Measuring Vital Signs (VS) Flashcards
an assessment of vital or critical physiological functions
vital signs (VS)
the degree of heat maintained by the body
body temperature
an adult’s normal internal temperature or (core temperature)
97-100 degrees F or
36.1-38.2 degrees C
the process of temperature regulation
thermoregulation
hairs standing on end
piloerection
the sum of all physical and chemical processes and changes that take place in the body
metabolism
the amount of energy required to maintain the body at rest
basal metabolic rate (BMR)
the metabolism of brown fat to product heat
nonshivering thermogenesis
is the loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air
radiation
the transfer of heat through currents of air or water
convection
when water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (breath)
evaporation
water loss by evaporation
insensible loss
moisture in the air
humidity
the process whereby heat is transferred from a warm to a cool surface by direct contact
conduction
a cyclical repetition of certain physiological processes that occurs every 24 hours
circadian rhythm
fever
pyrexia
a person with a fever
febrile
a person without a fever
afebrile
a fever above 105.8 F or 41.0 C
hyperpyrexia [hyper (above)-pyrexia (fever)]
fever-producing substances
pyrogens
specialized white blood cells
phagocytes
substances that reset the hypothalamic thermostat at a higher temperature
prostaglandins
reset value
set point
the period when body temperature is rising but has not yet reached the new set point
in initial phase (febrile episode or onset)
the period when body temp reaches its maximum (set point) and remains fairly constant at eh new higher level
the second phase (course)
the period when the temp returns to normal
the third phase ( defervescence or crisis)
temp alternates regularly between periods of fever and periods of normal or below-normal temp w/o pharmacological intervention : or the temp returns to normal at least once every 24 hours
intermittent fever
Very thin wasted appearance
Cachectic
In a general system what are normal/abnormal findings?
Normal: alert,oriented x3, properly dressed, cooperative
Abnormal: lethargic ,confused, uncooperative , angry, sad, depressed
CRT
Capillary refill time
In skin what are norm/abnormal findings? Interventions?
Norm: warm dry intact no tenting no bruises or lesions
Abnormal : cold clammy wounds open areas bruises rashes tenting cyanosis jaundice
Intervention: turn q 2hrs skin softeners dressing changed / protect wounds use Braden scale to predict pressure ulcers
fluctuations in temp above normal during 24 hour period
remittent fever
The first step of the nursing process
Assessment
temp may fluctuate slightly but always above normal
constant (sustained) fever
The systematic gathering of information related to the physical, mental, spiritual, socioeconomic , and cultural status of an individual , group, or community
Assessment
short periods of fever alternating with periods of normal temp each lasting 1-2 days
relapsing (recurrent) fever
fever reducing
antipyretic
a body temp above normal but the elevated temp higher than the set point
hyperthermia
a type of hyperthermia that is potentially life threatening; a state of weakness produced by exposure to heat, humidity and excessive loss of fluids and electrolytes; the body’s thermoregulatory system is still functioning
heat exhaustion
a derangement of thermoregulation with altered mental status and high body tem; occurs if heat exhaustion is not treated; caused by high temp and high humidity
heat stroke
an abnormally low core temp less than 95 F or 35 C
hypothermia
the contraction of the heart
systole
the resting phase of the heart
diastole
the quantity of blood forced out by each contraction of the left ventrical
stroke volume
the total quantity of blood pumped per minute
cardiac output
feeling
palpation
listening with a stethoscope
auscultation
a sound-transmitting device (bell and diaphragm) that is attached to earpieces by rubber tubing and hollow metal tubes
stethoscope
pulse at the apex of the heart
apical pulse
a place where an artery can be pressed by the fingers against a bone
peripheral pulse
a difference between the two counts
pulse deficit
count the number of beats per minute while palpating or auscultating
rate
brady
slow
cardiac
heart
bradycardia
slow hart
tachy
rapid
the intervals between heartbeats establish a pulse pattern
rhythm
dys
irregular
when the intervals between beats vary enough to be noticeable
dysrhythmia
ECG
Electrocardiogram
a procedure that traces the electrical pattern of the heart
Electrocardiogram (ECG)
pulse volume and bilateral equality of pulses
pulse quality
the amount of force produced by the blood pulsing through the arteries
pulse volume
literally equal on both sides (peripheral pulses that are equal in rate and amplitude on both sides of the body)
bilateral equality
the paleness of skin in one area when compared to another part of the body
pallor
a bluish or grayish discoloration of the sin due to deficient oxygen in the blood
cyanosis
cyan
blue
breathing
pulmonary ventilation
the exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply
external respiration
the transport of carbon dioxide and oxygen throughout the body
gas transport
the exchange of carbon dioxide and oxygen between the capillaries and body tissue
internal respiration
receptors located in the respiratory centers that is sensitive to CO2 and hydrogen ion (pH0 concentrations
central chemoreceptors
receptors (sense organ or sensory nerve ending) located in the carotid and aortic bodies that stimulate respirations when the partial pressures of oxygen in arterial blood (PaO2) falls below 100 mg Hg
peripheral chemoreceptors
drawing air into the lungs
inspiration
the expulsion of air from the lungs
expiration
the number of times a person breathes or completes a cycle of inhalation and exhalation
respiratory rate
the amount of air taken in on inspiration
tidal volume
the degree of work required to breathe
respiratory effort
labored breathing
dyspnea
difficulty or inability to breathe when in a horizontal position
orthopnea
high-pitched continuous musical sounds usually heard on expiration
wheezes
low-pitched continuous gurgling sounds caused by secretions in the large airways
rhonchi
discontinuous sounds usually heard on inspiration but they may be heard throughout the respiratory cycle
crackles
piercing, high-pitched sound that is heard w/o a stethoscope, primarily during inspiration, in infants who are experiencing respiratory distress or in someone with an obstructed airway
stridor
labored breathing that produces a snoring sound
stertor
the visible sinking of tissues around and between the ribs that occurs when the person must use additional effort to breathe
intercostal retraction
when tissues are drawn in beneath the sternum (breastbone)
substernal retraction
when tissues are drawn in above the clavicle (shoulder girdle)
suprasternal retraction
inadequate cellular oxygenation
hypoxia
loss of the nail angle
clubbing
a forceful or violent expulsion of air during expiration
cough
measures the partial pressures of oxygen and carbon dioxide and blood pH
arterial blood gas sampling
ABG
Arterial blood gas
a noninvasive method of monitoring respiratory status with a device that measures oxygen saturation
Pulse oximetry
an indication of the oxygen being carried by hemoglobin in the arterial blood
oxygen saturation
when rapid and deep breathing result in excess loss of CO2
Hyperventilation (hypocapnia)
when the rate and depth of respirations are decreased and CO2 is retained or alveolar ventilations compromised
hypoventilation
the pressure of the blood as it is forced against arterial walls during cardia contraction
blood pressure (BP)
the peak pressure exerted against arterial walls as the ventricles contract and eject blood
systolic pressure
the minimum pressure exerted against arterial walls between the cardiac contractions when the heart is at rest
diastolic pressure
the difference between the systolic and diastolic pressure
pulse pressure
arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls
peripheral resistance
thickness
viscosity
elasticity
compliance
the percentage of red blood cells in plasma
hematocrit
hardening of the arteries
arteriosclerosis
a vinyl or cloth cuff, a pressure bulb with a regulating valve, and a manometer
sphygmomanometer
dials that register BP by pointers attached to a spring
aneroid manometer
using a calibrated upright tube containing mercury
mercury manometer
the sound you listen for when you assess BP that describe the sounds of blood pulsating through arteries
Korotkoff sounds
the loss and later return of sound
auscultatory gap
when a person’s BP drops suddenly on moving from a lying position to a sitting or standing position
orthostatic or postural hypotension
a BP reading of 120 to 139 mm Hg systolic or 80-89 mm Hg diastolic, obtained with two reading taken 6 minutes apart, with the patient sitting
Prehypertension
a persistently higher than normal BP
hypertension
diagnosed when there is no known cause for the BP elevation
primary or essential hypertension
when there is a clearly identified cause for the persistent rise in BP
secondary hypertension
ADLs
Activities of daily living
seeing the patient every hour
hourly rounding
preparing the patient for breakfast or other activities such as diagnostic tests
early morning care
hygiene care that occurs after breakfast
A.M. (morning) care
preparing patients to receive visitors or afternoon rest
P.M. (afternoon) care
skin, the subcutaneous layer directly under the skin, the hair, nails and the seat and sebaceous glands
integumentary
the thicker, outer layer of skin it consists of stratified squamous epithelia tissue composed of keratinized (dead) cells which are fused to make to the skin waterproof
epidermis
epidermis continually shed
desquamates
pigment that provides protection against the ultraviolet rays of the sun and that together with circulating blood, gives skin its color
melanin
the thinner, second layer of the skin it contains the blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands
dermis
secrete an oily substance called sebum which helps waterproof and lubricate the skin and decrease bacterial growth
sebaceous glands
concentrated in the axillae and external genitalia, excrete water in the form of perspiration; evaporation produces a cooling effect on the skin
sweat glands
softening of the skin due to prolonged moisture
maceration
paleness of skin
pallor
redness of the skin
erythema
yellow discoloration of the skin occurs in patients with impaired liver function best seen in the sclerae of the eyes
jaundice
a bluish coloring of the skin caused by decreased peripheral circulation or decreased oxygenation of the blood
cyanosis
itching
pruritus
loss of the superficial layers of the skin caused for example by scratching and by the digestive enzymes in feces
excoriation
rubbing away of the epidermal layer of the skin especially over bony areas or prominences is often caused by friction or shearing forces that occur when a patient moves or is moved in bed
abrasion
lesions caused by tissue compression and inadequate perfusion
pressure ulcers (decubitus ulcers)
an inflammation of the sebaceous glands
acne
at risk for skin being adversely altered
risk for impaired skin integrity
altered epidermis or dermis
impaired skin integrity
when a nurse helps the patient with areas that may be difficult to reach such as the back feet and legs
assist bath
nurse cleanses only the areas that may cause odor or discomfort such as the axillae and perineum
partial bath
bath for patients who must remain in bed but who are able to bathe themselves
bed bath
nurse will was the patient’s entire body w/o assistance from the patient
complete bed bath
modification of the bed bath in which you place a large towel and a bath blanket in a plastic bag saturate the with a warmed commercially prepared mixture of moisturizer disinfectant, non-rinse cleaning agent and use them to bathe the patient
towel bath
a modification of the towel bath in which you use 8-10 washcloths instead of a towel and a bath blanket
bag bath
refers to a set of commercially prepared and packaged pre-moistened disposable washcloths
packaged bath
a prescribed bath with specific instructions for the type of bath and solution to be used or an area of the body to be treated an water temp
therapeutic baths
the area between the anus and vulva in the female or the anus and scrotum in a male
perineum
a cone-shaped thickening of the epidermis caused by continuous pressure
corn
