Quality
Does the pain travel or spread anywhere else? If so, where?
R = Radiation
What is the intensity of the pain? (on a 0 - 10 scale)
S = Severity
Is the pain constant or does it come and go?
T = Temporal
___ assesses the level of pain in children who are too young to cooperate verbally. It can also be used in adults who are unable to communicate.
FLACC pain scale
