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Nursing 210 Clinical Skills Lab > Measuring Vital Signs (VS) > Flashcards

Measuring Vital Signs (VS) Flashcards

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1
Q

an assessment of vital or critical physiological functions

A

vital signs (VS)

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2
Q

the degree of heat maintained by the body

A

body temperature

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3
Q

an adult’s normal internal temperature or (core temperature)

A

97-100 degrees F or

36.1-38.2 degrees C

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4
Q

the process of temperature regulation

A

thermoregulation

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5
Q

hairs standing on end

A

piloerection

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6
Q

the sum of all physical and chemical processes and changes that take place in the body

A

metabolism

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7
Q

the amount of energy required to maintain the body at rest

A

basal metabolic rate (BMR)

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8
Q

the metabolism of brown fat to product heat

A

nonshivering thermogenesis

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9
Q

is the loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air

A

radiation

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10
Q

the transfer of heat through currents of air or water

A

convection

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11
Q

when water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (breath)

A

evaporation

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12
Q

water loss by evaporation

A

insensible loss

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13
Q

moisture in the air

A

humidity

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14
Q

the process whereby heat is transferred from a warm to a cool surface by direct contact

A

conduction

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15
Q

a cyclical repetition of certain physiological processes that occurs every 24 hours

A

circadian rhythm

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16
Q

fever

A

pyrexia

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17
Q

a person with a fever

A

febrile

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18
Q

a person without a fever

A

afebrile

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19
Q

a fever above 105.8 F or 41.0 C

A

hyperpyrexia [hyper (above)-pyrexia (fever)]

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20
Q

fever-producing substances

A

pyrogens

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21
Q

specialized white blood cells

A

phagocytes

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22
Q

substances that reset the hypothalamic thermostat at a higher temperature

A

prostaglandins

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23
Q

reset value

A

set point

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24
Q

the period when body temperature is rising but has not yet reached the new set point

A

in initial phase (febrile episode or onset)

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25
Q

the period when body temp reaches its maximum (set point) and remains fairly constant at eh new higher level

A

the second phase (course)

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26
Q

the period when the temp returns to normal

A

the third phase ( defervescence or crisis)

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27
Q

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

A

intermittent fever

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27
Q

Very thin wasted appearance

A

Cachectic

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28
Q

In a general system what are normal/abnormal findings?

A

Normal: alert,oriented x3, properly dressed, cooperative
Abnormal: lethargic ,confused, uncooperative , angry, sad, depressed

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28
Q

CRT

A

Capillary refill time

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29
Q

In skin what are norm/abnormal findings? Interventions?

A

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

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30
Q

fluctuations in temp above normal during 24 hour period

A

remittent fever

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30
Q

The first step of the nursing process

A

Assessment

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31
Q

temp may fluctuate slightly but always above normal

A

constant (sustained) fever

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31
Q

The systematic gathering of information related to the physical, mental, spiritual, socioeconomic , and cultural status of an individual , group, or community

A

Assessment

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32
Q

short periods of fever alternating with periods of normal temp each lasting 1-2 days

A

relapsing (recurrent) fever

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33
Q

fever reducing

A

antipyretic

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34
Q

a body temp above normal but the elevated temp higher than the set point

A

hyperthermia

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35
Q

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

A

heat exhaustion

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36
Q

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

A

heat stroke

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37
Q

an abnormally low core temp less than 95 F or 35 C

A

hypothermia

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38
Q

the contraction of the heart

A

systole

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39
Q

the resting phase of the heart

A

diastole

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40
Q

the quantity of blood forced out by each contraction of the left ventrical

A

stroke volume

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41
Q

the total quantity of blood pumped per minute

A

cardiac output

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42
Q

feeling

A

palpation

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43
Q

listening with a stethoscope

A

auscultation

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44
Q

a sound-transmitting device (bell and diaphragm) that is attached to earpieces by rubber tubing and hollow metal tubes

A

stethoscope

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45
Q

pulse at the apex of the heart

A

apical pulse

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46
Q

a place where an artery can be pressed by the fingers against a bone

A

peripheral pulse

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47
Q

a difference between the two counts

A

pulse deficit

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48
Q

count the number of beats per minute while palpating or auscultating

A

rate

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49
Q

brady

A

slow

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50
Q

cardiac

A

heart

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51
Q

bradycardia

A

slow hart

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52
Q

tachy

A

rapid

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53
Q

the intervals between heartbeats establish a pulse pattern

A

rhythm

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54
Q

dys

A

irregular

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55
Q

when the intervals between beats vary enough to be noticeable

A

dysrhythmia

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56
Q

ECG

A

Electrocardiogram

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57
Q

a procedure that traces the electrical pattern of the heart

A

Electrocardiogram (ECG)

58
Q

pulse volume and bilateral equality of pulses

A

pulse quality

59
Q

the amount of force produced by the blood pulsing through the arteries

A

pulse volume

60
Q

literally equal on both sides (peripheral pulses that are equal in rate and amplitude on both sides of the body)

A

bilateral equality

61
Q

the paleness of skin in one area when compared to another part of the body

A

pallor

62
Q

a bluish or grayish discoloration of the sin due to deficient oxygen in the blood

A

cyanosis

63
Q

cyan

A

blue

64
Q

breathing

A

pulmonary ventilation

65
Q

the exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply

A

external respiration

66
Q

the transport of carbon dioxide and oxygen throughout the body

A

gas transport

67
Q

the exchange of carbon dioxide and oxygen between the capillaries and body tissue

A

internal respiration

68
Q

receptors located in the respiratory centers that is sensitive to CO2 and hydrogen ion (pH0 concentrations

A

central chemoreceptors

69
Q

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

A

peripheral chemoreceptors

70
Q

drawing air into the lungs

A

inspiration

71
Q

the expulsion of air from the lungs

A

expiration

72
Q

the number of times a person breathes or completes a cycle of inhalation and exhalation

A

respiratory rate

73
Q

the amount of air taken in on inspiration

A

tidal volume

74
Q

the degree of work required to breathe

A

respiratory effort

75
Q

labored breathing

A

dyspnea

76
Q

difficulty or inability to breathe when in a horizontal position

A

orthopnea

77
Q

high-pitched continuous musical sounds usually heard on expiration

A

wheezes

78
Q

low-pitched continuous gurgling sounds caused by secretions in the large airways

A

rhonchi

79
Q

discontinuous sounds usually heard on inspiration but they may be heard throughout the respiratory cycle

A

crackles

80
Q

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

A

stridor

81
Q

labored breathing that produces a snoring sound

A

stertor

82
Q

the visible sinking of tissues around and between the ribs that occurs when the person must use additional effort to breathe

A

intercostal retraction

83
Q

when tissues are drawn in beneath the sternum (breastbone)

A

substernal retraction

84
Q

when tissues are drawn in above the clavicle (shoulder girdle)

A

suprasternal retraction

85
Q

inadequate cellular oxygenation

A

hypoxia

86
Q

loss of the nail angle

A

clubbing

87
Q

a forceful or violent expulsion of air during expiration

A

cough

88
Q

measures the partial pressures of oxygen and carbon dioxide and blood pH

A

arterial blood gas sampling

89
Q

ABG

A

Arterial blood gas

90
Q

a noninvasive method of monitoring respiratory status with a device that measures oxygen saturation

A

Pulse oximetry

91
Q

an indication of the oxygen being carried by hemoglobin in the arterial blood

A

oxygen saturation

92
Q

when rapid and deep breathing result in excess loss of CO2

A

Hyperventilation (hypocapnia)

93
Q

when the rate and depth of respirations are decreased and CO2 is retained or alveolar ventilations compromised

A

hypoventilation

94
Q

the pressure of the blood as it is forced against arterial walls during cardia contraction

A

blood pressure (BP)

95
Q

the peak pressure exerted against arterial walls as the ventricles contract and eject blood

A

systolic pressure

96
Q

the minimum pressure exerted against arterial walls between the cardiac contractions when the heart is at rest

A

diastolic pressure

97
Q

the difference between the systolic and diastolic pressure

A

pulse pressure

98
Q

arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls

A

peripheral resistance

99
Q

thickness

A

viscosity

100
Q

elasticity

A

compliance

101
Q

the percentage of red blood cells in plasma

A

hematocrit

102
Q

hardening of the arteries

A

arteriosclerosis

103
Q

a vinyl or cloth cuff, a pressure bulb with a regulating valve, and a manometer

A

sphygmomanometer

104
Q

dials that register BP by pointers attached to a spring

A

aneroid manometer

105
Q

using a calibrated upright tube containing mercury

A

mercury manometer

106
Q

the sound you listen for when you assess BP that describe the sounds of blood pulsating through arteries

A

Korotkoff sounds

107
Q

the loss and later return of sound

A

auscultatory gap

108
Q

when a person’s BP drops suddenly on moving from a lying position to a sitting or standing position

A

orthostatic or postural hypotension

109
Q

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

A

Prehypertension

110
Q

a persistently higher than normal BP

A

hypertension

111
Q

diagnosed when there is no known cause for the BP elevation

A

primary or essential hypertension

112
Q

when there is a clearly identified cause for the persistent rise in BP

A

secondary hypertension

113
Q

ADLs

A

Activities of daily living

114
Q

seeing the patient every hour

A

hourly rounding

115
Q

preparing the patient for breakfast or other activities such as diagnostic tests

A

early morning care

116
Q

hygiene care that occurs after breakfast

A

A.M. (morning) care

117
Q

preparing patients to receive visitors or afternoon rest

A

P.M. (afternoon) care

118
Q

skin, the subcutaneous layer directly under the skin, the hair, nails and the seat and sebaceous glands

A

integumentary

119
Q

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

A

epidermis

120
Q

epidermis continually shed

A

desquamates

121
Q

pigment that provides protection against the ultraviolet rays of the sun and that together with circulating blood, gives skin its color

A

melanin

122
Q

the thinner, second layer of the skin it contains the blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands

A

dermis

123
Q

secrete an oily substance called sebum which helps waterproof and lubricate the skin and decrease bacterial growth

A

sebaceous glands

124
Q

concentrated in the axillae and external genitalia, excrete water in the form of perspiration; evaporation produces a cooling effect on the skin

A

sweat glands

125
Q

softening of the skin due to prolonged moisture

A

maceration

126
Q

paleness of skin

A

pallor

127
Q

redness of the skin

A

erythema

128
Q

yellow discoloration of the skin occurs in patients with impaired liver function best seen in the sclerae of the eyes

A

jaundice

129
Q

a bluish coloring of the skin caused by decreased peripheral circulation or decreased oxygenation of the blood

A

cyanosis

130
Q

itching

A

pruritus

131
Q

loss of the superficial layers of the skin caused for example by scratching and by the digestive enzymes in feces

A

excoriation

132
Q

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

A

abrasion

133
Q

lesions caused by tissue compression and inadequate perfusion

A

pressure ulcers (decubitus ulcers)

134
Q

an inflammation of the sebaceous glands

A

acne

135
Q

at risk for skin being adversely altered

A

risk for impaired skin integrity

136
Q

altered epidermis or dermis

A

impaired skin integrity

137
Q

when a nurse helps the patient with areas that may be difficult to reach such as the back feet and legs

A

assist bath

138
Q

nurse cleanses only the areas that may cause odor or discomfort such as the axillae and perineum

A

partial bath

139
Q

bath for patients who must remain in bed but who are able to bathe themselves

A

bed bath

140
Q

nurse will was the patient’s entire body w/o assistance from the patient

A

complete bed bath

141
Q

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

A

towel bath

142
Q

a modification of the towel bath in which you use 8-10 washcloths instead of a towel and a bath blanket

A

bag bath

143
Q

refers to a set of commercially prepared and packaged pre-moistened disposable washcloths

A

packaged bath

144
Q

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

A

therapeutic baths

145
Q

the area between the anus and vulva in the female or the anus and scrotum in a male

A

perineum

146
Q

a cone-shaped thickening of the epidermis caused by continuous pressure

A

corn

Nursing 210 Clinical Skills Lab (1 decks)

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